Fetal Heart Rate & Labor Progress PDF

Uterine Contraction Monitoring o Uterine activity can be evaluated by: correlating the woman’s perceptions of contractions with observation and abdominal palpation. Electronic monitoring methods: an external tocodynamometer or an intrauterine pressure catheter. accepted that three contra...

Uterine Contraction Monitoring o Uterine activity can be evaluated by: correlating the woman’s perceptions of contractions with observation and abdominal palpation. Electronic monitoring methods: an external tocodynamometer or an intrauterine pressure catheter. accepted that three contractions within 10 minutes is the minimum frequency necessary to achieve progressive cervical change in active labor.  Fetal Well-Being Ongoing and standardized fetal heart rate assessment is essential to evaluating fetal well-being throughout labor regardless of the method chosen.  Fetal Heart Rate Monitoring The methods of Fetal Assessment During Labor: - intermittent auscultation of the fetal heart rate. - continuous external fetal heart rate assessment. - continuous internal fetal heart rate assessment. Indications for continuous FHR monitoring: high-risk pregnancy (diabetes, high blood pressure,...) high risk fetus (IUGR, LBW, …). to check how tocolytes or induction agents are affecting fetus.  External Fetal Heart Rate Monitoring With this method, a pair of belts is wrapped around abdomen. One belt uses Doppler to detect the fetal heart rate. The other belt measures the length of contractions and the time between them.  Internal Fetal Heart Rate Monitoring With this method, a wire called an electrode is placed on the part of the fetus closest to the cervix, usually the scalp. This device records the heart rate. Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagina into uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured. Fetal Assessment During Labor  Labor Progress Digital Cervical Examinations cervical dilation can and should be obtained from each digital cervical examination that is performed during labor, in addition to: cervical effacement, position (posterior, mid- position, anterior), consistency (firm or soft), and fetal station and position. it is recommended that cervical examinations be performed by the same professional whenever possible. The traditional practice of conducting cervical examinations every 1 to 2 hours simply subjects the woman to unnecessary discomfort, intrusion, and increased risk of infection  During normal first-stage labor, a cervical examination may be indicated in the following situations: To establish an informational baseline that can be used for appropriately timing further examinations. to establish labor status prior to admission or labor interventions (prelabor, latent, or active labor). As an appropriately timed second examination to determine the woman’s labor progress. To inform management decisions related to management of labor pain. To verify complete dilation. To check for a prolapsed cord after spontaneous rupture of membranes if a prolapsed cord is a suspected risk (e.g., ballottable presenting part or fetal heart rate decelerations that do not resolve with usual maneuvers). Fetal Presentation, Position, and Station o Cervical examination provides information regarding: (1) fetal presentation; (2) fetal position; (3) fetal station; (4) the adaptation of the fetus to the pelvis (5) the presence or absence of molding; (6) the presence or absence of caput succedaneum Evaluation and Diagnosis of Ruptured Membranes Tests for and Classic Signs of Rupture of Membranes: 1. Observation of fluid coming from the cervical os. 2. The fern test is a classic method of assessing for ROM and is considered diagnostic in many settings when the classic pattern of ferning is clearly seen. 3. The nitrazine test uses limited-range pH paper or a commercially prepared swab to detect the rise in pH in vaginal discharge associated with the presence of amniotic fluid. The normal pH of the vagina of most women is acidic (approximately 4.5), whereas amniotic fluid is neutral to slightly alkaline (7.0–7.5). 4. Pooling of fluid in the posterior fornix of the vagina is a helpful sign, but it is not diagnostic for ROM without confirmation via ferning or nitrazine testing. 5. Ultrasound quantification may also be used.  Fern test During a sterile speculum examination, a sterile cotton swab is used to obtain a specimen of the fluid from the posterior vaginal fornix. Care must be taken not to touch the cervical os to avoid collecting cervical mucus. The specimen is spread thinly onto a microscope slide and allowed to dry thoroughly. The slide is then inspected without using a cover slip using a microscope at 10× power for a fern-like pattern (arborization) caused by crystallization due to the high sodium chloride and protein concentrations in amniotic fluid.  Diagnosis of Rupture of Membranes  The diagnosis of ruptured membranes is typically made via the constellation of history, physical examination, and positive testing Evaluation for Ruptured Membranes: History 1. Inquire about the time, amount, color, consistency, odor, and pattern of leaking (e.g., large gush, continued trickling). - These data are especially important for development of a management plan because the length of time from rupture of membranes to delivery is directly correlated with risk of maternal–fetal infection. - The characteristic of the fluid can reveal clues to fetal well-being. - ROM typically will cause a large gush of fluid, followed by a continuous watery discharge necessitating use of sanitary pads or even washcloths or towels. - In some instances of ruptured membranes, the only symptom the woman may notice is a feeling of moistness on her undergarments from a small, continuous discharge. - Assessing the woman’s ability to control the leakage with contraction of the pelvic floor muscles (Kegel) helps to differentiate PROM from urinary incontinence.  History Cont” 2. Inquire about any recent fever, abdominal pain, vaginal bleeding, abnormal discharge, urine symptoms, and last intercourse (Semen expelled from the vagina can sometimes be mistaken for amniotic fluid). 3. Inquire about signs of labor: contractions, bloody show, fetal movement, recent cervical assessments, or intercourse. 4. Confirm pregnancy dating (this is especially important if less than 37 weeks’ gestation). 5. Review the prenatal record for past obstetric history, prenatal issues, or current medical condition.  Physical Examination  When more than 6 to 12 hours passes, many of the diagnostic observations become unreliable because of lack of fluid. 1. Measure temperature, pulse, respirations, and blood pressure. 2. Perform heart and lung auscultation. 3. Palpate the abdomen for tenderness. 4. Perform Leopold’s maneuvers to assess fetal position, estimated fetal weight, and presenting part.  Ultrasound confirmation of the presenting part may be required. 5. Perform fetal assessment with Doppler or electronic FHR monitoring per institutional or practice guidelines.  Continuous electronic fetal heart rate monitoring is required for women who are between 24 to 37 weeks’ gestation.  Physical Examination Cont” 6. Perform a sterile speculum examination: Note the color, consistency, and amount of any fluid leaking from the vaginal introitus. As the speculum is carefully inserted, be alert for any evidence of prolapsed cord, bulging forebag, or protruding fetal parts. Visualize the cervical os and note any pooling of fluid in the vaginal vault or fluid leaking directly from the os.  Physical Examination Cont” Normal amniotic fluid can be clear, straw colored, or cloudy. - Flecks of white or creamy vernix may be noted in the amniotic fluid of preterm or near-term infants. - Dark yellow or green fluid indicates the presence of meconium in the amniotic fluid. - Meconium-stained fluid increases the risk for chorioamnionitis and can be an indication of fetal compromise. Amniotic fluid has a distinct musty odor, which differentiates it from urine, while foul-smelling fluid can be an indicator of infection.  Physical Examination Cont” If there is no visible fluid leaking from the os: 1. Have the woman perform a Valsalva maneuver or cough. 2. Alternatively, consider having an assistant apply gentle fundal pressure or gently elevate the presenting part abdominally to allow fluid to pass by the presenting part and flow through the cervical os. 3. Another option is to have the woman remain semi-reclining for 30 to 60 minutes and then repeat the sterile speculum examination. 4. Obtain sterile swab specimens of any fluid or discharge seen, avoiding the cervical mucus.  Physical Examination Cont” Using a sterile swab, collect a sample of fluid for 10–15 seconds from the vaginal pool at the posterior fornix or along the vaginal wall. Avoid the cervix. If a nitrazine swab is being used, the color change can be read directly from the swab. If nitrazine paper is being used, apply the swab to pH paper. A pH of 6.5 or higher is suggestive of amniotic fluid rupture. For fern test: - Immediately roll the swab across a dry, clean slide to create a thin film.Thick specimens may obscure ferning. - Set aside for 10 minutes. - Ferning is based on crystallization of the sodium chloride in amniotic fluid. This occurs as the liquid evaporates, so false-negative results are possible if the slide is examined before it is completely dry.  Physical Examination Cont” Obtain a wet mount of any discharge. Obtain a specimen for gonorrhea and chlamydia culture per protocols as required. Obtain GBS culture if the woman’s status is unknown or if it has been more than 5 weeks since the last GBS result. Visualize the cervix for dilation and length/effacement. Do not perform a digital vaginal/cervical examination unless signs of active labor are present. Microscopy Evaluation