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Fetal Adaptation to
Labor

Basis for Monitoring

Physiologic

Fetal

stress to the fetus

oxygen supply must be


maintained during labor

Monitoring Techniques
Intermittent auscultation

Pinard stethoscope

Doppler ultrasound

Ultrasound stethoscope

DeLee- Hillis fetoscope

Monitoring Techniques
Electronic Fetal Monitoring

External -- Ultrasound transducer,


Tocotransducer

Internal -- Scalp electrode, IUPC


cervix must be dilated
membranes must be ruptured
fetal descent at -1 station

Electronic Fetal
Monitoring

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Assessment of Uterine
Contractions
Palpation
External
IUPC

tocotransducer

Systematic Evaluation of
Fetal Heart Rate Tracing
Fetal Status

Baseline Fetal Heart Rate


Variability
Accelerations
Decelerations
Early
Late
Variable

Baseline FHR

Between Contractions
5-10 minute segment
Document as range
Normal is 110-160

VARIABILITY

The most reliable indicator of Fetal Well-being

Variability

undetectable

6-25 bpm

0-5 bpm

>25 bpm

Periodic and Episodic


Changes
Periodic

In response to contractions

Episodic

No relationship to uterine contractions

Acceleration

Etiology of Accelerations

Fetal

movement
Uterine contractions
Vaginal exam
ISE application
Fetal scalp stimulation
Partial cord compression
Breech presentation

ALWAYS
REASSURRING!

Accelerations

Etiology of Decelerations

Early

Head Compression

Late

Uteroplacental
Insufficiency

Variable

Cord Compression

Periodic FHR Changes

Early deceleration

Periodic FHR Changes

Late deceleration

Periodic FHR Changes

Variable deceleration

3-Tier Fetal Heart Rate


Interpretation System
Category I

Normal
NO ACTION REQUIRED

Not predictive of
abnormal fetal acid base
status but cant
categorize
I or III intraRe-evaluation,

Category II

utero tx and continued


surveillance
Category III

Abnormal fetal acid-base


status
ACTION REQUIRED

Category I

Must include ALL:


Baseline 110-160
Moderate variability
No late decelerations
Early decelerations +/Accelerations +/-

Normal

NO ACTION REQUIRED

Category II

Everything that not


categorized as either
Category I or III
Examples :
Tachycardia,
bradycardia with
normal variability
Absent variability,
marked variability
Lates + variability,
unusual variables

Re-evaluation, intrautero tx and continued


surveillance

Not
predictive
of
abnormal
fetal acid
base
status but
cant
categorize
I or III

Category III

Absent variability, plus


either..
Recurrent late
decelerations
Recurrent variable
decelerations
Bradycardia

Abnormal
fetal acidbase status

Sinusoidal pattern

ACTION REQUIRED

Management for Abnormal


Fetal Heart Rate Patterns

Reposition(Opposite lateral, Knee-chest,


Trendelenberg

Relax

Remove Pitocin

Rehydrate

Reoxygenate (8-10 Liters via face mask)

Report to MD

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Nursing Care for Active Labor

Vital signs (temperature, pulse, respirations and blood


pressure)

Hydration (Oral intake and Intravenous intake)

Elimination (Encourage voiding q 2hr, pt may receive


enema)

Ambulation and positioning(Encourage ambulation if


possible, if not, position change q 30-60 mins, with side
lying position preferred)

General hygiene-Offer warm shower or bath possible.


Encourage women to wash hands after voiding and
perform self hygiene. Change linen as needed for soiled
pads and sheets

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Nursing Care for Active Labor

Leopolds Maneuvers

Amniotic membrane status(Document time, type, color,


amount, and odor. Temp q 2hr)

Vaginal exam(dilation, effacement, station, position,


and presenting part

Neurological exam(LOC, DTR, clonus)

Laboratory data(Urine specimen, CBC, type and screen)

Second Stage of Labor

Maternal

positioning- (Supine, semi


recumbent, or lithotomy)

Open-glottis

pushing( Encourage
women to push as they feel like
pushing which is instinctive,
spontaneous pushing)

Amnioinfusion

Treatment of variable decels during labor

Dilute meconium-stained fluid

Induction and Augmentation

Amniotomy
Nipple Stimulation
Prostaglandins
Oxytocin

Operative Vaginal Birth

Forceps

Vacuum

assisted

Cesarean Birth

Planned,
Surgical

unplanned, or elective

technique

Complications
Anesthesia

VBAC

Approximately
Vaginal

70%-80% success rate

delivery after cesarean criteria

One previous low-transverse cesarean birth

Clinically adequate pelvis

No hx of uterine rupture or uterine scars

MD immediately available

Anesthesia available

Obstetric Emergencies

Meconium-stained amniotic fluid

Shoulder dystocia

Prolapsed umbilical cord

Uterine Rupture

Amniotic fluid embolism