Fetal Monitoring

Lauren Jansen RN, PhD

Assistant Professor
Wilson School of Nursing
Midwestern State University
(940) 397-4547
lauren.jansen@mwsu.edu

Objectives

Discuss the role of Electronic Fetal Monitoring

(EFM) in obstetrical care
Discuss standards of care and documentation of
EFM
Describe the technology of EFM
Investigate the role of acid/base balance
Identify normal characteristics of fetal heart rates
Plan interventions for non-reassuring patterns
Describe indications for antepartal testing
Interpret various rhythm strips

References
AAP/ACOG (1992). Guidelines for Perinatal Care.
Drukker Medical Themes, (1993). The Fourth Annual
Conference of Electronic Fetal Monitoring: The Art, The
Science, The Future.
Murray.M. (1997). Antepartum and Intrapartum Fetal
Monitoring, 2nd Edition.
Schifrin, B. (1989. Exercises in Fetal Monitoring.

History of Electronic Fetal Monitoring

1958: first reported by Dr. Edward Hon

1967: first clinically useful fetal monitor was created
with phonotransducer
Mid 1970s: monitors were being used in many
hospitals
1984: widespread use of EFM throughout the United
States; C/S rates were rising
Currently: 75% of patients are monitored during
labor

Why Monitor?

Goal of Fetal Monitoring

Prevent Maternal and Fetal Morbidity and

Mortality
Surveillance tool to detect the fetal heart
rate and maternal uterine activity
Assess fetal well being; 99% accurate in
predicting a well oxygenated fetus
Provides a permanent record
Records events that cannot be heard or
measured by auscultation alone

Standards
(Based on AWHONN and ACOG Guidelines)

Monitor FHR and its characteristics at specified intervals by selected methods and
document findings using appropriate technology
Monitor UA patterns using palpation and/or EFM
Apply the spiral electrode (ISE, FSE) and/or intrauterine pressure catheter (IUPC)
in accordance with nurse practice acts, institutional policy, and medical orders
Recognize normal and abnormal FHRs or non-reassuring characteristics and
promptly initiate appropriate nursing interventions
Recognize normal and abnormal uterine activity and intervene accordingly
Perform ongoing intrapartal assessment of comfort level
Perform and assess frequent monitoring of the FHR prior to delivery
Use a systematic approach forr tracing review
Intervene with non-supine positioning, IV bolus of non-glucose solution, O@ per
tight face mask at 8-10 L/min, discontinue oxytocin if indicated, and continue
EFM
Communicate changes promptly informing physician of FHR pattern and
interventions performed. If physician does not agree with nursing assessment, a
policy should be in place to resolve conflict

Guidelines for Monitoring

Guidelines

Low risk

Periodically during the latent phase

Every 30 minutes during the active phase
Every 15 minutes during the second stage

High risk

Every 30 minutes during the latent phase

Every 15 minutes the active phase
Every 5 minutes during the second stage

Charting

Documentation

Purpose of Documentation

Provides evidence of care given

May assist the nurse in the event of litigation

Where and What to Document

Monitor Strip
Identification information (patient name & med#)
Physician or nurse initiated treatment
An event or patient care activity which might affect
the FHR or UA tracing (ie. catheterization, etc)
Never assume the strip stand alone; document in
patient record as well

Patient Record

All information documented on tracing should appear

in patient record
Documentation of fetal heart rate, variability, presence
of accelerations in the heart rate, and decelerations in
the heart rate
Summary of significant events of patient care
Use late entry when adding information after the
fact; never backdate, tamper with, or add to notes that
were previously written

Special Issues

Fetal Heart Rate

Variability

Document in terms of terms of variability such as absent, minimal,

average or exaggerated
Acceleration in fetal heart rate

Fetal heart rate patterns

Document baseline as a range (120s, 130s, etc)

Uterine activity assessments (frequency, duration, intensity if palpated)
Describe fetal heart rate deviations with contraction or movement.

Describe decelerations in detail (ex: deceleration of fetal heart rate to

100s from baseline of 150s beginning at the peak of the contraction and
returning to baseline heart rate 30 seconds after contraction has ended)

Technically inadequate strips

Common Errors in Documentation

Failure to recognize non-reassuring or abnormal

uterine activity
Failure to take steps once non-reassuring
characteristics are noted
Failure to communicate changes in patient
condition in the medical record and to the
physician
Failure to continue monitoring until delivery

Monitoring Methods

Auscultation and Palpation

In order to hear fetal heart beats at various stages of development go to

http://heartbeatsathome.com/dopplerdetails.cfm
Auscultation

Advantages

Inexpensive, non-invasive
Assesses rate and significant rate changes of accelerations and decelerations

Disadvantages

DeLee Stethoscope
Doppler ultrasound device

Provides no permanent record for documentation

Does not allow for subtle changes
Requires 1:1 nurse:patient ratio

Interpretation

Performed during a contraction and for 30 seconds thereafter

Palpation

Advantage

Non-invasive
Can detect contraction frequency and duration, however intensity is
subjective

Disadvantage

Provides no permanent record for documentation

Cannot assess relationship between FHR and contractions

Electronic Monitoring

Indirect (external monitoring)

Technique

Advantages

Ultrasound transducer
Tocodynamometer
Non-invasive
Continuous
Provides Record

Disadvantages

Movement or change
of position may
affect tracing
Obesity
Maternal pulse
Greater than 240; less
Than 50
Cant detect dysrhythmias

-2

Direct (internal)

Technique

Advantages

Internal scalp
electrode
Intrauterine
pressure catheter
More direct
Not affected by
movement or
change of position
Measures contraction
intensity

Disadvantages

Membranes must be
ruptured; 1 CM dilation
Infection
Fetal trauma

Additional Information
A test pattern must be run and documented prior to
monitoring (press test button on monitor)
Paper speed at should be set at 3 cm/minute
Uterine baseline reference should be set at 10 mmHg
if monitoring externally and 0 if using an intrauterine
pressure catheter (press UA button on monitor)
Internal monitoring is contraindicated in AIDS,
Herpes, and know Beta Strept infections

Maternal/Fetal Oxygen Transport:

Acid/Base Balance

ACID-BASE BALANCE

Monitoring acid-base balance

Direct

PUBS (percutaneous umbilical blood sampling

Serial scalp sampling
Umbilical cord pH
Fetal pulse oximetry

Indirect

Baseline FHR
Variability
Accelerations
Decelerations

Factors Affecting 02/C02 Transport

(Acid-Base Balance)

Maternal

Placental

Anomalies: Tumors, calcifications`

Abruptions, Previas

Umbilical Cord

Medical conditions such as PIH, diabetes, seizures

Maternal substance abuse
Maternal medication

Anomalies
Compression: True knot; nucal cord, prolapse

Fetal

Anomalies: Anencehphaly, neural tube defects

Infection
ABO incompatibilities; RH sensitization

Normal Placental Function

Normal uterine blood

flow

Umbilcal Vein
Umbilical Arteries

Oxygenation in the
intervillous space
Exchange of O2/C02

Normal Acid/Base Values

Maternal:
-pH
-Pa02
-PaC02
-Bicarb

7.40-7.45
104-108 mm Hg
27-32 mm Hg
16-20 mEq/L

Maternal pulse oximetery should remain at 98-100%

< 94% is trending toward incompatible with fetal life
<90% is incompatible with fetal life

Fetal
-pH
Pa02
PaC02
-BD

7.25-7.35
20-30 mm Hg
40-50 mm Hg
< 10 mEq/L

Umbilical Cord:
Arterial

Umbilical Cord:

-pH
7.34 + 0.03
Pa02
26 +5 mmHg
PaC02 34 +6 mmHg

-pH >7.20
-Pa02>20 mmHg
-PaC02<60 mmHg

Venous

Fetal Scalp Sampling Values

Normal
Borderline
Acidosis
Critical

>7.25 mmHg
7.20-7.25
<7.20
<7.00

Respiratory vs Metabolic Acidosis

Respiratory

Metabolic

-pH

<7.20

-pH

<7.20

-Pa02
-PaC02
-BD

variable
>60 mmHg
<10mEq/L

-Pa02
-PaC02
-BD

<20 mm Hg
44-55 mmHg
> 10 mEq/L

Something New: Intrapartum

Oxygen Saturation Monitoring

Purpose

Measures O2
saturation in utero

Procedure

Insert catheter with

O2 sensing
microchip

Evaluating Baseline Fetal Heart

Rate

Fetal heart tones

contraction

FHR: Baseline

Norms

110-160 beats/minute
Ten minute period which excludes accelerations and
decelerations

Physiology: the Autonomic Nervous System

Sympathetic-dominant system until around the 28 th week of

gestation; cardioaccelerator
Parasympathetic-develops around the 28 th week of gestation;
cardiodecelerator
The interaction between the sympathetic and parasympathetic
produces variability in the fetal heart rate. It is demonstrated
on a strip by a squiggly line and is defined in terms of
absent, minimal, average, or marked variability

Normal Rhythm
Select one minute of strip
in which to evaluate fetal heart rate
Normal Rate Between 110-160 BPM

Each horizontal line

Represents 10 beats

60 sec from
One heavy line to next

120s130s

Select one minute of strip. Determine

highest fetal rate and lowest fetal rate during that minute.
The difference will represent variability. Using above: 130-120=10
Therefore the variability falls in the average range

FHR: Bradycardia

Norms

Causes

Fetal Heart Rate less than 110 x 10 minutes

Maternal/fetal infection
Prolonged maternal hypotension
Postmaturity
Fetal heart block

Interventions

Treat cause; in event of fetal heart block, the condition will often
correct after delivery. Intervention will occur after delivery.

Determine fetal heart rate and variability

FHR: Tachycardia

Norms

Causes

Fetal heart rate above 160 BPM for longer than 10 minutes.

Maternal fever
Maternal hypovolemia
Maternal/fetal infection
Medications such as Brethine

Interventions

Treat the cause

Using the examples for normal rhythm, determine fetal heart rate and variability
On the section of strip between red arrows.
Baseline above 160 BPM x 10 minutes

Determining Fetal Heart Tone

Variability
Amplitude of FHR
Change

Description

Undetectable from baseline Absent

Visually detectable from
baseline 5 beats per
minute

Minimal

6-25 beats per minute

Moderate

> 25 beats per minute

Marked

FHR: Variability

Absent Variability

Obstetrical Emergency!
Reposition Mother
IV fluid bolus of at least 500 ml LR or NS
O2 per mask at 10-12 L
Cease infusions of Pitocin
Notify Physician
Possibly ready for C/S

Absent Variability

FHR: Minimal Variability

Causes:
CNS depression
Volume depletion
Response to Medication
Significance:
O2 suppression to fetus
Intervention:
Fluid replacement
O2

FHR: Increased Variability

Causes

Significance

Immediate response to a hypoxic event

O2 saturation is being compromised

Intervention

Reposition

FHR: Sinusoidal Pattern

Description

Seesaw pattern that is uniform (see next slide)

Significance

Prolonged pattern may indicate an Rh

sensitization
Medications such as Nubain may cause periodic
sinusoidal patterns

Fetal Heart Tone Patterns

FHR: Accelerations

Causes
Response to fetal movement or stimulation
Description
Abrupt increase of fetal heart rate above baseline of 15 beats per
minute (bpm) and lasting 15 seconds bur < 2 minutes from the
onset to return to baseline.
Before 32 weeks of gestation, a peak 10 bpm above the baseline
and duration of 10 seconds is an accelerations.

Interventions
None

Accelerations

Decelerations
Early: This declaration reflects the vagal stimulation of the
compression of the uterus on the fetal head (head compression)
Late: The lowest point of the deceleration usually occurs after
peak of the contraction and does not return to the baseline until
after the contraction is completed. Often it is 15-30 seconds
before the fetal heart rate has returned to the baseline after The
contraction has completed.(utero-placental insufficiency)
Variable: Abrupt decrease of heart rate and rapid recovery.
Usually 15 bpm and last about 15-20 seconds. Associated with
cord compression
Prolonged: A decrease in baseline that may last from 2-20
minutes. Cause is unknown

FHR: Early Decelerations (can only be

evaluated when a contraction is present)

Causes

Description

Head compression

Decrease of heart rate which mirrors a contraction; the

heart rate will begin to decelerate at the onset of a
contraction and will return to baseline as the contraction
eases.

Intervention

None

FHR: Late Decelerations (Can only be evaluated

when a contraction is present)

Causes

Uteroplacental perfusion has be compromised

Description

Fetal heart rate will begin to decelerate around the peak of the contraction and
not return to the baseline until about 15-30 seconds after the contraction has
ended

Any deceleration of the fetal heart tones from the baseline lasting greater than
30 seconds

Intervention

Fetal Stress Protocol:

Position mother on side (either right or left)

O2 per mask at 10-12 L/min

IV fluid bolus of 350-500 cc fluid (preferably LR or D5LR)

Discontinue pitocin

Late Deceleration-Returning to baseline about 30 seconds after contraction has ended

Where is the baseline? Often it is difficult

to assess. In this case the decels are late.

FHR: Variable Decelerations (May occur

with or without a contraction)

Causes
Cord compression

Description
Deceleration will occur very quickly and return to
baseline as quickly. This gives the deceleration a V
shape. As they prolong, the shape changes to a U

Intervention
Reposition mother from side to side. In prolonged cases,
O2 and IV fluid may be given using the Fetal Stress
Protocol.

FHR: Prolonged Decelerations

Causes

Description

Unknown; may occur during a prolonged contraction; it is

often noted at the time the cervix is completely dilated

Prolonged decrease in fetal heart rate; may last as long as

5-10 minutes before returning to baseline

Interventions

Reposition mother; ensure adequate hydration and

oxygenation

-2

Non-reassuring

Progressive increase or decrease in

baseline
Tachycardia
Progressive decrease in baseline
variability
Severe variable decelerations

-2

Non-reassuring

Late decelerations
Absence of variability
Prolonged decelerations
Severe bradycardia

Caring for the Mom,

Not the Monitor!