FETAL ASSESSMENT DURING LABOR

Electronic Fetal Monitoring: visualizes FHR patterns on a monitor screen or printed tracing.
o Fetal Response: requires frequent monitoring
 Fetal oxygen supply can decrease in several ways:
1. Reduced blood flow due to maternal hypertension, hypotension (caused by supine
maternal position, hemorrhage or epidural analgesia or anesthesia) or hypovolemia
(caused by hemorrhage)
2. Reduction of the oxygen levels in maternal blood resulting from anemia or
hemorrhage
3. Compression of umbilical cord, placental separation or complete abruption or head
compression
4. Uterine hypertonus (excessive oxytocin release) causing reduced blood flow to the
placenta.
 Normal FHR are as follows:
o 110-160bpm
o moderate baseline FHR variability
o early decelerations present or absent
o accelerations present or absent
o Fetal Compromise: differentiating the normal patterns from the abnormal patterns can help identify
fetal compromises.
 Abnormal FHR patterns are associated with fetal hypoxemia, if not corrected can lead to
fetal hypoxia (inadequate supply of oxygen at cellular level)
 Examples of abnormal FHR patterns:
o Absent baseline FHR variability
o Recurrent late decelerations
o Recurrent variable decelerations
o Bradycardia ( less than 110bpm)
o Tachycardia ( greater than 160bpm)
o Sinusoidal FHR Patterns
o Decreased FHR during or within 30 seconds after a contraction
Monitoring Techniques: done during and immediately after contractions
o Intermittent Auscultation : performed with a Pinard fetoscope, Doppler ultrasound device,
ultrasound stethoscope or a DeLee- Hillis fetoscope
 The Fetoscope is applied to the listeners forehead so the bone acts as an amplifier to hear
fetal heart sounds for counting.
 The Doppler Ultrasound Device & Ultrasound stethoscope transmit high frequency sound
waves reflecting movement of the Fetal heart which can be counted
 PROS: IA is less invasive and inexpensive compared to EFM. It is also more comfortable and
gives more freedom for movement.
 CONS: Can be difficult to preform on obese women, does not provide permanent
documentation, when FHR is not being auscultated you may miss events. It also cannot be
used to assess changes or variability.
 Only terms such as bradycardia & tachycardia may be used.
 o Electronic Fetal Monitoring (EFM) – monitors the ongoing assessment of fetal oxygenation – the
goal is to detect fetal hypoxia and metabolic acidosis during labor.
 External Monitoring:
o FHR: ultrasound transducer
o UCs: tocotransducer
 Internal Moniotoring: - more invasive
o Allows a more accurate appraisal of fetal well-being
o Spiral Electrode: For this type of monitoring the membranes must be ruptured and the
cervix sufficiently dilated during (atleast 2-3 cm)

Fetal Heart Rate Patterns

o Baseline FHR: the average rate during a 10-minute segment that excludes periodic or episodic
changes, periods od marked variability, and segments of the baseline that differ by more than 25
bpm. The normal range at term is 110-160bpm
 Variability: irregular waves or fluctuations in the baseline of the FHR of two cycles per
minute or greater. – does not include accelerations or decelerations
 Absent or minimal : classified as either abnormal or indeterminate. Can be caused by
fetal hypoxemia and metabolic acidemia. Can also include congenital anomalies and
preexisting neurologic injury – minimal variability can also occur with the fetus in a
sleep state, tachycardia, or extreme variability
 Moderate: considered normal, predictive of a normal fetal acid-base balance.
 Tachycardia : baseline FHR greater than 160 bpm for duration of ten minutes or longer.
 Can be considered n early sign of fetal hypoxemia, can result from fetal or maternal
infection, maternal hyperthyroidism or fetal anemia
 Bradycardia : baseline FHR less than 110 bpm for a duration of ten minutes or longer.
 Not related to fetal oxygenation, it is caused by a type of fetal cardiac disorder,
maternal hypoglycemia and maternal hypothermia.

o Periodic & Episodic Changes in Fetal Heart Rate

 Periodic Changes: occur with UC’s (Uterine Contractions)
 Episodic Changes: do no occur or associate with UC’s.
 Acceleration: visually apparent & abrupt. (onset to peak <30secs) The peak is at least 15
bpm above the baseline and acceleration lasts 15 seconds or more - NORMAL
 Can occur in relation with fetal movement, vaginal exam, reaction to external sounds,
breeched, occiput posterior position..etc
 Decelerations: defined by the visual relation ship to the onset and end of contraction.
 Early decelerations: response to fetal head compression
o “mirror image” of a contraction, a decrease in return to the baseline,
o intervention not needed.
 Late decelerations: caused by uteroplacental insufficiency
o Deceleration begins after the contraction has started and the lowest point of the
decel occurs after the peak of the contraction – does not return to baseline until
after the contraction is over
o Can lead to metabolic acidemia or fetal hypoxemia
 o Intervention: change moms position (lateral), elevate moms legs, increase rate of
maintenance IV solution, palpate uterus & assess for tachysystole, & discontinue
oxytocin if infusing, administer oxygen, notify HCP.
 Variable: caused by compression of the umbilical cord
o The decrease is at least 15bpm or more below the baseline, lasts 15 seconds &
returns to the baseline in less than 2 min from the time of onset.
o Not always associated with UC’s.
o Often have a U,V, or W shape & a rapid descent and ascent from the nadir
(lowest point) of the decel.
o Intervention: change maternal position (side to side, knee chest), discontinue
oxytocin, administer oxygen, notify HCP,

FHR Pattern Mnemonic :

V- variable ---------------- C-cord compression

E- early -------------------- H- head compression
A- acceleration ----------- O- okay
L- late --------------------- P- placenta insufficiency

Nursing Care Management

o FHR response to stimulation
 Scalp Stimulation: using digital pressure during a vaginal examination
 Vibroacoustic Stimulation: device on moms abdomen over the fetal head for 1-5 secs
 Both desired results are accelerated FHR of at least 15 bpm for at least 15 seconds
 FHR acceleration = absence of metabolic acidemia.
o Fetal oxygen saturation monitoring
 Fetal pulse oximetry: intrauterine sensor placed in contact with the fetal check or
temple provides a continuous estimation of oxygen saturation.
o Fetal scalp blood sampling
 Samples pH, blood is obtained from the scalp through the dilated cervix after
membranes have ruptured.
o Amnioinfusion
 Infusion of normal saline or lactated ringers solution into the uterine cavity if the
amniotic fluid is low.
 Useful is relieving pressure off the umbilical cord
 Oligohydramnios: little amniotic fluid
 Anhydramnios: no amniotic fluid
 Usually a bolus of fluid will be givein over 20-30 min, no more than 1000mls
o Tocolytic therapy
 Relaxation of the uterus.
 Can be achieved throught he administration of drugs that inhibit UC’s
o Umbilical cord acid–base determination
 After birth, an umbilical cord blood sample is useful for the Apgar score.