Basic Fetal Heart Monitoring

Determine Uterine Contraction Pattern:

Timing: from beginning of contraction to beginning of next one
Duration: from beginning of contraction to end of contraction
Intensity: uterine palpation or intrauterine catheter pressure
External: mild, moderate, strong
Internal: mmHg of pressure

Basic Pattern Recognition:

1. Baseline rate
2. Baseline FHR variability
3. Presence of Accelerations
4. Periodic or episodic decelerations
5. Changes or trends of FHR over time

Fetal tracings can be classified into the following patterns:

 Baseline
 Baseline Variability
 Acceleration
 Bradycardia-FHR less than 120. Causes: fetal heart block, myocardial
conduction defects, serious fetal compromise, occiput posterior or
transverse position, post date gestations, cord prolapse, rapid descent,
epidural and spinal anesthesia, and vigorous vaginal exam.
 Early Deceleration
 Late Deceleration
 Tachycardia-FHR above 160. Causes: maternal fever, hypoxia, drugs,
fetal amniotis, anemia, parasympathetic drugs, prematurity,
hyperthyroidism, chorioamnionitis In presence of good variability,
tachycardia is not a sign of fetal distress.
 Variable Deceleration
 Prolonged Deceleration

Fetal Monitoring Equipment:

 3 fetal monitor strips
 fetal monitor handout for each student
 placental/internal scalp electrode
 intrauterine pressure catheter
 amniohook

Purpose and Brief History of Fetal Monitoring:

 Designed to help decide if uterine environment is safe for the baby
 Measures response of baby’s heart rate to contractions of uterus
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  Fetal monitoring began in the 1970’s. Although much is understood
about interpretation, it is not a complete knowledge and is still subject
to interpretation amongst providers
 Association of Women’s Health, Obstetrics and Neonatal Nurses
(AWHONN) is a professional organization that provides guidelines to
hospitals for continuous fetal monitoring during labor
 American Congress of Obstetrics and Gynecology (ACOGG) is
another professional organization that offers guidelines for fetal
monitoring
 A fetoscope is similar to a stethoscope and can be used to assess
FHR
 Doppler is an instrument that uses ultrasound to magnify sound. Fetal
heart tones can be heard between 10-12 weeks gestation
 Fetal movement is an important sign of the baby’s health. “Kick
counting” is a daily systematic record of Mom’s perception of their
baby’s movement during third trimester. Important to lay on left side
and document each movement. If baby does not move at least ten
times in a 2 hour period, or mother notices decreased movement, call
provider.

How to Interpret the Strips: Basic Steps to Reading Strips

 Top half of strip is baby and bottom half is mother
 Dark red line to dark red line is 60 seconds, small boxes are 10
seconds. The graph for fetal heart rate is 30-200. Normal baseline is
120-160.

 When looking at the bottom half of the graph, the dark red line interval
is the same sixty seconds. Vertically, it goes from 0-100 and each little
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 box is only 5. The bottom graph is to help show contraction frequency,
duration and intensity. “O mmHg” is the measurement in mm/Hg of
contractions that have the internal uterine monitor in place. Otherwise,
for an external monitor, the height of the contraction is only based
subjectively on how tight the external toco is placed on the abdomen.

Interpreting the Strip: Equipment

 Can be monitored via external equipment and internal equipment.
 Externally: belts are wrapped around the abdomen. One belt uses
Doppler to detect fetal heart rate and other belt measures the length of
contraction and time between. It does not measure the precise
strength of the contractions.
 Internally: The cervix must be dilated and the membranes ruptured
before monitoring can be performed internally. A small plastic device
is inserted through the cervix. A spiral wire called a fetal scalp
electrode is placed beneath baby’s scalp. This electrode then
transmits direct information about the fetus’s heart rate through a wire
to the fetal monitor that prints out the information. The internal
pressure transducer is the second part of the internal monitoring
system. This small device is placed through the dilated cervix into the
amniotic fluid cavity and an electronic pressure gauge detects the
internal pressure. This device is able to measure the frequency,
duration and intensity of contractions.

Interpreting the Strip:

 In order to determine whether there are changes in the fetus’
physiologic status, a baseline heart rate must first be determined as a
reference. The baseline FHR is the average FHR over a ten minute
period, and rounded to nearest 5 beats per minute.

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 The baseline FHR is set by the atrial pacemaker and the beat-to-beat
differences in the heart rate are governed by a balance between the
sympathetic and parasympathetic branches of the autonomic nervous
system.

 No variability is detectable in the fetal heart rate. Absent variability is

considered a non-reassuring sign.

 Minimal variability is <5 bpm variation from baseline

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 Moderate variability is 6-25 bpm from baseline. This indicates a
mature and well -oxygenated fetus.

 The fetal heart rate varies from baseline 25 or more beats/minute.

This is a non-reassuring sign of variability.

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 Accelerations must increase 15 beats above baseline and maintain this
for 15 seconds. Accelerations are always associated with good
oxygenation. Generally, reassures that there is no hypoxia.

 Early deceleration of FHR in response to contractions. These are a

normal response to head compression and are associated with fetal
descent. This occurs commonly during a vaginal exam. Typically
ends before contraction ends.

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 Late deceleration of FHR in response to contractions. These begin
during contraction, and return “late” to baseline. This is an indication
on uteroplacental insufficiency. There is an impairment of blood flow to
the fetus and is a sign of fetal distress requiring immediate
intervention. Treatment: 10 L O 2 via NRB, stop Pitocin, increase
intravenous fluid rate, and reposition mom from supine to left lateral.

 Variable decelerations of FHR occurs spontaneously and in

response to contractions. These indicate some type of cord
obstruction. Abrupt drop and quick return to baseline. Reposition
patient.
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 Use the acronym “VEAL CHOP” when evaluating a fetal monitor
pattern.

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 The newborn’s adaptation to life outside the uterus is evaluated at 1
minute and 5 minutes of age, using the above Apgar tool. This
evaluation method can be used anytime the newborn’s condition is in
question. Each item—heart rate, respiratory rate, muscle tone, color
and reflex irritability—is assigned a score of 0 to 2. A score of 8 to 10
requires no special attention. A score of 4 to 7 requires oxygen and
stimulation. This score can indicate respiratory depression from mom
receiving narcotics during labor. A score of 0 to 3 indicates baby’s
need for immediate resuscitation.
 Proper identification must be made in the delivery room before the
mother and infant are separated. ID bands are made and compared,
and baby’s footprint is taken. Infant measurements are then taken
(height, weight, head circumference, chest circumference) as well as
vital signs (temperature, apical heart rate, respiratory rate, blood
pressure, pain assessment), and a newborn assessment performed.

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References:

"QCOM - Fetal Heart Monitoring - EFM Basics." QCOM - Fetal Heart

Monitoring - EFM Basics. Web. 7 Oct. 2015.

Maternal Child Nursing, 4th edition by McKinney, Chapter 17:

Intrapartum Fetal Surveillance, pages 370-387.

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