basic fetal monitoring 2008-1

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5/1/2012 1

Basic Fetal Monitoring

Designed For

New Labor and Delivery Nurses

By

Pat Burroughs MSN, RN

Copyright 1996-98 © Dale Carnegie & Associates, Inc.



5/1/2012 2

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



5/1/2012 3

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



5/1/2012 4

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



5/1/2012 6

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.



5/1/2012 7

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 .



5/1/2012 8

Who Should Perform

Intermittent Auscultation?

• Someone with knowledge of normal FHR

characteristics

• Someone with knowledge and skill toperform appropriate interventions if

problem noted



5/1/2012 9

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



5/1/2012 10

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.



5/1/2012 11

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.



5/1/2012 12

Methodical Method

Follow Recommended Pattern



5/1/2012 13

Systematic Method

Use If Unsuccessful With Methodical

Method



5/1/2012 14

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



5/1/2012 15

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



5/1/2012 16

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.



5/1/2012 17

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



5/1/2012 18

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



5/1/2012 19

When is Electronic Fetal

Monitoring Used?

• When ordered by the physician, midwife,

or indicated by hospital policy.

– For screening or surveillance – Intermittently or continuously



5/1/2012 20

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



5/1/2012 21

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



5/1/2012 22

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



5/1/2012 23

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



5/1/2012 24

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



5/1/2012 25

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.



5/1/2012 26

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



5/1/2012 27

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



5/1/2012 28

Examples of Periodic Changes

• Variable decelerations: Result from some

type of cord compression.

– Nuchal cord, True knot – Decreased amniotic fluid



5/1/2012 29

Severe Variable Decelerations

Note the depth from the baseline

Baseline



5/1/2012 30

Early Deceleration

• Occur as a result of vagal stimulation to the

fetal head during contractions which push

the fetal head toward the pelvis.



5/1/2012 31

Late Decelerations

• Occur in response to uteroplacentalinsufficiency. (blood flow to the fetus is

compromised and there is less oxygen

available to the fetus)



5/1/2012 32

Late Decelerations

With Absent Variability

Note the smoothness of the FHR pattern



5/1/2012 33

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



5/1/2012 34

Example Prolonged Deceleration

• Note the duration of the deceleration lasts

more than 2 minutes.



5/1/2012 35

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.



5/1/2012 36

Example Accelerations

• Note the increase from the fetal heart

baseline



5/1/2012 37

Sinusoidal Pattern

• Persistent wave variation of the baseline

only seen in about 2% of patients.

• Related to severe fetal anemia, hypoxia, oracidosis.



5/1/2012 38

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.



5/1/2012 39

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



5/1/2012 40

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



5/1/2012 41

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



5/1/2012 42

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



5/1/2012 43

Determination of True Labor

• Contractions will be regular

– Contractions will increase in strength,

frequency, and duration

– Cervix will change!



5/1/2012 44

Questions Regarding Auscultation

or Electronic Fetal Monitoring?



5/1/2012 45

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.



5/1/2012 46

The End

basic fetal monitoring 2008-1

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