OB/GYN: Fetal Monitoring

Most accurate diagnostic measurement available in determining gestational age.

**Ultrasound

detected through abdominal wall with a transducer (CTG-cardiograph) that emits ultrasound. Uterine contractions are also detected.

*1. External (indirect) Electronic FHR monitoring

*Causes of Fetal Tachycardia

*1. Maternal fever-most common cause of fetal tachycardia 2. Asphyxia (early) 3. Fetal infection 4. Prematurity 5. Drugs (ritodrine and atropine) 6. Fetal stimulation 7. Arrhythmias 8. Maternal anxiety 9. Maternal thyrotoxicosis 10. Unknown causes (idiopathic)

uses bipolar spiral electrode attached to fetal scalp (FSE or FSC) which detects peak R-wave voltage of fetal ECG.

*2. Internal Electronic FHR monitoring

What is *Usually found in association with acute or chronic uteroplacental vascular insufficiency?

*2. Late Decelerations:

Uses US and cardiotocography to ascertain fetal well-being.

*3. Biophysical Profile (BPP):

Abnormal FHR pattern; can be mild, moderate or severe. Due to cord compression and/or head compression. If they are recurrent, suspect cord around neck or under arm of fetus

*3. Variable Decelerations:

*_________________ is the most important variable. A normal profile equals____________. A score is__ or less is suspect for asphyxia and the BPP should be repeated in_____ hours or consider delivery.

*Amniotic fluid volume/index 8 to 10 6 4-6 hours

________ is the single most important characteristic of the baseline FHR and indicator of fetal status/fetal well being.

*BTBV *Beat-to-Beat Variability

-Increase in FHR above baseline of at least 15 bpm, usually 15-20 seconds duration and associated with intact fetus, unstressed by hypoxia and acidemia.

*FHR Accelerations:

*Fetal Distress: What does it affect and what is it correlated with? How is it detected?

*Fetal distress/hypoxia affects entire fetus. Correlates with fetal hypoxia. Detected through changes in fetal heart rate and fetal blood pH.

*____________________ is the Gold standard in determining well-being of fetus (is baby doing ok)

*Fetal scalp pH [Management of Non-Reassuring Fetal Status: Fetal Scalp Blood Sampling]

Cause is unknown. Rate is 120-160 bpm but there is a smooth, undulating pattern of 5 to 10 bpm in amplitude and shortened short term variability.

*Sinusoidal Pattern:

*2. Late Decelerations: Characteristics or causes

*a. Usually found in association with acute or chronic uteroplacental vascular insufficiency b. Slowing of FHR that occurs after peak of and extends past the length of the uterine contraction. Often a slow return to baseline. c. Brought on by hypoxemia (slows FHR as result of CNS asphyxia), direct myocardial depression or both. d. May be associated with mixed resp and metab acidosis e. Increased incidence in patients with preeclampsia, hypertension, DM, IUGR, or other disorders associated with chronic placental insufficiency. f. Seen with abruptio placentae, maternal hypotension from anesthesia, or excessive uterine activity (hyperstimulation during oxytocin infusion)

*Cervical Changes are called

*ripening

*Causes of Fetal Bradycardia:

1. Asphyxia (sudden or profound) 2. Drugs 3. Reflex (ex: pressure on fetal head) 4. Arrhythmias 5. Hypothermia 6. Idiopathic (unknown)

Fetal Complications of Post-Dates:

1. Brachial Plexus Injury 2. Oligohydramnios 3. Placental Dysfunction 4. Meconium Aspiration

Management of Postdates Pregnancy:

1. Careful monitoring and observation as long as fetus is "doing well" by prenatal testing. A good majority of moms will go into spontaneous labor. 2. Electronic intrapartum fetal heart monitoring; mainstay for intrapartum management of labor. 3. Be prepared for increased risks of long labor, cervical trauma, forceps delivery and C-section

Intervention for Late Decelerations:

1. Change maternal position to the lateral recumbent position 2. Give oxygen by face mask 3. Stop oxytocin infusion 4. Provide IV fluid bolus 5. Give IV tocolytic drug (MgSO4) 6. Monitor maternal blood pressure 7. If decelerations persist longer than 30 minutes, get fetal scalp blood pH and consider C-section

*Monitor Fetal Distress with:

1. Continuous fetal heart rate monitoring 2. Fetal scalp capillary blood sampling--> fetal blood pH

Approach to Reading Intrapartum Fetal Monitoring:

1. Evaluate recording 2. Type of monitor used 3. Identify: •Baseline fetal heart rate •Variability o Long term o Beat to beat 4. Presence of accelerations or decelerations 5. Identify pattern of uterine contractions 6. Correlate accelerations and decelerations with uterine contractions and identify pattern 7. Identify changes in FHR over time 8. Determine if FHR is reassuring or non-reassuring

*Causes of Decreased Beat-to-Beat Variability:

1. Fetal asphyxia and/or acidemia 2. Drugs (atropine, scopolamine, tranquilizers, narcotics, barbiturates, anesthetics, MgSO4) 3. Prematurity 4. Fetal tachycardia 5. Physiologic fetal "sleep states" 6. Fetal cardiac and CNS abnormalities 7. Arrhythmias 8. Prolonged uterine contractions (uterine hypertonus) 9. Maternal academia

Improvement of Fetal Oxygenation:

1. Give O2 to mom.

Fetal Distress Definitions:

1. Hypoxemia 2. Hypoxia 3. Acidemia 4. Acidosis 5. Asphyxia

*Stressed fetus

1. Increased CO2 causes situation similar to adult respiratory acidosis 2. Continued hypoxia--> build-up of organic acids 3. Accumulation of pyruvic and lactic acids--> metabolic acidosis 4. Transient decreases in fetal or uterine perfusion lead to respiratory acidosis; prolonged or severe decrease in perfusion leads to both respiratory and metabolic acidosis. 5. Fetal oxygen deprivation--> fetal bradycardia, an adaptive response by fetus.

Complications of Scalp pH (not common):

1. Infection 2. Occasional bleeding (sinus) 3. Disseminated infection (from mom)-group B strep 4. ITP (if mom has ITP)

Dysmaturity Syndrome (Post-maturity Syndrome):

1. Loss of subcutaneous fat; growth retarded --> "elderly appearance" 2. Dry, wrinkled, and cracked skin 3. Meconium staining of the skin, membranes, and umbilical cord respiratory distress from mechanical obstruction of small and large airways and chemical pneumonitis. 4. Long nails 5. An unusual degree of alertness 6. 25% of post-terms --> macrosomic infant (BW > 4000g)

High-risk Indications for Continuous Fetal Heart Rate Monitoring:

1. Maternal Medical illness-GDM, HTN, asthma 2. Multiple gestation 3. Post-dates 4. IUGR 5. Premature rupture of membranes 6. Congenital malformations 7. Third-trimester bleeding 8. Induction/augmentation of labor 9. Preeclampsia 10. Psychosocial risk factors-no prenatal care, tobacco use, drug abuse

Antepartum Risk Assessment for the Postdates Fetus: Biochemical Evaluation:

1. Maternal Urinary Estriol 2. Human Chorionic Somatomammotropin (hCS)/HPL

Improvement in Umbilical Blood Flow:

1. Maternal position-change position from side-to-side, to Trendelenburg or knee-chest position. 2. Fetal head position-with cord prolapse, manual elevation of fetal head out of pelvis to take pressure off cord while preparing for C-section

Increases in Beat-to-Beat Variability:

1. Mild fetal hypoxemia

Methods of Induction:

1. Oxytocin Infusion: Depends on condition of cervix. Unripe cervix may not respond to oxytocin. 2. Prostaglandin gel: Prostaglandin "PGY" gel "ripens" cervix Two prostaglandins available in US Only dinoprostone (PGE2) approved for ripening Mistoprostol (Cytotec)-PGE1 synthetic Side effects-nausea, vomiting, uterine hyperstimulation, uterine rupture Apply to cervix day before attempting oxytocin infusion to try to soften cervix and get it ready for labor. 3. Laminaria Tents-from seaweed

Improvement of Uterine Blood Flow:

1. Place mom in one of the lateral recumbent positions. 2. Provide adequate hydration, including IV fluids. With late decels, use infusion of lactated Ringer's or physiologic saline. 3. Uterine relaxation-D/C oxytocin and consider IV ritodrine or SC terbutaline [tocolytics]

Components of Biophysical Profile:

1. Reactivity (non-stress test) 2. Fetal breathing movements (chest wall movements) 3. Fetal tone (flexion and extension of an extremity) 4. Fetal activity (gross trunk or limb movements) 5. Amniotic fluid index

*Effects of Decelerations on FHR:

1. Severe-change of heart rate greater than 60 beats/min, lasting at least 1 minute duration OR a heart rate of less than 90 bpm-BAD sign 2. Mild-change in heart rate of less than 20 beats/min-not bad 3. Moderate-falls in between mild and severe-can be Bad sign

Medications Used:

1. Sodium bicarbonate (counteract acidosis) 2. Epinephrine-stimulate heart 3. Naloxone-d/t narcotic effect from mom

Newborn Assessment: Immediate Newborn Procedures:

1. Suction of Mouth and Nasal Passages: Use bulb syringe to remove mucus and amniotic fluid from NB mouth and nose. 2. Clamping and Cutting of Umbilical Cord: 3. Infant Dried: To minimize evaporative loss of core temp. *4. Apgar Evaluation:

Newborn Exam:

1. Vital signs 2. Physical exam--> gross malformations, molding, caput, spina bifida 3. Warmed 4. Eye meds-preventively treated with antibiotics for possible GC to prevent blindness 5. Vitamin K-1.0 mg IM or orally at birth

*A low or low-normal scalp pH should be repeated in _________ minute intervals

15-30 minutes

An equivocal CST should be repeated in________ hours. > 80% of repeat tests will be ___________.

24-72 hours negative

*Criteria for negative CST is _____ uterine contractions over___ minutes with no evidence in the FHR of late decels, severe variable decels or loss of beat-to-beat variability.

3 10 minutes [Interpretation of CST: Negative CST]

*Uterine contractions increase in the first stage of labor progressively and in intensity from ____ mm Hg to ___ mm Hg. The frequency increases from___ to ____ contractions per____minutes.

35 mmHg to 50 mmHg 3 to 5 10 minutes

*Delivery indicated if there is evidence of deteriorating fetal well-being or if pregnancy is over _____ weeks.

42 weeks

A positive CST [severe variable or late decelerations with > ____% of contractions] is associated with adverse perinatal outcome in 35-40% of cases. ____________ rate exceeds 50%.

50 False-positive [Interpretation of CST: Negative CST]

*Approximately ______% of females with post-term pregnancies will have prolonged pregnancy with next gestation

50%

*pH less than _______ indicative of significant asphyxia

7.20 [Management of Non-Reassuring Fetal Status: Fetal Scalp Blood Sampling]

pH between________ considered pre-acidotic.

7.20-7.24 [Management of Non-Reassuring Fetal Status: Fetal Scalp Blood Sampling]

*Normal fetal capillary pH is _________ in the first stage of labor

7.25-7.35 [Management of Non-Reassuring Fetal Status: Fetal Scalp Blood Sampling]

No cervical ripening agents when Bishop score is greater than ___?

8

*In the second stage of labor contractions increase even more to ____ to ____ mm Hg and in frequency to __ to __ per ___ minutes.

80 mmHg to 100 mmHg 5 to 6 10 minutes

Non-reactive NST (NR-NST):

A non-reactive stress test should be interpreted in light of gestational age. A non-reactive NST at term is associated with poor perinatal outcome in only 20% of cases. A non-reactive test must be immediately followed with more of a work-up like a biophysical profile.

*Evaluates five signs of fetal status, assigning a maximum of 2 points for each.

APGAR • Heart rate • Respiratory effort • Muscle tone • Reflex • Color

Less than 5 amniotic fluid index. Most common cause is rupture of membranes. Associated with IUGR in 60% of cases.

Abnormal Amniotic Fluid Volumes: Oligohydramnios:

Greater than 20 amniotic fluid index, or 2 liters.

Abnormal Amniotic Fluid Volumes: Polyhydramnios:

*Periodic Fetal Heart Rate Changes:

Accelerations (increases in fetal HR) and decelerations (decreases in fetal HR) related to uterine contractions.

increased concentration of hydrogen ions in the blood

Acidemia

increased concentration of hydrogen ions in tissue

Acidosis

Infusion of fluid into the amniotic cavity through dilated cervix; relieves pressure on a compressed umbilical cord.

Amnioinfusion

Intervention for Variable Decelerations

Amnioinfusion-infuse normal saline into the uterus through the IUPC to alleviate cord compression. Change maternal position to side/Trendelenburg position. Deliver fetus by C-section.

A calculation of the volume of amniotic fluid. Maternal abdomen divided into quadrants. Using US the maximum vertical pocket of each quadrant is measured in centimeters and added.

Amniotic Fluid Index (AFI):

hypoxia with metabolic acidosis

Asphyxia

*Sinusoidal Pattern:

Associated with extreme fetal jeopardy (Rh isoimmunization and fetal anemia from fetomaternal transfusion). Also seen after giving narcotics to mother. Probable sign of fetal compromise.

Iatrogenic Causes of Fetal Distress: 2. Oxytocin Stimulation

Associated with increased incidence of late decelerations and decreased placental perfusion. Can minimize hyperstimulation by oxytocin by using an infusion pump and an internal pressure catheter.

*Degree of cervical ripeness quantified by

Bishop Score

Major Effects of Fetal Distress: *2. Fetal Death:

Can result from severe intrapartum asphyxia.

Major Effects of Fetal Distress: 1. Neurologic Abnormalities:

Cerebral palsy and mental retardation; may not be noticed at birth. Felt that 20-40% of all neurologic disorders are influenced by intrapartum events.

Oxytocin is more likely to work if _______?

Cervix is ripe

Cervical Changes:

Cervix undergoes histologic changes to facilitate dilation and effacement in response to pressure of presenting part.

*Variability *Beat-to-Beat Variability (BTBV):

Continuous interaction of autonomic nervous system (sympathetic and parasympathetic systems) to adjust FHR for changes in metabolism or hemodynamics. An important index of fetal CNS integrity.

Accurate Pregnancy Dating: 1. First Visit Early in Pregnancy:

Determine uterine size, first FHR, quickening, fundal height

*Scoring of Biophysical Profile:

Each test given from 0 to 2 points for maximum of 10 points. Two points is awarded if the variable is present or normal; 0 points if absent or abnormal.

paralysis of deltoid and infraspinatus and flexor muscles.

Erb or Duchenne palsy

Brachial Plexus Injuries:

Erb or Duchenne palsy Klumpke's paralysis

Amniotic Fluid Evaluation: 1. Ultrasound:

Estimate of amniotic fluid volume; indirect index of placental function

Baseline fetal heart rate < 120 bpm for > 10-15 mins.

Fetal Bradycardia:

Intrauterine Resuscitation:

Fetal distress may mean immediate delivery via C-section or vaginally. Intrauterine resuscitation may be attempted if time permits.

*Fetal Heart Rate Decelerations:

Four patterns of decelerations based on configuration of wave form and timing of the deceleration in relation to uterine contraction.

Hormone secreted by placenta. Level is proportional to weight of fetus and the placenta. Should follow serial measurements

Human Chorionic Somatomammotropin (hCS)/HPL

decreased oxygen content in blood

Hypoxemia

decreased level of oxygen in tissue

Hypoxia

Accurate Pregnancy Dating: *2. Ultrasound Exam:

In the first trimester, transvaginal and transabdominal --> +/- 1 or 2 weeks, by measuring the gestational sac and embryo/fetus. In the 2nd trimester --> +/- 2 weeks. In the third trimester --> +/- 2 to 3 weeks (14-21 days)

consists of monitoring of the fetal heart rate and the maternal contractions.

Intrapartum Fetal Monitoring

*Long-term Variability (LTV):

Irregular, crude wave-like (oscillatory) pattern with a cycle of 3-6 cycles per minute and an amplitude of 5 to 15 bpm. Results in waviness of baseline. Can be measured by Doppler or FSE (fetal scalp electrode).

*4. Prolonged Decelerations

Isolated decelerations lasting 90 to 120 seconds or more Causes-prolonged umbilical cord compression, profound placental insufficiency, sustained head compression

paralysis of hand from injury to lower nerves of brachial plexus

Klumpke's paralysis

Inaccurate Pregnancy Dating:

Late first visit, ? LMP, oligo-ovulation, US late in pregnancy, acute illness, IUGR, metabolic disturbances, heavy drug use

Can be used to indicate fetal compromise. Absolute values not as important as the serial values over days or weeks. Less than 12 mg/24 hr indicates fetal jeopardy.

Maternal Urinary Estriol Note that normal estriol levels do not rule out fetal distress and decreased levels of estriol may also represent other disease states.

Fetal Movements Charts ("Kickcharts"):

Maternal appreciation of fetal movement is reliable. Fetal movement decreases with advancing gestational age, oligohydramnios, smoking and betamethasone therapy. "Kickcharts" involve either counting all fetal movements in 1 hour or counting the time it takes the fetus to kick 10 times (count-to-ten). Measurements should be repeated at least twice daily. Use of kickcharts in high-risk pregnancies can decrease perinatal mortality 4-fold.

Normal Amniotic Fluid Volumes:

Maximum amniotic fluid is reached at about 34-38 weeks--> 800-1000 ml After 38 weeks, amniotic fluid decreases. By 42 weeks, amniotic fluid is at 500 ml.

*Decreased Variability:

May be sign of loss of fine autonomic control of FHR.

Severe resp distress from mechanical obstruction of large and small airways --> pneumonitis *Seen in 13-15% of all term pregnancies

Meconium Aspiration

Non-stress Test (NST): Procedure

Mom placed in left lateral, supine position. Continuous FHR tracing obtained using Doppler US. The heart rate changes that result from fetal movements are determined.

APGAR Score of 8-10 means?

NB is in good condition

APGAR score of less than 8 means?

NB needs assistance or intervention

*Fetal Heart Rate Testing/Assessment of Fetal Well-Being/Management of High-Risk Pregnancies: *1. Non-stress Test (NST):

Non-invasive test of fetal activity. Correlates with fetal well-being. Watch fetal heart acceleration during fetal movement, recorded by external monitor. Interpretation is fairly subjective.

Is intervention necessary for Early Deceleration?

None necessary

Interpretation of NST: *Reactive Test (R-NST):

Normal baseline heart rate (120-160 bpm), normal variability and at least two accelerations in 20 minutes, each lasting > 15 secs and peaking at 15 bpm above baseline. Reactive--> Normal Repeated every 3-4 days depending on the clinical situation.

Incidence of Post-dates Pregnancy:

Occurs more frequently in primigravidas and grandmultiparas (more than 6 pregnancies with viable fetuses) Postdates have higher perinatal mortality.

Leads to increased fetal stress and distress. Amniotic fluid approximately 1 liter at 36-38 weeks, then decreases to 500 ml at 42 weeks

Oligohydramnios --> decreased protection of cord --> cord impingement.

When perfusion is decreased because of impaired uterine or umbilical blood flow, transfer of O2 to fetus is decreased. This leads to accumulation of CO2 in fetus.

Pathophysiology of Fetal Hypoxia: *Stressed fetus

Seen in approximately 40% of cases --> infarcts, calcification and fibrosis post-term--> intrauterine nutritional and resp. deprivation.

Placental Dysfunction

*Asphyxia often responsible for perinatal morbidity and mortality in which stage of pregnancy?

Post-dates

A pregnancy that continues for more than 42 weeks. Approximately 10% of all pregnancies go beyond 42 weeks.

Postdates Pregnancy: Postdatism [post-term pregnancy; postmaturity] *Exact cause unknown but there are many associations.

*Fetal Tachycardia:

Rate greater than 160 bpm. Suspicious tachycardia 161-170 bpm. Pathological pattern is above 170 bpm.

*FHR Accelerations: Examples

Reassuring and usually indicates fetal well being. Example: Stimulation of fetal scalp by digital exam --> acceleration Sound/vibration stimulation (acoustic stimulation) --> acceleration

*Reactivity:

Response of a healthy fetus when stimulated. Usually results in a transient increase in variability or baseline acceleration [10-15 bpm]. Stimulation may be external (sound or scalp stimulation) or internal [spontaneous fetal movement]

Vibroacoustic Stimulation:

Response of the FHR to a vibroacoustic stimulus. An acceleration on NST (> 15 bpm for > 15 sec) is a positive result. Useful adjunct to decrease the time to achieve a "reactive" NST (R-NST) and to decrease the proportion of non-reactive NST at term, precluding the need for further testing.

*Bishop Score:

Scored by 0 to 3 points assigned for each parameter *Score based on: • fetal station • degree of dilation • effacement • consistency of cervix • position of cervix

*1. Early Deceleration:

Slowing of FHR, but never < 100 bpm Early decelerations are normal. The timing of onset, peak and end coincides with the timing of the contraction. The degree of deceleration is proportional to the contraction strength.

FHR Pattern: *Baseline Fetal Heart Rate:

Steady rate. A heart rate lasting greater than or equal to 10 minutes. Central "beat per minute". Beat-to-beat variability present. *Normal baseline is 120-160 beats per minute.

Iatrogenic Causes of Fetal Distress: 1. Maternal Position:

Supine position--> uterus obstructs blood flow through abdominal aorta and inferior vena cava-->supine hypotension with decreased cardiac output; can lead to decreased placental perfusion and fetal distress.

Iatrogenic Causes of Fetal Distress: 3. Peridural Anesthesia:

Sympathetic block may cause decreased venous return and cardiac output, maternal hypotension, decreased uteroplacental perfusion and late decelerations. Avoid problems by hydrating well and lying in lateral position.

*Fetal Heart Rate Testing/Assessment of Fetal Well-Being/Management of High-Risk Pregnancies: *2. Contraction Stress Test (CST):

Test of FHR in response to artificially induced uterine contractions. A minimum of three contractions in 10 minutes are required to interpret the test. *Indirect measure of placental function (test for uteroplacental dysfunction) *A CST can be preformed when the NST is non-reactive. *Negative CST--> baseline FHR unchanged and NO FHR decels in response to contractions. Considered reassuring.

Bishop score of 0

Totally unripe cervix no dilation, no effacement, firm, posterior, "-3" station

*Good Variability:

Usually predicts good fetal outcome. The presence of good variability is highly Suggestive of adequate fetal CNS oxygenation.

Neonatal Resuscitation:

Usually with premature births but occasionally happens at term. *Most important to check ABC's-airway, breathing, circulation Normally, gentle stimulation of baby at birth to get breathing; if not breathing, ambu bag with pedi mask. CPR: No heart rate-->gentle chest massage 2 fingers to compress chest. Get ABG's, O2, suction. *Keep baby warm-put on mom's abdomen.

*Short-term Variability (STV):

Variation in amplitude seen on a beat-to-beat basis, normally 3-8 bpm. It is the roughness (STV present) or smoothness (STV absent) of the FHR tracing. May be decreased/absent due to alterations in the CNS or inadequate fetal oxygenation. Measured only by fetal scalp electrode.

Amniotic Fluid Evaluation: 2. Amniocentesis:

When gestational age is in question; for maturity studies.

2. Uterine Contraction Monitoring:

a. External tocodynamometer b. Internal uterine pressure catheter (IUPC)-pressure is calculated in Montevideo units. It is calculated by increases in uterine pressure above baseline {8-12 mm Hg] multiplied by contraction frequency per 10 minutes.

Characteristics or causes of Early Deceleration

a. Not caused by systemic hypoxia b. Do not appear to be associated with poor fetal outcome; physiologic cause c. Occur with fetal head compression (also with vaginal stimulation)--> reflex response via vagus nerve with Ach at fetal SA node d. Begin with onset of uterine contractions e. Reach lowest point at peak of contraction f. Return to baseline as contraction ends g. "Mirror image" of uterine contraction

*3. Variable Decelerations: Characteristics and causes

a. Slowing of FHR inconsistent in configuration. May start before, during or after contraction starts b. No uniform relationship to onset of contraction. Variable in location, pattern, and cause. Characterized by rapid fall in FHR, often < 100 bpm, then rapid return to baseline c. Usually result of transient compression of umbilical cord between fetal parts or between fetus and maternal tissues. d. Often associated with oligohydramnios, +/- ruptured membranes e. Causes short-term resp acidosis if mild f. May be associated with profound combined acidosis if prolonged and recurrent *g. Most common periodic FHR pattern

*No beat-to-beat variability =

acidosis and the fetus must be delivered immediately

Negative CST usually predicts a favorable (but not always) outcome. *CSTs have a 25% _______________ rate.

false-positive [Interpretation of CST: Negative CST]

*Major concern in postdates pregnancy is ______________________ secondary to _____________________ from placental aging.

fetal compromise placental insufficiency

The goal is to detect events that might result in potentially preventable poor fetal outcomes like [name some]

hypoxic ischemic encephalopathy, cerebral palsy and fetal death.

*Relieve supine hypotension by placing woman in ________________

lateral recumbent position

Oligohydramnios correlates with__________________________________

placental insufficiency.

*The single most reliable sign of fetal compromise is _________________?

prolonged diminished beat-to-beat variability.

Bishop score of 8

ripe cervix

*Decreased beat-to beat variability is diagnosed if short-term variability is absent, and there is less than _____ cyclic changes/minute of long term variability.

two

macrosomic infant (BW > 4000g) at risk for:

•Altered glucose--> hypoglycemia due to placental dysfunction decreased transfer of water, electrolytes, glucose, amino acids and oxygen •Altered bilirubin--> hyperbilirubinemia •Maternal trauma •Increased incidence of birth trauma o Shoulder dystocia o Clavicle fx o Erbs Palsy o C-section d/t CPD (cephalo-pelvic disproportion)

Approach to Interpretation of Intrapartum Fetal Monitoring: Dr. C. Bravado

•DR-determine risk o Clinical risk status of fetus assessed in conjunction with interpretation of continuous EFM •C-contractions •BRA-baseline rate [fetal monitor strip] •V-variability •A-accelerations •D-decelerations •O-overall assessment (interpretation)

Structured Intermittent Auscultation: Procedure:

•Determine position of fetus by palpation •Place Doppler over area of maximal intensity of fetal heart tones •Differentiate maternal pulse from fetal pulse •Palpate for uterine contraction during FHR auscultation to determine relationship •Count FHR between contractions for 60+ secs to determine average baseline rate •Count FHR after uterine contraction for 60 secs to identify fetal response to active labor

Components of Intrapartum Fetal Monitoring:

•Fetal heart rate monitoring •Maternal uterine contraction monitoring