NURS 3334 Lecture Notes - Lecture 14: Tocolytic, Amniotic Fluid, Stim

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Intrapartum Fetal Assessment
Physiologic Influences on FHR
Three Categories
o Extrinsic
Maternal
Decreased blood volume
Decreased oxygen level
Uteroplacental
Hypertonus: every time uterus squeezes, affects placenta and constricts
blood vessels
o Too many or too strong
Placental changes
Maternal stress/anxiety
Umbilical cord
Compression
Knots
Nuccal cord: wrapped around the neck
Causes compression and low fetal HR
o Intrinsic
Fetal Autonomic Nervous system
Parasympathetic: stimulation of vagus nerve= decreased FHR
o Vagus stimulated can lead to meconium
Sympathetic: release of epinephrine/norepinephrine= increased FHR
Baroreceptors: variable decels
Chemoreceptors: mayorFHR
Adrenal Glands
Central Nervous System
Increased heart rate shows baby is moving and nerves are intact
o Homeostatic
Compensatory mechanism
↓PO2 and ↑PCO2
Increase blood flow to heart, brain, and adrenal glands/ Decrease blood
flow to gut, spleen, kidneys, limbs
If prolonged hypoxemia, decompensation occurs resulting in ↓cardiac
output and FHR resulting in brain damage or even death
Guidelines for intermittent auscultation or continuous electronic fetal monitoring
This means charting, interpretation and nursing actions based on results
Low risk:
o Latent phase = q 60 minutes
o Active phase = q 30 minutes
o Second stage = q 15 minutes
High risk:
o Latent phase = q 30 minutes
o Active phase = q 15 minutes
o Second stage = q 5 minutes
Indications
Multiple gestation
Augmentation or induction with Pitocin
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Placenta previa
Fetal bradycardia
Gdm, gestational hypertension, kidney disease
IUGR
Postdate
Active labor
Meconium stained fluid
Abruption placenta suspected or actual
Abnormal uterine contractions
Fetal distress
Interventions
RN responsibility: assess FHR patterns, characteristics of contractions, implement nursing
interventions and report nonreassuring patterns or abnormal ctx patterns.
Maternal-fetal risk factors determine method and frequency of survillence
Electronic fetal heart rate monitoring or Intermittent Auscultation after any of the follow scenarios:
Rupture of membranes spontaneous or artificial
Before and after ambulation
Before, during or after change in medication analgesia
At peak action of anesthesia
After vaginal exam
Following expulsion of enema
After urinary cath
Abnormal or excessive uterine contractions
Intermittent FHR Auscultation
Advantages: mobility, can be used in water, more natural
Limitations: requires more frequent contact with staff, no continuous record, can’t distinguish
type of decal
Devices
o Doppler & Fetascope: both can determine baseline, accelerations, and decelerations
o Fetascope: can detect presence of irregular heart rate, clarify if EFM is doubling or
halving
Can’t use intermittent with pitocin administration
Procedure: Count FHR for 30-60 sec. after a ctx
o Assess baseline, rhythm, presence/absence of accelerations or decelerations.
Frequency: q15-30min in 1st stage. Q5-15min in 2nd stage.
Electronic FHR/CTX Monitoring
Advantages: Shows fetal response to each contraction, sound of heartbeat may comfort
mother, use of contraction monitor helpful to labor partner, less staff intensive
Limitations: Maternal position change requires equipment adjustment, more technical
atmosphere, staff may focus on monitor, not on mother
Frequency of documentation
External FHR/CTX Monitoring
Advantages: noninvasive, does not require ROM or cervical dilation
Limitations: signal may be influenced by maternal obesity, maternal position, fetal position,
fetal movement
Devices
o Tocotransducer: placed near fundus, detects pressure with a button to show
contractions
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o Ultrasound transducer (FHR)
Internal Monitoring Devices
Advantages: continuous tracing of FHR, maternal position does not affect tracing of FHR. IUPC
accurately assesses strength of ctx and resting tone
Limitations: is invasive, requires ROM and cervical dilation, potential risk for infection or
injury, may record maternal heart rate in case of IUFD
Devices
o Fetal Scalp Electrode (FSE)
o Intrauterine Pressure Catherter (IUPC)
Strong contraction: feels like forehead
Moderate: feels like nose
Fair: feels like chin
FHR Interpretation: what does it tell us?
Fetal response to labor or uterine environment can be evaluated with a Nonstress Test (NST) is
the fetus experiencing stress from the uterine ctx?
Reactive (normal) Non Stress Test (NST)
o 2 or more accelerations in 20 minutes period with or without fetal movement felt by
mother. Acceleration = 15 beats above baseline for 15 seconds 32 -40 weeks.
o 10 beats above baseline for 10 seconds for under 32
Nonreactive (abnormal) Non Stress Test
o One that lacks sufficient FHR accelerations over 40 minute period
Terminology for Evaluating Uterine Contractions
Frequency beginning of one contraction to beginning of next contraction = how often
Duration beginning of one contraction to end of contraction = length of contraction
Intensity strength (only assessed with palpation and internal monitoring)
Resting Tone between contractions when optimum uterine relaxation is achieved.
Increment rise of contraction
Acme peak of contraction
Decrement fall of contraction
System to Evaluate FHR
1. Determine uterine resting tone
2. Assess contractions =
frequency, duration, intensity
3. Determine FHR baseline =
normal, tachy, brady
4. Determine FHR variability = absent, minimal, moderate
5. Sinusoidal very bad
6. Periodic changes = accelerations, decelerations
Systematic Assessment of FHR Data
Baseline FHR
o Rounded to 5bpm, measured over 2 min during a 10 min period
o Normal 110-160 BPM
o Bradycardia = less than 110 for at least 10 minutes
If + accels and mod var may be normal in term infant. If decreased var, -accels,
and + decels may be hypoxia
o Tachycardia = FHR more than 160 for at least 10 minutes
May be maternal fever or fetal distress
Variability
o Absent: undetectable
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Document Summary

Increased heart rate shows baby is moving and nerves are intact: homeostatic, compensatory mechanism, po2 and pco2. If prolonged hypoxemia, decompensation occurs resulting in cardiac. Increase blood flow to heart, brain, and adrenal glands/ decrease blood flow to gut, spleen, kidneys, limbs output and fhr resulting in brain damage or even death. Indications: multiple gestation, augmentation or induction with pitocin. Iugr: placenta previa, fetal bradycardia, gdm, gestational hypertension, kidney disease, postdate, active labor, meconium stained fluid, abruption placenta suspected or actual, abnormal uterine contractions, fetal distress. Interventions: rn responsibility: assess fhr patterns, characteristics of contractions, implement nursing interventions and report nonreassuring patterns or abnormal ctx patterns, maternal-fetal risk factors determine method and frequency of survillence. Internal monitoring devices: advantages: continuous tracing of fhr, maternal position does not affect tracing of fhr. Acceleration = 15 beats above baseline for 15 seconds 32 -40 weeks: 10 beats above baseline for 10 seconds for under 32, nonreactive (abnormal) non stress test.

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