6. Disorders affecting fluid-gas transport: fetal
   1. Fetus in jeopardy - general aspects:
      1. Pathophysiology - maternal hypoxemia, anemia, ketoacidosis, Rh isoimmunization, or decreased uteroplacental perfusion.
      2. Etiology - maternal:
         1. Preeclampsia/eclampsia.
         2. Heart disease.
         3. Diabetes.
         4. Rh or ABO incompatibility.
         5. Insufficient uteroplacental/cord circulation due to:
            1. Maternal hypotension/hypertension.
            2. Cord compression:
               1. Prolapsed.
               2. Knotted.
               3. Nuchal.
            3. Hemorrhage; anemia.
            4. Placental problem:
               1. Malformation of the placenta/ cord.
               2. Premature “aging” of placenta.
               3. Placental infarcts.
               4. Abruptio placentae.
               5. Placenta previa.
            5. Postterm gestation.
            6. Maternal infection.
            7. Hydramnios.
            8. Hypertonic uterine contractions.
         6. Premature rupture of membranes (PROM) with chorioamnionitis.
         7. Dystocia (e.g., from CPD).
      3. Assessment - intrapartal:
         1. Amniotic fluid examination - at or after rupture of membranes. Signs of fetal distress: meconium stained, vertex presentation - due to relaxation of fetal anal sphincter secondary to hypoxia/anoxia. Note: Fetus “gasps” in utero - may aspirate meconium and amniotic fluid.
         2. Fetal activity:
            1. Hyperactivity - due to hypoxemia, elevated CO₂.
            2. Cessation - possible fetal death.
         3. Methods of monitoring FHR:
            1. Fetoscope.
            2. Phonocardiography with microphone application.
            3. Internal fetal electrode - attached directly to fetus through dilated cervix after membranes ruptured.
            4. Doppler probe using ultrasound flow.
            5. Cardiotocograph - transducer on maternal abdomen transmits sound.
         4. Abnormal FHR patterns.
            1. Persistent arrhythmia.
            2. Persistent tachycardia of 160 or more beats/min.
            3. Persistent bradycardia of 100 or fewer beats/min.
            4. Early deceleration - due to vagal response to head compression.
            5. Late deceleration - due to uteroplacental insufficiency.
            6. Variable deceleration - due to cord compression.
            7. Decreased or loss of variability in FHR pattern.
         5. Medical evaluation - procedures: fetal blood gases, pH.
            1. Purpose - to identify fetal acid-base status.
            2. Requirements for:
               1. Ruptured membranes.
               2. Cervical dilation.
               3. Engaged head.
            3. Procedure - under sterile condition, sample of fetal scalp blood obtained for analysis.
            4. Signs of fetal distress:
               1. pH <7.20 (normal range is 7.3 - 7.4).
               2. Increased CO₂.
               3. Decreased PO₂
      4. Analysis/nursing diagnosis:
         1. Impaired gas exchange, fetal, related to decreased placental perfusion/insufficient cord circulation.
         2. Altered tissue perfusion related to hemolytic anemia.
         3. High risk for fetal injury related to hypoxia.
   2. Prolapsed umbilical cord
      1. Pathophysiology - cord descent in advance of presenting part; compression interrupts blood flow, exchange of fetal/maternal gases —> fetal hypoxia, anoxia, death (if unrelieved).
      2. Etiology:
         1. Spontaneous or artificial rupture of membranes before presenting part is engaged.
         2. Excessive force of escaping fluid, as in hydramnios.
         3. Malposition - breech, compound presentation, transverse He.
         4. Preterm or SGA fetus - allows space for cord descent.
      3. Assessment:
         1. Visualization of cord outside (or inside) vagina.
         2. Palpation of pulsating mass on vaginal examination.
         3. Fetal distress - variable deceleration and persistent bradycardia.
      4. Analysis/nursing diagnosis:
         1. Impaired gas exchange, fetal, related to interruption of blood flow from placenta/ fetus.
         2. Anxiety/fear, maternal, related to knowledge of fetal jeopardy.
      5. Nursing care plan/implementation:
         1. Goal: reduce pressure on cord.
            1. Position: knee to chest; lateral modified Sims’ with hips elevated; modified Trendelenburg.
            2. With gloved hand, support fetal presenting part.
         2. Goal: increase maternal/fetal oxygenation: oxygen per mask (8-10 L/min).
         3. Goal: protect exposed cord: continuous pressure on the presenting part to keep pressure off cord.
         4. Goal: identify fetal response to above measures, reduce threat to fetal survival: monitor FHR continuously.
         5. Goal: expedite termination of threat to fetus: prepare for immediate cesarean birth.
         6. Goal: support mother and significant other by staying with them and explaining.
      6. Evaluation/outcome criteria:
         1. FHR returns to normal rate and pattern.
         2. Uncomplicated birth of viable infant.
7. Summary of danger signs during labor
   1. Contractions - strong, every 2 min or less, lasting 90 sec or more; poor relaxation between contractions.
   2. Sudden sharp abdominal pain followed by boardlike abdomen and shock - abruptio placentae or uterine rupture.
   3. Marked vaginal bleeding.
   4. FHR periodic pattern decelerations - late; variable; absent (see Figure 4-10).
   5. Baseline.
      1. Bradycardia (<100 beats/min).
      2. Tachycardia (>160 beats/min).
   6. Amniotic fluid.
      1. Amount: excessive; diminished
      2. Odor.
      3. Color: meconium stained; port-wine; yellow.
      4. 24 hr or more since rupture of membranes.
   7. Maternal hypotension, or hypertension.