GROUP 1

ANDOY BAUTISTA
APADAN CORATO
ARCENA CORTEZA
BABAS COSTELO
BALAGON DAGNAOS
Content Outline
Topic For Discussion

CARDIOTOCOGRAPHY/EFM

CONTRACTION STRESS TEST

NON-STRESS TEST
Cardiotocography
/ EFM
It is a continuous recording of the fetal heart
rate and is obtained via an ultrasound
transducer placed on the mother's abdomen
It is widely used in pregnancy as a method of
assessing fetal well‐being, predominantly in
pregnancies with an increased risk of
complications
 PURPOSE Cardiotocography/
Electronic Fetal Monitoring

To record FHS continuously

To check uterine activity

To detect any fetal distress

To gain information about the rate, the rhythm of the fetal heart rate, and fetal
movement.
 PURPOSE

To record FHS continuously

The average fetal heart rate is between 110 and

160 beats per minute.

An abnormal fetal heart rate may mean that the

baby is not getting enough oxygen or that there
are other problems.
 PURPOSE

To check uterine activity

Uterine Activity is also known as uterine contraction. It is the
tightening and shortening of the uterine muscles.

Accurate information on Uterine Activity is essential because

elevated Uterine Activity during the first and second stage of
labor can increase the risk of adverse fetal outcome (National
Library of Medicine, 2007).

Allows us to distinguish between true vs. false labor. Signs of

false labor include:
Irregular contractions that don’t get closer together.
Contractions that stop when the patient walk, rest or change
position.
 PURPOSE

To detect any fetal distress

Babies who experience fetal distress are at greater risk of
complications after birth. Prolonged lack of oxygen during
pregnancy and birth can lead to serious complications for
the baby, if it is not noticed and managed early.
Complications may include brain injury, cerebral palsy and
even stillbirth.

The most common signs of fetal distress are: Changes in the

fetal heart rate (lower or higher rate than normal). The
fetus moves less for an extended period of time. Low
amniotic fluid.
 PURPOSE

To gain information about the rate, the rhythm

of the fetal heart rate, and fetal movement.

Fetal heart rate monitoring is especially

helpful for high-risk pregnancy conditions such
as diabetes, high blood pressure, and problems
with fetal growth.
 When is electronic fetal
monitoring recommended? EFM is used in pregnancies
considered high risk due to:
Maternal health conditions such
as preeclampsia, diabetes,
previous cesarean or bleeding
during pregnancy.
Meconium staining during labor,
which is the release of stool by
your baby and can indicate fetal
distress.
Small fetal size or congenital
abnormalities.

Despite these recommendations, many

Ob/Gyns still routinely use EFM.
Nursing Responsibilities
Prenatal
Have the client void
Explain the test to decreased anxiety
Placement of the equipment
Observe the fetal monitor
Observe any abnormal findings from the
result
Record for future reference
Nursing Responsibilities
Intra natal
Have the client void
Explain the test to decreased anxiety
Placement of the equipment
Observe the fetal monitor
Observe any abnormal findings from the result
Prepare for possibility of internal monitoring during labor
Perform the insertion of the device when necessary and
appropriate. (It is not appropriate when the given situation is the
baby must be head first and not breech or footling presentation.
 DEFINITIONS
Baseline fetal heart rate (FHR)
Is the mean level of the FHR when this is stable, excluding
accelerations and decelerations. It is determined over a
time period of 5-10 minutes, expressed as beats per minute
(bpm)

Accelerations
Are transient increases in FHR of 15bpm or more above the
baseline and lasting 15 seconds.

Decelerations
Are transient episodes of decrease of FHR below the baseline
of more than 15 bpm lasting at least 15 seconds.
 DEFINITIONS

Baseline variability

is the minor fluctuation in baseline FHR. It is assessed by

estimating the difference in bpm between the highest peak and
lowest of fluctuation in one minute segments of the trace. 

Normal variability 6-25 beats per minute 

Reduced variability 3-5 beats per minute 
Absent variability <3 beats per minute 
Increased (salutatory) variability > 25 beats per minute
 INTERPRETATIONS

ANTENATAL
Normal antenatal CTG trace: The normal antenatal CTG is
associated with a low probability of fetal compromise and has
the following features:

Baseline fetal heart rate (FHR) is between 110-160 bpm
Variability of FHR is between 5-25 bpm
Decelerations are absent or early
Accelerations x2 within 20 minutes

Any CTG that does not meet these criteria is by definition

abnormal. The full clinical picture must be considered when
evaluating any CTGs.
 INTERPRETATIONS

INTRAPARTUM
Normal intrapartum CTG trace: The normal intrapartum CTG is
associated with a low probability of fetal compromise and has
the following features: 
Baseline FHR is between 110-160 bpm 
Variability of FHR is between 6-25 bpm 
Decelerations are absent or early 
The significance of the presence or absence of accelerations
is unclear. Therefore, exclude accelerations during
interpretation.

Any CTG that does not meet these criteria is by definition

abnormal. The full clinical picture must be considered when
evaluating any CTGs.
PLACEMENT OF EQUIPMENT
 Procedure
Before Procedure
Determine the indication for fetal monitoring
Explain the purpose, time required for the test
Instruct the patient to empty the bladder

During Procedure
Place the woman in the supine position
Uncover the abdomen
The toco-transducer is placed over the uterine fundus in the
area of greatest contractility to monitor uterine contractions.
The other ultrasound transducer records the baseline FHR,
long-term variability, accelerations, and decelerations. It is
positioned on the maternal abdomen in the midline between
the umbilicus and the symphysis pubis.
 Procedure
The diaphragm of the ultrasound transducer is moved
to either side of the abdomen to obtain a stronger
sound an then attached to the second elastic belt.
This transducer converts the fetal heart movements
into audible beeping sounds and records then on
graph paper
Labeled the woman's name, I.P. number, date, and
time in the CATAG graph.

After Procedure
Turn off the monitor and replace it.
Read the CTG and immediately notify the doctor, if
any abnormality is seen.
 CONTRACTION STRESS TEST
Contraction stress test is a test for pregnant people.It
measures the baby’s heart rate during labor
contractions. In a contraction, the baby’s oxygen and
blood supply temporarily drop. Most babies can
handle this decrease. But if the baby’s heart rate
stays low after a contraction, it could mean that the
baby will have problems with typical labor.

The healthcare provider typically performs a

contraction stress test when the patient is 34 or
more weeks pregnant.

In a contraction stress test, the healthcare provider

gives the patient a hormone called oxytocin.
Reasons for Conducting CST

One method of assessing a fetus's health before to labor is using

contraction stress tests (CST). Non-stress testing (NST) and a
biophysical profile are two more common late-stage pregnancy
monitoring techniques (BPP).

All late-stage pregnancy tests aim to determine the likelihood of a

stillbirth in the fetus. In the event that the CST results are
unsatisfactory, medical professionals may act before labor.
Reasons for Conducting CST

The doctor will recommend CST, if:

The pregnancy is high-risk.

Patient is diabetic.
There are difficulties during a prior pregnancy.
The 40th week of the pregnancy has passed.
An NST or BPP's results are unusual
A CST is not advised for those who are at risk for preterm labor or who
have placenta previa because it can occasionally jump-start labor.
Risks of CST and its Alternatives

Risks of CST include:

Possibility of jump-starting
labor
Pitocin may cause fetal
distress
Discomfort

Stress Test Alternatives

Non-stress test (NST)
Biophysical profile (BPP)
Doppler ultrasound exam
Procedures:
The woman is attached to an external uterine
contraction and fetal heart rate monitor.
The woman is instructed to roll a nipple
between her fingers and thumb to produce
uterine contractions.
Within a 10 minute window, three contractions
with a duration of 40 seconds or longer must be
present.
The test is negative or normal if there are no
deceleration in the fetal heart rate during
contractions.
It is positive or abnormal if there is a late
deceleration at the end of a contraction and
even after the contraction.
Nursing Responsibilities
Assess and Monitor the patient’s vital signs frequently, such as BP, pulse rate, and FHR.
R: In order to give warning of early or dangerous deterioration

Determine and review the patient’s chart for indications, progress and past physical examinations
R: In order to establish a baseline data

Inform the patient with the procedure such as Fasting before the test, and its importance, such as
the equipment or medications that will be needed like oxytocin
R: in order for them to acquire knowledge and understanding which gains their participation.

Inform the patient that there will be touching and may be presence of discomfort during the
procedure such as Massages in nipples.
R: In order for them to be mentally prepared upon the procedure.

Assess the patient’s understanding of the procedure and condition

R: in order to encourage them to ask further any questions
Nursing Responsibilities
Encourage patient to void before the procedure or test

Before beginning, instruct the patient to lie on bed with a slightly elevated back and
carefully place two straps over the patient’s abdomen
R: in order to properly prepare the patient to start the test.

Perform the procedure by checking the patient’s pulse and blood, then proceed to
apply the external fetal monitor.
R: In order to monitor the progress of the patient before, after, and during of the
procedure to further assess any medical problems that may occur

Stay with the patient and assure the patient to be with them
R: in order to ensure comfort and safety throughout the procedure and to decrease
the level of anxiety.
Nursing Responsibilities
Collect the data obtained from the test during contractions occurs
R: In order to further assess and monitor the patient’s condition during the
procedure

If oxytocin is ordered by the Physician, Follow the three check method before
administering the medication
R: In order to avoid medication error and harm to patient

NOTE: Nipple stimulation is An Alternative method is done for CST and can be
instructed by the use of palmar surface of the fingers and rubbing it in a gentle
manner for 2 minutes, then rest and evaluate reaction for 5 minutes and if it doesn’t
induce contraction, a second attempt can be done. Failed to do reactions or
contractions, oxytocin can be administered.
Nursing Responsibilities
Assemble the Iv equipments and intravenous infusion, as per physicians
order while following the three check method
R: In order to prepare the equipments needed to save time.

Mix oxytocin and Piggyback the oxytocin solution using the infusion
pump through the intravenous lines

Instruct or assist the patient to massage the nipples as per physicians

order
R: in order to induce the contractions.

Document the medication on the delivery record

R: in order to record any medical administration history the patient
has acquired.
Nursing Responsibilities
Monitor the patient’s vital signs every 30 minutes or every change of Oxytocin rate and
record on the Labour partogram
R: In order to detect any changes of the patient’s vital signs in the procedure.

Assess the fetal heart rate pattern every 15 minutes using the electronic fetal monitor
and Record the obtained data

Assess the uterine activity, frequency, duration and intensity of the contractions every
15 minutes and record it in the Partogram

Increase the oxytocin until 3 lasting palpable contractions are present for 40-60
seconds during the 10 minute period and record it in the Partogram.

Decrease or discontinue the oxytocin if the uterine tachysystole occurs or an abnormal

fetal heart pattern occurs.
R: in order to detect if the baby’s heart rate slows after the contraction which may
indicate a developing health issue during the labour contractions.
Nursing Responsibilities
Discontinue Oxytocin infusion once the test is complete.

Provide emotional support care to the patient and family

R: In order to assure the patient and the family with comfort and care which will decrease their anxiety.

Provide feedback or results once it has the adequate contraction pattern

R: Interpret the results to keep the patients informed about the health status of the baby, most importantly the
increase or decrease level of the fetal heart rate.

Continue the EFM and contraction assessment until uterine activity ad FHR patterns returns to the baseline status.
R: In order to continuously monitor any sudden changes before and after the procedure.

After the procedure, inform the patient and the family about any concerning health problem and ways to prevent
it.
R: In order to increase the level of understanding and knowledge of the condition of the baby and to clarify any
misconceptions about the health status or medical condition.

Encourage the patient and the family to contact the physician for further concerns.
R: Follow up check up visits can help the patient and the family to identify any misunderstandings, and clear
out questions and adjust any treatments.
 Results of CST results may be positive or negative.
They may also be uncertain.
Contraction Stress
Test Positive:
Abnormal findings show that for more than
half of the contractions, the fetal heart rate
slows and remains slow after the
contraction.
Negative:
A healthy test reveals fetal heart tones that
do not slow down before, during, or after
contractions.
Equivocal:
Results of the exam are occasionally
ambiguous.
Unacceptable:
There might not be enough contractions to
generate a quantitative result.

If results are negative or inconclusive, the

doctor may want to repeat the test weekly or
twice a week until birth.
Non- Stress Test
A nonstress test is a common prenatal
test used to check on a baby's health.
During a nonstress test, the baby's heart
rate is monitored to see how it responds
to the baby's movements. The term
"nonstress" refers to the fact that
nothing is done to place stress on the
baby during the test.

Assessing for intact fetal CNS during the

third trimester. Ruling out the risk for fetal
death in clients who have diabetes mellitus.
Used twice a week or until after 28 weeks
gestation.
Purpose of NST:

To assess the fetal ability to cope with continuation of

a high risk preganancies.
To assess the fatal status in women for whom CST is
contraindicated such as previous caesarian section,
placenta previa, or threatened abortion, otherwise, the
indication for an NST are the same as those for CST.
 Why it is done
The health care provider might recommend a Non-Stress Test if
the patient have:

A multiple pregnancy with certain complications

An underlying medical condition, such as type 1 diabetes, heart
disease or high blood pressure during pregnancy
A pregnancy that has extended two weeks past your due date
(post-term pregnancy)
A history of complications in a previous pregnancy
A baby who has decreased fetal movements or possible fetal
growth problems
Rh (rhesus) sensitization — a potentially serious condition that
can occur, typically during a second or subsequent pregnancy,
when your red cell antigen blood group is Rh negative and your
baby's blood group is Rh positive.
Low amniotic fluid (oligohydramnios)
 Procedure
Explain to the mother the procedure, its purpose,
and how she has to cooperate.
Make sure that the woman has eaten food and
ask her to empty the urinary bladder.
Turn on the monitor and press the test button to
dee that if it is working and adjust the paper
speed.
Perform an abdominal palpation (Leopold's
Maneuver)
Confirm the fetal heart tones with a fetoscope or
stethoscope and note the are of maximum
intensity.
 Procedure
Position the women in semi - fowler's or lateral tilt
position and place the monitor belt under her back.
Connect the ultrasound transducer and
tacotransducer to the fetal monitor.
Apply ultrasound gel to the ultrasound transducer.
Place the ultrasound transducer on the fetal back.
Move the transducer until clear, audible fetal heart
sound are heard.
Secure the device in place with belt.
Place the tocotransducer on the fundus of the
uterus and secure in place with the belt.
Run the monitor and evaluate the quality of the
tracing to determine if it is adequate for
interpretation. If it is not, reposition the transducer
until interpretable, data is obtained.
 Procedure

Give the hand buttom to the woman and ask her to

press the button every time she feels the fetal
movement.
Run the monitor and obtain a tracing for at least 20
minutes.
On completion, put off the monitor and tae out the
stripes of paper.
Remove the abdominal straos and wipe off the gell
from the abdomen and transducer.
Make the woman comfortable and give a relevant
instructions.
 Care after procedure

Clean the gel that is used during procedure.

Make the client in comfortable position.
Replace all article to the utility room.
Wash hands
Record the date and time of NST
Document the recording
 NURSING
RESPONSIBILITIES

Explain the procedure to the patient.

R: To help keep your patients comfortable with the procedure and allow them to make
informed decisions based on their needs
Provide privacy.
R: It will help for building trust between patient and the nurse.
Maintain a safe, comfortable position for the client.
R: To provide clients with stability and comfort, which will leave them calmer and more
relaxed.
Gather all the article needed for NST.
R: To save time and effort.
The woman must empty her bladder.
R: An empty bladder is necessary for transvaginal ultrasounds. A full bladder would obstruct
the technologist's view for these ultrasound scans.
Let the client seat in a reclining chair or place in semi-Fowlers or left-lateral position. Apply
conduction gel to the client's abdomen.
R: To reduce practical variations among health care providers, which, in turn, may reduce the
need for unnecessary, expensive, and even hazardous interventions.
Apply two belts to the client's abdomen and attach the FHR and uterine contraction monitors.
FHR is the maintained for approximate 20-30 min.
R: To listen to or record the fetal heartbeat through the mother's abdomen and movement,
and the other records contractions.

Instruct the client to press the button on the handheld event marker each time she feels her
fetus move.
R: This allows the nurses to record the heart rate during movement.If there are no fetal
movements (eg, the fetus is sleeping), vibroacoustic stimulation (sound source, usually a
laryngeal stimulator)may be activated for 3 seconds on the belly over the fetal head to
awaken a sleeping fetus. Reminder: It is important that fetus not be in sleep state during
entire procedure.

An abdominal palpation can be used.

R: To arouse the fetus.

Document the recording.

R: Appropriate documentation provides an accurate reflection of nursing assessments,
changes in clinical state, care provided and pertinent patient information to support the
multidisciplinary team to deliver great care.
 Client Assure the client that this

Education procedure is non-invasive

and does not bother the
baby.

Ensure understanding how

the monitoring works and
the importance of her
participation with the
handheld event marker.
 Interpretation of findings
The non-stress test, or NST, is interpreted as reactive, non reactive or unsatisfactory

Reactive Non Reactive Unsatisfactory

The non-stress test, or NST, is
interpreted as reactive if the
FHR is a normal baseline rate
with moderate variability,
accelerates to 15 beats/min
for at least 15 seconds, and
occurs two or more times
during a 20-min period.
Nonreactive NST indicates that
the fetal heart rate does not
accelerate adequately with fetal
movement. It does not meet the
above criteria after 40 min. If so,
further assessments such as a
contraction stress test or
biophysical profile is indicated.
Unsatisfactory or suspicious
NST is one which there we can
not interpretate because of
poor quality of fetal heart rate. I
f test is suspicious it should be
repeated in 24 to 48hrs. The NST
can be repeated and continued
at any desired frequency w/out
concern for adverse effect to
the fetus.
THANK
YOU
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