Fetal Assessment in labor

Teri Stone Godena, CNM, MSN

N 344 Fall, 2015

Nursing responsibilities

Interpreting FHR patterns

Initiating appropriate nursing interventions

Communicating with CNM/MD

Documenting FHR & outcome of any

interventions

How can you assess?

Intermittently or Continuously

Intermittent with Doptone or EFM

Continuous with EFM

Externally
Internally

Procedure?

Intermittent: Using doppler, fetoscope or EFM

Listen during contraction & 30 seconds

afterward
Every 15-30 minutes in 1st Stage,
Every 5-15 minutes in 2nd Stage

Risks vs benefits intermittent

Benefits: No increase in risk for mother

or baby over continuous monitoring in
low risk women. Mobility

Risks: May provide less complete data;

may be difficult to assess subtle trends

Electronic Fetal Monitoring

(EFM)

Benefits:
May provide more data
and detect subtle trends
Convenient for the
nurses and providers
May provide clues to
assist with pushing with
an epidural

Risks:
Limited mobility
Provides medical
atmosphere to birth
Associated with
increased C/Sections
Not associated with
improved fetal
outcomes

Procedure

External EFM
Pressure tocodynomometer
Placed at the fundus

Ultrasound transducer placed

at PMI for fetal heart

Electronic Fetal Monitoring

(EFM)

Used >85% hospital births

Useful for high risk situations: Pitocin,
maternal or fetal disease

Procedure

Internal fetal monitor:

Fetal Scalp Electrode placed trans
vaginally on the fetal occiput.

Wires that extend from spiral electrode are attached to a

leg plate and then to fetal monitor

Risks vs Benefits internal

Benefits:
Not as affected by
maternal or fetal
movement.
Useful when difficulty
assessing FHT
externally

Risks:
Must have ROM.

Increase risk of
ascending infection.
(Avoid if +GBS or other
infection risk hepatitis B
or C, HIV, etc.)

Can cause fetal scalp

lacerations

Interpreting the Data

Contraction Pattern:
With External: Duration and frequency
With Internal: Duration, frequency, strength
and resting tone
Fetal Heart Patterns:
Baseline, Variability, Accelerations,
Decelerations and Category

Frequency
Duration
Strength

CONTRACTIONS

Contractions

Frequency appreciated from peak to peak or beginning of one to the beginning of the
next. Each small cell = 10 or 20 seconds, each large cell = 60 seconds.
Duration measured from when contraction leaves baseline until it returns to baseline

Clinical application

Clinical application

Determining strength

Manual palpation: Hand over fundus

Maternal Response: Direct verbal report or
observing behavioral changes
Direct measurement of mmHgonly with
internal contraction monitor: intrauterine
pressure catheter (IUPC).

Direct intrauterine measurement

Expressed in Montivideo units

Calculate Montivideo units

Assume strip looks like this for 10 minutes

Calculate montivideo units

Are they adequate for dilatation?

How many is too many contractions?

> 5 contractions in 10 minutes averaged over

30 minutes is tachysystole
Some fetuses tolerate contraction that close for
a period of time.

Rate
Rhythm
Accelerations
Decelerations
Category

FETAL HEART RATE

INTERPRETATION

Rate

110-160 bpm. Expressed as a single number

rounded to the nearest 5, eg, 125, 130.
Determined over 2 minutes without Ucs.

Too High

Tachycardia > 160 bpm

Causes: maternal fever, dehydration, infection, hyperthyroid

Anxiety. Some medications (eg. terbutaline),
Fetal hypoxia, SVT, prolonged activity

Nursing responsibilities: Oxygen 8-10 L by mask.

Bolus IV fluids.
If fever, antipyrectics + antibiotics per provider order.

Too Low

< 110 bpm

Causes: Maternal: Position, hypotension, anesthesia,

beta-blockers (eg. labetalol), Lupus
Fetal: Mature ParaSympathetic NS, cord
compression, decompensation, excessive PS tone
from head compression
Cardiac defect

Too Low

Nursing responsibilities:
D/c pitocin if in use.
Side lying position.
Oxygen 8-10 L by mask.
IV fluids.
Tocolytic, per order.
Notify Provider.

Rhythm (Variability)
Absent 0-2 bpm

Minimal 3-5 bpm

Moderate 6-25 bpm

Marked or Saltatory >25 bpm

Sinusoidal In the form of a sine wave with no variaibility

Variability

Single most important predictor of well being

Reflects fetal CNS ability to regulate heart rate
Decreased variability with persistent late or
severe variable decelerations associated with
fetal hypoxia

Causes of decreased variabiility

Hypoxia
Drugs affecting the CNS: Sedatives,
Analgesics, Anesthesia, Magnesium sulfate
Prematurity- Parasympathetic nervous system
immature
Normal Sleep cycle

Absent variability

Causes: Fetal acidemia or pre-existing

neurological insult if baseline is within normal
range and no decelerations are present

Minimal variability

Associated with fetal sleep if normal baseline

and no decelerations
May be predictive of fetal acidemia in
combination with other patterns
Associated with maternal drug ingestion
Nursing responsibility: Prompt assessment
unless immediately preceded by reassuring
tracing

Moderate variability

Predictive of an intact CNS, mature

parasympathetic NS and adequate fetal
oxygenation

Marked variability

Usually associated with tachysystole

May reflect deterioration of fetal CNS

Sinusoidal

Oscillations are regular, smooth, sine like with

a frequency of 305 oscillations per minute
persisting > 20 minutes
Associated with fetal Anemia
Considered ominous

Sinusoidal appearing

Pseudosinusoidal have a saw toothed

appearance. Less consistency in oscillation
pattern. May have normal variability. May
have accelerations
Associated with maternal opoid administration
or fetal thumb sucking

Accelerations
Early Decelerations
Late Decelerations
Variable Decelerations
Prolonged Decelerations

PERIODIC CHANGE

Episodic FHT changes

Episodic (Not always associated with

contractions
Accelerations
Variable decelerations
Prolonged decelerations

Periodic Changes

Always associated with contractions

Early decelerations
Late decelerations

Accelerations

Accelerations- transient abrupt increase (onset to

peak < 30 sec) in FHR of >15 bpm lasting for 15
sec. In a fetus <32 weeks, 10 bpm lasting for 10
sec.
Prolonged acceleration lasts >2minutes, < 10
minutes
Absence of accelerations on an otherwise normal
tracing remains unclear.
Presence of FHR Accelerations have Good
outcome

Accelerations

Decelerations

To determine type of deceleration consider

Timing: Is it gradual or abrupt in onset and
return to baseline
Shape: Is the shape uniform or nonuniform

VEAL CHOP

Variable
Early
Acceleration
Late

Cord
Head
O.K.
Placenta

Period Decelerations

Follow both shape and timing of contractions

Early: Gradual decrease of FHT from
baseline (>30 sec) to nadir. Nadir occurs with
peak of contraction
Recurrent if they appear >50% of the time

Periodic decelerations

Late: Gradual decrease of FHT from baseline

(>30 sec) to nadir.
Deceleration is delayed in time with nadir
occuring after the peak of the contraction.
In most cases, the onset, nadir and recovery
occur after the onset, peak and ending of the
contraction
Recurrent if it occurs > 50% of the time
Usually related to placental insufficiency

Late deceleration

Nursing responsibilities: Reposition to side-lying or knee-chest.

D/C Pitocin.
Apply oxygen at 8-10 L/min by mask.
Increase IV fluids.
Vibroacoustic or scalp stimulation
Notify Provider.

Scalp stimulation

Stroke or massage fetal scalp during vaginal

exam.

Acceleration in response to fetal scalp stim is a

reassuring sign that fetus is not acidotic
(pH > 7.20).

Episodic decelerations

Variable decelerations have an apparent abrupt

decrease in FHT onset to nadir < 30 sec.
Decrease is >15 bpm x > 15 seconds and < 2 minutes.
When accompanying contractions, depth and duration
may vary with each contraction.

Nursing responsibilities
Cause of Variable decelerations is usually cord compression
Nursing responsibilities
Reposition
If persistent, d/c pitocin if in use
Increase IV fluids
Oxygen 8-10 L by mask*
Prepare for Amnioinfusion if persistent, deep

* Evidence not conclusive oxygen helps

Amnioinfusion
Warmed saline infused by a pump into the uterus by of an intra
Uterine pressure transducer

Episodic deceleration cont.

Prolonged deceleration
Onset is abrupt < 30 sec., steep > 30 bpm
Offset is gradual with return to baseline between 2-10
minutes
Deceleration >10 minutes = bradycardia

Prolonged Deceleration

Causes: cord compression (including

prolapse), maternal hypotension (epidural)
ROM, rapid descent
Nursing responsibilities:
Identify cause
Notify provider. Prepare for immediate birth
Same interventions as for variable and late
decelerations

Categories of Tracings

Category I
Normal baseline 110-160 bpm.
Moderate variability.
No late or variable decels.
+/- accelerations.

Category III

Abnormal- Warrants immediate attention

Absent variability with bradycardia or
recurrent variable or late decels
Sinusoidal pattern

Category II

Any tracing that is not Category I or III.

May have:

Tachycardia or bradycardia
Minimal or marked variability
Absent variability not accompanied by bradycardia or
recurrent decels
No acceleration with stimulation
Decelerations with minimal or moderate variability
Prolonged decel of 2-10 minutes

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Interventions

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Interventions

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Interventions