1. BASIC ELECTRONIC FETAL HEART MONITORING

3. Electronic Fetal Heart Monitoring

4. What Does Fetal Monitoring Tell Us?
Fetal oxygenation
Acid-base status of the fetus
Ability of the CNS to regulate FHR
Why monitor? Prevention of hypoxia/asphyxia

5. Fetal Circulation

6. Fetal Oxygen Supply Affected by:
Maternal hyper/hypotension, hypovolemia
Maternal Cellular Oxygen content (anemia)
Alterations in fetal circulation
Decreased Blood flow to Intravillous space
(damage vasculature from disease process)

7. Consequences of Uterine Hypoxia/Asphyxia
Cerebral Palsy
Mental Retardation
Epilepsy
RDS
Renal Damage
NEC (Necrotizing Enterocolitis)
Chronic Brain Impairment

8. External Monitoring: Device Placement
Top device is the toco transducer which senses uterine activity
The ultra sound device is lower and senses the fetal heart beat

9. Device Placement

10. Ultrasound Device
Remember….only the round ultrasound transducer which detects the heart beat gets the ultrasound jelly

11. Internal Monitoring: Internal Devices

12. Fetal Scalp Electrode (FSE)

13. External vs. Internal Monitoring

14. External vs. Internal Devices
Monitoring Fetal Heart Rate
Monitoring Contractions
External: Ultrasound device
Internal: Fetal scalp electrode (FSE)
External: Toco transducer
Internal: Intrauterine pressure catheter (IUPC)

15. Remember…..
The intensity of contractions can only be measured objectively with an IUPC in place
Without it, the nurse must assess the strength of the contraction subjectively by palpating the fundus during a contraction
If the fundus tone feels like:
Tip of the nose=mild contraction
Chin=moderate contraction
Forehead=strong contraction

16. Fetal Heart Monitoring
Top tracing represents fetal heart rate
Bottom tracing represents contractions

18. Counting Contractions
Duration: From the beginning to the end of one contraction (length of contraction)
Frequency: Beginning of one contraction to the beginning of the next contraction

19. Uterine Perfusion During Contractions

20. Three Important Components of the Fetal Heart Monitor Strip
1) Baseline Heart Rate
Is it normal, bradycardia, tachycardia?
2) Variability
Minimal/Moderate/Marked
3) Periodic Changes
1) Accelerations (increases in fetal HR)
2) Decelerations: (decreases in fetal HR)
I) Early Decels (Benign)
II) Late Decels (Ominous)
III) Variable Decels (Ominous)

21. Basic Pattern Recognition
Baseline FHR: for 10 min.
Tachycardia: FHR> 160 for >10 min.
Bradycardia: FHR<110 for > 10 min.

22. Bradycardia

23. Tachycardia
Most common cause of tachycardia is maternal infection

25. Variability The “squiggliness” of the FHR tracing
Baseline variability is a measure of the interplay (the push-pull effect) between the sympathetic and parasympathetic nervous systems
Lack of variability is ominous
Variability is the best indicator of fetal well-being

26. Periodic Changes: Accelerations
Transient increases above the FHR baseline
Fetal movement
Contractions
Accelerations are positive/reassuring

27. Variability with Accelerations

28. Periodic Changes:1) Early Decelerations
Gradual onset before peak of contraction
Return to baseline before end of contraction
Uniform shape; similar to one another
Cause: Head compression which causes increased intracranical pressure and vagal nerve stimulation with an accompanying decrease in FHR
May indicate cephalo-pelvic disproportion (CPD)
Not associated with hypoxia or acidosis

29. Early Decelerations

30. Periodic Changes: 2) Variable Decelerations
U, V, or W shaped; varied shape
Variable in duration, timing, depth, not uniform
Cause: Cord compression
Interventions:
Position change, vaginal exam to R/O prolapsed cord, stop oxytocin, anticipate amnioinfusion, notify MD

31. Variable Decelerations
Note the U,V, W shaped decelerations in heart rate

32. Variable Decelerations

33. What is an Amnioinfusion?
Effective for replacing diminished amniotic fluid levels which
helps prevent cord compression

34. Periodic Changes: 3) Late Decelerations
Decent of FHR begins after contraction
Delayed onset. Also delayed return to fetal baseline HR after contraction ends. Therefore a late recovery
Cause: Utero-placental insufficiency
Interventions:
Lateral positioning, stop oxytocin, oxygen, IV fluid bolus, notify MD, anticipate expedient delivery

35. How Maternal Positioning Affects Fetal Perfusion

36. Late Decelerations

37. Prolonged Deceleration

38. True Knot in the Cord
What type of periodic change would you expect to see with this situation?

39. Categorizations of Intrapartum Fetal Heart Rate Patterns
The National Institute of Child Health and Human Development has defined three categories of intrapartum FHR patterns:
Category I: Normal
Category II: Indeterminate
Category III: Abnormal

40. Category I: Normal
The fetal heart rate tracing shows ALL of the following:
Baseline FHR BPM, moderate FHR variability, accelerations may be present or absent, no late or variable decelerations, may have early decelerations
Strongly predictive of normal acid-base status at the time of observation. Routine care

41. Category II: Indeterminate
The fetal heart rate tracing shows ANY of the following
Tachycardia, bradycardia without absent variability, minimal variability, absent variability without recurrent decelerations, marked variability, absence of accelerations after stimulation, recurrent variable decelerations with minimal or moderate variability, prolonged deceleration > 2minute but less than 10 minutes, recurrent late decelerations with moderate variability, variable decelerations with other characteristics such as slow return to baseline
Not predictive of abnormal fetal acid-base status, but requires continued surveillance and re-evaluation

42. Category III: Abnormal
The fetal heart rate tracing shows EITHER of the following:
Sinusoidal pattern OR absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia
Predictive of abnormal fetal-acid base status at the time of observation. Depending on the clinical situation, efforts to expeditiously resolve the underlying cause of the abnormal fetal heart rate pattern should be made

43. Sinusoidal Fetal Heart Pattern
A sinusoidal fetal FHR pattern is defined as a pattern of fixed, uniform fluxuations of the FHR that creates a pattern resembling successive geometric sine waves. Characterized by the absence of variability. Associated with increased perinatal morbidity and mortality and poor perinatal outcome.

45. Think “Veal Chop” V (Variable decel) E (Early decel) A (Accelerations)
L (Late decels)
= Cord compression = Head compression = OK = Placental insufficiency