Fetal Assessment During Labor
Fetal Assessment During Labor NSG 330
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This 0 page Class Notes was uploaded by Brieanna Phipps on Monday March 14, 2016. The Class Notes belongs to NSG 330 at University of North Carolina - Wilmington taught by Dr. Goff in Spring 2016. Since its upload, it has received 16 views. For similar materials see Maternal Infant in Nursing and Health Sciences at University of North Carolina - Wilmington.
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Date Created: 03/14/16
Fetal Assessment During Labor Goff MaternalFetal Unit 0 O 0 000000 0 Labor is a period of physiologic stress for the fetus Fetal oxygen supply must be maintained Frequent monitoring of fetal status is an important nursing care Circulation affects oxygenation resulting in changes of fetal heart rate Maternal position or exercise Maternal blood pressure changes or hypovolemia Contractions Reduction of 02 in maternal blood Alterations in fetal circulation due to cord compression or other problems Reduction in blood ow to intervillous spaces in placenta part of Fetal Monitoring Techniques 0 O O O Intermittent Auscultation Continuous Electronic Fetal Monitoring Count baseline FHRin between contractions LEA ILDF v we Lee Fig 216 ereee ef meeimei inn temeily ef fetal heart tenee fer differing peeitiene rigl ii eeerum enlerier HOP right eeeispiieeeelerier EMA right mentum errterier RDA right eeeipiteemerier LEA left eeler39urri enterier LOP left eeeipiteeeeterier l irlfl 3lw left merltumi emlerier L left eeeipifeehterien Fri Preeemtetien is usually icrreeeh if EH39lfe are heard ebeee umbilieue Eu PFEEE ll llll l39ll l5 U S U lllly 39FE39IE EI ll FlHTE are l l lfi l l l Iurileilieue Cepyrigh i EDD has M by ll m ei filieie Elleexr39ier line elm rights weeeruee Electronic Fetal Monitoring EFM O O O 0 Useful tool for visualizing fetal heart rate patterns on monitor screen or printed tracing Fetal wellbeing assessed by response of FHR to uterine contractions Primary mode of intrapartum fetal assessment since the 197039s Researchers and clinicians believe that interpretation is often subjective and dif cult leading to erroneous assessment of fetal physiologic condition External Monitoring 0 Ultrasound transducer Monitors fetal heart rate Apply gel amp place over PMI of FHT Check gel and reposition if necessary 0 Toco transducer Monitors contractions Placed on fundus Internal Monitoring 0 0 Spiral electrode FSE attached to presenting part to monitor FHR quot3 Fetal scalp electretle FEEL an internal fetal heart meniter intrauterine tiresatire catheter llUFEL an internal rer1trattiert maniter Solid or uid lled intrauterine pressure catheter IUPC Used when external monitor not recording contractions well More accurate Membranes must be ruptured Must be in active labor with suf cient dilation amp 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 O O O O Contraction Pattern or Uterine Activity Baseline Rate Variability Accelerations Decelerations Uterine Activity Assessment 0 O O O 0 Frequency Duration Intensity Resting Tone pressure when uterus not contracting should be soft Relaxation Time time in between contractions when uterus is relaxed At least 60 seconds in active phase At least 45 seconds in second stage Contractions quanti ed as number present in a 10minute window averaged over 30 minutes O O 0 Normal average is 5 or less Greater than 5 is called tachysystole Applies to both spontaneous amp stimulated labor but response may be different 0 Causes of Tachysystole O O O O O Pitocin Prostaglandin Cocaine Hypoxia Abruption Treatment of tachysystole O O O O O Decrease or stop pitocin Remove cervidil IV bolus of LR or NS Oxygen Terbutaline SQ if abruption RO Assessment of FHR 0 000000000 Before initiation of laborenhancing procedures Ambulation Administration or initiation of analgesia or anesthesia Transfer or discharge of client AROM or SROM Vaginal exam Ambulation After admission of client Recognition of abnormal uterine patterns Administration of meds Effect of Medications on FHR O O Butorphanol Stadol Transient sinusoidal pattern Decreased variability Cocaine Zidovudine AZT Meperidine Demerol No characteristic changes Corticosteroids such as betamethasone or dexamethasone Dec variability with betamethasone not seen w dexamethasone Morphine Dec frequency of accelerations Nalbuphane Nubain Dec frequency of accelerations Decva abH y Terbutaline Abolishment or dec in frequency of late or variable decelerations Magnesium Sulfate Dec baseline and variability 0 Frequency of FHR Auscultation 0 Obtain 20minute strip on all clients admitted to labor unit 0 Low risk every 30 minutes active phase and every 15 minutes second stage 0 High risk every 15 minutes active phase and every 5 minutes second stage 0 Characteristics of FHR o BaseHne Average rate during a 10minute 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 beatsmin 110 to 160 beatsminute o Variability Irregular uctuations in baseline FHR of two cycles per minute or greater At least 510 beat to beat variability indicates a welloxygenated 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 beattobeat Long term or uctuations over time 0 Both tend to increase or decrease at same time Factors affecting Variability Gestation Fetal activity Fetal sleep state Medications Maternalfetal oxygen status Increased Variability Possible Causes early hypoxia fetal stimulation 0 Nursing Care Intervention not necessary if benign continue to closely monitor FHR changes Decreased Variability Possible Causes prematurity drugs hypoxia acidosis arrythmias fetal sleep 0 Nursing Care alleviate cause scalp pH prepare for delivery if indicated 0 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 decelerations late 0 Decelerations Increased parasympathetic response At least 15 BPM for 15 secs and returns to baseline in less than 2 minutes from time of onset quotProlongedquot are 2 to 10 minutes Greater than 10 minutes is a change in baseline Early Decels Fetal head compression Uniform shape quotMirror imagequot Usually dilated 47 cm or when pushing No intervention necessary Late Decels Uteroplacental insuf ciency 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 0 Maternal BP changes Placenta previa or abruption Regional anesthetics Postmaturity IUGR Severe anemia Smoking Poor nutrition Asthma o Tachysystole Nursing priorities 0 Change maternal position lateral Correct maternal hypotension elevate legs Increase lV rate Palpate uterus DC Pitocin 02 10 Lmin with tight face mask Internal monitor Fetal scalp or acoustic stimulation 0 Fetal 02 sat Variable Decels Occur in about 50 of labors Most common deceleration OOOOOOO OOOOOOO Abrupt sharp dips U V or W shape May have quotshouldersquot Recovery in 8 to 27 seconds anything longer is slow recovery Umbilical cord compression fetal blood flow decreased so 02 decreased Nuchal cord knots in cord proapsed cord cord compressed by pelvic bones or around body May be due to oligohydramnios usually in postterm pregnancies Amniotomy increases risk More common in preterm labor Usually transient and correctable Usually not concerning uness dece is less than 70 bpm amp lasts more than 60 seconds Could indicate hypoxia Nursing Priorities 0 Change maternal position side to side or kneechest o DC Pitocin o 02 810 Lmin with tight face mask 0 Assist vaginal or speculum exam to assess for cord prolapse o If ordered assist with amniofusion 0 Fetal 02 sat 0 Assist with birth if unable to correct Considered reassuring if 0 Duration asts less than 30 secs 0 Rapid return to baseline from nadir 0 Moderate FHR variability or accelerations present 0 Normal FHR variability and not increasing quotveaIChopquot V Variable C Cord Compression E Early H Head Compression A Acceleration 0 oxygenation activity L Late P Placentaluteral insufficieny Prolonged Decels Decrease in FHR of 15 beatsminute 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 0 Treat hypotension 0 IV bolus 0 Position change 0 Oxygen 0 Treat uterine tachysystole Tachycardia 0 Baseline FHR greater than 160 beatsmin for 10 minutes or longer or more than 30 above baseline for more than 30 minutes 0 Mother39s fever most frequent cause causes acceleration of fetal metabolism prolonged rupture of membranes dehydration anxiety hyperthyroidism drugs fetal infection 0 Signi cance ominous if associated with late decelerations severe variable decelerations andor absence of variability 0 Possible Fetal Causes acute hypoxia prematurity infection asphyxia anemia prolonged stimulation arrhythmias 0 Nursing Care review maternal history oxygen alleviate cause treat fever Bradycardia 0 Baseline FHR less than 110 beatsmin for 10 minutes or longer or 30 beats below normal baseline for 30 min 0 Signi cance ominous if associated with loss of variability and late decelerations later sign of fetal hypoxia 0 Possible Causes terminal hypoxia drugs anesthesia hypotension cord prolapse or prolonged compression congenital heart block 0 Nursing Care oxygen alleviate cause Sinusoidal Patterns 0 Regular smooth undulating wavelike pattern 0 Uncommon o Classically occurs with severe fetal anemia 0 Related to fetal release of arginine vasopressin ADH which may cause uctuations in BP amp FHR 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 0 Baseline FHR in normal range of 110 to 160 beatsminute with no periodic decelerations and moderate baseline variability o Accelerations with fetal movement 0 Almost always associated with normal fetal acidbase status Nonreassuring FHR patterns 0 Progressive increase or decrease in baseline rate 0 Tachycardia 0 Progressive decrease in baseline variability 0 Severe variable decelerations Fetal Distress o Meconiumstained uid in a vertex presentation 0 Changes in FHR Late decelerations Severe variable decelerations Decrease or lack of variability Bradycardia O Some colors of meconium O O O 0 Dark green acute staining Black green fresh Brown or muddybrown not fresh chronic staining Yellowbrown old Meconium Consistency O O O O O Watery Thinly stained Thin light Turbid viscous Particulate thick Fetal Distress nursing Priorities 0 O O 1 Increase blood volume increase IV correct hypotension elevate legs 2 Open maternal and fetal vascular system change position 3 Increase oxygenation of blood volume decrease oxytocics oxygen at 810 Lmin via facemask Documenting decelerations 00000 Duration amp Depth Assessments Actions Communications Fetal amp Maternal Responses to Actions RESCUE 00000 O RReview history EEvauate tracing SState baseline CCassify your ndings accels decels etc UYou provide interventions EEvauate interventions and call health care provider 3 tier fetal heart interpretation system 0 O 0 Category I Normal Includes all of the following 0 Baseline 110 to 160 bpm Moderate baseline variability Absent late or variable decels Present or absent early decels Present or absent accelerations Category II Indeterminate Include all tracings not categorized as Category I or Category III 0 Examples Bradycardia not accompanied by absent baseHne Tachycardia Minimal Absent or Marked variability No accelerations after fetal stimulation Periodic or episodic decelerations Category III Abnormal Predictive of fetal acidbase status Require immediate evaluation amp intervention Include either sinusoidal pattern or absent baseline FHR variability amp any of the following Recurrent late decelerations Recurrent variable decelerations Bradycardia o 2008 National Institute of Child Health amp Human Development Workshop
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