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Fetal Monitoring
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Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Chapter 17Chapter 17
Fetal AssessmentFetal AssessmentDuring LaborDuring Labor
2Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fetal Assessment During LaborFetal Assessment During Labor
Electronic fetal monitoring is a useful tool for Electronic fetal monitoring is a useful tool for visualizing fetal heart rate (FHR) patterns on visualizing fetal heart rate (FHR) patterns on monitor screen or printed tracingmonitor screen or printed tracing First used in 1970sFirst used in 1970s Anticipated effect was a decrease in cerebral Anticipated effect was a decrease in cerebral
palsypalsy Believed to be more sensitive than auscultation in Believed to be more sensitive than auscultation in
predicting fetal compromisepredicting fetal compromise
3Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring Basis for Monitoring
Fetal responseFetal response Labor is a period of physiologic stress for fetusLabor is a period of physiologic stress for fetus Frequent monitoring of fetal status is part of Frequent monitoring of fetal status is part of
nursing care during labornursing care during labor Fetal oxygen supply must be maintained during Fetal oxygen supply must be maintained during
labor to prevent fetal compromiselabor to prevent fetal compromise
4Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’d Basis for Monitoring—cont’d
Fetal oxygen supply can decrease:Fetal oxygen supply can decrease: Reduction of blood flow through maternal vessels Reduction of blood flow through maternal vessels
as result of:as result of:• Maternal hypertension: chronic or pregnancy-induced Maternal hypertension: chronic or pregnancy-induced
hypertensionhypertension
• Hypotension caused by supine maternal position, Hypotension caused by supine maternal position, hemorrhage, epidural analgesia, or anesthesiahemorrhage, epidural analgesia, or anesthesia
• Hypovolemia caused by hemorrhageHypovolemia caused by hemorrhage
5Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’d Basis for Monitoring—cont’d
Fetal oxygen supply can decrease: Fetal oxygen supply can decrease: Reduction of oxygen content in maternal blood as Reduction of oxygen content in maternal blood as
result of hemorrhage or severe anemiaresult of hemorrhage or severe anemia Alterations in fetal circulation with compression of Alterations in fetal circulation with compression of
umbilical cord umbilical cord Reduction in blood flow to intervillous space Reduction in blood flow to intervillous space
in placentain placenta
6Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’d Basis for Monitoring—cont’d
Fetal well-being during labor measured by Fetal well-being during labor measured by response of FHR to uterine contractions response of FHR to uterine contractions (UCs)(UCs)
Reassuring FHR patterns are:Reassuring FHR patterns are: Baseline FHR in normal range of 110 to 160 Baseline FHR in normal range of 110 to 160
beats/min, with no periodic changes and a beats/min, with no periodic changes and a moderate baseline variabilitymoderate baseline variability
Accelerations of FHR with fetal movementAccelerations of FHR with fetal movement
7Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’dBasis for Monitoring—cont’d
Fetal compromise Fetal compromise Goals of intrapartum FHR monitoring are to Goals of intrapartum FHR monitoring are to
identify nonreassuring patterns indicative of fetal identify nonreassuring patterns indicative of fetal compromisecompromise
Nonreassuring FHR patterns associated with: Nonreassuring FHR patterns associated with: • Fetal hypoxemia, deficiency of oxygen in arterial bloodFetal hypoxemia, deficiency of oxygen in arterial blood
8Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’dBasis for Monitoring—cont’d
Fetal compromiseFetal compromise Hypoxemia can deteriorate to severe fetal hypoxiaHypoxemia can deteriorate to severe fetal hypoxia
• Inadequate supply of oxygen at cellular levelInadequate supply of oxygen at cellular level
Nurse’s role is to assess that FHR pattern reflects Nurse’s role is to assess that FHR pattern reflects adequate fetal oxygenationadequate fetal oxygenation
9Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Basis for Monitoring—cont’d Basis for Monitoring—cont’d
Nonreassuring FHR includes:Nonreassuring FHR includes: Baseline FHR <110 or >160 beats/minBaseline FHR <110 or >160 beats/min Decrease in baselineDecrease in baseline Irregular rhythmsIrregular rhythms Decreased FHR during or within 30 seconds after Decreased FHR during or within 30 seconds after
a contraction a contraction
10Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Monitoring TechniquesMonitoring Techniques
Intermittent auscultation (IA)Intermittent auscultation (IA) Listening to fetal heart sounds at periodic Listening to fetal heart sounds at periodic
intervals to assess FHRintervals to assess FHR IA can be performed with: IA can be performed with:
• Leff scopeLeff scope
• DeLee-Hillis fetoscopeDeLee-Hillis fetoscope
• Pinard fetoscopePinard fetoscope
• Ultrasound device Ultrasound device
11Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Monitoring Techniques—cont’dMonitoring Techniques—cont’d
EFMEFM External monitoringExternal monitoring
• FHR: ultrasound transducerFHR: ultrasound transducer
• UCs: tocotransducerUCs: tocotransducer
Internal monitoring (invasive)Internal monitoring (invasive)• Spiral electrodeSpiral electrode
12Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-2. A, External noninvasive fetal monitoring with tocotransducer and ultrasound transducer. FHR, Fetal heart rate. B, Ultrasound transducer is placed below umbilicus over the area where fetal heart rate is best heard, and tocotransducer is placed on uterine fundus.
13Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-3. Diagrammatic representation of internal invasive fetal monitoring with intrauterine pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated).
14Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fetal Heart Rate Patterns Fetal Heart Rate Patterns
Baseline FHRBaseline FHR Baseline rate is average during 10-minute Baseline rate is average during 10-minute
segment, excluding: segment, excluding: • Accelerations Accelerations
• DecelerationsDecelerations
• Periods of marked variabilityPeriods of marked variability
• Normal range at term 110 to 160 beats/minNormal range at term 110 to 160 beats/min
15Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-4. Display of fetal heart rate and uterine activity on monitor paper. A, External mode with ultrasound and tocotransducer as signal source. FHR, Fetal heart rate; UC, uterine contractions. B, Internal mode with spiral electrode and intrauterine catheter as signal source. Frequency of contractions is measured from the beginning of one contraction to the beginning of the next. FHR, Fetal heart rate; UA, uterine activity.
16Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-5. Fetal heart rate variability. A, Absent or undetected.
17Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-5. Fetal heart rate variability. B, Minimal.
18Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-5. Fetal heart rate variability. C, Moderate.
19Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-5. Fetal heart rate variability. D, Marked.
20Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fetal Heart Rate Patterns—cont’d Fetal Heart Rate Patterns—cont’d
Baseline FHRBaseline FHR VariabilityVariability Tachycardia: baseline more than 160 beats/min Tachycardia: baseline more than 160 beats/min
for duration of 10 minutes or longer for duration of 10 minutes or longer Bradycardia: baseline less than 110 beats/min for Bradycardia: baseline less than 110 beats/min for
duration of 10 minutes or longerduration of 10 minutes or longer
21Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fetal Heart Rate Patterns—cont’d Fetal Heart Rate Patterns—cont’d
Changes in FHRChanges in FHR Periodic changes occur with UCsPeriodic changes occur with UCs Episodic (nonperiodic) not associated Episodic (nonperiodic) not associated
with UCswith UCs AccelerationsAccelerations DecelerationsDecelerations
• Early decelerations: response to fetal head Early decelerations: response to fetal head compressioncompression
• Late decelerations caused by uteroplacental Late decelerations caused by uteroplacental insufficiencyinsufficiency
22Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-6. Accelerations of fetal heart rate.
23Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-7. Deceleration patterns. A, Early.
24Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-7. Deceleration patterns. B, Late.
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Fig. 17-7. Deceleration patterns. C, Prolonged.
26Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-7. Deceleration patterns. D, Variable.
27Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fetal Heart Rate Patterns—cont’d Fetal Heart Rate Patterns—cont’d
Changes in FHRChanges in FHR Variable decelerations: caused by umbilical cord Variable decelerations: caused by umbilical cord
compressioncompression Prolonged decelerations: FHR below baseline of Prolonged decelerations: FHR below baseline of
15 beats/min and lasting more than 2 minutes15 beats/min and lasting more than 2 minutes
28Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Fig. 17-9. With integration of the fetal monitor tracing into the electronic medical record, the nurse can view the fetal tracing while charting.
29Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Care Management Nursing Care Management
EFM pattern recognitionEFM pattern recognition Must evaluate five components of an FHR tracingMust evaluate five components of an FHR tracing Determine whether intervention is neededDetermine whether intervention is needed Identify indications to expedite birthIdentify indications to expedite birth
30Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Care Management—cont’d Nursing Care Management—cont’d
Additional methods of assessment and Additional methods of assessment and interventionintervention FHR response to stimulationFHR response to stimulation Fetal oxygen saturation monitoringFetal oxygen saturation monitoring
• Fetal pulse oximetry Fetal pulse oximetry
Fetal scalp blood samplingFetal scalp blood sampling AmnioinfusionAmnioinfusion Tocolytic therapyTocolytic therapy Umbilical cord acid-base determinationUmbilical cord acid-base determination
31Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Nursing Care Management—cont’d Nursing Care Management—cont’d
Additional methods of assessment and Additional methods of assessment and interventionintervention Patient and family teachingPatient and family teaching
• Maternal positioningMaternal positioning
• Discouraging Valsalva maneuverDiscouraging Valsalva maneuver
DocumentationDocumentation EvaluationEvaluation
32Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Key PointsKey Points
Fetal well-being during labor is gauged by Fetal well-being during labor is gauged by response of FHR to UCsresponse of FHR to UCs
FHR characteristics include baseline FHR FHR characteristics include baseline FHR and periodic changes in FHRand periodic changes in FHR
Monitoring of fetal well-being includes:Monitoring of fetal well-being includes: FHR assessmentFHR assessment Watching for meconium-stained amniotic fluidWatching for meconium-stained amniotic fluid Assessment of maternal vital signs and uterine Assessment of maternal vital signs and uterine
activityactivity
33Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points—cont’d Key Points—cont’d
Responsibility of nurse to: Responsibility of nurse to: Assess FHR patternsAssess FHR patterns Implement independent nursing interventionsImplement independent nursing interventions Report nonreassuring patterns to physician or Report nonreassuring patterns to physician or
nurse-midwifenurse-midwife
34Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points—cont’d Key Points—cont’d
Established and published care standards Established and published care standards and guidelines for fetal heart monitoringand guidelines for fetal heart monitoring Association of Women’s Health, Obstetric and Association of Women’s Health, Obstetric and
Neonatal Nurses (AWHONN)Neonatal Nurses (AWHONN) American College of Obstetricians and American College of Obstetricians and
Gynecologists (ACOG)Gynecologists (ACOG)
35Mosby items and derived items © 2010, 2006, 2002 by Mosby, Inc., an affiliate of Elsevier Inc.
Key Points—cont’d Key Points—cont’d
Emotional, informational, and comfort needs Emotional, informational, and comfort needs of woman and family must be addressed of woman and family must be addressed when mother and her fetus are being when mother and her fetus are being monitoredmonitored
Documentation is initiated and updated Documentation is initiated and updated according to institutional protocolaccording to institutional protocol