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Fetal Monitoring Exam Two
why do you assess FHR? - ✔✔to recognize abnormal uterine patterns, evaluate effects of Pitocin and other meds what are the two methods of fetal monitoring? - ✔✔intermittent (auscultation with fetoscope or doppler) electronic/continuous (External toco transducer with ultrasound, internal scalp electrode with IUPC) intermittent fetal monitoring - ✔✔low risk, one-to-one nurse-to-pt ratio, non invasive, mom can be ambulatory disadvantages of intermittent fetal monitoring - ✔✔Is a learned skill May miss detection of information with a weak signal or movement of mom and baby Difficult to identify periodic changes Difficult to detect variability No printed record other than nursing documentation AWHONN and ACOG Standards for Intermittent fetal monitoring - ✔✔for high risk mom: stage I - Q30min, stage II - Q15min for low risk mom: stage I - Q15min, stage II - Q5 min advantages of EFM - ✔✔Continuous information Variability can be determined Printed record as long as mom is on the monitor disadvantages of EFM - ✔✔Requires advanced assessment and clinical judgment skills
Has a history of controversy for interpretation and interventions Restriction of mom's activity Expensive May increase C/S rate, infections Use should be based on risk assessment but also is based on obstetric staff preference and hosp policy AWHONN standards for EFM - ✔✔Initiation of monitoring and ongoing evaluation only by licensed healthcare providers Fetal heart rate monitoring includes: Application of monitoring components Initial assessment of mother and fetus Intermittent auscultation Ongoing monitoring and interpretation Clinical interventions RISK FACTORS to consider for EFM - ✔✔Maternal Risk Factors Fever Infection Preeclampsia Any disease process Grand multiparity Previous C/S Fetal Risk Factors Decreased movement Meconium Post dates IUGR Abnormal presentation
FHR tachy may be caused by - ✔✔fever, infection, dehydration, betasympathomimetic drugs (terbutaline, ritodrine, atropine), prolonged stimulation, early fetal hypoxia, get rid of CO2 or lactic acid, chronic hypoxemia, prematurity, fetal anemia Tx for fetal tachy - ✔✔Look for cause and treat Enhance uterine blood flow Decrease uterine activity Give O2, fluids Notify the MD Ominous sign if occurs with late decels, severe variables, decreased/absent variabiltiy causes of fetal bradycardia - ✔✔Hypotension Regional anesthesia and anesthesia Accidental monitoring of maternal pulse Prolonged head compression (vagal) Prolonged umbilical cord occlusion Fetal dysrhythmia Hypoxemia or late fetal asphyxia Tx of fetal brady - ✔✔Look for the cause Change maternal position Give O2, increase fluids DC labor stimulants (Pitocin) Notify the MD Ominous if appear with decreased variability and or late decelerations sinusoidal baseline fetal heart pattern - ✔✔undulant sine wave associated with
severe fetal anemia/Rh isoimunization in labor associated with sever asphyxia Chronic fetal bleeding Fetal isoimmunization Twin to twin transfer Umbilical cord occulsion CNS malformations OR may be benign are arrhythmias easy to diagnose? - ✔✔no, they generally have to use invasive/advanced monitoring three categories of fetal arrhythmias - ✔✔irregular rhythms, sustained tachy, sustained brady baseline variability - ✔✔seen after 32 seeks, important parameter of fetal well being, push-pull interplay of sympathetic and parasympathetic system, seen as the grass like fluctuations on baseline, assessment is visually made and simply indicates an intact brain stem, adequate current O2 in the brain does baseline variability r/o prior injury? - ✔✔no classification of variability - ✔✔Absent = No fluctuations present Minimal = 0-5 bpm Moderate = 6-25 bpm Marked = >25 bpm Saltatory pattern - ✔✔Note pattern of marked LTV. FHR varies markedly between 120 and 190 beats per minute. With this type of pattern, it is not possible to determine an average baseline FHR because of the wide, marked variations. STV is present Etiology unknown - occurs frequently with severe variable deceleration
episodic decelerations - ✔✔not related to contractions, are variables or related to vag exams, ROM, or meds periodic decelerations - ✔✔occurs with contractions, can be early or lates, considered repetitive if with 50% or more of contractions shape of early decereations - ✔✔mirror image of the contraction - peak (nadir) of deceleration occurs simultaneously with peak(nadir) of contraction, are smooth and uniform, depth may be 30-40 beats onset of early decelerations - ✔✔gradual! begins with the onset of the contraction and ends when the contraction ends Range generally normal 110- 160 Single or repetitive etiology of early decelerations - ✔✔head compression (stimulation of vagal nerve) by contractions, fetal head rotation or 2nd stage descent significance of early decelerations - ✔✔benign pattern- unless they are seen with lack of head entering the pelvis/dilation <4 cm interventions for early decelerations - ✔✔none required when the baby's head is compressed, how does that make the FHR decrease? - ✔✔it causes a cerebral flow change causing them to vagal down late decelerations shape - ✔✔uniform, can mirror image the contraction after CTX begins Smooth and uniform in appearance
onset of late decelerations - ✔✔gradual onset, peak (nadir) of deceleration occurs after peak of contraction/ does not begin with contraction Range usually within normal Occasional, consistent to repetitive etiology of late decelerations - ✔✔uteroplacental insufficiency and decreased oxygen to fetus significance of late decelerations - ✔✔All lates mean hypoxia/ uteroplacental insufficiency causing a reduction in fetal oxygenation during a contraction persistent lates signal hypoxic stress for fetus and increasing acidosis reflex lates are due to what? - ✔✔transient uteroplacental insufficiency - somehthing we have done (Hypotension, epidural, aorta-caval compression, hyperstimulation) they Resolve with NI variability is present/may have accelerations myocardial lates - ✔✔= late decels (not variable decels) LEADS TO ACIDEMIA AND ASPHYXIA they are metabolic (non-reassuring) lates that do not resolve with NI, are recurrent in nature, frequently very subtle/shallow, generally no FHR accelerations or variability nursing interventions for late decelerations - ✔✔enhance uterine blood flow/placental perfusion; improve oxygenation to fetus and decrease uterine activity Give O2, Increase fluids, DC Pitocin, Correct hypotension, Change mom's position, Look for any reassuring signs, Continue to monitor Mom's V/S, Notify the MD, Prepare for C/S mechanism of late decels - ✔✔Decreased Uteroplacental O2 transfer
DC pitocin; R/O prolapsed cord O2, Notify Dr., amnioinfusion if severe; pathway of variables - ✔✔Vein Occlusion Fetal Hypotension Artery Occlusion (total cord) Fetal Hypertension - and Hypoxemia Vagal Stimulation Myocardial Depression and Acidosis FHR Deceleration – Variable when do you assess FHR - ✔✔during labor Prior to labor stimulants, periods of ambulation, administration of medications, initiation of anesthesia following ROM, vaginal exams, periods of ambulation, and procedures such as enemas and caths atypical variable decelerations - ✔✔The presence of any of these types of variable decelerations is very suggestive of fetal hypoxia, especially when variability is decreased. when the deceleration goes above baseline after it plummets - ✔✔variable decelerations with overshoot VEAL CHOP - ✔✔Variable - cord compression Early - Head compression Accelerations - oxygenation ok Late - placental perfusion problems prolonged decelerations shape - ✔✔can be in any shape and any pattern
onset of prolonged deceleration - ✔✔can occur at any time in the contraction cycle lasts more than 2 minutes but less than 10 minutes and is 15 beats or more off the baseline etiology of prolonged decelerations - ✔✔maternal hypotension occult or frank prolapse of the cord tetonic contractions rapid fetal descent vaginal exam sustained maternal valsalva significance of prolonged decelerations - ✔✔depends upon the etiology interventions for prolonged decelerations - ✔✔nursing care as with the late decelerations R/O prolapsed cord, DC pitocin, change mom's position, give O2, increase fluids, notify the MD; give tocolytic; prepare for C/S category I FHT - ✔✔Normal: baseline of 110-160, variability is moderate, periodic patterns (accelerations with fetal movements, early decelerations may be present, lates or variables absent strongly predictive of normal fetal acid-base status, continue with "routine" assessments Category II FHT - ✔✔Tracing is indeterminate Not predictive of acid-base status But cannot be reassured Requires further evaluation, continued surveillance Consider the associated clinical circumstances of mother
3 contx in 10 min what is a negative contraction stress test? - ✔✔no lates what is a positive contraction stress test? - ✔✔lates with 50% of contx what is sometimes used instead of an OCT? - ✔✔biophysical profile (optical coherence tomography) what does a biophysical profile on a fetus measure? - ✔✔FHR accelerations (NST) Ultrasound: Fetal breathing movement, movement, tone, and amniotic fluid volume what do you need to document when you document a contraction? - ✔✔frequency, duration, intensity, resting tone what do you need to document when you document a Fetal heart rate? - ✔✔baseline, variability, periodic changes, reassuring (normal) or nonreassuring (worrisome) or use of three categories (CVBADC)
