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Lecture Six: Methods of Assessing Fetal Status

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Title: Lecture Six: Methods of Assessing Fetal Status


1
Lecture Six Methods of Assessing Fetal Status
  • NURS 2208
  • T. Dennis RNC, MSN

2
Objectives
  • Identify antenatal surveillance indicators
  • Discuss the use of ultrasound in pregnancy
  • Discuss methods of antenatal fetal surveillance
  • Compare NST, CST and BPP
  • Contrast amniocentesis and CVS
  • Discuss Leopolds maneuver
  • Compare various fetal heart rate patterns and
    interventions

3
Indications for Antenatal Surveillance (pg. 439)
  • Decreased fetal movement
  • Elevated maternal serum AFP
  • Hemoglobinopathies
  • Fetal heart rate arrythmias
  • Infections
  • Maternal disease
  • PIH Pregnancy Induced Hypertension

4
Fetal Monitoring
  • Fetal oxygen supply must be maintained during
    labor to prevent fetal compromise and promote
    newborn health after birth.
  • Reduction of blood flow through the maternal
    vessels.
  • Reduction of the oxygen content in the maternal
    blood.
  • Alteration in fetal circulation.
  • Reduction in blood flow to the intervillous space
    in the placenta secondary to uterine hypertonus.

5
Monitoring Techniques
  • Intermittent Auscultation
  • Electronic Fetal Monitoring
  • Fetal blood sampling
  • FHR response to stimulation
  • Fetal oxygen saturation monitoring
  • Cord blood sampling

6
Determination of Fetal position and Presentation
(pg. 515)
  • Inspection
  • Palpation Leopolds Maneuvers 1) Find the
    head/buttocks, 2) Find the back, 3) Determine
    presenting part, 4) Determine brow
  • Vaginal examination
  • Ultrasound

7
Intermittent Auscultation
  • Listening to fetal heart sounds at periodic
    intervals to assess the FHR.
  • Fetoscope or doppler
  • Perform Leopolds to determine fetal back
  • Palpate maternal pulse
  • Count between contractions for baseline and 30
    seconds after the contraction
  • 1 hr, 30 minutes, 15 minutes or 30 minutes, 15
    minutes and 5 minutes.

8
Electronic Fetal Monitoring
  • External method involves the use of external
    transducers placed on the maternal abdomen to
    assess uterine contractions and the FHR.
  • Internal method uses spiral electrode and
    intrauterine pressure catheter to monitor and
    record FHR, uterine activity and intrauterine
    pressure.

9
External Fetal Monitoring
  • FHR Ultrasound transducer
  • High frequency sound waves
  • used antepartally and intrapartally
  • noninvasive
  • Does not require RBOW or dilatation
  • Uterine activity Tocotransducer
  • Monitors frequency and duration of contractions
    by use of a pressure sensing device on abdomen
  • Antepartally and intrapartally
  • Noninvasive

10
External Fetal Monitoring
11
Internal Fetal Monitoring
  • FHR Spiral electrode
  • converts fetal ECG to via cardiotachometer
  • Used when RBOW
  • Cervix dilated
  • Penetrates presenting part
  • Must be securely attached
  • Contractions IUPC
  • measures frequency, duration and intensity of
    contractions
  • two types
  • measure intrauterine pressure at catheter tip
  • Used with RBOW and dilatation

12
Internal Fetal Monitoring
13
Baseline Fetal Heart Rate
  • Baseline fetal heart rate
  • Tachycardia
  • Bradycardia
  • Variability

14
Baseline Fetal Heart Rate
  • The average rate during a ten minute segment that
    excludes periodic and non-periodic (episodic)
    changes, periods of marked variability, and
    segments that vary by more than 25 BPM.
  • Normal range is 110-160.

15
Tachycardia
  • A baseline FHR above 160 BPM for a ten minute
    period or greater.
  • Can be considered an early sign of fetal hypoxia.
  • Can result from maternal or fetal infection,
    maternal hyperthyroidism, or fetal anemia.
  • May occur in response to drugs such as
    terbutaline, atropine, cocaine.

16
Bradycardia
  • A baseline FHR below 110 BPM for a period greater
    than 10 minutes.
  • Considered a later sign of fetal hypoxia.
  • Known to occur before fetal demise.
  • Can occur from drugs (anesthetics, prolonged
    compression of the umbilical cord, maternal
    hypotension or hypothermia.

17
Variability
  • Described as irregular fluctuations in the
    baseline FHR of 2 cycles per minute or greater.
  • Described as short term or long term.
  • Absent or undetected variability
  • Minimal variability (lt 5 BPM)
  • Moderate variability (6 to 25 BPM)
  • Marked variability (gt 25 BPM)

18
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19
Variability
  • In clinical practice used to describe
    fluctuations in the FHR.
  • Absence of variability is considered
    non-reassuring.
  • May result from fetal hypoxemia and acidosis (may
    be related to drugs).
  • A temporary decrease can occur with fetal sleep.

20
Periodic and Non-periodic FHR Changes
  • Accelerations
  • Decelerations
  • Early deceleration
  • Late deceleration
  • Variable deceleration
  • Prolonged deceleration

21
Accelerations
  • A visually apparent abrupt increase in FHR above
    the baseline rate.
  • Increase is 15 BPM or greater that lasts 15
    seconds or more with return to baseline in less
    than 2 minutes.
  • Can be periodic or non-periodic (episodic).
  • Indications of fetal well being.

22
Decelerations
  • May be benign or non-reassuring.
  • Described by their relation to the onset and end
    of the contraction and shape.
  • Three types
  • Early decelerations
  • Late decelerations
  • Variable decelerations
  • Prolonged Decelerations

23
Early Decelerations
  • Gradual decrease in and return to FHR baseline.
  • In response to head compression.
  • Uniform in shape.
  • Seen with pushing.
  • No intervention required.

24
Late Decelerations
  • Caused by uteroplacental insufficiency
  • Begins after beginning of ctx and ends after end
    of the contraction.
  • May be correctable or ominous

25
Variable Decelerations
  • Caused by umbilical cord compression
  • Abrupt in descent and return to baseline
  • May occur early or late in labor
  • May be repetative

26
Prolonged Decelerations
  • May be caused by vaginal exam, spiral electrode
    application, etc.
  • Usually isolated events
  • May occur just before fetal death.

27
Fetal Well-being
  • Can be measured by response of the FHR to uterine
    contractions.
  • FHR patterns can be described as reassuring or
    non-reassuring.

28
Reassuring FHR patterns
  • Baseline FHR in the normal range of 110 to 160
    BPM with no periodic changes and a moderate
    baseline variability.
  • Accelerations with fetal movement.

29
Non-reassuring Patterns
  • Progressive increase or decrease in the fetal
    baseline
  • Tachycardia of 160 BPM or more
  • Progressive decrease in baseline variability
  • Severe variable decelerations
  • Late decelerations of any magnitude
  • Absence of FHR variability
  • Prolonged deceleration
  • Severe bradycardia

30
Normal Uterine Activity
  • Occurring every 2 - 5 minutes
  • Lasting less than 90 seconds
  • Moderate to strong in intensity (by palpation or
    100mm Hg by IUPC)
  • 30 second lapse period between contractions
  • Uterine relaxation between ctx by palpation or 15
    mm Hg by IUPC

31
Fetal Compromise
  • The goals of intrapartum FHR monitoring are to
    identify and differentiate the rassuring from the
    nonreassuring , which can be indicative of fetal
    compromise.
  • Nonreassuring FHR patterns are those associated
    with fetal hypoxia (a deficiency in oxygen in the
    arterial blood) and if uncorrected hypoxia (at
    the cellular level).

32
Nonstress Test NST (pg. 452-454)
  • A reactive NST shows two or more accelerations
    of 15 bpm or more within 20 minutes of beginning
    the test.
  • A nonreactive NST contains a tracing that does
    not meet the above criteria. Accelerations are lt
    two in number or lt 15 bpm or no accelerations are
    present.

33
Contraction Stress Test CST(pg. 455)
  • Contractions occurring spontaneously
  • Nipple stimulation
  • Necessary component is the presence of three
    uterine contractions of at least 40 sec duration
    in 10 minute span
  • Not done prior to prior to 28 wks gestation
  • NEGATIVE, POSITIVE EQUIVOCAL

34
Biophysical Profile (BPP)
  • Assessment of 5 variables in the fetus that help
    to evaluate fetal risk breathing movement, body
    movement, tone amniotic fluid volume, and fetal
    heart rate activity.
  • A score of 8 to 10 is normal.
  • A score of 6 or below indicates fetal compromise

35
Fetal Acoustic Stimulation Test
  • Lets buzz the baby!!!!!

36
Ultrasound
  • Most common diagnostic procedure
  • 70 of pregnant women have at least one
  • Abdominal, vaginal, or labial
  • May be basic or limited
  • Can evaluate both structural and functional
    characteristics
  • BP diameter, head circumference, femur length,
    abdominal measurements
  • Fetal growth, congenital anomalies, placental
    growth and location, cervical length

37
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38
Amniocentesis (pg. 457-459)
  • A simple procedure needle is inserted through
    the maternal abdomen into the uterine cavity to
    withdraw a sample of amniotic fluid.
  • Early pregnancy DNA studies
  • Late Pregnancy Lung maturity
  • Complications Preterm labor, fetal scratches,
    maternal hemorrhage, infection, Rh sensitization
    (RhoGam may be indicated)

39
Tocolytic Therapy
  • Tocolysis can be achieved by administering drugs
    that inhibit uterine contractions.
  • May be used during management of fetal
    compromise.
  • Magnesium sulfate, terbutaline, nifedipine may be
    used.

40
Maternal Positioning
  • Maternal supine hypotensive syndrome is caused by
    the weight and pressure of the gravid uterus on
    the ascending vena cava when the woman is in a
    supine position.
  • A side-lying position or semi-fowlers position
    with a lateral tilt to the uterus is recommended.

41
Other Available Tests(pg. 459-467)
  • AFP (Amniotic Fluid)
  • Rh sensitized pregnancies
  • Fetal Maturity
  • L/S ratio and PG
  • CVS
  • Fetoscopy
  • Percutaneous Umbilical Blood Sampling
  • MRI

42
EFM Nursing Diagnosis
  • Maternal anxiety related to lack of knowledge
    about use of electronic fetal monitor.
  • Risk for fetal injury related to inaccurate
    placement of transducers/electrodes,
    misinterpretation of results or failure to use
    other assessment techniques to monitor fetal
    well-being.

43
Nursing Assessment Diagnosis
  • Knowledge Deficit related to insufficient
    information about the fetal assessment test and
    its purpose, benefits, risks, and alternatives
  • Fear related to the specific test or possible
    unfavorable results
  • Disruption in bonding due to high risk label

44
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