1. Fetal Monitoring and Fetal Assessment
A few new techniques and protocols!

2. IA= Intermittent Auscultation
At the start of the 20th Century, IA of the FHR during labor was the predominant method of assessment.
IA is the practice of using a device that allows one to listen to the fetal heart sounds over time.
Examples would be placing the ear over the pregnant abdomen, using a fetoscope, or using a Doppler.

3. EFM= Electronic Fetal Monitoring
Research in Randomized Clinical Trials on Low- risk pregnancies has demonstrated that (Anderson, 1994)
“The use of EFM as compared with IA has not been shown to reduce neonatal morbidity or mortality rates but has been associated with increased rates of cesarean section and maternal infection” (p. 165).

4. EFM= Electronic Fetal Monitoring
This research is a cause for concern as we look at research-based practice and the fact that we are doing “stuff” that has not been necessarily supported by research!
Something to think about and ponder!
The future practice of EFM may change if agencies choose to practice based on clinical research findings.

5. Clinical Decision-making Based on Auscultation Findings
Continue Individualized
Assessment and Care
Assess with IA & palpation per pt/care provider preferences, guidelines, & availability (1:1 nurse to fetus ratio)
Promote maternal comfort & continued fetal oxygenation(position change; anxiety reduction measures
Notify midwife or MD when a problem exists or is resolved
Auscultate FHR
Interpretation
Yes
Reassuring FHR Pattern?
Baseline rate
Regular rhythm
Absence of decrease from baseline No

6. Non-Reassuring FHR Pattern
Baseline <110 pbm
Baseline >160 bpm (unexplained persistent tachycardia for > 3 contractions or > minutes
Irregular rhythm
FHR during & 30 seconds after contractions
Gradual or abrupt change in FHR
Intervention/Management
 frequency of IA to clarify FHR charracteristics
Assess potential cause of FHR characteristics
Attempt to remove problem(s)/cause
Intervene to promote 5 physiologic goals:
Improve uterine blood flow
Improve umbilical blood flow
Improve oxygenation
 uterine activity (e.g. position change, hydration)

7. Continue interventions
Problem Solved ??
YES—Return to Continued Individualized Assessment & Care No
FHR Pattern Persists?
Continue interventions
Apply EFM to clarify pattern interpretation, assess variability, to further assess fetal status
Notify midwife or MD
Consider additional assessments (e.g. fetal scalp stimulation; fetal acoustic stimulation)

8. Goals of Physiologic Interventions
Improve Uterine Blood Flow
Maternal position change
Hydration
Anxiety reduction
Medication
Improve Oxygenation
Maternal oxygen
Maternal breathing techniques
Improve Umbilical Circulation
Vaginal manipulation
Amnioinfusion
Reduce Uterine Activity
Modified pushing
Medication (e.g. discontinue or  rate of labor-stimulating drug infusion

9. PATTERN DEFINITION Baseline
Definitions of Fetal Heart Rate Patterns National Institute of Child Health and Human Development (NICHD)
PATTERN
DEFINITION
Baseline
The mean FHR rounded to increments of 5 bpm during a 10 min. segment, excluding:
- Periodic or episodic changes
- Segments of baseline that differ by more than 25 bpm
The baseline must be for a minimum of 2 min. in any 10 min. segment

10. PATTERN DEFINITION Baseline Variability
Fluctuations in the FHR of two cycles per min or greater
Variability is visually quantitated as the amplitude of peak-to-trough in bpm Absent—amplitude range undetectable- -Minimal—amplitude range detectable but 5 bpm or fewer- -Moderate (normal)—amplitude range bpm-
-Marked—amplitude range greater than bpm

11. PATTERN DEFINITION Acceleration
A visually apparent increase (onset to peak less than 30 sec.) in the FHR from the most recently calculated baseline
The duration of an acceleration is defined as the time from the initial change in FHR from baseline to the return of the FHR to baseline
At 32 weeks of gestation and beyond, an acceleration has an acme of 15 bpm or more above baseline, with a duration of 15 sec. or more but less than 2 min.
Before 32 weeks gestation an acceleration has an acme of 10 bpm or more above baseline, with a duration of 10 sec. or more but less than 2 min.
If an acceleration lasts 10 min. or longer it is a baseline change

12. PATTERN DEFINITION Bradycardia Early deceleration
Baseline FHR less than 110 bpm
In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 sec. or more) decrease in FHR with return to baseline*Nadir of the deceleration occurs at the same time as the peak of the contraction

13. PATTERN DEFINITION Late deceleration Tachycardia
In association with a uterine contraction, a visually apparent, gradual (onset to nadir 30 sec. or more) decrease in FHR with return to baseline
Onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively
Baseline > 160 bpm

14. PATTERN DEFINITION Variable Deceleration Prolonged Deceleration
An abrupt (onset to nadir less than 30 sec), visually apparent decrease in the FHR below the baseline
The decrease in FHR is 15 bpm or more, with a duration of 15 seconds or more, but < 2 minutes
Visually apparent decrease in FHR below the baseline
Deceleration is 15 bpm or more, lasting 2 minutes or more but less than 10 minutes from onset to return to baseline.

15. That’s it for now!!
Have fun learning more about the Fetal Heart Monitor on the clinical unit!
Technology is really going places in fetal surveillance, so who knows what will be next!!