1. Fetal Assessment during Labor
Nancy W. Vines, RN, BSN
Graduate Student
East Carolina University
College of Nursing
January, 2009

2. Objectives Discuss the various types of fetal monitoring
Demonstrate application of external fetal monitor (EFM)
Define terminology associated with fetal monitoring
Determine fetal heart rate (FHR) baseline
Identify common FHR patterns
Describe and differentiate among nursing interventions
used for managing specific fetal heart rate patterns

3. Indications for Fetal Monitoring
Primary tool for assessment of fetal well-being
Primary method of obtaining information about uterine activity

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5. Types of Intermittent Monitors

6. Intermittent Auscultation

7. External Monitoring
Ultrasound (cardio)
transducer
Tocotransducer

8. Application of External Monitors
Position mother
Semi-fowler’s
Lateral recumbent
Wedged to one side
Apply EFM belts snuggly
Use “quarter size” amount of transducer gel

9. Transducers Cardio Transducer “Cardio”
Ultrasonic transducer that picks up movement within the fetal heart
Tocotransducer “Toco”
Detects changes in the shape of the woman’s abdominal wall directly above her fundus—is pressure sensitive

10. Placement of Cardio Apply over fetal back Leopold’s Obesity
Lateral position
Breech
Maternal pulse

11. Placement of Toco Palpate fundus Term—Place toco ABOVE umbilicus
Preterm—Place toco BELOW umbilicus

12. Monitor Paper Moves 3cm per minute Divided into 2 sections:
Top half records FHR
Bottom half records uterine
contractions

13. FHR graphs in this section in beats per minute
Uterine Contractions graph in this section; the numbers in this section are not significant with an external monitor

18. Internal Monitoring Spiral electrode
Intrauterine pressure catheter -IUPC

19. Uterine Tone
The lowest intrauterine pressure between contractions is called resting tone
Normal resting tone is 5-10 mmHg; during labor resting tone may rise to mmHg
Pressure during contractions rises to ~ mmHg (varies with stage)
A resting pressure above 20 mmHg causes decreased uterine perfusion

20. Uterine Tone Determined by palpation if external monitoring
Montevideo units (MVUs) if internal
Add peak pressures from all contractions in a 10 min period and subtract sum of baseline tones of the contractions – nl ; more common practice today is to just add peak pressures from baseline in a 10 minute period

21. Review of Physiologic Basis for Monitoring
Factors necessary for optimal fetal well-being:
Intact, functional maternal physiology
Intact, functional placenta
Intact, functional fetus

22. Maternal Component
Insufficient oxygen or nutrition in the mother can cause:
Intrauterine growth restriction (IUGR)
Fetal hypoxia
Fetal metabolic acidosis
Acute asphyxia
Fetal death

23. Placental Component
Inadequate placental function can cause insufficient oxygen and nutrient transfer to the fetus
Placental function can be chronically impaired by:
Maternal hypertension (pre-existing or PIH)
Pre-eclampsia
Diabetes mellitus (insulin dependent)
Intrauterine infection
Placental anomalies
Decreased 02 content in maternal blood (smoking; asthma)

24. Placental Component
Placental function during labor can be acutely impaired by:
Placental separation
abruptio placenta
Sudden maternal hypotension
Tachysystole of uterus
Valsalva maneuver for pushing (holding breath decreases O2 to placenta)

25. Fetal Component Inadequate oxygen causes fetal hypoxemia
Fetal hypoxemia causes tissue hypoxia
Tissue hypoxia results in anaerobic metabolism
Anaerobic metabolism causes production of lactic acid
Lactic acid causes
metabolic acidosis
fetal death

26. Physiology of FHR Regulation
FHR is dependent on fetal, maternal, uterine, and placental features designed to regulate blood flow and nutrient and gas exchange
FHR regulated by:
Sympathetic and parasympathetic nervous systems based on baroreceptor and chemoreceptor responses
Central Nervous System

27. Physiology, continued
Parasympathetic nervous system is a cardiodecelerator
Sympathetic nervous system is a cardioaccelerator
Baroreceptors –decrease fetal heart rate
Chemoreceptors- increase fetal heart rate
Central Nervous System
Sleep state- decreases variability and reactivity
Alert state- increases variability and reactivity

28. FHR and Uterine Activity

29. Fetal Monitoring Terminology
1997—Meeting in Washington, D.C. to develop list of terms used in interpreting fetal monitor strips—NICHD (National Institute of Child Health and Human Development Research Planning Workshop)
Lay dormant for many years
2005—AWHONN and ACOG reviewed 1997 document and adopted it in 2005

30. Why Change to NICHD?
Standardize and simplify key clinical terms and protocols
Improve communication
Promote patient safety
Recommended by The Joint Commission in a July, 2004 Sentinel Event Alert (# 30)
Make terminology consistent among professional organizations (AWHONN/ACOG)

31. 5 Basic Components of a Fetal Heart Rate Tracing
Baseline fetal heart rate
Variability
Accelerations
Decelerations
Changes or trends over time

32. FHR Baseline Baseline—FHR
rounded to increments of 5 bpm, over a 10 minute period of time (not including accels, decels, and periods of marked variability)
fetus is not under stress
range is bpm
minimum baseline duration must be at least 2 minutes in the 10 minute segment
reported as a single number, not a range

33. FHR Variability
Variability—Normal irregularity (fluctuations) of cardiac rhythm due to continuous balancing interaction of the sympathetic and parasympathetic divisions of the fetal autonomic nervous systemIrregular fluctuations from baseline of 2 cycles per minute or more (in the absence of contractions, accelerations, decelerations)
Measured from peak to trough of single cycle
Measured in bpm
Absence of variability can be a sign of fetal CNS depression and hypoxia

34. Variability

35. Causes of Decreased Variability
Prematurity
Narcotics, tranquilizers, barbituates, anesthetics, anticonvulsants, smoking
Fetal hypoxia and acidosis
Fetal sleep states (can last up to 40 minutes
Fetal cardiac arrhythmias

36. Responses to Decreased Variability
Interventions to enhance uterine blood flow
Mom in left lateral position
IV hydration
02 at 8-10 lpm per mask
Communication
Maternal assessments
FHR pattern and fetal movement
Actions
Fetal response to actions

37. Accelerations
Indicate fetal well-being when they occur with fetal movement
Increase in FHR – may be with contractions or with other activities
Can be periodic or episodic
Abrupt (onset to peak <30 sec) increase
Increase of 15 bpm, lasting 15 sec, return to baseline < 2 min

38. Accelerations

39. Decelerations
Decelerations are changes in the FHR that are classified on:
their SHAPE, and
their TIMING in relationship to the contraction

40. Changes in FHR Periodic changes – occur with contractions
Episodic changes (non periodic) – do not occur with contractions

41. Tachycardia Tachycardia >160 bpm for ≥10 min
Causes – maternal fever, infection, fetal anemia, drugs, maternal anxiety; maternal hemorrhage
Response – left lateral position; increase IV hydration; O2 at 8-10 lpm via face mask; notify MD; may need to decrease uterine activity; administer meds as ordered

42. Bradycardia Bradycardia <110 bpm for ≥10 min
Causes – profound fetal hypoxia, epidural drugs, maternal hypotension, maternal substance abuse, cord compression, uterine tachysystole
Response – left lateral position; increase IV hydration; O2 at 8-10 lpm via face mask; vaginal exam (why?); notify MD

43. Early Decelerations
Early – associated with head compression during contractions
Shape is uniform, symmetrical
Usually begins at the onset of the contraction and resolves at the end of the contraction (periodic)
Must be repetitive**
Typically a mirror image of the corresponding contraction
Rarely drops below 100 bpm
Considered benign with usually no intervention needed (FHR returns to baseline as pressure on fetal head is released)

44. Early Deceleration

45. Intervention for Early Decelerations
Vaginal exam for presentation, dilatation, and station
Change maternal position
Surveillance—document and continue to observe**

46. Variable Decelerations
Variable- associated with cord compression
A visually apparent abrupt decrease in FHR (<30 sec)
Occurs at any time during or between the contraction (unrelated to timing of uc) (periodic or episodic)
Often drops below 100 bpm
Shape may be U, V, or W
Return to baseline varies; may have rapid or prolonged return to baseline

47. Variable Decelerations
Variables, continued
Frequently observed with pushing
Not necessarily repetitive
Severe uncorrected variables are associated with fetal hypoxia, acidosis, and low apgars
May be reassuring or non-reassuring- thus “variable!”

48. Variable Deceleration

49. Interventions for Variable Decelerations
Change maternal position
Notify attending physician
If variables are severe:
Discontinue Pitocin if infusing
Administer oxygen at 8-10 lpm**
Vaginal or speculum exam to assess for cord**
Amnioinfusion**
Termination of labor is severe variables are not correctable
Decrease uterine activity (Terbutaline)

50. Amnioinfusion

51. Amnioinfusion

52. Late Decelerations Late- associated with uteroplacental insufficiency
Shape is uniform and symmetrical
a visually apparent, gradual decrease and return of the FHR associated with a uc
Must be repetitive
Rarely less than 100 bpm; lowest point after peak of uc
Clinical significance: Omnious – Indicates decreased O2 available to fetus; hypoxia
Intervention usually needed

53. Causes of Uteroplacental Insufficiency
Pitocin causing uterine tachysystole (previously known as hyperstimulation)
Maternal or supine hypotension
Pre-eclampsia or eclampsia
Post maturity
Maternal diabetes
Placenta previa / abruption

54. Late Deceleration

55. Interventions for Late Decelerations
Change maternal position** (L side)
Correct maternal hypotension
Increase IV fluid rate or give bolus, especially if maternal hypotension or dehydration present**
Discontinue pitocin if infusing**
Administer O2 at 8-10 lpm by mask**
Notify attending physician
Terminate labor if pattern not correctable

56. Prolonged Decelerations
Lasts for more than 2 minutes but less than 10 minutes
Can be abrupt or gradual
Usually >15 bpm below baseline
Intervention needed

57. Review of Assessment and Management
Reassuring and Non-reassuring FHR Patterns and Management

58. Reassuring Patterns Baseline Rate- 110-160 bpm No periodic changes
No late decelerations
No non-reassuring variable decelerations
Moderate baseline variability
Accelerations with fetal movement
No concerning changes or trends over time

59. Non-reassuring Patterns
Progressive > or < in baseline rate
Tachycardia
Severe bradycardia
Absent or minimal variability
Severe variable decelerations
Repetitive or uncorrected late decelerations
Prolonged deceleration
One or more of the 5 FHR components
is abnormal

60. Priorities- A-B-C-Ds of Intrapartum Fetal Monitoring
A. Assess Oxygen Pathway
Lungs
Heart
Vasculature
Uterus
Placenta
Cord

61. Priorities- A-B-C-Ds of Intrapartum Fetal Monitoring
B. Begin Corrective Measures
Supplemental oxygen
Maternal position changes
IV fluid administration
Correcting maternal BP
Reducing uterine activity
Alter 2nd stage pushing technique
Amnioinfusion
Re-evaluate

62. Priorities- A-B-C-Ds of Intrapartum Fetal Monitoring
C. Clear Obstacles to Rapid Birth
Plan ahead (i.e., call OR , check equipment, anesthesia, urinary catheter, tocolytics)

63. Priorities- A-B-C-Ds of Intrapartum Fetal Monitoring
D. Decision to Birth Time
- Decision to allow labor to continue or to proceed with delivery- need to weigh the benefit of vaginal birth against the risk of fetal metabolic acidemia – must be individualized

64. Other Methods of Fetal Assessment
Fetal Scalp Sampling
Scalp stimulation
Acoustic stimulation
Fetal pulse oximetry
Umbilical cord acid base determination

65. Client Teaching Explanation of monitoring technique used
Maternal position – not supine
Don’t use valsalva maneuver for 2nd stage labor

66. Documentation
Varies by institution – computer or hard copy chart, fetal monitor strip
What should be documented –
Maternal Assessments
Fetal Assessment
Monitor adjustments
Interventions
Evaluation

67. Review of Decelerations
If you get to class EARLY—that’s good!
If you get to class LATE—that’s bad!
If you vary between early and late—that’s VARIABLE and can be good or bad depending on the situation! 

70. References
Chauhan, S. P., & Macones, G. A. (2005). Intrapartum fetal heart rate monitoring. [ACOG Practice Bulletin].
The American College of Obstetricians and Gynecologists, 106(6),
Lowdermilk, D. L., & Perry, S. E. (2007). Maternity & Women’s Health Care. In C. Jackson & L. Gower (Eds., 9h
ed.). Fetal Assessment during Labor (pp ). St. Louis: Mosby Elsevier.
Macones, G. A., Hankins, G. D., Spong, C. Y., Hauth, J., & Moore, T. (2008). The 2008 national institute of child
health and human development workshop report on electronic fetal monitoring: Update on definitions,
interpretation, and research guidelines. [JOGNN Principles & Practice Bulletin]. Journal of Obstetric,
Gynecologic & Neonatal Nursing, 37,