Why do we monitor the FHR?
To find out how baby is doing and making sure they are okay
What is the source of all fetal 02?
Placenta (umbilical cord vein)
Every contraction decreases the blood supply to the fetus- about 50%, why?
Contractions squeeze the uterine wall, squeezing the placenta which cuts off the blood supply to the fetus
How does the maternal/cord influence fetal oxygenation (6)?
1. O2 levels of mom (maybe decreased due to anemia, asthma, smoking, hyperventilate or be hypoxic)
2. B/P of mom- too high or too low (↓ perfusion to baby). An epidural will ↓BP so they hydrate the mom
3. Posture of mom- do not lay supine, compresses vena cava
4. Position of the cord in the uterus (cord compression)
5. Character of contractions = DIF. ↑ these → ↓ perfusion
6. Resting tone fo the uterus. relaxing means baby gets more O2.
How does contractions influence fetal oxygenation (2)?
1. The longer the duration, the more intense, the more frequent...all decrease O2
2. Diminished or absent resting tone...palpate; is it relaxed or constantly contracted?
All act to decrease fetal blood supply
What are 6 fetal factors regulating the FHR?
1. Parasympathetic nervous system decrease the FHR
2. Sympathetic nervous system speeds up the FHR
Both act according to info sent from baroreceptors and chemoreceptors
3. Baroreceptors in heart respond when BP ↑ & ↓ FHR
4. chemoreceptors sense O2, CO2 & acid-base and adjust the FHR accordingly
5. CNS states- sleep
6. Drugs in the fetus from Mom that cross the placental barrier (may cause baby to sleep)
How do mothers 'monitor' their babies (4)?
1. Fetal movement is a reflection of fetal O2 levels
2. Kick counts- begins in 3rd trimester
3. Mom lies on her side and concentrates on the fetal movements;
--report if less than 4 movements in 30 min
--report if less than 10 movements in 1 hour
4. count fetal movements for 30 min in morning and evening to establish baseline--if 50% decrease or no fetal movement; report
When you report kick counts (3)?
1. report if less than 4 movements in 30 min
2. report if less than 10 movements in 1 hour
3. if 50% decrease or no fetal movement
What is EFM (4)?
1. Electronic Fetal Monitoring
2. "Admission strip"- 1st 20-30 minutes to establish baseline record
3. If fetus well oxygenated, FHR strip will be 'reassuring' or WNL--doesn't mean baby will be normal
-anacephalic babies may display WNL strip
4. reassuring tracing has a 99% predictive value for fetal well being (oxygenation wise)
What is admission strip?
1st 20-30 minutes of electronic fetal monitoring to establish baseline record
What is an ultrasound for FHR (2)?
1. Use leopold's maneuver - apply US over the fetal back
2. Verify fetal life- check maternal pulse (so that the HR you are hearing is not the moms); fetoscope
What is a toco (2)?
1. For uterine activity palpate uterus for area of hardest contraction & place it there
2. Apply over fundus- make sure there is contact
What is leopolds maneuver (3)?
1. Purpose: to determine presentation and position of fetus and aid in location of FHR
2. Method: explain procedure to pt, have woman empty bladder, wash hands, stand beside, facing woman's head
3. 4 maneuvers
What is the first leopold's maneuver (4)?
1. Determines presenting part
2. Palpate uterine fundus
3. Vertex (head down) - buttocks is softer and more irregular than head
4. Breech- head is harder and round, uniform
What is the second leopold's maneuver (4)?
1. Determines which side of the uterus is the fetal back located (that is where the FHR is found)
2. Hold left hand steady on side of uterus while palpating opposite side of uterus w/ right hand
3. back is smooth, convex
4. arms and legs feel bumpy, may move
What is the third leopold's maneuver (5)?
1. Confirms presenting part is engaged (locked in)
2. Palpate suprapubic area
3. Expect a hard rounded head
4. grasp presenting part gently btwn thumb & fingers
5. if presenting part is not engaged, presenting part will float upward
What is the fourth (bump-cephalic prominence) leopold's maneuver (5)?
1. Determines whether the head is flexed or extended (Face presentation)
2. Omit if fetus is breech
3. Turn to face woman's feet
4. place hands on each side of uterus w/ fingers pointed toward pelvic outlet
5. on one side, slide fingers downward/feel for bump
-if head is flexed, it will be one smooth movement & you will feel cephalic prominence on opposite side
-if head is extended, you will feel a bump
Where would you expect to find the best location to assess the FHR?
after leopold's maneuver, on baby's back
What are some factors that influence the quality of EFM tracing (3)?
1. Adipose tissue; interferes w/contraction monitoring
2. Proper location of toco; is required for good tracing, palpate for most prominent area on fundus
3. FHR is affected by the position, size and movement of fetus. if the baby/mom moves --> move the US
What is a FECG/Spiral Electrode (4)?
1. Direct/Internal EFM
2. Use for internal fetal heart rate monitoring
3. EKG of fetus
4. Verify fetal life: compare maternal pulse; fetoscope
What is an Intrauterine Pressure Catheter (IUPC)?
1. Direct/Internal EFM
2. Used for internal uterine contraction monitoring.
3. Can tell you the intensity of the contraction & the resting tone
4. cmH20 pressure or mmHg
5. slides in next to baby
What are the risks of direct/internal monitoring (2)?
2. careful what you are screwing into (face, fontanel, eye)
What are some safety tips for an internal EFM (3)?
1. Membranes must be ruptured
2. Dilation must be to 1-2 cm, easier application if dilation further
3. Must be appropriate presenting part
What are the 5 steps for evaluate the FHR tracing?
1. Baseline rate
2. Variability-> most sensitive O2 indicator **most important
3. Accelerations (Periodic change)
4. Decelerations (Periodic change)
5. Uterine Contraction (UC) Pattern
How do you identify the FHR baseline (5)?
1. Determine by approximating the mean FHR rounded to increments of 5 bpm during 10 MIN WINDOW excluding accels and decels and marked variability. Need 2 mins of definition base or use previous 10 min window
2. Read between contractions
3. Normal- 110-160 (premie will have higher rate due to immature PNS)
4. Bradycardia= 10 min <110 Abnormal → cause is hypoxia
5. Tachycardia= 10 min >160 Abnormal → causes are
hypoxia, maternal fever, infection
FHR Bradycardia what are the levels & causes?
10 min <110 Abnormal
Cause is hypoxia
FHR Tachycardia what are the levels & causes?
10 min >160 Abnormal
Causes are hypoxia, maternal fever (check mom's temperature), infection
How do you determine the FHR variability (2)?
1. Fluctuations in the baseline FHR. Like some variability. Shows PNS & SNS are working well together
2. Indicator of fetal O2 status specifically of the Autonomic nervous system (Part of the CNS)
What are factors that influence variability (5)?
1. * decreased O2 status in the fetal CNS always worry about this
2. Narcotics that mom takes
4. Fetal sleep (30 mins)
5. Abnormalities in the fetal CNS, heart or both
What is the definition of variability?
Fluctuations in the baseline FHR that are irregular in amplitude and frequency- these fluctuations are visually quantified as the amplitude of the peak-to-trough in bmp determined in a 10 min window, excluding accels and decels
--sleeping fetus may have decreased variability which lasts approximately 30 mins
What are the four variability classifications?
Absent- amplitude range undetectable
Minimal- amplitude range > undetectable and <=5 bpm
Moderate- amplitude range 6-25 bpm
Marked- amplitude range > 25 bpm
How do you evaluate FHR for accelerations (8)?
1. Called a "periodic change"
2. Accels are REASSURING sign of adequate fetal oxygenation & well being
3. Accels are assessed in relation to the baseline, associated with fetal movement
4. Peak must be 15 bpm above baseline & last at least 15 (15X15 rule)
5. Antepartum (Prior to labor) accels are also used as a means of establishing fetal oxygenation status. if you see accels then everything is good. If not, maybe an early delivery
6. may use scalp stimulation to initiate an acceleration
7. Prolonged accel >=2 mins but <10 mins. IF >=10 mins this is a baseline change
8. **Prior to 32 weeks use the 10x10 rule
How do you evaluate the FHR for decelerations (3)?
- named for the relationship to uterine contractions
What is an early deceleration (6)?
1. FHR drops as contraction rises MIRROR the UC. Begins with UC & returns to baseline by end of UC
2. FHR drop is about 30 bpm & usually remains above 100 bpm
3. Gradual rather than abrupt. SAUCER shaped
4. Consistent pattern
5. Benign = no intervention needed
6. Cause by fetal head compression
the nadir (lowest point) of the decel occurs at the same time as the peak of the UC
What is the cause of early decelerations?
fetal head compression (increased intracranial pressure causing the vagus nerve to slow the HR)
What are Nursing Interventions for Early decels (6/really 2)?
2. Prepare for delivery
3. NO link to decrease in fetal O2 status
4. Always continue to monitor the pt.
5. Does mom feel urge to push? Does she feel increasing pressure at the peak of each contraction? Last cervical check?
6. Notify MD
What are late decelerations (7)?
1. timing is "late" in relation to UC. The FHR starts to drop at the peak or just slightly after the peak of the contraction. Shifting right. Looks similar to early decels but...
2. Does not return to baseline until after the UC ends
3. Drop can be subtle (SAUCER) - only 10-30 bpm
4. Recurrent, consistent pattern
5. BAD/WORST kind of decel. Fetus needs HELP. may be hypoxic. Treat ASAP
6. Cause is uteroplacental insufficiency
7. Must have more than one to be late
Decel is delayed in timing w/ the nadir of the decel occurring after the peak of UC, in the most cases the onset, nadir and recovery of the decel occur after the beginning peak and end of the UC
What is the cause of late decelerations?
- maternal hypotension, excess uterine activity (too much=hypoxia), abrupt/previa, chronic hypertension, maternal DM, severe maternal anemia, maternal cardiac disease (poor circulation)
What are some STAT nursing actions for late decels (6)?
1. Turn woman to her side; Left first then right (Improves venous return and therefore increases BP)
2. Start O2 by mask 8-12L
3. Increase "PLAIN- no meds" IV fluids
4. Turn off pitocin (b/c causes contractions & baby not getting O2. want baby to get O2)
5. Notify MD, watch pattern, document, anticipate need for C/S if recurrent
6. Call anesthesia, supervisor-staffing, call nursery, set up C/S room
What is POISON & when to perform?
P = position on side
O = Oxygenation, give O2
I = IV fluid bolus
S = Sterile VE
O = Oxytocin off
N = Notify MD/midwife
Perform when late decelerations
What are variable decels (7)?
1. Timing is variable in relation to the contractions
2. abrupt onset and offset (Onset to nadir of decel <30 secds)
3. Sharp dip
4. Typical shapes are U, V & W
5. Caused by umbilical cord compression--flow of blood and there O2 is slowed or stopped to fetus
6. The decel is >=15 bpm and lasts >=15 secs and <2 min in duration
7. Possible shoulders and overshoots
What is the cause of variable decelerations?
Umbilical cord compression = fetal blood flow is decreased & therefore O2 supply is decreased
Examples: nuchal cord, cord around body, cord pressed in by the pelvic bones, oligohydramnios, knot in cord, prolapsed cord
What are the nursing interventions for variable decelerations (6)?
#1. Maternal position change-- (usually to the left) to induce a fetal position change that relieves the cord compression and therefore restores blood flow and oxygenation. float the presenting part off the cord
2. Evaluate pattern and document
3. This pattern can be a danger to the fetus
4. Possible O2
5. Possible IV changes
6. Notify MD
What is a shoulder?
In a variable decel, accelerative phase
-brief accels that may PRECEDE or FOLLOW the variable decel
-progressive amts of pressure being placed on and removed from the umbilical cord (think in terms of blood flow and fetal O2)
-usually moderate variability is present- so reassuring
- if the shoulder is after the decel, return to baseline is fast
What is an overshoot?
Only occurs after the variable decel as the FHR attempts to recover to baseline rate
The compromised fetus attempts to recover to baseline, but raises his FHR way over the baseline rate
Usually minimal to absent variability
Usually the overshoot lasts a significant time period (longer then shoulder) so NON reassuring in a post-term fetus-- associated w/ hypoxia/acidosis
Anticipated rx is preterm or if mom has Atropine
How do you evaluate uterine contractions?
What is the DIF?
-Internal IUPC required to evaluate intensity accurately
-External TOCO must palpate: mild, moderate, strong
Resting tone Goal: < 20 mmHg IUPC or relaxed if on Toco transducer
How do you palpate a UC (4)?
1. Place fingerpads of one hand on the uterine fundus, using light pressure
2. Contractions usually begin in the fundus
3. Avoid constant moving of the hands over the uterus, may stimulate contractions
4. Estimate strength;
Mild, easily indented, tip of nose
Moderate, indents w/ more difficulty, chin
Strong, firm, cannot be easily indented, forehead
What is tachysytole (4)?
1. Always qualify as presence or absence of associated FHR decels
2. Applies to spontaneous and stimulated labor
3. >5 UC in 10 mins, averaged over 30 mins
4. Normal UC <=5 in 10 mins over 30
What is Category I FHR (6)?
1. Baseline HR 110-160
2. Moderate Variability
3. NO late or variable decels
4. Early decels, present or absent
5. Accels present OR absent
6. NORMAL TRACING!!!! Strongly predictive of WNL fetal acid base balance-- follow in a routine manner, no specific manner. Continue to monitor
What is Category II FHR (11)?
1. Indeterminate; not yet predictive of abnormal fetal acid base status- not adequate evidence to classify as cat I or III so continued surveillance and reevaluation w/ look at entire clinical situation
2. Includes all FHRs that are not I or III:
3. Baseline--bradycardia with variability
5. Absent variability (w/o recurrent decels) minimal or marked variability
6. Absence of induced accel after fetal stimulation
7. Recurrent variable decels w/min to mod variability
8. Prolonged decels ≥2 mins but <10 mins
9. Recurrent late decels w/ mod. variability
10. Variable decels w/ slow return to baseline, overshoots, shoulders
What is Category III FHR (3)?
1. ABNORMAL; requires prompt evaluation and actions --> POISON
2. Sinusoidal Pattern
3. Absent variability and any of these:
--recurrent late decels, recurrent variabiles, bradycardia
What is a sinusoidal pattern (4)?
1. Visually apparent smooth, sine wave-like undulating pattern in FHR baseline w/ cycle frequency of 3-5 minutes that persits for >=20 mins
2. Associated w/ fetal anemia, hypoxia, and acidosis (cases- occult cord prolapse, pre-eclampic Mom w/ partial abruption)
3. Poor prognosis
4. Autonomic nervous system turned off by hypoxia
What is VEAL CHOP?
V;Variable Decel ---reposition mom---C;Cord Compression
E; Early Decel----------Expected-------H; Head Compression
A; Accels----reassuring----------------O;O2 adequate (okay)
L; Late decel-O2, no pitocin, MD, reposition-P; Placental Insufficieny (problem)
Fetal Cord Blood Gases and pH (4)
1. Umbilical cord blood analysis is used to assess infant oxygenation and acid-base balance immediately after birth
2. blood drawn into a heparinized syringe sent to lab stat (draw artery 1st then vein)
3. can determine if acidosis exists
4. indicator of how baby tolerated labor and delivery process
-Remember vein carried oxygenated blood
if pH 7.2-7.25 watch for up to 30 minutes for improvement
pH 7.2 requires stat interventions for birth
head to big to fit thru pelvis