LEARN MAT 6

TOPIC I. Care of At-Risk/ High Risk: Nursing Care of the Client during Labor and Delivery – FHR and
FHT monitoring

Let’s first review your background of anatomy and physiology of reproductive system.

Introduction

Nursing procedures performed during labor and delivery includes monitoring of the FHR, monitoring uterine activity and
cervical examination.

Analysis of the FHR is one of the primary evaluation tools used to determine fetal oxygen status indirectly. FHR
assessment can be done intermittently using a fetoscope (a modified stethoscope attached to a headpiece) or a
Doppler (ultrasound) device, or continuously with an electronic fetal monitor applied externally or internally.

Fetal Monitoring
• The fetal monitor displays the fetal heart rate (FHR).
• The device monitors uterine activity.
• The monitor assesses frequency, duration, and intensity of contractions.
• The monitor assesses FHR in relation to maternal contractions.
• Baseline FHR is measured between contractions; the normal FHR at term is 110 to 160 beats/minute.

How often to monitor?

Interpretation of FHR and uterine contractions should be conducted at regular intervals. The Association of Women’s
Health, Obstetric, and Neonatal Nurses (AWHONN) specifies guidelines for monitoring patients who lack risk factors and
monitoring of patients who have risk factors.

For a patient with no risk factors,

• the FHR and uterine activity should be assessed every 30 minutes during the first stage of labor and every 15
minutes during the second stage of labor.
 • The assessment of the FHR may be done via auscultation or electronically, and the assessment of uterine activity
may be done via palpation or electronically.
• AWHONN guidelines specify that a patient with risk factors needs continuous FHR monitoring, and the
assessment should be done every 15 minutes during the first stage of labor and every 5 minutes during the
second stage of labor.

What’s in a risk factor

• Risk factors are those known items which could cause complications to either the mother or the fetus/neonate.
• Risk factors can be discovered at any stage of pregnancy or during the labor process.
• Risk factors can be found to originate in the patient’s obstetric (OB) history, medical history, current OB status,
or psychosocial status. Examples of each include:

• History of preterm labor or preterm birth

• History of cesarean birth
OB history • History of infertility
• History of infant born with a neurologic deficit or congenital
anomaly
• Metabolic diseases (diabetes, thyroid disorders)
• History of gastrointestinal (GI) disorders or genitourinary
Medical history (GU) problems
• History of sexually transmitted diseases
• History of cardiac or pulmonary disease
• Inadequate prenatal care
• Preterm labor or postdates pregnancy
• Abnormal fetal presentation
Current OB • Placenta previa or abruption
• Abnormal fetal surveillance tests (including change of fetal
status during labor)
• Multiple gestation
• Inadequate finances
• Absent or inadequate social support
• Maternal age <16 years or >35 years
Psychosocial
• Substance/alcohol abuse
• Domestic violence
• Psychiatric history

Intermittent Monitoring Of Fetal Status

Fetal heart rate assessment

Intermittent FHR monitoring is the periodic auscultation of FHR by either fetoscope or a handheld Doppler device.
Because the Doppler is more sensitive to fluctuations in FHR, it’s more commonly used.

Up and about

Intermittent FHR monitoring allows the patient to ambulate during the first stage of labor. Because auscultation isn’t
done until after a contraction, this type of monitoring doesn’t document how the fetus is responding to the stress of
labor as well as continuous FHR monitoring does.

Limited Intermittent
FHR monitoring can detect FHR baseline rate and rhythm as well as changes from the baseline; however, it can’t detect
variability in FHR as documented by electronic fetal monitoring.

Baseline

To establish the baseline FHR:

• auscultate FHR for 30 to 60 seconds immediately after a contraction has ended.

• This type of auscultation can be done until a change in the patient’s condition occurs, such as the onset of
bleeding or rupture of amniotic fluid membranes.
• Assess FHR more frequently after the patient ambulates, after cervical examination, or after pain medication
administration.
• Auscultate FHR every 30 minutes during labor for a low-risk patient and every 15 minutes for a high-risk patient.

Risky business

For patients whose pregnancy is considered high-risk—because of an increased risk for prenatal death, cerebral palsy or
neonatal encephalopathy, and the use of oxygen for labor induction or augmentation—continuous electronic fetal
monitoring is recommended.

Uterine contraction palpation

External uterine palpation can tell you the frequency, duration, and intensity of contractions and the relaxation time
between them. The character of contractions varies with the stage of labor and the body’s response to labor-inducing
drugs, if administered. As labor advances, contractions become more intense, occur more often, and last longer. In some
patients, labor progresses rapidly, preventing the patient from entering a health care facility.

To palpate uterine contractions:

• Review the patient’s admission history to determine the onset, frequency, duration, and intensity of
contractions. Also, note where contractions feel strongest or exert the most pressure.
• Describe the procedure to the patient.
• Assist the patient into a comfortable side-lying position.
• Drape the patient with a sheet.
• Place the palmar surface of your fingers on the uterine fundus and palpate lightly to assess contractions.
Each contraction has three phases: increment (rising), acme (peak), and decrement (letting down or ebbing).

How fast?

To assess frequency, time the interval between the beginning of one contraction and the beginning of the next.

How long?

To assess duration, time the period from when the uterus begins tightening or contracting until it has relaxed
completely.

How hard?

To assess intensity, palpate the uterine fundus and compare the degree of tightness as described previously in
the section, “Do you feel a nose (mild contraction), a chin (moderate contraction), or a forehead (strong contraction)?”

• Determine how the patient copes with discomfort by assessing her breathing and relaxation techniques.
• Assess contractions in low-risk patients every 30 minutes in the latent phase and the active phases, and every 15
minutes in the transition phase of the first stage of labor. More frequent assessments are required for high-risk
patients. High-risk fetal status assessments should also occur every 30 minutes during the latent phase, every 15
minutes during the active phase, and every 5 minutes in the second stage.
Contraction without relaxation

If any contraction lasts longer than 90 seconds and isn’t followed by uterine muscle relaxation, or if the relaxation period
is less than 1 minute between contractions, notify the doctor. This may indicate tachysystole of the uterus or tetanic
contractions. When the uterus doesn’t relax, or the relaxation period is less than 1 minute, uteroplacental blood flow is
interrupted, which can lead to fetal hypoxia and fetal distress. If you determine that the patient’s contractions last
longer than 90 seconds or if the relaxation period is less than 1 minute, follow these steps:

• Discontinue the oxytocin infusion to stop uterine stimulations (if the patient is receiving oxytocin).
• Make sure that the patient is lying on her left side; this increases uteroplacental perfusion.
• Administer oxygen via face mask to increase fetal oxygenation.
• Notify the doctor or nurse-midwife immediately.

Continuous external electronic monitoring

Continuous external electronic monitoring is an indirect, noninvasive procedure. Two devices, an ultrasound transducer
and a tocotransducer, are placed on the mother’s abdomen to evaluate fetal well-being and uterine contractions during
labor. These devices are held in place with an elastic stockinette or by using plastic or soft straps.

Electronic fetal heart rate monitoring

Steps to follow:
• Explain the procedure to the patient, and make sure that she has signed a consent form, if required by your
facility.
• Ensure that the patient you are caring for is the same patient you are documenting on, whether you are
documenting on a paper chart or electronically. Make sure your documentation and the strip (whether a paper
strip or an electronic one) match for all components of the FHR assessment.

Fetal strip evaluation

Fetal strip evaluation should be done in systematic fashion that addresses all components of the strip. In 2008, the
National Institute of Child Health and Human Development (NICHD) has updated criteria for interpretation of electronic
FHR monitoring data that is considered the national standard of assessment and documentation of electronic FHR
monitoring data. The strip should be evaluated considering uterine activity/contractions, the baseline FHR, the
variability of the FHR, periodic or episodic changes to the FHR, and changes in the FHR over time. Following the
evaluation of the electronic FHR monitoring strip, the strip should be graded into one of three categories.

Uterine activity

Uterine contraction activity should be evaluated in segments of 10 minutes but averaged over a 30-minute window. A
normal contraction pattern should mean that there are less than or equal to five contractions in 10 minutes (averaged
over 30 minutes). If greater than five contractions occur in the 10-minute period, the terminology assigned to it is
tachysystole. Additional components of a uterine contraction pattern assessment include intensity of the contraction,
duration of the contraction, and rest or relaxation time between contractions. Uterine tachysystole or hypercontractility
are not considered valid term to apply to assessment of uterine activity. Also, the assessment of the uterine activity
should be considered in light of the response of the FHR.

Baseline fetal heart rate

• The normal baseline FHR should range from 110 to 160 beats per minute (bpm) and is rounded to increments of
5 bpm in a 10-minute window.
• Periodic and episodic changes are not considered when determining the baseline.
• An FHR in excess of 160 bpm is defined as fetal tachycardia and an FHR less than 110 bpm is defined as fetal
bradycardia.
 • Sinusoidal pattern is a smooth undulating wave pattern in which no acceleration or deceleration are noted. (See
Identifying baseline FHR irregularities, page 337.)

Fetal heart rate variability

FHR variability is a fluctuation of the baseline FHR that occur as variations in the amplitude and frequency. This
fluctuation represents the interaction between the sympathetic and parasympathetic nervous systems of the fetus. The
constant interactions between these systems results in a moment-to-moment change in the FHR. It signals that both
nervous systems are working. This interaction can be termed as: absent, minimal, moderate, or marked and is
determined by the bpm.

Changes to the fetal heart rate

Changes to the FHR can be reassuring or non-reassuring, depending on the change and the whole picture of FHR and
uterine activity and last less than 2 minutes. (See Changes to the FHR, pages 338 and 339.) Changes that last greater
than 2 minutes and less than 10 minutes are considered a prolonged change, and changes that last more than 10
minutes are considered a baseline change.

Episodic or periodic

Changes to the FHR are classified as either episodic or periodic. Episodic changes are not associated with uterine
contractions, and periodic changes are associated with uterine contractions.

• Accelerations (increases in FHR)

• Decelerations (decreases in FHR)
➢ Early Decels (Benign)
➢ Late Decels (Ominous)
➢ Variable Decels (Ominous)

Fetal Heart Rate Variability

Variability Amplitude range Implications
If occurs with variable or late decelerations, this variability is
Absent Undetectable considered to represent a significant risk of fetal acidosis.

This variability level can be an indicator of hypoxic stress to

the fetus and mandates further investigation to determine
Greater than
fetal well-being. If this occurs without the presence of
Minimal undetectable but not
periodic/episodic changes, it is consistently unrelated to
more than 5 bpm
fetal acidemia but could be the result of fetal sleep,
maternal medication, or maternal substance abuse.
This level of variability is considered a predictor of adequate
Moderate 6 to 25 bpm fetal oxygenation. Departures from this variability level may
signal a change in the oxygenation status of the fetus.
Infants who have displayed this pattern have also had low
Apgar
Marked >25 bpm
scores and less than desirable neonatal outcome. Has been
associated with a variety of causes.

Reading a fetal monitor strip

Presented in two parallel recordings,

• the fetal monitor strip records the FHR in beats per minute in the top recording and
• uterine activity (UA) in millimeters of mercury (mm Hg) in the bottom recording.
You can obtain information on fetal status and labor progress by reading the strips horizontally and vertically.

• Reading horizontally on the FHR or the UA strip, each small block represents 10 seconds. Six consecutive small
blocks, separated by a dark vertical line, represent 1 minute.
• Reading vertically on the FHR strip, each block represents an amplitude of 10 beats/minute. Reading vertically
on the UA strip, each block represents 5 mm Hg of pressure.

2 readings, 1 printout

• Top tracing represents fetal heart rate

• Bottom tracing represents contractions

Identifying Baseline FHR Irregularities

FHR, you need to be familiar with irregularities that may occur, their possible causes, and nursing interventions to
take. Here’s a guide to these irregularities.
Irregularity Possible causes Clinical significance Nursing interventions
Baseline tachycardia • Early fetal hypoxia Persistent tachycardia • Intervene to alleviate
FHR >160 beats/minute • Maternal fever without periodic changes the cause of fetal
• Parasympathetic doesn’t usually adversely distress, and provide
agents, such as affect fetal well-being, supplemental oxygen
atropine and especially when associated as ordered. Also
scopolamine with maternal fever. administer I.V. fluids as
• Beta-adrenergics, such However, tachycardia is an prescribed.
as ritodrine and ominous sign when • Discontinue oxytocin
terbutaline associated with late infusion to reduce
• Amnionitis decelerations, severe uterine activity.
(inflammation of inner variable decelerations, • Turn the patient onto
layer of fetal or lack of variability. her left side and
membrane or amnion) elevate her legs.
• Maternal • Continue to observe
hyperthyroidism FHR.
• Fetal anemia
• Fetal heart failure

Baseline bradycardia
FHR <110 beats/minute
Sinusoidal
A smooth wavelike pattern
that persists for at least 20
minutes
Changes To The Fetal Heart Rate
Change
Accelerations
• Fetal arrhythmias
• Late fetal hypoxia
• Beta-adrenergic
blockers, such as
propranolol, and
anesthetics
• Maternal hypotension
• Prolonged umbilical
cord compression
• Fetal congenital heart
block
• Severe fetal anemia of
several etiologies e.g.
Rh isoimmunization
• Twin-to-twin
transfusion
• Fetal intracranial
hemorrhage
• Massive fetal-maternal
hemorrhage
• Effects of drugs e.g.
narcotics
• Fetal asphyxia/hypoxia
• Fetal infection
• Fetal cardiac anomalies
• Fetal sleep cycle
Definition Possible Causes
Abrupt May occur
visual spontaneously or
Bradycardia with good
variability and no periodic
changes doesn’t signal
fetal distress if FHR
remains higher than 80
beats/minute. However,
bradycardia caused by
hypoxia and acidosis is an
ominous sign when
associated with loss of
variability and late
decelerations.
A rarely occurring rhythm
that represents a
compromised fetus.
Clinical
Significance
Represents
adequate fetal
• Document
interventions and
outcomes.
• Notify the practitioner;
further medical
intervention may be
necessary
• Intervene to correct
the cause of fetal
distress. Administer
supplemental oxygen
as ordered. Start an
I.V. line and administer
fluids as prescribed.
• Discontinue oxytocin
infusion to reduce
uterine activity.
• Turn the patient onto
her left side and
elevate her legs.
• Continue observing
FHR.
• Document
interventions and
outcomes.
• Notify the practitioner;
further medical
intervention may be
necessary.
• Notify the delivering
provider if is an initial
rhythm.
• Obtain a maternal
history.
• Assess the mother for
signs and symptoms of
blood loss.
• Administration of
some opioids to the
mother can induce a
sinusoidal-like rhythm.
Nursing
Interventions
In 32 weeks’
gestation, the
Beats/minute increase in be induced by oxygenation acceleration should
the FHR— external and the go 15 bpm above the
an episodic stimulation presence of baseline and last
change accelerations longer than 15
can rule out seconds. In <32
fetal acidemia. weeks’ gestation, the
acceleration should
mmHg go 10 bpm above the
baseline and last at
least 10 seconds.
When evaluating the
accelerations during
a nonstress test
(NST), two
accelerations in a 20-
minute window
allows for
interpretation of the
NST as reactive.
Early decelerations Gradual • Fetal head Early • Reassure the
Beats/minute visual compression decelerations patient that the
decrease are benign, fetus isn’t at risk.
from and indicating fetal • Observe FHR.
return of head • Document the
the FHR to compression frequency of
the baseline at dilation of 4 decelerations.
associated to 7 cm.
with a
uterine
contraction
mmHg that
matches or
mirrors the
contraction
—a periodic
change.
Late decelerations A gradual • Uteroplacental Late • Turn the patient
Beats/minute visual circulatory decelerations onto her left side
decrease insufficiency indicate to increase
from (placental uteroplacental placental
and return hypoperfusion) circulatory perfusion and
to the caused by insufficiency decrease
baseline decreased and may lead contraction
associated intervillous to fetal frequency.
with a blood flow hypoxia and • Increase the I.V.
uterine during acidosis if the fluid rate to
contraction, contractions or underlying boost
but lowest a structural cause isn’t intravascular
point placental corrected. volume and
of the defect such as placental
deceleratio abruptio perfusion, as
n occurs placenta prescribed.
after
 the peak of • Uterine • Administer
the hyperactivity oxygen by mask
contraction caused by to increase fetal
—an excessive oxygenation as
episodic oxytocin ordered.
change. infusion • Assess for signs
• Maternal of the underlying
hypotension cause, such as
• Maternal hypotension or
supine uterine
hypotension tachysystole.
• Take other
appropriate
measures such as
discontinuing
oxytocin as
prescribed.
• Document
interventions
and outcomes.
• Notify the
practitioner;
further medical
intervention may
be necessary.
Variable decelerations An abrupt • Umbilical cord Variable • Help the patient
visual compression decelerations change position.
Beats/minute decrease in causing decreased are the most No other
the FHR by fetal oxygen common intervention is
at least 15 perfusion deceleration necessary unless
bpm that pattern in you detect fetal
lasts >15 labor because distress.
seconds and of • Explain that cord
<2 minutes contractions compression
and is not and fetal affects the fetus
associated movement. the same way
with that
mmHg contractions breathholding
—an affects her.
episodic • Start I.V. fluids
change. and administer
oxygen by mask
at 10 to 12
L/minute, as
prescribed.
• Document
interventions
and outcomes.
• Discontinue
oxytocin infusion
to decrease
uterine activity.
 Think “Veal Chop”
V (Variable decel) = Cord compression
E (Early decel) = Head compression
A (Accelerations) = OK
L (Late decels) = Placental insufficiency

Classifications Of Fetal Heart Rate Monitoring

Classifications of FHR monitoring were developed, by the National Institute of Child Health and Human
Development (NICHD), as a means to help organize the data obtained from a systematic evaluation of the FHR. There
are three categories of interpretation: Class I, Class II, and Class III.

Class I (Normal)

• The tracings are normal and a solid predictor of a normal fetal acid-base balance.
• No actions are recommended for tracings in this class.
• Criteria for this class includes:
➢ baseline FHR within normal limits (110 to 160),
➢ moderate variability,
➢ no late or variable decelerations, and early deceleration and
➢ acceleration may or may not be present.

Class II (Indeterminate)

• The tracings are considered indeterminate and,

• While not predictive of an abnormal fetal acid-base balance,
• they also lack the features of either Class I or III.
• Criteria for this class includes:
➢ baseline FHR either tachycardic or bradycardic;
➢ absent, minimal, or marked variability;
➢ no accelerations can be induced;
➢ recurrent variable decelerations with minimal or moderate variability;
➢ variable decelerations with additional features like a slow return to baseline or an increase in the rate before
return to baseline; any prolonged deceleration (>2 minutes and <10 minutes); and
➢ persistent late decelerations with moderate variability.

Class III (Abnormal)

• The tracings are considered abnormal and are predictive of an abnormal fetal acid-base balance.
• Efforts to resolve the FHR pattern needs to be made.
• Criteria for this class includes:
➢ absent FHR variability with recurrent late decelerations,
➢ recurrent variable deceleration or bradycardia, or sinusoidal pattern.

Cardiotocography (CTG)

• a technical means of recording (-graphy), the fetal heart beat (-cardio), and the uterine contractions (-toco)
during pregnancy, typically in the third trimester.
 • a test used in pregnancy to monitor both the fetal heart pattern as well as the uterine contractions.
• It should only use in the 3rd trimester when fetal neural reflexes are present.
• Its purpose is to monitor fetal well-being & allows early detection of fetal distress antenatal or intra-partum.
• An abnormal CTG indicates the need for further invasive investigation & ultimately may lead to emergency CS.

Types of CTG Monitoring

• Continuous external electronic monitoring

• Continuous internal electronic monitoring

Continuous External Electronic Monitoring

Continuous external electronic monitoring is an indirect, noninvasive procedure. Two devices, an ultrasound
transducer and a tocotransducer, are placed on the mother’s abdomen to evaluate fetal well-being and uterine
contractions during labor. These devices are held in place with an elastic stockinette or by using plastic or soft straps.

Applying Continuous External Monitoring Devices

To ensure clear tracings that define fetal status and labor progress, be sure to precisely position continuous external
monitoring devices. These devices include an ultrasound transducer and a tocotransducer.
Fetal heart monitor Tocotransducer Adjustments
Palpate the uterus to locate the Tocotransducer A tocotransducer records uterine Periodically adjust
fetus’s back and place the motion during contractions. Place the both the ultrasound
ultrasound transducer, which reads tocotransducer over the uterine fundus where it transducer and the
the fetal heart rate, over the site contracts, either midline or slightly to one side. Place tocotransducer to
where the fetal heartbeat sounds your hand on the fundus and palpate a contraction ensure the best tracing
the loudest. Then tighten the belt. to verify proper placement. Secure the quality being obtained
Use the fetal heart tracing on the tocotransducer’s belt; then adjust the pen set so and promote good
monitor strip to confirm the that the baseline values read between 5mm and 15 maternal skin care.
transducer’s position. mm Hg on the monitor strip.
Continuous internal electronic monitoring

Internal monitoring, also called direct monitoring, is an invasive procedure that uses a spiral electrode attached
to the presenting fetal part (usually the scalp) and an IUPC. This helps assess fetal response to uterine contractions,
measures intrauterine pressure, and tracks labor progress.

Internal monitoring is indicated for high-risk pregnancies. However, it can be performed only if the amniotic sac
has ruptured, the cervix is dilated at least 2 cm, and the presenting part of the fetus is at least in the 1 station. Maternal
complications of internal fetal monitoring may include uterine perforation and intrauterine infections. Fetal
complications may include abscess, hematoma, and infection.

Applying an internal electronic fetal monitor

During internal electronic fetal monitoring, a spiral electrode monitors the FHR and an internal catheter monitors
uterine contractions.
Monitoring FHR Monitoring uterine contractions
• Help the patient into the lithotomy position so the • Attach the connection cable to the uterine activity
practitioner can perform a cervical examination. outlet on the monitor, and zero the catheter with a
gauge on the distal end of the catheter.
 • After identifying the presenting fetal part and level of
descent, the practitioner applies a fetal scalp
electrode to the fetal scalp.
• Attach the internal fetal scalp electrode to a cable
from the monitor. Then secure the electrode to the
mother’s body
• The provider will perform a vaginal examination,
insert the catheter into the uterine cavity until it
advances to the black line, and secure the catheter
with manufacturer provided device or use
hypoallergenic tape to the patient’s inner thigh.

Spiral electrode

The spiral electrode, sometimes called a fetal scalp electrode or FSE, detects the fetal heartbeat and transmits it to the
monitor, which converts the signals to a fetal electrocardiogram (ECG) waveform.

Intrauterine Pressure Catheter

An IUPC may be used if external uterine monitoring doesn’t provide satisfactory information. It may also be necessary in
high-risk pregnancies or if the patient is obese. Insertion of an IUPC is done only by specially trained health care
provider. Nurses need to check the policy per institution on who is allowed to place an IUPC.
References:

1. Pilliteri, Adele, (2010). Maternal and child Health Nursing: Care of the Childbearing and Child Rearing Family (6th
ed). Philadelphia: Lippincott Williams and Wilkins.
2. https://www.youtube.com/watch?v=BCVOjdX4mso
3. https://www.youtube.com/watch?v=DvcDXvlCXAE
4. https://www.youtube.com/watch?v=fDeulZdDc_g
5. https://www.youtube.com/watch?v=ac14n5uD4_0&t=21s