-Stress = uterine contractions They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation.15 The presence of accelerations is considered a reassuring sign of fetal well-being. 1. ), What do Braxton Hicks contractions feel like? Per the practitioner's order and the patient's request, the nurse has been monitoring the fetal heart rate by IA. [7] The fetal heart rate tracing categorizes into I, II, or III depending upon the criteria as mentioned above. 4 It is. Prolonged. Fetal Tracing Index. You have to lie down or sit in a reclined position for the test, which lasts about 20 minutes. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/fetal-heart-monitoring This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Contractions are classified as normal (no more than five contractions in a 10-minute period) or tachysystole (more than five contractions in a 10-minute period, averaged over a 30-minute window).11 Tachysystole is qualified by the presence or absence of decelerations, and it applies to spontaneous and stimulated labor. Structured intermittent auscultation can be used for low-risk labor because it statistically decreases cesarean and operative vaginal delivery rates without increasing cerebral palsy or fetal death. A nurse notes the following fetal heart rate pattern on the external fetal monitor. C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. Continuous electronic fetal monitoring (EFM), using external or internal transducers, became a part of routine maternity care during the 1970s; by 2002, about 85 percent of live births (3.4 million out of 4 million) were monitored by it.1 Continuous EFM has led to an increase in cesarean delivery and instrumental vaginal births; however, the incidences of neonatal mortality and cerebral palsy have not fallen, and a decrease in neonatal seizures is the only demonstrable benefit.2 The potential benefits and risks of continuous EFM and structured intermittent auscultation should be discussed during prenatal care and labor, and a decision reached by the pregnant woman and her physician, with the understanding that if intrapartum clinical situations warrant, continuous EFM may be recommended.3, There are several considerations when choosing a method of intrapartum fetal monitoring. Although detection of fetal compromise is one benefit of fetal monitoring, there are also risks, including false-positive tests that may result in unnecessary surgical intervention. 5. Ominous patterns require emergency intrauterine fetal resuscitation and immediate delivery. Decelerations (D). Instruct the woman to drink 1 to 2 quarts of water. A systematic approach is recommended when reading FHR recordings to avoid misinterpretation (Table 2). What should the nurse do in this situation? The normal range for baseline FHR is defined by NICHD as 110 to 160 beats per minute (bpm; Online Figure A). Assess fetal pH (fetal scalp stimulation, scalp pH, or acoustic stimulation), 8. Increase mainline IV Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. With a Doppler ultrasound, for example, an ultrasound probe is fastened to your stomach. -Fetal breathing movements Auscultation of the fetal heart rate (FHR) is performed by external or internal means. 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). Recurrent deep variable decelerations can be corrected with amnioinfusion. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the FHR during a uterine contraction and for 30 seconds thereafter to identify fetal response. Suppose the 4040 \Omega40 resistance in the distribution circuit is replaced by a 2020 \Omega20 resistance. Variable decelerations are shown by an acute fall in the FHR with a rapid downslope and a variable recovery phase. Intraobserver variability may play a major role in its interpretation. For example, fetuses with intrauterine growth restriction are unusually susceptible to the effect of hypoxemia, which tends to progress rapidly.4, A growing body of evidence suggests that, when properly interpreted, FHR assessment may be equal or superior to measurement of fetal blood pH in the prediction of both good and bad fetal outcomes.13 Fetuses with a normal pH, i.e., greater than 7.25, respond with an acceleration of the fetal heart rate following fetal scalp stimulation. Management includes further investigation into and correction of possible stressors.14,33, Variable decelerations are recurrent when they occur with greater than 50% of contractions in any 20-minute period2,5 (Figure 57). A patient is in active labor and is being continuously monitored with a fetal monitor. Initiate scalp stimulation to provoke fetal heart rate acceleration, which is a sign that the fetus is not acidotic. Your doctor can confirm the likelihood of hypoxic injury using fetal heart tracing. The clinical risk status (low, medium, or high) of each fetus is assessed in conjunction with the interpretation of the continuous EFM tracing. What characteristic of this fetal heart rate tracing is indicative of fetal well-being? c. Reassure the family the finding is normal. - When considering the effectiveness of Electronic Fetal Monitoring, it comes down to the experience and knowledge of the person identifying the tracings. Heres how to tell if youre experiencing them. https://www.mayoclinic.org/tests-procedures/nonstress-test/about/pac-20384577 -Contraction Stress Test (CST), How? You have to lie down or sit in a reclined position for the test, which lasts about 20 minutes. While caring for a patient who is gravida 2 para 1 being induced for oligohydramnios, the nurse notices a pattern of recurrent abrupt decelerations down to 70 bpm with contractions lasting for 1 minute. -0-2: Deliver promptly, -Assesses fetal tolerance of stress This is followed by occlusion of the umbilical artery, which results in the sharp downslope. Fetal bradycardia (FHR less than 110 bpm for at least 10 minutes) is more concerning than fetal tachycardia, and interventions should focus on intrauterine resuscitation and treating reversible maternal or fetal causes (Table 62,5,7 and eFigure C). AMIR SWEHA, M.D., TREVOR W. HACKER, M.D., AND JIM NUOVO, M.D. Place the Doppler over the area of maximal intensity of fetal heart tones, 3. Self Guided Tutorial. The periodic review includes ensuring that a good quality tracing is present and that abnormalities are appropriately communicated. The onset, nadir, and recovery of the deceleration usually coincide with the beginning, peak, and ending of the contraction, respectively.11 Early decelerations are nearly always benign and probably indicate head compression, which is a normal part of labor.15, Variable decelerations (Online Figure I), as the name implies, vary in terms of shape, depth, and timing in relationship to uterine contractions, but they are visually apparent, abrupt decreases in FHR.11 The decrease in FHR is at least 15 bpm and has a duration of at least 15 seconds to less than two minutes.11 Characteristics of variable decelerations include rapid descent and recovery, good baseline variability, and accelerations at the onset and at the end of the contraction (i.e., shoulders).11 When they are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions.11 Overall, variable decelerations are usually benign, and their physiologic basis is usually related to cord compression, with subsequent changes in peripheral vascular resistance or oxygenation.15 They occur especially in the second stage of labor, when cord compression is most common.15 Atypical variable decelerations may indicate fetal hypoxemia, with characteristic features that include late onset (in relation to contractions), loss of shoulders, and slow recovery.15. Data Sources: PubMed searches were completed using the key terms intrapartum fetal heart monitoring, cardiotocography, structured fetal heart monitoring, National Institute of Child Health and Human Development classifications, amnioinfusion, and advanced life support in obstetrics. This content is owned by the AAFP. A patient is in active labor with spontaneous contractions occurring every 2 minutes and lasting 90 to 100 seconds. The resulting printout is known as a fetal heart tracing, which will be read and analyzed. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. The nurse notes that the fetal heart rate is 140-170 bpm and charts that the variability is which of the following? Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. A way to assess your babys overall health, fetal heart tracing is performed before and during the process of labor. Compared with structured intermittent auscultation, continuous EFM showed no difference in overall neonatal death rate. You scored 6 out of 6 correct. Continuous electronic fetal monitoring has been shown to reduce the incidence of neonatal seizures, but there has been no beneficial effect in decreasing cerebral palsy or neonatal mortality. The first-order bright fringe is at a position ybright=4.52mmy_{\text {bright }}=4.52 \mathrm{~mm}ybright=4.52mm measured from the center of the central maximum. A gradual decrease is defined as at least 30 seconds from the onset of the deceleration to the FHR nadir, whereas an abrupt decrease is defined as less than 30 seconds from the onset of the deceleration to the beginning of the FHR nadir.11, Early decelerations (Online Figure H) are transient, gradual decreases in FHR that are visually apparent and usually symmetric.11 They occur with and mirror the uterine contraction and seldom go below 100 bpm.11 The nadir of the deceleration occurs at the same time as the peak of the contraction. Author disclosure: No relevant financial affiliations. The number of migratory animals (in hundreds) counted at a certain checkpoint is given by. 140 145 150 155 160 FHT Quiz 1 Fetal Tracing Quiz Perfect! The use of amnioinfusion for recurrent deep variable decelerations demonstrated reductions in decelerations and cesarean delivery overall. This system can be used in conjunction with the Advanced Life Support in Obstetrics course mnemonic, DR C BRAVADO, to assist in the systematic interpretation of fetal monitoring. A normal baseline rate ranges from 110 to 160 bpm. 3. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. -4: Suspect lack of adequate oxygen, If >36 wks: deliver, If < 36 wks: Lung Maturity Test Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing. The nurse would chart this change in baseline as which of the following? Your doctor analyzes FHR by examining a fetal heart tracing according to baseline, variability, accelerations, and decelerations. The electronic fetal monitor uses an external pressure transducer or an intrauterine pressure catheter (IUPC) to measure amplitude and frequency of contractions. -2 points for each normal, 0 for abnormal, -8-10: Normal result ,Repeat BPP weekly The patient in labor is having multiple deep variable decelerations down to 60-70 bpm. Copyright 2023 American Academy of Family Physicians. 8. In the United States, an estimated 700 infant deaths per year are associated with intrauterine hypoxia and birth asphyxia.5 Another benefit of EFM includes closer assessment of high-risk mothers. The nurse understands that the test will be read as which of the following? The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. According to AWHONN, the normal baseline Fetal Heart Rate (FHR) is A. Ordinarily, your babys heart beats at a faster rate in the late stage of pregnancy, when theyre especially active. Yes, and the strip is reactive. 4. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Air Force, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. government. Baseline is calculated as a mean of FHR segments that are the most horizontal, and also fluctuate the least. Thus, it has the characteristic mirror image of the contraction (Figure 5). They are characteristically variable in duration, intensity and timing. The patient is being monitored by external electronic monitoring. From this information, we wish to predict where the fringe for n=50n=50n=50 would be located. Fetal heart tracing allows your doctor to measure the rate and rhythm of your little ones heartbeat. -NST What should the nurse do next? Professionals using Electronic Fetal Monitoring in their practice should also take advantage of: The EFM Resources page with linked papers and articles including the NCC monograph Fetal Assessment and Safe Labor Management authored by Kathleen Rice Simpson, PhD, RNC-OB, CNS-BC, FAAN. 2023 National Certification Corporation. Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. https://www.uptodate.com/contents/nonstress-test-and-contraction-stress-test?search=fetal%20heart%20rate%20assessment&source=search_result&selectedTitle=3~138&usage_type=default&display_rank=3 What information about this assessment is most appropriate? Internal monitoring involves intravaginal placement of monitors within the uterine cavity.7 A fetal scalp electrode is recommended for fetal heart monitoring when fetal position and/or maternal habitus make external monitoring suboptimal.4 External monitors measure only contraction frequency, but an intrauterine pressure catheter can also determine the strength of contractions.13 Placement of an intrauterine pressure catheter or fetal scalp electrode requires cervical dilation and amniotomy, which can increase the risk of intrauterine infection, fetal injury, and the transmission of herpes simplex virus and hepatitis B or C.4,13, Structured intermittent auscultation is a fetal monitoring option for detecting fetal acidosis in low-risk pregnancies.7,14,15 Typically, the labor nurse auscultates the fetal heartbeat with a handheld Doppler device (Table 1).7,1417 Structured intermittent auscultation is not standard practice in the United States because of 1:1 nursing staff requirements and physician oversight concerns, whereas continuous electronic fetal monitoring can be monitored centrally with continuous recording capabilities.7,1418, Despite these challenges, structured intermittent auscultation should be considered for low-risk labor because it statistically decreases cesarean and operative vaginal delivery rates without an increase in unfavorable outcomes associated with continuous monitor use and a high false-positive rate.1,7,14,16,17 Compared with women who receive structured intermittent auscultation, those who receive continuous electronic fetal monitoring for an initial 20-minute period at admission are at increased risk of continuing use for the duration of their labor (relative risk [RR] = 1.30; 95% CI, 1.14 to 1.48; n = 10,753) and a possible 20% increased rate of cesarean delivery.19. A. A more recent article on intrapartum fetal monitoring is available. https://www.acog.org/Patients/FAQs/Fetal-Heart-Rate-Monitoring-During-Labor?IsMobileSet=false The FHR recordings may be interpreted as reassuring, nonreassuring or ominous, according to the pattern of the tracing. 2. Monochromatic light of wavelength \lambda is incident on a GP pair of slits separated by 2.40104m2.40 \times 10^{-4} \mathrm{~m}2.40104m and forms an interference pattern on a screen placed 1.80m1.80 \mathrm{~m}1.80m from the slits. This pattern is most often seen during the second stage of labor. The nurse is reviewing a non-stress test (NST) and notes the following: FHR baseline of 120-130 bpm with increase in FHR noted to 150 for 15 seconds and an increase of FHR noted to 135 for 10 seconds over a 20 minute time frame. The NICHD has stated that it is no longer useful to distinguish between short-term and long-term variability and has categorized variability into the following classifications, depending on the amplitude of the FHR tracing: absent (Online Figure C), minimal (Online Figure D), moderate (Online Figure E), and marked (Online Figure F).11, Sleep cycles of 20 to 40 minutes or longer may cause a normal decrease in FHR variability, as can certain medications, including analgesics, anesthetics, barbiturates, and magnesium sulfate.15 Loss of variability, accompanied by late or variable decelerations, increases the possibility of fetal acidosis if uncorrected.15, Sinusoidal pattern is a smooth, undulating sine wave pattern defined by an amplitude of 10 bpm with three to five cycles per minute, lasting at least 20 minutes.11 This uncommon pattern is associated with severe fetal anemia and hydrops, and it usually requires rapid intervention in these settings.15 Similar appearing benign tracings occasionally occur because of fetal thumb sucking or maternal narcotic administration, and generally these will persist for less than 10 minutes.15. Adequate documentation is necessary, and many institutions are now employing flow sheets (e.g., partograms), clinical pathways, or FHR tracing archival processes (in electronic records). NCC EFM Tracing Game. Results in this range must also be interpreted in light of the FHR pattern and the progress of labor, and generally should be repeated after 15 to 30 minutes. -Neither period yields adequate accelerations 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). Minimal. However, structured intermittent auscultation remains difficult to implement because of barriers in nurse staffing and physician oversight. If you want to see how you are doing overall, try the comprehensive assessment: 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. c) caldera Document in detail interpretation of FHR, clinical conclusion and plan of management. 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. EFM In-Depth. The patient is now 7 cm dilated, 100% effaced, and at +1 station. The nurse is instructing a new staff nurse on reassuring FHR patterns. May 2, 2022 The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. Beta-adrenergic agonists used to inhibit labor, such as ritodrine (Yutopar) and terbutaline (Bricanyl), may cause a decrease in variability only if given at dosage levels sufficient to raise the fetal heart rate above 160 bpm.19 Uncomplicated loss of variability usually signifies no risk or a minimally increased risk of acidosis19,20 or low Apgar scores.21 Decreased FHR variability in combination with late or variable deceleration patterns indicates an increased risk of fetal preacidosis (pH 7.20 to 7.25) or acidosis (pH less than 7.20)19,20,22 and signifies that the infant will be depressed at birth.21 The combination of late or severe variable decelerations with loss of variability is particularly ominous.19 The occurrence of a late or worsening variable deceleration pattern in the presence of normal variability generally means that the fetal stress is either of a mild degree or of recent origin19; however, this pattern is considered nonreassuring. The most important risk of EFM is its tendency to produce false-positive results. Postdate gestation, preeclampsia, chronic hypertension and diabetes mellitus are among the causes of placental dysfunction. Category I tracings reflect a lack of fetal acidosis and do not require intervention. Continuous EFM reduced neonatal seizures (NNT = 661), but not the occurrence of cerebral palsy. Since variable and inconsistent interpretation of fetal heart rate tracings may affect management, a systematic approach to interpreting the patterns is important. Give amnioinfusion for recurrent, moderate to severe variable decelerations, 9. 740-591-8118. Which nursing intervention is necessary before a second trimester transabdominal ultrasound? 140 145 150 155 160 2. In 1991, the National Center for Health Statistics reported that EFM was used in 755 cases per 1,000 live births in the United States.2 In many hospitals, it is routinely used during labor, especially in high-risk patients. This content is owned by the AAFP. Home. Detection is most accurate with a direct fetal scalp electrode, although newer external transducers have improved the ability to detect variability. Any written information on the tracing (e.g., emergent situations during labor) should coincide with these automated processes to minimize litigation risk.21, Table 5 lists intrauterine resuscitation interventions for abnormal EFM tracings.9 Management will depend on assessment of the risk of hypoxia and the ability to effect a rapid delivery, when necessary. Prematurity decreases variability16; therefore, there is little rate fluctuation before 28 weeks. -Contractions started by: IV pitocin or Nipple stimulation The purpose of initiating contractions in a CST is to. These segments help establish an estimated baseline (for a duration of 10 minutes) which is expressed in beats per minute. The nurse's best response is, b. 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. Fetal heart rate decreases lasting 10 minutes are categorized as a new baseline heart rate. Questions and Answers 1. 3. Foremost, the entire fetal heart rate tracing requires evaluation, which includes assessing the uterine activity for tachysystole, presence or absence of variability, and accelerations. The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. All Rights Reserved. A.>6 contractions in 10 minutes averaged over twenty minutes B. 10. For more information on the use, interpretation and management of patients based on Fetal Heart Tracings check out the resources below. Table 1 lists examples of the criteria that have been used to categorize patients as high risk. 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. Fetal heart rate. Faculty, Students, State Boards & Volunteers. Fetal scalp sampling for pH is recommended if there is no acceleration with scalp stimulation.11.
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fetal heart tracing quiz 10