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Maternal/Child > Lecture 7.1 - At Risk Birth (Part 1) > Flashcards

Lecture 7.1 - At Risk Birth (Part 1) Flashcards

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1
Q

What is considered absent, minimal, moderate, and marked variability in FHR?

A

Absent - 0-3 bpm
Minimal - 4-5 bpm
Mod - 6-25 (normal)
Marked - > 25

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2
Q

What is the baseline FHR?

A

Approximate mean FHR rounded to an increment of 5 in a 10-minute tracing
–> Excludes accelerations, decels, and periods of marked variability
–> Must be present for at least 2 minutes in any 10 minute segment

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3
Q

What is considered fetal tachycardia? What length of time for fetal tachycardia is considered atypical or abnormal?

A

Baseline > 160 bpm for more than 10 minutes
Atypical: 30-80 minutes
Abnormal: 80+

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4
Q

Fetal tachycardia is a warning sign for what? What might it indicate?

A

Warning sign of fetal hypoxemia

May indicate fetal anemia

May indicate maternal fever, infection, medications or drug use

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5
Q

What is considered fetal bradycardia? What bradycardia is considered atypical or abnormal?

A

Baseline < 110 for 10+ minutes
Atypical: 100-110 bpm
Abnormal: < 100 bpm

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6
Q

Fetal bradycardia can indicate what?

A

Cardiac Problem
Viral infections
Maternal hypoglycemia
Maternal hypothermia

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7
Q

What is an acceleration?

A

Abrupt increase (<30 second) increase in FHR (15 bpm x 15 seconds) with a return to baseline in < 2 minutes.

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8
Q

What is considered a prolonged acceleration?

A

Lasting 2-10 minutes.

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9
Q

How are decelerations described?

A

Their visual onset to end of the contraction and the nature of their descent

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10
Q

What is an early deceleration?

A

Gradual decrease and return to baseline that correspond to the beginning, peak, and end of a contraction
–> Due to transient compression of fetal head

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11
Q

What is a late deceleration?

A

Gradual descent. Begins after the contraction has started and the lowest point of the deceleration occurs after the peak of the contraction. Usually does not return to baseline until after the contraction is over.
–> Persistent and repetitive late decels can be ominous

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12
Q

What might late decelerations indicate?

A

Uteroplacental insufficiency

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13
Q

What are variable decelerations? What might they indicate?

A

Abrupt in beginning and end (>15 bpm x > 15 sec)
–> Result of cord compression, usually do not have clinical significance

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14
Q

What is considered a prolonged deceleration?

A

lasting 2-10 minutes

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15
Q

When would a prolonged deceleration be an expected finding?

A

Following epidural

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16
Q

What is the initial intervention when there is a concerning FHR tracing?

A

Reposition the patient - or check maternal pulse for brady

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17
Q

What interventions are performed for fetal tachycardia

A

Reposition
Check maternal pulse + BP

Rule out fever, dehydration, drug effects, prematurity
Consider correcting maternal hypovolemia

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18
Q

What interventions will be performed for fetal bradycardia?

A

Check maternal pulse + BP
Reposition

Consider vaginal exam to rule out prolapse
Consider correcting maternal hypovolemia

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19
Q

What interventions are performed for late decelerations?

A

Reposition
Check maternal VS

If repetitive: Intrauterine resuscitation

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20
Q

How can we intervene for variable decelerations?

A

Usually correctable with repositioning
–> If complicated, assess for cord prolapse

Intrauterine resuscitation

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21
Q

What should we expect if abnormal tracing persist and are non-correctable?

A

Consider jailbreaking baby

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22
Q

What is involved in intrauterine resuscitation?

A

Stop/decrease oxytocin

Change position (start with Left Lateral)

Check maternal VS and differentiate maternal and fetal HR
Notify physician or midwife

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23
Q

In the second (pushing stage), what can be done as part of intrauterine resuscitation?

A

Modify breathing + pushing techniques

Consider cord prolapse

Administer 8-10L O2 by mask if hypoxemia suspected
Improve hydration with IV bolus if necessary

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24
Q

What is considered pre-term birth?

A

20-37 weeks

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25
What is considered a late preterm birth?
34-37 weeks GA --> Surfactant production is adequate
26
What is considered a low birth weight?
< 2500g --> Related to any combination of factors that result in IUGR
27
Do most spontaneous preterm births have risk factors?
Not always predictable (1/2 of preterm births had no identified risk factors)
28
What percent of preterm births are indicated?
1/4
29
What are risk factors for spontaneous preterm birth?
Complex etiology Family Hx Multiple gestation Bleeding of uncertain origin Maternal genital tract infection Low Pre-pregnancy weight Low SES Lack of access to prenatal care
30
What is fetal fibronectin?
A glycoprotein that adheres the chorionic membrane to the uterine decidual
31
When is it normal for fetal fibronectin to be found of vaginal secretions?
Up to 22 weeks and after 34 weeks. --> Only seen between 24-34 weeks unless there is cervical dilation or effacement
32
What can a fetal fibronectin test predict?
Most accurate at predicting who will not give birth in the next 14 days. --> False positives make it better at ruling out risk of preterm birth than at predicting who is going into labour soon.
33
How is cervical length determined?
Transvaginal ultrasound
34
What cervical length indicated a lowered risk of preterm birth?
> 30 mm
35
How can we prevent preterm birth and labour?
Main strategies are to increase preconception and prenatal care + access to the social determinants of health
36
All women should we aware of the signs and symptoms of preterm labour. What are they?
Uterine activity - differentiate Braxton Hicks Discomfort - cramping, back pain Vaginal discharge
37
If preterm labour symptoms begin what should patients consider doing?
Empty bladder Drink 2-3 glasses of water Lie down on your side for an hour and palpate for contractions If symptoms stop, resume light activity but not what you were doing when symptoms began If they continue or return, call HCP or go to the hospital
38
What are signs of preterm labour indicate that a person should go to the hospital?
Contractions q10 for 1+ hours Vaginal bleeding Fluid leaking
39
The goal of tocolytics in Canada is not to stop labour. What are their purpose?
To slow its progression - to allow for glucocorticoid administration or transfer to another unit
40
What is the diagnostic criteria for preterm labour?
GA 20-36 weeks --> Regular uterine activity, change in cervical dilation/effacement or both Initial presentation with regular contractions and cervical dilation of at least 2 cm
41
What activity restriction is recommended to prevent preterm labour?
Modified activity that is individualized, restriction of sexual activity --> not bedrest (never good)
42
What is a major consideration when deciding whether to hospitalize a person at risk of preterm labour?
Distance from hospital
43
What are some contraindications to tocolysis?
If there is a condition that can harm the person or fetus, we want to end the pregnancy ASAP.
44
What medications are used off label as tocolytics in Canada?
Nifedipine (CCI) Indomethacin (NSAID) MgSO4 - inhibits uterine activity
45
What is the traditional approach to preventing PTB?
Bedrest, IV hydration --> Unknown effectiveness and potential harm
46
Which pregnant people should receive antenatal corticosteroids? When should they receive it?
All at 24-34 weeks GA at risk of PTB in next week --> 2 doses, 24 hours apart
47
There is strong evidence that a single course of antenatal corticosteroids can decrease the incidence of which complications?
RDS, IVH, NEC, death
48
MgSO4 can slow the labour, but this is not the main purpose of administering it. What is the main purpose? When is it indicated?
Neural protection - reduce risk of CP Indicated when birth is imminent in next 24 hours at 24-33 weeks.
49
What dosage of MgSO4 is given to reduce infant morbidity/mortality?
4 gram loading dose over 30 minutes --> Sometimes with a gram/hour maintenance infusion until birth for a maximum of 24 hours
50
What is premature rupture of membranes?
Spontaneous ROM before the onset of labour at any GA
51
Labour is induced due to risk of infection how long after ROM?
24 hour
52
pPROM accounts for what percent of preterm births?
33% of preterm births
53
What are risk factors for pPROM?
Hx of pPROM or cervical injury STI, UTI, bleeding, uterine overdistention, trauma, PTL in current pregnancy Short cervical length in 2nd trimester
54
What pre-existing maternal factors can be risk factors for pPROM?
Pulmonary disease, connective tissue disorders, low SES or BMI, nutritional deficiencies, cigarette smoking.
55
What are maternal complications following pPROM?
Chorioamnionitis leading to Endometritis/sepsis Placental abruption Complications in birth --> Retained placenta, hemorrhage
56
What are fetal complications for pPROM?
Related to infection/prematurity Placental abruption Hypoxia d/t cord prolapse or compression
57
How is pPROM diagnosed?
Patient history and sterile speculum exam for visualization Also consider Nitrazine and Ferning test
58
What is a Nitrazine Test? What can cause false positives?
Testing pH of fluid --> >6.0-6.5 will turn paper blue False positives can be caused by blood, semen, vaginal infection
59
What is a Ferning test?
Microscopic examination of vaginal fluid --> Look for fern-like pattern.
60
When is expectant management used for pPROM?
If no contraindications, expectant management for all pts < 37 weeks Expectant contraindicated in: --> Active labour --> Evidence of infection --> Placental abruption --> Cord prolapse --> Abnormal fetal health serveillance
61
How can cord prolapse be managed?
Positioning or physical support of presenting part through vagina
62
What is expectant management for pPROM?
Hospitalization in facility with NICU If 24-34+6 weeks - corticosteroids + short term tocolytics to allow for administration or transfer Monitor for signs of infection + Prophylactic antibiotics (Amp, Erythromycin) MgSO4 for neuroprotection If there is no infection or complications, there is no advantage to inducing labour early
63
What teaching is necessary for someone with pPROM?
AF production continues S&S of infection Daily FA counts Peri-hygiene Consult with neonatologist Psychological support
64
How is chorioamnionitis managed?
Broad spectrum IV antibiotics at birth
65
What is the difference in management of PROM vs pPROM?
With PROM we want delivery within 12-24 hours With pPROM we want expectant management to balance hazards of prematurity and risk of infection
66
What is considered a post-term pregnancy?
Beyond 42 weeks GA
67
What are maternal risks for post-term prenancy?
Longer pregnancy - large impact on uterus's ability to contract following delivery leading to PPH, dystocia, chorioamnionitis Complications related to delivering large fetus - severe perineal injuries, c/s
68
What are some risks for the fetus with post-term pregnancy?
Higher risk of meconium aspiration, cord compression Associated with oligohydramnios, macrosomia or small for gestational age, cord compression.
69
When is someone offered an induction if they do not go into spontaneous labour?
After 41+3 days. --> Monitoring much more closely from this point onward. Will use EFM during labour.
70
What are the three main methods of labour induction?
Cervical ripening Amniotomy Oxytocin
71
Induced labour carries what risks?
Increased rate of c-section + NB morbidity + Cost
72
What is a Bishop score?
An assessment of inducibility on a 13-point scale Assessed dilation, effacement, station, cervical consistency and position
73
Labour induction is usually successfully with what Bishop score?
7 or more.
74
Prior to induction, most people need what first step?
Cervical Ripening to soften cervix
75
What is membrane sweeping?
Vaginal exam that involves disconnecting the membranes from the cervix - results in release of prostaglandins and can soften cervix
76
What are alternative methods of cervical ripening?
Walking & sex
77
What is the most commonly used mechanical dilator?
Foley cath
78
What synthetic prostaglandins are used for cervical ripening?
PGE1 --> Misoprostol tablets PGE2 --> Cervidil insert of Prepidil gel (both dinoprostone)
79
Labour usually begins how soon after AROM? When do we start worrying about infection?
within 12 hours labour begins --> Assess for infection q2 hours
80
When is AROM contraindicated?
With STIS and use caution with HIV When the presenting part is not engaged and applied to the cervix
81
How does synthetic oxytocin differ from endogenous oxytocin?
Synthetic does not cross BBB - Does not decrease sensitivity to pain in the way endogenous oxytocin does.
82
What monitoring is necessary when administering oxytocin?
EFM - monitor contraction pattern and fetal tolerance
83
What is dystocia?
Abnormally slow progression of labour
84
What is considered labour dystocia in the first active stage of labour?
Less than 0.5 cm/hour of cervical dilation over 4 hours OR No cervical dilation change over two hours
85
What are some problems with the powers that can cause labour dystocia?
Hypertonic ctx Hypotonic ctx Alteration to 2° (bearing down) powers)
85
What is considered labour dystocia during the second stage of labour?
Greater than 1 hour of active pushing with no descent on the presenting part
86
What problems with the passage can cause labour dystocia?
Pelvic / soft tissue dystocia
87
What problems with the passenger can result in dystocia?
Anomalies CPD Malposition (ROP or LOP) Malpresentation (Breech, shoulder) Macrosomia Multifetal pregnancies
88
What is the nursing role following an external cephalic version?
EFM for 1 hour Observe for bleeding Prevent isoimmunization for Rh negs
89
How is a external cephalic version monitored during the procedure?
NST + US Nurses monitor EFM, VS, and provide comfort care
90
What are some contraindication to attempting breech delivery?
Cord compression fetal growth restriction or macrosomia (Outside of 2800-4000g range) Footling inadequate pelvic size Fetal anomaly Hyperextended fetal head.
91
What are the different classifications of operative vaginal births based on height of the presenting part?
Outlet - visible scalp Low - lower than 2+ station Mid - fetus above 2+ station High - Not engaged* *a high operative vaginal delivery is not recommended because rates of complications are very high
92
What are some indications for a forceps-assisted birth?
Need to shorten a prolonged 2nd stage of labour d/t abnormal FHR, abnormal presentation, or maternal exhaustion
93
What are the criteria for operative vaginal births?
Cervix must be fully dilated Bladder empty Presenting part engaged, Membranes ruptures Adequate pelvic size
94
Do operative vaginal births increase the instances of tears?
Yes, increased risk of 3rd and fourth degree perineal tears
95
What are the advantages are using vacuum assisted birth over forceps?
Easier to use, less anesthesia
96
After what age can a vacuum assisted birth be attempted?
At least 34 weeks GA to prevent neural damage to fetus.
97
What are the nursing considerations for operative vaginal births?
Empty bladder Prepare for neonatal resuscitation Prepare for anesthesia or analgesia as needed Prepare for possible emergency c/s
98
What are some indications for use of tocolytics?
Slow of delay birth when... --> There is a diagnosis of preterm labour with fetal weight < 1500g and/or immature fetal lungs Allows time to transfer or for glucocorticoid administration
99
What position must the fetus be in for a vacuum assisted birth?
Vertex

Maternal/Child (14 decks)

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