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Basic Fetal Monitoring

Designed For New Labor and Delivery Nurses

By

Pat Burroughs MSN, RN

Copyright 1996-98 © Dale Carnegie & Associates, Inc.

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Introduction

• Credentials– 28 Years Obstetric Experience

• Labor and Delivery primary focus

• 17 Years Charge RN Experience

• 3 Years Obstetric Educator Experience

• 6 Years AWHONN Fetal Monitor Instructor Status

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Review of Materials

• Folder contents– Handout of power point presentation– Handout with fetal heart variability examples– Check off forms for FHR Auscultation and

Contraction assessment skills

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Agenda

• Basic FHR Monitoring– Intermittent Auscultation

• Doptone• Fetoscope

– Electronic Fetal Monitor (EFM)• External• Internal

– Fetal Heart Patterns and Characteristics• Normal baseline rate• Variability• Periodic and episodic patterns• Reassuring and nonreassuring characteristics

– Contraction Assessment

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Basic Fetal Monitoring

• Definition of fetal monitoring– Method of assessing fetal status before and

during labor

• Why is fetal monitoring important– To provide insight that may affect fetal

outcomes

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Intermittent Auscultation

• Doptone: Converts sound waves to audible tones to count.

Fetoscope: Considered best alternative because it enables user to hear actual heart sounds opening and closing of valves.

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What is intermittent auscultation?

• Auscultation of the FHR at intervals ordered by the physician, midwife, or determined by hospital policy.

• Can be used in gestations from 10 - 40+ weeks.

• Can be used to determine the rate and rhythm of the fetal heart .

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Who Should Perform Intermittent Auscultation?

• Someone with knowledge of normal FHR characteristics

• Someone with knowledge and skill to perform appropriate interventions if problem noted

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Advantages and Disadvantages of Auscultation

• Advantages– It is noninvasive and relatively painless procedure for

the patient– Patient has freedom to move– Does not require electricity– Patient is reassured by RN presence

• Disadvantages– Requires skilled RN at bedside– Difficult to use when patient obese or FHR is too fast to

count– No paper record to show physician or midwife

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How is Intermittent Auscultation Performed?

• Explain procedure to patient and assist her to a comfortable position

• Determine gestational age• Palpate the uterus to determine where the fetal

back is located• Auscultate the FHR between contractions for at

least 60 seconds, noting the rate and rhythm• Palpate maternal pulse to differentiate between

FHR and maternal heart rates.

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Where to Auscultate

• Optimal place to auscultate is over the fetal back. (Takes skill and practice to determine)– Cannot determine in early gestations or if patient is

very obese

• Guidelines to help locate the FHR– Recommended search pattern is in packet as

handout.

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Methodical MethodFollow Recommended Pattern

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Systematic MethodUse If Unsuccessful With Methodical

Method

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General Principles of Auscultation for Student Nurses

• Utilize standard precautions• Obtain supplies, doptone, fetoscope, ultrasound

gel, washcloth– Evaluate equipment for cleanliness prior to use

• Clean with appropriate solutions

• Provide education instruction to patient, family, and/or significant other and answer questions– Ask patient if she would prefer others leave during the

procedure

• Document and report results to primary RN

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Safety Practices• Verify orders and identify patient• Position patient in semi-fowlers position preferably with a lateral

tilt• Elevate bed to appropriate working level

– Return to low position and give call light to patient

• Assess abdomen for best location to auscultate• Listen to FHR for at least 60 seconds

– Note rate, rhythm, and listen for increases or decreases following fetal movement or contractions

• Document and report findings– Immediately report any abnormal findings– Utilize resources as needed

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Normal Assessment Findings

• FHR between 110-160 in gestations 32-40+ weeks– Rates slightly above 160 are normal in gestations less

than 32 weeks. Recommendation is that nursing students report findings to Primary RN.

• Regular rhythm• Increases in the FHR associated with fetal

movement that return to original rate range• Decreases may be heard

– Recommendation that nursing students report any decreases heard to the Primary RN.

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Electronic Fetal Monitoring Clarification

• Information for students is for educational purposes only

• Students should not assume any responsibility for interpretation of fetal monitor tracings

• It takes months to years of experience in addition to continuing education to be prepared to interpret fetal monitor tracings

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Electronic Fetal Monitoring

• Definition– Electronic method of providing a continuous

visual record of the FHR and uterine activity

• Information is recorded on graph paper or in archiving database system

• Information is permanent part of the maternal medical record

• Information is retrievable for litigation

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When is Electronic Fetal Monitoring Used?

• When ordered by the physician, midwife, or indicated by hospital policy.– For screening or surveillance – Intermittently or continuously

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Methods of Electronic Fetal Monitoring

• External– Noninvasive method– Utilizes an ultrasonic transducer to monitor

the fetal heart – Utilizes the tocodynamometer (toco) to

monitor uterine contraction pattern– Application directly impacts results of data

received

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Methods of Electronic Fetal Monitoring

• Internal Fetal Monitoring– Invasive– FHR is monitored via a fetal scalp electrode

(IFSE)– Uterine activity is monitored by an

intrauterine pressure catheter (IUPC)

• A combination of external and internal fetal monitoring is common practice

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Advantages and Disadvantages of Internal Fetal Monitoring

• Advantages– Patient can move without much interference in data

transmission– More accurate measurement of data– Data less likely to be affected by artifact

• Disadvantages– Invasive– Membranes have to be ruptured and cervix dilated– Application requires more skill– Procedures more uncomfortable for the mother– Risk of trauma and infection for mother and fetus

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Components of the Fetal Monitor Paper Tracing

• Example of monitor paper in packet– Strip has two components

• Upper graph records FHR data– Small squares represent 10 bpm increases as well as 10

seconds duration

• Lower graph records contraction data– Small squares represent 10 second duration or 10 mmHg

intensity (if IUPC used)

– Dark line to dark line represents one minute of time

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Baseline FHR

• Normal baseline FHR in a term fetus 37 completed weeks or more is 110-160 bpm.– Determination of the baseline FHR does not include

accelerations or decelerations

– Determination of the baseline FHR is done between contractions

– Baseline is rounded in increments of 5 bpm example; if the FHR is running 125-135 then the baseline FHR should be documented as 130

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FHR Variability

• Normal changes and fluctuations in the FHR over time. Is a characteristic of the baseline exclusive of accelerations or decelerations and is best assessed between contractions

• Variability is considered to be the best indicator of fetal well-being

• Variability can be influenced by hypoxic events, maternal hemodynamic issues, drugs, etc.

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Examples of Variability

• Refer to examples in handout• Absent: Not detectable from baseline• Minimal: Less than 5 bpm from baseline but

more than undetectable– May occur with normal fetal sleep patterns or if

mother has received analgesia for pain but should not be a persistent variability pattern

• Moderate : 6-25 bpm from baseline (optimal pattern)

• Marked:More than 25 bpm from baseline

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Periodic and Episodic FHR Characteristics

• Periodic: Refers to changes in the FHR that occur with or in relationship to contractions

• Episodic: Refers to changes in the FHR that occur independent of contractions

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Examples of Periodic Changes

• Variable decelerations: Result from some type of cord compression.– Nuchal cord, True knot– Decreased amniotic fluid

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Severe Variable Decelerations

Note the depth from the baseline

Baseline

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Early Deceleration

• Occur as a result of vagal stimulation to the fetal head during contractions which push the fetal head toward the pelvis.

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Late Decelerations• Occur in response to uteroplacental

insufficiency. (blood flow to the fetus is compromised and there is less oxygen available to the fetus)

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Late Decelerations With Absent Variability

Note the smoothness of the FHR pattern

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Prolonged Deceleration

• Deceleration of the FHR from the baseline lasting more than 2 minutes but less than 10 minutes.

• There is no one explanation for why these occur but are commonly associated with uterine hyperstimulation.

• Can also occur without any uterine activity

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Example Prolonged Deceleration

• Note the duration of the deceleration lasts more than 2 minutes.

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FHR Accelerations

• Are the most common type of FHR changes• The are abrupt changes and will increase from

the baseline 15 bpm lasting 15 seconds before return to the baseline in a healthy gestation more than 32 weeks.

• Less than 32 weeks increases of 10 bpm lasting 10 seconds are indication of a well oxygenated fetus.

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Example Accelerations

• Note the increase from the fetal heart baseline

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Sinusoidal Pattern

• Persistent wave variation of the baseline only seen in about 2% of patients.

• Related to severe fetal anemia, hypoxia, or acidosis.

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Uterine Activity Assessment

• Periodic tightening and relaxing of the uterine muscle.

• Pituitary gland is triggered to release a hormone called oxytocin that stimulates the uterine tightening.

• Difference in Braxton Hicks (false labor) and true labor is the strength of the contractions and the changes in the cervix.

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Characteristics of Contractions

• Frequency: How often they occur. They are timed from the beginning of a contraction to the beginning of the next contraction.

• Regularity: Is the pattern rhythmic?• Duration: From beginning to end how long does

each contraction last?• Intensity: By palpation mild, moderate, or strong.

– By IUPC intensity in mmHg– Subjectively: Patient description

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Segments of Contractions

• Increment: Beginning, building of pressure

• Acme: Most intense part of the contraction

• Decrement: Diminishing of the contraction

• Rest: Period of time between contractions

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Assessment of Contractions

• Palpation: Use the fingertips to palpate the fundus of the uterus– Mild: Uterus can be indented with gentle

pressure at peak of contraction– Moderate: Uterus can be indented with firm

pressure at peak of contraction– Strong: Uterus feels firm and cannot be

indented during peak of contraction

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Electronic Assessment of Contractions

• External electronic monitor– Toco: Palpate uterus to find fundus and place on firmest part.– If patient states she is having contractions but none are

showing on fetal monitor tracing the first intervention is to readjust the toco.

– Problems associated with obesity and patient movement or position changes

• IUPC– Physician or CNM inserts device– RN measures strength of contractions in Montevideo Units

(MVU’s)– Follow trouble shooting instructions per manufacturer

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Determination of True Labor

• Contractions will be regular– Contractions will increase in strength,

frequency, and duration– Cervix will change!

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Questions Regarding Auscultation or Electronic Fetal Monitoring?

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References

• Martin, E.J., (2002) Intrapartum Management Modules: A Perinatal Education Program. (pp 119-123). Lippincott Williams & Wilkins 3rd Edition.

• Simpson, I., & Creehan, P. (2001) Perinatal Nursing 2nd Edition, (pp 379-383). Philadelphia, New York, Baltimore, Lippincott.

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The End