Nursing Care of Mother Undergoing Electronic Fetal Monitoring (EFM)

What is continuous Fetal Monitoring ?

FM is a method of assessing fetal status both before and during labor. The fetal heart tones are obtained and evaluated to identify any abnormalities that can impact fetal wellbeing. This evaluation can be done at intervals by intermittent auscultation, or continuously by minute to minute EFM.

This kind of fetal monitoring is an electronic method of continuously assessing the fetal heart rate and obtaining information about the laboring woman’s uterine activity, this information is recorded on graph paper, allows on ongoing minute to minute assessment of fetal well being during labor and provides a permanent record for the medical chart.

1.Ante-partal risk factors 2. Intra-partal risk factors

* External FM *Internal FM *A combination

* EFM is also called indirect fetal monitoring or noninvasive fetal monitoring. *A ultrasonic transducer to monitor the FHR. *While the contraction pattern is monitored with atocdynamometer both are applied to the laboring woman’s abdomen.

* The patient can be monitored at any time. * It is convenient * Minimal training is required * No fetal or maternal complications are associated with E.F.M.

* Direct FM. * Invasive FM. *FHR is monitored by the use of a helix electrode which is applied directly to the presenting part of the fetus. * Contraction Pattern is monitored by the use IUPC which is inserted directly into the uterine cavity through the cervix.

* The helix can be used with breach or vertex presentation. In VP the helix is attached the fetal scalp. In BP the helix is attached to the buttocks or feet to minimize the risk of fetal injury. *The face, fontanells suture lines, genitals and rectum must be avoided during electrode attachment. *The IUPC is inserted through the cervix beside the presenting part of the fetus. *The IUPC is used to determine the actual pressure inside the uterus during contraction.

3. A combination of internal & external FM *The FHR is monitored internally by the use of a helix electrode and contraction pattern is monitored externally by the use of tocodynamometer. Hwever, the opposite also be used.

*Can be described as irregular fluctuations in the baseline FHR of 2 cycles per minute or greater. *Variability has been described as short term (beat to beat) or long term (rhythmic waves or cycles from baseline).

Decreased variability can result from fetal hypoxemia and acidosis, as well as from certain drugs that depress the CNS, including analgesics, narcotics, barbiturates, tranquilizers, and general anesthetics. In addition, a temporary decrease in variability can occur when the fetus is in a sleep state. These sleep states do not usually last longer than 30 minutes.

Increased variability can result from early mild hypoxemia, Fetal stimulation by the following: *Uterine palpation *Uterine contractions *Fetal activity *Maternal activity *Street drug (e.g., cocaine and methamphetamines)

Periodic and Episodic changes in FHR *Periodic changes occur with uterine contractions. *Episodic changes not associated with uterine contractions. These patterns include accelerations and decelerations.

Abrupt increase in FHR above the baseline rate. The increase is 15 beats per minute or greater and lasts 15 seconds or more. Accelerations can be periodic or episodic.

Periodic accelerations caused by dominance of the sympathetic nervous response and are usually with breech presentation. Pressure of the contraction applied to the fetal buttocks results in accelerations, whereas pressure applied to the head results in decelerations

Accelerations of the FHR that are episodic occur during fetal movement and are indications of fetal well-being.

A Decelerations caused by dominance of parasympathetic response may non- reassuring. Their relation to the onset and end of a contraction and by their shape.

1.Early deceleration of the FHR Is a visually apparent gradual decrease in and return to baseline FHR in response to compression of the fetal head. It is a normal and usually benign finding.

This deceleration is characterized by a uniform shape and an early onset corresponding to the rise in intra amniotic pressure as the uterus contracts. When present, it usually occurs during the first stage of labor when the cervix is dilated 4 to 7 cm.

Early decelerations sometimes are seen during the second stage when the woman is pushing. They also occur in response to fetal head compression during uterine contractions, during vaginal examinations, as a result of fundal pressure, and during placement of the internal mode for FM.

2. Late deceleration of the FHR Utero-placental insufficiency causes late deceleration the FHR. The deceleration begins after the contraction has started, and the lowest point of the deceleration occurs after the peak of the contraction. Usually the deceleration does not return to baseline until after the contraction is over.

3. Variable deceleration A visual abrupt decrease in FHR below baseline. The decrease is usually more than 15 beats per minute, lasts at least 15 seconds, and usually returns to baseline in less than 2 minutes from the time of onset.

Variable decelerations occur any time during the uterine contracting phase and are caused by compression of the umbilical cord.

NURSING CARE OF MOTHER USING EFM * Explain and demonstrate to mother and labor support partner how the electronic monitor (internal or external) works in assessing FHR and in detecting and assessing quality of uterine contractions to remove fear of unknown and ensure that mother can work with the monitor.

* When making adjustments to the monitor, explain to the couple what is being done and why because information increases understanding and allays anxiety. * Explain that fetal status can be continuously assessed even during contraction. * Explain that use of external monitoring usually requires the woman’s cooperation during positioning and movement.

* Provide rationale for maternal position other than supine. * Carefully follow guidelines and checklist for application and initiation of monitoring to ensure proper placement of monitoring devices and production of accurate output from monitoring device.

Check placement throughout monitoring process to ensure that devices remain correctly placed. * Auscultation FHR with stethoscope or if in doubt as to validity of tracing. *

* Regularly assess and record results of EFM (FHR variability, decelerations, accelerations, uterine activity, contractions, uterine resting tone) to provide consistent and timely evaluation of fetal well-being and progress of labor.

* Auscultate FHR and palpate contractions on a regular basis to provide a cross-check on the EFM output and ensure fetal well-being.

Documentation: Monitor Strip Observations: Maternal vital signs Maternal position/repositioning Vaginal examinations and findings Medications; anesthesia/analgesia Voidings; emesis Fetal movement, baseline FHR Pushing/bearing down

Adjustments Adjustments Relocation of transducers Flushing or adjustment of catheter Replacement of catheter Time lapsed while changing monitor strip paper

Interventions Position Change Parenteral fluids Discontinuance of oxytocin Oxygen administration Notification of physician/CNM

Emergency measures Implement immediately for nonreassuring pattern: * Reposition patient in lateral position to increase uteroplacental perfusion or relieve cord compression * Administer oxygen at 10 to 12L/min or per hospital protocol via face mask * Discontinue oxytocin if infusing

* Correct maternal hypovolemia by increasing IV as ordered * Assess for bleeding or other cause of pattern change, such as maternal hypotension * Notify physician/ certified nurse midwife

It is responsibility of the nurse to assess FHR patterns, perform independent nursing interventions, and report non- reassuring patterns to the physician or nurse -midwife.

The emotional, informational, and comfort needs of the woman and her family must be addressed when the mother and her fetus are being monitored.