Summary

Class,

As you can see from the videos, rapid intervention is the key to avoiding or minimizing adverse outcomes for the newborn. There a several nursing interventions that can be instituted when bradycardia or other non reassuring fetal heart patterns are identified. They include the following:
1. Apply oxygen via face mask at 8-10 liters/minute to the mother
2. Turn patient on her left side to maximize blood flow to the placenta
3. Turn off a pitocin drip if one is running
4. Open the IV for hydration
5. Most importantly - Notify the physician!!!

Be sure to document the fetal heart tracing as you see it, describing it accurately. Be sure to include the baseline FHR, variability, any accelerations or decelerations, describe the depth and duration of the decelerations, and relationship to the contractions. Be sure to document all communications with physicians.

Please post your final thoughts and comments. I will return again with another blog to continue on our quest to ensure obstetric safety for all mothers and babies.

Hope you all enjoy the video.


http://www.youtube.com/watch?v=RP4abiHdQpc&feature=related

Fetus at Risk for Metabolic Acidemia

Class,
I am posting part 2 of the video on fetal heart rate monitoring. This is a seven and one half minute video that discusses the importance of intervention when fetal bradycardia occurs. The longer the delay in delivery when bradycardia occurs the more chance for an infant to be born with a metabolic acidemic. There is an increase risk for severe fetal injury the longer there is a delay to delivery.

Please post your questions and remarks after viewing the video.

Click on the link below to view.

http://www.youtube.com/watch?v=BXg13t97zfI&feature=related

Fetal Response to Interrupted Oxygenation

Class,

In my last posting, I discussed the environmental causes of interrupted oxygenation to the fetus. This post we will discuss the fetal response to interrupted oxygenation. What information can the fetal heart tracing provide regarding transfer of oxygen?

Interruption of the pathway of oxygen transfer from the environment to the fetus caused by compression of the umbilical cord can result in a variable deceleration.

Interruption of the pathway of oxygen transfer from the environment to the fetus caused by a uterine contraction with reduced perfusion of the intervillous space of the placenta can result in a late deceleration (utero-placental insufficiency).

Interruption of the oxygen pathway at any point can result in a prolonged deceleration.

What do we know about the fetal response to interrupted oxygen transfer?

The fetal response to interrupted oxygenation follows this pathway:

FETUS

↓

HYPOXEMIA

↓

HYPOXIA

↓

METABOLIC ACIDOSIS

↓

METABOLIC ACIDEMIA

↓

POTENTIAL INJURY

Please think about some of the potential injuries you might see with progressive interrupted oxygenation to the fetus and post your response.

Physiology of fetal oxygenation

Fetal Oxygenation Pathway

Class,

In order to understand the fetal response to the lack of oxygenation, you need to understand the oxygenation pathway to the fetus. Oxygen is transferred from the environment to the fetus by maternal and fetal blood along a pathway that includes the maternal lungs, heart, vasculature, uterus, placenta, umbilical cord, and fetus.

ENVIRONMENT

↓

MATERNAL LUNGS

↓

HEART

↓

VASCULATURE

↓

UTERUS

↓

PLACENTA

↓

UMBILICAL CORD

↓

FETUS

Summary of the Oxygen pathway and causes of interrupted oxygen transfer

Oxygen Pathway	Causes of interrupted oxygen transfer
Lungs	Respiratory depression (narcotics, magnesium sulfate) Apnea, seizures (eclampsia) Pulmonary embolus, pulmonary edema Pneumonia, ARDS Asthma, atelectasis
Heart	Decreased cardiac output Hypovolemia Compression of the inferior vena cava Regional anesthesia (sympathetic blockade) Cardiac arrythmias
Vasculature	Hypotension Hypovolemia Compression of the inferior vena cava Regional anesthesia(sympathetic blockade) Medications (hydralazine, labetalol, nifedipine)
Uterus	Excessive uterine activity Uterine stimulants (prostaglandins, oxytocin) Uterine rupture
Placenta	Placental separation Rarely vasa previa Rarely fetal-maternal hemorrhage Placental infarct, infection (usually confirmed retrospectively)
Umbilical cord	Cord compression Cord prolapse “True” knot

Please post your comments and questions.

Next module, I will be discussing the fetal response to interrupted oxygenation.

Miller, L. (2008). Electronic fetal monitoring. HANYS Obstetric Safety Initiative. Train the trainer power point presentation.

Perinatal SBAR

 Perinatal SBAR Tool

Class,

As you have seen from the video, communication with all members of the healthcare team is critical when minutes count. It is essential that communication is clear and accurate when reporting the events around a non reassuring FHR tracing.

The SBAR (Situational – Background – Assessment – Recommendation) technique provides a framework for communication between members of the health care team about a patient’s condition. SBAR is easy to remember and is useful in any conversation, especially critical ones, that require immediate attention and action. It is an easy and focused way to set expectations for what will be communicated and how the information is communicated between team members which is essential for developing team work and fostering a culture of safety.

I am attaching a sample SBAR tool for you to review. Please post your comments or questions regarding the usefulness of this tool in the L&D setting. As you look at this tool, do you think the tool will be useful in communicating effectively to the physicians? Why? Do you think the recommendations by the nursing staff will be acted upon by physicians?

http://www.ihi.org/NR/rdonlyres/E8DE1B16-7F12-4C80-ABFC-EFAC4EA97063/3237/SetonPerinatalSBARReportTooltophysicianaboutacriti.pdf

Institute for Healthcare Improvement (2008). Perinatal SBAR. Retrieved from:

http://www.ihi.org/IHI/Topics/PerinatalCare/PerinatalCareGeneral/EmergingContent/Peri

natalSBARTools.htm