Transcript NURSING CARE OF MOTHER USING EFM

Nursing Care of Mother
Undergoing Electronic Fetal
Monitoring (EFM)
What is continuous
Fetal Monitoring ?
FM is a method of assessing
fetal status both before and during
labor. The fetal heart tones are
obtained and evaluated to identify
any abnormalities that can impact
fetal wellbeing. This evaluation
can be done at intervals by
intermittent
auscultation,
or
continuously by minute to minute
EFM.
This kind of fetal monitoring is an
electronic method of continuously
assessing the fetal heart rate and
obtaining information about the laboring
woman’s
uterine
activity
,
this
information is recorded on graph paper,
allows on ongoing minute to minute
assessment of fetal well being during
labor and provides a permanent record
for the medical chart.
1.Ante-partal risk factors
2. Intra-partal risk factors
*External FM
*Internal FM
*A combination
*EFM is also called indirect fetal
monitoring or noninvasive fetal monitoring.
*A ultrasonic transducer to monitor
the FHR.
*While the contraction pattern is
monitored with atocdynamometer both
are applied to the laboring woman’s
abdomen.
* The patient can be monitored
at any time.
* It is convenient
* Minimal training is required
* No fetal or maternal
complications are associated
with E.F.M.
* Direct FM.
* Invasive FM.
*FHR is monitored by the use of a helix
electrode which is applied directly to the
presenting part of the fetus.
* Contraction Pattern is monitored by the
use IUPC which is inserted directly into the
uterine cavity through the cervix.
* The helix can be used with breach or
vertex presentation. In VP the helix is
attached the fetal scalp. In BP the helix is
attached to the buttocks or feet to minimize
the risk of fetal injury.
*The face, fontanells suture lines, genitals
and rectum must be avoided during electrode
attachment.
*The IUPC is inserted through the cervix
beside the presenting part of the fetus.
*The IUPC is used to determine the actual
pressure inside the uterus during contraction.
3. A combination of
internal & external FM
*The FHR is monitored internally
by the use of a helix electrode
and contraction pattern is monitored
externally by the use of
tocodynamometer. Hwever,
the opposite also be used.
*Can be described as irregular
fluctuations in the baseline FHR of 2
cycles per minute or greater.
*Variability has been described as
short term (beat to beat) or long term
(rhythmic waves or cycles from
baseline).
Decreased variability can result from
fetal hypoxemia and acidosis, as well
as from certain drugs that depress the
CNS, including analgesics, narcotics,
barbiturates, tranquilizers, and general
anesthetics.
In addition, a temporary decrease in
variability can occur when the fetus is
in a sleep state. These sleep states do
not usually last longer than 30 minutes.
Increased variability can result from
early mild hypoxemia,
Fetal stimulation by the following:
*Uterine palpation
*Uterine contractions
*Fetal activity
*Maternal activity
*Street drug (e.g., cocaine and
methamphetamines)
Periodic and Episodic
changes in FHR
*Periodic changes occur with
uterine contractions.
*Episodic changes not associated with
uterine contractions.
These patterns include accelerations and
decelerations.
Abrupt increase in FHR above
the baseline rate. The increase is 15
beats per minute or greater and lasts
15 seconds or more.
Accelerations can be periodic or
episodic.
Periodic accelerations caused by
dominance of the sympathetic
nervous response and are usually
with breech presentation. Pressure of
the contraction applied to the fetal
buttocks results in accelerations,
whereas pressure applied to the head
results in decelerations
Accelerations of the FHR that are
episodic
occur
during
fetal
movement and are indications of fetal
well-being.
A Decelerations caused by dominance of
parasympathetic response may nonreassuring. Their relation to the onset
and end of a contraction and by their
shape.
1. Early deceleration of the FHR
Is a visually apparent gradual
decrease in and return to baseline
FHR in response to compression of
the fetal head. It is a normal and
usually benign finding.
This deceleration is characterized
by a uniform shape and an early
onset corresponding to the rise in
intra amniotic pressure as the uterus
contracts. When present, it usually
occurs during the first stage of labor
when the cervix is dilated 4 to 7 cm.
Early decelerations sometimes are
seen during the second stage when
the woman is pushing. They also
occur in response to fetal head
compression
during
uterine
contractions,
during
vaginal
examinations, as a result of fundal
pressure, and during placement of
the internal mode for FM.
2. Late deceleration of the FHR
Utero-placental insufficiency causes
late
deceleration
the
FHR.
The deceleration begins after the
contraction has started, and the lowest
point of the deceleration occurs after the
peak of the contraction. Usually the
deceleration does not return to baseline
until after the contraction is over.
3.
Variable
deceleration
A visual abrupt decrease in FHR
below baseline. The decrease is
usually more than 15 beats per
minute, lasts at least 15 seconds, and
usually returns to baseline in less
than 2 minutes from the time of
onset.
Variable decelerations occur any
time during the uterine contracting
phase and are caused by compression
of the umbilical cord.
NURSING CARE OF
MOTHER USING EFM
* Explain and demonstrate to mother
and labor support partner how the
electronic monitor (internal or
external) works in assessing FHR
and in detecting and assessing
quality of uterine contractions to
remove fear of unknown and ensure
that mother can work with the
monitor.
* When making adjustments to the
monitor, explain to the couple what is
being done and why because information
increases understanding and allays
anxiety.
* Explain that fetal status can be
continuously assessed even during
contraction.
* Explain that use of external monitoring
usually
requires
the
woman’s
cooperation during positioning and
movement.
* Provide rationale for
position
other
than
maternal
supine.
* Carefully follow guidelines and
checklist for application and initiation
of monitoring to ensure proper
placement of monitoring devices and
production of accurate output from
monitoring device.
•Check placement throughout
monitoring process to ensure that
devices remain correctly placed.
*
Auscultation
FHR
with
stethoscope
or
if in doubt as to validity of tracing.
*
* Regularly assess and record
results of EFM (FHR variability,
decelerations,
accelerations,
uterine
activity,
contractions,
uterine resting tone) to provide
consistent and timely evaluation
of fetal well-being and progress of
labor.
Auscultate FHR and palpate
contractions on a regular basis to
provide a cross-check on the EFM
output and ensure fetal well-being.
*
Documentation: Monitor Strip
Observations:
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Maternal vital signs
Maternal position/repositioning
Vaginal examinations and findings
Medications; anesthesia/analgesia
Voidings; emesis
Fetal movement, baseline FHR
Pushing/bearing down
Adjustments
• Relocation of transducers
• Flushing or adjustment of catheter
• Replacement of catheter
• Time lapsed while changing
monitor strip paper
Interventions
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Position Change
Parenteral fluids
Discontinuance of oxytocin
Oxygen administration
Notification of physician/CNM
Emergency measures
Implement immediately for
nonreassuring pattern:
* Reposition patient in lateral position
to increase uteroplacental perfusion
or relieve cord compression
* Administer oxygen at 10 to 12L/min
or per hospital protocol via face
mask
* Discontinue oxytocin if infusing
* Correct maternal hypovolemia by
increasing
IV
as
ordered
* Assess for bleeding or other
cause of pattern change, such as
maternal
hypotension
* Notify physician/ certified nurse
midwife
•
It is responsibility of the nurse
to assess FHR patterns, perform
independent
nursing
interventions, and report nonreassuring patterns to the
physician or nurse -midwife.
• The
emotional,
informational, and comfort
needs of the woman and her
family must be addressed
when the mother and her fetus
are
being
monitored.