Assessing the Fetus During Labor

Umbilical cord blood gases/ acid base after the birth

Additional Fetal Assessment Techniques · Fetal Scalp Stimulation (finger in vagina) · Vibroacoustic Stimulation (loud sound) § Indirect method to identify fetal hypoxia and acidemia § A well-oxygenated fetus will respond when stimulated (tactile/noise) by moving in conjunction with an acceleration of 15 bpm above baseline HR >15 seconds · ________________________: Done after birth to assess fetal acid-base balance and oxygenation at birth. Can determine if acute or chronic acidosis. § If its acidic, it can mean the fetus experienced some hypoxia · Fetal scalp blood sampling: checks for acidemia, not widely used in US

Every 5-15 minutes

Guidelines for Intermittent Monitoring · Get initial 20 minute continuous electronic Fetal Heart Rate (FHR) strip on admission · Assess for any increased risk due to prenatal & labor factors: HTN, diabetes, premature baby, low/high AFV · During the latent phase of labor: assess Fetal Heart Rate (FHR) every 30-60 minutes · First stage of labor (active phase): assess Fetal Heart Rate (FHR) pattern at a minimum of: Every 15-30 minutes during active labor · Second stage of labor: assess Fetal Heart Rate (FHR) at a minimum of: _______________________ · Count for a minute between, before, during, & after contraction

110-160/min excluding accelerations, decelerations, and periods of marked variability within a 10 minute window

How to Read EFM Strips: BE SYSTEMATIC · 1. Assess UTERINE ACTIVITY · 2. Note the FHR BASELINE: ____________________________________________________ · 3. Identify VARIABILITY: the heart rate should speed up or slow down every now and then (this shows the brain is oxygenated because it recognizes changes) · 4. Assess for periodic changes from the baseline: § ACCELERATIONS § DECELERATIONS

110-160/min

Interpretation of External/Internal FHR monitoring · A normal fetal heart rate baseline at term is ______________________ excluding accelerations, decelerations, and periods of marked variability within a 10 minute window. · Fetal heart rate baseline variability is a fluctuation in the FHR baseline that is irregular in frequency and amplitude. Expected variability is moderate variability.

1. Change position to side-lying 2. Use O2 at 8-10L/min via non-rebreather face mask 3. Give IV bolus of fluids

Name 3 Interventions in Order for Decreased Variability: 1. 2. 3.

· Spontaneous fetal movement · Vaginal exam, scalp stimulation · Electrode application · Abdominal palpation · Uterine contractions

Periodic and Episodic Changes in Fetal Heart Rate Above or Below Baseline · Periodic changes occur with contractions · Episodic (nonperiodic) changes not associated with contractions · Accelerations: FHR going up, above baseline (it = fetal well-being) § Acceleration of FHR is a visually apparent, abrupt (onset to peak) increase in FHR above the baseline. § The peak is at least 15 beats/min above the baseline, and the acceleration lasts 15 seconds or more, with return to baseline less than 2 minutes from the beginning of accelerations § Causes of Accelerations (any stimulation to CNS): - - - - - § Shows normal reaction of fetal CNS, so good oxygenation

· Baseline FHR in normal range of 110 to 160 beats/min · No ominous decelerations · Moderate baseline variability · In the preterm infant, baseline FHR may be higher

Reassuring FHR Patterns: 1. 2. 3. 4.

§ Absent baseline variability and any of the following: · Recurrent late decelerations · Recurrent variable decelerations · Brady cardia § Sinusoidal pattern

3-Tier Fetal Heart Rate Classification · Category 3: - - - - -

D. Relaxation between uterine contractions

A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse knows that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions

B. "It can detect abnormal fetal heart tones early." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."

A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include? (SATA) A. "It is considered a noninvasive procedure." B. "It can detect abnormal fetal heart tones early." C. "It can determine the amount of amniotic fluid you have." D. "It allows for accurate readings with maternal movement." E. "It can measure uterine contraction intensity."

Tachycardia

Abnormal Baseline Fetal Heart Rates: know the normal heart range · __________________: a baseline FHR over 160 beats/min for over 10 min. - Causes of ___________________: § Maternal fever, dehydration, hyperthyroidism § Fetal arrhythmia § Infection (fetal or maternal), chorioamnionitis § Fetal anemia § Medications/ drugs {terbutaline, caffeine, cocaine, meth} § Fetal cardia dysrhythmias

Amnioinfusion

Additional Interventions · __________________ - (provides a cushion) it is an infusion of room-temperature isotonic fluid into the uterine cavity if the volume of amniotic fluid is low. It relieves intermittent umbilical cord compression that results in variable decelerations and transient feta hypoxia. · Tocolytic therapy (terbutaline): stops the contractions by relaxing the uterus! This is done when women are having excessive uterine contractions spontaneously

uterine contractions range from 40-70mmHg in first stage and over 80mmHg in second stage

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC) § Can use external and internal EFM · Duration: uterine contraction duration is stable ranging from 45-80 seconds § Can use external and internal EFM · Strength: ____________________________________ § Must use internal monitoring or palpation, NOT external EFM

average resting tone of uterus is 10mmHg

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC) § Can use external and internal EFM · Duration: uterine contraction duration is stable ranging from 45-80 seconds § Can use external and internal EFM · Strength: uterine contractions range from 40-70mmHg in first stage and over 80mmHg in second stage § Must use internal monitoring or palpation, NOT external EFM · Resting Tone: _____________________________ § Only internal monitoring or palpation

range from 100-250 in first stage but may rise to 300-400 in second stage

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC) § Can use external and internal EFM · Duration: uterine contraction duration is stable ranging from 45-80 seconds § Can use external and internal EFM · Strength: uterine contractions range from 40-70mmHg in first stage and over 80mmHg in second stage § Must use internal monitoring or palpation, NOT external EFM · Resting Tone: average resting tone of uterus is 10mmHg § Only internal monitoring or palpation · Relaxation time: 60 seconds or more in first stage and 45 seconds or more in second stage · Montevideo units (MVUs): ___________________________ · Each uterine contraction is composed of the following: · Increment: the beginning of the contraction as intensity is increasing · Acme: the peak intensity of the contraction · Decrement: the decline of the contraction intensity as the contraction is ending

60 seconds or more in first stage and 45 seconds or more in second stage

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC) § Can use external and internal EFM · Duration: uterine contraction duration is stable ranging from 45-80 seconds § Can use external and internal EFM · Strength: uterine contractions range from 40-70mmHg in first stage and over 80mmHg in second stage § Must use internal monitoring or palpation, NOT external EFM · Resting Tone: average resting tone of uterus is 10mmHg § Only internal monitoring or palpation · Relaxation time: _________________________________

§ Fetal bradycardia § Fetal tachycardia § Absence of FHR variability § Late decelerations § Variable decelerations

Baseline Fetal Heart Rate · Baseline Fetal Heart Rate is the average rate during a 10 minute segment, excluding: § Periodic or episodic changes (accelerations or decelerations) § Periods of marked variability § Segments of the baseline that differ by more than 25 beats per minute · USE THE STRAIGHT EDGE OF A PAPER TO DETERMINE BASELINE RATE!!! · There must be at least 2 minutes of interpretable baseline data in a 10 minute segment of tracing to determine the baseline fetal heart rate. After 10 minutes of tracing is observed, the approximate mean rate is rounded to the closest 5 beats/min interval. · Nonreassuring Fetal Heart Rate Patterns: - - - - -

Minimal Variability

Decreased Variability = Flat Line · Absent variability: variability where the amplitude range is undetectable · _______________________: variability where the amplitude is less than or equal to 5 beats/min · Absent and minimal variability caused by: § Uteroplacental insufficiency § Cord compression § Maternal hypotension § Uterine hyperstimulation § Placenta abruption § Fetal dysrhythmia § Fetal hypoxemia or metabolic acidemia § Drugs that depress the CNS: barbiturates, tranquilizers, general anesthetics § Fetal sleep cycle (usually not more than 30 minutes)

Absent variability

Decreased Variability = Flat Line · _________________: variability where the amplitude range is undetectable

between the fetal shoulder blades

EXTERNAL Fetal Monitoring · Fetal Heart Rate Location · Place the electrodes __________________________

Continuous electronic auscultation

Fetal Heart Rate (FHR) Monitoring · Fetal Heart Rate (FHR) is a key tool to indirectly determine fetal oxygen status · Intermittent Auscultation (off & on) involves listening to fetal heart sounds at periodic intervals to assess the Fetal Heart Rate (FHR). It is less expensive and invasive than EFM § Doppler ultrasound and ultrasound stethoscopes use sound waves (reflecting movement of the fetal heart) to create an electronic signal that can be counted § Fetoscope: this is applied to the listener's forehead because bone conduction amplifies fetal heart sounds § Ultrasound visualization § Because Intermittent Auscultation is intermittent, events can occur when the FHR is not being monitored OR · ______________________________, with uterine activity too § External (Doppler ultrasound): placed on mom's belly and held in place with a belt § Internal (ECG): wires are inserted into the vagina/cervix and onto the baby's head

Intermittent Auscultation (off & on)

Fetal Heart Rate (FHR) Monitoring · Fetal Heart Rate (FHR) is a key tool to indirectly determine fetal oxygen status · ___________________________ involves listening to fetal heart sounds at periodic intervals to assess the Fetal Heart Rate (FHR). It is less expensive and invasive than EFM § Doppler ultrasound and ultrasound stethoscopes use sound waves (reflecting movement of the fetal heart) to create an electronic signal that can be counted § Fetoscope: this is applied to the listener's forehead because bone conduction amplifies fetal heart sounds § Ultrasound visualization § Because Intermittent Auscultation is intermittent, events can occur when the FHR is not being monitored

A. maternal fever A Correct: Fetal tachycardia can be considered an early sign of fetal hypoxemia and can also result from maternal or fetal infection.

Fetal Tachycardia is most often caused by: A. maternal fever B. umbilical cord prolapse C. regional anesthesia D. morphine administration

assess Fetal Heart Rate (FHR) every 30-60 minutes

Guidelines for Intermittent Monitoring · Get initial 20 minute continuous electronic Fetal Heart Rate (FHR) strip on admission · Assess for any increased risk due to prenatal & labor factors: HTN, diabetes, premature baby, low/high AFV · During the latent phase of labor: ______________________ · First stage of labor (active phase): assess Fetal Heart Rate (FHR) pattern at a minimum of: Every 15-30 minutes during active labor · Second stage of labor: assess Fetal Heart Rate (FHR) at a minimum of: Every 5-15 minutes · Count for a minute between, before, during, & after contraction

§ 1. Ruptured membranes (water bag broken) § 2. Cervical dilation of at least 2 cm § 3. Presenting fetal part low enough to allow placement of scalp electrode § 4. Skilled practitioner available to insert spiral electrode

Internal Electronic Fetal Monitoring Criteria · 4 criteria for internal monitoring : - - - -

Fetal Scalp Electrode (FSE)

Internal Fetal Monitoring · ____________________ monitors the FHR and can be used with an intrauterine pressure catheter (UIPC) to monitor frequency, duration, and intensity of contractions § Maternal temperature and vitals must be taken every 1-2 hours § Encourage frequent repositioning of the client. · Advantages of Internal Monitoring: continuous tracing of FHR, maternal position does not affect tracing of FHR. IUPC accurately assesses strength of ctx and resting tone. § Early detection of abnormal FHR § Accurate measurement of FHR and uterine contraction § Greater maternal freedom of movement · Limitations of Internal Monitoring: is invasive, requires ROM and cervical dilation, potential risk for infection or injury, may record maternal heart rate in case of IUFD § Membranes must have ruptured to use internal monitoring § Cervix must be dilated 2-3cm § Presenting part must have descended to place electrode § Potential risk of injury to fetus if electrode is not applied right § A provider or trained RN must perform the procedure § Potential risk of infection to the client and fetus

§ Turning woman on her left side to increase placental perfusion § Administering oxygen 8-10L/min by non-rebreather mask to increase fetal oxygenation § Increase the IV fluid rate to improve intravascular volume § Discontinue oxytocin if infusing/stop contractions § Consider internal monitoring: palate uterus for tachysystole § Notify provider § Correct maternal hypotension by elevating legs

Late Decelerations = BAD · Late = remains after contraction · Late decelerations: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease and return to baseline FHR well after the uterine contraction has ended; these usually indicate uteroplacental insufficiency § The deceleration begins after the contraction has started, and the lowest point of deceleration occurs after the peak of the contraction § The deceleration usually does not return to baseline until after the contraction is over § begins after onset of contraction returns after the end · Late decelerations are Uniform, inversely mirrors contraction, late onset/recovery · With Late decelerations, the lowest point of deceleration occurs AFTER peak of contraction · Late decelerations are caused by reflex fetal response to transient hypoxemia during a uterine contraction that reduces delivery of O2 blood to the placenta · Utero-placental insufficiency, so ALWAYS considered ominous § Causes: Epidural or spinal {maternal hypotension}, abruption, hypertension, IUGR, infection § Others: maternal supine hypotension, epidural/spinal anesthesia, placenta previa, placental abruption, hypertensive disorders, postterm gestation, intrauterine growth restriction, diabetes mellitus, intraamniotic infection · Nursing Interventions: 1. 2. 3. 4. 5. 6.

Epidural or spinal {maternal hypotension}, abruption, hypertension, IUGR, infection § Others: maternal supine hypotension, epidural/spinal anesthesia, placenta previa, placental abruption, hypertensive disorders, postterm gestation, intrauterine growth restriction, diabetes mellitus, intraamniotic infection

Late Decelerations = BAD · Late = remains after contraction · Late decelerations: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease and return to baseline FHR well after the uterine contraction has ended; these usually indicate uteroplacental insufficiency § The deceleration begins after the contraction has started, and the lowest point of deceleration occurs after the peak of the contraction § The deceleration usually does not return to baseline until after the contraction is over § begins after onset of contraction returns after the end · Late decelerations are Uniform, inversely mirrors contraction, late onset/recovery · With Late decelerations, the lowest point of deceleration occurs AFTER peak of contraction · Late decelerations are caused by reflex fetal response to transient hypoxemia during a uterine contraction that reduces delivery of O2 blood to the placenta · Utero-placental insufficiency, so ALWAYS considered ominous § Causes: __________________________________

Uniform, inversely mirrors contraction, late onset/recovery

Late Decelerations = BAD · Late = remains after contraction · Late decelerations: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease and return to baseline FHR well after the uterine contraction has ended; these usually indicate uteroplacental insufficiency § The deceleration begins after the contraction has started, and the lowest point of deceleration occurs after the peak of the contraction § The deceleration usually does not return to baseline until after the contraction is over § begins after onset of contraction returns after the end · Late decelerations are ___________________________________________ · With Late decelerations, the lowest point of deceleration occurs AFTER peak of contraction · Late decelerations are caused by reflex fetal response to transient hypoxemia during a uterine contraction that reduces delivery of O2 blood to the placenta!!!!!!!!!!!!!!!!!!!!!!!!!!

Marked variability

Normal Variability = Reassuring · Moderate variability is considered normal and indicates that FHR is not affected by fetal sleep cycles, tachycardia, prematurity, congenital abnormalities, neurologic injury, or CNS depressant medications § Indicates fetal autonomic/CNS well developed/oxygenated § Reassuring sign of fetal well-being and correlates with absence of metabolic acidosis · _________________________: is a normal variability Normal § Unclear significance § Sinusoidal pattern

Moderate variability

Normal Variability = Reassuring · ___________________________ is considered normal and indicates that FHR is not affected by fetal sleep cycles, tachycardia, prematurity, congenital abnormalities, neurologic injury, or CNS depressant medications § Indicates fetal autonomic/CNS well developed/oxygenated § Reassuring sign of fetal well-being and correlates with absence of metabolic acidosis

· Increase IV rate · STOP PITOCIN · OXYGEN BY MASK

Nursing Interventions with Late Decelerations · Maternal considerations: § CHANGE POSITION: · Vena cava compression · Move to left side § FLUID REPLACEMENT 1. 2. 3. § CHECK VITALS · MONITOR · CALL MD · REASSURE !

Decelerations

Periodic and Episodic Changes in Fetal Heart Rate Above or Below Baseline · Periodic changes occur with contractions · Episodic (nonperiodic) changes not associated with contractions · Accelerations: FHR going up, above baseline (it = fetal well-being) · ______________________________: FHR going down, below baseline § 1. Early decelerations: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease in and return to baseline FHR associated with uterine contractions. · Caused by fetal response to fetal head compression · It is normal and benign § 2. Late decelerations caused by uteroplacental insufficiency § 3. Variable decelerations, caused by cord compression

Accelerations

Periodic and Episodic Changes in Fetal Heart Rate Above or Below Baseline · Periodic changes occur with contractions · Episodic (nonperiodic) changes not associated with contractions · _____________________________: FHR going up, above baseline (it = fetal well-being) § ____________________ of FHR is a visually apparent, abrupt (onset to peak) increase in FHR above the baseline. § The peak is at least 15 beats/min above the baseline, and the acceleration lasts 15 seconds or more, with return to baseline less than 2 minutes from the beginning of accelerations § Causes of ________________________ (any stimulation to CNS): · Spontaneous fetal movement · Vaginal exam, scalp stimulation · Electrode application · Abdominal palpation · Uterine contractions § Shows normal reaction of fetal CNS, so good oxygenation

1. Change maternal position (side to side, knee chest) to relive cord compression 2. Assess for Prolapsed Cord, if the decelerations become prolonged... 3. Administer O2 10L/min via nonrebreather face mask 4. Give IV Fluid Bolus 5. Amnioinfusion 6. Notify physician or midwife and assist with vaginal examination

Variable Decelerations · Variables = Cord Compression · Variable deceleration of the FHR is a visually abrupt (onset to lowest point less than 30 seconds) and apparent decrease in FHR below the baseline 15beats/min or more for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contraction. § Variable Deceleration: The decrease is at least 15beats/min or more below baseline, lasts at least 15 seconds, and returns to baseline in less than 2 minutes · Variable decelerations are caused by compression of the umbilical cord (pushing, maternal position, knot in cord, short cord, prolapsed cord, nuchal cord) · Variable decelerations Vary in duration and intensity, vary in relation to contraction and resolve abruptly - Often "U" or "V" shaped · Repetitive, prolonged or more severe decelerations with slow return or overshoot to baseline are ominous and indicate fetal asphyxia. Also if FHR<60 for at least 60sec. · Interventions for Variable Decelerations: 1. 2. 3. 4. 5. 6.

· Reduction of blood flow through maternal vessels due to hypertension or hypotension · Reduction of oxygen content in maternal blood due to hemorrhage or severe anemia or maternal hypoxia (COVID19, pneumonia, seizures, asthma attacks) · Alterations in fetal circulation due to compression of umbilical cord · Reduction in blood flow to intervillous space in placenta, due to decreased perfusion of uterus

Why do we worry about the fetus during labor? · Labor is a period of physiologic stress for fetus because: § 1. Uterine contractions intermittently decrease perfusion of placenta, and § 2. Compression of the umbilical cord can occur with contractions In Labor, Fetal Oxygen Supply can Decrease due to: 1. 2. 3. 4.

Fetal anemia, sepsis, narcotic administration

· Causes of Sinusoidal FHR: ___________________

provide education to the client that the monitor does not pose a risk to the fetus. - Encourage frequent maternal position changes, which can require adjustments to monitors. - If the client needs to void and ambulate and it is not contraindicated, the nurse can disconnect the monitor. - If ambulation is contraindicated, the nurse can bring a bed pan.

· External Electric Fetal Monitoring (EFM): this is accomplished by securing an ultrasound transducer over the client's ABD, which records Fetal Heart Rate (FHR)pattern, and a Toco transducer on the fundus to record the uterine contractions § Less invasive, less risk for infection, no membranes ruptured, no cervix dilation, BUT Less precise, contraction intensity is not measurable § Toco transducer: measures/detects frequency and duration of uterine contractions (placed on fundus). It does NOT tell the strength of contractions. § Ultrasound transducer: measures FHR by reflecting high frequency sound waves off a moving interface. It does not require rupture of membranes or cervical dilation § Preparation: based on Leopold maneuvers, auscultate Fetal Heart Rate (FHR). Palpate the fundus to identify uterine activity for proper placement of the tocotransducer to monitor contractions § Procedure: ____________________

Variability of the Fetal Heart Rate

· _________________ is normal physiologic variations in FHR baseline excluding decelerations and accelerations; irregular waves or fluctuations in the baseline FHR of 2 cycles per minute or greater · The up and down "wiggle" in the baseline · Combined result of autonomic nervous system function - its presence implies both sympathetic and parasympathetic branches are oxygenated and working = the brain is getting oxygen · There are 4 types of variability: § Absent variability: an amplitude range of the FHR fluctuations that is not detectable to the unaided eye § Minimal variability: an amplitude range that is detectable to the unaided eye, but is less than 5 beats/min § Moderate variability: is considered normal and indicates that FHR is not affected by fetal sleep cycles, tachycardia, prematurity, congenital abnormalities, neurologic injury, or CNS depressant medications § Marked variability is a normal variability !!!!!!!!!!!!!!!! Sinusoidal pattern is uncommon and usually occurs with sever fetal anemia, fetal sepsis, or opioid analgesic administration.

Prolonged deceleration

· ____________________ is a visually apparent decrease (gradual or abrupt) in FHR of at least 15 beats/min below the baseline lasting for more than 2 minutes but less than 10 minutes · Interruption to fetal oxygen supply · Caused by maternal hypotension, uterine tachysystole or uterine rupture, extreme placental insufficiency, prolonged cord compression/ prolapse How Can We Help The Fetus? (TREAT THE CAUSE) · 1. Position change (lateral, hands and knees) - relieves pressure on cord, increases blood supply to uterus, gives better rest between contractions - the first move! · 2. Oxygen by non-rebreather mask, 8 - 10 liters/min · 3. Increase IV fluids for better perfusion · 4. STOP OXYTOCIN, STOP CONTRACTIONS · 5. Correct hypotension - ephedrine? · 6. Notify provider and document continuously · 7. Operative delivery?? (cesarean section, forceps, vacuum)

Internal Electric Fetal Monitoring (EFM)

· __________________________- NOT used routinely. It is usually used when we use the external monitoring and we are worried about something with the fetus § More invasive, but § More accurate appraisal of fetal wellbeing § 2 membranes must be ruptured, the cervix must be sufficiently dilated, and the presenting part low enough to allow placement of the spiral electrode § Intrauterine Pressure Catheter {IUPC}- a soft catheter that is inserted into the mother's uterus that measures changes in intrauterine pressure · Montevideo units (MVUs) are calculated by subtracting the baseline uterine pressure from the peak contraction pressure for each contraction that occurs in a 10 minute window § Fetal Scalp Electrode (FSE)- two wires that contain a spiral electrode are applied directly to fetal scalp to assess fetal ECG directly. It gives us a direct fetal electrocardiogram (ECG)

Variable deceleration

· _______________________________ = Cord Compression · _______________________________ of the FHR is a visually abrupt (onset to lowest point less than 30 seconds) and apparent decrease in FHR below the baseline 15beats/min or more for at least 15 seconds, variable in duration, intensity, and timing in relation to uterine contraction. § _______________________________: The decrease is at least 15beats/min or more below baseline, lasts at least 15 seconds, and returns to baseline in less than 2 minutes · _______________________________ are caused by compression of the umbilical cord (pushing, maternal position, knot in cord, short cord, prolapsed cord, nuchal cord) · _______________________________ Vary in duration and intensity, vary in relation to contraction and resolve abruptly - Often "U" or "V" shaped · Repetitive, prolonged or more severe decelerations with slow return or overshoot to baseline are ominous and indicate fetal asphyxia. Also if FHR<60 for at least 60sec.

External Electric Fetal Monitoring (EFM)

· _______________________________: this is accomplished by securing an ultrasound transducer over the client's ABD, which records Fetal Heart Rate (FHR)pattern, and a Toco transducer on the fundus to record the uterine contractions § Less invasive, less risk for infection, no membranes ruptured, no cervix dilation, BUT Less precise, contraction intensity is not measurable § Toco transducer: measures/detects frequency and duration of uterine contractions (placed on fundus). It does NOT tell the strength of contractions. § Ultrasound transducer: measures FHR by reflecting high frequency sound waves off a moving interface. It does not require rupture of membranes or cervical dilation

§ Baseline rate of 110-160 beats/min § Baseline FHR variability: Moderate § Late or Variable decelerations: absent § Early decelerations: present or absent § Accelerations: present or absent

3-Tier Fetal Heart Rate Classification · Category 1: - - - -

§ Baseline rate: bradycardia or tachycardia § Baseline FHR variability: · Minimal baseline variability · Absent baseline variability · Marked baseline variability § No accelerations § Periodic or episodic decelerations · Recurrent variable decelerations accompanied by minimal/moderate baseline variability · Prolonged decelerations (greater than 2min but less than 10 minutes) · Recurrent late decelerations with moderate baseline variability · Variable decelerations with other characteristics

3-Tier Fetal Heart Rate Classification · Category 2: - - - - - - - -

B. Rupture of membranes

A nurse is caring for a client who is having an induction of labor. Based on the use of external electronic fetal monitoring, the nurse notes that the FHR variability is decreased and resembles a straight line. The client has not received pain medication. Which of the following should occur first before the nurse can apply an internal scalp electrode? A. Dilation B. Rupture of membranes C. Effacement D. Engagement

A. Assist the client into the left-lateral position.

A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position. B. Apply a fetal scalp electrode. C. Insert an IV catheter. D. Perform a vaginal exam.

B. Palpate the fundus of the uterus.

A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp the lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.

A. Moderate variability B. FHR accelerations D. Normal baseline FHR

A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds, and have moderate variability. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (Select all that apply.) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia

Bradycardia

Abnormal Baseline Fetal Heart Rates: know the normal heart range · ________________________: a baseline FHR less than 110 beats/min for over 10 min. - Causes of _____________: § Maternal hypotension, hypoglycemia, hypothermia § Fetal heart failure/ heart block (atrioventricular dissociation) § Structural defects § Fetal arrhythmia § Severe fetal hypoxia and acidemia § Umbilical cord compression § Anesthetic medications § Uteroplacental insufficiency

§ Frequency less than 2 minutes apart § Less than 60 seconds between the contractions § Duration greater than 90 seconds § Resting tone elevated (not completely relaxed)

Abnormal Uterine Activity: · Not enough rest for uterus or fetus (gimme a minute!!!): - - - - · ALL are considered: Hyperactivity of the uterus § Often associated with use of oxytocin

Vibroacoustic Stimulation (loud sound)

Additional Fetal Assessment Techniques · Fetal Scalp Stimulation (finger in vagina) · _____________________: § Indirect method to identify fetal hypoxia and acidemia § A well-oxygenated fetus will respond when stimulated (tactile/noise) by moving in conjunction with an acceleration of 15 bpm above baseline HR >15 seconds

assess Fetal Heart Rate (FHR) pattern at a minimum of: Every 15-30 minutes during active labor

Guidelines for Intermittent Monitoring · Get initial 20 minute continuous electronic Fetal Heart Rate (FHR) strip on admission · Assess for any increased risk due to prenatal & labor factors: HTN, diabetes, premature baby, low/high AFV · During the latent phase of labor: assess Fetal Heart Rate (FHR) every 30-60 minutes · First stage of labor (active phase): _____________________________ · Second stage of labor: assess Fetal Heart Rate (FHR) at a minimum of: Every 5-15 minutes · Count for a minute between, before, during, & after contraction

· Top is Fetal Heart Rate · Bottom is Contractions

How do you read fetal monitor paper? - -

Late decelerations

· ____________________ = remains after contraction · ____________________: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease and return to baseline FHR well after the uterine contraction has ended; these usually indicate uteroplacental insufficiency § The deceleration begins after the contraction has started, and the lowest point of deceleration occurs after the peak of the contraction § The deceleration usually does not return to baseline until after the contraction is over § begins after onset of contraction returns after the end

§ Dependent on cause § Discontinue oxytocin is being given § Assist the client to a side lying position § Administer O2 by mask at 10L/min via non-rebreather § Insert an IV catheter is one is not placed to give maintenance fluids § Administer tocolytic medication § Notify the doctor

Abnormal Baseline Fetal Heart Rates: know the normal heart range · Bradycardia: a baseline FHR less than 110 beats/min for over 10 min. - Causes of bradycardia: § Maternal hypotension, hypoglycemia, hypothermia § Fetal heart failure/ heart block (atrioventricular dissociation) § Structural defects § Fetal arrhythmia § Severe fetal hypoxia and acidemia § Umbilical cord compression § Anesthetic medications § Uteroplacental insufficiency - Nursing Interventions for bradycardia: - - - -

§ Dependent on the case § Reduce maternal fever with antipyretics as ordered with cooling measures § Oxygen at 10L/min by nonrebreather face mask may be of some value § Administer IV fluid bolus § Carry out doctor's orders based on case

Abnormal Baseline Fetal Heart Rates: know the normal heart range · Tachycardia: a baseline FHR over 160 beats/min for over 10 min. - Causes of tachycardia: § Maternal fever, dehydration, hyperthyroidism § Fetal arrhythmia § Infection (fetal or maternal), chorioamnionitis § Fetal anemia § Medications/ drugs {terbutaline, caffeine, cocaine, meth} § Fetal cardia dysrhythmias - Nursing Interventions for tachycardia: - - - -

uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC)

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: _______________________________ § Can use external and internal EFM

uterine contraction duration is stable ranging from 45-80 seconds

Assessing Uterine Activity During Labor; Normal Uterine Activity During Labor · Frequency: uterine contraction frequency ranges from 2-5 per ten minutes in first stage and up to 5 contractions in ten minutes in the second stage; (beginning of one contraction (UC) to beginning of next UC) § Can use external and internal EFM · Duration: _______________________________________ § Can use external and internal EFM

average rate during a 10 minute segment, excluding: § Periodic or episodic changes (accelerations or decelerations) § Periods of marked variability § Segments of the baseline that differ by more than 25 beats per minute

Baseline Fetal Heart Rate · Baseline Fetal Heart Rate is the _________________________________ · USE THE STRAIGHT EDGE OF A PAPER TO DETERMINE BASELINE RATE!!! · There must be at least 2 minutes of interpretable baseline data in a 10 minute segment of tracing to determine the baseline fetal heart rate. After 10 minutes of tracing is observed, the approximate mean rate is rounded to the closest 5 beats/min interval.

§ correctly interpreting FHR patterns, § initiating interventions for fetal oxygenation, § documenting the FHR & interventions, and § notifying the OB provider, initiating the chain of command if a difference of opinion occurs.

Big Reason for Monitoring Fetal Heart Rate (FHR) · 1. Prevent fetal damage by identifying non-reassuring FHR patterns early § Abnormal fetal heart rate patterns are associated with fetal hypoxemia (deficiency of O2 in blood), which can lead to fetal hypoxia (inadequate cellular O2 resulting in metabolic acidosis. Metabolic acidosis can lead to acidemia in the blood, which is a marker of interruption of fetal oxygenation · Nurses caring for women during childbirth are legally responsible for: 1. 2. 3. 4.

Early decelerations

Decelerations of FHR · ______________________________: of FHR is a visually apparent, gradual (onset to lowest point greater than 30 seconds) decrease in and return to baseline FHR associated with uterine contractions. § Decelerations begin at onset of contraction & return to baseline by end of contraction § Caused by fetal response to fetal head compression from vaginal stimulation (uterine contractions, vaginal examinations, fundal pressure) · Fetal head compression from vagal stimulation § It is normal and benign · Smooth, uniform curve, seldom go below 90 bpm · No intervention, THESE ARE NORMAL. Keep assessing the progress of labor!!!!!!!!!!!!!!!!!!!! · __________________ deceleration onset, nadir (lowest point), and recovery correspond to the beginning, peak, and end of the contractions = Mirrors contraction

1. Move Mom to left-lateral or on hands and knees position 2. IV fluid bolus 3. oxygen 8-10L/min by non-rebreather face mask 4. notify provider 5. document findings 6. consider internal monitoring and prepare for surgical birth if persists - Stimulate fetal scalp - Assist with application of scalp electrode

Decreased Variability = Flat Line · Absent variability: variability where the amplitude range is undetectable · Minimal Variability: variability where the amplitude is less than or equal to 5 beats/min · Absent and minimal variability caused by: § Uteroplacental insufficiency § Cord compression § Maternal hypotension § Uterine hyperstimulation § Placenta abruption § Fetal dysrhythmia § Fetal hypoxemia or metabolic acidemia § Drugs that depress the CNS: barbiturates, tranquilizers, general anesthetics § Fetal sleep cycle (usually not more than 30 minutes) · IMMEDIATE interventions!: 1. 2. 3. 4. 5. 6. - -