Fetal Assessment During Labor/FHR Pattern and Uterine Contraction Monitoring Flashcards Preview

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Flashcards in Fetal Assessment During Labor/FHR Pattern and Uterine Contraction Monitoring Deck (30):
1

Intermittent Auscultation of the FHR

Intermittent auscultation of the FHR is a low-technology method that can
be performed during labor using a hand-held Doppler ultrasound device, an ultrasound stethoscope, or fetoscope to assess FHR. In conjunction, palpation of contractions at the fundus for frequency, duration, and intensity is used
to evaluate fetal well-being. During labor, uterine contractions compress the uteroplacental arteries, temporarily stopping maternal blood flow into the uterus and intervillous spaces of the placenta, decreasing fetal circulation and oxygenation. Circulation to the uterus and placenta resumes during uterine relaxation between contractions. For low-risk labor and delivery, this procedure allows the woman freedom of movement and can be done at home or a birthing center.

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Guidelines for intermittent auscultation or continuous electronic fetal monitoring

■ Guidelines for intermittent auscultation or continuous electronic fetal monitoring

☐ Low-risk women
X During latent phase, every 60 min
X During active phase, every 30 min
X During second stage, every 15 min

☐ High-risk women
X During latent phase, every 30 min
X During active phase, every 15 min
X During second stage, every 5 min

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Guidelines for intermittent auscultation or continuous electronic fetal monitoring
INDICATIONS (2)

Indications
◯ Potential diagnoses
■ Rule out labor
■ Active labor

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Guidelines for intermittent auscultation following routine procedures (8)

Guidelines for intermittent auscultation following routine procedures
■ Rupture of membranes, either spontaneously or artificially
■ Preceding and subsequent to ambulation
■ Prior to and following administration of or a change in medication anesthesia
■ At peak action of anesthesia
■ Following vaginal examination
■ Following expulsion of an enema
■ After urinary catheterization
■ In the event of abnormal or excessive uterine contractions

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Interpretation of Findings
-A normal, reassuring FHR is

Interpretation of Findings
◯ A normal, reassuring FHR is 110 to 160/min with increases and decreases from baseline.

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Interpretation of Findings:
NURSING ACTIONS
Preparation
Ongoing Care
Interventions

●● Nursing●Actions
PREPARATION OF CLIENT
■● Perform●Leopold●maneuvers●to●determine●point●of●maximum●impulse●(PMI).
■● Auscultate●at●PMI●using●listening●device.
■● Palpate●the●client’s●abdomen●at●uterine●fundus●to●assess●uterine●activity.
■● Count●FHR●for●30●to●60●seconds●to●determine●baseline●rate.
Auscultate●FHR●during●a●contraction●and●for●30●seconds●following●the●completion● of●the●contraction.

ONGOING CARE
■● Identify●any●nonreassuring●FHR●patterns●and●notify●the●primary●care●provider.

INTERVENTIONS
■● It●is●the●responsibility●of●the●nurse●to●assess●FHR●patterns,●implement●nursing●
interventions,●and●report●nonreassuring●patterns●to●the●primary●care●provider.
■● The●emotional,●educational,●and●comfort●needs●of●the●mother●and●the●family● must●be●incorporated●into●the●plan●of●care●while●continuing●to●assess●the●FHR● pattern’s●response●to●the●labor●process.
◯●
The●method●and●frequency●of●fetal●surveillance●during●labor●will●vary●and●depend● on●maternal-fetal●risk●factors●as●well●as●the●preference●of●the●facility,●primary●care● provider,●and●client.●

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DESCRIPTION OF PROCEDURE
Continuous electronic fetal monitoring

ADVANTAGES (5)
DISADVANTAGES (3)

●● Description●of●Procedure
◯● Continuous●electronic●fetal●monitoring
■● Continuous●external●fetal●monitoring●is●accomplished●by●securing●an●ultrasound● transducer●over●the●client’s●abdomen●to●determine●PMI,●which●records●the● FHR●pattern,●and●a●tocotransducer●on●the●fundus●that●records●the●uterine● contractions.

■● ADVANTAGES●of●external●fetal●monitoring
☐● Noninvasive●and●reduces●risk●for●infection
☐● Membranes●do●not●have●to●be●ruptured
☐● Cervix●does●not●have●to●be●dilated
☐● Placement●of●transducers●can●be●performed●by●the●nurse
☐● Records●permanent●record●of●FHR●tracing
■● DISADVANTAGES●of●external●fetal●monitoring
☐● Contraction●intensity●is●not●measurable
☐● Movement●of●the●client●requires●frequent●repositioning●of●transducers
☐● Quality●of●recording●is●affected●by●client●obesity●and●fetal●position

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Continuous electronic fetal monitoring
INDICATIONS FOR MONITORING
POTENTIAL DIAGNOSES (12)


Indications for Monitoring

Potential diagnoses
■ Multiple gestations; oxytocin (Pitocin) infusion (augmentation or induction of labor)
■ Placenta previa
■ Fetal bradycardia
■ Maternal complications (diabetes mellitus, pregnancy-induced hypertension, renal disease)
■ Intrauterine growth restriction
■ Post dates
■ Active labor
■ Meconium-stained amniotic fluid
■ Abruption placenta – suspected or actual
■ Abnormal nonstress test or contraction stress test
■ Abnormal uterine contractions
■ Fetal distress

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Continuous electronic fetal monitoring
INTERPRETATION OF FINDINGS

A normal FHR baseline at term is?
excluding (3) ?
within a ? min window.
At least ? min of baseline segments
in a ? min window should be ?.
A single number should be documented instead of a base line range

Interpretation of findings

A normal FHR baseline at term is 110 to 160/ min

excluding accelerations, decelerations and periods of marked variability

within a 10 min window.

At least 2 min of baseline segments

in a 10 min window should be present.
A single number should be documented instead of a base line range



Reassuring FHR patterns consist of a heart rate of 110 to
160/min with beat-to-beat variability of 15/min, lasting at least
15 seconds, with a return to baseline in less than 2 min with no decelerations.

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Fetal HR baseline variability described as fluctuations in the FHR baseline that are irregular in frequency and amplitude. Classification:

Variability 4 kinds
Absent
Minimal
Moderate
Marked

Absent variability (considered nonreassuring)
Minimal variability ( 25/min)

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Reassuring FHR patterns consist of a heart rate of?

Reassuring FHR patterns consist of a heart rate of 110 to
160/min with beat-to-beat variability of 15/min, lasting at least 15 seconds, with a return to baseline in less than 2 min with no decelerations.

12

Each uterine contraction is comprised of:

Each uterine contraction is comprised of:
☐ Increment – the beginning of the contraction as intensity is increasing.
☐ Acme – the peak intensity of the contraction.
☐ Decrement – the decline of the contraction intensity as the contraction is ending.

13

Nonreassuring FHR patterns are associated with fetal hypoxia and include: (5)

Nonreassuring FHR patterns are associated with fetal hypoxia and include:

Fetal bradycardia.
Fetal tachycardia.
Absence of FHR variability.
Late decelerations.
Variable decelerations.

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FHR Pattern:
Accelerations (variable transitory increase in the FHR above baseline)

Cause/Complications (4)
Nursing Intervention (3)

Accelerations (variable transitory increase in the FHR above baseline)

Cause/Complications
• Healthy fetal/placental exchange
• intact fetal central nervous system (CNs) response to fetal movement
• vaginal exam
• Fundal pressure

Nursing Intervention
Reassuring
• No interventions required
• indicate reactive nonstress test

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FHR Pattern:
Fetal bradycardia (FHR <110/min for 10 min or more)

Cause/Complications (6)
Nursing Intervention (7)

Fetal bradycardia (FHR <110/min for 10 min or more)

Cause/Complications
• uteroplacental insufficiency
• umbilical cord prolapse
• maternal hypotension
• Prolonged umbilical cord compression
• Fetal congenital heart block
• anesthetic medications

Nursing Interventions
• discontinue oxytocin (Pitocin) if it is being infused.
• Help the client into a side-lying position.
• administer oxygen
(8 to 10 l/min by mask).
• start an iv line if one is not in place.
• administer a tocolytic medication as prescribed.
• stimulate the fetal scalp.
• Notify the primary care provider.

16

FHR Pattern:
Fetal tachycardia (FHR>160 beats/min for 10 min or more)

Cause/Complications (6)
Nursing Intervention (3)

Fetal tachycardia (FHR
>160 beats/min for 10 min or more)

Cause/Complications
• maternal infection, chorioamnionitis
• Fetal anemia
• Fetal heart failure
• Fetal cardiac dysrhythmias
• maternal use of cocaine or methamphetamines
• maternal dehydration

Nursing Interventions
• if maternal fever exists, administer antipyretics as prescribed.
• administer oxygen
(8 to 10 l/min by mask).
• give bolus of iv fluids.

17

FHR Pattern:
Decrease or loss of FHR variability (decrease or loss of irregular fluctuations in the baseline of the FHR)

Cause/Complications (4)
Nursing Intervention (3)

Decrease or loss of FHR variability (decrease or loss of irregular fluctuations in the baseline of the FHR)

Causes/Complications
• medications that depress the CNs such as narcotics, barbiturates, tranquilizers, or general anesthetics
• Fetal hypoxemia with resulting acidosis
• Fetal sleep cycle
• Congenital abnormalities

Nursing Interventions
• stimulate the fetal scalp.
• assist primary care provider with application of scalp electrode or fetal blood pH sampling.
• Position the client into a left-lateral position.

18

FHR Pattern:
early deceleration of FHR (slowing of FHR with start of contraction with return of FHR to baseline at end of contraction)

Cause/Complications (4)
Nursing Intervention (0)

early deceleration of FHR (slowing of FHR with start of contraction with return of FHR to baseline at end of contraction)

Causes/Complications
• Compression of the fetal head resulting from uterine contraction
• vaginal exam
• Fundal pressure
• No intervention required.

Nursing Interventions
NONE

19

FHR Pattern:
Late deceleration of FHR (slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended)


Cause/Complications (2)
Nursing Intervention (6)

Late deceleration of FHR (slowing of FHR after contraction has started with return of FHR to baseline well after contraction has ended)

Causes and Complications
• uteroplacental insufficiency causing inadequate fetal oxygenation
• maternal hypotension, abruptio placentae, uterine hyperstimulation with oxytocin (Pitocin)

Nursing Interventions
• Change the client to a side-lying position.
• start an iv line if not in place or increase the iv rate.
• discontinue oxytocin (Pitocin) if being infused.
• administer oxygen
8 to 10 l/min per mask.
• Notify the primary care provider.
• Prepare for an assisted vaginal birth or cesarean birth.

20

FHR Pattern:
Variable deceleration of FHR (transitory, abrupt slowing of FHR

Variable deceleration of FHR (transitory, abrupt slowing of FHR

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FHR monitoring
Nursing Actions (3)
Ongoing Care (4)

●● Nursing●Actions
■● Preparation●of●the●Client
☐● Use●Leopold●maneuvers●to●locate●the●fetal●presenting●part●and●the●optimal● location●for●placement●of●the●ultrasound●transducer●for●the●best●possible● auscultation●of●FHR.
☐● Palpate●uterine●activity●at●the●fundus●to●identify●proper●placement●location● for●the●tocotransducer●to●monitor●uterine●contractions.

■● Ongoing●Care
☐● Provide●education●regarding●the●procedure●to●the●client●and●the●client’s●
partner●during●placement●and●adjustments●of●the●fetal●monitor●equipment.
☐● Encourage●frequent●maternal●position●changes.●Explain●to●the●client●that● adjustments●of●the●monitor●may●be●necessary●with●position●changes.
☐●If●the●client●needs●to●void●and●can●ambulate,●and●it●is●not●contraindicated,● the●nurse●can●disconnect●the●external●monitor●for●the●client●to●use●the● bathroom.
☐● If●disconnecting●of●FHR●monitor●is●contraindicated●or●internal●FHR●monitor● is●being●used,●the●nurse●can●bring●the●client●a●bedpan.

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Advantages of internal fetal monitoring (5)

☐● Advantages●of●internal●fetal●monitoring

X●Early●detection●of●abnormal●FHR●patterns●suggestive●of●fetal●distress
X● Accurate●measurement●of●uterine●contraction●intensity
X● Obesity●or●maternal●and●fetal●movement●does●not●affect●recording
X● Accurate●assessment●of●FHR●variability
X●Allows●greater●maternal●freedom●of●movement●without●compromising● tracing

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Disadvantages of Internal Fetal Monitoring (7)

☐ Disadvantages of internal fetal monitoring

X Membranes must have ruptured to use internal monitoring
X Cervix must be adequately dilated to a minimum of 2 to 3 cm
X Presenting part must have descended enough to place electrode
X Potential risk of injury to fetus if electrode is not properly applied
X Contraindicated with vaginal bleeding
X Potential risk of infection to the client and the fetus
X A primary care provider, nurse practitioner/midwife, or specially trained registered nurse must perform this procedure

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Internal fetal monitoring

REVIEW ATI
NURSING ACTIONS
COMPLICATIONS
pg 150-151

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Changes in FHR patterns are categorized as episodic or periodic changes.
EPISODIC CHANGE
PERIODIC CHANGES

EPISODIC CHANGES are not associated with uterine contractions

PERIODIC CHANGES occur with uterine contractions

THESE CHANGES INCLUDE ACCELERATIONS AND DECELERATIONS

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Category I
Baseline fetal heart rate of?
Baseline fetal heart rate variability?
Accelerations?
Early decelerations?
Variability or late decelerations?

Current recommendations for fetal monitoring include a three tier fetal heart rate interpretation system

ATI pg 147

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Category II
Baseline rate? (2)
Baseline FHR variability? (3)
Episodic or periodic decelerations (4)
Accelerations? (1)

Current recommendations for fetal monitoring include a three tier fetal heart rate interpretation system

ATI pg 147

28

Category III
Sinusoidal pattern
Absent baseline fetal heart rate variability and any of the following? (3)

Current recommendations for fetal monitoring include a three tier fetal heart rate interpretation system

ATI pg 147

29

Each uterine contraction is comprised of? (3)

Current recommendations for fetal monitoring include a three tier fetal heart rate interpretation system

ATI pg 148

30

Nonassuring FHR patterns associated with fetal hypoxia and include the following (5)

Fetal bradycardia
Fetal Tachycardia
Absence of FHR variability
Late decelerations
Variable decelerations

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