Electronic Fetal Heart Rate Monitoring for Nursing students

1. Prepared By
Dr. Eman R. Ahmad
Prof OB/Gyn. Ng

2. Introduction
Overview of Electronic FHR monitoring (EFHRM)
Overview of common procedures & tasks
Nursing Care for FHR Decelerations
Nursing Responsibilities in Electronic Fetal
Monitoring
 Review & Scenario
Outline

3. Introduction
Every parent dreams of a perfectly healthy baby
however those who have conditions placing the fetus at
risk for UPI need more attention. For that a variety of
methods can be used to determine fetal well-being. One
of them is The Fetal Monitoring that allows
intervention before fetal death or damage from
asphyxia.

4. Electronic FHR monitoring (EFHRM)
DF: EFHR monitoring is a SCREENING TEST
that provides information to alert the clinician that a
true test for fetal welfare assessment needs to be
performed e.g: fetal blood sampling (FBS)
Antenatal CTG is most commonly performed in the
third trimester of pregnancy (after 28 weeks).

5. Electronic FHR monitoring (EFHRM)
Frequency of testing varies widely in practice,
depending on the indication for the CTG.
The Range may be from weekly to [3] times a
day
-The Royal College of Obstetricians and
Gynecologists recommends:-
• Continuous electronic FHR monitoring during
labor for high risk women.
• Intermittent auscultation for low risk women.

6. Why?
Who?
How?
Antenatal Monitoring

7. Why?
2/3 of fetal deaths occur before the
onset of labor.
Many antepartum deaths occur in
women at risk for Uteroplacental
insufficiency.
Ideal test: allows intervention
before fetal death or damage from
asphyxia.

8. • Preeclampsia, chronic hypertension,
• Diabetes mellitus, renal disease,
• Fetal or maternal anemia, blood group
sensitization,
• Hyperthyroidism, thrombophilia, cyanotic
heart disease,
• Postdate pregnancy,
• Fetal growth restriction
Conditions placing the fetus at
risk for UPI
Who?

9. Methods of electronic
Fetal Monitoring
how?

10. Intermittent auscultation by
Doppler
Continuous external
monitoring
Continuous internal
monitoring

11. 1st You have to do Leopold’s
Maneuver

12. Leopold’s Maneuver, cont.

13. Intermittent auscultation can be done with a
Fetascope or Doppler for FHT’s
Auscultation by Doppler

14. The tocodynamometer
(“toco”) is placed over
the uterine fundus. The
toco provides
information that can be
used to monitor
uterine contractions.
The ultrasound
device is placed
over the area of
the fetal back.
This device
transmits
information
about the FHR.
External Monitoring

15. The spiral electrode is attached to
the fetal scalp
Wires that extend from
attached spiral electrode are
attached to a leg plate and
then attached to electronic
fetal monitor.
Internal Monitoring

17. Assessment parameters of the FHR are
classified as
baseline rate, baseline variability
(long-term and short-term),
and periodic changes in the rate
(accelerations
and decelerations).
FHR Patterns

18. • Baseline FHR = 120 – 160 bpm
Baseline Fetal Heart rate
Normal Pattern

19. Tachycardia – baseline above 160 BPM
RT= maternal fever, fetal hypoxia,
intrauterine infection, drugs
Bradycardia – baseline below 110 BPM
RT = profound hypoxia, anesthesia, beta-
adrenergic blocking drugs
Patterns

20. Baseline Variability
Normal/ increased
variability or
irregularity of a
cardiac rhythm.
Absence or decreased
variability, or a smooth
flat baseline, is a sign of
fetal compromise.

21. Hypoxia and acidosis
Medications
Sleep cycle
Preterm status
Causes of Decreased
Variability

23. Periodic changes in the
FHR
Accelerations – increase in the fetal heart
rate 15 bpm for 15 seconds with a return to
baseline. (Indication of fetal well-being)

24. Baseline fetal heart rate is 120-160 with preserved beat-to-beat variability.
Accelerations last for 15 or more seconds above baseline, and eak to 15 or more bpm.
Reassuring Acceleration
Pattern

25. Example of a reactive nonstress test
(NST). Accelerations of 15 beats per
minute lasting 15 seconds with each
fetal movement (FM).
Non-Stress Test
Example of a nonreactive NST.
There are no accelerations of
FHR with FM.

26. • Fetal tachycardia with loss of variability
• Prolonged marked bradycardia (<90 bpm)
• Severe variable decelerations (<70 bpm)
• Persistent late decelerations
Ominous signs
Interpreting FHR Patterns
Sources: Moses, 2003; Littleton & Engebretson, 2005; Feinstein et al., 2003; Engstrom, 2004; Tucker, 2004.
• Normal baseline (110–160 bpm)
• Moderate bradycardia (100–120 bpm); good
variability
• Good beat-to-beat variability and fetal
accelerations
Reassuring FHR
signs
Fetal tachycardia (>160 bpm)
• Moderate bradycardia (100–110 bpm); lost
variability
• Absent beat-to-beat variability
• Marked bradycardia (90–100 bpm)
• Moderate variable decelerations
Non reassuring
signs

27. Example of a positive contraction stress test (CST). Repetitive late
decelerations occur with each contraction. Note that there are no
accelerations of FHR with three fetal movements (FM).
Contraction Stress Test
The goal of the test is to achieve
[3] uterine contractions lasting
more than 40 seconds in a 10-
minutes period. This can occur
spontaneously with the aid of
nipple stimulation, which causes
the release of endogenous
oxytocin, or through the use of
an oxytocin infusion (Harrison,
2002).

29. The onset and return of the deceleration coincide
with the start and end of the contraction.
Fetal Heart Rate
Contractions
Early Deceleration

30. Variable Deceleration
Variable decelerations are variable in duration, intensity, and timing
Intervention ( Reposition, Amnioinfusion)

31. Late Deceleration
The fetal heart tones return to the baseline AFTER end of contraction

32. Late Deceleration

33.  Acceleration
 FM
 Baseline FHR (110-
160b/m)
 Variability
(Good, moderate)
Reactive NST

34. FHR
Variability
 Deceler.
 FM
Non-Reactive NST

35. Early – related to head
compressions.
Interventions not
necessary
Variable – related to cord
compression.
Interventions vary, but
focus on position changes.
Late – related to
Uteroplacental
insufficiency. Most
ominous and need
immediate attention.
Periodic changes in the FHR
Decelerations

36. • Stop the Pitocin.
• Reposition - Turn woman to a side-lying
position, or knee- chest position. Avoid
supine position.
• Increase rate of the mainline IV.
• Administer oxygen by mask at 10 L/min.
• Notify the primary care provider.
• If condition does not improve, then
prepare for immediate delivery
Nursing Care for FHR Decelerations

37. Nursing Responsibilities in
Electronic Fetal Monitoring
• Placement of equipment.
• Teaching the woman about use.
• Notation of events on the strip.
• Evaluation of data.
• Intervention as indicated by data.

38. • Interpr
etation
• How?
•Who?• Why? UPI
(2/3 deaths
before birth)
Postd.
IUGR
PET
R. NST
Non-R.
NST
Summary

39. Review

40. Review

41. Review

42. Review

43. 100 bpm
Moderate
Present
What is the baseline FHR?
Variability?
Accelerations?
Decelerations?
Interventions?
Continued
surveillance
Absent
1st Case

44. 3rd Case

45. What is the baseline FHR?
Variability?
Decelerations?
Interventions?
Oxygen
IV fluids
Reduce contraction frequency
Amnioinfusion
PREPARE for delivery
150 bpm
Absent
Recurrent variables
3rd Case
Change position

46. While you are working in your first week of residency
training, a 27-year-old gravid 2, para 1 pregnant
woman at 39 weeks was attached on fetal monitoring.
The obstetrician evaluated the fetal condition and
decided that both the patient and her baby are OK. He
then ordered you to off the patient (disconnect her) for
re-monitoring on the next day. Then you observed
infrequent variable deceleration. It is now 3 AM!
What’s your response in this case?
Scenario: Fetal Monitoring

47. What would you do and why?
(Student leader should lead the group discussion and write the notes)
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What did you learn from this situation?
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48. Reference
Susan Scott Ricci; Essential of maternity,
newborn, and women’s health nursing. Second
edition, chapter 10; Lippincott Williams &
Wilkins, 2009

49. We hope you find these
notes helpful