Fetal Assessment During Labor - Reviewing key concepts/Thinking critically

It is critical that a nurse working on a labor unit be knowledgeable concerning factors associated with a reduction in fetal oxygen supply, characteristics of normal (reassuring) and abnormal (nonreassuring) FHR patterns, and the characteristics of normal uterine activity.

A. DESCRIBE the factors associated with a reduction in fetal oxygen supply.

B. STATE the characteristics of normal (reassuring) FHR patterns (Category I).

C. STATE the characteristics of indeterminate FHR patterns (Category II).

D. STATE the characteristics of abnormal (nonreassuring) FHR patterns (Category III).

E. STATE the characteristics of normal uterine activity during labor.

Factors that affect fetal oxygen supply and characteristics of FHR and uterine activity.

A. Factors that can reduce fetal oxygen supply: see Fetal Response section for a discussion of these factors.

B. Characteristics of Category I FHR patterns: see Fetal Response section, Table 18-1, and Box 18-1.

C. Characteristics of Category II FHR patterns: see Fetal Response section, Table 18-1, and Box 18-1.

D. Characteristics of Category III FHR patterns: see Fetal Response section, Table 18-1, and Box 18-1.

E. Characteristics of normal and abnormal uterine activity: see Table 18-1.

Low-risk client (risk factors are absent during labor): Evaluate FHR pattern and uterine activity every _____________________________ in the first stage of labor and every _____________________________ in the second stage of labor.

30 minutes; 15 minutes

High-risk client (risk factors are present during labor): Evaluate FHR pattern and uterine activity every _____________________________ in the first stage of labor and every _____________________________ in the second stage of labor.

15 minutes; 5 minutes

The five essential components of an FHR tracing that must be evaluated at the recommended frequency for the maternal risk status are _____________________________, _____________________________, _____________________________, _____________________________, and _____________________________.

Baseline rate; baseline variability; accelerations; decelerations; changes or trends over time

STATE the legal responsibilities related to fetal monitoring for nurses who care for women during childbirth.

Legal responsibilities related to fetal monitoring during childbirth: see Nurse Alert in Intermittent Auscultation section and Legal Tip—Fetal Monitoring Standards; evaluate FHR pattern at frequency that reflects professional standards, agency policy, and condition of maternal-fetal unit; consider the correct interpretation of FHR patterns in terms of Categories; take appropriate action; evaluate response to actions taken; notify primary health care provider in a timely fashion; know the chain of command if a dispute about interpretation occurs; document assessment findings, actions, and responses.

A laboring woman's uterine contractions are being internally monitored. When evaluating the monitor tracing, which finding is a source of concern and requires further assessment?

A. Frequency every 2½ to 3 minutes

B. Duration of 80 to 85 seconds

C. Intensity during a uterine contraction of 85 to 90 mm Hg

D. Average resting pressure of 20 to 25 mm Hg

D

the average resting tone during labor should be 10 mm Hg; choices A, B, and C are all findings within the expected ranges.

External electronic fetal monitoring will be used for a woman just admitted to the labor unit in active labor. Guidelines that the nurse should follow when implementing this form of monitoring are to: (Circle all that apply.)

A. Use Leopold maneuvers to determine correct placement of the tocotransducer

B. Assist the woman to maintain a dorsal recumbent position to ensure accurate monitor tracings that can be evaluated easily

C. Apply contact gel to the ultrasound transducer prior to application over the point of maximum intensity of the FHR

D. Reposition the tocotransducer when the fetus changes its position

E. Caution the woman to avoid effleurage when the transducers are in place

F. Palpate the fundus periodically to estimate the intensity of the uterine contractions

C, F

Leopold maneuvers are used to locate the PMI for correct placement of the ultrasound transducer; the tocotransducer is always placed over the fundus; the ultrasound transducer's position needs to change with fetal movement; the tocotransducer cannot assess intensity of contractions; therefore periodic palpation is an essential assessment measure; effleurage can be used around the transducers or on other parts of the woman's body.

A nurse caring for women in labor should be aware of signs characterizing normal (reassuring) and abnormal (nonreassuring) FHR patterns. What would be characteristic of abnormal patterns? (Circle all that apply.)

A. Moderate baseline variability

B. Average baseline FHR of 100 beats/minute

C. Acceleration of the FHR with movement

D. Late deceleration patterns approximately every three or four contractions

E. FHR of 170 beats/minute between contractions

F. Early deceleration patterns when the cervix is dilated to 7 cm

B, D, E

the baseline rate should be 110 to 160 beats/minute; accelerations should occur with fetal movement; no late deceleration pattern of any magnitude is normal (reassuring), especially if it is repetitive or uncorrectable; early deceleration patterns are expected findings when fetal head compression by the cervix occurs.

A laboring woman's temperature is elevated as a result of an upper respiratory infection. The FHR pattern that reflects maternal fever is:

A. Diminished variability

B. Variable decelerations

C. Tachycardia

D. Early decelerations

C

the FHR increases as the maternal core body temperature elevates; therefore tachycardia is the pattern exhibited; it is often a clue of intrauterine infection because maternal fever is often the first sign; diminished variability reflects hypoxia, variable decelerations are characteristic of cord compression, and early decelerations are characteristic of head compression by the cervix.

A nulliparous woman is in the active phase of labor and her cervix has progressed to 6 cm dilation. The nurse caring for this woman evaluates the external monitor tracing and notes the following: decrease in FHR shortly after onset of several uterine contractions returning to baseline rate by the end of the contraction; shape is uniform. Based on these findings, the nurse should:

A. Change the woman's position to her left side

B. Document the finding on the woman's chart

C. Notify the physician

D. Perform a vaginal examination to check for cord prolapse

B

the pattern described is an early deceleration pattern, which is considered to be benign, requiring no action other than documentation of the finding; changing a woman's position and notifying the physician would be appropriate if abnormal (nonreassuring) signs such as late or variable decelerations were occurring; prolapse of cord is associated with variable decelerations as a result of cord compression

When evaluating the external fetal monitor tracing of a woman whose labor is being induced, the nurse identifies signs of persistent late deceleration patterns and begins intrauterine resuscitation interventions. Which choice indicates that the following appropriate interventions were implemented in the recommended order of priority?

1. Increase rate of maintenance IV solution.

2. Palpate uterus for tachysystole.

3. Discontinue oxytocin (Pitocin) infusion.

4. Change maternal position to a lateral position, and then elevate her legs if woman is hypotensive.

5. Administer oxygen at 8 to 10 L/minute by nonrebreather face mask.

A. 2, 1, 5, 4, 3

B. 4, 1, 2, 3, 5

C. 5, 3, 4, 1, 2

D. 4, 5, 1, 2, 3

B

The usual priority is as follows:

1. Discontinue oxytocin if infusing.

2. Assist woman to lateral (side-lying) position.

3. Administer oxygen at 10 L/min by nonrebreather face mask.

4. Correct maternal hypotension by elevating legs.

5. Increase rate of maintenance intravenous solution.

6. Palpate uterus to assess for tachysystole.

7. Notify physician or nurse-midwife.

8. Consider internal monitoring for more accurate fetal and uterine assessment.

9. Assist with birth (vaginal-assisted or cesarean) if pattern cannot be corrected.

Nurses working on a childbirth unit at a small rural hospital primarily use intermittent auscultation with an ultrasound fetoscope to assess fetal health and well-being during the labors of low-risk women.

A. STATE the advantages and disadvantages of intermittent auscultation as a method of fetal assessment during childbirth.

B. CREATE a protocol that these nurses could follow when monitoring the fetus using the intermittent auscultation method.

A. State advantages and disadvantages.

■ Advantages: high-touch/low-tech approach, natural method facilitating activity, comfortable, noninvasive.

■ Disadvantages: inconvenient and time consuming, increased anxiety if nurse has difficulty locating PMI, less information about FHR pattern is obtained, less accurate.

B. Protocol to follow: cite the specific guidelines that should be used

1. Perform Leopold maneuvers by palpating the maternal abdomen to identify fetal presentation and position (see Box 19.5).

2. Apply ultrasonic gel to device if using Doppler ultrasound. Place listening device (see Fig. 18.1A) over area of maximal intensity and clarity of fetal heart sounds to obtain clearest and loudest sound, which is easiest to count. This location is usually over the fetal back. If using fetoscope, firm pressure may be needed.

3. Count maternal radial pulse while listening to FHR to differentiate it from fetal rate.

4. Palpate abdomen for presence or absence of UA to count FHR between contractions.

5. Count FHR for 30-60 seconds after a uterine contraction to identify auscultated baseline rate and changes (increases or decreases) in it.

6. Auscultate FHR before, during, and after contraction to identify FHR during the contraction or as a response to the contraction and to assess for absence or presence of increases or decreases in FHR.

7. When distinct discrepancies in FHR are noted during listening periods, auscultate for longer period during, after, and between contractions to identify significant changes that may indicate need for another mode of FHR monitoring.

A nurse caring for a laboring woman in active labor notes an abnormal (nonreassuring) FHR pattern when evaluating the monitor tracing. DESCRIBE the action the nurse should take based on this finding.

Nonreassuring pattern noted on evaluation of a monitor tracing: see Nursing Management of Abnormal Patterns section and Box 18-8; evaluate the tracing according to the five essential components and implement intrauterine resuscitation measures as appropriate; actions most often involve repositioning the mother, administering oxygen, altering rate of IV, discontinuing oxytocin (Pitocin), assessing for possible causes, notifying primary health care provider, and preparing for emergency treatment.

Basic Interventions

• Administer oxygen by nonrebreather face mask at a rate of 10 L/min for approximately 15-30 min.

• Assist woman to a side-lying (lateral) position.

• Increase maternal blood volume by increasing rate of primary IV infusion.

Darlene, a primigravida in active labor, has just been admitted to the labor unit. She becomes very anxious when external electronic fetal monitoring (EFM) equipment is set up. She tells the nurse that her father had a heart attack 2 months ago. "He was so sick they had to put him on a monitor, too. Does this mean that my baby has a heart problem just like my father?"

A. DESCRIBE the response the nurse should make to address Darlene's expressed concern.

B. OUTLINE the care measures that the nurse should implement to ensure that the EFM is used in an effective manner to provide accurate data and to ensure that Darlene remains comfortable during this assessment technique.

A. Client and family teaching when EFM is used: see Box 18-9 and Client and Family Teaching section.

■ Discuss how fetus responds to labor and how the monitor will assess these responses.

■ Explain the advantages of monitoring.

■ Show her a monitor strip and explain what it reveals; tell her how to use the strip to help her with breathing techniques.

B. Nursing care measures for woman being monitored externally: see Care Management section, including Client and Family Teaching and Documentation and Boxes 18-7 and 18-9 for a detailed outline related to assessing tracings and maternal responses, palpation of contractions, and caring for woman in terms of comfort, changing position, transducer placement and site care, and keeping her and her family informed about fetal and maternal status and progress of labor.

Terry is a primigravida at 43 weeks of gestation. Her labor is being stimulated with oxytocin administered intravenously. Her contractions have been increasing in intensity with a frequency of every 2 to 2½ minutes and a duration of 80 to 85 seconds. She is currently in a supine position with a 30-degree elevation of her head. On observation of the monitor tracing, you note that during the last two contractions the FHR decreased after the contraction peaked and did not return to baseline until about 10 seconds into the rest period. A slight decrease in variability and baseline rate was observed.

A. IDENTIFY the pattern described and the possible factors responsible for it.

B. DESCRIBE the actions you would take. STATE the rationale for each action.

A. Pattern described and causative factors: late deceleration patterns as a result of uteroplacental insufficiency associated with intense uterine contractions, supine position (supine hypotension), and placental aging related to postterm gestation of 43 weeks (see Figs. 18-8, 18-13, and 18-14).

B. Nursing interventions: see Nursing Management of Abnormal Patterns, Table 18-3, and Boxes 18-5; discontinue oxytocin to stop stimulation of contractions but continue primary infusion; change to lateral position and elevate legs to enhance uteroplacental perfusion; administer oxygen via mask to increase oxygen availability to fetus; assess response to actions and notify primary health care provider; see Documentation section for guidelines related to recording findings organized around data, action, and response.

Taisha is a multiparous client in active labor. Her membranes rupture and the nursing caring for her immediately evaluates the EFM tracing.

A. What type of periodic FHR pattern would the nurse be alert for when evaluating the tracing? EXPLAIN the rationale for your answer.

B. STATE the actions the nurse should take in order of priority if the pattern is noted.

A. Nurse should be alert for variable deceleration pattern; see Variable Deceleration section and Figs. 18-15 and 18-16.

B. Actions to take if variable decelerations occur: see Nursing Management of Abnormal Patterns section and Boxes 18-6 and 18-8.