Why Monitor?

Labor is a physiologic stress to fetuses Fetal monitoring allows the health-care team to evaluate fetal response to labor Monitoring is predictive of infants post-delivery status

Methods of Fetal Monitoring

Auscultation with fetoscope and palpation of contractions External electronic fetal monitoring (EFM) Tocotransducer to monitor uterine activity Ultrasound transducer to monitor FHR Internal EFM (most accurate, most invasive) Intrauterine pressure catheter (IUPC) to monitor uterine activity Fetal scalp electrode (FSE) to monitor FHR

External Fetal Monitoring

Internal Fetal Monitoring

Internal Fetal Monitoring: FSE

Internal Fetal Monitoring: IUPC

Fetal Monitor Paper

The top half of the strip is the fetal heart rate. The bottom half of the strip are the contractions.

Fetal Monitor Paper

Horizontal Calibration: One large box= 1 minute = 3cm One small box= 10 seconds

FHR Baseline
Normal FHR 110-160 Rounded to increments of 5 bpm The FHR baseline excludes periodic or episodic changes (accelerations & decelerations) periods of marked variability segments of baseline that differs by >25bpm

Fetal Bradycardia
baseline of <110 bpm for at least 10 minutes

Fetal Tachycardia
baseline of >160 bpm for at least 10 minutes

Variability
Fluctuations in the baseline Variability represents a mature, intact nervous system pathway through the brain, vagus nerve, and cardiac conduction system *The most significant indicator of fetal wellbeing Reflects the fetal oxygen reserve

Variability
Absent Amplitude range undetectable Minimal Amplitude range < 5 bpm Moderate Amplitude range 6-25 bpm Marked Amplitude range >25 bpm

Absent Variability
Non-reassuring fetal heart status Notify the provider immediately Prepare for c-section

Minimal Variability
Fetal sleep (cycles usually < 30 minutes) Maternal drugs: Nubain or Stadol for pain, tranquilizers, barbiturates, ETOH Hypoxia: evaluate for potential causes Prematurity

Moderate Variability
Reassuring Fetus has good oxygen reserve.

Moderate Variability

Marked Variability
Hypoxia/acidosis reduced oxygen to the fetus Second stage of labor/pushing phase

Accelerations
Increase of FHR 15 bpm above baseline for at least 15 seconds (15x15). This is reassuring. The fetal heart rate accelerates when the fetus moves.

Decelerations
Variable Early Late Prolonged

Variable Decelerations

Variable Decelerations
An abrupt decrease in FHR of > 15 bpm The onset of the deceleration to the nadir of the contraction is < 30 seconds *Caused by cord compression May occur with or without the contraction

Variable Decelerations

Variable Decelerations

Interventions for Variable Decels

(Will depend on the severity)

*Reposition Notify physician Amnioinfusion Discontinue oxytocin Oxygen per face mask Consider vaginal exam

Early Decelerations

Early Decelerations
Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. The nadir occurs with the peak of a contraction. Benign, often indicative of fetal descent *Caused by head compression No nursing interventions indicated, but consider getting prepared for delivery of infant

Early Decelerations

Late Decelerations

Late Decelerations
Gradual onset of a deceleration (> 30 seconds from onset to nadir); the nadir of the deceleration occurs after the peak of the contraction Non-reassuring if the late decelerations are recurrent *Cause: uteroplacental insufficiency

Late Decelerations

Late Decelerations

Interventions for Late Decelerations

Reposition Oxygen Discontinue pitocin Administer fluid bolus Notify the physician Check the blood pressure Administer terbutaline Possibly prepare for c-section

Prolonged Decelerations
More than 2 minutes in duration

Prolonged Deceleration

Review of the Decelerations

A, Early decelerations caused by head compression.

B, Late decelerations caused by uteroplacental insufficiency.

C, Variable decelerations caused by cord compression.

Contractions
Frequency of contractions is timed by counting the minutes from the beginning of one contraction to the beginning of the next Duration of contractions is measured by counting the seconds between the onset and ending of a contraction Strength of the contractions is measured by palpation when you have an external monitor. Internal monitors measure the strength in mmHg.

Contractions

Contractions
ALWAYS remember that external tocotransducers are used only as a rough tool to time contractions and MUST be combined with palpation of abdomen.

Contractions

Contractions

Summary
FHR Baseline 110-160 Tachycardia >160 for 10 minutes Bradycardia <110 for 10 minutes Variability
Absent Amplitude range undetectable Minimal Amplitude range < 5 bpm Moderate Amplitude range 6-25 bpm Marked Amplitude range >25 bpm

Decelerations
Variable cord compression Early head compression Late uteroplacental insufficiency Prolonged-- > 2 minutes

Contractions
Frequency time from the beginning of one contraction to the beginning of the next Duration time from the start of a contraction to the end of the contraction Intensity
External palpation Internal mmHg

Remember
Look at the big picture: Always think about prenatal history and physical assessment data when evaluating strip There are several basic cook-book interventions you will see used with a non-reassuring FHR. Be prepared to help with repositioning, O2 administration, etc. Experienced RNs often consult one another when evaluating strips. Dont be afraid to ask questions.

Questions?