1. Fetal Assessment during Labor
Miss Shurouq Qadous

2. The goals of intrapartum FHR monitoring are to identify and differentiate the normal ( reassuring ) patterns from the abnormal ( nonreassuring ) patterns. Nonreassuring FHR patterns are those associated with fetal hypoxemia, which is a deficiency of oxygen in the arterial blood. If uncorrected, hypoxemia can deteriorate to severe fetal hypoxia, which is an inadequate supply of oxygen at the cellular level.

3. Monitoring Techniques
1- Intermittent Auscultation (IA) listening to fetal heart sounds at periodic intervals to assess the FHR. IA of the fetal heart can be performed with a Pinard stethoscope, Doppler ultrasound device, an ultrasound stethoscope or a DeLee- Hillis fetoscope.

4. a Pinard stethoscope

7. IA is - easy to use. - Inexpensive. - less invasive
IA is - easy to use. - Inexpensive. - less invasive. It is often more comfortable for the woman and gives her more freedom of movement, such as ambulation and the use of baths or showers, are easier to carry out when IA is used. On the other hand, IA may be difficult to perform in women who are obese.

8. IA does not provide a permanent documented visual record of the FHR and cannot be used to assess visual patterns of the FHR variability (Normal irregularity of fetal cardiac rhythm or fluctuations from the baseline FHR of two cycles or more) or periodic changes (Changes from baseline that occur with uterine contractions).

9. 2- Electronic Fetal Monitoring The purpose of electronic FHR monitoring is the ongoing assessment of fetal oxygenation. The goal is to detect fetal hypoxia and metabolic acidosis during labor so that interventions to resolve the problem can be implemented in a timely manner before permanent damage or death occur.

10. The two modes of electronic fetal monitoring include the external mode, which uses external transducers placed on the maternal abdomen to assess FHR and UA, and the internal mode which uses a spiral electrode applied to the fetal presenting part to assess the FHR and an IUPC to assess UA and pressure.

11. A- External monitoring Separate transducers are used to monitor the FHR and UCs . The external transducer is easily applied by the nurse, but it must be repositioned as the woman or fetus changes position .The woman is asked to assume a semi-sitting or a lateral position. The equipment is removed periodically to wash the applicator sites and to give back rubs. Use of an external transducer confines the woman to bed.

12. External noninvasive fetal monitoring with toco transducer and ultrasound transducer.

15. B- Internal monitoring Internal monitoring allows an accurate appraisal of fetal well-being during labor. For this type of monitoring, the membranes must be ruptured, the cervix sufficiently dilated (2-3 cm), and the presenting part low enough to allow placement of the electrode. A small spiral electrode attached to the presenting part shows a continuous FHR on the fetal monitor strip.

16. A solid catheter has a pressure-sensitive tip that measures changes in intrauterine pressure. A catheter filled with sterile water also can be used. As the catheter is compressed during a contraction, pressure is placed on the pressure transducer ; this pressure is then converted into a pressure reading in millimeters of mercury. The average pressure during a contraction ranges from 50 to 85 mm Hg.

17. Diagrammatic representation of internal invasive fetal monitoring with intrauterine pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated).

19. The FHR and UA are displayed on the monitor paper, with the FHR in the upper section and UA in the lower section. Each small square represents10 seconds; each larger box of six squares equals 1 minute.

21. Fetal Heart Rate Patterns
Refers to the average FHR that occurs during a 10-minute segment that excludes periodic or episodic rate changes, such as tachycardia or bradycardia. The normal range at term is 110 to 160 beats/min.

22. DR C BRAVADO for Interpretation of Continuous Electronic Fetal Monitoring
DR: Determine risk High
medium, or low risk (i.e., risk in terms of the clinical situation)
C: Contractions
Rate, rhythm, frequency, duration, intensity, and resting tone
BRA: Baseline rate
Bradycardia (< 110 bpm), normal (110 to 160 bpm), or tachycardia (> 160 bpm); rising baseline
V: Variability
Reflects central nervous system activity
A: Accelerations
D: Decelerations
O: Overall assessment and written plan

23. Variability
Variability of the FHR can be described as irregular fluctuations in the baseline FHR. Or how much the peak and troughs of the heart rate deviate from the baseline rate. They are 4 categories of variability have been identified.

25. 1- Absent variability
Causes
Fetal hypoxemia and acidosis
- Congenital anomalies
- CNS depressant medication
Including analgesics, narcotics
(meperidine [Demerol])
Fetal in sleep state
Extreme premature

27. 2- Minimal variability

29. 3- Moderate variability, amplitude range 6 – 25 beats/min.
Considered normal
Its presence is highly predictive of a normal fetal acid – base balance.

31. 4- Marked variability, amplitude range>25beats/min
- Mild, transient hypoxemia

33. Tachycardia
Tachycardia is a baseline FHR greater than 160 beats/ min for a duration of 10 minutes or longer. Causes: Maternal related causes: ■ Fever ■ Infection ■ Chorioamnionitis ■ Dehydration ■ Anxiety ■ Anemia ■ Illicit drugs (cocaine, methamphetamines)

35. Fetal related causes: ■ Infection or sepsis ■ Activity/stimulation ■ Cardiac abnormalities ■ Anemia

37. Nursing Intervention Priority dependent on cause: - Reduce maternal fever with antipyretics as ordered, hydration, and cooling measures - Oxygen at 8-10 L/min by face mask may be of some value

38. Bradycardia
Bradycardia is a baseline FHR less than 110 beats/min for a duration of 10 minutes or longer.
Causes:
Fetal cardiac problems (e.g., fetal heart failure)
Maternal hypoglycemia
Maternal hypotension

41. Nursing Intervention Priority dependent on cause and based on stage of labor: - all interventions to improve fetal oxygenation (i.e., lateral maternal positioning, hydration, correction of maternal hypotension, maternal oxygenation and discontinuing oxytocin) may be implemented

42. Periodic and Episodic Changes in Fetal Heart Rate
Changes in FHR from the baseline are categorized as periodic or episodic. Periodic changes are those that occur with UCs. Episodic changes are those that are not associated with UCs.

43. Accelerations
- Acceleration of the FHR is defined as a visually apparent abrupt increase in FHR above the baseline rate. The increase is 15 beats/min or greater and lasts 15 seconds or more, with the return to baseline less than 2 minutes from the beginning of the acceleration.
Acceleration of the FHR for more than 10 minutes is considered a change in baseline rate.
Accelerations are considered an indication of fetal well- being. Its presence is highly predictive of a normal fetal acid – base balance.

46. Causes:
Spontaneous fetal movement
Vaginal examination
Reaction to external sounds
Electrode application, scalp stimulation
Uterine contractions
Fundal pressure
Abdominal palpation
Nursing intervention
- None required

47. Decelerations
FHR deceleration are categorized as early, late, and variable. FHR decelerations are described by their visual relation to the onset and end of a contraction and by their shape.

48. 1- Early decelerations
Early deceleration of the FHR is a visually apparent gradual decrease and return to baseline FHR.
The deceleration generally starts before the peak of the UC and returns to the baseline at the same time as the UC returns to its baseline.
For this reason, early decelerations are sometimes called the “ mirror image “ of a contraction.
Early deceleration are thought to be caused by transient fetal head compression and are considered a benign finding.

53. Early decelerations may occur during:
vaginal examinations
fundal pressure
- placement of the internal mode of fetal monitoring.
Because early decelerations are considered to be benign,
interventions are not necessary.

54. 2- Late decelerations Late deceleration of the FHR is a visually apparent gradual decrease in and return to baseline FHR associated with UCs. The deceleration begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction. The deceleration usually does not return to baseline until after the contraction is over.

58. Uteroplacental insufficiency causes late decelerations
Uteroplacental insufficiency causes late decelerations. Persistent and repetitive late decelerations usually indicate the presence of fetal hypoxemia that result from insufficient placental perfusion. They can be associated with fetal hypoxemia progressing to hypoxia and acidemia progressing to acidosis.

59. Late decelerations caused by uteroplacental insufficiency can result from:
Uterine hyperstimulation with oxytocin
Gestational hypertension
Postdate or postterm pregnancy
Amnionitis
SGA fetus
Maternal diabetes
Placenta previa, abruptio placentae,
Conduction anesthetics (producing maternal hypotension), maternal cardiac disease, and maternal anemia.
- Maternal supine hypotension cause Late decelerations.

60. Nursing Intervention
The usual priority is:
Change maternal position (lateral)
Correct maternal hypotension by elevating legs
Increase rate of maintenance IV solution.
Palpate uterus to assess for hyperstimulation
Discontinue oxytocin if infusing
Administer oxygen at 8-10 L/min with tight face mask
Consider internal monitoring for a more accurate fetal and uterine assessment
Assist with birth (cesarean or vaginal assisted) if pattern cannot be corrected

61. 3- Variable decelerations Variable deceleration is defined as a visual abrupt decrease in FHR below the baseline. The decrease is 15 beats/min or more, lasts at least 15 seconds, and 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. Variable decelerations often have a U,V or W shape. * Repetitive variable decelerations indicate recurrent disruption in the fetus oxygen supply.

64. Causes
Umbilical cord compression caused by the
following:
Maternal position with cord between fetus and maternal pelvis
Cord around fetal neck, arm, leg, or other body part
Short cord
Knot in cord
Prolapsed cord

65. Nursing Intervention
The usual priority is:
Change maternal position (side to side, knee chest)
if decelerations are severe, proceed with following
measures:
a. Discontinue oxytocin if infusing
b. Administer oxygen at 8-10 L/min with tight face mask
c. Assist with vaginal or speculum examination to assess for cord prolapse
f. Assist with birth (vaginal assisted or cesarean)
if pattern cannot be corrected

66. 4- Prolonged decelerations Is a visually apparent decrease in FHR below the baseline 15 beats/min or more and lasting more than 2 minutes but less than 10 minutes. A deceleration lasting more than 10 minutes is considered a baseline change.

68. Prolonged decelerations may be caused by:
Prolonged cord compression
Uteroplacental insufficiency
Sustained head compression
Other more benign causes of prolonged deceleration are pelvic examination, application of a spiral electrode, rapid fetal descent, and sustained maternal Valsalva maneuver.

69. The nurse must ensure that the monitor is recording FHR and UA accurately and that the tracing is interpretable.
AAP and ACOG (2007) recommends that the FHR tracing be evaluated at least every 30 minutes during the first stage of labor and every 15 minutes during the second stage of labor in low risk women.
If risk factors are present, then the FHR tracing should be evaluated, every 15 minutes in the first stage of labor and every 5 minutes in the second stage of labor.

70. Nursing management of nonreassuring patterns.
The term intrauterine resuscitation is sometimes used to refer to those interventions initiated when a nonreassuring FHR pattern is noted; they are directed primarily toward improving uterine and intervillous space blood flow and secondarily toward increasing maternal oxygenation and cardiac output

71. Management of abnormal fetal heart rate (FHR) patterns
Basic interventions
Administer oxygen 8 – 10 L/min by nonrebreathe mask
Side- lying position
Increase IV infusion …. Lead to increase maternal blood volume.

72. Intervention for specific problems
Maternal hypotension
Increase rate of IV infusion
Lateral or Trendelenburg positioning
Administer ephedrine to increase BP, if previous measures not successful.
Uterine tachysystole
D/C oxytocin (pitocin)
Administer tocolytic medication (uterine relaxant) e.g., terbutaline (Brethine)

73. Other methods of assessment and intervention
The methods include fetal scalp stimulation and umbilical cord acid-base determination , fetal scalp blood sampling, fetal pulse oximetry. Amnioinfusion, and tocolytic therapy are two interventions used to improve abnormal FHR..

74. Assessment techniques Fetal scalp stimulation
Stimulation of the fetus is done to elicit an acceleration of the FHR of 15 beats/min for at least 15 seconds. Fetal stimulation currently in
practice are scalp stimulation (using digital pressure during a vaginal examination).

76. Umbilical cord acid-base determination
In assessing the immediate condition of the newborn after birth, a sample of cord blood is a useful adjunct to the Apgar score. The procedure is generally done by withdrawing blood from both the umbilical artery and the umbilical vein .Both samples are then tested for pH, PCO2, and PO2. Umbilical cord gas measurements reflect the acid-base status of the newborn at birth.
Normal Values for cord blood
Artery Vein
PH: 7.2 – – 7.4
Pco2: 45 – – 45
Po2: 15 – – 36
Hco3: < < 12

77. Fetal scalp blood sampling
Fetal scalp blood sampling. Sampling of the fetal scalp blood was designed to assess the fetal pH, PO2, and PCO2. The procedure is performed by obtaining a sample of fetal scalp blood through the dilated cervix after the membranes have ruptured.

78. Fetal pulse oximetry
Or Continuous monitoring of fetal oxygen saturation (FSpO2) or fetal pulse oximetry (FPO) is a method of fetal assessment, measures the oxygen saturation of hemoglobin in fetal blood.

79. Interventions
1-Amnioinfusion is the infusion of room- temperature isotonic fluid usually normal saline or R/L solution into the uterine cavity if the volume of amniotic fluid is low.

80. Purpose of amnioinfusion:
To relive intermittent umbilical cord compression that results in variable decelerations and transient fetal hypoxemia by restoring the amniotic fluid volume to a normal or near – normal level.
Candidates for this procedure:
Oligohydramnios
Anhydramnios
Both can result UPI, PROM
- In the past amnioinfusion was used to prevent meconium aspiration syndrome.

81. Risks of amnioinfusion are overdistention of the uterine cavity and increased uterine tone.
The fluid is usually warmed with a blood warmer before administration for the preterm or SGA fetus.
No more than 1000ml of fluid will need to be administered.
- Intensity and frequency of UCs should be continually assessed during the procedure.

82. 2- Tocolytic therapy Tocolysis (relaxation of the uterus) can be achieved through the administration of drugs that inhibit UCs. Tocolysis improves blood flow through the placenta by inhibiting UCs. A tocolytic drug such as magnesium sulfate or terbutaline(sub/q) can be administered intravenously to decrease UA. If the FHR pattern improves, the woman may be allowed to continue labor; if there is no improvement, immediate cesarean birth may be needed.

83. Thanks