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Basic Fetal Monitoring Southwest Washington Perinatal Education Consortium Kathleen Murray, CNM, MN, RN.

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Presentation on theme: "Basic Fetal Monitoring Southwest Washington Perinatal Education Consortium Kathleen Murray, CNM, MN, RN."— Presentation transcript:

1 Basic Fetal Monitoring Southwest Washington Perinatal Education Consortium Kathleen Murray, CNM, MN, RN

2 Objectives Identify the components of a fetal heart rate pattern: baseline, variability, accelerations, decelerations, periodic, and non-periodic changes Discuss maternal and fetal physiology and how it influences fetal heart rate patterns Differentiate criteria for reassuring and non- reassuring fetal heart rate patterns

3 Fetal Heart Rate Monitoring Techniques Auscultation Fetoscope

4 Auscultation Fetoscope Low tech Need quiet room

5 Auscultation Doppler Motion detector Portable Some models are made for underwater use (in tub)

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7 Doppler Doppler used throughout pregnancy and labor

8 Auscultation Benefits Detects baseline FHR rhythm and dysrhythmias Hear changes in fetal heart rate Differentiates maternal from fetal heart rate

9 Auscultation Limitations Not continuous No printout or computer record Can’t demonstrate variability Requires some 1:1 nurse-time May be limited by position of mother

10 Fetal Heart Rate Monitoring Techniques Electronic Fetal Monitoring External Internal

11 Fetal Monitoring Strip

12 What’s the Purpose of Fetal Monitoring ???

13 Purpose of Electronic Fetal Monitoring Identify reassuring signs of fetal well-being Screen for non-reassuring signs of a fetus who is at risk

14 Benefits of External Fetal Monitoring (EFM) Noninvasive Paper document Demonstrates variability Less labor intensive

15 Limitations of EFM Restricts patient movement Measures cardiac motion, is not ECG Doubling or half-count of FHR possible Might pick up maternal HR instead

16 Internal Fetal Monitoring Spiral electrode (FSE) provides direct ECG Measures interval between R waves Produces very accurate picture of FHR

17 Benefits of Internal Monitoring (Using FSE) Accurate measure of FHR and variability May detect dysrhythmias Can allow for more patient movement

18 Limitations of FSE Membranes must be ruptured to use Risk of infection If fetus has died, may pick up maternal heart rate accidentally

19 Uterine Activity Monitoring External: tocotransducer Detects frequency and length, not strength Requires palpation to assess strength of contractions

20 Uterine Monitoring Note the normal- looking UC first Then baseline rises and next few UC’s seem high (false) External UC monitor does not accurately show strength

21 External Uterine Monitoring BENEFITS Noninvasive Provides documentation of UC frequency and duration LIMITATIONS Does not measure strength of contraction, nor resting tone of uterus Difficult to use in maternal obesity, in some positions

22 Monitoring With Internal Uterine Pressure Catheter (IUPC) Accurate measure of uterine pressure Contraction strength, and resting tone Measured in mmHg Accurate timing of FHR changes in relation to UC’s

23 IUPC INDICATIONS External reading not adequate Labor dystocia Fetal distress Amnioinfusion for cord compression RISKS Infection Uterine perforation Placental injury Extraovular placement

24 IUPC placement

25 Are You Worried?

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28 Fetal Heart Rate Monitoring Baseline, rounded up to nearest 5 bpm Variability Accels and Decels Periodic changes (with UC’s) Non-periodic changes (spontaneous)

29 Fetal Heart Rate Monitoring Baseline Normal: bpm Tachycardia : >160 bpm for >10 minutes Bradycardia: 10 minutes

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31 Variability Characteristic of FHR baseline Smoothness, or roughness of the line Very important characteristic of FHR, must be present for reassuring strip

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33 Variability Assessed in between UC’s and periodic changes Absent: undetectable Minimal: 1-5 bpm amplitude Moderate: 6-25 bpm (normal) Marked: >25 bpm (also called saltatory)

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35 Causes of Decreased Variability Non hypoxic causes Fetal sleep (20 min) Medications Tachycardia (such as from maternal fever) Fetal anomaly dysrhythmia Hypoxic causes Uteroplacental insufficiency Cord compression Mat. Hypotension Tachysystole Abruption Tachycardia

36 Interventions Determine cause Position change IV fluids Oxygen 10 liters snug face mask Stop or turn down pitocin Place internal FSE Notify MD/CNM without delay

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38 Sinusoidal Pattern Not to be confused with variability!! Regular, sine-like wave pattern with amplitude of 5-15 bpm above and below baseline Ominous in most cases, requires prompt intervention, usually immediate C-section Usually caused by severe fetal anemia, can be from hypoxia, or briefly from narcotic dose

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40 Causes of Increased Variability Uteroplacental insufficiency or Cord Compression or Fetal Activity and A compensatory response to a mild hypoxic event

41 Interventions Determine cause Position change Assess fetal response

42 Accelerations Caused by sympathetic nervous system response to fetal movement or stimuli, normal and reassuring, rules out acidosis But, periodic accels, with UC’s are mild cord compression

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44 Criteria for Accelerations <32 weeks gestation, stays 10 beats above baseline for at least 10 seconds For > 32 weeks, acceleration stays 15 beats above baseline for at least 15 seconds

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47 Early Decelerations Caused by pressure on fetal head, vagal response Uniform, mirrors contraction Gradual onset, reaches nadir >30 sec. Reaches nadir at peak of UC, returns to baseline by the end of UC Benign

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49 Variable Decelerations Caused by cord compression, baroceptor response quickly slows FHR to compensate Abrupt onset, reaches nadir < 30 sec. Decel. Of >15 bpm lasting > 15 sec., and return to baseline < 2 minutes

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51 Causes of Variable Decelerations Intrauterine Nuchal cord, or body entanglement Oligohydramnios Rupture of membranes Short cord or true knot Occult prolapse of cord Maternal conditions Positioning Second stage labor with descent Monoamniotic multiple gestation

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53 Variable Decel. Characteristics Shape, depth, and duration vary (not uniform), can be V, W, U shaped Timing may vary Watch for fetal compromise increasing baseline loss of variability slow return to baseline

54 Interventions Vag. Exam rule out prolapse Position change IV fluids Oxygen 10 l/mask Turn pit off or down Assess fetal response Call MD/CNM Same list as with late decels, except added vag exam, and If ordered, start amnioinfusion

55 Late Decelerations Caused by uteroplacental insufficiency Fetus runs low on oxygen during a UC Maternal, placental, or fetal cause of inadequate oxygen to fetal heart Often indicates metabolic acidosis Needs urgent response

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57 Late Decel. Characteristics Always associated with a UC, with delay in timing Gradual decrease from baseline to nadir >30 seconds Nadir occurs after peak of UC Depth of decel usually only 5-30 bpm

58 Interventions Lateral position, (usually left works best) Increase IV fluids Oxygen 10 l/mask Stop pitocin Call MD/CNM Determine cause, and correct if possible Assess fetal response Prepare for possible delivery

59 Prolonged deceleration Deceleration of >15bpm, lasting more than 2 minutes, less than 10 minutes Measured from onset until return to baseline Often is long, exaggerated variable Cause often: cord compression, or tachysystole, or maternal hypotension

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61 Interventions Without Looking at Your Notes, Tell Me What You’d Do for a Prolonged Decel? Hint: Same List As for lates

62 Interventions Lateral position Increase IV fluids Oxygen 10 l/mask Stop pitocin Call MD/CNM Determine cause, and correct Assess fetal response Prepare for possible delivery, moving into O.R. by 3 rd minute if not resolving

63 Uterine Contractions

64 Contraction Monitoring Interval “how far apart are they?” Duration “how long do they last?” Resting tone: how does the uterus feel between contractions Intensity “how hard are they?” mild moderate strong

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66 Electronic Fetal Monitoring Strip Interpretation

67 Systematic Review of strip Baseline Normal is ___________ Variability Expressed as _________ Accelerations Present, or absent Decelerations Present, or absent 3 major types: ________________ Contraction pattern

68 Begin…. By looking at what is reassuring on the strip Then, note any concerning features

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71 Documentation Critical job for you, your hospital, the patient Chart as if the hard copy of your strip will get lost later…10% or more of all strips do Clear, concise language Institution-specific Standards of care

72 Documentation on the strip Label/write patient name, date etc. Events, actions, nursing interventions Calls to MD, CNM, nursery, etc. What not to write on strip

73 Auscultation documentation Rate Rhythm (regular, irregular) Increases in rate (audible accels) Decreases (audible decels, and the timing)

74 FHR Documentation Intervals Auscultation or EFM Low risk patient: Active labor every 30 minutes 2 nd stage every 15 minutes High risk patient Active labor every 15 minutes 2 nd stage every 5 minutes

75 If Confusing Pattern Complex patterns, combination of 2 types of decelerations sometimes exist Focus on: baseline stable or not, variability and accels, whether decels are periodic or not, timing related to UC’s, abruptness of change from baseline Sometimes helps to draw decel in your chart notes

76 Documenting Uterine Activity What four characteristics do you note? ____________________

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78 Example of Charting 2100-FHR baseline 130, accels to 160 present, no decels. UC’s q 2.5 minutes x seconds, palpate moderate, resting tone soft. K Jones, RN

79 Non-reassuring FHR Patterns Document the following: Pattern Nursing intervention Evaluation of response Notification of MD or CNM

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81 Example of Charting FHR 170, minimal variability, no accels, no decels. UC’s q minutes x seconds, peaks 40-50mmHg, resting tone 25. Positioned Left-lateral, O2 on 10 l per tight mask, pitocin turned off, IV rate increased. No change in FHR pattern. Phoned Dr James with report of non-reassuring strip and asked him to come now to evaluate. He stated he is on his way. Explained to patient and husband. K Jones, RN

82 Conclusion Methods of fetal monitoring Components of FHR, and uterine activity Causes of various changes Nursing interventions Systematic review of strip Documentation

83 References Abcdefm:electronic fetal monitoring, Curran, Carol, and Torgersen, Keiko, Colley Avenue Copies & Graphics, Virginia Beach, VA, 2006, pp.31,158-9, 167,169,170, Fetal Heart Monitoring Principles & Practices 4th ed., Lyndon, Audrey et al editors, AWHONN, Kendall/Hunt, Dubuque, Iowa, NCC Monograph, Vol 2, No. 1, 2006, National Certification Corporation, pages 6-11.


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