Fetal Monitoring pt 2+Labor Stages, and Management

Fetal Monitoring

• Central Monitoring: ICU-like setup with screens and tracings allows nurses to quickly assess patient status. Experience allows for quick recognition of well-doing rooms vs. rooms needing immediate attention. Intuition plays a significant role alongside defined parameters.

• Tracing Indications: Tracings typically indicate the $110$ line and $160$ line for easy reference. York Hospital uses a red line for these baselines.

• Example Tracing Analysis: A "nice tracing" indicates a baby tolerating the uterine environment, including contractions.

  • Baseline: Normal, tacky (tachycardia), brady (bradycardia), indeterminate.

    • The example tracing showed a baseline of approximately $135$ or $140$ BPM, which is considered normal.

    • Indeterminate: Occurs when there are gaps in the tracing due to factors like baby movement, insufficient information, or monitor displacement. Nurses frequently readjust external monitors for continuous tracking.

  • Variability: Refers to the fluctuation in the fetal heart rate between contractions.

    • The example showed moderate variability, fluctuating at least $10$ beats per minute.

    • Significance of Moderate Variability: It is the primary indicator that the baby is well-oxygenated.

  • Accelerations: Transient increases in fetal heart rate.

    • The example tracing showed present (two nice ones).

    • Gestational Age Inference: The presence of well-formed accelerations indicates a developed Central Nervous System (CNS) (sympathetic and parasympathetic systems), suggesting the baby is at least over $32$ weeks gestation (term baby).

    • Indeterminate for Accelerations: Gaps in tracing prevent assessment.

    • Non-applicable for Accelerations: Used for very preterm babies where the brain is not expected to produce such signals.

  • Decelerations: Transient decreases in fetal heart rate.

    • The example tracing showed absent decelerations.

  • Uterine Contractions: Monitored for frequency, duration, and intensity.

    • Time Marks: Dark lines represent one minute intervals, fainter boxes represent $10$-second marks.

    • Frequency: Measured from the beginning of one contraction to the beginning of the next.

      • Example: Contractions every $2.5$ minutes.

      • Absent Frequency: No contractions.

      • Normal Frequency: The example tracing showed normal frequency.

      • Tachysystole: Six or more contractions in a $10$-minute window.

      • Indeterminate for Contractions: Maternal movement (e.g., sneezing, vomiting) can make it difficult to get a continuous, clear tracing.

Fetal Heart Rate Tracing Categories

• Purpose: Standardize communication among healthcare providers regarding fetal monitoring.

• Category One (Desired State): Infant is tolerating labor well.

  • Characteristics:

    • Normal baseline fetal heart rate.

    • Moderate variability.

    • Accelerations present.

    • No late or variable decelerations.

    • May have early decelerations (often near the end of labor, indicating head compression if pushing is imminent).

  • Management: Continue current management; no intervention needed, regardless of labor duration.

• Category Three (Critical State): Immediate action required; "dropping your donut and running into the room."

  • Characteristics:

    • Absent or minimal variability.

    • Recurrent late decelerations (contraction after contraction).

    • Recurrent variable decelerations.

    • Bradycardia.

    • Sinusoidal pattern (wavy pattern indicating poor oxygenation and potential oxygen deficiency injury).

  • Management: Emergency interventions, including potential rapid vaginal delivery or immediate C-section. Acknowledges risk of brain tissue death from prolonged poor oxygenation.

• Category Two (Indeterminate State/Most Common): Concerning elements present, but often with identifiable causes that can be addressed.

  • Characteristics (Any of the following):

    • Minimal variability (e.g., due to narcotics, fetal sleep cycle).

    • Absent accelerations (e.g., due to fetal sleep cycle).

    • Recurrent variable decelerations (e.g., due to umbilical cord compression).

    • Prolonged decelerations.

    • Tachycardia (e.g., maternal fever, dehydration, infection).

    • Bradycardia (e.g., fetal heart block).

  • Management: Investigate the cause and implement interventions to improve the tracing. Often involves a trial of intrauterine resuscitation interventions.

VEAL CHOP Acronym

• Variable Decelerations: Cord Compression

• Early Decelerations: Head Compression

• Accelerations: Oxygenation is A-okay

• Late Decelerations: Placental Insufficiency

Intrauterine Resuscitation

• Goal: Improve the fetal environment before considering delivery.

• Priority Order (for exams/NCLEX):

  1. Discontinue Oxytocin (DC Oxytocin): Oxytocin causes contractions. Turning it off reduces uterine activity.

  2. Reposition Mother: Changes in maternal position can improve placental perfusion and fetal oxygenation (e.g., left lateral, right lateral, hands and knees to relieve cord/head compression). Gravitational benefits. In practice, nurses often reposition first due to immediate effect compared to medication half-life.

  3. Increase IV Fluids: Improves maternal hydration and blood volume, thus enhancing uterine and placental perfusion.

  4. Administer Oxygen to Mother: Use a face mask at $10$ liters per minute (nasal cannula not used in OB). Supplemental oxygen can improve oxygenation to the placenta and fetus.

  5. Call Physician (or notify): While nurses initiate the first four, physician notification is simultaneous.

• Additional Interventions:

  • Terbutaline (Tribulene): A smooth muscle relaxant given subcutaneously by physician order to calm the uterus, especially in cases of tachysystole. Primarily used as a stop-gap measure and will wear off.

• Application: Intrauterine resuscitation is performed for Category 3 tracings and for specific concerning elements in Category 2 tracings.

Stages of Labor

• Stage 1: From onset of labor until cervix is $10$ centimeters dilated.

• Stage 2: From $10$ centimeters dilation until the baby is born.

• Stage 3: From baby's birth until the placenta is delivered.

• Stage 4: The first couple of hours postpartum, focusing on uterine contraction, bleeding, and overall maternal stability.

False Labor vs. True Labor

• False Labor / Braxton Hicks:

  • Uterine contractions (muscle contracting, not brain-initiated).

  • Often relieved by rest, hydration, or lying down.

  • Cervix does not change (no effacement or dilation).

• True Labor:

  • Contractions are regular and lead to cervical change.

  • Cervix undergoes effacement (thinning) and dilation (opening).

Rupture of Membranes (ROM)

• Significance: Breaking of the amniotic sac and leakage of amniotic fluid.

• Importance of Assessment: Needs to be confirmed vs. urine or other fluids.

• TACO Acronym for ROM Assessment:

  • Time: When did the water break? Determines the duration of risk.

  • Amount: Was it a trickle or a gush?

  • Color / Consistency: Expected to be clear or slightly yellowish. Green/brown indicates meconium (fetal bowel movement), which can be sludgy if recent.

  • Odor: Body/musty odor is normal; foul odor suggests infection.

• Implication of ROM: Delivery is anticipated within next $1-2$ days due to increased risk of infection as the protective barrier is gone.

• Differentiating from Urine: Urine can be colorless and odorless at the end of pregnancy. Pelvic muscle contraction (Kegel) can stop urine flow, but not amniotic fluid.

• Diagnostic Process:

  1. Visual Assessment: Large gush or puddle often indicates ROM.

  2. Speculum Exam: Directly visualize fluid coming from the cervix.

  3. Nitrazine Paper Test: pH paper turns bright blue for alkaline amniotic fluid; remains yellow/acidic for urine.

  4. Ferning Test: Amniotic fluid crystals dry in a distinctive fern-leaf pattern under a microscope.

Cervical Assessment

• Performed by: Nurses and providers using gloved fingers (two fingers) with lubrication.

• Components:

  1. Dilation: The opening of the cervix, measured from $0$ to $10$ centimeters.

     • Nurses learn to estimate dilation using their fingers (e.g., Cheerio ~$1$ cm, Ritz cracker ~$3-4$ cm).

  2. Effacement: The thinning of the cervix, measured in percentages (or in centimeters for thickness).

     • A non-effaced cervix is about $2.5$ cm (or $1$ inch) thick.

     • $100\%$ effaced means it's as thin as paper.

     • First-time mothers often efface completely before significant dilation.

     • Multiparous mothers (those who have given birth before) may efface and dilate concurrently.

  3. Station: The position of the fetal head (or presenting part) relative to the maternal ischial spines.

     • Ischial Spines: Represents the $0$ station.

     • Negative Numbers ($-5$ to $-1$): Fetal head is above the ischial spines (not yet engaged).

     • Positive Numbers ($+1$ to $+5$): Fetal head is below the ischial spines (descending into the pelvis).

     • Contrast with fundal assessment: In postpartum, $+$ means above umbilicus, -$ means below umbilicus; in labor, for station, +$indicates lower in the pelvis.</p></li></ul></li></ol></li></ul><h5 id="c77af50b-f4d0-4e6f-bf23-4f4295767913" data-toc-id="c77af50b-f4d0-4e6f-bf23-4f4295767913" collapsed="false" seolevelmigrated="true">Nursing Care During Labor (Intrapartum)</h5><ul><li><p><strong>Responsibilities:</strong> Monitoring both mother and baby, pain management, providing support.</p></li><li><p><strong>Staffing Ratios:</strong> Can range from$2:1$to$1:1$$ depending on the stage of labor and maternal/fetal condition.

     Pain in Childbirth

     • Causes: Organ pain (uterine contractions), somatic pain (head pressure in pelvis), fear of the unknown, lack of prepared childbirth education.

     • First Stage Labor Pain: Primarily visceral pain from uterine contractions, often has breaks between contractions.

     • Second Stage Labor Pain: More somatic pain due to consistent pressure of the fetal head in the pelvis; tends to be more constant.

     Physiological Adaptations in Labor

     • Cardiovascular: Increased heart rate and blood pressure (monitor vitals).

     • Metabolic: Increased metabolic rate.

     • Gastrointestinal (GI): Motility slows significantly.

       • Nursing Action: Often managed with clear liquids or ice chips, not full regular diets.

     • Urinary: Risk of urinary retention due to pressure and decreased sensation.

       • Nursing Action: Palpating for bladder distention, encouraging frequent voiding, or catheterization.

     The 5 P's of Labor

     • Individualized Labor: Labor progression varies greatly for each person; rigid timeframes for delivery are no longer universally applied as long as mother and fetus are tolerating labor.

     • 1. Passenger: The fetus and placenta.

       • Position: Vertex (head down) is ideal for vaginal delivery due to effective "battering ram" action.

       • Presentation: Breech (bum or feet first) makes vaginal delivery more challenging/risky.

       • Fetal Lie/Attitude: Cattywampus (asynclitic) or tilted positions can hinder progress.

     • 2. Passageway: The mother's bony pelvis and soft tissues.

       • Pelvic size and shape influence ability for vaginal birth.

       • Prior injuries (e.g., fractured pelvis) or anatomical variations (e.g., dwarfism) can impact the passageway.

     • 3. Powers: Uterine contractions and maternal pushing efforts.

       • Effective contractions are essential for cervical change and fetal descent.

       • Factors like infection can impair uterine contractility.

     • 4. Position: Two aspects.

       • Fetal Position: How the fetus is oriented within the birth canal (e.g., relationship of presenting part to maternal pelvis).

       • Maternal Position: Upright positions are generally beneficial due to gravity.

         • Maternal walking is encouraged.

         • Epidural/spinal anesthesia can limit upright positions by causing motor function loss.

         • Hands-and-knees position can be comfortable or aid in certain situations.

     • 5. Psyche: The mother's psychological state.

       • Fear, anxiety, and stress can impact labor progression.

       • A strong mindset can influence physiological processes (e.g., remaining at a certain dilation).

     Clinical Orientation / Review

     • Next week's clinical will cover stages of labor, cardinal movements, Apgar score, and placenta-related information.