ABCD
A- Asses the oxygen pathway and consider other
causes of fetal heart rate changes.
● Potential things to check for
○ Is the maternal airway compromised
○ Is maternal breathing normal
○ Maternal heart rate and rhythm
○ Adequate blood pressure and volume
Oxygen Pathway
Pathway to Fetus
Environment -
Oxygen is 21% of air the birthing person
breaths to begin the the oxygen transfer
to the fetus
Lungs -
Inhalation brings the oxygenated air to the
alveoli of the lungs. From the alveoli
oxygen diffuses across the blood gas
barrier into the pulmonary capillary blood.
After passing the blood gas barrier 98%
of the oxygen mixes with hemoglobin in
maternal red blood cells.
Heart -
The maternal blood carries the oxygen to
the heart where it enters at the left atrium
and then passes to the right atrium
through the mitral valve and into the left
ventricle and out of the aorta for
distribution.
Vasculature -
After leaving the heart the oxygenated
blood moves from the aorta, common iliac
artery, internal iliac artery, and uterine
Interruptions
Maternal apnea and medications like
narcotics and magnesium can interrupt
the oxygen transfer. From the alveoli to
the pulmonary capillary blood can be
interrupted by things such as ventilation-
perfusion, diffusion defects from things
like pulmonary embolus, pneumonia,
asthma atelectasis, or adult respiratory
distress syndrome.
Interruptions at this step can by cause by
anything that effects cardiac output.
Altered heart rate, hypovolemia, ischemic
heart disease, diabetes, diomyopathy,
CHF, and hypertension. The most
common cause of reduced cardiac output
is hypovolemia or compression of the
inferior vena cava by the gravid uterus.
Hypotension from anesthesia,
hypovolemia, impaired venous return,
impaired cardiac output or medications
can affect oxygenation. Vasoconstriction
artery. From the uterine artery it goes the
arcuate arteries, radial arteries, and then
the spiral arteries before going from the
maternal vasculature and entering the
intervillous space of the placenta.
Uterus -
From the uterine arteries to the placenta
there are the arcuate, radial, and spinal
arteries that are around the muscular wall
of the uterus.
Placenta -
On the maternal side of the placenta the
blood enters the intervillous space and
surrounds the chorionic villi. On the fetal
side the paired umbilical arteries carry
blood from the fetus through the umbilical
cord to the placental. At the placental
insertion site the blood splits into many
branches and goes across the surface of
the placenta and into the fetal side of the
intervillous space. From there simple
diffusion, facilitated diffusion, active
transport and other mechanisms are used
to transport substances to each side such
as oxygen.
Umbilical cord -
Oxygen combines with the fetal
hemoglobin after diffusion oxygenated
blood returns to the fetus through
placental veins that unite to form a single
umbilical vein inside the umbilical cord.
Fetus - The blood from the umbilical cord
goes through the fetus providing
oxygenated blood.
Intermittent Auscultation (IA)
and conditions associated with chronic
vasculopathy like chronic hypertension,
diabetes, collagen vascular disease,
thyroid disease, and renal disease can
cause an interruption in oxygen and
nutrients to the fetus.
Contractions that compress blood vessels
and impede the flow of blood can cause
an interruption in fetal oxygenation.
Uterine injury from rupture or trauma can
also cause interruption at this level.
Placental abruption, bleeding placenta
previa, or vasa previa could be possible
causes of oxygen interruption at this level.
Damaged vessels conditions and that
affect diffusion such as hemorrhage,
inflammation, thrombosis, infarction,
edema, fibrosis, and excessive cellular
proliferation also can have an affect.
Compression is the main form of oxygen
interruption at the umbilical cord. Other
things such as vasospasm, thrombosis,
atherosis, hypertrophy, hemorrhage,
inflammation, or a true knot also are
possible causes.
Normal pattern -
Normal pattern is a baseline rate from 110 bpm to 160 bpm and the presence of
accelerations and a regular rhythm.

Steps to take when normal -

When the fetal heart rate is normal IA can be continued as per protocol and continue to
promote maternal comfort, fetal oxygenation and provide supportive care. Typical IA is
done every 15-30 minutes during active phase. Every 15 minutes during the second
stage, and every 5 minutes during pushing.

Chart the findings. The charting should include the full FHR data consisting of the
baseline, rhythm, and the nature of any changes as well as the uterine activity
frequency, duration, intensity, and resting tone. Note in the chart if your findings are
within normal.

B - Begin corrective measures if indicated

Interventions when outside of normal -
If the heart rate is outside of normal further assessments should be done to determine
the cause.
● Compare the abnormal findings to the whole clinical picture
● Check maternal pulse, BP and temperature
● Perform a vaginal exam
● Increase frequency of auscultation to ensure problem is not persistent.
● Attempt to reduce the effects of the problem by improving uterine blood flow,
improving umbilical blood flow, improving maternal/fetal oxygenation, decrease
uterine activity.
○ Reposition to increase utero-placental perfusion or alleviate cord
compression
○ IV fluids to correct maternal hypovolemia if needed
○ Provide fetal scalp stimulation

Chart the abnormal findings as well as your plan of action, any interventions you will be
taking and the maternal and fetal response to these interventions. If this resolves the
FHR issues chart the return to normal. Also chart maternal status at the time the
abnormality was noted.

What to do if problem persists -

If the problem continues a transfer may be needed to allow for EFM, fetal scalp blood
sampling, or rapid delivery if necessary.
C - Clear obstacles to rapid delivery
If transfer becomes needed to clear obstacles the hospital should be contacted ahead
of time and all of the clients chart should be sent over as soon as possible. Speak with
the birthing person about potential interventions they may face at the hospital so they
can begin the informed decision making process.

D - Determine decision to delivery time

In your decision to transfer to continue out of hospital care consider the time it make
take for response. How far away is the hospital and how long it might take to initiate
delivery.
 Resources

American College of Nurse Midwives. (2015) Intermittent auscultation for intrapartum

fetal heart rate surveillance. American College of nurse midwives clinical bulletin 60

Miller, L., Miller, D., & Cypher R. (2017), Mosby’s pocket guide to fetal monitoring a
multidisciplinary approach. St. Louis, MO: ELSEVIER.

The Canadian perinatal programs coalition. (2009). Fundamentals of fetal health

surveillance a self learning manual. Vancouver, BC Canada: Perinatal Services BC

Maude, R., Skinner, J., & Fourer, M. (June 2016) Putting intelligent structured
intermittent auscultation (ISIA) into practice. Women and Birth, 29(3), 285-292.
https://doi.org/10.1016/j.wombi.2015.12.001