Introduction to Electronic Fetal Monitoring
Looking for oxygenation when looking at the fetal monitor
Metabolic acidemia and hypoxia
Maternal pathway to oxygenation of the fetus (asthma, preeclampsia, HTN)
Disruption can be maternal, disruption at the umbilical cord, at the placenta, or at the fetus
Toconometer- Band measuring contractions at the top of the fundus
Fetal monitoring occurs lower on the abdomen, allows continuous monitoring for FHR (fetal heart rate). If
heart tones are found on the fundus, baby is probably breech.
Primary Objective
1.To provide information about fetal oxygenation and prevent fetal injury from impaired oxygenation
2.To detect fetal heart rate changes before they are prolonged and profound
Leopold’s Maneuvers: Determining the position of the fetus to assist with monitor placement
- If you feel some squishy up high, probably buttocks, if it’s hard, probably head
- Check side to side, find fetal back and place monitor there
Fetal Strip:
- Time between big boxes is 1 minute, small boxes are 10 seconds
- Fetal heart rate in upper pane, uterine contractions in lower pane
Contractions: Measure from the start of one contraction to the start of the next for frequency, count from
beginning of one contraction to the end of same contraction for duration.
- More than 5 uterine contractions in 10 minutes (averaged over 30 minutes), or 2 uterine
contractions lasting more than 120 seconds in duration is called tachysystole and requires nurse
intervention. (Too many contractions, can be caused by Pitocin
Fetal Monitor Interpretation:
- Baseline FHR
- FHR variability (think oxygenation)
- Are HR accelerations present? (if you have accel, you have oxygenation)
- Are decelerations present? If yes, which variety
- Determine FHR category
- Intervention necessary
Normal Values:
- 110-160 FHR
What is variability?
- Absent= no changes= not good= metabolic acidemia or hypoxia
- Minimal 0-5 beats of change (less than ½ box) = acuity depending on situation
- Moderate 6-25 beats of change (more than ½ box to 2 ½ boxes)= we have fetal oxygenation
- Marked= greater than 25 beats of change (more than 2 ½ boxes)
Accelerations: 15 beats above baseline for at least 15 seconds, usually accompanied by fetal movement
(called 15 x 15’s), younger babies may only be 10 x 10’s
Decelerations:
- Variable= below baseline 15 beats, abrupt descent of FHR, may occur with contraction or
independently= related to cord compression
-
Early= Occurs with a contraction, will mirror contraction (starts at same time and ends at same time)
Late= Starts after the contraction has started (usually after the peak of the contraction) = uterine
placental insufficiency
Prolonged= below baseline for more than 2 minutes but less than 10 min= metabolic acidemia or
hypoxia, baby needs to be delivered
Epidural= can cause hypotension, and decreased perfusion, but can cause late decelerations. Usually, fluid is
given prior to getting an epidural to try and prevent the hypotension and late deceleration.
Sinusoidal FHR pattern= baby has metabolic acidemia, fetal hemorrhage or anemia, abnormal neural tube.
Strip looks like equal triangles up and down, like a uniformed v-fib
Deceleration/Cause
V=Variable—C= Cord compression
E=Early—H= Head compression
A= Acceleration—O= Okay or oxygen
L= Late—P= Placental Insufficiency
Category 1 – GoodBaseline range 110-160Baseline variability - moderateLate or variable decelerations –
absentEarly decelerations – present or absentAccelerations – present or absent (baby is okay, no
metabolic acidemia or hypoxia)
- NICHD Terminology: Normal baseline FHR, moderate variability, and lack of concerning
decelerations- Continue monitoring.
Category 2 – Caution *Baseline range – may have tachycardia or bradycardia without absent
variability*Baseline variability – minimal or absent without recurrent decelerations or marked.*Late or
variable decelerations – recurrent variable with minimal or moderate variability, Prolonged >2min but <10
min, recurrent late with moderate variability*Early decelerations – present or absent*Accelerations – present
or absent (baby could be okay, but also could be heading towards metabolic acidemia or hypoxia)
- NICHD Terminology: FHR patterns that are concerning enough to warrant increased frequency in
monitoring, but that respond to interventions provided- General measures; consider discontinuing
oxytocin; consider potential need to expedite delivery if abnormalities persist or worsen.
Category 3 – Intervention neededBaseline range – 110-160, bradycardia or tachycardiaBaseline variability
–AbsentLate or variable decelerations – recurrent variable or recurrent late (Impending or current
metabolic acidemia or hypoxia, needs immediate delivery within 30 min)
- NICHD Terminology: Absent baseline FHR variability with recurrent late or variable decelerations
and/or bradycardia or with a sinusoidal patter- General measures; discontinue oxytocin; expedite
delivery by operative vaginal or cesarean delivery.
Uterine Resuscitation: (position change, IV fluids, O2, Pitocin)
- IV Fluid Bolus (lactated Ringer’s 500 mL rapidly with pressure bag)
- Maternal position change (left lateral, right lateral, hands and knees, hips open with the use of
peanut ball, high Fowler’s).
- Apply O2 10 L via non-rebreather facemask
- Turn Pitocin off.
Fetal tachycardia main cause is MATERNAL FEVER
Laboring:
First stage of labor: begins with onset of regular uterine contractions, ends with full cervical effacement and
dilation
- Latent phase: up to 3cm of dilation
- Active phase: 4-7 cm of dilation
- Transition phase: 8-10cm of dilation
•Maternal status (vital signs, pain, prenatal record review)
- Vaginal examination (cervical dilation, effacement, membrane status, fetal descent and
presentation)
- Rupture of membranes
- Uterine contractions
- Leopold’s maneuvers
Typical signs of 2nd stage: Contraction frequency, duration, intensity, Maternal vital signs, Fetal response to
labor via FHR, Amniotic fluid with rupture of membranes, Coping status of woman and partner.
-
Infant is born
Begins with full cervical dilation (10 cm)
Complete effacement (100%)
Ends with baby’s birth
Upper limits for duration of second stage
-
Two phases:
o
o
o
Latent: relatively calm with passive descent
Descent: active pushing and urges to bear down
S/S of impending birth
Third stage: Placental separation and expulsion, Firmly contracting fundus, Change in shape of uterus,
Sudden gush of dark blood from introitus, Apparent lengthening of umbilical cord, Vaginal fullness
Blood loss for deliveries: 500mL vaginal, 1000mL C-section
Ideal presentation: Occiput, anterior. If it is occiput posterior, baby is coming out sunny side up
Fourth stage: Assessment
- Vital signs, fundus, perineal area, comfort level, lochia, bladder status
- Interventions
- Support and information
- Fundal checks; perineal care and hygiene
- Bladder status and voiding
- Comfort measures
- Parent–newborn attachment
- Breastfeeding support
- Teaching
Jeopardy
Baby’s first vaccine is Hep B
Most common cause of maternal hemorrhage is uterine atony
Most common cause of fetal tachycardia is maternal fetus
Saturated perineal pad 3 hrs after birth- massage the fundus
Variable fetal decelerations caused by cord compression
2 reasons for a postpartum Pt to have bladder distention: urethral trauma, epidural interfering with
sensation to void
Why does mag sulfate admin during labor poses a risk for PPH? Works on smooth muscle, so uterus relaxes
and bleeding can occur
Newborn stomach only holds 5-7mL
Best reason for recommending formula over breastfeeding is if the mother has a medical condition or is
taking drugs that can pass through the breast milk
The presence of adequate urine output indicates adequate tissue perfusion
Why is Vit K given? B/C gut is sterile and they don’t have the bacteria to be able to synthesize vitamin K for
the first week of life
Claiming, synchronicity,
Mastitis can be avoided by massaging the ducts and frequent breast feeding, also making sure baby is latched
over the whole areola and not just the nipple