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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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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 andrhythm 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 toperform appropriate interventions if
problem noted
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Advantages and Disadvantages
of Auscultation• Advantages
– It is noninvasive and relatively painless procedure forthe 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 fetalback is located
• Auscultate the FHR between contractions for atleast 60 seconds, noting the rate and rhythm
• Palpate maternal pulse to differentiate betweenFHR 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 Method
Follow Recommended Pattern
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Systematic Method
Use If Unsuccessful With Methodical
Method
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General Principles of
Auscultation for Student Nurses• Utilize standard precautions
• Obtain supplies, doptone, fetoscope, ultrasoundgel, 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 theprocedure
• Document and report results to primary RN
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Safety Practices
• Verify orders and identify patient
• Position patient in semi-fowlers positionpreferably 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 decreasesfollowing 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 nursingstudents 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 anydecreases heard to the Primary RN.
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Electronic Fetal Monitoring
Clarification
• Information for students is for educationalpurposes only
• Students should not assume anyresponsibility for interpretation of fetalmonitor tracings
• It takes months to years of experience in
addition to continuing education to beprepared to interpret fetal monitor tracings
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Electronic Fetal Monitoring
• Definition
– Electronic method of providing a continuousvisual record of the FHR and uterine activity
• Information is recorded on graph paper orin 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 thefetal 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 datatransmission
– 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 10seconds 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 FHRshould 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 notbe a persistent variability pattern
• Moderate : 6-25 bpm from baseline (optimalpattern)
• 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 uteroplacentalinsufficiency. (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 theseoccur 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 oxygenatedfetus.
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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, oracidosis.
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Uterine Activity Assessment
• Periodic tightening and relaxing of theuterine muscle.
• Pituitary gland is triggered to release ahormone called oxytocin that stimulatesthe uterine tightening.
• Difference in Braxton Hicks (false labor)
and true labor is the strength of thecontractions and the changes in the cervix.
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Characteristics of Contractions
• Frequency: How often they occur. They aretimed from the beginning of a contraction to thebeginning 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 beindented during peak of contraction
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Electronic Assessment of
Contractions• External electronic monitor
– Toco: Palpate uterus to find fundus and place onfirmest part.
– If patient states she is having contractions but none are
showing on fetal monitor tracing the first interventionis to readjust the toco.
– Problems associated with obesity and patientmovement or position changes
• IUPC – Physician or CNM inserts device
– RN measures strength of contractions in MontevideoUnits (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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