Fetal assessment during labor – ATI CH 13 – Flashcards
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Leopold maneuvers
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External palpations of the maternal uterus through the abdominal wall
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What does Leopold maneuvers determine?
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■ Number of fetuses ■ Presenting part, fetal lie, and fetal attitude ■ Degree of descent of the presenting part into the pelvis ■ Expected location of the point of maximal impulse (PMI)
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What is PMI?
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Point of Maximal Impulse PMI is the optimal location where the fetal heart tones are auscultated the loudest on the woman's abdomen.
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Where is PMI best heard?
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Directly over the fetal back
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Where do you find PMI in vertex presentation?
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In vertex presentation, PMI is either in the right- or left-lower quadrant or below the maternal umbilicus.
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Where do you find PMI in breech presentation?
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In breech presentation, PMI is either in the right- or left-upper quadrant above the maternal umbilicus.
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Before performing Leopold maneuvers, how do you prepare the client?
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■ Ask the client to empty her bladder before beginning the assessment. ■ Place the client in the supine position with a pillow under her head, and have her flex her knees slightly. ■ Place a wedge under her right hip to displace the uterus to the left and prevent supine hypotension syndrome.
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What are the steps of Leopold maneuvers?
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1. Identify the fetal part occupying the fundus. 2. Validate presenting part 3. Identify descent of presenting part into pelvis 4. Identify the fetal attitude
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What should it feel like when identifying the fetal part occupying the fundus in step 1 of Leopold maneuvers?
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1. Identify the fetal part occupying the fundus. The head should feel round, firm, and move freely. The breech should feel irregular and soft. This maneuver identifies the fetal lie (longitudinal or transverse) and presenting part (cephalic or breech).
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How do you validate the presenting part in step 2 of Leopold maneuvers?
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2. Validate presenting part Locate and palpate the smooth contour of the fetal back using the palm of one hand and the irregular small parts of the hands, feet, and elbows using the palm of the other hand. This maneuver validates the presenting part.
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How do you determine the part that is presenting into the pelvis in step 3 of Leopold maneuvers?
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3. Identify descent of presenting part into pelvis Determine the part that is presenting over the true pelvis inlet by gently grasping the lower segment of the uterus between the thumb and fingers. If the head is presenting and not engaged, determine whether the head is flexed or extended. This maneuver assists in identifying the descent of the presenting part into the pelvis.
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How do you identify the fetal attitude in step 4 of Leopold maneuvers?
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4. Identify the fetal attitude Face the client's feet and outline the fetal head using the palmar surface of the fingertips on both hands to palpate the cephalic prominence. If the cephalic prominence is on the same side as the small parts, the head is flexed with vertex presentation. If the cephalic prominence is on the same side as the back, the head is extended with a face presentation. This maneuver identifies the fetal attitude.
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For a low-risk L&D patient, what are two noninvasive methods for monitoring fetal well-being?
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1. Intermittent auscultation of the FHR is a low-technology method that can be performed during labor using a hand-held Doppler ultrasound device, an ultrasound stethoscope, or fetoscope to assess FHR. 2. Palpation of contractions at the fundus for frequency, duration, and intensity is used to evaluate fetal well-being
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What happens to fetal circulation during a contraction?
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During labor, uterine contractions compress the uteroplacental arteries, temporarily stopping maternal blood flow into the uterus and intervillous spaces of the placenta, decreasing fetal circulation and oxygenation. Circulation to the uterus and placenta resumes during uterine relaxation between contractions.
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For a low-risk woman in labor, how often should you monitor contractions and FHR?
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☐ Low-risk women During latent phase, every 60 min During active phase, every 30 min During second stage, every 15 min
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For a high-risk woman in labor, how often should you monitor contractions and FHR?
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☐ High-risk women During latent phase, every 30 min During active phase, every 15 min During second stage, every 5 min
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What are the guidelines for intermittent auscultation following routine procedures?
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■ Rupture of membranes, either spontaneously or artificially ■ Preceding and subsequent to ambulation ■ Prior to and following administration of or a change in medication analgesia ■ At peak action of anesthesia ■ Following vaginal examination ■ Following expulsion of an enema ■ After urinary catheterization ■ In the event of abnormal or excessive uterine contractions
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What is a normal, reassuring FHR?
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110 to 160/min with increases and decreases from baseline
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How do you determine baseline FHR?
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First, count FHR for 30 to 60 seconds to determine baseline rate. Then, auscultate FHR during a contraction and for 30 seconds following the completion of the contraction.
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What is the nurse's responsibility concerning FHR and contractions?
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It is the responsibility of the nurse to assess FHR patterns and characteristics of uterine contractions, implement nursing interventions, and report nonreassuring patterns or abnormal uterine contractions to the provider.
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Describe continuous electronic fetal monitoring
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Continuous external fetal monitoring is accomplished by securing an ultrasound transducer over the client's abdomen to determine PMI, which records the FHR pattern, and a tocotransducer on the fundus that records the uterine contractions.
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What are the advantages of external fetal monitoring?
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☐ Noninvasive and reduces risk for infection ☐ Membranes do not have to be ruptured ☐ Cervix does not have to be dilated ☐ Placement of transducers can be performed by the nurse ☐ Provides permanent record of FHR and uterine contraction tracing
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What are the disadvantages of external fetal monitoring?
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☐ Contraction intensity is not measurable ☐ Movement of the client requires frequent repositioning of transducers ☐ Quality of recording is affected by client obesity and fetal position
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How does the nurse interpret the findings from external fetal monitoring?
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A normal fetal heart rate baseline at term is 110 to 160/min excluding accelerations, decelerations, and periods of marked variability within a 10 min window. At least 2 min of baseline segments in a 10 min window should be present. A single number should be documented instead of a baseline range.
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What is fetal heart rate baseline variability?
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Fluctuations in the FHR baseline that are irregular in frequency and amplitude.
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What are the classifications of FHR variability?
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☐ Absent or undetectable variability (considered nonreassuring) ☐ Minimal variability (greater than undetectable but less than 5/min) ☐ Moderate variability (6 to 25/min) ☐ Marked variability (greater than 25/min)
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How are changes in FHR patterns defined?
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Changes in fetal heart rate patterns are defined as episodic or periodic changes. Episodic changes are not associated with uterine contractions Periodic changes occur with uterine contractions. These changes include accelerations and decelerations.
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What is CATEGORY I of the fetal monitoring 3-tier FHR interpretation system?
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Category I: Baseline FHR of 110 to 160/min Baseline FHR variability: moderate Accelerations: present or absent Early decelerations: present or absent Variable or late decelerations: absent
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What is CATEGORY II of the 3-tier FHR interpretation system?
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Category II: All FHR tracings not categorized as Cat I III: Baseline rate - Tachycardia Bradycardia not accompanied by absent baseline variability Minimal Baseline FHR variability Absent baseline variability not accompanied by recurrent decelerations Marked baseline variability Episodic or periodic decelerations Prolonged fetal heart rate deceleration greater than 2 min but less than 10 min Recurrent late decelerations with moderate baseline variability Recurrent variable decelerations with minimal or moderate baseline variability Variable decelerations with additional characteristics, including "overshoots," "shoulders," or slow return to baseline fetal heart rate Accelerations Absence of induced accelerations after fetal stimulation
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What is CATEGORY III of the 3-tier FHR interpretation system?
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Category III: FHR tracings include either: Sinusoidal pattern or Absent baseline fetal heart rate variability and any of the following: ■ Recurrent variable decelerations ■ Recurrent late decelerations ■ Bradycardia
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What is a uterine contraction comprised of?
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☐ Increment - the beginning of the contraction as intensity is increasing ☐ Acme - the peak intensity of the contraction ☐ Decrement - the decline of the contraction intensity as the contraction is ending
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Nonreassuring FHR patterns are associated with fetal hypoxia and include the following:
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☐ Fetal bradycardia ☐ Fetal tachycardia ☐ Absence of FHR variability ☐ Late decelerations ☐ Variable decelerations
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What are the causes and complications for FHR accelerations?
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Variable transitory increase in the FHR above baseline Healthy fetal/placental exchange › Intact fetal CNS response to fetal movement › Vaginal exam › Fundal pressure
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What are the nursing interventions for FHR accelerations?
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Variable transitory increase in the FHR above baseline › REASSURING › No interventions required › Indicate REACTIVE NST
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What are the causes and complications for fetal bradycardia?
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FHR less than 110/min for 10 min or more › Uteroplacental insufficiency › Umbilical cord prolapse › Maternal hypotension › Prolonged umbilical cord compression › Fetal congenital heart block › Anesthetic medications
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What are the nursing interventions for fetal bradycardia?
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FHR less than 110/min for 10 min or more › Discontinue oxytocin (Pitocin) if being administered. › Assist the client to a side-lying position. › Administer oxygen by mask at 8 to 10 L/min. › Insert an IV catheter if one is not in place. › Administer a tocolytic medication as prescribed. › Notify the provider.
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What are the causes and complications for fetal tachycardia?
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FHR greater than 160 beats/min for 10 min or more › Maternal infection, chorioamnionitis › Fetal anemia › Fetal heart failure › Fetal cardiac dysrhythmias › Maternal use of cocaine or methamphetamines › Maternal dehydration
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What are the nursing interventions for fetal tachycardia?
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FHR greater than 160 beats/min for 10 min or more › Administer prescribed antipyretics for maternal fever › Administer oxygen by mask at 8 to 10 L/min. › Administer IV fluid bolus.
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What are the causes and complications for decrease or loss of FHR variability?
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Decrease/loss of variability in the baseline of the FHR › Medications that depress the CNS, such as narcotics, barbiturates, tranquilizers, or general anesthetics › Fetal hypoxemia with resulting acidosis › Fetal sleep cycle › Congenital abnormalities
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What are the nursing interventions for the decrease or loss of FHR variability?
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› Stimulate the fetal scalp. › Assist provider with application of scalp electrode. › Place client in left-lateral position.
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What are the causes and complications for early deceleration of FHR?
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Slowing of FHR with start of contraction-return to baseline at end of contraction › Compression of the fetal head resulting from uterine contraction › Vaginal exam › Fundal pressure
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What are the nursing interventions for early deceleration of FHR?
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No intervention required.
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What are the causes and complications for late deceleration of FHR?
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Slowing of FHR after contraction has started with return to baseline well after contraction has ended › Uteroplacental insufficiency causing inadequate fetal oxygenation › Maternal hypotension, abruptio placentae, uterine hyperstimulation with oxytocin (Pitocin)
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What are the nursing interventions for late deceleration of FHR?
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Slowing of FHR after contraction has started with return to baseline well after contraction has ended › Place client in side-lying position. › Increase rate of IV fluid administration. › Discontinue oxytocin (Pitocin) › Administer oxygen by mask at 8 to 10 L/min. › Notify the provider. › Prepare for an assisted vaginal birth or cesarean birth.
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What are the causes and complications of variable deceleration of FHR?
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Transitory, abrupt slowing of FHR less than 110 beats/min, variable in duration, intensity, and timing in relation to uterine contraction › Umbilical cord compression › Short cord › Prolapsed cord › Nuchal cord (around fetal neck) › Oligohydramnios
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What are the nursing interventions for variable deceleration of FHR?
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Transitory, abrupt slowing of FHR less than 110 beats/min, variable in duration, intensity, and timing in relation to uterine contraction › Reposition client from side to side or into knee-chest. › Discontinue oxytocin (Pitocin) › Administer oxygen by mask at 8 to 10 L/min. › Perform or assist with a vaginal examination. › Assist with an amnioinfusion if prescribed
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How is continuous internal fetal monitoring performed?
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Continuous internal fetal monitoring with a scalp electrode is performed by attaching a small spiral electrode to the presenting part of the fetus to monitor the FHR. The electrode wires are then attached to a leg plate that is placed on the client's thigh and then attached to the fetal monitor.
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What are the advantages of internal fetal monitoring?
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■ Early detection of abnormal FHR patterns suggestive of fetal distress. ■ Accurate assessment of FHR variability. ■ Accurate measurement of uterine contraction intensity. ■ Allows greater maternal freedom of movement because tracing is not affected by fetal activity, maternal position changes, or obesity.
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What are the disadvantages of internal fetal monitoring?
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■ Membranes must have ruptured to use internal monitoring. ■ Cervix must be adequately dilated to a minimum of 2 to 3 cm. ■ Presenting part must have descended to place electrode. ■ Potential risk of injury to fetus if electrode is not properly applied. ■ A provider, nurse practitioner/midwife, or specially trained registered nurse must perform this procedure. ■ Contraindicated with vaginal bleeding. ■ Potential risk of infection to the client and the fetus.
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What types of ongoing care should be provided with internal fetal monitoring?
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■ Monitor maternal vital signs, and obtain maternal temperature every 1 to 2 hr. ■ Encourage frequent repositioning of the client. If the client is lying supine, place a wedge under one of the client's hips to tilt her uterus.
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What are the complications of using internal fetal monitoring?
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◯ Misinterpretation of FHR patterns ◯ Maternal or fetal infection ◯ Fetal trauma if fetal monitoring electrode or IUPC are inserted into the vagina improperly ◯ Supine hypotension secondary to internal monitor placement
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A nurse is providing care for a client who is in active labor. Her cervix is dilated to 5 cm, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150 to 155/min that last for 25 seconds, and have beat-to-beat variability of 20/min. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (Select all that apply.) A. Moderate variability B. FHR accelerations C. FHR decelerations D. Normal baseline FHR E. Fetal tachycardia
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A. CORRECT: There is moderate variability of 20 beats/min (6 to 25/min is expected). B. CORRECT: FHR accelerations are present with increases up to 150 to 155/min lasting for 25 seconds. C. INCORRECT: There are no FHR decelerations because the FHR does not slow down. D. CORRECT: There is a normal baseline FHR of 115 to 125/min (110 to 160/min is expected). E. INCORRECT: There is no evidence of fetal tachycardia because there is a normal baseline FHR of 115 to 125/min.
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A nurse is caring for a client who is having an induction of labor. Based on the use of external electronic fetal monitoring, the nurse notes that the FHR variability is decreased and resembles a straight line. The client has not received pain medication. Which of the following should occur first before the nurse can apply an internal scalp electrode? A. Dilation B. Rupture of the membranes C. Effacement D. Engagement
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A. INCORRECT: The cervix must be dilated 2 to 3 cm before internal monitoring can be used, but this is not the first criterion to consider. B. CORRECT: The membranes must be ruptured prior to the insertion of an internal electrode or intrauterine pressure catheter. C. INCORRECT: Effacement of the cervix must occur before internal monitoring can be used, but this is not the first criterion to consider. D. INCORRECT: Engagement of the presenting part must occur before internal monitoring can be used, but this is not the first criterion to consider.
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A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse knows that a fetus receives more oxygen when which of the following appears on the tracing? A. Peak of the uterine contraction B. Moderate variability C. FHR acceleration D. Relaxation between uterine contractions
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A. INCORRECT: Compression of the arteries to the uteroplacental intervillous spaces is most acute at the peak (acme) of the uterine contraction, resulting in a decrease in fetal circulation and oxygenation. B. INCORRECT: Moderate variability indicates fluctuations in the fetal heart and is not an indication the fetus is receiving more oxygen. C. INCORRECT: FHR accelerations indicate an intact fetal CNS and is not an indication the fetus is receiving more oxygen. D. CORRECT: A fetus is most oxygenated during the relaxation period between contractions. During contractions, the arteries to the uteroplacental intervillous spaces are compressed, resulting in a decrease in fetal circulation and oxygenation.
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A nurse is caring for a client who is in labor and observes late decelerations on the electronic fetal monitor. Which of the following is the first action the nurse should take? A. Assist the client into the left-lateral position. B. Apply a fetal scalp electrode. C. Insert an IV catheter. D. Perform a vaginal exam.
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A. CORRECT: The greatest risk to the fetus during late decelerations is uteroplacental insufficiency. The initial nursing action should be to place the client into the left-lateral position to increase uteroplacental perfusion. B. INCORRECT: The application of a fetal scalp electrode will assist in the assessment of fetal well-being, but this is not the first action the nurse should take. C. INCORRECT: Inserting an IV catheter is an intervention for late decelerations, but this is not the first action the nurse should take. D. INCORRECT: The nurse may perform a vaginal exam to assess dilation, but this is not the first action the nurse should take.
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A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A. Apply palms of both hands to sides of uterus. B. Palpate the fundus of the uterus. C. Grasp lower uterine segment between thumb and fingers. D. Stand facing client's feet with fingertips outlining cephalic prominence.
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A. INCORRECT: Using the palms of the hands on the sides of the uterus to identify the fetal back and small body parts verifies the presenting part. B. CORRECT: Palpating the fundus of the uterus identifies the fetal part that is present, indicating the fetal lie (longitudinal or transverse). C. INCORRECT: The descent of the presenting part into the pelvis is determined by gently grasping the lower uterine segment between the thumb and fingers. D. INCORRECT: Fetal attitude is identified by facing the client's feet and outlining the cephalic prominence (fetal head) using the fingertips of both hands.
