1. Fetal Health Surveillance (FHS) Part 2 – Electronic Fetal Monitoring*
Maternal Newborn Orientation Learning Module
Reproductive Care Program of Nova Scotia, 2012
*FHS: Part 1 should be viewed prior to review of this module

2. References

3. Objectives
Review skilled use of the electronic fetal monitor (EFM) during labour
Risks/benefits of electronic fetal monitoring
Indications
Methods of electronic fetal monitoring
Analysis, interpretation and classification of tracings
Appropriate interventions in the event of atypical or abnormal tracings
Communication and documentation

4. Risks/benefits
Some association with a reduction in neonatal seizures; no difference in cerebral palsy or perinatal mortality
 in C-sections and operative vaginal births

5. SOGC Recommendation (2007)
‘The normal, healthy fetus is well-equipped to withstand the repeated, transient hypoxia associated with labour contractions.’ ‘Intermittent auscultation (IA) is the preferred method of fetal surveillance for healthy women without risk factors for adverse outcomes’. For those at risk for adverse outcomes, electronic fetal monitoring is advised.

6. Indications for using the EFM
Examples of risk factors for ‘adverse outcomes’:
Antepartum maternal
HDP  Hemorrhage
Diabetes  Morbid Obesity
Antepartum fetal
Prematurity  Oligohydramnios
IUGR  Multiple pregnancy

7. Indications for using the EFM
Examples of risk factors for ‘adverse outcomes’:
Intrapartum maternal
Prolonged ROM  Postterm pregnancy > 42+0
Previous C/S  Augmented/induced labour*
Intrapartum fetal
Meconium staining
Abnormal FHR on auscultation
*Augmentation  continuous EFM
* Induction  EFM can be interrupted periodically once the infusion is stable, and provided there are no additional risks and the tracing has been normal

8. Methods of electronic fetal monitoring

9. Applying the external EFM
Leopold’s
Maneuver

10. Internal Fetal Monitoring
IUPC
Scalp electrode

11. Equipment - Monitor Paper
20 bpm
10 sec.
1 minute

12. Quality of the tracing – FHR

13. Quality of the tracing - contractions
Cont’n
Cont’n

14. Features of the tracing
Contractions FH
Baseline
Variability
Accelerations
Decelerations

15. Contractions
Estimate frequency from the start one contraction to the start of the next
Duration estimated in seconds
Estimate over 10 min
Document range  ‘q 2-3 min x sec’
Resting tone ‘soft’ or ‘firm’ by palpation; approx. 20 mmHg measured by IUPC
frequency
Resting tone

16. Abnormal contraction patterns
Tachysystole – more than 5 contractions in 10 minutes, averaged over 30 minutes
Hypertonus – resting tone > 20 to 25 mmHg

17. Baseline FHR
Approximate mean of the FHR (rounded to 5 bpm) assessed over 10 minutes
Excludes accelerations and decelerations
Normal baseline 110 to 160bpm

18. Tachycardia Causes: Prematurity Maternal anxiety/medication
Prolonged fetal activity
Fever/infection
Chronic fetal hypoxemia
Baseline > 160 bpm x > 10 min

20. Bradycardia Causes: Postmaturity Fetal heart block Vagal stimulation
Fetal hypoxia/acidosis (late sign)
Atypical if baseline 100 to 110 bpm;
Abnormal if baseline < 100 bpm

22. Variability Refers to fluctuations in the baseline FHR
Occurs because of push and pull between sympathetic nervous system (pushes the FHR up) and parasympathetic nervous system (pulls the FHR down)
Requires an intact, well functioning nervous system and oxygenated brain stem

23. Variability To determine variability:
120
150
180 90
To determine variability:
Select a 1-minute section of the tracing
Look at the amplitude/range of fluctuations
Ensure there is a minimum of 2 fluctuations/cycles within the minute
CMNRP
Average # of cycles – 2 to 4/min
Moderate variability (amplitude) – 6 to 25 bpm

24. Classification of variability
Absent – range undetectable
Moderate bpm
Minimal ≤ 5 bpm
Marked > 25 bpm

25. Minimal or absent variability
Causes:
Fetal sleep
Prematurity
Medications
Hypoxia/acidemia
Atypical – if ≤ 5 bpm x 40 to 80 min
Abnormal – if ≤ 5 bpm x > 80 min

28. Marked Variability Causes: Uncertain etiology Mild hypoxia
Catecholamines
Abnormal – if ≥ 25 bpm x > 10 minutes
*rule out artifact

29. Accelerations Causes:
Normal response of a well-oxygenated, non- acidotic fetus to sympathetic stimulation or fetal activity
If not spontaneous, may be elicited by fetal scalp stimulation
Abrupt increases in the FHR at least 15 bpm above the baseline, lasting 15 sec to 2 min
(> 32 weeks gestation)

30. Describe this tracing including features reviewed so far

32. Decelerations - Early
‘Mirror image’ of contractions Nadir of deceleration occurs with peak of contraction; FHR returns to baseline as the contraction ends Mechanism – vagal response from head compression Benign
CMNRP

33. Decelerations - Late
Gradual decrease in the FHR with nadir after peak of contraction and gradual return to baseline following the contraction Deceleration may be almost undetectable; nadir usually not more than 10 to 20 bpm below the baseline Mechanism – uteroplacental insufficiency
CMNRP
Chronic/Acute Conditions

34. Decelerations - Late

35. Decelerations - Late

36. Decelerations - Variable
120
150
180 90
100 25 50 75
Abrupt decrease in the FHR, at least 15 bpm below the baseline, lasting ≥ 15 seconds and < 2 minutes Uncomplicated variables have ‘shoulders’ – accelerations before and following decel Mechanism – cord compression
CMNRP
Normal if occasional;
Atypical if repetitive (≥ 3)

37. Complicated variable decels
 to < 70 bpm x > 60 seconds
Loss of variability
Slow return to baseline
Baseline continues at a lower rate
Prolonged secondary acceleration (overshoot)
Biphasic
Tachycardia or bradycardia
CMNRP
Overshoot
Biphasic

39. Prolonged decelerations
In FHR ≥ 15 bpm below baseline (most often ≥ 30 bpm), lasting ≥ 2 min, < 10 min
Possible causes include cord prolapse, hypertonus, uterine rupture, and sudden fetal descent

40. Rare, distinctive tracings

42. Classification of EFM Tracings (SOGC, 2007)
Parameter
Normal
Atypical
Abnormal
Baseline
110 to 160 bpm
Bradycardia 100 to 110 bpm
Tachycardia > 160 bpm x > 30 min to < 80 min
Rising Baseline
Bradycardia < 100 bpm
Tachycardia >160 bpm x > 80 min
Erratic baseline
Variability
6 to 25 bpm
≤ 5 bpm x < 40 min
≤5 bpm x min.
≤ 5 bpm x > 80 min
≥ 25 bpm x > 10 min
Sinusoidal
Decelerations
None or occasional uncomplicated variables
Early decels
Repetitive (≥ 3) uncomplicated variables
Occasional lates
Single prolonged > 2 min, < 3 min
Repetitive (≥ 3) complicated variables
Lates >50% of contractions
Single prolonged >3, < 10 min
Accelerations
Spontaneous accelerations
Accelerations with scalp stimulation
No acceleration with fetal scalp stimulation
Usually absent

43. Recommended actions Normal Atypical Abnormal Action
May interrupt EFM for periods up to 30 minutes if condition stable and oxytocin rate stable
Further assessment required
Review overall clinical situation; scalp pH may be obtained; prepare for delivery
pH > 7.25 – continue monitoring; repeat scalp gas in 30 minutes
if atypical or abnormal tracing persists
pH 7.20 to repeat scalp gas in 30 minutes
pH <7.20 – delivery is advised

44. Atypical/Abnormal Tracings
Clinical Evaluation is essential:
Are there health, pregnancy or labour complications?
What is the labour status and progress? Is labour spontaneous or induced? Is the fluid clear or meconium stained?
Is this pattern an abrupt change? How was the earlier tracing?

45. Interventions in response to abnormal features
May be specific to the atypical/abnormal features, as appropriate
Variable decelerations  cord compression  relieve pressure on the cord
change maternal position
consider V/E to assess for cord prolapse
Tachycardia
check maternal temperature
promote intrauterine resuscitation

46. Interventions in response to abnormal features
Late decelerations  uteroplacental insufficiency  maximize uteroplacental blood flow
left lateral maternal position
promote intrauterine resuscitation
Minimal/absent variability for > 40 minutes
scalp stimulation to elicit accelerations

47. Promoting intrauterine resuscitation
Discontinue oxytocin
Position change/left lateral position
 IV rate to improve hydration
Modify breathing and pushing techniques (2nd stage)
Administer oxygen at 8-10 l/min*
*Prolonged use of oxygen should be avoided; its effectiveness varies depending on the clinical situation; increases fetal pO2 only slightly.

48. G1, 40 3/7 wks; SRM x 26 hours, spontaneous labour, 3 cm, ‘0’

50. G1 induced for HDP at 40 4/7 wks; 4 cm dilated, station ‘0’, strong contractions, meconium stained fluid

52. Communication
Always keep the labouring woman informed of findings of FHS including rationale for interventions
Effective, interprofessional communication is essential
Suboptimal communication was identified as a ‘root cause’ in 72% of reported adverse outcomes

53. Communication tools SOGC recommends ‘CHAT’ C – Current Condition
H – History
A – Assessment
T – Treatment
SBAR is commonly used in NS
S – Situation
B – Background
A – Assessment
R – Recommendation

54. Documentation-clear, concise, and accurate
Contraction pattern and details of the FHR q 15 to 30 minutes during active labour (q15 minutes when oxytocin running), and every 5 minutes during 2nd stage.
Tracing interpretation/classification
Actions undertaken to improve atypical or abnormal tracings
Plan of care

55. Legal ‘protection’ Consistent terminology and classification
Regular interprofessional education and review of tracings
Effective communication and complete documentation
Consistent ‘times’ on a high quality tracing, in the partogram and throughout the record
Each portion of the tracing labeled; do not circle or mark ‘suspicious’ findings but do note adjustment of transducers and/or tocodial

56. In summary
Regular interprofessional education related to fetal health surveillance and electronic fetal monitoring is essential for all health care providers who care for labouring women.
This education should promote consistent terminology and a common approach that is based on current SOGC guidelines and standards of care.
Regular education related to EFM (and other methods of FHS) that includes recommended terminology, classification of tracingis essential

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