1. Basic Fetal Monitoring Designed For New Labor and Delivery Nurses
Facilitation skills offer immediate, practical benefits to any group process. As facilitator, your role is to set the agenda, encourage participation, and guide the pace of the meeting. Use these Dale Carnegie Training® strategies to help make your meeting a success.
You can provide handouts to focus the discussion and give attendees a place to record their ideas. If you print handouts with three slides per page, PowerPoint will automatically include blank lines for your meeting participants to take notes. By
Pat Burroughs MSN, RN
4/22/2017
Copyright © Dale Carnegie & Associates, Inc.

2. Introduction Credentials 28 Years Obstetric Experience
Labor and Delivery primary focus
17 Years Charge RN Experience
3 Years Obstetric Educator Experience
6 Years AWHONN Fetal Monitor Instructor Status
Begin with a strong opening, relevant to the topic and your audience. Appeal to your audience’s interests. Your energy and attitude set the tone and provide momentum for the meeting.
Facilitation is a process that helps people communicate and work together. Establish an open environment conducive to problem solving and change.
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3. Review of Materials Folder contents
Handout of power point presentation
Handout with fetal heart variability examples
Check off forms for FHR Auscultation and Contraction assessment skills
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4. Agenda Basic FHR Monitoring Intermittent Auscultation
Doptone
Fetoscope
Electronic Fetal Monitor (EFM)
External
Internal
Fetal Heart Patterns and Characteristics
Normal baseline rate
Variability
Periodic and episodic patterns
Reassuring and nonreassuring characteristics
Contraction Assessment
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5. Basic Fetal Monitoring
Definition of fetal monitoring
Method of assessing fetal status before and during labor
Why is fetal monitoring important
To provide insight that may affect fetal outcomes
Bridge to your key topic. State the purpose and importance of your meeting.
As facilitator, you are a catalyst for change. Ask questions. Coach participants. Encourage participation. Record comments. Thank participants for their individual contributions, ideas, and insights.
You can use PowerPoint’s Meeting Minder to record comments during the meeting.
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6. Intermittent Auscultation
Doptone: Converts sound waves to audible tones to count.
Fetoscope: Considered best alternative because it enables user to hear actual heart sounds opening and closing of valves.
Set clear goals for the meeting. Clarify the problem to be solved. Get agreement from the group on the agenda, the problem and the process.
As facilitator, guide, inspire, and support participation from all attendees. Solicit personal experiences. Ask for evidence to back up points. Make every participant feel they are valuable with something to contribute.
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7. What is intermittent auscultation?
Auscultation of the FHR at intervals ordered by the physician, midwife, or determined by hospital policy.
Can be used in gestations from weeks.
Can be used to determine the rate and rhythm of the fetal heart .
Once you have defined the problem, move to solution-finding. Encourage participants to be open-minded, think creatively, and suggest solutions.
Respect diverse opinions. Diversity strengthens problem-solving and adds substance to discussions.
Record ideas. Consider all suggestions. Keep a positive attitude throughout the process. Bring all participants into the process. List and prioritize options. Use the group process to determine the solution.
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8. Who Should Perform Intermittent Auscultation?
Someone with knowledge of normal FHR characteristics
Someone with knowledge and skill to perform appropriate interventions if problem noted
Now that you have a solution, outline your action plan. Using the group process, agree upon an orderly direction to reach your goals.
List the action steps. You can use the Meeting Minder to record action items for meeting participants. Identify resources needed. Assign responsibilities. Establish methods of accountability. Define a time line. Identify costs. Define current resources.
Also, consider what is needed for success. Training? Specific expertise? Additional information? Special materials? Additional resources? Management buy-in?
Proper planning prior to action leads to goal achievement.
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9. Advantages and Disadvantages of Auscultation
It is noninvasive and relatively painless procedure for the patient
Patient has freedom to move
Does not require electricity
Patient is reassured by RN presence
Disadvantages
Requires skilled RN at bedside
Difficult to use when patient obese or FHR is too fast to count
No paper record to show physician or midwife
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10. How is Intermittent Auscultation Performed?
Explain procedure to patient and assist her to a comfortable position
Determine gestational age
Palpate the uterus to determine where the fetal back is located
Auscultate the FHR between contractions for at least 60 seconds, noting the rate and rhythm
Palpate maternal pulse to differentiate between FHR and maternal heart rates.
Close your meeting with a brief summary. Thank participants for their input. Review action plans, assignments, and accountability measures. Thank the group for following the process, working together as a team, and committing to problem solving and goal achievement.
If you used Meeting Minder to keep track of action items, PowerPoint will automatically add a slide with the action items to the end of your presentation. Use this slide to review the action items and get buy-in from participants.
Facilitation is leadership in action. Close your presentation with a strong comment to reinforce the success of the team. Empower the group to work toward goal achievement.
Apply effective facilitation skills and you will have productive, profitable meetings.
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11. Where to Auscultate
Optimal place to auscultate is over the fetal back. (Takes skill and practice to determine)
Cannot determine in early gestations or if patient is very obese
Guidelines to help locate the FHR
Recommended search pattern is in packet as handout.
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12. Methodical Method Follow Recommended Pattern
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13. Systematic Method Use If Unsuccessful With Methodical Method
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14. General Principles of Auscultation for Student Nurses
Utilize standard precautions
Obtain supplies, doptone, fetoscope, ultrasound gel, washcloth
Evaluate equipment for cleanliness prior to use
Clean with appropriate solutions
Provide education instruction to patient, family, and/or significant other and answer questions
Ask patient if she would prefer others leave during the procedure
Document and report results to primary RN
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15. Safety Practices Verify orders and identify patient
Position patient in semi-fowlers position preferably with a lateral tilt
Elevate bed to appropriate working level
Return to low position and give call light to patient
Assess abdomen for best location to auscultate
Listen to FHR for at least 60 seconds
Note rate, rhythm, and listen for increases or decreases following fetal movement or contractions
Document and report findings
Immediately report any abnormal findings
Utilize resources as needed
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16. Normal Assessment Findings
FHR between in gestations weeks
Rates slightly above 160 are normal in gestations less than 32 weeks. Recommendation is that nursing students report findings to Primary RN.
Regular rhythm
Increases in the FHR associated with fetal movement that return to original rate range
Decreases may be heard
Recommendation that nursing students report any decreases heard to the Primary RN.
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17. Electronic Fetal Monitoring Clarification
Information for students is for educational purposes only
Students should not assume any responsibility for interpretation of fetal monitor tracings
It takes months to years of experience in addition to continuing education to be prepared to interpret fetal monitor tracings
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18. Electronic Fetal Monitoring
Definition
Electronic method of providing a continuous visual record of the FHR and uterine activity
Information is recorded on graph paper or in archiving database system
Information is permanent part of the maternal medical record
Information is retrievable for litigation
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19. When is Electronic Fetal Monitoring Used?
When ordered by the physician, midwife, or indicated by hospital policy.
For screening or surveillance
Intermittently or continuously
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20. Methods of Electronic Fetal Monitoring
External
Noninvasive method
Utilizes an ultrasonic transducer to monitor the fetal heart
Utilizes the tocodynamometer (toco) to monitor uterine contraction pattern
Application directly impacts results of data received
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21. Methods of Electronic Fetal Monitoring
Internal Fetal Monitoring
Invasive
FHR is monitored via a fetal scalp electrode (IFSE)
Uterine activity is monitored by an intrauterine pressure catheter (IUPC)
A combination of external and internal fetal monitoring is common practice
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22. Advantages and Disadvantages of Internal Fetal Monitoring
Patient can move without much interference in data transmission
More accurate measurement of data
Data less likely to be affected by artifact
Disadvantages
Invasive
Membranes have to be ruptured and cervix dilated
Application requires more skill
Procedures more uncomfortable for the mother
Risk of trauma and infection for mother and fetus
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23. Components of the Fetal Monitor Paper Tracing
Example of monitor paper in packet
Strip has two components
Upper graph records FHR data
Small squares represent 10 bpm increases as well as 10 seconds duration
Lower graph records contraction data
Small squares represent 10 second duration or 10 mmHg intensity (if IUPC used)
Dark line to dark line represents one minute of time
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24. Baseline FHR
Normal baseline FHR in a term fetus 37 completed weeks or more is bpm.
Determination of the baseline FHR does not include accelerations or decelerations
Determination of the baseline FHR is done between contractions
Baseline is rounded in increments of 5 bpm example; if the FHR is running then the baseline FHR should be documented as 130
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25. FHR Variability
Normal changes and fluctuations in the FHR over time. Is a characteristic of the baseline exclusive of accelerations or decelerations and is best assessed between contractions
Variability is considered to be the best indicator of fetal well-being
Variability can be influenced by hypoxic events, maternal hemodynamic issues, drugs, etc.
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26. Examples of Variability
Refer to examples in handout
Absent: Not detectable from baseline
Minimal: Less than 5 bpm from baseline but more than undetectable
May occur with normal fetal sleep patterns or if mother has received analgesia for pain but should not be a persistent variability pattern
Moderate : 6-25 bpm from baseline (optimal pattern)
Marked:More than 25 bpm from baseline
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27. Periodic and Episodic FHR Characteristics
Periodic: Refers to changes in the FHR that occur with or in relationship to contractions
Episodic: Refers to changes in the FHR that occur independent of contractions
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28. Examples of Periodic Changes
Variable decelerations: Result from some type of cord compression.
Nuchal cord, True knot
Decreased amniotic fluid
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29. Severe Variable Decelerations
Note the depth from the baseline
Baseline
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30. Early Deceleration
Occur as a result of vagal stimulation to the fetal head during contractions which push the fetal head toward the pelvis.
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31. Late Decelerations
Occur in response to uteroplacental insufficiency. (blood flow to the fetus is compromised and there is less oxygen available to the fetus)
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32. Late Decelerations With Absent Variability
Note the smoothness of the FHR pattern
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33. Prolonged Deceleration
Deceleration of the FHR from the baseline lasting more than 2 minutes but less than 10 minutes.
There is no one explanation for why these occur but are commonly associated with uterine hyperstimulation.
Can also occur without any uterine activity
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34. Example Prolonged Deceleration
Note the duration of the deceleration lasts more than 2 minutes.
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35. FHR Accelerations Are the most common type of FHR changes
The are abrupt changes and will increase from the baseline 15 bpm lasting 15 seconds before return to the baseline in a healthy gestation more than 32 weeks.
Less than 32 weeks increases of 10 bpm lasting 10 seconds are indication of a well oxygenated fetus.
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36. Example Accelerations
Note the increase from the fetal heart baseline
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37. Sinusoidal Pattern
Persistent wave variation of the baseline only seen in about 2% of patients.
Related to severe fetal anemia, hypoxia, or acidosis.
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38. Uterine Activity Assessment
Periodic tightening and relaxing of the uterine muscle.
Pituitary gland is triggered to release a hormone called oxytocin that stimulates the uterine tightening.
Difference in Braxton Hicks (false labor) and true labor is the strength of the contractions and the changes in the cervix.
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39. Characteristics of Contractions
Frequency: How often they occur. They are timed from the beginning of a contraction to the beginning of the next contraction.
Regularity: Is the pattern rhythmic?
Duration: From beginning to end how long does each contraction last?
Intensity: By palpation mild, moderate, or strong.
By IUPC intensity in mmHg
Subjectively: Patient description
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40. Segments of Contractions
Increment: Beginning, building of pressure
Acme: Most intense part of the contraction
Decrement: Diminishing of the contraction
Rest: Period of time between contractions
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41. Assessment of Contractions
Palpation: Use the fingertips to palpate the fundus of the uterus
Mild: Uterus can be indented with gentle pressure at peak of contraction
Moderate: Uterus can be indented with firm pressure at peak of contraction
Strong: Uterus feels firm and cannot be indented during peak of contraction
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42. Electronic Assessment of Contractions
External electronic monitor
Toco: Palpate uterus to find fundus and place on firmest part.
If patient states she is having contractions but none are showing on fetal monitor tracing the first intervention is to readjust the toco.
Problems associated with obesity and patient movement or position changes
IUPC
Physician or CNM inserts device
RN measures strength of contractions in Montevideo Units (MVU’s)
Follow trouble shooting instructions per manufacturer
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43. Determination of True Labor
Contractions will be regular
Contractions will increase in strength, frequency, and duration
Cervix will change!
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44. Questions Regarding Auscultation or Electronic Fetal Monitoring?
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45. References
Martin, E.J., (2002) Intrapartum Management Modules: A Perinatal Education Program. (pp ). Lippincott Williams & Wilkins 3rd Edition.
Simpson, I., & Creehan, P. (2001) Perinatal Nursing 2nd Edition, (pp ). Philadelphia, New York, Baltimore, Lippincott.
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46. The End
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