Fetal Monitoring: Skills and Techniques - Nursing Education PDF

Skills #2 :Fetal Monitoring Schenoah Wickliffe, MSN, RN.  2 Student Learning Outcomes 1. Review Leopold’s maneuver and place toco and ultrasound transducers in proper place for fetal monitoring. 2...

Skills #2 :Fetal Monitoring Schenoah Wickliffe, MSN, RN.  2 Student Learning Outcomes 1. Review Leopold’s maneuver and place toco and ultrasound transducers in proper place for fetal monitoring. 2. Review fetal monitoring strips and using criteria, state if tracing is assuring or non- reassuring. 3. Demonstrate proper technique for palpation of uterine contractions. 4. Discuss the three phases of a labor contraction and how labor contractions are counted (frequency, duration and intensity). 5. Discuss amniocentesis, Alpha Fetoprotein Screening and Chorionic Villus Sampling 6. Describe Nonstress test, Contraction Stress Test, Biophysical Profile Fetal monitoring Intermittent Auscultation and Uterine Contraction Palpation External- evaluates long term variability. Uses a hand-held doppler device, stethoscope or fetoscope to assess FHR. Palpation used during contractions to determine frequency, intensity, duration, and resting tone as well as fetal well being Used with at home births and at birthing centers Continuous external fetal monitoring External – evaluates long term variability. Use Leopold maneuver to locate the fetal heartbeat. Ultrasound sound transducer is  4 Fetal Monitoring (Cont’d) Intermittent Auscultation Continuous external fetal and Uterine Contraction monitoring Palpation Pros: continuous information, Pros: inexpensive, assess distress earlier, assess noninvasive, easy to use. corrective actions earlier, Cons: Assessment of fetal permanent record, legal wellbeing is limited. documentation. Cons: Length of training.  5 Scalp electrode Spiral (scalp) electrode  Internal  Evaluates short and long term variability. Patient must have: Rupture of membranes Dilated to 2 cm Able to reach fetal head to place Helpful for monitoring: Multiple fetuses Obese patients Uterine contraction monitoring 6 equipment Tocotransducer IUPC (Intrauterine Pressure Catheter) External (pic on slide 3)  Measures true intensity of the contraction and relaxation in the uterus. Frequency and duration only  Patient must have:  ROM True intensity cannot be  Dilation at least 2cm measured.  -1 station Affected by movement and placement. Contraindications:  Blood dyscrasias Used before membranes  Uncertain presentation rupture.  Placenta Previa  Risks:  Infection  Perforation Uterine contraction Monitoring Components 7 Frequency Time between contractions (start to start or peak to peak) Assess over time period (10 minutes) Intensity True strength measured by IUPC only Must palpate abdomen when external toco is used Rated as mild, moderate, or strong Acme- highest point Tonus Resting pressure between contractions (soft or rigid) Normal resting tonus is 10-12mmhg Duration (width) in seconds Time between onset and completion of the contraction  8 Fetal Heart Rate (FHR) Best to be evaluated between contractions. Why is this? Baseline- the average FHR during 10-minute period, rounded in increments of 5 (i.e. 140, 145. 155) Minimum baseline duration must be at least 2 minutes. Normal fetal heart rate is 110- 160. As fetal gestational age nears term, FHR decrease. How do we read the strip? Top pane- monitors fetal heart rate. Lower pane- monitors uterine contractions.  10 Reading a strip (Cont’d) Looking horizontal- six small boxes- equal 10 secs. (6= 1 min). Looking vertical – fetal heart rate- 10 beats per minute. The bold red lines on the strip shows the one- minute interval.  Periodic vs Nonperiodic Heart Rate 11 Changes Periodic- occur with uterine contractions Nonperiodic (Episodic)- not related to uterine contractions  12 Variability Reflects Normal irregularity of fetal cardiac rhythm Intact neuro system: push-pull between sympathetic (increase in heart rate) and parasympathetic (decreases heart rate). Fetal oxygenation Fetal O2 reserve Absence of short-term variability is non-reassuring! Sleep states – 20 to 40 minutes  13 Variability –Short Term Beat to beat changes reflecting 02 reserve (CNS function). Documented as present or absent can only be determine with internal Normal: 2-3 bpm or greater  14 Variability- Long Term Rhythmic changes/waves or cycling over time from baseline Difference between lowest & highest FHR in each cycle per minute. Normal: 3-5 cycles/min with amplitude change of 6-10 beat per minute. Fetal sleep may decrease long-term Fetal sleep 20-40 minute cycles  15 Moderate Variability VEAL CHOP 16  17 Temporary Changes in Accelerations Definition Fetal heart increase associated with fetal movement (non- periodic) or contractions (perioidic) 15 beats per min above baseline lasting 15 seconds or more with return to baseline less than 2 minutes from beginning. Types and description Periodic Smooth hill with contractions Non-periodic (episodic) Sharper with fetal movement/stimulation and not occurring with uterine contractions Acceralation 10 minutes or more are considered a baseline change. “Recurrent” if occurs with 50% or more uterine contractions in 20 minutes.  18 Temporary Changes in Early Decelerations  Description  Decrease in FHR from baseline that starts just before the contraction and ends as the contraction ends. (Mirrors the contraction pattern.  Lowest point (nadir) at peak of contraction and is rarely more than 100- 110 or 20-20 bpm.  No decrease in variability  Potential cause is head compression  May see more with early rupture of membranes  Often “normal or benign” with head compression at 4-7cm dilated. If at 0-3 cm, may indicate cephalopelvic disproportion (CPD).  19 Early Decelerations  20 Late Decelerations  Description  Decreased heart rate that starts after beginning of contraction with late recovery ( after contraction ends)  Smooth- reflecting contraction strength (depth not always = severity)  Variability important (oxygenation)  Ominous: uteroplacental insufficiency= hypoxia Predisposing factors:  Maternal position  Excessive uterine activity (Pitocin, abruptio)  Maternal disorders (DM, hypo or hypertension, previa, abruptio  Fetal disorders (growth disorders, Rh disease, congenital anomalies)  Post- maturity  21 Late Decelerations  22 Variable Decelerations  Description  Abrupt decrease in baseline of 15 bpm and 15 seconds or more  Usually “U”, “V”, or “W” shaped  Most common decel  Varies with intensity, duration, on set time, occurrence with or without contraction and waveform not related to the contraction  Usually outside normal FHR  May see after rupture of membranes (ROM)  Interventions needed if repetitive and FHR less than 90.  Potential causes: cord compression (nuchal, prolapse cord, short cord)  Treatment (for repetitive)  Knee to chest position of mother, butt higher than hips and head down  Check for prolapse cord  Amnioinfusion by physician.  23 Variable Decelerations  24 Fetal Tachycardia  Less than 160 bpm for 10 minutes  Mild 161-180 Sever 181 or higher  Causes:  Fetal: Early hypoxia, infection, anemia, prematurity, or heart failure  Maternal: drugs ( atropine, epi, terbutaline) hyperthyroidism, infection (fever), dehydration.  Intervention  O2, IV fluids, turn to side, monitor and document, notifying the physician (assess and treat cause ASAP).  25 Fetal Bradycardia  Less than 110 for 10 minutes.  Mild: 100-109, mod 80-99, Severe is less than 80 bpm for 2-3 minutes.  Causes:  Fetal: Late sign of fetal hypoxia, prolonged cord compression, arrhythmias, or heart block  Maternal: hypotension, hypothyroid, drugs (anesthesia, narcotics, Pitocin), hypothermia  Ominous with decrease variability or late decels  Nursing interventions:  O2, IV fluids, turn to the side, observe and document, notify the physician.