NSG 3111: Fetal Health Surveillance & Gestational/Pre-existing HTN

26 weeks

From what point in pregnancy should all mothers be advised to regularly monitor fetal movements?

Intermittent auscultation & continuous external EFM

What are the 2 methods to monitor a fetus?

Contractions

What does the toco monitor pick up?

Uterine fundus

Over which body part is the tocotransducer placed?

Leopold maneuvers

Series of 4 types of abdominal palpitation for determining fetal position

Right lower

In which quadrant of the mother's abdomen (anatomical position) would you place your stethoscope to listen to the FHR if the fetus presents in right occipitoanterior?

Left upper

In which quadrant of the mother's abdomen (anatomical position) would you place your stethoscope to listen to the FHR if the fetus presents in complete breech

False

True or false? Repetitive decelerations are normal when listening to the FHR using intermittent auscultation

Ultrasound transducer

Placed below the umbilicus where the FHR is best heard

≥2 within a 40-min window over max 80 min

Normal amount of accelerations during a non-stress test

6-25 bpm

Moderate amount of variability (normal)

5 bpm

Minimal amount of variability; normal if under 40 min period

Causes of fetal bradycardia

Maternal hypotension, maternal position, cord prolapse w/ ROM, fetal cardiac problems

Causes of fetal tachycardia

Maternal fever or infection

10 seconds

What does each box on the x axis represent on a FHR tracing?

Absent

How would you classify this variability?

Minimal

How would you classify this variability?

Acceleration

Abrupt (onset to peak in <30 seconds) increase in FHR above baseline; ≥15 bpm above baseline lasting ≥15 seconds

Fetal wellbeing/optimal oxygenation & fetal movement

Presence of accelerations indicate...

Decelerations

Decrease from baseline by ≥15 bpm lasting ≥15 seconds

Variable deceleration

Abrupt deceleration; onset to nadir <30 seconds; complicated and uncomplicated

Uncomplicated decelerations

Type of variable deceleration; ≥15 bpm below baseline for ≥15 sec BUT <60 seconds

Cord compression

What is the main cause of uncomplicated variable decelerations?

True

True or false? Uncomplicated variable decelerations are normal as long as they are not repetitive

Complicated decelerations

A type of variable deceleration that lasts >60 secs AND decreases to 60bpm or less OR the heart rate deceleration is equal or greater than 60bpm below the baseline

Cause of complicated deceleration

Fetal depletion of reserves/hypoxemia related to significant cord compression

Early decelerations

Type of deceleration with a smooth and gradual decrease and return to baseline; onset, nadir, and recovery occur at the same time as the mother's contraction

Head compression

What are early decelerations caused by?

False (early decels are normal)

True or false? Early decelerations are a sign of fetal hypoxia and require immediate intervention

Late decelerations

Type of deceleration which begins after the contraction starts, the nadir occurs after the contraction's peak, and the recovery occurs after the contraction ends; always concerning

Uteroplacental insufficiency (decreased fetal oxygenation)

Cause of late decelerations

Repositioning, maternal VS, IV, O2, oxytocin

What are some interventions the nurse could execute after observing late decelerations?

Increment

Phase of the contraction in which the uterus slowly increases in tension, pressure rises from resting tone towards the peak

Acme (peak)

The strongest point of the contraction, uterine pressure is at its maximum, early FHR decelerations often hit their nadir at this time

Decrement

Uterine tension decreases from the peak back to its resting tone and blood flow to the placenta increases again

Frequency

Start of one contraction to the start of the next, taken over a 10 minute period

Duration

The length of the contraction (in seconds) from the increment to the decrement

Intensity

The palpable strength of the contraction at its peak; subjective to the mother, but also can be palpated by HCP

Mild

When palpating the mother's uterus, this uterine contraction has the same firmness as the tip of the nose

Moderate

When palpating the mother's uterus, this uterine contraction has the same firmness as the chin

Strong

When palpating the mother's uterus, this uterine contraction has the same firmness as the forehead

Placental abruption

What is a significant complication and cause of mortality from HTN in pregnancy?

≥140 mmHg

What must the systolic BP be to diagnose HTN disorder in pregnancy?

≥90 mmHg

What must the diastolic BP be to diagnose HTN disorder in pregnancy?

Systolic >160 mmHg OR Diastolic >110 mmHg

What values of BP are classified as severe hypertension?

Chronic HTN (pre-existing)

HTN predates pregnancy or appears before 20 weeks without evidence of pre-eclampsia

Gestational HTN

HTN occurs after 20 weeks without evidence of pre-eclampsia

Transient HTN

HTN related to environmental stimuli

White coat HTN

HTN present only in clinician's office, normal otherwise

Masked HTN

BP normal in clinician's office, abnormal otherwise

Pre-eclampsia

Multisystemic vasospastic disease process of reduced organ perfusion; HTN + new proteinuria OR evidence of organ dysfunction

Symptoms of CNS dysfunction (related to pre-eclampsia)

Severe headache/visual symptoms; eclampsia, cortical blindness/retinal detachment, GCS <13, stroke, TIA

Symptoms of cardiorespiratory dysfunction (related to pre-eclampsia)

Chest pain/dyspnea, SpO2 <97, myocardial ischemia or infarction

Symptoms of hematological dysfunction (related to pre-eclampsia)

Low platelet count

Symptoms of renal dysfunction (related to pre-eclampsia)

Elevated serum creatinine, AKI, new indication for dialysis

Symptoms of hepatic dysfunction (related to pre-eclampsia)

RUQ or epigastric pain, elevated AST, ALT, hepatic hematoma or rupture

Symptoms of uteroplacental dysfunction (related to pre-eclampsia)

Atypical/abnormal NST/CTG, fetal growth restriction, oligohydramnios, absent/reversed end-diastolic flow by umbilical artery, angiogenic imbalance

Effects of maternal arteriolar vasospasm

Diminished diameter of BV, impeded BF to all organs (eyes, kidneys, placenta, brain, liver), hypertension

Proteinuria

Protein concentration ≥0.3g/day OR ≥30mg/mmol of urinary creatinine in a spot (random) urine sample

Pre-eclampsia high risk factors

Prior pre-eclampsia, pre-pregnancy BMI >30, chronic HTN, pre-gestational DM, CKD, systemic lupus erythematous/antiphospholipid antibody syndrome, assisted reproductive therapy

Eclampsia

Seizure activity or coma from profound cerebral effects of pre-eclampsia

HELLP syndrome

Laboratory diagnostic variant of severe pre-eclampsia that involves hepatic dysfunction characterized by decreased RBCs due to damage from vasospasms, elevated liver enzymes, and low platelets

Hemolysis, elevated liver enzymes, low platelets

What does HELLP syndrome stand for?

Magnesium toxicity

What does an absent or sluggish reflex response indicate?

Cerebral S&S of severe pre-eclampsia

What do more brisk, hyperactive, or a clonus reflex response indicate?

Betamethasone

Glucocorticosteroid given to enhance fetal lung maturity; given at <36+4

Magnesium sulphate

Anticonvulsant given to prevent seizures; antidote is calcium gluconate

Labetalol

First choice of antihypertensive drug to control pre-eclampsia

Nifedipine, methyldopa

Other drugs used to control blood pressure during pregnancy

2+

Normal grade for reflex response

Hyperemesis gravidarum

When nausea and vomiting in pregnancy is excessive; weight loss, electrolyte imbalance, nutritional deficiencies, ketonuria

Cholestasis

Stoppage of bile flow due to disruption of hepatic blood flow; generalized pruritis

Chorioamnionitis

Bacterial infection of amniotic cavity; S&S include maternal fever, maternal/fetal tachycardia, uterine tenderness, foul odor of amniotic fluid

True

True or false? Insulin cannot cross the placental barrier

1st trimester

In which trimester(s) is there increased insulin production, increased peripheral use of glucose (therefore decreased blood glucose), and lower fasting blood glucose?

Hypoglycemia

What is the mother at risk for during the 1st trimester due to increased insulin production?

2nd & 3rd trimesters

In which trimester(s) does pregnancy have a diabetogenic effect, increasing insulin resistance and glucose sparing to meet the needs of the growing fetus?

Hypoglycemia

What are these S&S of? Irritability, hunger, sweating, weakness, pallor, rapid pulse, shallow respirations, dizziness

Hyperglycemia

What are these S&S of? Nausea/vomiting, abdominal pain, constipation, drowsiness, increased urination, weak & rapid pulse, rapid breathing

3.4-6.7 mmol/L

Normal blood glucose levels (euglycemia)

In assessing the knowledge of a pre-gestational patient with T1DM concerning changing insulin needs during pregnancy, a nurse recognizes that further teaching is warranted when the patient states

"I will need to increase my insulin dosage during the 1st 3 months of pregnancy"

3 multiple choice options

Antiretroviral therapy

What should HIV be treated with before and during pregnancy?

Decrease risk of transmission to fetus

What is the goal of HIV management during pregnancy?

Fetal scalp electrode

Small electrode attached to the fetal scalp that senses the potential differences created by the depolarization of the fetal heart