MENNONITE COLLEGE OF NURSING
at
Illinois State University
Maternal Infant Nursing -316
Fetal Assessment Worksheet
The purpose of this worksheet is to guide your understanding of the normal fetal heart rate
patterns, variations in heart rate patterns during labor, components of the biophysical profile, tests
of fetal maturity, and antenatal testing interpretation.
Complete the worksheet and bring it to class on the assigned day. We will review and discuss the
content in the worksheet in class. You will be responsible for this material and will be tested on it.
Chapter 21 on Assessment of Fetal Well-being and section on Evaluating Labor Progress &
Electronic Fetal Monitoring in Chapter 23 in Olds(9th ed.) to complete most of the questions in
this worksheet.
The next two pages of this worksheet and the last several slides on the Fetal Assessment
Powerpoint have current information on fetal monitoring interpretation that would be extremely
helpful to you when you are assigned to be in Labor for a clinical day. It would behoove you to
bring it with you to clinical on those days. 
1
FETAL HEART RATE/VARIABILITY/DECELERATIONS
I.
Fetal Heart Rate (FHR)
A.
Baseline FHR consists of:
1. The mean of the FHR observed between contractions during a continuous 10minute period of monitoring rounded to the nearest 5bpm. It does not include the rate during
accelerations or decelerations.
Fetal Heart Rate levels:
Marked bradycardia
 70 BPM
Mod. bradycardia
71-99 BPM
Mild bradycardia
100-109 BPM
Normal
110-160 BPM
Moderate tachycardia
161-179 BPM
Marked tachycardia
>180 BPM
•
2.
FHR variability-- Baseline variability is a measure of the interplay effect
between the sympathetic nervous system and the parasympathetic
nervous system. It is defined as:
•
•
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 6-25 bpm-Marked—amplitude range greater than 25 bpm
**Beat-to-beat Variability is probably the most accurate indicator of fetal
well-being that the nurse has. If BTBV is poor, the fetus is probably in distress and
needs to be delivered SOON.
•
•
•
•
B.
Periodic changes - changes in FHR, either accelerations or decelerations, from
baseline returning to baseline that occur in response to contractions or fetal
movement
1.
Accelerations
1. Description-- A visually apparent abrupt 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
2. Cause- stimulation of autonomic nervous system of the fetus seen
with fetal movement, vaginal exams, abdominal palpation, uterine
contractions. These are usually seen as signs of fetal well-being.
3. Nursing intervention - None.
2
2.
Decelerations-- Periodic decreases in FHR from the normal baseline. There
are 3 types that we discuss.
A. Early Decelerations
1. Description-- "mirrors" contraction.
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
2. Cause - head compression after:
- Uterine contraction
- Vaginal exam
- Fundal pressure
- Placing internal fetal scalp electrode
3. Nursing interventions--benign pattern, no intervention required.
B. Late Decelerations
1. Description
- 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
- Very ominous when associated with loss of STV, rising baseline, or tachycardia
- Repetitious
2. Cause - uteroplacental insufficiency or decreased maternal-fetal
exchange during contractions causing hypoxemia
Seen with
- Hyperstimulation of uterus with oxytocin
- Toxemia
- Postmaturity
- SGA
- Maternal diabetes, anemia, or cardiac disease
- Placenta previa or abruption
3. Nursing interventions
- Change maternal position to left lateral
- Stop Pitocin/Oxytocin if being used
- O2/mask at 7-10L/min
- Correct maternal hypotension
- Increase mainline IV rate (Bolus)
- Elevate legs
C. Variable Decelerations
1.
Description-- V, U, or W shaped
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.
2.
3.
3
Cause - umbilical cord compression. If repetitive, it may
indicate nuchal cord (cord around baby’s neck).
Nursing Intervention
- Change maternal position
- If severe, may need to try Amnioinfusion
ASSESSMENT OF FETAL WELL-BEING
Chapters 21
MATERNAL ASSESSMENT OF FETAL MOVEMENT
1. Describe the “Cardiff Count-to-10 Method” or “Daily Fetal Movement Record” (DFMR) method for assessing
fetal movement. (sample instructions and chart in Self-Care Guide in back of text). Also see pp383-385.
USE OF ULTRASONOGRAPHY IN PREGNANCY
2. Identify and define the 3 levels of ultrasound presently defined by American College of Obstetricians and
Gynecologists (ACOG).
a.
b.
c.
3. Name two methods that can be used when performing an ultrasound. Differentiate them. Which can be used
earliest in pregnancy?
a.
b.
4. What information can be obtained from an ultrasound during the first trimester? second?
Third?
5. Describe the measurements that can be obtained to determine gestational age of the fetus during the
pregnancy.
a.
b.
c.
d.
6. How is ultrasound used to assess placental maturity (grading 0 – 3)? Placental location? Cervical length?
7.
4
Define IUGR and discuss the importance of early detection in relation to fetal well-being.
ANTENATAL FETAL SURVEILLANCE
8. Why is Amniotic Fluid Volume (AFV) or Amniotic Fluid Index (AFI) evaluation important in assessing fetal wellbeing?
9. Review Tables 21-5 & 6 Biophysical Profile (BPP) (p.515) and become familiar with the 5 parameters
assessed.
Think about what two pieces of equipment are used to complete a BPP.
What are the 2 most important components of the BPP?
Nuchal Translucency Pg. 503.
10. Define Nuchal Translucency?
11. What does it detect?
12. At what gestation is it done?
OTHER ANTENATAL TESTING
1.
Complete the table on the next page on CST, and NST.
2.
How is the vibroacoustic stimulator used in an NST?
5
ANTEPARTAL FETAL HEART RATE MONITORING
Compare/contrast the NonStress Test (NST) & the Contraction Stress Test(CST) by completing the following table.
Nonstress Test
(NST)
also called Fetal Activity Determination Test
Contraction Stress Test
(CST)
Advantagest
Disadvantages
Procedure
Interpretation of Tests:
What terms are used?
Include criteria used:
Normal
Reactive
Clinical Significance
Negative
Clinical Significance
Abnormal
Nonreactive
Clinical Significance
Positive
Clinical Significance
Equivocal
Unsatisfactory
Clinical Significance
Suspicious
Hyperstimulation
Unsatisfactory
Risks to mother & fetus
6
Clinical Significance
AMNIOTIC FLUID STUDIES
10. Contrast how amniocentesis is used early in pregnancy versus later in pregnancy.
11. What is the significance of the following amniotic fluid studies?
a. AFP Screening-Maternal Serum Alpha Fetal Protein (MSAFP) is a screening tool for which defects in pregnancy?
When is the test most accurate? What follow-up testing should be done if an abnormal result is
obtained?
b. Quadruple Check—what are the 4 tests included here? What do they detect?
c.
Bilirubin  OD450/nm - normal value = (ch. 20 pp. 478-479)
d. L/S Ratio
e. Phosphatidylglycerol (PG)
f.
Color
OTHER DIAGNOSTIC TESTS
12. What is Chorionic Villi Sampling and when is Chorionic Villi Sampling (CVS) done during a pregnancy? Why
might this be advantageous to the mother?
13. Fetoscopy is not done as often as in the past because of advances in Sonography and use of PUBS. When
might Fetoscopy still be indicated, and what is the nurse’s role during and after the procedure?
14. What is Cordocentesis/Percutaneous Umbilical Blood Sampling (PUBS) and how is it used during the 2nd
and 3rd trimesters to detect fetal status?
15. What is the significance of fetal fibronectin in relation to preterm delivery?
7
INTRAPARTUM FETAL MONITORING AND CARE
CHAPTER 23, BASIS FOR MONITORING
1. What are the goals of Fetal Heart Monitoring (FHM)?
2. Describe the advantages and disadvantages of external uterine monitoring.
EVALUATION OF UTERINE ACTIVITY
3. In addition to uterine activity, what other activities of the mother may be reflected on the tracing with the
tocodynamometer?
4. Internal monitoring measures what aspect of the uterine contraction that the external monitor does not
measure?
5. Differentiate between the water-filled intrauterine pressure catheter (IUPC) from the INTRAN IUPC.
Normal baseline uterine resting tone from an IUPC should remain between _5-15_ mm Hg.
Normal pressures during uterine contractions should be 50-85 mm Hg.
6. Hypertonicity of the uterus puts a fetus at risk. How can the nurse detect the effects of hypertonicity on the
fetus? What is the nursing action in this situation?
(A Critical Thinking Exercise!)
FYI:
*If uterine pressure is > 30 mm Hg, there is  oxygen getting to baby, but baby usually can compensate.
*If uterine pressure is > 70 mm Hg, there is no perfusion of oxygen getting to the baby. The nurse needs
to monitor closely to see that the fetus is able to cope with the  oxygen supply.
7. Define the following:
a. Duration of contraction
b. Frequency of contraction
(Review deceleration patterns discussed at beginning of worksheet.)
8. What changes in FHR pattern might you see indicating that the fetus is not coping?
8
9. Complete the following table on frequency of fetal monitoring.
Low-Risk
High-Risk
Frequency of Auscultation
Pregnancy
Pregnancy
1st Stage
Latent Phase
Active Phase
2nd Stage
EVALUATION OF FETAL HEART RATE
Match the following terms and/or fetal heart rates:
1.
2.
3.
4.
5.
6.
7.
8.
____
____
____
____
____
____
____
____
9.
____
10.
____
11.
12.
__
____
13.
____
14.
____
15.
List causes of fetal tachyardia.
16.
List causes of fetal bradycardia.
17.
What kinds of drugs may decrease variability?_______________________
18.
Identify what constitutes a reassuring fetal heart rate(FHR) patterns?
a.
b.
c.
d.
9
Normal Fetal Heart Rate
Tachycardia
Bradycardia
Moderate tachycardia
Mild Bradycardia
Marked Tachycardia
Moderate bradycardia
Reflects balance between
sympathetic and parasympathetic effect on
fetal heart rate
FHR changes in association
with uterine contractions
Caused by fetal head
compression
Marked Bradycardia
Caused by umbilical cord
compression
Caused by uteroplacental
insufficiency
Transient increases in FHR
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
Periodic changes
< 100 BPM
110-160 BPM
Late Deceleration
> 160 for >10 min.
Acceleration
100-109 BPM
160-179 BPM
Early Deceleration
> 180 BPM
< 110 for > 10 min.
Variability
Variable Decels
< 70 BPM
19.
Identify what constitutes nonreassuring FHR patterns?
a.
b.
c.
d.
e.
Additional Assessment Techniques
20.
How is fetal scalp stimulation used to to re-establish fetal well-being?
21.
What is the significance of drawing a umblical cord pH?
22.
How does the Base Deficit(BD) reflect either metabolic or respiratory acidosis?
BD and Base Excess(BE) is derived based on the pH, pCO2, H2CO3, and reflects how much base was
“used up” during labor.
10
Cord Blood Gasses
Normal Umbilical Artery levels
pH 7.20
pCO2 < 60
pO2 > 20
BE < -10 or BD < 10
Severity of pH
mild = 7.1 - 7.2
mod = 7.0 - 7.1
severe= < 7.0 usually indicates severe neurological damage
Respiratory Acidemia--usually caused by a build-up of CO2 and not severe
pH < 7.2
pCO2 > 60
pO2 variable
BE < -10
Metabolic Acidemia-- usually caused by hypoxemia and more severe
pH < 7.2
pCO2 <60
pO2 <20
BE < -10
Mixed Respiratory and Metabolic Acidemia
pH < 7.2
pCO2 > 60
pO2 < 20
BE worse
Cord blood gasses are good to have in cases of low Apgar Scores or non-reassuring baselines.
11