1. Chapter 18 Fetal Assessment During Labor
Copyright © 2016 by Elsevier Inc. All rights reserved.

2. Learning Objectives
Identify typical signs of normal and abnormal fetal heart rate (FHR) patterns.
Compare FHR monitoring performed by intermittent auscultation with external and internal electronic methods.
Explain the baseline FHR and evaluate periodic changes.
Describe nursing measures that can be used to maintain FHR patterns within normal limits.
Differentiate among the nursing interventions used for managing specific FHR patterns, including tachycardia and bradycardia, absence of or minimal variability, and late and variable decelerations.
Review the documentation of the monitoring process necessary during labor.

3. Basis for Monitoring Fetal response
Oxygen supply must be maintained to prevent fetal compromise.
Decrease in oxygen supply due to:
Reduction of blood flow through maternal vessels
Reduction in oxygen content in maternal blood
Alterations in fetal circulation
Reduction in blood flow to intervillous space in placenta

4. Basis for Monitoring (Cont.)
Uterine activity: Monitoring provides information on uterine contractions.
Fetal compromise: The goals of intrapartum FHR monitoring are to identify and differentiate the normal (reassuring) patterns from the abnormal (nonreassuring) patterns, which can be indicative of fetal compromise.

5. Monitoring Techniques
Intermittent auscultation
Listening to fetal heart sounds at periodic intervals to assess FHR
Easy to use, inexpensive, less invasive than EFM
Difficult to perform on women who are obese
Does not provide a permanent record
Electronic fetal monitoring
External monitoring
Ultrasound transducer
Toco transducer (tocodynamometer)
Monica AN24: Introduced in 2011; 5 electrodes on woman; information transmitted via Bluetooth

6. Monitoring Techniques (Cont.)

7. Monitoring Techniques (Cont.)
Electronic fetal monitoring (Cont.)
Internal monitoring
Spiral electrode
Intrauterine pressure catheter (IUPC)
Display: displayed on the monitor paper or computer screen, with the FHR in the upper section and UA in the lower section

9. Fetal Heart Rate Patterns
Baseline fetal heart rate
Average rate during a 10-minute segment that excludes:
Periodic or episodic changes
Periods of marked variability
Segments of the baseline that differ by more than 25 beats/min
There must be at least 2 minutes of interpretable data

10. Fetal Heart Rate Patterns (Cont.)
Baseline fetal heart rate (Cont.)
Variability
Described as irregular waves or fluctuations in the baseline FHR of two cycles per minute or greater
4 possible categories of variability:
Absence
Minimal
Moderate
Marked

12. Fetal Heart Rate Patterns (Cont.)
Tachycardia: >160 beats/min  10 minutes or more
Bradycardia: <110 beats/min  10 minutes or more
Changes in FHR
Periodic changes occurring with UCs
Episodic (nonperiodic changes) not associated with UCs
Accelerations
Considered an indication of fetal well-being

13. Fetal Heart Rate Patterns (Cont.)

14. Fetal Heart Rate Patterns (Cont.)
Changes in FHR (Cont.)
Decelerations
Early decelerations in response to fetal head compression
Late decelerations due to uteroplacental insufficiency
Variable decelerations due to umbilical cord compression
Prolonged decelerations

15. Fetal Heart Rate Patterns (Cont.)

16. Fetal Heart Rate Patterns (Cont.)

17. Fetal Heart Rate Patterns (Cont.)

18. Fetal Heart Rate Patterns (Cont.)

19. Fetal Heart Rate Patterns (Cont.)

20. Fetal Heart Rate Patterns (Cont.)

21. FHR Monitoring: Care Management
EFM pattern recognition and interpretation
NICHD Workshop 2008 proposed a three-tier system for EFM interpretation
Category I: normal
Category II: indeterminate
Category III: abnormal
Fetal monitoring standards
Nursing management of nonreassuring patterns

22. Fetal Heart Rate Categories
Normal FHR patterns described as reassuring
Category I
Baseline FHR in the normal range of beats/min
Baseline fetal heart rate variability: moderate
Late or variable decelerations: absent
Early decelerations: may be present or absent
Accelerations: either present or absent
(ACOG Practice Bulletin 2009) 22

23. Fetal Heart Rate Categories (Cont.)
Indeterminate FHR patterns
Category II
Bradycardia not accompanied by absence of baseline variability
Tachycardia
Minimal or absence of baseline variability not accompanied by recurrent decelerations
Marked baseline variability
No accelerations in response to fetal stimulation
Periodic or episodic decelerations

24. Fetal Heart Rate Categories (Cont.)
Abnormal FHR patterns described as nonreassuring
Category III
Nonreassuring FHR patterns associated with fetal hypoxemia
Hypoxemia can deteriorate to severe fetal hypoxia
Absence of baseline variability
Recurrent or late decelerations
Bradycardia
Sinusoidal pattern

25. FHR Monitoring: Care Management
Nursing management of abnormal patterns
The five essential components of the FHR tracing that must be evaluated regularly are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time.
If any component is abnormal, corrective measures must be taken immediately to improve fetal oxygenation: intrauterine resuscitation
Supplemental oxygen
Maternal position changes
Increasing intravenous fluids

26. FHR Monitoring: Care Management (Cont.)
Other methods of assessment and interventions
Fetal scalp stimulation and vibroacoustic stimulation
Umbilical cord acid-base determination
Fetal scalp blood sampling
Amnioinfusion
Tocolytic therapy

28. Key Points
Fetal well-being during labor is gauged by the response of the FHR to UCs.
Standardized definitions for many common FHR patterns have been adopted for use in clinical practice by the ACNM, ACOG, and AWHONN.
The five essential components of the FHR tracing are baseline rate, baseline variability, accelerations, decelerations, and changes or trends over time.

29. Key Points (Cont.)
The monitoring of fetal well-being includes FHR and UA assessment and assessment of maternal vital signs.
The FHR can be monitored by either IA or EFM. The FHR and UA can be assessed by EFM using either the external or internal monitoring mode.
Assessing FHR and UA patterns, implementing independent nursing interventions, and reporting abnormal patterns to the physician or nurse-midwife are the nurse’s responsibilities.

30. Key Points (Cont.)
The AWHONN and ACOG have established and published health care provider standards and guidelines for FHR monitoring.
The emotional, informational, and comfort needs of the woman and her family must be addressed when the mother and her fetus are being monitored.
Documentation of fetal assessment is initiated and updated according to institutional protocol.

31. Question
While evaluating an external monitor tracing of a woman in active labor whose labor is being induced, the nurse notes that the fetal heart rate (FHR) begins to decelerate at the onset of several contractions and returns to baseline before each contraction ends. The nurse should:
Change the woman’s position
Discontinue the oxytocin infusion
Insert an internal monitor
Document the finding in the client’s record
ANS: D
Feedback
A Incorrect: The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings.
B Incorrect: It is inappropriate for the nurse to discontinue the oxytocin infusion at this time. The presence of early decelerations is not an ominous sign and does not require any intervention.
C Incorrect: The presence of early decelerations is not an ominous sign and does not require any intervention. It is unnecessary for the nurse to insert an internal monitor.
D Correct: The FHR indicates early decelerations, which are not an ominous sign and do not require any intervention. The nurse should simply document these findings.