Decrease in fetal heart rate during contraticon, low point is near peak contraction & usually not lower than 30-40 BPM from baseline. No fetal compromise so no intervention is necessary

Decreased fetal heart rate of at least 15 BPM & between 15 seconds - 2 minutes. No uniform appearance and are sharp/abrupt in fall & rise. May or may not be related to contractions

Decrease in fetal heart rate related to deficient oxygen exchange/waste products in placenta. Often begins after fetal contraction and FHR returns to baseline after contraction ends. Usually not lower than 30-40 BPM from baseline, but are shifted to right in relation to contraction

Abrupt temporary increase in fetal heart rate. At least 15 BPM above baseline & lasts at least 15 seconds. Often occurs with fetal movement, may or may not be related to contractions. usually a good sign of responsive, non-acidotic fetus. 

Fluctuations in baseline fetal heart rate. many factors constantly speed & slow fetal heart rate. Shows an irregular line rather than a smooth line on monitor strip.

4 types:  Absent, minimal, moderate, marked

Absent: undetectable (straight line) 

Minimal: undectable to <5BPM away from baseline 

Moderate: 6-25BPM away from baseline 

Marked: > 25BPM away from baseline

1. What is the source of all fetal oxygen?

2. Every contraction decreases blood supply to fetus, why?

3. What are a couple causes that may compromise a fetus & cause distress?

1. Mom (if she is hypoxic, baby is hypoxic) so if she is hyperventilating baby may not get good oxygenation

2. Because the contraction has a turniquet effect

3. Pre-term or unhealthy placenta

 How do these Maternal factors influence fetal oxygenation?

6. positon of cord in uterus

1. If mom's hypoxic baby is hypoxic

2. Will often decrease after epidural and can decrease oxygen to fetus, should bolus mom with 1-2 L  fluid before epidural

3. On back puts pressure on inferior vena cava; she should be on side.

4. Duration, Intensity, frequency; problems if too close or too long

5. Pressure of uterus should be <20 when not contracting to give baby chance to get oxygen since contractions are like holding breath if >20 baby is not getting good perfusion

6. Normal is floating, when compressed perfusion is decreased, knot in cord, nucocord (around neck), length of cord; if knots or nucocord is not tight it's ok

Fetal factors regulate fetal heart rate

1. Autonomic Nervous System
2. Barorecptors
3. Chemorecptors
4. CNS states (sleep)
5. Drugs

1. Sympathetic Nervous System (Adrenal glands) speeds up FHR AND Parasympathetic Nervous system decreases FHR  BOTH Must work perfectly

2. Stretch receptors on carotids & major arteries aroung heart respond when fetal BP increases & stimulate Vegas nerve to slow FHR decreasing BP leads to decrease CO (cardiac output)

3. Chemical receptors sense changes, decrease O2, increase CO2, & decrease pH which triggers increase in FHR (prolonged hypoxia & acidosis can decrease FHR)

4. Sleep decrease FHR & Movement increases FHR

5. May cross the placental barrier (asthma meds can do this)

 How do these Maternal factors influence fetal oxygenation?

5. Resting tone of uterus

5. Pressure of uterus should be <20 when not contracting to give baby chance to get oxygen since contractions are like holding breath if >20 baby is not getting good perfusion

 How do these Maternal factors influence fetal oxygenation?

4. Contraction characteristics (DIF)

4. Duration, Intensity, frequency; problems if too close or too long

 How do these Maternal factors influence fetal oxygenation?

3. Posture of Mom

3. On back puts pressure on inferior vena cava; she should be on side.

 How do these Maternal factors influence fetal oxygenation?

2. BP of Mom

2. Will often decrease after epidural and can decrease oxygen to fetus, should bolus mom with 1-2 L  fluid before epidural

 How do these Maternal factors influence fetal oxygenation?

1. O2 level of Mom

1. If mom's hypoxic baby is hypoxic

Fetal factors regulate fetal heart rate

1. Autonomic Nervous System
2. Barorecptors
3. Chemorecptors
4. CNS states (sleep)
5. Drugs

1. Sympathetic Nervous System (Adrenal glands) speeds up FHR AND Parasympathetic Nervous system decreases FHR  BOTH Must work perfectly

2. Stretch receptors on carotids & major arteries aroung heart respond when fetal BP increases & stimulate Vegas nerve to slow FHR decreasing BP leads to decrease CO (cardiac output)

3. Chemical receptors sense changes, decrease O2, increase CO2, & decrease pH which triggers increase in FHR (prolonged hypoxia & acidosis can decrease FHR)

4. Sleep decrease FHR & Movement increases FHR

5. May cross the placental barrier (asthma meds can do this)

How does this fetal factors regulate fetal heart rate

Autonomic Nervous System

Sympathetic Nervous System (Adrenal glands) speeds up FHR AND Parasympathetic Nervous system decreases FHR  BOTH Must work perfectly

How does this Fetal factors regulate fetal heart rate?

Chemorecptors

Chemical receptors sense changes, decrease O2, increase CO2, & decrease pH which triggers increase in FHR (prolonged hypoxia & acidosis can decrease FHR)

How does this Fetal factors regulate fetal heart rate?

Barorecptors

Stretch receptors on carotids & major arteries aroung heart respond when fetal BP increases & stimulate Vegas nerve to slow FHR decreasing BP leads to decrease CO (cardiac output)

Fetal factors regulate fetal heart rate

Drugs

 May cross the placental barrier (asthma meds can do this)

***Monitor the fetal oxygen status***

Promote adequate fetal oxygen

Take corrective action as needed

Notify MD of fetal oxygenation problems

Kick counts (mom's monitor baby)

Begins when?

How is it done?

In 3rd trimester near due date

mom lies on side and focus on fetal movements then counts them

Report if <4 movements in 30 min.

or

Report if < 10 movements in 1 hour

or

Report if 50% decrease or no movement

Count in morning & evening to establish baseline

Electronic Fetal Monitoring is standard care in hospital

What is admission strip?

If Fetal heart rate is within normal limits; what does this mean? Will the baby be normal?

If a baby is ancephephalic (absence of brain, no treatment), how will the strip look?

What does a reassuring tracing predict?

1st 20-30 minutes to establish a baseline & see how it looks.

The heart looks healthy, fetus is well oxygenated

Does NOT mean baby will be normal

May display a within normal limit strip

99% positive prediction of fetal well-being

Reliability of Electronic Fetal Monitoring (EFM)

How long has it been used?

What has it shown in r/t cerebral palsy(CP)?

What % of fetuses demonstrate a nonreassuring FHR tracing sometime during labor?

Wide use for over 30 years

No change in incidence of (CP) which is usually r/t lack of oxygen during pregnancy(antepartum event) NOT labor;

Improved rate of survival in premies which results in increased rate of (CP)

30% or about 1/3 of fetuses have a period of nonreassuring fetal heart rate

What are 2 types of external (indirect) electronic fetal monitoring?

What are they used for? & what must be done to be sure they are used correctly?

No risk from equipment

Ultrasound: monitors fetal heart rate, round ultrasound disk is applied over fetal back, use leopolds maneuver to determine where fetal back is, & verify fetal life by checking maternal pulse (if mom's pulse & monitor have same pulse the monitor is in the wrong place)

TOCO: transducer for uterine activity, palpate uterus for contraction, Apply over fundus(top b/c strongest contraction is felt hers)- make sure there is contact

Leopold's Maneuver

What is the purpose?

What do you do before procedure?

How many maneuvers are involved?

Determine presentation & position of fetus & aid in location of fetal heart sounds; Identify where the fetal back is.

Explain procedure to pt. *Have pt. empty bladder * Wash hands or wear gloves * Stand beside, facing pt. head with your dominate hand nearest her

4 Maneuvers

Step 1 of Leopold's maneuver

Determines?

Palpate top of fundus to distinguish between cephalic (vertex) & breech presentation

This is what you will feel in fundus if presentation is:

Vertex: buttock is softer & more irregular shaped than head

Breech: Head is harder and round, uniform

Step 2 of Leopold's Maneuvers

Determines?

Feel where fetal back is by palpating sides of uterus

Hold left hand steady on side of uterus & palpate opposite side with right hand

Fetal back is smooth and convex

Fetal arms & legs feel nodular, fetus moves them during palpation

Step 3 of Leopold's maneuvers

Confirms?

Confirms presenting part is engaged by palpating suprapubic area & confirms presentation determined in step 1 .

Attempt to gently grasp presenting part between thumb and forefingers. Expect a hard rounded head (unless breech) if you squeeze:

Head floats up = NOT engaged

Head doesn't move = engaged

Step 4 of Leopold's maneuvers

Determines?

If head is flexed or not (face presentation)

Do NOT attempt if fetus is breech

Turn to face pt. feet & place hands on sides of uterus with fingers pointed toward pelvic outlet slide fingers downward and feel for cephalic prominence (bump)

Bump = head extended

NO bump (smooth) = Head flexed

(cephalic prominence felt on opposite side from back)

Adipose tissue interferes with monitoring contractions (heavy & thin pt. may have same uterine activity/contractions, but shows up better on monitor in thin pt)

Proper location of toco for good tracing by palpating fundus for prominent area

Fetal heart rate is affected by position, size, & movement of fetus

Internal (direct) electronic fetal monitor

What are they & what do they do?

What are risks of internal monitoring?

FECG/Spiral electrode (screwed into baby's head)

used for fetal heart rate monitoring (fetus EKG) to verify fetal life; compare to maternal pulse; fetoscope 

Intrauterine Pressure Catheter (IUPC) used for internal uterine contraction monitoring cmH20pressure

Risk of infection

Internal Fetal Monitor FECG/spiral electrode

What must be done before it can be placed?

3

Membranes must be ruptured

Dilation must be 1-2cm (easier insertion)

Must be appropriate presenting part (head first, so it is not screwed into an eye)

5 steps to evaluate a fetal heart rate tracing

What is most important?

Baseline rate

Variability ***Most important

Accelereations (periodic change)

Decelerations (periodic change)

Contraction pattern

1-Determine fetal heart rate baseline

Need a least a ___ min. strip

Read the rate between____

Normal rate

Bradycardia

Tachycardia

10 minute strip

Read rate betweeen contractions

Normal fetal HR: 110-160

Bradycardia is 10 minutes <110 (not periodic changes) usually hypoxia

Tachycardia is 10 minutes > 160 (not periodic changes) may be hypoxia, but usually maternal fever, infection

2- Determine fetal heart rate variability

Fluctuations in baseline fetal heart rate

Indicator of fetal O2 status specifically of the autonomic nervous system

5 Factors that influence variability

1. Narcotics
2. Prematurity
3. Decreased oxygenation of the fetal central nervous system
4. Fetal sleep
5. Abnormalities in the fetal CNS, heart or both

NICHD (national institute of child health and human development) Baseline Variability

Currently accepted by AWHONN & ACOG

Quantified as the aplitude of peak to trough

What are the (4 catagories) Scored?

Absent: amplitude undetectable

Minimal: detectable, but 5 bpm or fewer away from baseline

Moderate: normal, 6-25 bpm away from baseline;GOOD

Marked: > 25 bpm away from baseline

3 Evaluate Fetal Heart rate for accelerations

Also called?

Accels are a ___ sign of fetal well being and ___

Rule to be accel

May use___ to initiate an acceleration

During antepartum accels are used to evaluate___

Accels are used in relation to the ___, associated with___

periodic change

reassuring sign, adequate oxygenation

***(15 X15 rule) Must be at least 15 bpm over baseline & for at least 15 seconds

Scalp stimulation

fetal well-being

baseline, fetal movement

4- Evaluate the fetal heart rate for decelerations

What are the 3 basic types?

decels are ___ in fetal heart rate in relation to ___

Early, Late, & Variable

drops in fhr, r/t uterine contraction

Early Decelerations

1. Describe
2. Caused by
3. Intervention

1. Fetal heart rate drops as contraction rises (mirrors uterine contractions) begins with contraction & returns to baseline by end of contraction. FHR usually drops about 30bpm, but remains above 100bpm. The drop is subtle/gradual, consistent pattern.

2. ***Fetal head compression (intracranial pressure causes the vagal nerve to slow the HR)

3. No medical interventions, just Vag. exam to check dilation & set up room for delivery.

Late Deceleration

1. Describe
2. Cause
3. Intervention

1. Timing is late in relation to uterine contraction. Fetal heart rate starts to drop at peak or after peak of contraction and does not return to baseline until after the contraction ends. The drop is subtle and about 10-30bpm below baseline, recurrent (must have more than 1 to be late decel)

2. ***Uteroplacental insuffieiency (maternal hypotension or chronic hypertension, excess uterine activity, DM, etc)

3. *Worst kind of decels- fetus needs help (see next card)

Variable Decelerations

1. Describe
2. Cause
3. Intervention

1. Timing is variable in relation to contractions **Occurs at any time (randomly)* not consistent, may be with or without contractions and is ABRUPT/sharp dips & the typical shapes are U, V, or W.

2. **Umbilical cord compression (fetal blood flow is decreased so O2 is decreased). nuchal cord, knots in cord, oligohydramnios (not much amniotic fluid), prolapsed cord, cord compressed by pelvic bones or around body.

3. #1 Maternal position change (float presenting part off cord)  see separate card for more interventions

VEAL

CHOP

(chop is cause for veal)

V- variable               C- cord compression

E- early                   H- Head compression

A- Acceleration         O- oxygenation, activity

L- Late                    P- placental uteral insuffiency

Category 1 (good)Normal Routine care, no action required

Category 2 (suspicious) Predictive of fetal acid-base imbalance, requires continued surveilance

Category 3 (abnormal) Acid-base status, Promt treatment required; tream maternal hypotension- maternal oxygen & position change, discontinue labor stimulation

Baseline 110-160

Moderate variability

No late or variable decels

Early decels present or absent

Accelerations present or absent

NORMAL

Routine care with no specific action required

Bradycardia with variability, Tachycardia

Absent, minimal, or marked variability

Absence of induced accelerations after fetal stimulation

Recurrent variable decels, minimal or moderate variability

Prolonged deceleration >2min, but <10 min

Recurrent late decels with moderate variability

Variable decels with slow return to baseline, "overshoots" or "shoulders"

SUSPICIOUS- Predictive of fetal acid-base imbalance, requires continued surveilance

Absent variability and any of the following

• Recurrent late decels
• Recurrent variable decels
• Bradycardia

Sinusoidal pattern

ABNORMAL - Acid-base status

Require prompt treatment: maternal oxygen, change in maternal position, discontinue labor stimulation (pitocin), tx of maternal hypotension

Umbilical cord blood analysis used to assess infant oxygenation & acid base balance after birth

Blood is drawn into heparinized syringe, sent STAT

Determine if acidosis exists

Indicator of how baby tolerated labor

Arterial blood is drawn 1st, because if venous was 1st cord would collapse

Baby Acidosis- Baby had periods of hypoxia Normal pH is 7.35-7.45 Acidosis is <7.35 

What does variability tell you about the fetus?

What are 3 types of decelerations?

What is the significance of accelerations?

What is the RN's responsibility in regards to electronic fetal monitoring?

Variability- peak & trough or highs & lows of fetal heart rate

Early, late, & variable

accelerations are a reassuring sign that shows fetal well being & adequate oxygenation

RN: monitor oxygenation status, promote adequate fetal oxygenation, corrective action as needed, notify MD of oxygenation problems

Use fingertips of 1 hand on top of uterine fundus, with light pressure estimate strength of contraction. Do no move hands over uterus in constant motion, may stimulate contractions.

Mild- easly indented (tip of nose)

Moderate- indents with more difficutly (chin)

Strong- Firm, cannot be easily indented (forehead)

5- Evaluate Uterine Activity

1. How does uterine activity influence fetal oxygenation

Are there contractions? What is the DIF

Intensity: Can you tell the strength of contraction with external TOCO?

What is the goal of resting tone?

1. A lot of contractions will decrease perfusion

D= duration, I= intensity, F= frequency

*You can NEVER tell the strength using a TOCO (adipose, location..) IUPC (Intrauterine pressure catheter) is required to evaluate the intensity accurately!!!

Resting tone should be <20mmHg (between contractions)

#1. Start oxygen at 8-12 Liters (may be non-rebreather or regular mask).

Change mom's position to her R or L side to improve venous return and increase BP (telling mom "change in monitor, we need you to turn")

Increase/bolus PLAIN IV fluids

Turn off pitocin to help uterus relazx & increase perfusion

Notify MD, watch pattern, document, anticipate need for C-section.

Call anesthesia, supervisor-staffing, call nursery, set-up room

Uteroplacental insufficiency

Definition & causes

Inability of the placenta to exchange oxygen, carbon dioxide, nutrients, and waste products properly between the maternal and fetal circulations.

Maternal hypotension, excess uterine activity, abruptio/previa, chronic hypertension, maternal diabetes mellitus, severe maternal anemia, maternal cardiac disease

Variable Deceleration Interventions

#1 is Maternal position change to float the presenting part off the cord.

Notify MD (don't forget this on test)

This pattern can be dangerous to fetus

Evaluate pattern & document

Possible IV changes (may increase fluids)

1. What causes early decels?

2. What causes late decels?

3. What causes variables?

4. What is the worst kind of decel?

5. What are the goals of pitocin?

1. Fetal head compression

2. Uteroplacental insufficiency

3. Umbilical cord compression

4. Late decel

5. contraction every 2-3 min. lasting 40-90 seconds, intensity 50-80mmHg, Resting tone <20Hg via IUPC

Find a Strip to look at & ask these questions

What is baseline?

Are there any periodic changes?

How far apart are the contractions?

What else do you see? (bradycardia, decel what kind?)

What about variability?

What are the interventions?