Ch 14 intrapartum fetal surveillance

fetal strip features to describe

• uterine contraction patterns

• baseline fetal heart rate (FHR)

• FHR variability

• presence of accelerations

• presence & type of decelerations

external fetal monitoring

• fetal monitor

  • ultrasound

  • toco transducer

• all connected!

  • traces FHR/contraction pattern

toco transducer

• monitors contractions

• hard shell w/ soft button

  • firm abd presses w/ squeezing

• placed at top of fundus, where contractions are strongest

  • palpate!

ultrasound monitor

• measures FHT/FHR

• hard plastic

• place on abd w/ gel

  • place where fetal spine felt & palpated toward fetal head

    • specifically neck-shoulder connection

  • ie: baby head down? where monitor goes!

• move w/ baby repositioning

internal fetal monitoring

• mom has amniotic membrane ruptured

• pt at least 1 ½ cm dilated

• indicates labor progression & how fetus is tolerating

• 2 devices

  • fetal scalp electrode

  • intrauterine pressure catheter

fetal scalp electrode/clip

• aka FSE

• monitors FHR

• used when fetal positioning/high maternal weight make external monitoring difficult

  • tones NEED to be tracked

• be cautious of eyes w/ face presenting babies

placement of fetal scalp electrode

1. vaginal exam + sliding electrode in

2. feel for hard spot on fetal head

   1. insert metal coil tip!

   2. twist into tissue

3. connect to machine & monitor

• mind what you are feeling

  • can be placed in dangerous spots

    • ie fontanelle

intrauterine pressure catheter

• aka IUPC

• used w/ high maternal weight

• monitors contractions

  • + strength! may indicate pictocin need

• soft, flexible

• placed similarly to scalp electrode

  • w/ vaginal exam

intrauterine pressure catheter placement

• like fetal scalp electrode

  • w/ vaginal exam

• placed btwn uterine wall & fetal back

• mostly an MD thing

  • can accidentally be placed into edge of placenta → increased bleeding & placental issues

FSE complications

• can be placed in eye

• can cause insertion site infection!

  • rare, but can happen

  • antibiotic ointment usually put on opening to prevent it

  • often when mom has infection too

  • outweigh pros & cons!

IUPC complications

• placenta previa/separation

  • bleeedingggg

contraction characteristics

• frequency

• duration

• intensity

contraction frequency

• how often?

• measured start → start of 2 contractions

normal contraction frequency

• 5 or less in 10 min over 30 min

  • more? tachysystole!

contraction duration

• how long?

• measured in seconds

  • start → end of one contraction

big box on fetal strip

• ~60 seconds

small box on fetal strip

• ~10 seconds

whole fetal strip

• ~7 minutes

contraction intensity

• how strong?

• mild, moderate, strong

• measured in montevideo units (MVU)

  • from internally!

mild contraction intensity

• like nose

moderate contraction intensity

• like chin

strong contraction intensity

• like forehead

external contraction intensity monitoring

• palpate during the contraction!

  • toco does not pick up strength

• don’t depend on wave - not indicative of strength

  • super thin? bigger wave

  • vice versa w/ larger pts

normal uterine activity

• abt 12 min strip

  • 5 contractions

• normal!

tachysystole

• more than 5 contractions in 10 min over abt 30 min

  • regardless of FHR decelerations

• oxygenation issue!

  • uterus supposed to relax & replenish O2 to fetus stores → baby continuously squeezed instead

    • late decels

• no meds being given? give something!

• 7 contractions in 10 min

• 
  PIC HERE

pictocin & tachysystole

• decrease the dose!

FHR characteristics

• baseline

• variability

• accells & decels

FHR baseline

• where the HR stays!

• look @ tracing - where is the line mostly?

• taken as an average

FHR BPM normal

• 110-160

FHR variability

• periodic changes/fluctuations in baseline rate

  • we want this!

• irregular in amplitude & frequency

• measured beat-to-beat

• 4 types

FHR variability estimation

• highest point

• lowest point

  • diff btwn them!

• how much does the line flucturate above & below baseline?

FHR variability types

• absent

• minimal

• moderate

• marked

absent variability

• straight line

• bad.

  • practically asystole

• amplitude range undetectable

PIC HERE

minimal variability

• changes of <5 bpm

• <5 changes in 1min period

  • subtract high point from low somewhere in the duration!

moderate variability

• what we really want!

• changes of 6-25bpm

marked variability

• very high # of changes

• excited periods!

• okay for short time frames

pt causes of FHR bradycardia

• sympatholytic mecs (methyldopa)

• beta blockers (labetalol [normodyne], propranolol)

• sjogren’s antibodies

• hypoglycemia

• hypothermia

• viral infection (cytomegalovirus)

fetal causes of FHR bradycardia

• cardiac conduction abnormalities

• heart block

• fetal HF (hydrops)

• structural cardiac defects

• heterotaxia

• hypothyroidism

• interrupted fetal oxygenation pathway (umbilical cord prolapse)

pt causes of FHR tachycardia

• beta-sympathomimetic drugs (terbutaline, epinephrine)

• parasympatholytic drugs

• fever

• hyperthyroidism

• infection (chorioamnionitis, appendicitis)

• cocaine

fetal causes of FHR tachycardia

• acute blood loss

• fetal anemia

• heart failure

• hyperthyroidism

• hypoxia/hypoxemia

• increased metabolic rate

• infection & fetal sepsis

• tachyarrhythmias

preterm FHR

• at upper end of normal

  • closer to 160

fetal tachycardia

• baseline FHR >160

fetal bradycardia

• baseline FHR <110

acceleration

• any FHR baseline increase that then returns to normal

PIC HERE

variable deceleration

• like a carrot!

  • rapid

  • drops then rises again suddenly

  • how u tell its diff from early/late decels

• bc of cord compression

  • have mom change positions

• not always associated w/ contractions - don’t pay attention to them

• last ~30 sec

  • decreased by at least 15bpm for at least 15 sec

late deceleration

• contractions start → baby squeezed

  • if goes to O2 reserve and there is none? decel!

    • hypoxic event

• FHR returns to normal after squeeze

  • smooth, gradual decrease

• caused by placental insuffiency

• contraction THEN decel - at lowest after contraction has peaked

  • late to the partayyy

early deceleration

• mirror contractions!

• gradual, temporary decrease in HR

• bc of head compression - esp closer to delivery

  • occurs during contractions

• nothing we can do - benign response

labor & early decels

• nothing we can do - benign response

  • part of labor! intervention would stop it

  • happen esp as baby drops when further along

• typically 8-9cm

VEAL CHOP MINE

• acronym to remember acceleration/deceleration details

• read as type → cause → intervention

VEAL

• V - variable deceleration

• E - early deceleration

• A - acceleration

• L - later deceleration

CHOP

• C - cord compression

• H - head compression

• O - Okay..! things are good!

• P - Placental insuffiency

MINE

• M - movement (mom repositioning)

• I - identify labor progress

• N - no special intervention needed

• E - emergency action required!

variable decel intervention

• change maternal position

  • decreases the compression

early decel intervention

• none needed

  • continue to monitor pt & fetal strip

acceleration intervetion

• no intervention needed

late deceleration intervention

• change position

• increase IV fluids

  • help blood flow - easier going thru

• start/increase O2

  • hyperoxygenate mom → O2 to baby

• stop pitocin if being used

pitocin & late decels

• stop!

  • gives baby more time to oxygenate

  • decreases contractions

FHR categories

• assign to every strip

• 3!

  • category one

  • category two

  • category three

FHR category 1

• what we want!

• normal & strong predictor of normal fetal acid-base status

  • no distress

FHR category 1 characteristics

• FHR baseline 110-160 bpm

• moderate variability

• accelerations present/absent

• variable/late decelerations absent

• early decelerations present/absent

• <5 contractions in 10 min period

FHR category 2

• indeterminate & fetal acid-base balance uncertain

  • not 1 or 3? 2!

• tracings not categorized as I or III

• can’t rlly tell baby’s state

FHR category 3

• horrible

• abnormal & predictive of fetal acid-base status

  • fetal distress noted

• notify MD → prepare for c-section!

• get baby outta there!!!

FHR category 3 characteristics

• absent variability

• AND

  • recurrent late decels

  • recurrent variable decels

  • bradycardia

• sinusoidal pattern

• any or all!

sinusoidal pattern

• from cardiac anomaly

• wooooosh smooth wave

• very rare!

• can be pseudo-sinusoidal → benign

sinusoidal pattern causes

• severe fetal distress

• hypoxia

• fetal distress