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Lecture on Six Fetal Assessment

Published Jan 18, 2013 in Other
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Lecture Six: Methods of Assessing Fetal Status
NURS 2208
T. Dennis RNC, MSN

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 Leopold’s maneuver
Compare various fetal heart rate patterns and interventions

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

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.

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

Determination of Fetal position and Presentation (pg. 515)
Palpation: Leopold’s Maneuvers: 1) Find the head/buttocks, 2) Find the back, 3) Determine presenting part, 4) Determine brow
Vaginal examination

Intermittent Auscultation
Listening to fetal heart sounds at periodic intervals to assess the FHR.
Fetoscope or doppler
Perform Leopold’s 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.

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.

External Fetal Monitoring
FHR: Ultrasound transducer
High frequency sound waves
used antepartally and intrapartally
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

External Fetal Monitoring

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

Internal Fetal Monitoring

Baseline Fetal Heart Rate
Baseline fetal heart rate

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.

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.

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.

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 (< 5 BPM)
Moderate variability (6 to 25 BPM)
Marked variability (> 25 BPM)

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.

Periodic and Non-periodic FHR Changes
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration

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.

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

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

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

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

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

Fetal Well-being
Can be measured by response of the FHR to uterine contractions.

FHR patterns can be described as reassuring or non-reassuring.

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.

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

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

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).

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 < two in number or < 15 bpm or no accelerations are present.

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

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

Fetal Acoustic Stimulation Test
Let’s “buzz” the baby!!!!!

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

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)

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.

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.

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

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.

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