care exam 3 - basic fetal heart monitoring

baseline fetal heart rate monitoring

used to help determine fetal well being

abnormal heart rate may be a sign of fetal distress

equipment used

TOCO on top (for contractions)

fetal heart rate on bottom

how to interpret fetal monitor strip

fetal HR on top

contractions on bottom

DR. C BRAVADO

DR: determine risk

C: contraction rate

BRA: baseline rate

V: variability

A: accelerations

D: decelerations

O: overall assessment and written plan

DR: determine risk

helps to determine frequency of documentation

high risk:

• latent phase q 30 min

• active phase q 15 min

• second stage: q 5 min

low risk

• latent phase q 60 min

• active phase q 30 min

• second stage: q 15 min

C: contractions rate

frequency: How often contractions occur, measured from the beginning of one contraction to the beginning of the next

duration: How long each contraction lasts, measured from start to finish

intensity: How strong the contraction is

resting tone: How relaxed or soft the uterus is between contractions

BRA: baseline Heart rate

normal: 110-160 bpm

bradycardia: less than 110 bpm

tachycardia: more than 160 bpm

V: variability

reflects central nervous system activity

Absent: No detectable fluctuations in FHR (0 bpm)

minimal: Fluctuations of >0–5 bpm.

moderate: Fluctuations of 6–25 bpm (normal/reassuring)

marked: Fluctuations of >25 bpm

A: accelerations

brief increases in fetal heart rate of at least 15 bpm above the baseline for at least 15 seconds, typically associated with fetal movement and well-being.

spontaneous, stimulated, none

D: decelerations

Temporary decreases in fetal heart rate (FHR) below baseline

Absent: No decelerations present (normal/reassuring).

early: Gradual decrease in FHR that mirrors contractions. Caused by fetal head compression

variable: Abrupt decrease in FHR that varies in timing and shape. Caused by umbilical cord compression.

late: Gradual decrease in FHR that begins after the contraction starts, with the lowest point occurring after the contraction's peak. Caused by uteroplacental insufficiency

prolonged: Decrease in FHR of ≥15 bpm lasting 2–10 minutes

nursing interventions for nonreassuring patterns

call for assistance

determie and correct cause

change maternal position

administer fluid bolus

administer oxyen

perform vaginal exam

discontinue oxytocin