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34 Cards in this Set
- Front
- Back
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Variables measured by fetal monitoring |
a. contractions b. baseline FHR |
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fetal monitoring measures the contractions at- |
-beginning, peak (acme) and end of of each contraction |
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Contraction duration |
length of each contraction from beginning to end |
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contraction frequency |
beginning of one contraction to beginning of next (3 to 5 contractions must be measured) |
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contraction intensity |
measured not by external monitoring but in mm Hg by internal (intrauterine) monitoring after amniotic membranes have ruptured; ranges from 30 mm Hg (mild) to 70 mm Hg (strong) peak |
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baseline FHR range |
the range of FHR (average 110 to 160 bpm) between contractions, monitored over a 10 min period |
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Parasympathetic/sympathetic impulses |
the balance between parasympathetic and sympathetic impulses produces no observable changes in the FHR during uterine contractions |
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The most imp indicator of the health of the fetal CNS |
fetal heart rate |
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FHR results from the balance between |
the parasympathetic and sympathetic branches of the ANS |
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Variability |
a characteristic of the baseline FHR and described as normal irregularity of the cardiac rhythm |
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4 categories of variability |
-absent-amplitude range undetectable -minimal-amplitude range detectable up to and including 5 beats/min -moderate-amplitude range of 6 to 25 beats/min marked: amplitude range>25 beats/min |
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Fetal Heart Rate Nursing Actions |
-assess contractions using monitor strip -assess FHR for normal baseline range and variability |
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FHR accelerations |
-caused by sympathetic fetal response -occur in response to fetal mvmt -indicative of a reactive, healthy fetus |
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Early decelerations |
-benign pattern caused by parasympathetic response (head compression) -heart rate slowly and smoothly decelerates at beginning of contraction and returns to baseline at the end of contraction |
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Nursing actions for early decelerations |
-no nursing interventions are required except to monitor the progress of labor -document the processes of labor |
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Causes of absent or minimal FHR (variability) |
-hypoxia (asphyxia) -acidosis -maternal drug ingestion (narcotics, CNS depressants) -fetal sleep |
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bradycardia |
baseline FHR is below 110 bpm (assessed between contractions) for 10 min |
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bradycardia causes |
-late manif of fetal hypoxia -medication induced (narcotics, MgSo4) -maternal hypotension -fetal heart block -prolonged umbilical cord compression |
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tachycardia |
baseline FHR is above 160 bpm (assessed between contractions) for 10 min |
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tachycardia causes |
-early sign of fetal hypoxia -fetal anemia -dehydration -maternal infection, maternal fever -maternal hyperthyroid disease -med induced (atropine, terbutaline, hydroxyzine) |
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Nursing action for decreased variability, bradycardia, tachycardia |
treatment based on cause |
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Most common periodic pattern. Occurs in 40% of all labors and caused by cord compression but can also indicate rapid fetal descent |
Variable deceleration pattern |
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Variable deceleration pattern is characterized by |
an abrupt transitory decrease in the FHR that is variable in duration, depth of fall, and timing relative to the contraction cycle |
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Nursing actions for variable deceleration |
-change maternal position -stimulate fetus -discontinue oxytocin (Pitocin) if infusing -admin oxygen 10 L by tight facemask -check for cord prolapse -report findings to physician |
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Nonreassuring (Ominous signs) Severe variable decelerations |
-FHR below 70 bpm lasting longer than 30-60 sec -slow return to baseline -decreasing or absent variability |
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Nonreassuring (Ominous signs) Late decelerations |
-an ominous and potentially disastrous nonreassuring sign -indicative of uteroplacental insuff -the shape of the deceleration is uniform, and FHR returns to baseline after the contraction is over -the depth of the deceleration does not indicate severity, rarely falls below 100 bpm |
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Severe/Late decelerations Nursing Actions |
-immediately turn client to side -discontinue oxytocin (pitocin) if infusing -admin 10 ml oxygen via facemask -assist w/fetal blood sampling if indicated -maintain intravenous line, elevate legs to increase venous return -correct underlying hypotension -determine presence of FHR variability -notify HCP -document pattern and response to each nursing action |
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Check for _____ if early decelerations are noted |
labor progress |
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Early decelerations caused by head compression and fetal descent usually occur in |
the second stage of labor between 4 and 7 cm dilation |
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If cord prolapse is detected |
position the mother to relieve pressure on the cord (ie knee-chest position) or push the presenting part off the cord until immediate cesarean delivery can be accomplished |
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Late decelerations indicate uteroplacental insufficiencyand are assoc with |
conditions such as postmaturity, preeclampsia, DM, cardiac disease, and abruptio placentae |
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When deceleration patterns (late or variable) are assoc with decreased or absent variability and tachycardia |
the situation is ominous (potentially dangerous) and requires immediate intervention and fetal assessment |
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A decrease in uteroplacental perfusion results in |
late deceleration |
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Cord compression results in |
a pattern of variable decelerations |
