AWHONN INTERMEDIATE FETAL MONITORING.pdf, Exams of Public Health

Download AWHONN INTERMEDIATE FETAL MONITORING.pdf and more Exams Public Health in PDF only on Docsity! AWHONN INTERMEDIATE FETAL MONITORING / 1 AWHONN Fetal Heart monitoring basics EXAM 2024-2025 QUESTIONS AND ANSWERS 100 % PASS SOLUTION A+ GRADE Explain an episodic deceleration and what causes episodic decelerations. What are the 3 questions to ask related to episodic decels? Ask 3 questions: 1.is there an obvious event that caused the decel? 2.Does FHR return to baseline when the event is over? 3.Is there moderate variability assoc. with the decleration? - ANSWER- - Its an isolated event sometimes in conjunction with a procedure. May occur in response to transient cord compression, uterine tachysystole or excessive uterine activity, administration of anesthetics, maternal position change, or vaginal exam. By definition, they do not occur uniformly or repetitively. --Explain transient interruptions in fetal oxygen supple during labor. - ANSWER A normal part of labor. As contractions build increased uterine pressure prevents blood from entering/leaving the intervillous space. During the peak the fetus relies completely on its oxygen reserve (an aerobic challenge that is not an issue for a health fetus. Define Uteroplacental insufficiency (UPI) ) - ANSWER-- Chronic deficiency of placenta function, usually from an interruption of oxygenation pathway due to abruption, mat. hypo or hypertension or other issues. Infant is not tolerant of contractions. Can result in fetal grow restrictions (FGR a visually apparent decrease in FHR below the baseline rate of 15 bpm or more and lasting > 2 minutes but < 10 minutes, prolonged decels are usually isolated events that end spontaneously. Prolonged decel's typically have an abrupt onset, reach the nadir in <30 sec, and are in response to a sudden significant change in the fetal environment. IF > 10 min it is a baseline change. With prolonged decelerations, further maternal and fetal assessment is needed to determine if immediate intervention is needed. - ANSWER-- What is a prolonged deceleration? D. Late decelerations notice the gradual decrease in baseline that follows the peak of each contraction. - ANSWER-- Describe this tracing: A. Accelerations B. Early Decelerations C. Variable decelerations D. Late decelerations E. Episodic deceleration A. Absent notice the smoothness of the tracing indicating absent variability. - ANSWER--Describe the variability in this tracing: A. Absent B. Minimal C. Moderate D. Marked B. A baseline within normal range The baseline is 150 BPM which is within the range for normal fetal baseline heart rate. - ANSWER--This tracing shows: A. Tachycardia B. A baseline within normal range C. Bradycardia Category I (normal) FHR tracings are normal & predictive of normal fetal acid-base status at that time. No action is required. Baseline FHR rate: 110-160BPM Baseline FHR variability: moderate Accelerations: present or absent Late or variable decelerations: absent Early decelerations: present or absent - ANSWER--Define a category I (normal) fetal heart rate tracing. A method of assessing fetal acid-base status through vigorously rubbing the fetal head with a gloved hand to elicit an acceleration. This is dune when FHR is at baseline. Do not do during a deceleration to attempt to increase the FHR. A well-oxygenated fetus will respond with an acceleration of 15 BPM or more for > 15 seconds. This is a reliable prediction of the absence of fetal metabolic acidemia at that time. This does not predict fetal acidemia or fetal compromise. Stimulation is not needed if the tracing has category I characteristics. - ANSWER--What is Scalp Stimulation? Acceleration Early decelerations Variable decelerations Late decelerations Episodic decelerations Moderate the jaggedness of this tracing indicates variability is present, and the amplitude of variability is between 6 and 25 BPM. - ANSWER--The variability in this tracing is: Absent Minimal Moderate Marked A baseline with in normal range. The range is 110-160 BPM - ANSWER--The tracing shows: Tachycardia A baseline within normal range Bradycardia Category I as it has accelerations, moderate FHR variability, normal FHR baseline and no interventions are needed at this time. - ANSWER--The tracing is classified as: Category I Category II Category III Likely the cause of late decels is tachysystole. Tachysystole interrupts blood flow which can result in fetal hypoxemia. The lack of oxygen availability has led to slowing of the FHR. Contractions are so close in timing that Fetal heart is unable to recover as normally would. 3 Goals to achieve through assessment and interventions: reduce uterine activity max uterine blood flow max oxygenation SO: notify MD, DC oxytocin, change position, admin IV fluid bolus, admin oxygen by non- rebreather mask 10L/min - ANSWER--Case study #1 First pregnancy. Contractions every 7 min lasting 40 seconds, moderate by palpation, pain rated 4/10. Vaginal exam shows 4cm dilated, 100% effaced and -1 station. However no change in the last 3 hours. Oxytocin was ordered to augment, an FSE & IUPC was placed. 2hrs after oxytocin started this is the tracing. Contractions q 1.5 min, lasting 60-70 seconds, 55- 60 mmHg. Resting tone btwn contractions is 25 mmHg. Baseline FHR 155 BPM w minimal variability. A pattern of late decelerations is emerging. You should be able to see relationship btwn uterine activity pattern & FHR tracing characteristics. 140 BPM Minimal variability Late decelerations Normal uterine activity Present accelerations - ANSWER--Identify the tracing characteristics: FHR Baseline FHR variability FHR Decelerations Uterine Activity FHR Accelerations 140 BPM Moderate variability No decelerations Normal uterine activity Present accelerations - ANSWER--Identify this tracing's characteristics: FHR Baseline FHR variability FHR Decelerations Uterine Activity FHR Accelerations Tachycardia absent variability Variable decelerations Normal uterine activity Absent accelerations - ANSWER--Identify the tracing's characteristics: FHR Baseline FHR variability FHR Decelerations Uterine Activity FHR Accelerations (Per AWHONN) If no risk factors are present at admission, evaluate the standard Q 30 min in the latent (4-5 cm) and active phases of the 1st & 2nd stage passive fetal descent phase and Q15min in the 2nd stage active pushing stage of labor. If risk factors present on admission or appear during labor evaluate Q 15 min during active phase, the 2nd stage passive fetal descent, and at least Q 5 mind during 2nd stage active pushing. If the FHR baseline changes in my 10 min window document what the tracing shows you. Write a note describing it. If baseline started out at 120 BPM and increases to 130 BPM...write it. - ANSWER--Monitoring and intervention questions: What should I do if the fetal heart rate (FHR) baseline changes? What if the FHR baseline changes in my 10 min window? Notify MD regarding the irregular rhythm, request physician assess for preterm labor and perform an ultrasound. If found + for preterm contractions she would be treated appropriately, then discharged to follow up with a level 2 ultrasound for confirmation of arrhythmia. - ANSWER--In this situation what could you do to be sure you are obtaining accurate information about FHR? 17y/o pt G2 T0 P1 A0 L1. She is 23 5/7wks gest, her mom is with her, states she has been contracting for several hours. Reports this is a normal pregnancy thus far. You assess using Leopold's to determine fetal position, palpating frequent movement but have difficulty detecting the FHR due to baby activity and size. A handheld Doppler helps to better locate FHR but an unusual rhythm. The electronic fetal monitor ultrasound signal shows an interrupted rate of 160BPM, irregular pattern with long interruptions in the rhythm. failing to : perform initial assessment ongoing mat/fetal assessments recognize changes in mat/fetal status take appropriate precautions /actions neglecting to document or communicate information notify and obtain timely response involvement in a surgical team's error stabilize and transport appropriately - ANSWER--Name areas of potential liability. failing to : monitor FHR or contractions evaluate the information obtained recognize deteriorating fetal condition taking appropriate actions in response to FHR patterns notify a provider and obtain a timely response monitor the FHR in the delivery room or OR prior to C/S - ANSWER-- List documentation issues that may increase liability. a) Frequency b) Duration - ANSWER--Which contraction characteristics can be assessed with a tocodynamometer? a) Frequency b) Duration c) Intensity Uterus - ANSWER--All Fetuses of mothers in labor experience an interruption of the oxygenation pathway at which point? a) Throughout labor and delivery unless the use of a more accurate method is clearly indicated - ANSWER--The FHR can be monitored using doppler ultrasound? a) Throughout labor and delivery unless the use of a more accurate method is clearly indicated b) Internally c) Only early in labor d) The FHR cannot be monitored by doppler ultrasound b) 110-160 bpm - ANSWER--What is the normal range for FHR base line in a term infant? a) 80-120 bpm b) 110-160 bpm Resting tone when assessed externally is termed soft or firm. When assessed via IUPC 5-20 is normal, >20 may be elevated tonus and can hinder O2/CO2 exchange. - ANSWER--What is resting tone and how is it described? A frequency of (tachysystole) more than 5 contractions in 10 min. over a 30 min. window. - ANSWER--What is an unfavorable frequency of contractions? Duration of contractions lasting more than 120 second may have a negative impact on fetal oxygenation. - ANSWER--What is an unfavorable duration for contractions? Intensity via palpation is termed mild, moderate or strong. Intensity via IUPC averages 30mm hg in early 1st stage, 50-60 in the later 1st stage and 70-80 in the second stage of labor. - ANSWER--What is contraction intensity and what are the averages via IUPC during early 1st stage, late 1st stage, and the 2nd stage of labor? MVU's quantify uterine activity over 10 min period, requires the use of an IUPC. Minus the resting tone from the peak intensity of each contraction in a 10 min period and add the values together. At least 200 MVU's results in progressive cervical change. - ANSWER-- What is a Montevideo unit (MVU)? How do you calculate MVU's? Using your fingertips at the fundus you can assess duration and frequency. Intensity: nose= mild chin=moderate forehead=strong - ANSWER--How do you palpate a contraction? Describe the intensities. Monitors changes in the contour of the maternal abdomen caused by uterine contractions, is placed over the fundus. Can measure relative changes in pressure, duration and frequency of contractions. Can NOT measure intensity. Women with large amounts of abdominal adipose tissue can be difficult to monitor. - ANSWER--Explain what a Tocodynamometer is, what it measures and its limitations. Most accurate method of assessing uterine contractions. Inserted through dilated cervix, its sensor tip monitors changes in pressure of the amniotic fluid. Measures resting tone, duration, frequency and intensity of contractions. Can NOT be used unless membranes are ruptured. - ANSWER--Explain what an intrauterine pressure catheter is, what it measures and its limitations. Fetal heart rate patterns 5 characteristics 1 Baseline heart rate 2 Rhythm 3 FHR variability 4 Presence of accelerations 5 Periodic or episodic deceleration's - ANSWER--How do you determine fetal oxygenation? Name the 5 characteristics Must be 2 min of segments. Range 110-160 BPM (represented in a multiple of 5) <32 weeks is usually high normal >32 weeks gradual decrease due to increased vagal tone. Change in baseline is >10min. - ANSWER--What are fetal baseline guidelines? Range? <32 weeks gest >32 weeks gest change in baseline It is the heart's internal pacemaker. It is specialized clump of cells at the top of the right atrium that gives electrical impulses to cause the heart to beat. The intrinsic rate is 110-160 in term fetus. Early in gestation (15- 20 wks) can be much higher. In 26-28 weeks may be in the upper range of normal. - ANSWER--What is the SA Node? Generated in the fetal brainstem carried via sympathetic fibers to the heart. Increases FHR, strength of myocardial contraction of the heart and fetal cardiac output. Sympathetic stimulation influences FHR variability. The sympathetic branch of the autonomic nervous system is present very early in fetal development. - ANSWER--Explain the sympathetic impulses of the fetal central nervous system. Generated in the fetal brainstem carried via the vagus nerve to the fetal heart. Stimulates vagus nerve which increases fetal blood pressure, decreases firing rate at SA node and decreases FHR. Also influences the presence of fetal heart variability. The parasympathetic nervous system matures later in pregnancy. This balances out the sympathetic branch, the baseline heart rate gradually decreases toward the middle of the normal range. - ANSWER--Explain the parasympathetic impulses of the fetal central nervous system. Baseline FHR is 130 BPM which falls within the range of normal baselines 110-160 BPM - ANSWER--Is the baseline in this fetal tracing of a fetus at 40 weeks gestation normal or abnormal? Baseline FHR is 135 BPM which falls within the range of normal baselines 110-160 BPM - ANSWER--Is this baseline in this fetal tracing of a fetus at 26 weeks gestation normal or abnormal? The baseline heart rate is 210 BPM which is outside the range of the normal baseline of 110-160 BPM. - ANSWER--Is this baseline in this fetal tracing of a fetus at 24 weeks gestation normal or abnormal? A baseline FHR of 160 BPM for at least 10 min. Contributing factors include hyperthermia, infections (maternal or fetal), maternal dehydration, hyperthyroidism, anxiety, drugs that stimulate the central nervous system, fetal immaturity, a cardiac conduction defect, or hypoxemia. - ANSWER--Define fetal tachycardia and factors that contribute to fetal tachycardia. A baseline FHR of <110 BPM for at least 10 min. Contributing factor include stimulation the fetal vagus nerve possibly due to prolonged head compression or application of the forceps or vacuum, fetal cardiac conduction defect such as heart block, maternal hypotension and drugs that timulate the parasympathetic branch or block the sympathetic branch of the autonomic nervous system such as anesthesia and regional analgesia or hypoxemia. Hypoxic causes include maternal hypotension, placental abruption, cord prolapse or uterine rupture. - ANSWER--Define fetal bradycardia and factors that contribute to fetal bradycardia. increase or speed up - ANSWER--Sympathetic impulses decrease or increase a fetal heart rate? decrease or slow down - ANSWER--Parasympathetic impulses decrease or increase a fetal heart rate? Fluctuations in the baseline FHR that are irregular in amplitude and frequency. Visually quantified as the amplitude of the peak to the trough in BPM within the baseline range. It is an indirect measure of fetal oxygenation. - ANSWER--Define fetal variability. undetectable amplitude range can be indicative of impending fetal hypoxia - ANSWER--Explain absent FHR variability. amplitude >undetectable (visually detectable but less than or equal to 5 BPM) can be indicative of impending fetal hypoxia - ANSWER--Explain minimal variability. amplitude range 6-25 BPM - ANSWER--Explain moderate variability. amplitude range >25 BPM - ANSWER--Explain marked variability. A compromised fetus. -the lowest point of the decel will occur after the peak of the contraction. They dip no more than 30-40 BPM below the baseline. This does not tell the degree of hypoxia. - ANSWER--Define a late deceleration Abnormal fetal acid-base status and require an evaluation and prompt intervention. - ANSWER-- What are late decels with absent variability predictive of? May be periodic or episodic, the most common pattern seen during labor. Their shape and depth are variable, not like early or late's, rarely smooth and regular. A visually apparent abrupt decrease in FHR from onset of decel to nadir of <30 seconds. The decrease is >15 BPM lasting >15 seconds and < 2 minutes in duration. Usually assoc. with cord compression, fetal baroreceptors increase the FHR to maintain cardiac output. - ANSWER--What are variable decelerations? A decrease in FHR of > 15 BPM lasting > 2 min but < 10min from onset to return to baseline. Any decel longer than >10 min is a baseline change. Prolonged decels are due to a sudden significant change in the fetal environment rather than a repetitive stimulus. Immediate communication/ intervention is necessary. - ANSWER--Define prolonged deceleration of the FHR. true - ANSWER--True or False A preterm fetus my be more susceptible to hypoxemia true - ANSWER--True or False The nervous system is not fully developed in fetuses prior to 32 wks gest. 1.Higher baseline FHR i.e. a 23 wk gest may have a baseline of 155 BPM but at term, the same baby may have a baseline of 130 BPM. Any baseline above 160 BPM is still considered tachycardia. 2.Decreased variability bc the central nervous system is not fully developed, variability may be decreased. 3.lower amplitude accels in preterm (before 32 wks) accels of at least 10 BPM above baseline for at least 10 sec is acceptable. 4.more frequent occurrences of variable decels - ANSWER--What are the different characteristics of a fetus prior to 32 wks gest. than a term fetus? When information can not be obtained by palpation or use of toco and if there are no contraindications to its use. i.e. increasing oxytocin w/ elevated BMI if contractions are not being detected using toco. - ANSWER--When should an IUPC (intrauterine pressure catheter) be placed? The primary obstetric provider. - ANSWER--Who may insert an IUPC? Ultrasound monitors externally FHR. Fetal Spiral Electrode (FSE) monitors internally FHR. Tocodynamometer (TOCO) monitors externally contractions. Intrauterine pressure catheter (IUPC) monitors internally contractions. - ANSWER--Name several techniques/devices of fetal monitoring. External- Doppler ultrasound transducer (converts movement into sound to tracing on paper) Tocodynamometer (TOCO) monitors externally contractions. Internal- Fetal Spiral Electrode (FSE) monitors internally FHR. Intrauterine pressure catheter (IUPC) monitors internally contractions. - ANSWER--Identify the 4 types of electronic instrumentation used to assess FHR and uterine activity. If the reflecting surface is moving the reflected signal has a frequency change known as a doppler shift. If the reflecting surface is moving toward the signal source the frequency of the signal increases; if the frequency decreases the surface is moving away. The back and forth movement of the fetal myocardium will produce an alternately higher and lower frequency. Stationary surfaces undergo no frequency change. The US ignores all reflected signals that have the same frequency as the transmitted signal. Those signals that have undergone a frequency change - a Doppler shift- are converted into electronic signals. - ANSWER--Explain the principles of the Doppler shift as related to FHR monitoring. 1.Performing Leopold's maneuvers. 2.Applying the conduction gel. 3.Securing the ultrasound. 4.Reading the FHR tracing. - ANSWER--List the 4 steps in using the external ultrasound device. Assess fetal lie, presentation, position and descent by abdominal palpation. This includes 4 maneuvers to assess the fetal part in the upper uterus, location of fetal back, presenting part and descent of the presenting part. - ANSWER--What are Leopold maneuvers are used to determine? Advantages-detects FHR baseline, variability, accels, decels, & rhythm. Provides permanent recording of tracing. Non-invasive, can be used prior to ROM and w/o cervical dilation. Limitations-Movement may result in weak or absent tracing. Elevated BMI, fetal position, presentation & anterior placental location my affect signal quality. May double FHR if below 30 BPM and 1/2 FHR if > 240BPM. US indirectly measures Fetal heart movement. External US monitoring may restrict ambulation. - ANSWER--List advantages and limitations of the ultrasound transducer. too high or low FHR pattern- *maternal pulse interference, palpate mothers pulse compare to assure differentiation. *dysrhythmia can cause unusual pattern, auscultate FHR to confirm *May double FHR if below 30 BPM and 1/2 FHR if > 240BPM, establish rate by auscultation *test button to reset *check connections *reposition the US transducer *reposition the mother *monitor by other means (auscultation or fetal spiral electrode FSE) - ANSWER--Identify clinical measures for troubleshooting the ultrasound transducer. FSE is only direct method for monitoring the FHR & is less affected by outside interference. The tip if FSE is fine surgical grade wire in shape of corkscrew attached to the fetal presenting part. The electrode detects fetal heart electrical activity, sending and ECG signal to the monitor & produces PQRST waves. BPM are converted btwn R to R intervals. - ANSWER--Explain how the FSE monitors FHR. The electrode is sterilely inserted through the dilated 2-3 cm cervix to the presenting part. Gently turning the electrode clockwise 1.5 turns allows the spiral tip to penetrate the top layer of skin (scalp or buttock) avoiding fontanels, suture lines, face or genitals enabling production of the the ECG. Once secure remove the introducer & attach the wires to the leg plate & secure to mothers thigh or abd near symphysis. To remove turn counter clockwise, do not pull as it can cause injury. Wires are non sterile so remove prior to C/S. - ANSWER--Describe the procedures for application and removal of the FSE Advantage- FSE is only direct means of assessing the FHR. Limitations- *Most will not record R-R intervals (FHR) greater than 240 BPM *Maternal pacemaker may interfere. *Requires ROM and dilated cervix. *May measure maternal heart rate in case of fetal demise. e. Fetal movement/activity f. Maternal position change or sudden baseline shift g. Obscured or low baseline setting h. Inverted waveform r/t placement of toco - ANSWER--Identify the uterine contraction variation: a. Uterine contraction wave form normal b. Maternal respiration c. Valsalva maneuver or pushing d. Maternal activity such as vomiting or seizure e. Fetal movement/activity f. Maternal position change or sudden baseline shift g. Obscured or low baseline setting h. Inverted waveform r/t placement of toco - ANSWER--Identify the uterine contraction variation: a. Uterine contraction wave form normal b. Maternal respiration c. Valsalva maneuver or pushing d. Maternal activity such as vomiting or seizure e. Fetal movement/activity f. Maternal position change or sudden baseline shift g. Obscured or low baseline setting h. Inverted waveform r/t placement of toco - ANSWER--Identify the uterine contraction variation: a. Uterine contraction wave form normal b. Maternal respiration c. Valsalva maneuver or pushing d. Maternal activity such as vomiting or seizure e. Fetal movement/activity f. Maternal position change or sudden baseline shift g. Obscured or low baseline setting h. Inverted waveform r/t placement of toco - ANSWER--Identify the uterine contraction variation: a. Uterine contraction wave form normal b. Maternal respiration c. Valsalva maneuver or pushing d. Maternal activity such as vomiting or seizure e. Fetal movement/activity f. Maternal position change or sudden baseline shift g. Obscured or low baseline setting h. Inverted waveform related to placement of toco - ANSWER--Identify the uterine contraction variation: Advantages- it is external so it is non invasive and ROM is not necessary Limitations- it is location sensitive so improper placement or movement can cause uninterpretable tracing. It is not a means of assessing true resting tone or intensity so must use in conjunction with direct palpation. Toco only gives an approximate measure of duration and frequency. Reading can vary greatly based on mat. weight, mat. position, and position of belt. - ANSWER-- What are the advantages and limitation of Toco? top center is where you should receive the most accurate reading of uterine contractions as term. - ANSWER--Select the best location for placement of Toco for a term pregnancy. It is the only method that directly measures the uterine resting tone, contraction intensity, frequency and duration. It is an invasive procedure that requires ROM and cervical dilation. IUPC is used when there is a need for more detailed information than palpation or toco can provide. The IUPC measures hydrostatic pressure in the uterus, measuring intrauterine pressure during and between contractions. - ANSWER-- What is an Intrauterine pressure catheter (IUPC) and what does it measure? 1.When labor and not progressing & assessment of the adequacy of the contraction is needed. 2.When the nature or event of previous uterine scarring necessitates internal monitoring 3.Amnioinfusion is required 4.Differentiation of FHR patterns relative to contractions is needed - ANSWER--What are indications for IUPC monitoring? Similar to toco tracings, contractions are in (mm HG) and appear as elevations from the baseline resting tone and are quantified measures of contractions intensity and resting tone. Normal baseline tone is 5-20 mmHg Mild contractions w/ peak of <40 mm Hg Moderate contractions w/ peak of 40-70 mm Hg Strong contractions w/ peak of >70 mm Hg - ANSWER--How are IUPC tracings displayed, what are normal values? Normal resting tone 15 mm Hg is with in normal range of 5-20 mm Hg - ANSWER--Does this IUPC tracing show normal resting tone or elevated tone? Elevated tone 30 mmHg is above the normal resting tone of 20-25 - ANSWER--Does this IUPC tracing show normal resting tone or elevated tone ? Normal resting tone 15 mm Hg is with in the normal range of 5-20 mm Hg - ANSWER-- Does this IUPC tracing show normal resting tone or elevated tone ? Used to measure uterine contractions it is inserted via sterile introducer tube placed within the cervix next to the presenting part. The catheter itself is flexible is inserted into the uterus. Insertion is complete when the mark on the catheter is just visible at the introitus. - ANSWER-- How is an IUPC intrauterine pressure catheter placed? *check all attachment points *verify position (can be displaced or perforated uterus or uterine rupture) have pt cough/valsalva if place correctly tracing will spike with cough simultaneously palpate abd to verify presence/absence of contractions *a tracing with no visible resting tone may be improperly zeroed. *abnorm wave form can be due to IUPC lodging against uterine wall or body part *Notify MD if none of above helps and use another method to monitor such as toco or palpation - ANSWER--Discuss troubleshooting of the IUPC *IUPC is assoc w/ increased risk of uterine, placental and cord perforation. *is an invasive method *limits maternal ambulation *catheter tips may be wedged against wall or body part preventing accurate data *higher pressure readings may occur *maternal position may affect the pressure readings - ANSWER-- Discuss the limitations of the IUPC Document what you see on the tracing. If baseline starts at 120 BPM and increases to 130BPM for 10 min or more this is a baseline change. If the FHR continues to show characteristics of a Category I tracing cont. routine assessment and doc. of variability, accels, uterine activity and other changes you observe. - ANSWER--What should I do if the fetal heart rate baseline changes? ACOG says if no risk factors on admission Q30min in 1st stage then Q15min in 2nd stage active pushing of labor If on oxytocin or risk factors then Q15 in 1st stage then Q5 in 2nd stage active pushing of labor - ANSWER--How often should I assess the FHR when using electronic monitoring? Late decels with normal FHR baseline, moderate variability and/or accelerations can be managed conservatively versus late decels with minimal or absent variability. Interventions are toward maximizing uteroplacental blood flow thereby improving oxygen delivery to the fetus. Turn mom on her side, increase IV fluids, decrease or d/c oxytocin, notify MD. Document assessment, interpretation, interventions and evaluate effects of actions. - ANSWER- -What does the presence of late decelerations tell us about the oxygen status of the fetus? Interventions may include administering a tocolytic to decrease uterine activity if tachysystole or elevated resting tone are present. Admin. Oxygen at 10 L/min by non rebreather and notify MD - ANSWER--What actions would you take for late decels that are recurrent and occur with minimal or absent FHR variability? Variable Decelerations, which are a visually abrupt decrease in the fetal heart rate (<30 seconds from onset to beginning of the nadir). The decrease is >15 BPM lasting >15 seconds and < 2 min in duration - ANSWER--What is the most common decel pattern seen in labor? Prior to a contraction the umbilical arteries and vein are wide open; fetal BP is stable. With the beginning of the contraction of the vein, then the arteries are compressed & the fetal body detects decreased blood flow from the fetal heart. In response, the fetal baroreceptor increases the FHR to maintain cardiac output. As it continues to strengthen arteries are compressed increasing fetal BP. The vagus nerve slows down FHR. As the contraction eases the umbilical arteries are released and FHR returns to baseline, fetal HTN is resolved and carbon dioxide can be cleared from the fetal body. Lastly the umb. the vein is released, blood press stabilizes and oxygenation normalizes. - ANSWER--What causes a variable deceleration? Change the mother's position to her side, sitting up, on hands and knees, or a combination of position to maximize umbilical circulation. - ANSWER--How do you alleviate umbilical cord compression? vaginal exam - ANSWER--How do you rule out cord prolapse? relieve cord compression, maximize umb. circulation and rule out cord prolapse and amnioinfusion. Admin oxygen by non-rebreather facemask, reduce or stop oxytocin to decrease uterine activity if needed. Inform the physician if recurrent variable decels with absent FHR baseline variability as a quick delivery may be necessary. - ANSWER--What do you do if variable decelerations are associated with absent FHR variability or abnormal baseline rate and the absence of accelerations? Overshoots are exaggerated compensatory increases in FHR after a variable deceleration. Overshoots are usually at least 10-20 BPM above baseline range and at least 20 seconds in duration. Overshoots are usually accompanied by minimal or absent variability and a gradual return to baseline FHR. They resemble accelerations however unlike accels their significance to fetal acid-base status is unclear. - ANSWER- -What is an overshoot? 1.Mother (blood plasma, cardiac output, hemoglobin concentration & O2 saturation) 2.Placenta/intervillous space (uterine contractions & calcification's) 3.Fetus (vagal response aka decel or cord compression) - ANSWER-- What factors impact maternal oxygen delivery? 30-50% lateral recumbent or semi-Fowler's - ANSWER--By what % does maternal cardiac output increase above the non-pregnant state and what position helps this uteroplacental blood flow? >5 contractions in 10 min (more frequently than Q 2 min) averaged over 30 min window. Caused by oxytocin, aminoinfusion or in rare cases spontaneously. - ANSWER--Define tachysystole contractions and the cause of. Maintaining mat. volume, mat. positioning, intravenous hydration. Decreasing mat. pain/anxiety. 1.Reposition pt to side. 2.Admin IV fluid bolus. 3.Admin 0.25mg terbutaline SQ. 4.Admin O2 10L via non rebreather face mask. - ANSWER--List interventions for tachysystole contractions. higher conc. to lower concentration. 1.Oxygen from maternal (higher) to fetal compartment (lower) to fetal hgb then transported to fetal tissue. 2.CO2 returns to intervillous space by passive diffusion and is removed by the mat. venous system. - ANSWER--Describe passive diffusion as related to the maternal placental fetal system. Place her in lateral position, & increase IV fluids. If no improvement may need to give epi to increase vascular tone. - ANSWER--Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the client's blood pressure? Choose all that apply. A) Place the woman in a supine position. B) Place the woman in a lateral position. C) Increase intravenous (IV) fluids. D) Continuous Fetal Monitor E) Administer ephedrine per MD order systolic BP >= 140mm hg, a diastolic BP>= 90 mm hg or MAP of >=105 - ANSWER--Define maternal hypertension (gestational). 17g/dl, fetal hgb has a higher oxygen affinity than an adult to develop in an oxygen poor environment. The fetal circulatory pattern ensures blood with higher O2 and nutrition content is delivered to the vital organs (brain and heart) to tolerate the stress of labor. - ANSWER--What is the normal expected value for a term fetal HGB? 1 vein, 2 arteries encased in wharton's jelly. O2 (high content) travels via the vein CO2 travels via 2 arteries back to placenta - ANSWER--detail the umbilical cord A decrease of blood flow and O2 delivery to fetus & increases CO2 level in fetus. Transient cord compression can be common in labor. Variable FHR decel's is frequently associated with cord compression. - ANSWER-- Define cord compression. May lead to hypoxemia and fetal acidemia. The depth of variable deceleration's is not enough to determine degree. Evaluate oxygenation through baseline heart rate characteristics through rate, variability and presence or absence of accelerations. - ANSWER--Explain persistent or recurrent cord compression concerns and what to look at.