11/30/2020 Fetal Assessment - Learning Stream

11/30/2020Maternal-Fetal Assessment If the nurse cannot clinically evaluatethe effects of medication at least every15 minutes or if a physician who hasprivileges to perform a cesarean is notreadily available The oxytocin infusion should bediscontinued until that level of carecan be provided ACOG, 2009; Simpson, 2020, p. s16AWHONN 2018 Position Statement: Fetal HeartMonitoring Assessment of fetal status with oxytocin Latent phase: every 15 minutes Active phase: every 15 minutes Second stage with passive fetal descent Every 15 minutesFetal Assessment High-risk fetal assessments (evaluate/review) First stage of labor Every 15 minutes Second stage of labor Passive fetal descent phase Every 15 minutes Active pushing phase Every 5 minutes Document according to unit protocols Simpson, 2020, p s13Fetal Status Second Stage Continuous bedside attendance during pushing efforts isrecommended During the active phase of pushing, summary documentation of fetalstatus every 15 to 30 minutes indicating there was continuous nursingbedside attendance and evaluation is reasonable Simpson, 2020, pp. s13-14 Second stage with active pushing Every 5 minutes*Frequency of assessment should be determined based on status of mother andfetus and at times may need to occur more often based on clinical needs1

11/30/2020FHR Patterns Assess and respond to the FHRpatterns Observe the evolution of fetal heart ratepatterns over time Be on the watch for these patterns Absent variability with recurrent latedecelerations Absent variability with recurrentvariable decelerations Absent variability with fetal bradycardiaGravida 1, Para 0, 40 ½ weeksPitocin at 6 mu/minExternal toco, FSE2

11/30/2020Recurrent variable decelerations with absent variabilityLate decelerations with absent variabilityAssess and Respond toUterine Activitythe Generally, uterine activity is assessed atthe same frequency as the FHR Simpson, 2020, p. s13Gravida 2, Para 1, 38 ½ weeksTrail of Labor after Cesarean in spontaneous labor6 cm, 100%, -3External toco, FSE3

11/30/20201120 Complete, 100%, 2Coupling of contractionsIUPCCoupling and TriplingContractionsof May be seen during oxytocin administration Suggested treatment is Temporary discontinuation of oxytocin Lateral positioning Initiation of a fluid bolus Restart of oxytocin after 30 minutes or more Miller, Miller, & Cypher (2017) p. 96Coupling and Triplingof Contractions May occur with further increases in oxytocin rates Due to excessive oxytocin and oxytocin receptor site desensitization It is a myth that these types of patterns are best treated by increasingthe oxytocin rate (referred to as “Pit’ing through the pattern”) Simpson, 2020, p. s234

11/30/2020Coupling and TriplingContractionsof Management of these patterns Reduce or discontinue the oxytocinuntil uterine activity returns to normal Often a 30-minute to 1-hour restperiod with IV fluid bolus of LR will help Simpson, 2020, p. s23The Nurse Should Know, Assess for, andRespond toPotentialComplications Uterine tachysystole Fetal heart rate changes Uterine rupture Hyponatremia (water intoxication) HypotensionVital Signs Should be recorded at least every 4 hours Perinatal Guidelines (2017, p. 239) Depends upon what else is going on epidural analgesiaruptured membraneselevated temperatureelevated blood pressureEtc. Follow hospital protocol/policy/procedureTachysystole Defined by NICHD as frequency of contractions greater than 5 in 10 minutes averaged over a 30 minute window Don’t forget about duration, intensity and resting tone Example next slide 5

11/30/2020NICHD 2008 UpdateDescribe Uterine ActivityTerminology to Normal Less than or equal to 5 contractions in10 minutes, averaged over a 30 minutewindow Tachysystole Greater than 5 contractions in 10minutes, averaged over a 30-minutewindowNICHD 2008 Uterine Activity The terms hyperstimulation andhypercontractility are not defined andshould be abandoned .NICHD 2008 Uterine Activity Characteristics of uterine contractions Tachysystole should always be qualified as to the presenceor absence of associated FHR decelerations The term tachysystole applies to both spontaneous orstimulated labor The clinical response to tachysystole may differdepending on whether contractions are spontaneousor stimulatedExcessive Uterine Activity:Miller, Miller, & Cypher 2017, p. 87TachysystoleGreater than 5 contractions in 10minutes, averaged over 30 minutesExcessive contractionduration (also known astetanic contractions;uterine tetany)A single series of contractions lasting2 minutes or moreHypertonusResting tone greater than 20-25 mmHgwith an IUPC or a uterus that does notreturn to soft by palpation betweencontractionsInadequate relaxation timebetween contractionsFirst stage: less than 60 secondsSecond stage: less than 45 seconds6

11/30/2020Affect of Contractions on the FetusREMEMBER THIS! What Does ResearchTell Us? Uterine contractions result in Intermittent diminished blood flow to the intervillous space Where oxygen exchange occurs Most healthy fetuses tolerate this intermittent diminishedblood flow If this intermittent interruption of blood flow exceeds acritical level over time There is a risk for potential deterioration of fetal acid-baseSimpson (2020), p. s23What’s Missing From the2008 Definition?Limited to no exchange of O2 and CO2Reduced exchangeNICHD Duration of contractions What’s too long? Intensity What’s too strong? Resting tone What is too high?7

hysystole More than 5 contractions in 10 minutes averagedover 30 minutes Contractions lasting 2 minutes or more Insufficient return of uterine resting tone betweencontractions via palpation or intraamniotic pressureabove 25 mmHg between contractions via IUPC Simpson, 2020, p. s 23; s37The tracing continued like this for 30 minutesPatient is 2 cm with an IUPCNotice how the contractions aresquaring off at 100 mmHg?8

11/30/20201720What about the resting tone with an IUPC?Suggested Clinical ProtocolInduced Tachysystolefor Oxytocin- With normal FHR Lateral repositioning IV fluid bolus of at least 500 ml LR as indicated If uterine activity has not returned to normal after 10-15minutes Decrease oxytocin rate by at least half If uterine activity has not returned to normal after10-15 more minutes discontinue oxytocin until uterine activity isnormal Simpson, 2020, p. s25Sample Oxytocin Checklist9

11/30/2020Suggested Clinical Protocol for OxytocinInduced TachysystoleACOG (2010) Management of Uterine TachysystoleSpontaneous LaborLabor Induction or Augmentation With Indeterminate or Abnormal FHR Discontinue oxytocinLateral positioningIV fluid bolus of at least 500 mL of LR as indicatedConsider oxygen at 10 L/min via nonrebreather facemask Discontinue as soon as possible based on fetal rate pattern If no response, consider 0.25 mg terbutaline,subcutaneouslyCategory I TracingCategory II or III TracingNo InterventionsRequiredIntrauterine resuscitativemeasuresIf no resolution,consider tocolyticCategory I TracingDecrease uterotonicsCategory II or III TracingDecrease or stop uterotonicsIntrauterine resuscitativemeasures Simpson, 2020, p. s25If no resolution,consider tocolyticFrom American College of Obstetricians and Gynecologists (2010). Management of Intrapartum FetalHeart Rate Tracings. Practice Bulletin #116. Washington, DC: ACOG. Page 6Tachysystole “Waiting to respond to excessive uterine activity until there aresignificant changes in fetal heart rate is not appropriate” “To prevent fetal acidemia at birth, .focus on identifying andpromoting normal (adequate) uterine activity and correctingunderlying causes of any type of excessive uterine activity” Miller, Miller, & Cypher (2017, p. 87)Interventions forTachysystoleOxytocin-Induced Simpson & James (2008), found thatsimultaneous initiation of all threeinterventions resolved oxytocin-inducedtachysystole more rapidly than when usedindividually10

11/30/2020Interventions forTachysystoleOxytocin-InducedOxytocin discontinuationResolution 14.2 minutesOxytocin discontinuationplus IV fluid bolus of atleast 500 mL LRResolution 9.8 minutesOxytocin discontinuationplus IV fluid bolus of atleast 500 mL LR pluschange to lateral positionResolution 6.1 minutesOxygen and Oxytocin When oxygen is chosen for intrauterineresuscitation Oxytocin should not be infusingconcurrently with maternal oxygenadministration AWHONN, 2015, p. 175Simpson, 2008, p. 31; Simpson & James, 2008Oxygen and OxytocinAWHONN Oxygen “If there is a concern for fetal-well-being, simultaneousadministration of oxygen and oxytocin does not make sense in thecontext of minimizing stress to the fetus.” Based on research, withholding oxygen from mothers in labor whenthe FHR pattern is indeterminate or abnormal to prevent possibleadverse effects of oxygen-free radicals is NOT recommended Simpson, K. R. (2015) AWHONN, 2015, p. 17511

11/30/2020Oxygen forIntrauterine Resuscitation aspresented previously ACOG12

11/30/2020Pitocin is running at 5 mu/min.What would you do here?1120 Complete, 100%, 2IUPCWould you keep pitocin running here?What else would you do?13

More than 5 contractions in 10 minutes averaged over 30 minutes Contractions lasting 2 minutes or more Insufficient return of uterine resting tone between contractions via palpation or intraamniotic pressure above 25 mmHg between contractions via IUPC Simpson, 2020, p. s 23; s37 The tracing continued like this for 30 minutes .