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Chapter 17Chapter 17

Fetal AssessmentFetal AssessmentDuring LaborDuring Labor

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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Fig. 17-3. Diagrammatic representation of internal invasive fetal monitoring with intrauterine pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated).

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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

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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.

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Fig. 17-5. Fetal heart rate variability. A, Absent or undetected.

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Fig. 17-5. Fetal heart rate variability. B, Minimal.

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Fig. 17-5. Fetal heart rate variability. C, Moderate.

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Fig. 17-5. Fetal heart rate variability. D, Marked.

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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

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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

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Fig. 17-6. Accelerations of fetal heart rate.

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Fig. 17-7. Deceleration patterns. A, Early.

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Fig. 17-7. Deceleration patterns. B, Late.

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Fig. 17-7. Deceleration patterns. C, Prolonged.

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Fig. 17-7. Deceleration patterns. D, Variable.

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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

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Fig. 17-9. With integration of the fetal monitor tracing into the electronic medical record, the nurse can view the fetal tracing while charting.

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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

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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

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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

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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

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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

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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)

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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