Document in detail interpretation of FHR, clinical conclusion and plan of management. Electronic fetal monitoring may help detect changes in normal FHR patterns during labor. The American College of Obstetricians and Gynecologists (ACOG), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society for Maternal-Fetal Medicine developed a new three-tiered classification of fetal heart rate abnormalities and a system for interpreting these abnormalities (1). The first uses Doppler ultrasound to monitor FHR patterns, while the second measures the duration and frequency of uterine contractions. An increase in risk status during labor, such as the diagnosis of chorioamnionitis, may necessitate a change in monitoring from structured intermittent auscultation to continuous EFM. Unfortunately, precise information about the frequency of false-positive results is lacking, and this lack is due in large part to the absence of accepted definitions of fetal distress.7 Meta-analysis of all published randomized trials has shown that EFM is associated with increased rates of surgical intervention resulting in increased costs.8 These results show that 38 extra cesarean deliveries and 30 extra forceps operations are performed per 1,000 births with continuous EFM versus intermittent auscultation. A woman has just received pain medication in labor. T(t)=50+50cos(6t). It is important to review the pressure tracing before assessing the fetal tracing to accurately interpret decelerations. B. 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. The workshop introduced a new classification scheme for decision making with regard to tracings. Every piece of content at Flo Health adheres to the highest editorial standards for language, style, and medical accuracy. -0-2: Deliver promptly, -Assesses fetal tolerance of stress Self Guided Tutorial. 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. What should the nurse do in this situation? This content is owned by the AAFP. Fetal tachycardia may be a sign of increased fetal stress when it persists for 10 minutes or longer, but it is usually not associated with severe fetal distress unless decreased variability or another abnormality is present.4,11,17. Search dates: December 2018, July 2019, and March 2020. 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. RN 45 Nonstress Test (Maternal Newborn) Quiz, Evolve Fetal Heart Rate: Assessment via Inter, Barbara T Nagle, Hannah Ariel, Henry Hitner, Michele B. Kaufman, Yael Peimani-Lalehzarzadeh, Modulo 21: Impacto De La Ciencia Y La Tecnolo. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient in labor when repetitive late decelerations are noted on the external fetal monitor. Which of the following steps are included in this intervention? Contractions are occurring every 3 minutes and lasting 60 seconds, and are of moderate intensity with a soft resting tone. Appendix A: Amnioinfusion Appendix B: Selected FHR Tracings and Cases: Interpretation and . Describe the variability. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. A patient is in active labor with spontaneous contractions occurring every 2 minutes and lasting 90 to 100 seconds. Is perinatal asphyxia predictable? - PMC - National Center for 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. What Do Contractions Feel Like? The patient is being monitored by external electronic monitoring. 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. Intrapartum Fetal Monitoring | AAFP Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! Category II tracings are defined as indeterminate, are common, and represent all tracings that do not fall into the Category I or III groups.2,5 They vary widely in level of concern for acidosis, so the family physician must determine the severity of the Category II tracing and take the appropriate action.2,5,7,35, There is a direct association between fetal acidosis, recurrent decelerations, and depth of decelerations2,5,34,36; however, 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.2,4,26,27,34,3638 For Category II tracings without spontaneous or provoked accelerations, minimal/absent variability, or deep decelerations (i.e., FHR drops to 70 bpm or less), immediate action is needed.3,4, A management algorithm30 (eFigure A) has been developed that is based on the suspected degree of fetal acidosis and ideally minimizes unnecessary interventions.7, A five-tiered classification/management scheme for management of Category II tracings has been developed (http://www.obapps.org).7,37,39 Each continuous electronic fetal monitoring tracing is color coded to represent the threat of acidosis based on the National Institute of Child Health and Human Development definitions, and Category II is broken into three separate severity and intervention subcategories based on the presence of accelerations and/or moderate variability.7,37 This classification has been shown to improve identification of fetal acidosis and newborns requiring immediate intervention after delivery.37, Category II management should focus on first correcting reversible causes, including stopping uterotonic agents and placental fetal perfusion, through intrauterine resuscitation(Figure 1).2,7,16,21,27,3033 Lateral recumbent maternal positioning reduces compression of the maternal vena cava and aorta and the fetal umbilical cord.2,32,33 Intravenous fluid boluses up to 1 L have been shown to improve fetal oxygenation up to 30 minutes after administration.32,33 Maternal oxygen may be administered after other maneuvers, but it can be discontinued after tracing improvement because there is no evidence to support its routine use.2,32,33 Modification in maternal pushing efforts, such as initiating only with the urge to push and allowing for fetal recovery by pushing with every second or third contraction, can improve maternal and fetal oxygenation.40, Category III tracings, defined by a sinusoidal FHR pattern (Figure 37) or absent FHR variability (Figure 47) with recurrent late and/or variable decelerations or fetal bradycardia (see the Fetal Bradycardia section), require immediate intrauterine resuscitation and intervention.2,5,8,14,27,30,32,33,38,39 If the Category III tracing does not rapidly improve, expedited delivery is recommended. 7. Use a definite integral to find the number of animals passing the checkpoint in a year. During auscultation, the nurse hears an abrupt deceleration of the FHR down to 60 bpm that lasts for 1 minute before returning to baseline. A normal baseline rate ranges from 110 to 160 bpm. Electronic fetal monitoring may help detect changes in normal FHR patterns during labor. Ordinarily, your babys heart beats at a faster rate in the late stage of pregnancy, when theyre especially active. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. Variable decelerations associated with a nonreassuring pattern, Late decelerations with preserved beat-to-beat variability, Persistent late decelerations with loss of beat-to-beat variability, Nonreassuring variable decelerations associated with loss of beat-to-beat variability, Confirmed loss of beat-to-beat variability not associated with fetal quiescence, medications or severe prematurity, Administer oxygen through a tight-fitting face mask, Change maternal position (lateral or knee-chest), Administer fluid bolus (lactated Ringer's solution), Perform a vaginal examination and fetal scalp stimulation, When possible, determine and correct the cause of the pattern, Consider tocolysis (for uterine tetany or hyperstimulation), Consider amnioinfusion (for variable decelerations), Determine whether operative intervention is warranted and, if so, how urgently it is needed, A blunt acceleration or overshoot after severe deceleration, Late decelerations or late return to baseline (. Incorrect. One hour later, the nurse notices that the FHR baseline is 145 bpm with minimal variability. Practice Quizzes 1-5. Notify your provider if the baby's movement slows down, The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by, A pregnant woman's biophysical profile score is 8. Late. 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. The FHR baseline is 125 bpm. The normal FHR range is between 120 and 160 beats per minute (bpm). Minimal variability during the hour preceding fetal bradycardic events has been shown to be most predictive of fetal acidosis and need for emergent delivery.23 During periods of minimal variability, accelerations produced by scalp stimulation offer reassurance.15,23,26,41 Management of minimal variability includes intrauterine resuscitation and identifying and treating reversible causes (Table 7).2,7,16, Marked variability is defined as more than 25 bpm fluctuations in FHR around the determined baseline for more than 10 minutes and may represent hypoxic stress5,33 (eFigure E). A normal fetal heart tracing would reassure both you and your obstetrician that it's safe to proceed with labor and delivery. 140 145 Correct . On a drawing of the body locate the major body regions containing lymph nodes. The purpose of initiating contractions in a CST is to. 1. Accelerations are transient increases in the FHR (Figure 1). Recently, second-generation fetal monitors have incorporated microprocessors and mathematic procedures to improve the FHR signal and the accuracy of the recording.3 Internal monitoring is performed by attaching a screw-type electrode to the fetal scalp with a connection to an FHR monitor. 1. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Fetal Heart Tracing: All You'll Ever Need to Know - Flo Fetal scalp sampling, which requires amniotomy, tests fetal pH for the presence of acidemia.16 However, because of a 10% inadequate sample rate and a prolonged sample-to-result time of 18 minutes on average, this test is rarely performed in the United States.20 Lactate fetal scalp sampling (direct measurement of lactate by a probe) is another option that boasts a sample-to-result time of two minutes; however, its use has not resulted in improved newborn outcomes.21 An internal real-time fetal pulse oximetry probe (similar to an intrauterine pressure catheter) may lower operative vaginal delivery rates during the second stage of labor but has no apparent effect on neonatal outcomes.22,23 Fetal electrocardiograms have also been studied because fetal acidosis can affect the ST interval. She asks the nurse to explain the results. For the letters on this figure, choose the likely cause of melting for Site B. If any problems arise, reviews are done more frequently. (f) Comment on the agreement between the answers to parts (a) and (e). Fetal heart rate. Contractions (C). Relevant ACOG Resources. What is the peak current supplied by the emf Multivariate logistic regression analyses were performed to control for confounding variables (SPSS). The experienced nurse tells the new nurse that a Category III FHR tracing may include which characteristic? Electronic fetal heart rate monitoring (EFM) was first introduced at Yale University in 1958.1 Since then, continuous EFM has been widely used in the detection of fetal compromise and the assessment of the influence of the intrauterine environment on fetal welfare. Author disclosure: No relevant financial affiliations. None. "The test results are within normal limits.". Copyright 2009 by the American Academy of Family Physicians. Fetal heart rate monitoring is a process of monitoring the fetal heart rate during labor and delivery to assess the fetus's well-being. They are the most commonly encountered patterns during labor and occur frequently in patients who have experienced premature rupture of membranes17 and decreased amniotic fluid volume.24 Variable decelerations are caused by compression of the umbilical cord. May 2, 2022. Which of the following heart rate patterns would the nurse interpret as normal during the transitional phase of stage one? Another area of interest is the use of computer analysis for key components of the fetal tracing,29 or decision analysis for the interpretation of the EFM tracing.30 These have not been demonstrated to improve clinical outcomes.29,30 Fetal pulse oximetry was developed to continuously monitor fetal oxygenation during labor by using an internal monitor, requiring rupture of membranes.31 Trials have not demonstrated a reduction in cesarean delivery rates or interventions with the use of fetal pulse oximetry.31. 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. -Contractions started by: IV pitocin or Nipple stimulation -Reassuring for fetal well being Depending on your health status and your babys, nonstress tests (one to two times a week, if not daily) might be a good idea. distribution of tributaries influences Challenge yourself every tracing collection is FREE! Electronic fetal monitoring is performed in a hospital or doctors office. Describe a hypothesis that explains these results. Which nursing intervention is necessary before a second trimester transabdominal ultrasound? Minimal. A. Reassuring patterns correlate well with a good fetal outcome, while nonreassuring patterns do not. Accelerations (A). Intrapartum Fetal Heart Rate Monitoring - Perinatology.com 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. What should the nurse do before appropriate clinical interventions are initiated? c) caldera Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia (Figure 4) or congenital anomalies rather than hypoxia alone.16 Causes of fetal tachycardia are listed in Table 5. 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. Practice Quizzes 1-5 - Electronic Fetal Monitoring The nurse understands that the test will be read as which of the following? This is associated with certain maternal and fetal conditions, such as chorioamnionitis, fever, dehydration, and tachyarrhythmias. A.>6 contractions in 10 minutes averaged over twenty minutes B. (SELECT ALL THAT APPLY), Baseline rate of 110-160 bpm Moderate variability. Baseline of 140 - 150 with decelerations to 120 noted beginning with the contraction and returning to baseline by the end of the contraction. However, the strength of contractions cannot always be accurately assessed from an external transducer and should be determined with an IUPC, if necessary. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. 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. -Related to fetal movement Fetal heart tracing is also useful for eliminating unnecessary treatments. Hypoxia, uterine contractions, fetal head compression and perhaps fetal grunting or defecation result in a similar response. fetal heart tracing quiz 12 - islamichouseofisrael.com Antepartum Fetal Assessment 10. Non-Reactive NST: Combine your ability to read fetal tracings with clinical management with some cases: Cases 1-5. The number of migratory animals (in hundreds) counted at a certain checkpoint is given by. 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. The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. The FHR is controlled by the autonomic nervous system. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. Continuous EFM reduced neonatal seizures (NNT = 661), but not the occurrence of cerebral palsy. The nurse notes a prolonged deceleration of the FHR to 80 bpm and begins intrauterine resuscitation. Non-stress test PLUS Late Decelerations - StatPearls - NCBI Bookshelf What action by the student indicates to the registered nurse that the student understands the procedure? Other rare risks associated with EFM include fetal scalp infection and uterine perforation with the intra-uterine tocometer or catheter. The baseline FHR is 135 bpm with moderate variability. The clinician and the patient with a low-risk pregnancy discuss the benefits of structured intermittent auscultation vs. continuous electronic fetal monitoring; patient agreement to structured intermittent auscultation is documented in medical record; labor team ensures appropriate nurse staffing (1:1), Labor nurse determines current fetal position and best location to place Doppler handheld probe (usually over the fetal back) with Leopold maneuvers; transabdominal ultrasonography (passive mode) can be used to identify the location of the fetal heart if manual palpation proves difficult, With one hand holding the probe in place, the other hand palpates the uterine fundus to detect maternal contractions, Following contractions, baseline fetal heart rate is assessed by counting the number of beats during a 30- to 60-second interval, For a minimum of 1 minute following contraction onset, fetal heart rate is reassessed at 6- to 10-second intervals to detect accelerations or decelerations in heart rate, American College of Obstetricians and Gynecologists, Association of Women's Health, Obstetric and Neonatal Nurses, At least hourly (< 4 cm cervical dilation), 15 to 30 minutes (4- to 5-cm cervical dilation), Any condition in which placental insufficiency is suspected, Maternal preeclampsia/gestational hypertension, Use of oxytocin (Pitocin) or other uterine stimulants for labor induction or augmentation.