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Fetal Assessment during Labor

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Presentation on theme: "Fetal Assessment during Labor"— Presentation transcript:

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

4 Retrieved January 4, 2009 from

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,

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