III. Maternal & Fetal Monitoring

Question 1

How many stages of labor?

Answer 1

3

Question 2

What stage is the longest stage?

Answer 2

Stage one

Question 3

Begins with uterine contractions and continues until cervix fully dilated to 10cm.

Answer 3

Stage 1

Question 4

Begins with cervical dilated to 10 cm until delivery of Fetus

Answer 4

Stage 2

Question 5

stage: Until delivery of placenta

Answer 5

stage 3

Question 6

The ideal labor epidural should cover sensory loss from ____ to ____.

Answer 6

T10 to S5

Question 7

First Stage of labor:

Afferent/Efferent nerve impulses from the lower uterine segment and cervix cause visceral pain

Answer 7

Afferent

Afferent = sensory
Efferent = motor

Question 8

First Stage of Labor:

Nerve cell bodies are located in the dorsal root ganglia of ____ to ____.

Answer 8

T10 to L1

Question 9

What dermatome level is T10

Answer 9

umbilicus

Question 10

what stage has pain that is poorly localized?

Answer 10

Stage 1

Question 11

what stage of labor includes somatic pain that is well localized?

Answer 11

Stage 2

Afferent nerves innervating the vagina and perineum causes somatic pain which is better localized.

Question 12

Stage 2 Labor:

somatic pain impulses (from the vagina and perineum) travel primarily via the ____ to dorsal root ganglia of S1-S5

Answer 12

pudendal nerve

Question 13

How to assess a sensory nerve block:

Answer 13

1. Explain the procedure and purpose to the patient
2. Choose tool (ice cube, cold alcohol 4x4, broken tongue depressor)
3. Establish Control (Ice): place the ice on an area well away from the possible dermatome cover such as the neck or face and ask if they feel cold.
4. Apply the ice to an area likely blocked on the same side of the body and ask the patient, does this feel the same cold or different?
5. Apply ice to areas above and below this point until it is clear at which level the top and bottom of the block is covered.
6. Repeat the procedure on the opposite side of the body, as blocks may be uneven or unilateral.

Question 14

Dermatome level:

C4

Answer 14

Clavicles (C is 4 clavicles)

Question 15

Dermatome Level:

T4

Answer 15

Nipples (T is 4 tips of the nips)

Question 16

Dermatome Level:

T6

Answer 16

Xiphoid

Question 17

Dermatome Level:

T10

Answer 17

Umbilicus (0 looks like belly button)

Question 18

Dermatome Level:

S1

Answer 18

Pinky Toe

Question 19

Dermatome Level:

L1

Answer 19

Inguinal Line (top of bathing suit tan line - L1 is Lifeguard 1)

Question 20

name of syndrome that affects pregnant women when laying supine = ↓ venous return and CO.

Answer 20

Aortocaval Compression Syndrome

Question 21

When does aortocaval compression syndrome begin during pregnancy?

Answer 21

16-20 weeks gestation

Question 22

Signs and symptoms of Aortocaval Compression Syndrome?

Answer 22

• HoTN
• Pallor
• Sweating
• Nausea & Vomiting (2/2 to HoTN)

Question 23

Treatment for Aortocaval Compression Syndrome?

Answer 23

Left Uterine Displacement (LUD)

• wedge under right hip
• 15º tilt

Question 24

LIst HTN disorders experienced during pregnancy:

Answer 24

1. Gestational HTN/Pregnancy Induced HTN (PIH)
2. Pre-Eclampsia
3. Eclampsia
4. Sever Pre-Eclampsia
5. HELLP Syndrome

Question 25

What is considered Gestational HTN/PIH?

Answer 25

139/89 after 20 weeks

Question 26

Etiology of Gestational HTN/PIH

Answer 26

**1. Abnormal sensitivity to catecholamines & hormones 2. Fetal maternal antigen antibody reaction's** 3. Production of vasoactive prostaglandins (Thromboxane A & Prostacycline)

Question 27

What is a major symptom of preeclampsia that is missing in Gestational HTN/PIH?

Answer 27

proteinurea

Question 28

Gestational HTN/PIH usually resolves by ____ postpartum and treatment is NOT needed.

Answer 28

12 weeks

Question 29

Preeclampsia: BP: ____ Proteinurea: ____ Sx: ____

Answer 29

>140/90 >300mg/24 hr *Edema, Headaches, Visual disturbances, Hyperreflexia*

Question 30

Severe Preeclampsia: BP: ____ Proteinurea: ____ Sx: ____

Answer 30

160/110 >5g/24 hr *HELLP Syndrome (*8Hemolysis, Thrombocytopenia*, ↑Liver Enzymes, ↓PLT count)*

Question 31

The presence of what hallmark symptom graduates preeclampsia to eclampsia?

Answer 31

Seizures

Question 32

Because these HTN pregnancy disorders can affect ____, we should monitor closely and give careful consideration to regional anesthetics.

Answer 32

blood coagulation

Question 33

What coag studies are we interested in for pregnant HTN patients?

Answer 33

Full coag studies: - PT - PTT - Fibrinogen

Question 34

Most providers require what range of platelets IOT consider regional anesthesia?

Answer 34

70-100k *consider trend in PLT count*

Question 35

Is it safe to remove epidural catheter if PLT low?

Answer 35

Catheter should be left in Get another set of labs and wait until PLT is safe range (100+ ideally), maybe for couple days

Question 36

HELLP syndrome is a life threatening condition and is considered a sub-variant of ____.

Answer 36

Severe Pre-Eclampsia

Question 37

HELLP stands for:

Answer 37

H: Hemolysis (RBC breakdown = Hgb breakdown = ↑Bilirubin) EL: Elevated liver enzymes (ALT, AST) LP: Low PLT count/thrombocytopenia (<100k)

Question 38

What major vital may be normal with HELLP syndrome, delaying diagnosis?

Answer 38

BP

Question 39

HELLP Tx:

Answer 39

- Transfusion - Bedrest - Continuous monitoring of mom & baby - Mg - manage HTN if present

Question 40

At what point do we treat HTN in pregnant patients?

Answer 40

BP >159/109

Question 41

What are common drugs used to treat PIH?

Answer 41

- Oral Hydralazine (most common) - Labetalol - Clonidine - Nifedipine - NTG/SNP

Question 41

What are specific treatments for Preeclampsia?

Answer 41

1. Manage HTN (same as PIH) 2. Seizure Prophylaxis: Mg Sulfate (2 g/15min ≤ 4-6 g loading dose followed by 1-2 g/hr) 3. Definitive treatment is delivery of baby **[BQ] (Board Question)**

Question 42

Specific treatments for Eclampsia

Answer 42

1. Prevent aspiration 2. Manage airway 3. Control seizures - Midazolam 1-2 mg - Ativan 2-4 mg - Diazepam 5-10 mg *(Textbook answer)* - THEN *Mg Sulfate 1-2 g/hr*

Question 43

Mg Sulfate helps with both seizure prophylaxis and ____.

Answer 43

BP management

Question 44

If mother starts seizing while pregnant, what procedure will take place immediately.

Answer 44

STAT c-section

Question 45

uses for Mg Sulfate:

Answer 45

1. Prevention of Eclampsia & Seizures 2. Tocolytic (inhibits uterine contraction, slow/stops premature labor) 3. Cerebral Protectant for premature babies

Question 46

Therapeutic level of Mg Sulfate

Answer 46

4-8 mEq/L (4.8-9.6 mg/dL)

Question 47

Patients receiving Mg Sulfate should be closely monitored for ____.

Answer 47

Mg Toxicity

Question 48

T/F: Mg Toxicity symptoms are easily discernable in pregnant patients.

Answer 48

False *are the first symptoms of magnesium toxicity are fatigue, nausea and vomiting, blurred vision, EKG changes. These symptoms are not uncommon in otherwise healthy pregnant patients*

Question 49

What EKG changes are a result of magnesium toxicity?

Answer 49

1. Prolonged PRI 2. Widened QRS

Question 50

Mg Sulfate dose dependent side effects table picture

Answer 50

Question 51

Treatment for Mg toxicity?

Answer 51

1 g Calcium Gluconate IV over 10 min

Question 52

What consideration should anesthetist make if a patient is on magnesium at therapeutic levels?

Answer 52

1. Mg potentiates NMB : *Reduce doses of Rocuronium* 2. Tocolytic ∵ can cause post-partum hemorrhage: Hemabate, Methergine, *Pitocin*

Question 53

3 types of fetal monitoring

Answer 53

1. Auscultation 2. Electronic Fetal Monitoring 3. Internal fetal monitoring

Question 54

2 Auscultation methods:

Answer 54

1. Fetoscope (low-tech) 2. Portable Doppler

Question 55

Benefits of Auscultation methods:

Answer 55

1. Quick & portable 2. Detects Baseline 3. FHR rhythm and dysrhythmias 4. Helps detect changes in heart rate 5. Differentiates maternal from fetal HR

Question 56

Limitations of Auscultation methods:

Answer 56

1. No printout: *cannot assess changes over time* 2. Not continuous: *acute changes can be missed* 3. Cannot assess variability 4. Maternal position limiting (supine difficult) 5. Difficult to use on obese patients

Question 57

Electronic Fetal Monitoring (EFM) uses what two external belts?

Answer 57

1. Doppler (FHR monitor) 2. Tocodynamometer (contraction monitor)

Question 58

The tocodynamometer uses a ____ that records uterine contraction duration & intervals.

Answer 58

pressure transducer

Question 59

Electronic fetal monitoring picture

Answer 59

Question 60

Electronic fetal monitoring picture 2

Answer 60

Question 61

EFM Benefits:

Answer 61

1. Noninvasive 2. Continuous documentation 3. Not labor intensive 4. Shows variability (over time) 5. *Works well independent of pt position*

Question 62

EFM Limitations:

Answer 62

1. Restricts patient movement 2. Not ECG but measures cardiac motion 3. Double counting or picks up maternal heart tones *(especially if mom HR is tachycardic)* *newer technology is wireless and does NOT restrict movement*

Question 63

Internal Fetal Monitoring uses a ____ ____ electrode.

Answer 63

fetal spiral

Question 64

what must occur before the fetal spiral electrode is used for fetal monitoring?

Answer 64

The **amniotic sac must be broken** in order to allow obstetrician to place electrode vaginally through uterus onto **baby's forehead**.

Question 65

What method is most accurate assessment of fetal HR?

Answer 65

Internal Fetal Monitoring via Fetal Spinal Electrode (FSE)

Question 66

Benefits of FSE:

Answer 66

1. Detects FHR variability 2. Detects dysrhythmias (R-R interval monitoring on EKG) 3. Mother may have mobility *new tech has wireless models to allow for ambulation*

Question 67

Limitations of FSE:

Answer 67

1. **Can be used only after the membranes of the amniotic have ruptured (after "water breaks”)**: ↑risk of infection (invasive) 2. Discomfort during placement 3. Contraindicated in patient’s with herpes outbreak ↑risk of transferring virus to baby 4. Contraindicated in HIV+ women due to infection risk. *likely not an option during early labor*

Question 68

2 methods of monitoring uterine activity:

Answer 68

1. Tocodynamometer: external 2. Intrauterine pressure catheter (IUPC): Internal

Question 69

Main limitation of external tocodynamometer

Answer 69

hard to use in obese patients and dependent on position

Question 70

Main benefit of external tocodynamometer:

Answer 70

noninvasive

Question 71

Main benefits of IUPC:

Answer 71

1. More accurate uterine pressure (mmHg) monitoring 2. Accurate timing of heart rate changes with contraction

Question 72

Main limitation of IUPC:

Answer 72

Invasive

Question 73

Where is tocodynamometer placed?

Answer 73

over the fundus of uterus *superior of the two belts on the abdomen*

Question 74

Internal Fetal Monitoring Fetal Spinal Electrode Picture

Answer 74

Question 75

How do we determine the baseline of the FHR?

Answer 75

the average FHR over 10 min, rounded to the nearest 5 bpm

Question 76

Normal fetal heart rate (FHR)

Answer 76

110-160

Question 77

what does fetal heart rate best indicate clinically (i.e., what other vital is it closely correlated with)?

Answer 77

how well oxygenated the baby is (oxygenation status)

Question 78

Two classifications of clinical changes in fetal heart rate:

Answer 78

1. Accelerations 2. Decelerations (Early, Late, Variable)

Question 79

FHR: The Graph Display the intervals between the vertical red lines represent ____ minute/s.

Answer 79

1 minute

Question 80

FHR: The Graph Display Fetal heart tracing is displayed in the **lower/upper** pane?

Answer 80

upper

Question 81

FHR: The Graph Display what is displayed in the lower pane of the FHR graph?

Answer 81

uterine activity

Question 82

FHR Display Graph Picture

Answer 82

Question 83

what is the normal beat-to-beat variability in a healthy fetus?

Answer 83

5-25 bpm *measured from peak HR to lowest HR*

Question 84

beat to beat variability: Minimal: _____ Moderate: _____ Marked: _____

Answer 84

Minimal: >5 Moderate: 5-25 Marked: >25

Question 85

The following situations can decrease B-B variability:

Answer 85

1. **Hypoxia/Acidosis** 2. Congenital anomalies ø Anencephalic fetus: born w/o part of brain/skull 3. Medication Administration (↓CNS + Cross Placenta) ø Narcotics ø Sedatives/Anesthetics ø High dose anticholinergics

Question 86

If signs of fetal distress are present what should be done first?

Answer 86

alert obstetrician immediately

Question 87

Determine variability:

Answer 87

Normal "Moderate" Variability

Question 88

Determine variability:

Answer 88

Minimal *BUT this is sign of distress: there should be some degree of variability coinciding with contractions*

Question 89

Fetal Tachycardia range:

Answer 89

>160 bpm

Question 90

causes of fetal tachycardia

Answer 90

1. Recovery following asphyxia 2. Maternal or fetal infection 3. Catecholamine administration 4. Tachydysrhythmias 5. Thyrotoxicosis

Question 91

Fetal Bradycardia range:

Answer 91

<110 *for >2 MINUTES*

Question 92

Causes of fetal bradycardia

Answer 92

1. Acute hypoxia ø Idiopathic and benign if short lived 2. Drugs: ø Beta Blocker ø LA administration

Question 93

Most dangerous fetal rhythm

Answer 93

FHR < 60 bpm *will result in cardiac decompensation*

Question 94

what are some things nurses may do as first line if baby is experiencing bradycardia?

Answer 94

- supplemental O2 - change mom position (all fours)

Question 95

If baby's heart rate does not return to normal (after bradycardia) after a couple minutes, what will the next course of action?

Answer 95

STAT C-section

Question 96

Temporary increase in FHR

Answer 96

Acceleration

Question 97

requirements to considered "acceleration"

Answer 97

<32 weeks: 10 bpm **>15 sec, but <2 min** *>32 weeks: 15 bpm **>15 sec, but <2 min***

Question 98

Causes of fetal accelerations

Answer 98

Fetal movement Fetal stimulation Maternal contractions

Question 99

Accelerations are said to correlate with ____.

Answer 99

fetal well-being *reassuring sign; if they occur often mother may get supplemental O2*

Question 100

Gradual decrease and return to baseline

Answer 100

Deceleration

Question 101

the lowest point of decel (slowest FHR):

Answer 101

Nadir

Question 102

Early or late decels are termed in relation to ____.

Answer 102

uterine contraction

Question 103

EARLY decels are said to occur when the FHR decreases coincide with ____.

Answer 103

onset of uterine contractions

Question 104

Early Decels: Time from onset to the lowest point of deceleration is ____.

Answer 104

≥30s

Question 105

Early decels: ____ occurs with the peak of contraction.

Answer 105

Nadir

Question 106

Common etiology of early decels:

Answer 106

**Fetal head compression** (2/2 uterine squeeze) Mild hypoxia (well-tolerated)

Question 107

Early decels are caused by ____ produced when the head is compressed by uterine contraction.

Answer 107

vagal response

Question 108

Onset and depth of early decelerations mirror ____.

Answer 108

the shape of the contractions

Question 109

Early decelerations tend to be proportional to ____.

Answer 109

the strength of the contraction.

Question 110

Early decels graph picture

Answer 110

Question 111

T/F: Early decels are typically benign, common, and not an emergent situation.

Answer 111

True

Question 112

Graphically speaking, what is the difference in early and late decels?

Answer 112

- Late decels do NOT initiate with the onset of contraction; rather, the **onset is at or after peak contraction.** - **The Nadir occurs AFTER peak contraction (shifted right).**

Question 113

Late decelerations are characterized by decreasing FHR waveform and a return to baseline. The onset to Nadir is ____ seconds.

Answer 113

>30 sec

Question 114

Common etiology of late decelerations:

Answer 114

**Uteroplacental insufficiency** (prolonged asphyxia & fetal hypoxia) *Hypoxia* causes bradycardia, not contraction like in early decels

Question 115

What type of decel?

Answer 115

Late decels

Question 116

An abrupt, visually apparent decrease in the FHR below the baseline & recovery

Answer 116

variable deceleration

Question 117

Variable decelerations have what onset to nadir?

Answer 117

<30 seconds

Question 118

Common etiology of variable decelerations:

Answer 118

1. Cord Compression ø Due to oligohydramnios *(↓ Amniotic Fluid)* 2. Sustained head compression (vagal response)

Question 119

Variable decelerations have a ____ relationship to contraction.

Answer 119

variable (duh)

Question 120

if decel has a Nadir that occurs after peak contraction, it is either a "LATE" decel or "VARIABLE" decel; how can we decide?

Answer 120

LATE: onset to Nair > 30sec VARIABLE: onset to Nadir < 30 sec ("abrupt"

Question 121

What type of decel?

Answer 121

Variable decel

Question 122

What type of decel?

Answer 122

Variable Decel

Question 123

The more severe & sustained the bradycardia = the more severe the hypoxia = the higher the ____ of the baby

Answer 123

stress

Question 124

Besides sustained bradycardia, what are the two worst rhythms?

Answer 124

- late decels - variable decels

Question 125

VEAL CHOP mnemonic picture

Answer 125