1. Basic Fetal Monitoring Review
Ana H. Corona, FNP-C
Nursing Instructor
February 2009

2. Electronic 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
Information is recorded on graph paper
Information is permanent part of the maternal medical record
Information is retrievable for litigation
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3. Normal Assessment Findings
FHR between in gestations weeks
Rates slightly above 160 are normal in gestations less than 32 weeks.
Regular rhythm
Increases in the FHR associated with fetal movement that return to original rate range
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4. 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 to be prepared to interpret fetal monitor tracings
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5. 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
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6. Methods of Electronic Fetal Monitoring
Internal Fetal Monitoring
Invasive
FHR is monitored via a fetal scalp electrode
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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7. 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
Procedure is uncomfortable for the mother
Risk of trauma and infection for mother and fetus
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8. Components of the Fetal Monitor Paper Tracing
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
Dark line to dark line represents one minute of time
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9. Baseline FHR
Normal baseline FHR in a term fetus 37 completed weeks or more is bpm.
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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11. FHR Variability Normal changes and fluctuations in the FHR over time.
Best assessed between contractions
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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12. Examples of Variability
Absent: Not detectable from baseline
Minimal: Less than 5 bpm from baseline
May occur with:
normal fetal sleep patterns
mother has received analgesia for pain
Moderate : 6-25 bpm from baseline (optimal pattern)
Marked: More than 25 bpm from baseline
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13. How Do Uterine Contractions Affect Fetal Heart Rate?
Can affect FHR by increasing or decreasing the rate in association with any given contraction. 
3 primary mechanisms by which UCs can cause a decrease in FHR
         Fetal head
         Umbilical cord
         Uterine myometrial vessels

14. 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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15. Examples of Periodic Changes
Variable decelerations: Result from some type of cord compression.
Nuchal cord, True knot
Decreased amniotic fluid
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16. Severe Variable Decelerations
Note the depth from the baseline
Baseline
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17. 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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18. Late Decelerations
Occur in response to utero-placental insufficiency. Blood flow to the fetus is compromised and there is less oxygen available to the fetus)
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19. Late Decelerations with Absent Variability
Note the smoothness of the FHR pattern
Decreased FHR caused by utero-placental insufficiency
Compromised blood flow to fetus
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20. Prolonged Deceleration
Deceleration of the FHR from the baseline lasting more than 2 minutes but less than 10 minutes.
No explanation for why these occur
Commonly associated with uterine hyperstimulation.
Can also occur without any uterine activity
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21. Example Prolonged Deceleration
Note the duration of the deceleration lasts more than 2 minutes.
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22. FHR Accelerations Are the most common type of FHR changes
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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23. Example Accelerations
Note the increase from the fetal heart baseline
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24. 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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25. 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 contractions and true labor is the strength of the contractions and the changes in the cervix.
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26. 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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27. Uterine Contraction

28. 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

29. 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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30. Variable decelerations in FHR during labor are severe dips occurring at the peak of contraction. This FHR problem is associated with which one of the following conditions?
Utero-placental insufficiency
Fetal head compression
Uterine insufficiency
Pressure on the umbilical cord

31. Answer is D These decelerations are common during labor.
The FHR drops during the contraction resulting from stimulation from chemoreceptors and baroreceptors as the cord is compressed.
The nurse should recognize these readings on the fetal monitor as normal.

32. A nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate?
Document the findings and tell the mother that the monitor indicates fetal well-being
Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen.
Notify the physician of the findings.
Reposition the mother and check the monitor for changes in the fetal tracing

33. Answer is 1
Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement.
Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.

34. A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client’s abdomen. After attachment of the monitor, the initial nursing assessment is which of the following?
Identifying the types of accelerations
Assessing the baseline fetal heart rate
Determining the frequency of the contractions
Determining the intensity of the contractions

35. Answer is 2
Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur.
Options 1 and 3 are important to assess, but not as the first priority.

36. A nurse is monitoring a client in labor
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction?
Early decelerations
Variable decelerations
Late decelerations
Short-term variability

37. Answer is 2
Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus.
Early decelerations result from pressure on the fetal head during a contraction.
Late decelerations are an suggests utero-placental insufficiency during a contraction.
Short-term variability refers to the beat-to-beat range in the fetal heart rate.

38. The physician asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s contractions by timing from the beginning of one contraction:
Until the time it is completely over
To the end of a second contraction
To the beginning of the next contraction
Until the time that the uterus becomes very firm

39. Answer is 3
This is the way to determine the frequency of the contractions

40. When monitoring the FHR of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as:
An acceleration
An early elevation
A sonographic motion
A tachycardic heart rate

41. Answer is 1
An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate.
A tachycardic FHR is above 160 beats per minute.

42. Which of the following findings meets the criteria of a reassuring FHR pattern?
FHR does not change as a result of fetal activity
Average baseline rate ranges between BPM
Mild late deceleration patterns occur with some contractions
Variability averages between BPM

43. Answer is 4
Variability indicates a well oxygenated fetus with a functioning autonomic nervous system.
FHR should accelerate with fetal movement.
Baseline range for the FHR is 120 to 160 beats per minute.
Late deceleration patterns are never reassuring, though early and mild variable decelerations are expected, reassuring findings.

44. References AWHONN Clinical Position Statement P. Burroughs, MSN, RN
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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