Chapter 17 Intrapartum Fetal Surveillance Elsevier items and

Purposes of Fetal Surveillance Identify fetal well-being Identify the fetus who may be having

Fetal Oxygenation Normal flow of oxygenated maternal blood into the placenta Normal exchange within

Pathologic Influences on Fetal Oxygenation Maternal cardiopulmonary alterations Uterine activity Placental disruptions Interruptions in

Intermittent Auscultation and Palpation Advantages Mobility is the primary advantage of auscultation of the

Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of

Electronic Fetal Monitoring Advantages Supplies more data about the fetus and auscultation Ø Provides

External Fetal Monitoring Remote surveillance Ultrasound transducer Secured on the mothers abdomen with a

Internal Fetal Monitoring Accuracy is the main advantage of using internal devices Requires ruptured

Baseline Fetal Heart Rate Normal Ø Bradycardia Ø Tachycardia Ø Variability Absent Ø Minimal

Accelerations Temporary increase in FHR 15 bpm increase for 15 seconds Associated with fetal

Early Decelerations Mirror images of contraction Return to baseline fetal heart rate by end

Late Decelerations Begin after contraction begins (often near peak) Nadir occurs after peak of

Variable Decelerations Caused by reduced flow through umbilical cord (cord compression) Shape, duration, and

Indeterminate Patterns Tachycardia Bradycardia with presence of variability Minimal or marked baseline variability Absent

Nonreassuring Patterns Absent variability Recurrent late decelerations Ø Recurrent variable decelerations Ø Bradycardia Ø

Clarification of Data Fetal scalp stimulation Vibroacoustic stimulation Fetal scalp blood sampling Fetal oxygen

Obtaining a Sample of Cord Blood Elsevier items and derived items © 2013, 2009,

Responding to Nonreassuring Fetal Heart Rate Patterns Identify cause of pattern Increase placental perfusion

Nursing Responsibilities Promoting fetal oxygenation Identifying and reporting nonreassuring findings Supporting parents Communicating with

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Purposes of Fetal Surveillance Identify fetal well-being Identify the fetus who may be having hypoxic stress Two approaches to intrapartum fetal monitoring Intermittent auscultation with palpation of uterine activity Ø Electronic fetal monitoring Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 2

Fetal Oxygenation Normal flow of oxygenated maternal blood into the placenta Normal exchange within the placenta Patent umbilical cord vessels Normal fetal circulation Oxygen caring function Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 3

Pathologic Influences on Fetal Oxygenation Maternal cardiopulmonary alterations Uterine activity Placental disruptions Interruptions in umbilical flow Fetal alterations Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 4

Intermittent Auscultation and Palpation Advantages Mobility is the primary advantage of auscultation of the fetus in low-risk women Ø The woman is free to change position and walk Ø The atmosphere is more natural Ø Limitations 1 -1 nursing care Ø Uterine activity is assessed for a small part of the total labor Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 5

Electronic Fetal Monitoring Advantages Supplies more data about the fetus and auscultation Ø Provides a permanent record that may be printed or stored electronically Ø Gradual trends in FHR and uterine activity are apparent Ø Limitations Ø Reduced mobility is the major limitation Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 7

External Fetal Monitoring Remote surveillance Ultrasound transducer Secured on the mothers abdomen with a last straps Ø Less accurate than internal devices but are noninvasive and suitable for most women in labor Ø Toco transducer Ø A pressure sensitive area detects changes and abdominal contour to measure uterine activity Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 9

Internal Fetal Monitoring Accuracy is the main advantage of using internal devices Requires ruptured membranes and about 2 cm of cervical dilation Ø Slightly increased risk for infection Ø Fetal scalp electrode (FSE) Ø The FSE detects electrical signals from the fetal heart Intrauterine pressure catheter (IUPC) Ø 2 kinds of IUPCs can be used to measure uterine activity Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 11

Baseline Fetal Heart Rate Normal Ø Bradycardia Ø Tachycardia Ø Variability Absent Ø Minimal Ø Moderate Ø Marked Ø Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 13

Accelerations Temporary increase in FHR 15 bpm increase for 15 seconds Associated with fetal movement Reassuring Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 16

Early Decelerations Mirror images of contraction Return to baseline fetal heart rate by end of contraction Maternal position changes usually have no effect on pattern Associated with fetal head compression Not associated with fetal compromise Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 18

Late Decelerations Begin after contraction begins (often near peak) Nadir occurs after peak of contraction May remain in normal range and not fall far from baseline Reflect possible impaired placental exchange Occasional late decelerations accompanied by moderate variability Require nursing intervention to improve placetal blood flow and fetal oxygen supply Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 20

Variable Decelerations Caused by reduced flow through umbilical cord (cord compression) Shape, duration, and degree of fall below baseline rate are variable Fall and rise in rate is abrupt Require nursing intervention Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 22

Indeterminate Patterns Tachycardia Bradycardia with presence of variability Minimal or marked baseline variability Absent variability with no recurrent decelerations Absence of accelerations after fetal stimulation Periodic or episodic variations Variable decelerations with other characteristics Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 24

Nonreassuring Patterns Absent variability Recurrent late decelerations Ø Recurrent variable decelerations Ø Bradycardia Ø Sinusoidal pattern Ø A visually undulating pattern (rare) Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 25

Clarification of Data Fetal scalp stimulation Vibroacoustic stimulation Fetal scalp blood sampling Fetal oxygen saturation monitor Cord blood gases and p. H Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 26

Responding to Nonreassuring Fetal Heart Rate Patterns Identify cause of pattern Increase placental perfusion Increase maternal blood oxygen saturation Reduce cord compression Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 28

Nursing Responsibilities Promoting fetal oxygenation Identifying and reporting nonreassuring findings Supporting parents Communicating with the physician or nurse midwife Documenting all care Elsevier items and derived items © 2013, 2009, 2005 by Saunders, an imprint of Elsevier Inc. 29