Question

1.Examine the measures used to evaluate maternal status during labor and birth.

2.Define methods of monitoring fetal status during low-risk labor and birth.

3.Outline the nurse’s role in fetal assessment.

Answer 1

1.Answer :-The measures used to evaluate maternal status during labor and birth are as follows:- During prenatal care, the clinician and patient will discuss common events and procedures in labor, including methods of assessing fetal well-being.

Admission to Labor and Delivery:-The responsible clinician or nurse shall evaluate the patient, enter a note, and provide orders within two hours of his or her patient arriving at the Labor and Delivery unit.

The clinician or designee shall examine the patient before prescribing initial therapy with tocolytic agents in the second or third trimester. Documentation should include presumptive diagnosis, possible causes, and that informed consent has been obtained.

If the patient is not in active labor, and is low risk, i.e.:

(a)37–416/7 weeks gestation

(b)estimated fetal weight appropriate for gestational age

(c)has a Category I electronic fetal monitoring strip on admission, or a reassuring auscultation

(d)absence of meconium

(e)vertex presentation

(f)absence of any medical or obstetrical complications Then, initial assessment can be delayed until:

(*)a risk factor is identified.

(*)the patient enters active labor.

(*)the patient requests pain medication.

INITIAL EVALUATION BY CLINICIAN IN LABOR AND DELIVERY:-The clinician’s initial evaluation and documentation in Labor and Delivery shall include, at a minimum:

(a)reviewing the patient’s prior pregnancy(s).

(b)reviewing and summarizing the antenatal course;

(c)physical exam (including an estimated fetal weight);

(d)evaluation of status of labor, including a description of uterine activity, cervical dilation and effacement, and fetal station and presentation, unless vagin@l exam deferred;

(e)evaluation of fetal status, including interpretation of auscultation or electronic fetal monitoring strips, if generated; and

(f)the plan for delivery.

Fetal status must be assessed on every patient who is evaluated or admitted in a triage unit. This should be performed without delay for any fetus of 24 or more weeks. A recording of fetal heart rate (FHR) and uterine contractions is advised until categorization of the FHR tracing is determined. If a Category I pattern cannot be obtained in a reasonable time frame, continued evaluation should proceed.

First Stage of Labor After Initial Evaluation:-For a patient without complications, continuous FHR monitoring is not required if the initial FHR tracing exhibits a Category I tracing.

“Categorization of the FHR tracing evaluates the fetus at that point in time; tracing patterns can and will change. An FHR tracing may move back and forth between categories depending on the clinical situation and management strategies employed.”

Fetal heart rate (and variability—if electronically monitored) should be evaluated and recorded at least every 15–30 minutes, depending on the risk status of the patient, during the active phase of labor).2,3 The FHR should be evaluated as soon as is feasible after spontaneous rupture, or immediately after artificial rupture of the membranes.

Continuous fetal heart rate monitoring should be done for patients with any of these indicators:-

(A)history of an abnormal antepartum FHR or rhythm,

(B)breech presentation,

(C)history of prior cesarean delivery,

(D)multiple gestation,

(E)nonreassuring fetal assessment,

(F)significant maternal illness,

(G)use of oxytocin,

(H)abnormality of active or second stage labor,

(I)thick meconium, or

(J)heavy vagin@l bleeding.

Electronic fetal monitoring is also preferred when auscultation is not feasible. Once continuous electronic fetal monitoring is chosen and initiated, a technically satisfactory and continuous tracing should be achieved. If this cannot be accomplished, the reasons must be documented and an alternative plan for fetal assessment must be developed.

In the event of a Category III FHR tracing, the attending clinician or his or her designee shall promptly evaluate the fetal status and initiate efforts to resolve the abnormal FHR pattern. If corrective measures are not successful, preparations for delivery will be initiated.

An amnioinfusion may be considered when persistent variable decelerations are seen on the FHR tracing.

Evaluation During First Stage Labor:-The patient shall be evaluated by the responsible clinician or designee during labor at appropriate intervals. Each evaluation should include:

(A)assessment of maternal status;

(B)description of uterine activity;

(C)assessment of fetal status;

(D)description of findings on vaginal exam, if performed, including cervical dilation and effacement, fetal station, change in status of membranes, and progress since last exam;

(E)summary of maternal and fetal status; and

(F)plan, including plans for or performance of clinical interventions and pain management.

(G)Each evaluation should be recorded in the medical record.

Evaluation During Second Stage Labor:-The monitoring clinician should document in the medical record at the time of identification of second stage, after two hours of second stage, and hourly thereafter. This documentation, which should be dated and timed, should include, at a minimum:

(A)assessment of maternal status;

(B)assessment of fetal status;

(C)description of uterine activity;

(D)fetal station and, if known, position; and

(E)assessment of progression and a plan for delivery.

(F)Fetal heart rate should be evaluated and recorded at least every 5–15 minutes, depending on the risk status of the patient.2,3

In the event of a Category III FHR tracing, the attending clinician or his or her designee shall promptly evaluate the fetal status and promptly initiate efforts to resolve the abnormal FHR pattern. He or she may consider obtaining another opinion about the fetal status.

No later than the end of the second hour of the second stage of labor, and every hour thereafter, the attending physician or midwife should personally evaluate the patient and document in the medical record the minimum as noted above. Additionally, the providers involved (which may include the attending physician, resident, nurse midwife, RN, and/or charge nurse) shall discuss the patient’s progress and plan of care at each hourly interval.

Delivery:- If a patient is moved to another room for delivery, fetal monitoring should be established in that room unless delivery is reasonably expected to occur imminently. For patients about to undergo cesarean delivery, monitoring should continue as is feasible until abdominal preparation for surgery is begun.

When the delivering clinician is concerned about the fetal status at delivery, a double-clamped segment of the umbilical cord should be set aside for possible arterial blood gas assessment. If the neonatal 5-minute Apgar score is 5 or less4, or if requested by the delivering or newborn provider, umbilical artery blood should be sent for analysis whenever possible. Blood can be drawn from the clamped segment of cord at any time within an hour of delivery.

After Delivery:-Following delivery, the clinician must record in the medical record all the events relating to the delivery in a reasonable period of time after the patient’s needs have been fully attended to, using forms, notation, and/or dictation as appropriate to the case. The clinician should be readily available to return to the unit until the immediate (30 minute) postpartum period is complete and the patient is stable.

2.Answer:- methods of monitoring fetal status during low-risk labor and birth.:-

Fetal heart rate monitoring is the process of checking the condition of your fetus during labor and delivery by monitoring your fetus's heart rate with special equipment.

Purpose of doing fetal heart rate monitoring done during labor and delivery:-

Fetal heart rate monitoring may help detect changes in the normal heart rate pattern during labor. If certain changes are detected, steps can be taken to help treat the underlying problem. Fetal heart rate monitoring also can help prevent treatments that are not needed. A normal fetal heart rate can reassure both you and your obstetrician–gynecologist(ob-gyn) or other health care professional that it is safe to continue labor if no other problems are present.

types of monitoring are :-There are two methods of fetal heart rate monitoring in labor. (1)Auscultation monitoring, (2) electronic fetal monitoring

(1)Auscultation monitoring:-Auscultation is a method of periodically listening to the fetal heartbeat. Electronic fetal monitoring is a procedure in which instruments are used to continuously record the heartbeat of the fetus and the contractions of the woman's uterus during labor. The method that is used depends on the policy of your ob-gyn or hospital, your risk of problems, and how your labor is going. If you do not have any complications or risk factors for problems during labor, either method is acceptable.

auscultation procedure:-Auscultation is done with either a special stethoscope or a device called a Doppler transducer. When the transducer is pressed against your abdomen, you can hear your fetus's heartbeat.

When auscultation is used, your ob-gyn or other health care professional will check the heart rate of the fetus at set times during labor. If you have risk factors for problems during labor or if problems appear during labor, the fetal heart rate will be checked and recorded more frequently.

(2.)Electronic fetal monitoring :-Electronic fetal monitoring uses special equipment to measure the response of the fetus’s heart rate to contractions of the uterus. It provides an ongoing record that can be read. Your ob-gyn or other health care professional will review the electronic recording of the fetus’s heartbeat (called the fetal heart rate tracing) at set times. The tracing may be reviewed more frequently if problems arise.

Types of electronic fetal monitoring are:-Electronic fetal monitoring can be external, internal, or both. You may need to stay in bed during both types of electronic monitoring, but you can move around and find a comfortable position.

(a)external monitoring:-With this method, a pair of belts is wrapped around your abdomen. One belt uses Doppler to detect the fetal heart rate. The other belt measures the length of contractions and the time between them.

Internal monitoring:-With this method, a wire called an electrode is used. It is placed on the part of the fetus closest to the cervix, usually the scalp. This device records the heart rate. Uterine contractions also may be monitored with a special tube called an intrauterine pressure catheter that is inserted through the vagin@ into your uterus. Internal monitoring can be used only after the membranes of the amniotic sac have ruptured (after "your water breaks" or is broken).

3. Answer :-

Furtheraction of nurse if the fetal heart rate pattern is abnormal:-

Abnormal fetal heart rate patterns do not always mean there is a problem. Other tests may be done to get a better idea of what is going on with your fetus.

If there is an abnormal fetal heart rate pattern, your ob-gyn or other health care professional will first try to find the cause. Steps can be taken to help the fetus get more oxygen, such as having you change position. If these procedures do not work, or if further test results suggest your fetus has a problem, your ob-gyn or other health care professional may decide to deliver right away. In this case, the delivery is more likely to be by cesarean birth or with forceps or vacuum-assisted delivery.