EFM NCC Questions and Answers with Verified Solutions

EFM NCC Questions and Answers with Verified Solutions Why use fetal monitoring? ✔✔Primary goal is to prevent fetal and maternal morbidity and mortality (prevent injury and death to mother and/ or baby), to prevent bad ...

EFM NCC Questions and Answers with Verified Solutions Why use fetal monitoring? ✔✔Primary goal is to prevent fetal and maternal morbidity and mortality (prevent injury and death to mother and/ or baby), to prevent bad patient outcomes. What percent of babies who experience a suboptimal event while being fetal monitored, develop cerebral palsy? ✔✔3% of babies with poor tracing develop cerebral palsy What are most sentinel events due to? ✔✔Poor communication between providers. Most errors are traceable back to communication errors. Sentinel events ✔✔bad things that happen to patients due to a human or equipment error, and not due to the reason that they came into the hospital (disease process) Equipment ✔✔your hands (palpation) use fingertips, ultrasound transducer, FSE, tocodynamometer, Intrauterine Pressure Catheter, Auscultation (fetoscope, hand held doppler device). What if you can not get contractions? ✔✔palpate and readjust IUPC resting tone ✔✔20-25 IUPC resting tone with aminoinfusion ✔✔should not be above 40, troubleshoot if this is higher, weigh pads, make sure there is fluid return. Not meant for meconium or thick mec, they are used for variables or recurrent variables ✔✔amnioinfusion Auscultation tools ✔✔intermittent monitoring, use fetoscope or hand help doppler to trace. Only true auscultation tool ✔✔fetoscope, the reason is it is the only tool that listens to the open and close of the fetal heart valve Using the doppler or fetoscope ✔✔count the FHR before, during, and after a contraction. Document the baseline rate (range), regular vs irregular, increases or decreases. Do NOT document variability, accels, or decels doppler category 1 ✔✔normal FHR baseline, regular rhythm, presence of increases from FHR baseline, no decreases from baseline doppler category 2 ✔✔includes ANY of the following: irregular rhythm, presence of FHR decreases, tachycardia, bradycardia (i feel the need to intervene, I feel like I can't walk out of the room) doppler category 3 ✔✔there is none! auscultation because there is no variabile determination with auscultation goal of external EFM ✔✔external monitoring: goal is to detect fetal heart movement (efm) Autocorrelation ✔✔how the monitor adjusts with every third beat using a mathematical formula, that it is still monitoring this baby. Detected what is normal for this baby and is making the appropriate adjustments. What does the FSE measure? ✔✔Directly monitors R to R ratio (with scalp lead), definitively measures baby's heartbeat and when the heart is firing Narrow R-R interval ✔✔fetal tachycardia Prolonged R-R interval ✔✔fetal bradycardia FSE contraindications ✔✔communicable diseases: hepatitis and HIV Normal uterine activity ✔✔Normal activity: less than 5 ctx in a 10 minute period averaged over a 30 minutes period (5,5,6 OK but 6,5,6 NOT OK) Excessive uterine activity ✔✔Tachysystole (not hyperstim), hypertonus (with IUPC resting tone does not go below 20 mmHG-IUPC, 20-25mmhg shouldn't be higher..if higher usually due to inadequate relation time), inadequate relaxation time, tetanic contractions(cxn greater than 2 minutes) What do you do with tachysystole? ✔✔turn down pitocin (reposition etc) Reduce blood flow through the intervillous space ✔✔Mild Contractions (30 mmHG) No blood flow through the intervillous space ✔✔Moderate Contractions (50 mmHG) Adequate MVUS ✔✔200-300...greater than 200, spontaneous labor less than 280 for the first stage but up to 400 for the second stage. Typically less than 300 (so 200-300). Importance of doing multiple interventions sooner than later ✔✔you see tachysystole or deceleration, turn pitocin off & IV bolus & resposition. Multiple interventions are important. Why would it be in your best interest to bolus, turn off pit, and reposition? ✔✔will resolve tachysystole and decelerations faster Troubleshooting tips? ✔✔check cables, check connections (avoid wrapping too tightly), check patient position/ fetal position, palpate abdomen, check maternal pulse, listen to maternal hr vs fetal hr, run the monitors self test feature, document what you did! Monitoring patients FHR, after assessment done for admission, you see FHR that is tracing 90 for the last 30 minutes. What would you do? ✔✔Verify maternal HR. If bradycardic tracing, always verify maternal heart rate Patient who comes in ruptured with decreased FM. Can not get HR with US, FSE shows HR is 80. What do you do? ✔✔Request bedside ultrasound. Can get maternal tracing through FSE with fetal demise TOCO variations ✔✔We don't want to see maternal breathing, maternal vomiting, maternal pushing, fetal activity, inverted contractions. Always palpate and readjust.If vomiting is seen, make a note Quick spikes on TOCO? ✔✔can be fetal movement or vomiting Three fetal shunts? ✔✔V.O.A (venosus, ovale, arteriosis). blood goes from most oxygenation to least oxygenation Takes highly oxygenated blood, bypassess the liver, to the IVC and the R atrium) ✔✔ductus venosis Bypassess the lungs, moves blood from the R atrium to the L atrium ✔✔Foramen Ovale Moves blood from the pulmonary artery to the aorta to the rest of the body. Fetal blood LEAST oxygenated, point where fetal blood is least oxygenated ✔✔Ductus Arteriosus Transfer of oxygen from mom (the environment) to the fetus through organs and adaptations special for pregnancy (extrinsic factors) ✔✔Fetal oxygenation Extrinsic factors ✔✔Outside baby's belly button! Maternal influences (lung disease, chronic conditions, drugs), umbilical cord, amniotic fluid characteristics, uterus, placenta Intrinsic factors ✔✔anything bellybutton IN Oxygen transport, fetal circulation (SA Node), fetal nervous system (baroreceptors which respond to pressure-sudden, chemoreceptors which Co2 responds/ its chemical and takes longer to develop, and hormones), fetal reserves During NST is it ok to try and do fetal scalp skim to get accelerations? ✔✔YES. but NEVER do scalp stim if baby os bradycardic or already in a deceleration What causes early decelerations? ✔✔stimulus of the vagus nerve Responsible for variable decelerations? ✔✔Baroreceptors Responsible for late decelerations? ✔✔Chemoreceptors Where does Umbilical veIN carry blood? ✔✔carries oxygenated blood from the placenta to the fetus (IN with oxygen) Where does Umbilical Arteries carry blood? ✔✔Carry waste products away from the fetus to the placenta (Away with waste) If a baby only has one artery they can only take out half the Co2 build up. They have a higher chance of developing co2 build up, development of respiratory acidosis, and late decelerations Affinity of fetal hemoglobin for oxygen ✔✔Fetal blood has a higher Hgb concentration than adult blood allowing for greater O2 carrying capacity, They have a higher affinity, able to attract more red blood cells / hgb than adult blood. Why does fetus have a higher HR than an adult? ✔✔Fetus has a higher cardiac output and HR than an adult, resulting in more rapid circulation Fight or flight. Nerves fibers from the sympathetic branch are widely distributed through the heart. Stimulates catecholamine release (like norepinephrine) ✔✔Sympathetic nervous system Primary function of sympathetic nervous system ✔✔INCREASE FHR, more developed in preterm babies When babies detect insult to their o2 status, or are stressed out they release catecholamines, increase HR to do more with less. First prenatal visits FHR may be in the 180s, 26 weeks also have high HR. In preterm babies sympathetic nervous system is dominate Rest & digest, calm, chill. Originates in the medulla oblongata, resides in the vagus nerves, innervates the SA and AV node of the heart ✔✔Parasympathetic nervous system Primary function of parasympathetic nervous system ✔✔DECREASE FHR baseline. More dominant in full term or post term babies, as it takes longer to develop in pregnancy. This is why FHR is lower at this gestational age Interplay between the parasympathetic and the sympathetic nervous system, tug and pull, give and take ✔✔Variability Detect pressure changes, elicit a sudden response. Variable bottoms out a HR due to increased cord pressure. Always cause variables ✔✔Baroreceptors Due to the buildup of CO2, regulating respiratory activity. Always cause late decelerations. Takes longer for the chemoreceptor cascade to develop compared to baroreceptor. Elicits a decrease in FHR (late) usually delayed in timing. Co2 builds, and builds, and builds. That's why you need to intervene after just one late, there already is a high co2 build up. Intrinsic factor responsible for lates ✔✔Chemoreceptors The only way a fetus can increase cardiac output ✔✔Increasing their HR, CO is rate dependant, babies only have control over HR when they are stressed out pH is less than 7.2 (ABNORMAL) PCO2: greater than 60 (ABNORMAL) BD/BE is less than -12/12 ✔✔respiratory acidemia pH is less than 7.2 (ABNORMAL) pCO2 is less than 60 BD/BE is greater than -12/12 (ABNORMAL) Reflects a recurrent or prolonged disruption in fetal oxygenation that has resulted in tissue metabolism, anaerobic metabolism, and lactic acid production ✔✔metabolic acidemia pH 7.2 or higher PCO2: less than 60 Base Deficit (BD) or Base Excess (BE): less than -12/12( negative or positive doesn't matter, just less than 12) ✔✔NORMAL Mixed acidemia ✔✔everything is abnormal Category 1 fetal heart rate ✔✔normal FHR baseline, moderate variability, lack of concerning decelerations → continue monitoring :) Moderate variable, no variables or lates, or minimal/ marked variability Early decelerations are ok Category 2 fetal heart rate ✔✔FHR patterns are concerning enough to warrant increased frequency in monitoring, but that respond to the following interventions: d/c oxytocin, reposition, fluid bolus. 80% of strips are category 2 Minimal variability late/ variables Category 3 fetal heart rate ✔✔HAS TO BE ABSENT. absent FHR variability, with recurrent lates or variable decelerations/ with bradycardia, or with sinusoidal pattern (d/t prolonger hypoxia, fetal maternal hemorrhage) . Need to d/c oxytocin and expedite delivery!!!!! Absent variability with recurrent lates/ variables Absent variability with bradycardia Sinusoidal Fentanal: causes cxns to space, and the baby looks asleep. Continue to monitor, don't need to stop pit Can cause a sinusoidal appearing/like tracing. Recognize this and continue to monitor ✔✔Stadol Causes cxns to space, and the baby looks asleep. Continue to monitor, don't need to stop pit ✔✔Fentanal FHR baseline ✔✔Mean FHR rounded to the nearest increment of 5 during a 10 minute window excluding accels, decels, or periods of marked variability. 110-160. You need 2 of the 10 minutes to be the baseline value (2 minutes don't have to be next to each other), but if there are not 2 minutes of interpretable baseline it is indeterminate. Indeterminate baseline: marked variability, and less than 2 minutes of consistent HR value Happens with contractions, predictable (lates, earlys) ✔✔Periodic Are independent of contractions (variables, accelerations), random. Not associated with contractions ✔✔Episodic Fetal arrhythmias ✔✔Irregular heart rhythm can cause cardiac output disruption. Tachycardia and bradycardia is an arrhythmia. Most are benign, most resolve with delivery with the closure of the PDA. Treatment of arrhythmia after delivery: baby will be evaluated, but most arrhythmias require not fetal intervention after delivery Two categories: R-R interval variation (too fast or too slow) & disorder impulse control (abnormal beat, distorted QRS complex) How to diagnose fetal arrythmias? ✔✔Fetal echo, can't diagnose with EFM; May be no consequences, hydrops, or fetal death Less than 110 for more than 10 minutes (maternal drug use can slow FHR) ✔✔Bradycardia What medications speed up FHR? ✔✔Terbutaline/brealthine (beta sympathetic drug) can cause an increase in maternal HR and FHR. HR greater than 160 bpm for 10 minutes ✔✔Fetal tachycardia What can cause an irregular fetal rhythm? ✔✔maternal caffeine, nicotine, alcohol Much higher risk of developing a baby with fetal arrhythmias & anomalies (d/t the cause of the maternal antibody release) ✔✔Moms with autoimmune disease (RA, lupus) Cause for concern, 2nd most common cause of tachycardia (after a fever), associated with wolff parkinsons white syndrome, HR 210-260, may be reentry due to multiple pathways, the FHR monitor may half the FHR (half counting). Increase in fetal oxygen consumption during labor, less oxygen reserve to accommodate stress. Cannot meet oxygen reserve that leads to heart failure( not a working pump). Blood doesn't get pumped out to the body and back up into the lugs. Non immunologic hydrops is fluid in the fetal scalp, abdomen, liver, and spleen which can cause fetal death ✔✔Supraventricular tachycardia (SVT) Congestive HF in fetus is equal to ✔✔HYDROPS SVT treatment ✔✔digoxin, or other beta blockers (-olo) Heart block (fetal) 1st degree ✔✔resolve Heart block (fetal) 2nd degree blocks ✔✔Associated with maternal collagen diseases/ autoimmune (RA, lupus, Sjogrens, Scleroderma). ANti SSA and Anti SSB antibodies cross the placenta, latch on the the fetal AV node. Treat with STEROIDS! BMZ Heart block (fetal) 3rd degree block ✔✔(no talking between atrium and ventricle). Usually a structured defect, CMV & aPL syndrome, usually leads to cardiomyopathy, bradycardia, may add beta drugs to increase HR (beware monitor half counting). Pacing is TREATMENT Vibroacoustic stim ✔✔Can be used during NST, try and place the transducer where you think the baby's head is. Sound can be administered 3x no more than 3 seconds (Fetal Acoustic Stimulation Test), no benefit before 26 weeks baby cant hear yet NST ✔✔Two 15x 15 accels in 20 minutes once greater than 32 weeks gestations Two, 10x 10 accels in 20 minutes if less than 32 weeks gestations May be extended to 40 minutes to accommodate possible fetal sleep If normal AFI, reactive NST indicates fetal well being 99% of the time If you can get reactive stress test, do BPP BPP ✔✔30 minute test, no standard for when to start testing (usually after 24 wks), may be more than once a week 10/10 AFI: 6-25 rate, breathing, movement, tone, amniotic fluid Real Baby Mommas Take Alfalfa ✔✔R: Rate B: Breathing M: Movement T: Tone A: Amniotic Fluid (order in which BPP disappears if baby gets compromised/ poor O2) in order from first to disappear to last to disappear NST is preferable as a test to fetal well being (no pit, no IV, non invasive, can do in office, etc) ✔✔Contraction stress test Maternal perception usually 16-20 weeks, no one agreed upon measure (10 in 2 hours) just make sure you are educating patients if they leave about fetal activity and movement. Do it everyday at the same time everyday. Do not give mom juice for fetal activity! ✔✔Fetal kick counts When is fetal sleep the longest? ✔✔in 3rd trimester ( parasympathetic system) Hypertensive disorders of pregnancy ✔✔Chronic HTN gestational HTN Preeclampsia Eclampsia HELLP Most common complication of pregnancy Protein in urine ✔✔Preeclampsia High risk pregnancies ✔✔Diabetes, multiple gestation, preterm issues, AMA,postdates after 42 weeks, placenta disorders, previous surgeries..changes in FHR earliest sign of uterine rupture!! (change in baseline...bradycardia, variability, decelerations). Earliest sign of uterine rupture? ✔✔changes in FHR earliest sign of uterine rupture!! (change in baseline...bradycardia, variability, decelerations). New onset pain in anyone with uterine surgery/ past CS, you should be worried. ANY pain, even if in shoulder. Physical assess patient Cords when attached to placenta..connection is sloopy. Vessels grow into the amniotic sac. When the bag breaks, the vessels spurt blood into the abdomen. If water breaks, they should have bright red blood immediately. High morbidity and mortality rate for babies (causes change in HR and immediate bleeding) ✔✔Vasa Previa Conflict resolution/ chain of command ✔✔Don't be afraid to institute chain of command. Rephrase and restate concerns. Evidence based practice is effective with patient care, doing things that have been show to make patient outcomes Documentation should be.. ✔✔Terminology Timely (high risk vs low risk) Up to standard Compassion, take positive actions to help others and follow through on the desire to do good..to do good for the patient ✔✔Beneficence Remain confident in the field and report suspected abuse ✔✔Nonmalenficence Keep commitments based on virtue of caring ✔✔Fidelity Respect patients wishes, even when you don't agree ✔✔Autonomy Treat all patients fair and equal ✔✔Justice Consider the entire person when deciding which treatments a patient should receive ✔✔Principles of totality and integrity