Whenever possible, they will implement measures to prevent an unfavorable outcome. All Rights Reserved. A. Assess fetal pH (fetal scalp stimulation, scalp pH, or acoustic stimulation), 8. From this information, we wish to predict where the fringe for n=50n=50n=50 would be located. Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm (Figure 2). the presence of moderate variability and/or accelerations offers reassurance in Category II tracings because the presence is predictive of a lack of fetal acidosis, Category II management should focus on first correcting reversible causes, including stopping uterotonic agents and placental fetal perfusion, through intrauterine resuscitation, Amnioinfusion has been shown to reduce cord compression, leading to resolution of FHR decelerations (RR = 0.53; 95% CI, 0.38 to 0.74; n = 1,000) and lowering the likelihood of cesarean delivery. Position the patient on the left side for improved uteroplacental circulation. Copyright 2023 American Academy of Family Physicians. Any tracing not meeting the criteria of Category I or III, with any of the following findings: 5 contractions in 10-minute period averaged over 30 minutes, Tachysystole: > 5 contractions in 10-minute period averaged over 30 minutes, No response to intrauterine resuscitative measures; stopping/reducing uterotonic agents or tocolytics with persistent Category II/III tracing, 110 to 160 bpm; determine by 2-minute segment in 10-minute period, Fluctuations from baseline over 10-minute period, with 6 to 25 bpm: moderate, 15 bpm above baseline rate, onset to peak < 30 seconds, lasts for at least 15 seconds, Early: onset to nadir 30 seconds, nadir occurs with peak of contraction, Variable: onset to nadir < 30 seconds, decrease in fetal heart rate 15 bpm with duration 15 seconds to < 2 minutes, Recurrent late or prolonged decelerations for > 30 minutes or for > 20 minutes if reduced variability, No hypoxia/acidosis; no intervention necessary, Low probability of hypoxia/acidosis; take action to correct reversible causes and monitor closely, High probability of hypoxia/acidosis; take immediate action to correct reversible causes and expedite delivery. C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. A more recent article on intrapartum fetal monitoring is available. -No late or variable decelerations. The nurse observes smooth, gradual decelerations to 135 bpm occurring with more than 50% of the contractions. Continuous EFM increased cesarean delivery rates overall (NNH = 20) and instrumental vaginal births (NNH = 33). Persistent tachycardia greater than 180 bpm, especially when it occurs in conjunction with maternal fever, suggests chorioamnionitis. A normal fetal heart tracing would reassure both you and your obstetrician that it's safe to proceed with labor and delivery. The nurse understands that the primary intervention is to: The nurse notes that the fetal heart rate baseline is 120-130 with an increase in FHR to 145 bpm lasting 15 seconds. 140 145 150 155 160 FHT Quiz 1 Fetal Tracing Quiz Perfect! Determine Risk (DR). 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The recommendations for the overall management of FHR tracings by NICHD, the International Federation of Gynecology and Obstetrics, and ACOG agree that interpretation is reproducible at the extreme ends of the fetal monitor strip spectrum.10 For example, the presence of a normal baseline rate with FHR accelerations or moderate variability predicts the absence of fetal acidemia.10,11 Bradycardia, absence of variability and accelerations, and presence of recurrent late or variable decelerations may predict current or impending fetal asphyxia.10,11 However, more than 50 percent of fetal strips fall between these two extremes, in which overall recommendations cannot be made reliably.10 In the 2008 revision of the NICHD tracing definitions, a three-category system was adopted: normal (category I), indeterminate (category II), and abnormal (category III).11 Category III tracings need intervention to resolve the abnormal tracing or to move toward expeditious delivery.11 In the ALSO course, using the DR C BRAVADO approach, the FHR tracing may be classified using the stoplight algorithm (Figure 19), which corresponds to the NICHD categories.9,11 Interventions are determined by placing the FHR tracing in the context of the specific clinical situation and corresponding NICHD category, fetal reserve, and imminence of delivery (Table 4).9,11, If the FHR tracing is normal, structured intermittent auscultation or continuous EFM techniques can be employed in a low-risk patient, although reconsideration may be necessary as labor progresses.2 If the FHR tracing is abnormal, interventions such as position changes, maternal oxygenation, and intravenous fluid administration may be used. Have you tested your EFM skills lately? Mosby's Pocket Guide to Fetal Monitoring: A Multidisciplinary - eBay Your doctor will explain the steps of the procedure. Variability and accelerations C. Variability and decelerations D. Rate and variability 3. A scalp pH of less than 7.20 is considered abnormal and generally is an indication for intervention, immediate delivery, or both.12 A pH less than 7.20 should also be assumed in the absence of an acceleration following fetal scalp stimulation when fetal scalp pH sampling is not available. d. Places the tocotransducer over the uterine fundus, An NST in which two or more fetal heart rate (FHR) accelerations of 15 beats per minute (bpm) or more occur with fetal movement in a 20-minute period is termed. May 2, 2022. Shows FHR as well as uterine contractions. Self Guided Tutorial. Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! However, structured intermittent auscultation remains difficult to implement because of barriers in nurse staffing and physician oversight. Issues such as hypoxia, however, might slow their heart rate. When you've finished these first five, here are five more. The practitioner has ordered continuous electronic monitoring, but the patient requests IA for the early part of labor. Cochrane review of low-quality evidence and practice guidelines from the American College of Obstetricians and Gynecologists, Guidelines, with one small disease-oriented randomized controlled trial and one Cochrane review focusing on tocolytics aspect of intrauterine resuscitation. For the letters on this figure, choose the likely cause of melting for Site B. References. Conclude whether the FHR recording is reassuring, nonreassuring or ominous. The nurse's action after turning the patient to her left side should be:, The nurse is assessing a fetal monitor tracing and notes that the FHR baseline is 140-150 bpm with decreases to 120 bpm noted beginning . The presence of moderate variability and/or accelerations is predictive of a lack of fetal acidosis. Bradycardia of this degree is common in post-date gestations and in fetuses with occiput posterior or transverse presentations.16 Bradycardia less than 100 bpm occurs in fetuses with congenital heart abnormalities or myocardial conduction defects, such as those occurring in conjunction with maternal collagen vascular disease.16 Moderate bradycardia of 80 to 100 bpm is a nonreassuring pattern. Count FHR after uterine contraction for 60 seconds (at 5-second intervals) to identify fetal response to active labor (this may be subject to local protocols), Abnormal umbilical artery Doppler velocimetry, Maternal motor vehicle collision or trauma, Abnormal fetal heart rate on auscultation or admission, Intrauterine infection or chorioamnionitis, Post-term pregnancy (> 42 weeks' gestation), Prolonged membrane rupture > 24 hours at term, Regional analgesia, particularly after initial bolus and after top-ups (continuous electronic fetal monitoring is not required with mobile or continuous-infusion epidurals), High, medium, or low risk (i.e., risk in terms of the clinical situation), Rate, rhythm, frequency, duration, intensity, and resting tone, Bradycardia (< 110 bpm), normal (110 to 160 bpm), or tachycardia (> 160 bpm); rising baseline, Reflects central nervous system activity: absent, minimal, moderate, or marked, Rises from the baseline of 15 bpm, lasting 15 seconds, Absent, early, variable, late, or prolonged, Assessment includes implementing an appropriate management plan, Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline, Peak 15 bpm above baseline, duration 15 seconds, but < 2 minutes from onset to return to baseline; before 32 weeks gestation: peak 10 bpm above baseline, duration 10 seconds, Approximate mean FHR rounded to increments of 5 bpm during a 10-minute segment, excluding periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm, In any 10-minute window, the minimum baseline duration must be 2 minutes, or the baseline for that period is indeterminate (refer to the previous 10-minute segment for determination of baseline), The nadir of the deceleration occurs at the same time as the peak of the contraction, The nadir of the deceleration occurs after the peak of the contraction, Abrupt decrease in FHR; if the nadir of the deceleration is 30 seconds, it cannot be considered a variable deceleration, Moderate baseline FHR variability, late or variable decelerations absent, accelerations present or absent, and normal baseline FHR (110 to 160 bpm), Continue current monitoring method (SIA or continuous EFM), Baseline FHR changes (bradycardia [< 110 bpm] not accompanied by absent baseline variability, or tachycardia [> 160 bpm]), Tachycardia: medication, maternal anxiety, infection, fever, Bradycardia: rupture of membranes, occipitoposterior position, post-term pregnancy, congenital anomalies, Consider expedited delivery if abnormalities persist, Change in FHR variability (absent and not accompanied by decelerations; minimal; or marked), Medications; sleep cycle; change in monitoring technique; possible fetal hypoxia or acidemia, Change monitoring method (internal monitoring if doing continuous EFM, or EFM if doing SIA), No FHR accelerations after fetal stimulation, FHR decelerations without absent variability, Late: possible uteroplacental insufficiency; epidural hypotension; tachysystole, Absent baseline FHR variability with recurrent decelerations (variable or late) and/or bradycardia, Uteroplacental insufficiency; fetal hypoxia or acidemia, 2. During auscultation, the nurse hears an abrupt deceleration of the FHR down to 60 bpm that lasts for 1 minute before returning to baseline. -Relative: Multiple Gestation, History of classic cesarean section, -Negative (Normal): Adequate contractions, No concerning rate changes with contractions (no late decelerations) [7] The fetal heart rate tracing categorizes into I, II, or III depending upon the criteria as mentioned above. While assessing the FHR, the nurse notices a pattern of uniform decelerations that have an abrupt onset with a nadir down to 90 bpm for 30 seconds. What should be the nurse's next action? Prolonged decelerations (15 beats per minute drop below baseline for more than 2 and less than 10 minutes) Minimal variability. INTRODUCTION. Normal. The EFM toolkit also offers EFM CE opportunities and C-EFM. distribution of tributaries influences Author disclosure: No relevant financial affiliations. The fetal heart rate baseline increases 15 beats per minute after vibroacoustic stimulation. 3. Finally, the recovery phase is due to the relief of the compression and the sharp return to the baseline, which may be followed by another healthy brief acceleration or shoulder (Figure 8). Intrapartum Fetal Heart Rate Monitoring - Perinatology.com Powered by. What should the nurse do next? When continuous EFM tracing is indeterminate, fetal scalp pH sampling or fetal stimulation may be used to assess for the possible presence of fetal acidemia.5 Fetal scalp pH testing is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery (by operative vaginal delivery or cesarean delivery). The American College of Obstetricians and Gynecologists (ACOG) states that with specific intervals, intermittent auscultation of the FHR is equivalent to continuous EFM in detecting fetal compromise.4 ACOG has recommended a 1:1 nurse-patient ratio if intermittent auscultation is used as the primary technique of FHR surveillance.4 The recommended intermittent auscultation protocol calls for auscultation every 30 minutes for low-risk patients in the active phase of labor and every 15 minutes in the second stage of labor.4 Continuous EFM is indicated when abnormalities occur with intermittent auscultation and for use in high-risk patients. 1. What characteristic of this fetal heart rate tracing is indicative of fetal well-being? Continuous electronic fetal monitoring was developed to screen for signs of hypoxic-ischemic encephalopathy, cerebral palsy, and impending fetal death during labor. Late decelerations (Online Figure J) are visually apparent, usually symmetric, and have the characteristic feature of onset of the deceleration after the onset of the uterine contraction.11 The timing of the deceleration is delayed, with the nadir of the deceleration occurring after the peak of the contraction.11 The onset, nadir, and recovery of the deceleration usually occur after the beginning, peak, and ending of the contraction, respectively. 1. y=4105xy=4 \times 10^{5 x}y=4105x, -Fetoscope: horn or stethoscope-like instrument, -Fetal movement decreases with low oxygen intake, -Test for fetal well-being after 28 weeks, -Any maternal or fetal condition that increases risk of "fetal demise", Reactive (Normal):

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