OB/peds-unit 7- fetal monitoring
Describe nursing interventions if FHR variability is absent.
- Absent - means the amplitude range is undetectable - Need to contact the HCP - Change the maternal position
If doing intermittent fetal monitoring, how long should a FHR be assessed for after a contraction and why?
- Count for 15-60 secs - Will help detect the fetal baseline and see if the contraction has altered the FHR
Why would fetal scalp stimulation be done and what are they looking for as a result?
- It is used to evaluate fetal response to gentle tactile stimulation - Do it through a dilated cervix - Done when there is a indeterminate FHR tracing - It should not be attempted during a decel - The goal is to elicit a FHR acceleration which will suggest a normal acid-base balance
What are some reasons for a poor signal when tracing a FHR?
- Maternal HR being recorded - Obese woman - Preterm/multifetal gestations - Maternal movement - Improper location - Double-counting a slow FHR if it is less than 60 bpm
If a FHR is Category 1, is this good or bad, and why?
- Normal - good - FHR baseline is 110-160 bpm - Moderate variability - Accelerations present or absent - Variable or late - Decels absent - Early decels present or absent
How could the nurse ensure the FHR tracing is not the maternal heart rate?
- Palpate the maternal pulse while auscultating the FHR- this will help you determine between the fetal and the maternal pulse
cat II
- intermediate § Tracing not categorized as cat I or III
late decels-interventions
-1 ) Reposition pt - turn them to the L side -2) Increase IV fluids -3) Stop Pit -4) Apply O2 10-15 L face mask - isnt always the first thing we need to do - wouldn't leave it on the whole labor, only when see this on the strip -5) Notify HCP - if it continues, will be heading to the OR -Get O2 and blood to baby
Uterine Activity-normal
-< 5 contractions in 10 minutes, averaged over a 30 minute window
How is the baseline FHR determined?
-Approximating the mean FHR rounded in 5 bpm increments during a 10 min period -In this 10 mins assessment, period and episodic changes(accelerations and decelerations) and periods of marked variability are excluded -During the 10 mins, there must be at least 2 mins of identifiable baseline segments that do not need to be contiguous -If a 2 min period is uninterpretable - the fetal HR os considered indeterminate -Basically the average over 10 mins
Frequency
-Beginning of one contraction to the beginning of the next -What is the closest interval and whats the longest - provide the range
Uterine Activity/Contractions
-Frequency, duration, intensity, resting tone
Amplitude
-How high up it goes on the monitor -Not the same as intensity for external monitoring
Internal monitoring
-Internal Fetal Scalp Electrode -IntraUterine Pressure Catheter -Have to be ruptured and dilated atleast 2-3 cm
Intensity
-Need to palpate - for the intensity w/ external •Mild - tip of nose •Moderate - chin •Strong - feels like the forehead -IUCP - can actually tell the intensity
Changes in FHR-Accelerations-in depth
-Visually apparent abrupt increases in the FHR and may be periodic or nonperiodic -The peak acceleration must be at least 15 bpm above the baseline lasting at least 15 secs or more from the onset of return -The onset to peak occurs in less than 30 secs -Gestations that are less than 32 wks - peak of the acceleration must be at least 10 bpm above the baseline lasting at least 10 secs from the onset to return -Prolonged accelerations have a duration of 2-10 mins -Anything greater than 10 min is considered a FHR baseline change -They often occur w/ fetal movement but also may occur with vibroacoustic stimulation, uterine contractions, or fetal scalp stimulation(during a vag exam)
Amnioinfusion nursing management
-Weighing pads -Fluid will be coming back out -Monitor FHR - decrease variable decels -Decrease meconium - assess color
Resting tone
-When is it coming back to relaxation -If it doesn't come back to a relaxed state - will have a higher resting tone -from the end of one contraction to the start of the next Resting tone - are they coming back to 10-20 mmHg after contractions?
The nurse is helping a pregnant patient during labor by applying fundal pressure. What alteration in the fetal heart rate (FHR) pattern will result from this intervention? 1-Early decelerations 2-Late decelerations 3-Variable decelerations 4-Prolonged decelerations
1-Early decelerations Applying fundal pressure can cause fetal head compression and it may cause early decelerations in FHR. Disruption of oxygen transfer from the maternal environment to the fetus may result in late decelerations. Variable decelerations may be observed due to umbilical cord compression. If the mechanisms responsible for late or variable decelerations last for extended period, then they cause prolonged decelerations.
After monitoring the fetal heart activity the nurse documents the fetal heart rate (FHR) to be in category II, according to the three-tier FHR classification system. What findings would the nurse have observed? 1-Minimal variability 2-Moderate variability 3-Less than 110 beats/minute 4-Accelerations were present.
1-Minimal variability Minimum variability in the FHR indicates that there is insufficient oxygen supply to the fetus. This is categorized as a category II in a three-tiered FHR classification system. Moderate variability in FHR indicates the normal cardiac activity of the fetus, which is categorized under category I. Bradycardia (FHR less than 110 beats/minute) is categorized under category III. The FHR acceleration is completely absent according to category II and is present in category I.
The nurse is administering an amnioinfusion to a patient with oligohydramnios. What risk should the nurse primarily monitor for during administration? 1-Overdistension of the uterus 2-High risk of placental abruption 3-Fetal heart rate (FHR) accelerations 4-Increased uterine contractions
1-Overdistension of the uterus Oligohydramnios is the condition in which the patient has low levels of amniotic fluid. In this condition the nurse should administer an amnioinfusion. During this process the nurse should assess the abdominal size to make sure the patient is not receiving too much fluid. This may cause overdistention of the uterus. This procedure does not affect the uterine activity, placental hemorrhage, or the FHR. Placental abruption would cause conditions such as oligohydraminos. Decelerations in the FHR, not accelerations, are observed in oligohydraminos.
The nurse is monitoring the fetal heart rate (FHR) of a patient who is in labor at full term. What measure does the nurse take to obtain the most accurate baseline fetal heart rate? 1-Record or monitor a 10-minute segment of tracing. 2-Include periods of marked variability in the segment. 3-Include episodic changes in the segment of tracing. 4-Obtain at least 5 minutes of interpretable data in the segment.
1-Record or monitor a 10-minute segment of tracing. The baseline fetal heart rate is the average rate during a 10-minute segment, and that is why the nurse must obtain a 10-minute segment of tracing to determine the baseline FHR. In order to determine a baseline heart rate, the 10-minute segment must not include periods of marked variability or periodic or episodic changes. The nurse must ensure there are at least 2 minutes of interpretable baseline data in a 10-minute segment of tracing.
In which condition does the nurse document the fetal heart rate (FHR) tracing as category III? 1-Prolonged FHR decelerations 2-Presence of a sinusoidal pattern 3-Recurrent variable decelerations 4-Moderate baseline FHR variability
2-Presence of a sinusoidal pattern When categorizing the FHR tracing, the presence of a sinusoidal pattern meets the criteria for a category III, or abnormal, tracing. Immediate evaluation and prompt intervention is required when these patterns are identified. Prolonged FHR decelerations greater than or equal to 2 minutes but less than 10 minutes are category II FHR tracings. Recurrent variable decelerations accompanied by minimal or moderate baseline variability are also categorized as a category II FHR tracing. Category II FHR tracings are indeterminate and require continued observation and evaluation. An FHR tracing with moderate baseline FHR variability is categorized as category I, or normal.
While monitoring the fetal heart rate, the nurse instructs the patient to change her position and lie in the knee-to-chest position. What is the reason for the nurse to give this instruction to the patient? 1-Late decelerations in the fetal heart rate 2-Variable decelerations in the fetal heart rate 3-Early decelerations in the fetal heart rate 4-Prolonged decelerations in the fetal heart rate
2-Variable decelerations in the fetal heart rate Variable decelerations in the fetal heart rate are usually caused by umbilical cord compression. The knee-to-chest position is useful for relieving cord compression, and thus the nurse should ask the patient to move into this position. Prolonged decelerations in the fetal heart rate are not affected by the mother's position. If the nurse finds late decelerations in the fetal heart rate, the nurse should ask the mother to lie in the lateral position. Early decelerations in the fetal heart rate are a normal finding, and no nursing intervention is required.
While assessing the fetal heart rate (FHR) of a patient in labor, what does the nurse identify as normal variability of the FHR? 1-Absent variability 2-Minimal variability 3-Moderate variability 4-Marked variability
3-Moderate variability Moderate variability is highly predictive of a normal fetal acid-base balance. It indicates that FHR regulation is not significantly affected by fetal sleep cycles, tachycardia, prematurity, congenital anomalies, preexisting neurologic injury, or central nervous system depressant medications. Absent or minimal variability is classified as either abnormal or indeterminate. It can result from fetal hypoxemia and metabolic academia. The significance of marked variability is unclear.
The nurse notes variable fetal heart rate (FHR) decelerations while monitoring the fetal heart rate of a patient. What causes variable decelerations? 1-Uterine tachysystole 2-Maternal hypertension 3-Umbilical cord compression 4-Epidural or spinal anesthesia
3-Umbilical cord compression Variable FHR decelerations are usually transient and correctable. They can occur at any time during the uterine contraction phase and are caused by umbilical cord compression. Uterine tachysystole is a condition that causes frequent uterine contractions, often more than five contractions in 10 minutes. This causes disruption of oxygen transfer from the environment to the fetus, leading to late decelerations. Maternal hypertension leads to late FHR decelerations due to reduced oxygen transfer to the fetus. Epidural or spinal anesthesia reduces blood flow through maternal vessels, causing late decelerations.
Fetal bradycardia is common during what problem?1-Maternal hyperthyroidism 2-Fetal anemia 3-Viral infection 4-Tocolytic treatment using ritodrine
3-Viral infection Fetal bradycardia can be considered a later sign of fetal hypoxia and is known to occur before fetal death. Bradycardia can result from placental transfer of drugs, viral infections such as cytomegalovirus, maternal hypothermia, and maternal hypothermia. Maternal hyperthyroidism will most likely result in fetal tachycardia. Fetal anemia will most likely result in fetal tachycardia. Tocolytic treatment using ritodrine will most likely result in fetal tachycardia.
Prolonged deceleration
A visually apparent decrease (may be either gradual or abrupt) in FHR of at least 15 beats/min below the baseline and lasting more than 2 minutes but less than 10 minutes •FHR drops at least 2 mins •If it doesn't come back up after 2-5 mins - go to OR
Prolonged deceleration-what to do
EMERGENCY - may need to head to OR •Turn position •Increase fluids •O2 •Notify HCP •Stop pit •Scalp stimulation through vag exam
Baseline Characteristics- Variability
Fluctuation of the FHR - can change in amplitude and frequency -absent variability - minimal variability -moderate variability -marked variability
late decels-info
Gradual decreases to the HR, may not fall a lot below the baseline, consistent in shape Begin: after the contraction starts & returns to baseline Shape: uniform Considered: *ominous
The nurse is caring for a patient in labor who presents with variable decelerations in the fetal heart rate (FHR). Arrange the nursing interventions in the order in which they would be performed for this patient.
The nurse must first help the patient to change position from side to side or knee-to-chest position. This may help to reduce umbilical cord compression if this is the cause of the variable FHR decelerations. The nurse discontinues the oxytocin infusion, which may cause uterine hypertonus. The next priority is to administer oxygen at 8 to 10 L/minute using a nonrebreather mask. If these interventions do not help, the nurse must notify the physician or nurse-midwife. The nurse then assists with a vaginal or speculum examination. The nurse may need to assist with amnioinfusion if ordered. If the variable FHR deceleration pattern cannot be corrected, the nurse may have to assist with cesarean or assisted vaginal birth.
Accelerations in FHR
Transient increase in FHR (15x15)
VEAL, Chop, mine!
Variable decelerations - cause- Cord compression -priority interventions - move pt Early decelerations - cause- Head compression -priority interventions --Intervention not necessary. --Identify labor progress. Accelerations - cause-Outstanding -priority interventions -No intervention needed. Late decelerations: cause-Placental insufficiency priority intervention-Execute actions immediately. -Reposition mom -Stop Pitocin -Give IVF -Give O2 -Possible C/S if persists
Baseline Characteristics- Variability-moderate variability
amplitude range 6-25 bpm -Normal - good O2 to baby
Baseline Characteristics- Variability-marked variability
amplitude range > 25 bpm -Cant really tell the baseline -Baby may be hypoxic and trying to compensate for something going wrong -May be in this and come out - or compensation may not work and they could head into late decels -baby may be going into distress
Baseline Characteristics- Variability-minimal variability
amplitude range > undetectable < 5 bpm -Baby may be sleeping -Mom may have gotten narcotics -Mom on mag -Depressed CNS - continue to monitor
Baseline Characteristics- Variability-absent variability
amplitude range undetectable -Fetus is still alive -Mom needs O2 -bad, need to do interventions to correct it, baby isnt well oxygenated-contact HCP
Amnioinfusion
introduction of a solution into the amniotic sac; an isotonic solution is most commonly used to relieve fetal distress
early decels-interventions
no interventions needed besides continuing assessing pt and FHR, possible vag exam
Changes in FHR-Accelerations-What causes Accelerations?
oIntact fetal CNS response to fetal movement oNormal acid-base balance oAdequate o2 oHealthy fetal/placental exchange oVaginal exam oUterine contractions oFetal scalp stimulation oFundal pressure oThey are GOOD
Changes in FHR-Accelerations-NST
reactive NST -15 beats above the baseline for 15 secs times 2 w/in 20 mins - max 40 mins
high resting tone
the contractions aren't going back down to 20 mmHg
late decels-caused by
uteroplacental insuffiency
Bradycardia-NI
§Assess VS - BP §Discontinue oxytocin if being administered §Assist the client to a side-lying position §Administer O2 via nonrebreather mask §Insert IV and admin fluids §Sterile vag exam - cord prolapse? Stimulate baby via scalp stimulation §Notify HCP §Anticipate C-section if lasts for too long
Tachycardia-NI
§Check maternal temp §Administer prescribed antipyretics for maternal fever, if present - can give fluids as well to decrease §Administer o2 by nonrebreather mask §Administer IV fluids §If doesn't improve - can need to go to the OR
Tachycardia-causes
§Maternal infection, chorioamnionitis §Fetal anemia §Fetal cardiac dysrhythmias §Maternal use of cocaine §Maternal dehydration §Maternal or fetal infection §Maternal hyperthyroidism or fever §Baby compensating for hypoxia
Bradycardia-causes
§Uteroplacental insufficiency §Umbilical cord prolapse §Maternal hypotension §Prolonged umbilical cord compression §Fetal congenital heart block §Anesthetic medications §Viral infection §Maternal hypoglycemia §Fetal heart failure §Maternal hypothermia §Fetal hypoxia
Tachycardia
·greater than 160 for 10 mins or more - increase in sympathetic or decrease in parasympathetic - fetal or maternal causes
Bradycardia
·less than 110 for 10 mins or more - increase in parasympathetic or decrease in sympathetic
Internal monitoring-IntraUterine Pressure Catheter
•(IUPC) •Will be able ot see the strength of contractions •Will be used w/ an amnioinfusion or if aren't getting very good readings •HCP will only put it in
Prolonged deceleration-why it occurs
•Baby can no longer compensate after late decels •Dropped BP after epidural - fetal HR drops as well •Tachysystole •Decreased O2 to baby
Establishing a Baseline FHR
•Baseline characteristics Periodic changes Episodic changes
Variable decelerations-info
•Begin/occur: suddenly, vary in duration and intensity, resolve abruptly •Shape: variable, not consistent, V shape - may not be associated with contractions •Categorized: mild, moderate or severe
Variable decelerations-caused by
•Caused by: cord compression -Cord around the neck -Laying on the cord -Prolapsed cord - its coming out before babys head
Uterine Activity
•Descriptors of Uterine Activity -Normal -Tachysystole
Changes in FHR-Accelerations-prior to 32 wks
•Prior to 32 wks = acme > 10 bpm and duration of > 10 seconds is appropriate for gestational age
Changes in FHR-Accelerations-prolonged
•Prolonged accelerations are > or = to 2 minutes and <10 minutes in duration. If lasts > or = to 10 minutes then it's considered a baseline change
abruption on a fetal strip
•These shows abruption •Fetal distress will cause low amplitude and high frequency Interventions •Turn pt to side •Give IV fluids •Call HCP •STAT C-section
External Monitoring-Ultrasound transducer
•Used to see the FHR •Will do leopold maneuvers and put the transducer on the point of FHR on the babys back
External Monitoring-Tocotransducer, "toco"
•Will be used to feel the contractions •Will be placed by the fundus •Will be able to see the resting tone (should be 10-20 mmHg) along w/ the contractions •Can only tell us the frequency and duration - we have to palpate the strength of the contractions
Uterine Activity-Tachysystole-nursing interventions
•Will do interventions to stop it -On pit? decrease/stop pit -Not on pit? - adjust position, give IV fluids, give O2 -Notify HCP -May need to give terbutaline - will help get them out of this pattern
Establishing a Baseline FHR-Periodic changes
•occur with contractions -Accels, decels
Uterine Activity/Contractions-Nursing roles
-Proper location of monitors -Pt position - can affect the monitors -Obese pts - may have difficulty getting contractions monitored
Establishing a Baseline FHR-•Baseline characteristics
-Rate/range - 110-160 -Variability - how the HR changes beat to beat •Will measure CNS and oxygenation of the baby
Variable decelerations-nursing interventions
-Reposition the pt - turn to L side, hand knee position -Vag exam - pulsations on when you feel? Prolapsed cord -O2 -IV fluids -Advanced fetal monitoring -Amnioinfusion - decrease cord compression -Monitor variability of HR as well - can tell the severity
Amnioinfusion-indications
-Severe variable decelerations due to cord compression -Oligohydramnios due to placental insufficiency -Postmaturity or rupture of membranes -Preterm labor with premature rupture of membranes -Thick meconium fluid
duration
-To the beginning of the contraction to the end
External Monitoring
-Ultrasound transducer -Tocotransducer, "toco"
cat III
-abnormal § Absent variability and recurrent late decels OR bradycardia OR sinusoidal pattern
The nurse observes late decelerations in the fetal heart rate (FHR) while caring for a patient in labor. Which nursing intervention does the nurse perform for this patient? 1-Arrange for internal fetal heart rate monitoring. 2-Increase the dosage of exogenous oxytocin. 3-Provide external sound stimulation. 4-Assist the patient to a knee-to-chest position.
1-Arrange for internal fetal heart rate monitoring. If the nurse notices late FHR decelerations, then the nurse must arrange for internal monitoring to obtain a more accurate fetal and uterine assessment. The nurse may need to help prepare for cesarean birth if the pattern cannot be corrected. The nurse must discontinue any infusion of oxytocin because it may cause uterine hypertonus, leading to reduction in blood flow to the intervillous space in the placenta, causing fetal hypoxia. The nurse only provides external sound stimulation in order to elicit FHR accelerations during a fetal nonstress test. The patient must be assisted to a lateral position, not a knee-to-chest position. The knee-to-chest position is used if the nurse suspects umbilical cord compression.
Normal FHR
110-160
Which of the following FHR tracing characteristics are considered reassuring or normal (category I)? 1-Bradycardia not accompanied by baseline variability 2-Early decelerations, either present or absent 3-Sinusoidal pattern 4-Tachycardia
2-Early decelerations, either present or absent Early decelerations, the absence of late decelerations, and the presence of accelerations indicate a normal category I tracing. Bradycardia not accompanied by variability is a category II tracing. A sinusoidal pattern is considered an ominous sign and is definitely an abnormal category III tracing. Fetal tachycardia is a category II tracing and not considered normal.
The nurse observes late decelerations of the fetal heart rate (FHR) in the second phase of labor of a pregnant patient. The nurse assesses the pregnant patient and elevates the lower extremities of the patient. Which assessment finding would be the reason for this nursing intervention? 1-Placental abruption 2-Maternal hypotension 3-Maternal hemorrhage 4-Uterine contractions
2-Maternal hypotension Late decelerations in the FHR may be caused by maternal hypotension. Elevating the lower extremities helps to control maternal hypotension and increase the blood flow to the uterus. Elevating the legs would not control hemorrhage, placental abruption, or uterine contractions in a pregnant patient.
The nurse is monitoring the fetal heart rate (FHR) of a patient and notices late decelerations, including a gradual decrease in and return to baseline, associated with uterine contractions. To which condition does the nurse attribute this? 1-Fundal pressure 2-Uteroplacental insufficiency 3-Vaginal examination 4-Fetal scalp stimulation
2-Uteroplacental insufficiency Uteroplacental insufficiency leads to disruption of the oxygen transfer from the maternal blood to the fetus. This can lead to late decelerations of the fetal heart rate. Early FHR decelerations may be caused by fetal head compression caused by fundal pressure or vaginal examination. Fetal scalp stimulation typically causes FHR accelerations, not late FHR decelerations.
The nurse is monitoring a pregnant patient after amniotomy. Which observation would indicate a likelihood of umbilical cord compression? 1 The fetal heart rate (FHR) confirms tachycardia. 2 The patient's vaginal drainage has a foul-smell. 3 The patient has maternal chills frequently. 4 The FHR has variable decelerations.
4 The FHR has variable decelerations.
Uterine Activity-Tachysystole
> 5 contractions in 10 minutes, averaged over a 30 minute window - may also last longer than 120 secs •Baby and mom do not like it •Will do interventions to stop it
early decels-info
Begin: at onset of contractions & returns to baseline Shape: uniform -Gradual onset, uniform in shape, mirror the contraction, consistent in appearance Considered: *benign
early decels-caused by
Caused by: fetal head compression - usually occurs further in labor when the baby is descending
Establishing a Baseline FHR-Episodic changes
• not associated with contractions - Accels, decels
Internal monitoring-Internal Fetal Scalp Electrode
•(IFSE) •Goes right on the head of the baby •Nurse can place it w/ special training •Can be used if have abnormal fetal HR readings
Changes in FHR-Accelerations
•Associated with fetal movement •Reflect fetal well-being •If 15 sec x 15 bpm = rules out metabolic acidosis