Exam 2 Study Guide
Exam 2 Study Guide NSG 330
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This 44 page Study Guide was uploaded by Brieanna Phipps on Sunday March 6, 2016. The Study Guide belongs to NSG 330 at University of North Carolina - Wilmington taught by Dr. Goff in Spring 2016. Since its upload, it has received 231 views. For similar materials see Maternal Infant in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 03/06/16
Fetal Assessment During Labor (griggs) Advanced fetal monitoring core components o Acid Based Balance o Maternal/Fetal Factors o Best Practice: Using Evidence-Based Practice o Communication o Pitocin Management: A High Alert Medication o FHR monitoring is NOT a diagnostic tool, it is a screening tool, measures oxygenation of the baby Purpose: o The primary objective of EFM is to provide information about fetal oxygenation and prevent fetal injury that could result from impaired fetal oxygenation during labor (Fedorka, 2010) o If you have significant deceleration FHR probs not getting enough O2 Electronic Fetal Monitoring o EFM is used as a diagnostic indicator for nursing/medical interventions o Attempts now to foster uniformity in definitions and treatments o Now we have also management components with definitions Assumptions about EFM: o All clinically significant decelerations are a disruption of oxygen to the fetus o Fetal neurologic injury due to this disruption does not occur unless significant acidemia o Acidemia is highly unlikely in presence of moderate FHR variability and/or accelerations Background: o Central Electronic Fetal Monitoring is most common form of assessing fetal well-being o Current Perinatal mortality rate in US of 7.9 deaths per 1,000 live births (WHO, 2014) (IMR is inc.) o TJC reported over 900 sentinel perinatal deaths and permanent infant disabilities in 2009.(The Joint Commissions, 2009) o Communication played a role in 78% of unexpected neonatal deaths. o Originally developed to decrease incidence cerebral palsy Goals of Fetal Well-Being o Maintain appropriate uterine activity o Maximize uterine blood flow o Maximize umbilical circulation o Maximize oxygenation NICHD (National Institute for Child Health and Human Development) o A lack of consensus was found in the definitions and nomenclature related to fetal monitoring (ACOG, AWHONN, TJC) o NICHD sponsored a research planning group to address this issue o Formed because there was not uniform communication in the hospital NICHD Principles: o Definitions are for visual interpretation of the fetal heart rate o EFM patterns are defined as periodic and episodic o Periodic: occur with contractions o Episodic: occur without contractions o Look at the whole picture, not just one pattern. o Evaluate patterns over time** o No differentiation is made between short and long term variability. FHT Categories: o Category o Description o Fetal heart-rate (FHR) tracings include all of the following: o baseline rate is 110–160 bpm o baseline FHR variability o I (Everything is fine) is moderate o accelerations are present or absent o late or variable decelerations are absent o early decelerations are present or absent o Includes all FHR tracings o II (everything in between 1 and 3) not included in Category I or Category III o FHR tracings include: o absent baseline FHR o III (stop, C-section) variability : o sinusoidal pattern, or other non-reassuring patterns. o Source: NICHD Placental Physiology- o Maternal blood flows through the uterine arteries into the intervillous spaces, and then return through uterine veins to maternal circulation o Fetal blood flows through the umbilical arteries into the villous capillaries and returns through the umbilical vein to fetal circulation. o Exchange of blood gases depends on an unobstructed blood flow through the placenta. Uteroplacental exchange- o As the myometrium contracts, the flow of oxygenated blood through the uterine artery may be decreased. o Therefore, the fetus may have less oxygen available. Maternal response to pregnancy o Hematological Increased volume and erythrocytes State of hypercoagulation o Cardiovascular “Hemodiluted” due to increased volume (High Flow/Low Resistance) Cardiac output increase 40-50% at rest o Pulmonary Compensated respiratory alkalosis O2 consumption increased 25% in last 6 weeks of pregnancy o Renal Increased renal blood flow Maternal position affected Glomerular Filtration Rate increased Diurnal Pattern Extrinsic Factors on FHR- o Maternal Hypertension, hypotension, smoking, etc. o Uteroplacental perfusion The function and structure of the placenta and its surface vessels, age(post maturity), tachysystole o Umbilical circulation Two arteries, One Vein. Is circulation appropriate or altered. o Amniotic fluid characterizes o Extrinsic is “Outside” of the fetus o Affect the delivery of blood and O2 to the fetus o Hypertension can cause? Vasoconstriction and infarcts. Post-maturity o IF you have a 2 vessel chord the baby tends to be smaller Amniotic Fluid Volume o Peaks at 40 weeks and then decreses o Fluid comes from fetal kidneys Extrinsic influences- o A-Airway= Uterine blood flow o B- Breathing= Placental function o C- Circulation=Umbilical blood flow Uterine Maternal/Fetal o2 exchange- o Oxygen delivery to the fetus is via the uterine arteries to the uterus. o Uterus through the placenta, and from the placenta to the fetus via the umbilical vein. o Like a tea kettle. Higher pressure gradient to a lower one. o The air we breathe is 21% O2 -> we inhale with our lungs -> o2 rich blood gets pumped by the heart and into the vasculature-> the uterus receives o2 rich blood -> fetus receives o2 rich blood via the umbilical cord -> placenta receives o2 rich blood -> happy baby o The compensatory mechanisms redistribute blood flow to the brain, heart and adrenals during fetal hypoxemia Intrinsic Placenta Factors o Intrinsic = internal o Fetal circulation o Autonomic nervous system responses o Baroreceptors- sensitive to pressure o Chemoreceptors- sensitive to chemicals o Hormonal responses Redistribution of blood flow o Fetal homeostatic compensatory mechanisms Intrinsic/Extrinsic o Labor Bit- Placental causes, such as infarction or abruption are likely to not be ameliorated by normal resuscitative measures. Regulation of FHR o Autonomic nervous system o Baroreceptors o Chemoreceptors o Adrenal Gland o Central Nervous System FHR and Blood Flow o Cardioregulatory Center (CRC) o Collection of neurons in the medulla oblongata and the source of FHR baseline control. o Autonomic Nervous System: Parasympathetic branch Vagus nerve- decrease in FHR- increased PS tone occurs with increased gestation age. This causes a decrease in FHR Sympathetic branch (fight or flight) Simulation causes an increase in FHR, anxiety, fear, pain, drugs o Younger the gestation the more they are ruled by sympathetic system o Need a balance between parasympathetic and sympathetic in order to have a healthy fetus Parasympathetic/sympathetic o The autonomic nervous system fully develops by 24 to 28 weeks. o The complex interaction of the sympathetic and parasympathetic nervous systems exert their complex yin-yang effects on a second-by- second basis. o Any factor that affects the fetal brain, such as oxygenation, will alter this pathway. o Changes in fetal oxygenation will correspond and be reflected in a variation of cardiac activity. o This concept that is the basis for fetal heart monitoring Mechanics of Monitoring o External Toco (external contraction monitor) o External FHR o IUPC (internal contraction monitor) o FSE (internal FHR monitor) o Ultrasound Goals of Fetal Wellbeing o Maintain appropriate uterine activity o Maximize uterine blood flow o Maximize umbilical circulation Baseline FHR o FHR rounded to increments of 5bpm during a 10 min window excluding Acceleration and deceleration Periodic/episodic changed in the FHR (Decelerations) o Early – related to head compressions. Interventions not necessary, just continue to watch for any changes Gradual decrease in FHR and return to baseline associated with fetal contractions Onset to nadir is equal to or greater than 30 seconds. Nadir of deceleration occurs at the same time of the peak of the contraction. Slide 35 Physiology Transient head compression -> altered intracranial pressure and cerebral blood flow-> reflex parasympathetic outflow (sleep or weep) -> gradual slowing of the FHR -> Early Decel -> when the contraction is over, head compression is relieved and the autonomic reflex subsides o Prolonged- A visually apparent decrease in the FHT that drops at least 15 bpm below baseline and lasts at least 2 minutes but less than 10 minutes from their onset. May be abrupt or gradual. Always related to disrupted oxygenation Causes: Tachysystole Maternal hypotension Maternal hypoxia (eg. Seizure) Abruption Uterine Rupture Cord compression Prolapsed cord Ruptured vasa previa Profound head compression Rapid fetal descent Slide 39 MUST IMPROVE BLOOD FLOW TO THE PLACENTA TO INCREASE OXYGENATION Reposition Discontinue labor augmentation (TURN OFF PITOCIN) Treat hypotension/hypertension Oxygen by face mask (10L via face mask) Consider expediting delivery Reccurrent decels are defined as those that occur with at least 50% of contraction in 20 min period Intermmitent = less that 50% in 20 min period This is Episodic= not during a contraction o Variable – related to cord compression. Interventions vary, but focus on position changes. Interventions = repostition or amniofusion Visually apparent abrupt decrease in FHR Onset to Nadir >15 beats, last > 15 seconds, and < 2 minutes in duration. Associated with contractions Associated with Cord Compression Physiology Venous compression decrease in venous return Relative hypovolemia Reflex increase in FHR Arterial compression Increased SVR Elevated BP vagal response (dip in HR) When pressure is released, the FHR returns to baseline. Slide 46 o Late – related to uteroplacental insufficiency/ decreased perfusion. Most ominous and need immediate attention. Physiology Transient hypoxemia -> sympathetic outflow -> peripheral vasoconstrictions -> increase in BP -> baroreceptor stimulation -> vagal outflow -> deceleration Gradual decrease in in FHR and return to baseline associated with fetal contractions Onset to nadir is equal to or greater than 30 seconds. Nadir of deceleration occurs after the peak of the contraction. Happens late in the contraction and does not come back until the contraction is over Slide 53 Interventions- Increase Placental Blood Flow and Uterine Oxygenation! Reposition Discontinue labor augmentation (TURN OFF PITOCIN) Treat hypotension/hypertension Change maternal position Consider expediting delivery Use oxygen only as a last resort Did you know- o A “ Gradual” FHR decrease is defined as from the onset to the FHR nadir > or equal to 30 seconds. o “Recurrent” decels are defined as those that occur with at least 50% of contractions in a 20 minute period. o Intermittent decelerations are those that occur with < 50% if contractions in a 20 minute period. Contractions- o Normal are < or equal to 5 contractions in 10 minutes averaged over a 30 minute period o Tachysystole are > that 5 contractions in 10 minutes averaged over a 30 minute period o Terms “hyperstimulation” and “hypercontractilty” are not defined and should not be used. Internal Monitor o With an IUPC in place, quantitative data can be measured, most commonly using Montevideo units (MVU). o Criteria for Internal Monitoring: Amniotic membranes must be ruptured Presenting part down against the cervix o Spiral Electrode is placed on the fetal occiput which allows for more accurate continuous data then external monitoring. (do not do for HIV positive mother ) If mom has a lot of bleeding, do not put in Can put on breech baby but it is a last resort o Spiral electrode is attached to the fetal scalp o Wires that extend from attached spiral electrode are attached to a leg plate and then attached to electronic fetal monitor Montevideo Units- o Montevideo units is a measure of uterine contraction intensity during labor. o Units are calculated via internal pressure monitor, measuring uterine contraction peak pressure and subtracting the baseline resting tone. This is done over a 10 minute interval. o Generally, above 200 MVUs is considered necessary for adequate labor to bring about dilation and effacement during the active phase. Auscultation by Doppler o Intermittent auscultation can be done with a fetascope or Doppler Baseline FHR- o Rounded to increments of 5 bpm, during 10 minute segment excluding periodic or episodic changes o If segments differ by > 25 bpm= Marked o Must be recorded for at least 2 minutes in any 10 minute segment, (not necessarily contigous) o Normal = 120-160 bpm o Tachycardia – baseline above 160 BPM RT= maternal fever, fetal hypoxia, intrauterine infection, drugs o Bradycardia – baseline below 110 BPM RT = profound hypoxia, anesthesia, beta-adrenergic blocking drugs Variability o Irregular fluctuations in the baseline FHR. Measured as the amplitude of the peak to trough in bpm (beats per minute). o Refers to the fluctuation In the FHR over time o Considered the most important indicator of fetal oxygenation o Amplitude Range o Classification o Absent o Visually undetectable o Minimal o Less than or equal to 5 BPM o Moderate o 6-25 BPM o Marked o More than 25 BPM o Marked = don’t know if its good or bad, no known etiology o Slide 70 o Absence or decreased variability, or a smooth flat baseline, is a sign of fetal compromise. o A periodic decal/accel = with a contraction o Episodic = not with a contraction o 3 S’s of variability Sleep Sedation ? o Causes of Decreased variability- Hypoxia and acidosis Medications Sleep cycle Preterm status Accelerations- o Visually apparent in inc in FHR o Audible as well o Have 2 part criteria Must exceepd a 10 or 15 sec interval And exceed FHR in beats/min 10 to 15 above baseline Normal cord blood gas values o o Umbilical Vein o Umbilical Artery o pH o 7.28 o 7.25 o pO2 o 29 o 18 o pCO2 o 38 o 49 o HCO3 o 20 o 22 o B.E. o -4 o -4 Remember that oxygen delivery can be disrupted at any step along the oxygen delivery pathway.*** How fetus responds to disruption in O2 o Hypoxemia (dec. O2 in the blood)-> Hypoxia ( dec. O2 in the tissues) -> Metabolic Acidosis (inc in H+; dec. in pH -> Metabolic Acidemia (inc of H+ in blood) Link btwn poor fetal outcomes and Acid/Base o The criteria to define an acute intrapartum event sufficient enough to cause brain injury (i.e. cerebral palsy) is to prove metabolic acidosis is present in fetal umbilical cord blood at delivery. o Umbilical artery pH <7.0 and a base deficit of > 12 mmol/L When the fetal O2 delivery pathway is interrupted o Just like grown-ups, the fetus will switch to ANAEROBIC metabolism which will result in: Energy being used to maintain basal activity only Lactic acid waste build up Lactic acid is the same waste product that builds up in our muscles after “pumping iron” and makes our muscles sore! Comparing Values o Respiratory Acidemia o Metabolic Acidemia o Mixed Acidemia o Low pH o Low pH o Low pH o High pCO2 o Normal pCO2 o High pCO2 o Normal pO2 &HCO3 o Low pO2 & HCO3 o Low pO2 & HCO3 o Normal BE o Elevated BE o Elevated BE Oxytocin o HIGH-ALERT Medication!! (The Institute for Safe Medication Practices, 2007). o Medication errors involving IV oxytocin are often dose related and can result in adverse outcomes. o First stage of Labor Maternal circulating concentrations approximately 2 to 4 mU/min o Fetal Contribution Around 3 mU/min o Second stage of Labor: Surge of oxytocin at Ferguson’s reflex (decent of the fetal head) o Initial phase of exposure to exogenous oxytocin cxt increase progressively in frequency and intensity. o After several hours of exposure further increases can result in tachysystole/unfavorable FHR responses. o Receptor sites decrease o More oxytocin for dysfunctional labor will cause further desensitization. Oxytocin pharmacokinetics o Half-life 10-12 minutes o Three to four half-lives are needed to reach steady plasma concentrations o Basis for only increasing every 30-40 minutes. Oxytocin Dosage- o Based on the evidence: 90% of women will achieve active labor at less than 6mU/min. There is a lack of agreement on a definition of “adequate labor” (Clark, et al, 2009) Minimizing harm o Follow protocols and order sets based on best practice evidence based practice. o Utilize exceptional clinical judgment when managing Oxytocin. Go slow!! No tachysystole! o Do not be afraid to turn the oxytocin down or OFF! o No studies exist which promote pushing the “Pit”, or letting patients “declare themselves”. This will cause harm! Fetal Assessment During Labor (Goff) Maternal-Fetal Unit o Labor is a period of physiologic stress for the fetus o Fetal oxygen supply must be maintained o Frequent monitoring of fetal status is an important part of nursing care o Circulation affects oxygenation, resulting in changes of fetal heart rate o Maternal position or exercise o Maternal blood pressure changes or hypovolemia o Contractions o Reduction of O2 in maternal blood o Alterations in fetal circulation due to cord compression or other problems o Reduction in blood flow to intervillous spaces in placenta Fetal Monitoring Techniques o Intermittent Auscultation o Continuous Electronic Fetal Monitoring o Count baseline FHR in between contractions o Electronic Fetal Monitoring (EFM) o Useful tool for visualizing fetal heart rate patterns on monitor screen or printed tracing o Fetal well-being assessed by response of FHR to uterine contractions o Primary mode of intrapartum fetal assessment since the 1970’s o Researchers and clinicians believe that interpretation is often subjective and difficult, leading to erroneous assessment of fetal physiologic condition External Monitoring o Ultrasound transducer Monitors fetal heart rate Apply gel & place over PMI of FHT Check gel and reposition if necessary o Toco transducer Monitors contractions Placed on fundus Internal Monitoring o Spiral electrode (FSE) attached to presenting part to monitor FHR o o Solid or fluid-filled intrauterine pressure catheter (IUPC) Used when external monitor not recording contractions well More accurate Membranes must be ruptured Must be in active labor with sufficient dilation & fetal descent Monitors intensity of intrauterine pressure Can be used for amnioinfusion May use internal FHR with external tocotransducer Steps to evaluate fetal monitor tracing o Contraction Pattern or Uterine Activity o Baseline Rate o Variability o Accelerations o Decelerations Uterine Activity Assessment o Frequency o Duration o Intensity o Resting Tone: pressure when uterus not contracting; should be soft o Relaxation Time: time in between contractions when uterus is relaxed At least 60 seconds in active phase At least 45 seconds in second stage o Contractions quantified as number present in a 10-minute window, averaged over 30 minutes o Normal average is 5 or less o Greater than 5 is called tachysystole o Applies to both spontaneous & stimulated labor, but response may be different Causes of Tachysystole o Pitocin o Prostaglandin o Cocaine o Hypoxia o Abruption Treatment of tachysystole o Decrease or stop pitocin o Remove cervidil o IV bolus of LR or NS o Oxygen o Terbutaline SQ if abruption R/O Assessment of FHR o Before initiation of labor-enhancing procedures o Ambulation o Administration or initiation of analgesia or anesthesia o Transfer or discharge of client o AROM or SROM o Vaginal exam o Ambulation o After admission of client o Recognition of abnormal uterine patterns o Administration of meds Effect of Medications on FHR o Butorphanol (Stadol Transient sinusoidal pattern Decreased variability o Cocaine, Zidovudine (AZT), Meperidine (Demerol) No characteristic changes o Corticosteroids (such as betamethasone or dexamethasone) Dec. variability with betamethasone (not seen w/ dexamethasone) o Morphine Dec frequency of accelerations o Nalbuphane (Nubain) Dec frequency of accelerations Dec. variability o Terbutaline Abolishment or dec. in frequency of late or variable decelerations o Magnesium Sulfate Dec baseline and variability Frequency of FHR Auscultation o Obtain 20-minute strip on all clients admitted to labor unit o Low risk: every 30 minutes active phase and every 15 minutes second stage o High risk: every 15 minutes active phase and every 5 minutes second stage Characteristics of FHR o Baseline Average rate during a 10-minute segment that excludes periodic changes (occur with contractions) or episodic (not with contractions), periods of marked variability, and segments of baseline differing by more than 25 beats/min 110 to 160 beats/minute o Variability Irregular fluctuations in baseline FHR of two cycles per minute or greater At least 5-10 beat to beat variability indicates a well-oxygenated baby Most important predictor of adequate fetal oxygenation More accurate with internal fetal monitor electrode Always assessed during baseline and not during decelerations or accelerations Absent or undetected Minimal Moderate Marked Kinds of variability Short term or beat-to-beat Long term or fluctuations over time Both tend to increase or decrease at same time Factors affecting Variability- Gestation Fetal activity Fetal sleep state Medications Maternal-fetal oxygen status Increased Variability- Possible Causes: early hypoxia, fetal stimulation Nursing Care: Intervention not necessary if benign; continue to closely monitor FHR changes Decreased Variability- Possible Causes: prematurity, drugs, hypoxia, acidosis, arrythmias, fetal sleep Nursing Care: alleviate cause, scalp pH, prepare for delivery if indicated o Accelerations Increased sympathetic response Visually apparent abrupt increase above baseline rate 15 BPM or greater, lasting 15 seconds or more, with return to baseline less than 2 minutes from beginning of acceleration Expected with spontaneous fetal movement Can occur with vaginal or pelvic exam; scalp or vibroacoustic stimulation Repeated accelerations with contractions often precede late decelerations o Decelerations Increased parasympathetic response At least 15 BPM for 15 secs and returns to baseline in less than 2 minutes from time of onset “Prolonged” are 2 to 10 minutes Greater than 10 minutes is a change in baseline Early Decels- Fetal head compression Uniform shape “Mirror image” Usually dilated 4-7 cm. or when pushing No intervention necessary Late Decels- Uteroplacental insufficiency (UPI) Ominous with decreased variability and tachycardia Timing outweighs shape when deciding if early versus late The deeper the late deceleration, the lower the pH Potential Causes o Maternal BP changes o Placenta previa or abruption o Regional anesthetics o Post-maturity; IUGR o Severe anemia o Smoking o Poor nutrition o Asthma o Tachysystole Nursing priorities o Change maternal position (lateral) o Correct maternal hypotension: elevate legs o Increase IV rate o Palpate uterus o D/C Pitocin o O2 @ 10 L/min with tight face mask o Internal monitor o Fetal scalp or acoustic stimulation o Fetal O2 sat Variable Decels- Occur in about 50% of labors Most common deceleration Abrupt, sharp dips U, V, or W shape May have “shoulders” Recovery in 8 to 27 seconds, anything longer is slow recovery Umbilical cord compression (fetal blood flow decreased so O2 decreased) Nuchal cord; knots in cord; prolapsed cord; cord compressed by pelvic bones or around body May be due to oligohydramnios, usually in post-term pregnancies Amniotomy increases risk More common in preterm labor Usually transient and correctable Usually not concerning unless decel is less than 70 bpm & lasts more than 60 seconds Could indicate hypoxia Nursing Priorities o Change maternal position (side to side or knee/chest) o D/C Pitocin o O2 @ 8-10 L/min with tight face mask o Assist vaginal or speculum exam to assess for cord prolapse o If ordered, assist with amniofusion o Fetal O2 sat o Assist with birth if unable to correct Considered reassuring if: o Duration lasts less than 30 secs. o Rapid return to baseline from nadir o Moderate FHR variability or accelerations present o Normal FHR variability and not increasing “Veal Chop” V – Variable C – Cord Compression E – Early H – Head Compression A – Acceleration O- oxygenation activity L – Late P – Placental-uteral insufficieny Prolonged Decels- Decrease in FHR of 15 beats/minute or more for more than 2 minutes and less than 10 minutes in duration Associated with: maternal hypotension, uterine tachysystole, cord prolapse, uterine rupture, or fetal hypoxia Interventions- o Vaginal exam—imminent delivery, cord present o Treat hypotension o IV bolus o Position change o Oxygen o Treat uterine tachysystole Tachycardia o Baseline FHR greater than 160 beats/min for 10 minutes or longer or more than 30 above baseline for more than 30 minutes o Mother’s fever most frequent cause (causes acceleration of fetal metabolism); prolonged rupture of membranes, dehydration, anxiety, hyperthyroidism, drugs, fetal infection o Significance: ominous if associated with late decelerations, severe variable decelerations, and/or absence of variability o Possible Fetal Causes: acute hypoxia, prematurity, infection, asphyxia, anemia, prolonged stimulation, arrhythmias o Nursing Care: review maternal history; oxygen; alleviate cause; treat fever Bradycardia- o Baseline FHR less than 110 beats/min for 10 minutes or longer or 30 beats below normal baseline for 30 min. o Significance: ominous if associated with loss of variability and late decelerations; later sign of fetal hypoxia o Possible Causes: terminal hypoxia, drugs, anesthesia, hypotension, cord prolapse or prolonged compression, congenital heart block o Nursing Care: oxygen; alleviate cause Sinusoidal Patterns o Regular, smooth undulating wavelike pattern o Uncommon o Classically occurs with severe fetal anemia o Related to fetal release of arginine vasopressin (ADH), which may cause fluctuations in BP & FHR o ADH released when fetus has volume depletion such as severe anemia o Apparently may be released during hypoxia, metabolic acidosis, or asphyxia Reassuring FHR patterns- o Baseline FHR in normal range of 110 to 160 beats/minute with no periodic decelerations and moderate baseline variability o Accelerations with fetal movement o Almost always associated with normal fetal acid-base status Nonreassuring FHR patterns o Progressive increase or decrease in baseline rate o Tachycardia o Progressive decrease in baseline variability o Severe variable decelerations Fetal Distress o Meconium-stained fluid in a vertex presentation o Changes in FHR Late decelerations Severe variable decelerations Decrease or lack of variability Bradycardia Some colors of meconium o Dark green (acute staining) o Black green (fresh) o Brown or muddy-brown (not fresh, chronic staining) o Yellow-brown (old) Meconium Consistency o Watery o Thinly stained o Thin, light o Turbid, viscous o Particulate, thick Fetal Distress nursing Priorities o 1. Increase blood volume (increase IV; correct hypotension; elevate legs) o 2. Open maternal and fetal vascular system (change position) o 3. Increase oxygenation of blood volume (decrease oxytocics; oxygen at 8-10 L/min via facemask) Documenting decelerations o Duration & Depth o Assessments o Actions o Communications o Fetal & Maternal Responses to Actions RESCUE o R---Review history o E---Evaluate tracing o S---State baseline o C---Classify your findings (accels, decels, etc.) o U---You provide interventions o E---Evaluate interventions and call health care provider 3 tier fetal heart interpretation system o Category I: Normal Includes all of the following: Baseline 110 to 160 bpm Moderate baseline variability Absent late or variable decels Present or absent early decels Present or absent accelerations o Category II: Indeterminate Include all tracings not categorized as Category I or Category III Examples: Bradycardia not accompanied by absent baseline Tachycardia Minimal, Absent, or Marked variability No accelerations after fetal stimulation Periodic or episodic decelerations o Category III: Abnormal Predictive of fetal acid-base status Require immediate evaluation & intervention Include either sinusoidal pattern or absent baseline FHR variability & any of the following: Recurrent late decelerations Recurrent variable decelerations Bradycardia o 2008 National Institute of Child Health & Human Development Workshop Labor & Birth Process and Nursing Care Terms for Labor/Birth o Intrapartum o Confinement o Parturition o Childbirth Factors influencing the process of Labor o The five P's: Passageway Passenger Powers Position Psyche Passaageway- o Diameters of maternal pelvis: Pelvic inlet Midpelvis Pelvic outlet o Midplane- o Transverse or interspinous diameter o Normally largest plane and greatest diameter o 10.5 cm. Pelvic outlet o Transverse diameter (intertuberous diameter) presents smallest plane of pelvic canal: o > or = to 8 cm Types of Pelvis o Gynecoid (what you want) most common (50%), good measurements transverse and anterior and posterior o Android more heart shaped, can have vaginal but if more constricted maybe c section (23%) o Anthropoid more oval (24%) could have vaginal or C section o Platypelloid (3%), more flattened o Combination o Type of delivery not only depends on shape but size of shape, cannot always garuntee what type of delivery based on shape alone Cervical Dilatation and Effeacement o Cervical dilatation: involuntary widening of the cervical os., Widening from 0 cm to 10 cm. o Cervical effacement: shortening and thinning of the cervical canal. Expressed in %, 0-100% o Dilatation starts earlier in primigravida but the overall progression is slower o For multigravida dilatation, effacement, and lightening usually does not start until it is true labor Fetal Sutures o Junction of the adjoining bones of the fetal skull o Allow for molding of the fetal head o Help examiner identify position of fetal head during vaginal exam. o Frontal suture o Coronal suture o Sagittal suture o Lambdoid suture o o Fontanelles o Intersections of cranial sutures o Clinically useful in identifying position of fetal head in the pelvis. Anterior: diamond-shaped, closes by 18 months of age Posterior: triangular-shaped, closes by 6 to 8 weeks of age Molding o Overlapping of cranial bones to adapt to pelvic diameters Fetal Attitude o Relationship of the fetal parts to each other o Most fetus’ assume an attitude where head is markedly flexed with chin upon the chest, thighs flexed over abdomen and arms crossed over chest. o Want to see everything flexed – including head – if not may have difficulty with delivery o Alterations in fetal attitude cause fetus to present various diameters of the head to the maternal pelvis. o With increased extension of the passenger’s head, a larger diameter of the fetal skull must be accommodated to the pelvis. o Look at slides 36-38 for positions*** Presentation: Breech o Occurs in 3% of term births o Complete Body is flexed but upside down o Incomplete Everything is flexed but something (such as a leg) is sticking up o Frank Everything is flexed except both legs are sticking up o Footling Feet come out of birth canal first (slide 41) o Fetal Lie o Refers to relation between the long axis of the fetus and the long axis of the mother. Longitudinal or Vertical: long axis of the fetus is parallel with the long axis of the mother. Transverse, Horizontal, Oblique: long axis of the fetus is at right angles to that of the mother. Fetal Position o Prominent part of presenting part in relation to pelvis Cephalic = O Occiput Breech = S Sacrum Brow/face = M Mentum or Chin Shoulder = Sc Scapula o Its in relation to MOMS anterior and posterior and Right and Left o Cephalic: pertaining to head; head first o Vertex: crown or top of head o Prominent part to the Right or Left o Prominent part Anterior, Posterior, or Transverse o ROA and LOA are most common, that ones you wanna have o Do not look at where he is facing, its where the prominent piece of the skull is in relation to the pelvis Methods to determine fetal position o Leopold maneuvers o Vaginal exam o Ultrasound Fetal Station o Location of the presenting part in relation to level of the ischial spines. Expressed in cm’s. Level of the ischial spines is zero (0). Above the spines is -1, -2, etc. Below the spines is +1, +2, etc. Station -5 is at the pelvic inlet. +4 is at the pelvic outlet. o Engagement o Largest diameter of the presenting part reaches or passes through the pelvic inlet. BPD (biparietal diameter) in a cephalic presentation has reached the ischial spines (0 station) Engaged Floating Synclitic or asynclitic position Powers (uterine contractions) o 3 Phases: increment: acme: decrement: o Frequency: o Duration: o Intensity: o Duration is from beginning to end o Want to look at a strip for at least 10 min to get frequency Intensity of contractions o Mild: slightly tense & easy to indent (nose) o Moderate: firm & difficult to indent (chin) o Strong: rigid, board-like & almost impossible to indent (forehead) o External monitoring will not tell you how strong the contraction is Theories of onest of labor o Oxytocin stimulation theory o Progesterone withdrawal theory o Estrogen stimulation theory o Fetal cortisol theory o Uterine distention theory Impending (premonitory) signs of labor o Lightening o Increased vaginal discharge o Bloody show o Sudden burst of energy o Stronger Braxton-Hicks contractions o Cervical ripening o Diarrhea, nausea/vomiting, indigestion o Return of urinary frequency o Backache o Weight loss 0.5-1.5 kg. o Possible rupture of membranes Rupture of Membranes o SROM: Spontaneous rupture of membranes o AROM: Artificial rupture of membranes, amniotomy o Determining if they have ruptured Positive fern test (looks like fern leaves under microscope) Positive nitrazene test (dark blue/purple) pH of amniotic fluid is 6.5-7.5 o Nursing care with ROM Assess FHR- 1 thing if you are with her ****** Assess fluid for color, amount, odor Record time of rupture Monitor maternal temperature every 2 hours Provide comfort measures When should mother come to labor/delivery unit? o If the membranes rupture o Steady, 5-7 mins apart contractions for at least an hour o Vaginal bleeding o Decreased fetal movement o Symp of HBP, visual disturbances, headache What are the initial priorities of care upon admission ? o Assess FHR o Mothers vitals o Determine due date o Check membranes o Any kinds of problems during pregnancy o Determine if in labor and how far along (do a vaginal exam) Admission Data o Prenatal data o Time, onset, frequency, duration, and intensity of contractions o Location and character of discomfort o Persistence of contractions despite changes in position and activity o Presence & character of vaginal discharge or show o Status of amniotic membranes: SROM; AROM; amount, color, unusual odor o Nitrazine test or Fern test o Birth Plan o Psychosocial factors o Cultural factors Stages of Labor o First stage Early (latent) phase (0-3 cm) Active phase (4-7 cm) Transition phase (8-10 cm o Second stage: full dilatation and effacement through birth Full dilatation and effacement to birth Latent: rest and calm Descent: active pushing Ferguson Reflex presenting part of the baby is pressing on stretch receptors of the pelvic floor of mom When this happens is when mom should start pushing Just b/c fully dilated and fully effaced does not mean she is ready to push, should feel pressure b/c of Ferguson reflex Transition: presenting part on perineum and most effective bearing-down efforts o Third stage: from the birth of baby to expulsion of placenta From birth until placenta expelled Placenta separation indicators: Firmly contracting uterus Change in uterine shape from discoid to globular as placenta moves into lower uterine segment Sudden gush of dark blood from introitus Apparent lengthening of umbilical cord as placenta descends to introitus Finding of vaginal fullness (placenta) on vaginal or rectal exam or of fetal membranes at introitus o Fourth stage: first one to two hours after birth o Immediate care of Mother: 3 and 4 stages o Oxytocics o Immediate postpartum assessment o Infant contact o Maternal Systemic Response to Labor o Increased BP during contractions o Decreased pulse during labor o Supine hypotension o Diaphoresis, hyperventilation o Delayed GI emptying o Pain referred to lower abdominal wall and areas over the lumbar region and upper sacrum o Elevated WBC count o Decreased bladder tone o Temperature may be slightly elevated o Blood glucose levels may decrease Fetal Response to Labor o Fetal lung fluid cleared o PCo2 increases o Po2 decreases o Fetal respiratory movements decrease o Fetal heart rate has decreased progressively as term is reached Mechanisms of Labor o Series of maneuvers in order that the fetal body parts align in a favorable manner to pass through the birth canal, to accommodate to the pelvis. Also referred to as the cardinal movements: o Engagement o Descent o Flexion o Internal Rotation – his head rotates but his body will stay like it is o Extension o Restitution and External Rotation basically stops rotating o Birth by Expulsion o He extends and then his head externally rotates back to where it was (after head is born) o With these movements it is only the head that is moving until birth by expulsion Evaluating Labor Progress o Frequency of fetal heart rate and uterine contraction assessments: o Low-risk women: at least every 30 minutes in first stage and every 15 minutes in second stage o High-risk women: at least every 15 minutes in first stage and every 5 minutes in second stage Physical Care During Labor o General Hygiene o Nutrient & Fluid Intake o Voiding o Bowel Elimination; Rectal Pressure o Ambulatory Woman o Woman on Bed Rest Non-Pharmacologic Comfort Measures- o Support, explanations o Relaxation, focused breathing, effleurage, massage, sacral pressure, frequent mouth care, change linens, cool cloth on forehead, music o Encourage frequent voiding, catheterize as necessary o Position changes, hydrotherapy, birthing ball o Protect privacy and modesty Nursing Diagnoses o Risk for deficient fluid volume related to fluid intake and increased fluid loss during labor and birth o Impaired urinary elimination related to sensory impairment secondary to labor o Fatigue related to energy expenditure required during labor and birth o Anxiety related to labor and birthing process o Acute pain related to increasing frequency and intensity of contractions o Ineffective coping related to birthing process Fetal Danger signs in Labor o High or low fetal heart rate o Non-reassuring FHR patterns: fetal bradycardia (<110 bpm for >10 min); fetal tachycardia (>160 bpm for >10 min); late, severe variable, and prolonged deceleration patterns with decreased variability o Meconium staining, especially vertex o Hyperactivity o Fetal acidosis o If he is in breech you are more likely to see meconium o More risky to see meconium in vertex than in breech – sign of fetal distress Maternal Danger Signs in Labor o Rising or falling BP o Abnormal pulse o Inadequate or prolonged contractions (contraction interval < 2min, contractions consistently lasting > 90 seconds) o Vaginal bleeding o Temperature > 38 0 o Foul smelling amniotic fluid Mechanism of Birth: Vertex o Crowning – see the whole top part of the head o Ritgen maneuver o Nuchal cord o Suction immediately after birth for meconium-stained fluid in depressed infants but not for meconium-stained vigorous term gestation infants Episiotomies o Clear research evidence showing that episiotomies are likely to be harmful or ineffective o Increased PP pain, blood loss, risk for infection, 3 & 4 degree lacerations o Routine performance declined in US o Europe side-lying birth position used Lacerations- o Episiotomy o Midline: o Mediolateral: o Perineal lacerations: o First degree: involves fourchette, vaginal mucous membrane, no muscle involvement o Second degree: also involves muscles of the perineum o Third degree: also involves rectal sphincter o Fourth degree: also involves the rectal mucosa Management of Labor Discomfort- Factors Influencing Pain- o Perception o Expression o Physiology o Culture o Anxiety o Previous Experience o Environment o Comfort o Support Non pharmacologic comfort measures o Support, explanations o Frequent mouth care o Change linens o Cool cloth on forehead o Encourage frequent voiding, catheterize as necessary 30 ml every hour; check bladder at least every 2 hours If bladder is too full o Position changes, birthing ball o Protect privacy and modesty Nonpharmacological management- o Cognitive Strategies: Childbirth Education---Focusing, Relaxation, Breathing Hypnosis Biofeedback o Breathing Techniques- Slow-paced: 6-8 per minute; not less than half normal breathing***; latent into active; IN 2 3 4, OUT 2, 3, 4 Works best in LATENT into ACTIVE phase Modified-paced: 32-40 breaths per minute; not more than twice normal breaths; active into transition; IN OUT IN OUT Patterned-paced: same rate as modified; 3:1, 4:1; - the one is a big breathe out, so 3 short blows out and 1 big blow out enhances concentration; transition phase Cleansing breath first for all 3; at the start of a contraction and at end Can combine slow and modified-paced Do these during a contraction not really in between o Sensory Stimulation Strategies: Aromatherapy Breathing Techniques Music Imagery Focal Points o Cutaneous Stimulation Strategies: Counterpressure Use fist or tennis ball to press on lower back Effleurage Massage center to outer (abd) Very light touch Relaxes abd. Therapeutic Touch and Massage Must be trained to do this Walking Rocking o Application of Heat or Cold Must be careful culturally o Transcutaneous Electrical Nerve Stimulation (TENS) 2 pairs of electrodes Low intensity waves of electricity Battery operated, mother can turn to high during contraction and low when over Helps in latent into active phase Low back pain o Acupressure o Water Therapy o Intradermal Water Block 0.1 ml of sterile water injected Pic on slide 19 Works for about 45 mins to 2 hours; used in early labor Pharmacologic Management- o Epidural (Block) Analgesia Used for regular virginal labors Usually injected in the active phase of the first stage (can be given during transition but for multigravida may be too late b/c not enough time) Can slow down labor at first HYPOTENSION- load mother up with IV fluid o Spinal (Block) Analgesia Usually used for a C-Section Cannot be given until late in the first stage (must be fully dilated) May get headache b/c spinal fluid leaks outs o Combined Spinal-Epidural (CSE) Analgesia (“Walking Epidural”) Puncture the dura first for the spinal then pull back to leave catheter in the epidural space o Sedatives o Systemic Analgesia: o Opioid Agonist Analgesics o Opioid Agonist-Antagonist Analgesics o Opioid Antagonists o Pudendal Block o Local Infiltration Analgesia o Nitrous Oxide (Canada & Europe) o General Anesthesia o o Intrathecal- o Newer technique o Same place and technique as epidural o Same prerequisites o Very small dose of an opiate (usually morphine) or an opiate mixed with local anesthetic Fentanyl Sufantynl Or a combination of the 2 o Toxic effects minimal; possible itching and nausea o Better fetal tolerance; mother more relaxed; feels urge to push; progresses well o This is a one shot deal o Side effects are a lot less than with epidural or spinal block Baby and mother tolerate it better Possible Complications- o Maternal Hypotension With Decreased Placental Perfusion o Postdural Puncture Headache (PDPH) o Fetal Bradycardia (Combined SE) o Urinary Retention and Stress Incontinence o Elevated Temperature (Epidural) o Dizziness, Sedation, and Weakness of Legs o CNS Effects o Respiratory Arrest Maternal Hypotension Interventions-************ o Turn woman to lateral position, or place pillow or wedge under hip to displace uterus o Maintain IV per order and protocol o Administer O2 by face mask at 10 to 12 L/min or per protocol o Elevate legs o Notify health care provider and anesthesia professional o Administer IV vasopressor per protocol if above measures ineffective o Remain with woman o Continue to monitor BP & FHR every 5 minutes until stable and per order PDPH Treatment- o Oral Analgesics o Bed rest in quiet dimly lit or dark room o Caffeine o Increased fluid intake o May keep flat for at least 8 hours past administration of spinal anesthesia o Epidural blood patch if necessary General Nursing Care – o Assess factors influencing pain response o Provide comfort and support o Decrease stimuli in environment o Encourage nonpharmacologic management of discomfort o Promote relaxation and breathing techniques o Explain advantages and disadvantages of pharmacologic options o Have patient empty bladder before epidural, spinal, or combination, and empty every 2 hours thereafter o Monitor vital signs, especially BP, and fetal heart rate per protocol o Monitor effects of anesthesia or analgesia during labor and postpartum Labor and Birth Complications Dystocia o A difficult labor, a labor that is made longer or more painful by problems associated the five P's: Powers Passage Passenger Position Psychological Responses Powers o Primary- mom does not influence, she cannot control Leads to cervical change o Secondary- mom does control (while pushing) Probs w/ primary powers o Hypotonic – lot of contractions but they are low amplitude, just kinda crampy o Infrequent- strong but not occurring fast enough o I&H- not occurring strong or fast enough o Tachy- too many, can cause hypoxia o Hypertonic uterine dysfunction o Occurs during latent phase o Least common o Constant muscle tension, but no cervical change o noT effective in causing cervical dilation o Frequent low contractions o Extremely painful o Most often in anxious primigravida o Highest rate in women age 40 or older o Lowest rate in women ages 20 to 24 o Happens more in older first time moms o Risks: Maternal exhaustion, dehydration due to prolonged labor Fetal hypoxia > distress Fetal distress d/t decreased resting time between contractions o Medical management: 4 to 6 hour rest, fluids, sedatives No oxytocin Mom will likely wake up in labor after rest Hypotonic Uterine Dysfunction o Active phase dysfunction o Uterine contractions decrease in strength and frequency after the onset of true labor o Weak irregular contractions during the active phase of labor o Irregular, low amplitude contractions o Less than 1 cm dilatation per hour o Or No cervical dilatation in 2 hours o (Arrest of progress) o Etiology: Bladder distension Sedation CPD (baby too big for moms pelvis) o Risks: Infection PP hemorrhage due to uterine atony Maternal exhaustion Dehydration Mom is contracting but not making any progress. Labor is slow so mom gets tired, membranes are ruptured so risk of infection Hemorrhage due to uterine muscles being tired o Medical management: R/O CPD or presentation that would prevent a vaginal birth. (R/O = rule out) If CPD R/O, amniotomy and pitocin augmentation are used. Active Management of Labor (AMOL) Protocols o Labor is managed with amniotomy, timed cervical examinations, and Pitocin augmentation if adequate progress is not made. o Decreases ris
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