NUR 231
M. Johnston, RN-BC, M.Ed.
Cindy Irwin , RNC, MN
Types of Monitoring
Auscultation- listen to fetal heart rate (FHR)
Electronic Fetal Monitoring – use of instruments to record
FHR and uterine contractions(U/Cs)
Auscultation
 Doppler - ultrasound converts sounds waves to signals of
fetal heart
 Fetoscope - Like stethoscope, open end pressed on
abdomen, used less frequently
Electronic Fetal Monitoring
 Measures response of FHR to uterine contractions (U/Cs)
 Intermittent or Continuous
 External
 Ultrasound transducer
 Tocotransducer
 Internal
 Fetal Scalp Electrode
 Intrauterine Pressure Catheter
Fetal Monitoring Setup
Fetal Heart Rate Characteristics
 Evaluate to determine fetal status
 NICHD terminology
 Baseline Rate
 Baseline Variability
 Accelerations (present or absent)
 Decelerations (present or absent)
 Changes or trends over time
Baseline (BL)
 Normal range 110-160 bpm
 Measure between U/Cs for at least 2 min. period during
10 minute segment
 Tachycardia - >160 bpm for >10 minutes
 Bradycardia - <110 bpm for >10 minutes
Baseline
Classifications of FHR Variability
 Fluctuations in FHR, irregular in frequency and amplitude
 Absent 0-2 bpm
 Minimal >2 <6 bpm
 Moderate 6 -25 bpm
 Marked >25 bpm
Absent Variabilty
Minimal Variability
Moderate Variability
Marked Variability
Periodic/Episodic Changes
Periodic with uterine contractions
Episodic without uterine contractions
Accelerations
 Abrupt increase in FHR above BL
 Present or Absent
 < 32 wks gestation
 Peak ≥ 10 bpm above BL for at least 10 sec.
 >32 wks gestation
 Peak ≥ 15 bpm above BL for at least 15 sec.
 Accel ≥ 10 min. is defined as BL change
Accelerations
 Abrupt increase in FHR above BL
 Peak ≥ 15 bpm above BL for at least 15 sec.
Recognition Criteria for Fetal Heart
Rate Accelerations
 Transient increase in the Fetal Heart Rate
 > 32 weeks acceleration stays 15 beats above the baseline
for at least 15 seconds
 < 32 weeks acceleration stays 10 beats above the baseline
for at least 10 seconds
Types of Decelerations
 Early – Gradual decrease and return to BL, mirrors the
U/C
 Variable – Abrupt (<30 sec) decrease (≥15 sec down,
lasting ≥ 15 sec and <2 min from onset to return to BL)
 Late – Gradual decrease (≥30 sec) and gradual return to
BL; delayed timing nadir occurs after peak of U/C
 Prolonged – Decrease in FHR below BL ≥15 sec, lasting ≥ 2
min. but <10 min.
Early Deceleration
 Gradual decrease and return to BL
 Mirrors the U/C
Early Deceleration
Early Decelerations
 Usually benign
 May be associated with descent of fetus
 Monitor to assure fetal well-being, no evidence of
worsening condition
Variable Deceleration
 Abrupt (<30 sec) decrease (≥ 15 sec down, lasting ≥
15 sec and < 2 min. from onset to return to BL)
Variable Decelerations
Variable Deceleration- Cause and
Treatment
Cause Umbilical cord compression resulting
in baroreceptor stimulation
Treatment Assess baseline variability, rate
 Reposition mother
 Notify provider
 Check for cord prolapse
 Apply internal monitors
  or turn off oxytocin
 Administer O2 by mask
 Prepare for possible amnioinfusion
 Document interventions/FHR response
Late Deceleration
 Gradual decrease (≥ 30 sec) and gradual return to BL
 Delayed timing, nadir occurs after peak of U/C
Late deceleration
Late decelerations - Cause and
Treatment
Cause- Placental insufficiency
Treatment
 Assess baseline variability, rate, accelerations
 Reposition mother on side
  IV fluids
  or turn off oxytocin
 Notify provider
 Administer O2 by mask
 Apply internal monitors
 Evaluate scalp stimulation
 Document interventions/FHR response
 Exit plan
Prolonged Deceleration
 Decrease in FHR below BL ≥ 15 sec, lasting ≥ 2 min.
but < 10 min.
Causes of Prolonged Decelerations
 Uterine hyperstimulation or hypertonus
 Abruptio placenta
 Acute maternal hypotension
 Uterine rupture
 Maternal hypoxia
 Umbilical cord accidents
 Terminal fetal conditions
 Vasa previa
 Rapid fetal descent
 Vagal stimulation or maternal Valsalva
Treatment for Prolonged
Decelerations
 Notify provider
 Assess baseline variability, rate, accelerations Reposition
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mother on side
 IV fluids
 or turn off oxytocin
Administer O2 by mask
Apply internal monitors
Do not attempt scalp stimulation
Document interventions/FHR response
Exit plan
Sinusoidal FHR
Fetal Heart Rate Patterns
Normal
ALL required:
•Moderate variability
•Baseline rate 110-160
•No late or variable decels
•Early decels present or
absent
•Accels: present or absent
Indeterminate
FHR tracings that do not
meet the criteria for
Normal or Abnormal
Abnormal
Absent baseline variability
and any of the following:
• Recurrent late decels
• Recurrent variable decels
• Bradycardia
or
Sinusodial pattern
Category I
Category II
Category III
Strongly
associated with
normal acid base
status
Not predictive of
abnormal fetal acid
base status but
inadequate evidence
to classify as normal or
abnormal
Predictive of
abnormal fetal
acid base
status
Fetal Heart Rate Interpretation System
Category l
Normal
Associated with normal acid
base balance
Category ll
Indeterminate
Inadeq. evidence to classify as
normal or abnormal
Category lll
Abnormal
Predictive of abnormal acid
base status
FHR Interpretation
 Information about fetal oxygenation/placental function
 Somewhat subjective
 Abnormal patterns may need further testing
Monitoring Uterine Contractions
 Assess U/C pattern while assessing FHTs
 External
 Palpation
 EFM Toco measures frequency, duration
 Noninvasive
 Internal
 Intrauterine pressure catheter (IUPC)
 Measures exact intrauterine pressure
 Invasive
Why Monitor?
 FHR changes in response to oxygenation, gestation, and
certain stimuli
 EFM provides more objective data than auscultation
 Infers information about current and ongoing fetal
oxygenation
Interventions
 Abnormal FHR pattern:
 Notify provider
 Change maternal position
 Give oxygen via mask
 Increase IV fluids
 Consider medication to relax uterus
Other Fetal Surveillance
 Non-Stress Test (NST) - EFM
 Contraction Stress Test (CST) - EFM
 Biophysical Profile (BPP) - U/S
 Doppler Flow Studies/Growth - U/S
 Fetal Movement Count-maternal sensation/palpation
Intermittent Auscultation
 What’s the evidence?
 ACOG, AWHONN support the use of auscultation as an
appropriate way to evaluate fetal heart rate for the
uncomplicated patient
 Neonatal outcomes comparable to those with use of EFM
based on randomized clinical trials
Technique for IA
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Assess contractions by palpation
Determine fetal position
Determine maternal pulse rate
Place Doppler over fetal back or thorax
Determine baseline FHR by listening between contractions for
30-60 seconds: differentiate from maternal HR
 Count FHR immediately after contraction for 30-60 seconds
 Chart under Intermittent Auscultation- Baseline, Rhythm,
Increases, Decreases
How often?
On admission, obtain 20 minute FM tracing
If Category I tracing, no risk factors present, and provider
order for IA:
Document FHR and uterine activity:
 Latent phase: As ordered
 Active labor: Every 15-30 minutes
 Second stage: Every 5-15 minutes
Comparison Model for Palpation of Uterine
Activity
PALPATION OF UTERUS FEELS LIKE CONTRACTION
INTENSITY
• Easily indented • Tip of nose • Mild
• Can slightly indent • Chin • Moderate
• Cannot indent • Forehead • Strong
Limitations
 Difficult to hear FHR with if pt obese, has an increased
AFI, or with maternal or fetal movement
 No tracing to review at a later time
 Certain EFM characteristics cannot be measured
(sinusoidal pattern)
 Requires practice
Benefits
 Lower C/S and operative delivery rates compared to EFM
for patients without risk factors
 Allows maternal freedom of movement/ambulation
 Increased hands-on contact with patient
 Increased patient satisfaction