exam 2 - fetal surveillance

Question 1

A 42 yo gravida 3, para 1102 at 38 weeks estimated gestational age (EGA) is in labor. She asks about whether she requires electronic fetal monitoring.

Question 2

fetal surveillance: hx and intention

Answer 2

-In 1958, when the technology was first introduced by Dr Edward Hon, it became possible to evaluate the fetal heart rate electronically in labor
-The fetal heart rate patterns could screen for hypoxic-ischemic encephalopathy, cerebral palsy, and potential fetal demise
-With improvement in anesthesia, blood transfusions, surgical technique, and with better antibiotics, in the postwar era, obstetricians gradually began performing operative deliveries for the welfare of the fetus as well as for that of the patient
-Over time, a perfect or near-perfect outcome for parturient and fetus became the expectation
-Caesarean section also demonstrated that everything possible had been done to deliver a healthy fetus to a healthy patient
-Thus, electronic fetal monitoring became a potential source of litigation as well as a source of data in labor and delivery as well as in prenatal care, when indicated
-A meta-analysis of >37,000 patients found that continuous electronic fetal monitoring is not associated with:
-Improved Apgar scores
-Reduced hypoxic-ischemic encephalopathy
-Neonatal mortality

Question 3

Electronic fetal monitoring has definitely accomplished one thing:

Answer 3

it has increased the Caesarean section rate

Question 4

Percent increase in rate of placenta accreta syndrome in the U.S., 1970s-2016

Question 5

incidence of electronic fetal monitoring

Answer 5

Fetal monitoring is the most common procedure performed in Labor and Delivery units in the United States and is used in over 80% of parturients

Question 6

when should fetal HR monitoring be performed

Answer 6

-during labor -> intermittently in low risk parturients
-in outpatient settings:
-High risk pregnancies, such as in:
-Diabetes mellitus
-Hypertensive disorders of pregnancy
-And many other conditions
-As indicated, such as in:
-Decreased fetal movement
-Post-term pregnancies

Question 7

recommendations for performance of intrapartum intermittent auscultation

Answer 7

dont need to know

Question 8

intermittent auscultation by doppler stethoscope

Question 9

fetal heart rate monitoring

Answer 9

-Transducer transmits fetal heart tones to monitor equipment
-Tocodynamometer detects uterine contractions
-pt may mark fetal activity
-FHR is read on top part of strip
-Uterine activity is read on bottom part of strip

Answer 10

-110-160 normal HR
-contracting every 1-2 minutes

Question 11

baseline fetal HR on fetal heart rate strip

Answer 11

-Mean FHR rounded to increments of 5 beats per minute over a 10 minute segment
-Should range from 110-160 bpm
-Baseline FHR <110 bpm: fetal bradycardia
-Baseline FHR >160 bpm: fetal tachycardia

Question 12

fetal heart rate monitoring: variability

Answer 12

-Amplitude range (from peak HR to trough HR)
-This tracing illustrates variability of 10 BPM (moderate)
-Absent: 0 bpm; an ominous finding
-Minimal: 0-5 bpm; may represent fetal sleep or acidemia
-!!!!Moderate: 5-25 bpm; associated with adequate fetal oxygenation
-Marked: >25 bpm; may be normal variant or may be a response to hypoxemia after oxygenation is restored
-you want moderate variability
-if its minimal- may be asleep

Question 13

fetal heart rate monitoring: accelerations

Answer 13

-increase in fetal HR from baseline of at least 15 beats per minute, lasting at least 15s
-indicated oxygenated fetus
-Represents fetal well-being
-Increase of ≥15 bpm above baseline lasting ≥15 sec
-accelerations at 2 minutes and another 1 minute later

Question 14

fetal heart rate monitor: decelerations

Answer 14

-3 types:
-Early (due to head compression; normal in labor) -> could mean pt is dilated and ready to deliver
-Variable (due to cord compression: against uterine wall, against fetal body, compressed by fetal hand)- occasional is fine
-Late (due to uteroplacental insufficiency)- BAD- not enough O2 to placenta
-cause of decelerations:
-compression of uterine myometrial vessels- late
-compression of umbilical cord- variable
-normal compression of fetal head- early

Question 15

fetal heart monitoring: early decelerations

Answer 15

-Characterized by a GRADUAL (onset to nadir ≥30 sec) decrease in FHR during a uterine contraction
-Nadir of deceleration occurs at the same time as the peak of the contraction
-Caused by !head compression!
-HR 150 baseline
-NORMAL

Question 16

fetal heart monitoring: variable decelerations

Answer 16

-Defined as an ABRUPT! (ONSET to nadir ≤30 sec) decrease in FHR below the baseline of at least 15 bpm and lasting for at least 15 bpm to up to 2 minutes
-Common in labor
-not always associated with contraction
-!!!Caused by umbilical cord compression

Question 17

fetal heart monitoring: late decelerations

Answer 17

-Characterized by a GRADUAL (onset to nadir ≥30 sec) decrease in FHR during a uterine contraction
-Onset, nadir and recovery of deceleration occurs after the beginning, peak and end of the contraction -> dont line up
-!!Caused by uteroplacental insufficiency

Question 18

Answer 18

-late decelerations with absent variability

Question 19

Answer 19

early, late, and variable decelerations

Question 20

Answer 20

fetal bradycardia
-<110
-MC during epidural

Question 21

fetal bradycardia Etiologies

maternal vs fetal

Answer 21

Parturient:
-Epidural administration
-Uterine dehiscence/rupture
-Cord prolapse
-Rx (narcotics)

Fetal:
-Fetal hypoxia/acidosis
-Complete heart block in fetus due to maternal SLE

Question 22

fetal tachycardia etiology

maternal vs fetal

Answer 22

Maternal etiologies
-Maternal fever
-Maternal infection
-Maternal tachycardia
-Maternal drug use (cocaine, etc.)
-Maternal anxiety

Fetal etiologies:
-Fetal anemia
-Fetal hypoxia
-Fetal infection
-Prematurity

Question 23

National Institute of Child Health and Human Development (NICHHD) interpretations of electronic fetal monitoring

Answer 23

-In place since 2008
-Developed in partnership with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine
-Get the free app: EFM Guide

Question 24

interpretation of FHRs as per NICHHD, ACOG, and society for maternal fetal medicine guidelines: CATEGORY 1

Answer 24

-Category 1: normal
-MUST CONTAIN ALL OF THE FOLLOWING:
-Baseline FHR=110-160 bpm
-Moderate variability
-Accelerations are present or absent
-Early decelerations are present or absent
-MAY NOT CONTAIN: late or variable decelerations
-category 1 tracings are strongly predictive of normal fetal acid-base balance
-proceed with routine care

Question 25

reactive strip

Answer 25

-In outpatients, a Category 1 strip with at least two (2) accelerations present in 20-30 minutes is considered to be reactive -This is usually considered sufficient evidence of good fetal oxygenation so that the patient can be discharged, assuming there are no other concerns

Question 26

Interpretation of FHRs as per NICHD, ACOG, and Society for Maternal-Fetal Medicine guidelines: CATEGORY 3

Answer 26

-CATEGORY III: ABNORMAL -OCCURS WITH !ABSENT FHR VARIABILITY! -!!AND WHEN AT LEAST ONE OF THE FOLLOWING IS ALSO PRESENT: -Recurrent late decelerations -Recurrent variable decelerations -Fetal bradycardia -Sinusoidal heart rate -TX: -May administer O2, or not -Change maternal position to side -Consider discontinuation of oxytocin administration -Increase maternal BP, if indicated, via IV hydration -!!!Clear any potential obstacles to delivery -Ensure you have all personnel needed for emergent C/S -Attending obstetrician-gynecologist -PA or resident -Anesthesiologist and/or CRNA -Scrub nurse or scrub technician -Circulating nurse -Neonatologist or pediatrician (one per neonate) -Neonatal nurse (one per neonate) -other things you must have: -Signed, witnessed consent on chart -Foley catheter -Adequate anesthesia -IV antibiotics given -Antacid given -prep and drape: splash and clash if needed

Question 27

Interpretation of FHRs as per NICHD, ACOG, and Society for Maternal-Fetal Medicine guidelines: CATEGORY 2

Answer 27

CATEGORY II: INDETERMINATE -Any tracing whose pattern is NOT included in Category I or in Category III TX: If persistent → try to improve uteroplacental perfusion. -Discontinue uterotonics -Consider administration O2 to patient via face mask -However, it is potentially of no benefit -You may see O2 used, or not used -Increase IV hydration (1 liter of D5LR IV wide open) -Turn patient to side to decrease IVC compression and to increase venous return

Question 28

which of the following categories best describes the tracing displayed

Answer 28

category 1 -moderate variability -many accelerations

Question 29

biophysical profile

Answer 29

-assess fetal well being in real time US -takes up to 30 minutes to perform -> score 0-10 -score 0 OR 2 for each of 5 parameters -cannot receive score of 1 for a parameter -8-10/10 is reassuring of no immediate danger of fetal death -Expeditious delivery is indicated for any score <8/10

Question 30

Biophysical profile: Parameter 1: Fetal heart rate monitoring

Answer 30

-discussion of fetal monitoring as above -considered reactive if a category 1 strip with accelerations over the course of 20-30’ -reactive FHR: score 2 -nonreactive FHR: score 0

Question 31

biophysical profile parameter 2: gross fetal movement

Answer 31

-2 gross movements of body/limb in 30’ (score 2) -<2 movements: score 0

Question 32

biophysical profile parameter 3: fetal breathing movements

Answer 32

-Fetal breathing movements: watch chest for rise and fall; must have 1 or more episodes of breathing x 20 sec in 30’ -If absent=score 0

Question 33

biophysical profile parameter 4: fetal tone

Answer 33

-At least 1 episode of opening and closing hand or extension and flexion of limb and/or trunk during BPP (score 2) -absent = 0

Question 34

biophysical profile: parameter 5: amniotic fluid index

Answer 34

-Amniotic fluid index: divide abdomen in 4 quadrants and measure largest vertical pocket of fluid with no fetal parts, cord or placenta in it -Sum of size of all pockets=AFI -5-25 cm: normal (score 2) -<5 cm: oligohydramnios; score 0 ->25 cm: polyhydramnios; score 0

Question 35

which of the following most correctly describes a fetal heart rate pattern consistent with category 2

Answer 35

-baseline of 144 bpm; presence of moderate variability and accelerations -baseline of 165 bpm; presence of minimal variability and variable decelerations -baseline of 130 bpm; presence of moderate variability; absence of accelerations or decelerations -baseline of 150 bpm; absent variability; presence of late decelerations

Answer 36

-variable decerlations -cat 2 -variable HR -persistent -> can lead to acidosis if nothing is done

Answer 37

early decelerations -130bpm

Answer 38

minimal variability late decelerations

Answer 39

variable intermittent decelerations -moderate variability