*ATI Ch 13 fetal assessment during labor
Terms in this set (82)
consist of performing external palpations of the maternal uterus through the abdominal wall to determine the following: Number of fetuses Presenting part, fetal lie, and fetal attitude ■ ■
Point of maximal impulse
optimal location where the fetal heart tones are auscultated the loudest on the woman's abdomen. These tones are best heard directly over the fetal back.
PMI is either in the right- or left-lower quadrant or below the maternal umbilicus.
PMI is either in the right- or left-upper quadrant above the maternal umbilicus.
True or false.
Client must empty bladder before Leopold maneuver
Under right hip to displace uterus to the left and to prevent hypotension
Where do you place wedge when women is lying supine
The head should feel round, firm, and move freely. The breech should feel irregular and soft
Locate and palpate the smooth contour of the fetal back using the palm of one hand and the irregular small parts of the hands, feet, and elbows using the palm of the other hand.
Face the client's feet and outline the fetal head using the palmar surface of the fingertips on both hands to palpate the cephalic prominence. If the cephalic prominence is on the same side as the small parts, the head is flexed with vertex presentation.
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.
this is a technique by listening to FHR in intervals. technology method that can be performed during labor using a hand-held Doppler ultrasound device, an ultrasound stethoscope, or fetoscope to assess FHR. cheap and less invasive. hard to hear on obese women
waves, velocity, and sounds of the heart
the ultra sound device can listen to the
listen intermittently, used for low risk patients, in latent may be every 60 mins, then 30, then 15 min in second phase of labor.
if more serious patient, then half the amount of time
how often should you do intermitent auscultation during labor
Electronic fetal monitoring (EFM)
this type of FHR is External monitoring
Fetal Heart Rate: Ultrasound transducer
Uterine Contractions: Toco-transducer
toco is on top of funds and the ultra sound is lower
where is tocotransducer and ultrasound transducer placed when doing a external fetal monitoring
this device measures the pressure of contractions in mm mercury
this type of monitoring uses Spiral electrode
Intra Uterine Pressure Catheter (IUPC) used for high risk mothers
pass cervix, must have ruptured membrane and electrode will be wrapped around the head. will measure pressure during contractions and relaxation.
when can siral electrodes and intra uterine pressure catheter be placed.
to asses fetal heart rate by piercing fetus skull
what is a Spiral electrode used for
measures contraction pressure
Intra Uterine Pressure Catheter
from the start of duration of contraction to the end of the relaxation period.
what is measured in the frequency of contractions
during contractions uterus goes up and contracts thats why tocotranducer is placed on top. if too high contractions may look like they are going down
Latent 60, active 30, second 15. High risk women is half time
Guidelines for intermittent auscultation
True or false.
Count FHR for 30 to 60 seconds to determine baseline rate.
True or false.
Auscultate FHR during a contraction and for 30 seconds following the completion of the contraction.
Continuous external fetal monitoring
Non invasive procedure 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.
110 to 160 per minute
What is the normal fetal heart rate for term
10-minute segment that excludes:
Periodic or episodic changes
Periods of marked variability
Segments of the baseline that differ by more than 25 beats/min
Must be at least 2 minutes of interpretable data
Baseline Heart-rate above 160 BPM for a duration of 10 minutes or more
Fetal hypoxemia, Maternal fever, Drugs, Amnionitis, hyperthyroidism, Fetal anemia, Fetal heart failure, Fetal cardiac arrhythmias
what are the causes of fetal tachycardia
Baseline Heart-rate below 110 BPM for a period of 10 minutes or more
fetal hypoxemia, Beta-adrenergic blocking drugs, Anesthetics, Maternal hypotension, umbilical cord compression, Maternal Hypothermia, Hypoglycemia, heart block, cardiac arrhythmias, Cytomegalovirus
what are the causes of fetal bradycardia
if mother is hypotension then fetus will have hypotension and the same for hypertension
this is a Normal irregularity of fetal cardiac rhythm.
Results from a continuous balancing interaction of the sympathetic and parasympathetic branches of the autonomic nervous system
good to have variability for hear to accommodate to movements, cardioaccelerator, cardioinhibitory located in neck to regulate amount of oxygen fetus gets
absent variablity, baby could be sleeping or not getting enough oxygen to brain
when the FHR doesn't go up and down looks like a straight line,
when the FHR is almost undetected, but varies no more
than 5 BPM from the baseline rate. subtract highest and lowest
this type of variability is when the Heart rate varies anywhere from
6 - 25 BPM from the baseline rate. this is a good sign.
this is a type of variability where the Heart rate varies >25 BPM from the baseline rate. unknown if its good or bad sign
Determine the fetal baseline rate over a 10 min. period
2. Identify the highest BPM rate you observe on the strip during that period of time.*
3. Identify the lowest BPM rate you observe on the strip during that period of time.*
4. Determine the difference between the highest and lowest BPM, and you have determined the variability.
* Make sure that you aren't including accelerations, or decelerations in the process.
what are the unofficial steps in determining variability
Uterine Contractions (UCs)
what are Periodic fetal heart rate changes
Not associated with UCs
what are Episodic fetal heart rate changes
this is an increase in the FHR above the baseline rate by at least 15 BPM and lasting for at least 15 seconds
fetal head compression
Early decelerations happen in response to this happening to the fetus
uteroplacental insufficiency or poor perfusion
Late decelerations due to what
umbilical cord compression
Variable decelerations happen in response to this happening to the fetus
they look like a mirror image of fetal heart rate and uterine contractions. you can see them towards the end first stages of labor. this is uscally normal during labor. goes along with contractions
how does early decelerations look like and when do you see them
a fetus with a large head
if early decelerations are detected early in labor what can it be a sign of
this is a bad sign, will also go along with contractions but the difference is that deceleration will start during the contraction and end when the contractions are relaxed.
how does late decelerations look like and when do you see them
late decelerations can be dangerous because is can lead to brain damage
discontinue oxytocin, change maternal position turn to side, correct hypotension by elevating legs, increase rate of IV, palpate uterus for hyper stimulation, give oxygen 8-10 liters tight face mask
what nursing intervention would you do if a fetus is having late decelerations
rapid decrease and increase of heart rate cause by umbilical cord compression. more round for early and late and more narrow for variable deceleration. looks like W. fetus could be holding umbilical cord tight
how does a variable deceleration look like and what is it caused by
this type of deceleration lasts less than 45 seconds
Abrupt return to baseline
Normal FHR baseline
this type of deceleration lasts more that 60 seconds
Slow return to baseline
Increasing FHR baseline rate
Absence of Variability
change position side, knee to chest, discontinue oxytocin, 8 to 10 L oxygen
what nursing intervention would you do if a fetus is having late decelerations
Variable deceleration Cord compression
Early acceleration Head compression
Late deceleration Perfusion problems
what is VEALCHOP in change in fetal heart rate
Three tier fetal heart rate interpretation system
- the beginning of the contraction as intensity is increasing
- the peak intensity of the contraction
- the decline of the contraction intensity as the contraction is ending
50 to 85 mm hg
What is the average pressure for uterine contractions
Early detection of fetal distres; accurate FHR variability, contraction intensity
Advantages of internal fetal monitoring
Membranes must be ruptured; cervix dialated 2 to 3 cm, risk for injury to fetus
Disadvantages of internal fetal monitoring
There is moderate variability of 20 beats/min (6 to 25/min is expected).
Maintenance of oxygen supply to prevent fetal compromise
Reduction of blood flow through maternal vessels.
Reduction in oxygen content in maternal blood.
Alterations in fetal circulation.
Reduction in blood flow to intervillous space in placenta
what are some causes of decrease oxygen supply to the fetus
FHR accelerations are present with increases up to 150 to 155/min lasting for 25 seconds.
fetus is most oxygenated during the relaxation period between contractions. During contractions, the arteries to the uteroplacental intervillous spaces are compressed, resulting in a decrease in fetal circulation and oxygenation.
Baseline FHR in the normal range of 110-160 beats/min
Baseline fetal heart rate variability: moderate
Late or variable decelerations: absent
Early decelerations: may be present or absent
Accelerations either present or absent
greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The initial nursing action should be to place the client into the left-lateral position to increase uteroplacental perfusion. .
Bradycardia not accompanied by absent baseline variability
Minimal or absent baseline variability not accompanied by recurrent decelerations
Marked baseline variability
No accelerations in response to fetal stimulation
Periodic or episodic decelerations
The application of a fetal scalp electrode will assist in the assessment of fetal well-being, but this is not the first action the nurse should take
Nonreassuring FHR patterns associated with fetal hypoxemia
Hypoxemia can deteriorate to severe fetal hypoxia
Absent baseline variability
Recurrent or late decelerations
practice on ch 13 powerpoint with worksheet
There is a normal baseline FHR of 115 to 125/min (110 to 160/min is expected).
Inserting an IV catheter is an intervention for late decelerations, but this is not the first action the nurse should take.
The nurse may perform a vaginal exam to assess dilation, but this is not the first action the nurse should take.
Using the palms of the hands on the sides of the uterus to identify the fetal back and small body parts verifies the presenting part.
Palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse).
The descent of the presenting part into the pelvis is determined by gently grasping the lower uterine segment between the thumb and fingers. D.
Fetal attitude is identified by facing the client's feet and outlining the cephalic prominence (fetal head) using the fingertips of both hands.