Chapter 17

Fetal Assessment
During Labor

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Fetal Assessment During Labor

Electronic fetal monitoring is a useful tool for

visualizing fetal heart rate (FHR) patterns on
monitor screen or printed tracing

First used in 1970s

Anticipated effect was a decrease in cerebral
palsy
Believed to be more sensitive than auscultation in
predicting fetal compromise

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Basis for Monitoring

Fetal response

Labor is a period of physiologic stress for fetus

Frequent monitoring of fetal status is part of
nursing care during labor
Fetal oxygen supply must be maintained during
labor to prevent fetal compromise

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Basis for Monitoringcontd

Fetal oxygen supply can decrease:

Reduction of blood flow through maternal vessels

as result of:
Maternal hypertension: chronic or pregnancy-induced
hypertension
Hypotension caused by supine maternal position,
hemorrhage, epidural analgesia, or anesthesia
Hypovolemia caused by hemorrhage

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Basis for Monitoringcontd

Fetal oxygen supply can decrease:

Reduction of oxygen content in maternal blood as

result of hemorrhage or severe anemia
Alterations in fetal circulation with compression of
umbilical cord
Reduction in blood flow to intervillous space
in placenta

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Basis for Monitoringcontd

Fetal well-being during labor measured by

response of FHR to uterine contractions
(UCs)
Reassuring FHR patterns are:

Baseline FHR in normal range of 110 to 160

beats/min, with no periodic changes and a
moderate baseline variability
Accelerations of FHR with fetal movement

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Basis for Monitoringcontd

Fetal compromise

Goals of intrapartum FHR monitoring are to

identify nonreassuring patterns indicative of fetal
compromise
Nonreassuring FHR patterns associated with:
Fetal hypoxemia, deficiency of oxygen in arterial blood

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Basis for Monitoringcontd

Fetal compromise

Hypoxemia can deteriorate to severe fetal hypoxia

Inadequate supply of oxygen at cellular level
Nurses role is to assess that FHR pattern reflects
adequate fetal oxygenation

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Basis for Monitoringcontd

Nonreassuring FHR includes:

Baseline FHR <110 or >160 beats/min

Decrease in baseline
Irregular rhythms
Decreased FHR during or within 30 seconds after
a contraction

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Monitoring Techniques

Intermittent auscultation (IA)

Listening to fetal heart sounds at periodic
intervals to assess FHR
IA can be performed with:
Leff scope
DeLee-Hillis fetoscope
Pinard fetoscope
Ultrasound device

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Monitoring Techniquescontd

EFM

External monitoring
FHR: ultrasound transducer
UCs: tocotransducer
Internal monitoring (invasive)
Spiral electrode

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Fig. 17-2. A, External noninvasive fetal monitoring with tocotransducer and ultrasound
transducer. FHR, Fetal heart rate. B, Ultrasound transducer is placed below umbilicus over the
area where fetal heart rate is best heard, and tocotransducer is placed on uterine fundus.

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Fig. 17-3. Diagrammatic representation of internal invasive fetal monitoring with intrauterine
pressure catheter and spiral electrode in place (membranes ruptured and cervix dilated).
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Fetal Heart Rate Patterns

Baseline FHR

Baseline rate is average during 10-minute

segment, excluding:
Accelerations
Decelerations
Periods of marked variability
Normal range at term 110 to 160 beats/min

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Fig. 17-4. Display of fetal heart rate and uterine activity on monitor paper. A, External mode with
ultrasound and tocotransducer as signal source. FHR, Fetal heart rate; UC, uterine
contractions. B, Internal mode with spiral electrode and intrauterine catheter as signal source.
Frequency of contractions is measured from the beginning of one contraction to the beginning
of the next. FHR, Fetal heart rate; UA, uterine activity.
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Fig. 17-5. Fetal heart rate variability. A, Absent or undetected.

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Fig. 17-5. Fetal heart rate variability. B, Minimal.

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Fig. 17-5. Fetal heart rate variability. C, Moderate.

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Fig. 17-5. Fetal heart rate variability. D, Marked.

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Fetal Heart Rate Patternscontd

Baseline FHR

Variability
Tachycardia: baseline more than 160 beats/min for
duration of 10 minutes or longer
Bradycardia: baseline less than 110 beats/min for
duration of 10 minutes or longer

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Fetal Heart Rate Patternscontd

Changes in FHR

Periodic changes occur with UCs

Episodic (nonperiodic) not associated
with UCs
Accelerations
Decelerations
Early decelerations: response to fetal head

compression
Late decelerations caused by uteroplacental
insufficiency

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Fig. 17-6. Accelerations of fetal heart rate.

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Fig. 17-7. Deceleration patterns. A, Early.

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Fig. 17-7. Deceleration patterns. B, Late.

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Fig. 17-7. Deceleration patterns. C, Prolonged.

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Fig. 17-7. Deceleration patterns. D, Variable.

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Fetal Heart Rate Patternscontd

Changes in FHR

Variable decelerations: caused by umbilical cord

compression
Prolonged decelerations: FHR below baseline of
15 beats/min and lasting more than 2 minutes

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Fig. 17-9. With integration of the fetal monitor tracing into the electronic medical record, the
nurse can view the fetal tracing while charting.
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Nursing Care Management

EFM pattern recognition

Must evaluate five components of an FHR tracing

Determine whether intervention is needed
Identify indications to expedite birth

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Nursing Care Managementcontd

Additional methods of assessment and

intervention

FHR response to stimulation

Fetal oxygen saturation monitoring
Fetal pulse oximetry
Fetal scalp blood sampling
Amnioinfusion
Tocolytic therapy
Umbilical cord acid-base determination

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Nursing Care Managementcontd

Additional methods of assessment and

intervention

Patient and family teaching

Maternal positioning
Discouraging Valsalva maneuver
Documentation
Evaluation

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Key Points

Fetal well-being during labor is gauged by

response of FHR to UCs
FHR characteristics include baseline FHR
and periodic changes in FHR
Monitoring of fetal well-being includes:

FHR assessment
Watching for meconium-stained amniotic fluid
Assessment of maternal vital signs and uterine
activity

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Key Pointscontd

Responsibility of nurse to:

Assess FHR patterns

Implement independent nursing interventions
Report nonreassuring patterns to physician or
nurse-midwife

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Key Pointscontd

Established and published care standards

and guidelines for fetal heart monitoring

Association of Womens Health, Obstetric and

Neonatal Nurses (AWHONN)
American College of Obstetricians and
Gynecologists (ACOG)

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Key Pointscontd

Emotional, informational, and comfort needs

of woman and family must be addressed
when mother and her fetus are being
monitored
Documentation is initiated and updated
according to institutional protocol

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