Fetal Assessment

What does fetal assessment identify?

Fetal well-being, or signs that indicate fetal compromise—allowing problems to be addressed before they become emergencies.

What does fetal cord blood sampling and fetal scalp stimulation monitor?

These procedures evaluate whats going on in utero and assess fetal heart rate response.

What components are included in fetal assessment?

Characteristics of amniotic fluid, fetal heart rate (FHR) patterns (primary focus), fetal cord blood sampling, and fetal scalp stimulation for questionable FHR patterns.

What is the primary goal of fetal monitoring?

To reduce mortality and morbidity by ensuring hypoxic events are identified in time to allow removal or alteration of the cause.

Why is thorough documentation essential in fetal monitoring?

It proves appropriate care was given, identifies in utero conditions during investigation or litigation, and protects healthcare providers legally.

What are the four main types of fetal monitoring equipment?

1. Electronic fetal monitor (external)

2. Fetoscope (modified stethoscope)

3. Doppler ultrasound

4. Fetal scalp electrode (internal)

What do the two external monitoring belts measure (Electronic Fetal Monitor)?

One transducer measures the fetal heart rate (FHR); the tocotransducer measures uterine contraction frequency and duration. If the mother is having multiple children, additional belts may be used for each fetus.

Where is each external transducer placed on the maternal abdomen?

• Tocotransducer: Over the uterine fundus (area of greatest contractility).

• Ultrasound transducer: Midline between umbilicus and symphysis pubis, then adjusted laterally for the strongest signal for fetal heart sounds.

How is external monitoring managed for a multiple gestation pregnancy?

Multiple belts and transducers are used simultaneously, positioned over different abdominal areas to capture each baby's heart rate separately.

What are the benefits and trade-offs of cordless/wireless EFM?

Benefit: Allows maternal mobility during labor, facilitating progress while monitoring fetal tolerance. Trade-off: May struggle to maintain continuous signal clarity.

What is monitor artifact in a fetal tracing?

Irregular variations or absence of the FHR on the monitor record caused by mechanical monitor limitations or electrical interference.

What is intermittent FHR monitoring and when is it appropriate?

Listening to FHR for short periods at regular intervals using a fetoscope or Doppler. It is appropriate for low-risk laboring women and allows mobility during stage 1.

What can intermittent FHR monitoring detect?

Baseline heart rate, rhythm, and changes from baseline.

What can intermittent FHR monitoring NOT detect?

Baseline variability and specific types of decelerations (it does not provide a complete continuous picture of fetal response to labor stress).

How is a baseline heart rate established using intermittent auscultation?

Assess for a full $1\,\text{minute}$ after a contraction. Subsequently, listen for $30\,\text{seconds}$ and multiply by $2$.

When should intermittent FHR assessments increase in frequency?

With any maternal or fetal condition change: membrane rupture, onset of bleeding, post-ambulation, post-vaginal exam, or after pain medication administration.

How frequently should FHR be assessed during active labor and the second stage (pushing)?

• Active labor: Every 15-30 minutes

• Second stage/pushing: Every 5-15 minutes

Why is it important to begin intermittent auscultation at the END of a contraction?

The reason you listen at the end of a contraction is because if the baby is compromised and is having a deceleration in their heart rate you are most likely to catch it as soon as that contraction’s over, catching those late decels.

Through which anatomical location is the FHR best heard during auscultation?

Through the fetal back.

Where should you place the stethoscope/Doppler to hear FHR in a cephalic presentation?

In the mother's lower abdominal quadrant. (Baby’s head is down.

Where should you place the stethoscope/Doppler to hear FHR in a breech presentation?

At or above the level of the maternal umbilicus. (Baby’s feet are down, head is up)

How can you differentiate maternal pulse from fetal heart rate during auscultation?

Palpate the mother's radial pulse simultaneously while listening to the FHR.

What do ACOG, WHO, and AWHONN recommend upon admission to L&D?

An initial $10\text{--}20\text{-minute}$ continuous FHR tracing along with a comprehensive prenatal and labor risk assessment.

What maneuver helps locate the fetal heart rate if it cannot be found quickly?

Leopold maneuvers (to identify fetal presentation and location of the fetal back).

What are the primary objectives of continuous electronic fetal monitoring (EFM)?

Assessing fetal oxygenation, perfusion, preventing fetal injury, and how well the baby’s tolerating labor based on mom’s contractions, and detecting FHR changes early.

What is an example of a advantage of Continuous EFM?

If the baby starts to not tolerate labor and their heart rate is dropping after every contraction, or even occasionally, you’ll be able to catch it early and increase oxygenation or prefusion to stop some of those deceleration in heart rate and prevent potential complications. Continuous EFM allows for real-time monitoring, ensuring timely interventions.

If the baby continues to decline in heart rate,…

we could potentially be looking at losing the child or significant loss of oxygenation to the brain which may lead to severe long term neurological damage or stillbirth.

What is a main disadvantage of continuous external EFM?

It limits maternal mobility and encourages supine positioning, which can reduce placental perfusion by lowering blood flow to baby and mom.

What are clinical indications for continuous EFM?

Oxytocin infusion, epidural analgesia, maternal/fetal compromise, PROM > $24\,\text{hours}$, moderate hypertension (> $150/100\,\text{mmHg}$), or delayed labor progress.

What does oxytocin infusion do to contractions and in turn the baby?

Oxytocin infusion stimulates uterine contractions, which can enhance labor progression but may also lead to increased fetal heart rate decelerations or distress if overly strong contractions occur, so it is important mom is on continous EFM.

What is PROM>24 hours?

Premature Rupture of Membranes occurring more than 24 hours before labor begins, increasing the risk of infection and complications for both mother and baby.

Why is early detection of fetal hypoxia (lack of oxygenation to the fetus) so critical?

Hypoxia alters FHR patterns and is the most common cause of fetal injury and death; early detection allows preventative intervention and sometimes imminent delivery.

What are the main advantages of continuous external EFM?

It is fast to set up, It is noninvasive and can be utilized with both intact membranes/undilated cervix and ruptured membranes/dilated cervix.

What specific FHR parameter CANNOT be detected by external monitoring?

Short-term (beat-to-beat, little changes to the heart beat) variability.

What is a fetal spiral electrode (FSE) and how is it placed and removed?

A corkscrew-shaped electrode attached beneath the skin of the fetal presenting part (parietal bone or head dowm); unscrewed after delivery, leaving a mild abrasion. It is a Continuous Internal Monitor (CIM)

What is the primary benefit of continuous internal FHR monitoring?

It is the most accurate method for detecting fetal heart rate characteristics, baseline variability, and pattern details.

What are indications for internal fetal heart rate monitoring?

Multiple gestation, decreased fetal movement, abnormal auscultation, IUGR, maternal fever, preeclampsia, dysfunctional labor, preterm labor, diabetes, or hypertension.

What does IUGR stand for and what does it mean?

Intrauterine Growth Restriction—a condition where something causes the fetus not to grow properly in utero.

What is Preeclampsia?

A pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often occurring after the 20th week of gestation.

What four criteria MUST be met before internal fetal monitoring can be initiated?

1. Ruptured membranes

2. Cervical dilation of at least $2\,\text{cm}$

3. Presenting part engaged low enough for electrode placement (Baby needs to be lower in the birth canal)

4. Skilled practitioner available to insert electrode

What fetal presentation is required for placement of a fetal scalp electrode?

Cephalic presentation (head down); it cannot be safely attached to a breech presentation.

How is baseline fetal heart rate defined and measured?

The average FHR rounded to increments of $5\,\text{bpm}$ during a $10\text{-minute}$ window, excluding accelerations, decelerations, and marked variability. Assessed between contractions.

What is the normal baseline fetal heart rate range at term?

$$110\text{--}160\,\text{bpm}$$

How is fetal bradycardia defined?

A baseline FHR less than $110\,\text{bpm}$ lasting for more than $10\,\text{minutes}$.

How is fetal tachycardia defined?

A baseline FHR greater than $160\,\text{bpm}$ lasting for more than $10\,\text{minutes}$.

What do the top and bottom panels on a standard fetal monitor strip represent?

• Top panel: Fetal heart rate (FHR)

• Bottom panel: Maternal uterine contraction pattern

How is time represented on a standard fetal heart rate tracing strip?

Distance between bold vertical lines = $1\,\text{minute}$; each small interior box = $10\,\text{seconds}$.

If you see a straight line on a fetal monitor strip, what does that indicate?

A flat line in fetal heart rate monitoring indicates either fetal demise or a lack of variability, suggesting significant fetal compromise.

What factors can disrupt or interfere with an internal monitoring signal?

Maternal obesity, fetal malpresentation, excessive fetal movement, and electrical/mechanical artifact.

What are common causes of fetal tachycardia?

Early response to hypoxia/asphyxia(not getting good oxygen, and sometimes FHR goes up before it tanks), maternal fever, maternal dehydration, amnionitis/infection, drugs/medications, maternal anxiety, or fetal prematurity.

What is amnionitis?

Amnionitis is an infection of the amniotic fluid and membranes surrounding the fetus, often leading to maternal fever, uterine tenderness, and fetal heart rate abnormalities.

What are common causes of fetal bradycardia?

Late fetal hypoxia, maternal hypoglycemia (low blood sugar), fetal acidosis, maternal analgesics/anesthetics, hypothermia, maternal hypotension, prolonged umbilical cord compression, or congenital heart block.

When do fetal bradycardia and tachycardia become ominous clinical signs (VERY BAD SIGN)?

When they are accompanied by a decrease or loss of baseline variability. (Baby is not tolerating well from stress, and intervention is needed)

What five components should be routinely evaluated on a fetal monitor strip?

1. Adequacy of tracing

2. Type of monitor used (external vs. internal)

3. Baseline FHR and presence of variability

4. Presence of accelerations or decelerations

5. Trends over time

Why is a flat line (absent variability) on a fetal monitor strip alarming?

Variability represents an intact, well-oxygenated fetal nervous system; a flat line indicates absent variability and potential central nervous system depression or acidemia. Warrants investigating and interventions.

What is a Category I FHR tracing and what does it indicate?

Normal tracing; strongly predictive of normal fetal acid-base status at the time of observation. Baby is no stressed and nothing is causing stress to the baby in utero. Requires routine care without any specific intervention.

What specific criteria define a Category I FHR tracing?

• Baseline FHR: $110\text{--}160\,\text{bpm}$

• Baseline variability: Moderate

• Late or variable decelerations: Absent

• Early decelerations: Present or absent

• Accelerations: Present or absent

What is a Category II FHR tracing and what action does it require?

Indeterminate tracing; not predictive of abnormal acid-base status, but requires continued evaluation, surveillance, and potential reevaluation/intervention. (Some concerns are there and interventions may be needed but not immediately necessary.)

What is the simplest way to classify a Category II FHR pattern?

It encompasses all tracings that do not meet criteria for Category I (Normal) or Category III (Abnormal).

What are examples of Category II FHR strip findings?

Baseline bardycardio or tachycardia without baseline variability, minimal/marked variability, absent variability without decels, absence of accelerations after fetal stimulation, or recurrent variable decels with variability with minimal or moderate variability. Prolonged decels of >2 min and <10mins. Recurrent late decelerations with moderate variability, Variable decelerations with slow return to baseline, overshoots, or shoulders.

What is a Category III FHR tracing and what does it indicate?

Abnormal tracing; predictive of abnormal fetal acid-base status. Requires prompt evaluation and immediate clinical intervention. (ABSOLUTE NEED TO BE ON TOP OF ASAP)

What specific findings qualify an FHR strip as Category III?

1. Absent variability WITH recurrent late decelerations

2. Absent variability WITH recurrent variable decelerations

3. Absent variability WITH bradycardia

4. Sinusoidal pattern

What does the term 'recurrent' mean when describing decelerations?

Decelerations occurring with $\ge 50\%$ of uterine contractions in a $20\text{-minute}$ window.

What immediate maternal interventions are required for a Category III tracing?

Provide oxygen, reposition mother, increase IV fluids, increase perfusion. discontinue oxytocin/uterotonics, and treat maternal hypotension.

Why is it crucial to document the FHR category in the medical record?

It provides a clear clinical record of fetal status during labor to substantiate care decisions and defend against litigation if adverse outcomes occur.

What is baseline FHR variability?

Irregular fluctuations in the baseline FHR of two cycles per minute or greater, excluding accelerations and decelerations. Measured in BPM

What physiological mechanism creates baseline FHR variability?

The interplay ('push-and-pull') between the sympathetic and parasympathetic nervous systems acting on the sinoatrial node. Presence means that the system is working and recieving adequate oxygen (so no danger)

What key physiological factors influence baseline variability?

Fetal oxygenation status, cardiac output, and any drug effects

What are the four categories of FHR variability and their amplitude ranges?

• Absent: Amplitude range undetectable

• Minimal (Small Changes): Amplitude range $\le 5\,\text{bpm}$

• Moderate (IDEAL): Amplitude range $6\text{--}25\,\text{bpm}$

• Marked: Amplitude range $> 25\,\text{bpm}$

Which level of FHR baseline variability is considered normal and ideal?

Moderate variability ($6\text{--}25\,\text{bpm}$).

What does moderate baseline variability indicate about fetal status?

An intact, well-oxygenated autonomic/central nervous system, absence of metabolic acidemia, and overall fetal well-being.

How do you determine metabolic acidosis?

Metabolic acidosis can be determined by getting blood cord samples to assess pH levels and base excess. A low pH and decreased base excess indicate metabolic acidosis.

What clinical interventions are needed for moderate variability?

None; continue routine monitoring.

Alone minimal and marked variability is not a concern, but….

coupled with other factors such as maternal conditions and fetal heart rate patterns, it may indicate a need for further assessment. (Something that will get your attention)

What are common clinical causes of absent or minimal variability?

Fetal acidemia, uteroplacental insufficiency (not getting enough os something; i.e good perfusion, good oxygen,), cord compression, fetal sleep cycle, prematurity, maternal hypotension, uterine hyperstimulation (giving oxytocin), placental abruption, or CNS depressant drugs.

What is uteroplacental insufficiency?

A condition where the placenta does not provide adequate blood flow and oxygen to the fetus, potentially leading to fetal distress.

What nursing interventions should be taken for absent or minimal variability?

IMPROVE maternal blood flow and perfusion. Position mother in lateral position, increase IV fluid rate, administer oxygen ($8\text{--}10\,\text{L/min}$ via mask), consider internal monitoring, notify provider, and prepare for surgical delivery (C-section) if no improvement.

When is minimal variability considered a non-pathological (benign) finding?

During a fetal sleep cycle (typically lasting 30 minute) or following maternal administration of opioid analgesics. If the baby doesn’t come out of it when the 30 minutes are up or after the administration of analgesics, further evaluation may be necessary and concern is valid.

What conditions can cause marked FHR variability ($> 25\,\text{bpm}$)?

Cord compression/prolapse , maternal hypotension, uterine hyperstimulation/tachysystole, and early placental abruption.

Whaat is the concern of a cord prolapse?

A cord prolapse occurs when the umbilical cord slips ahead of the presenting part of the fetus, so the cord is going to come through the vaginal opening before the baby, which can lead to cord compression and reduced blood flow to the fetus. This presents a risk of fetal distress and necessitates immediate medical intervention.

What interventions are indicated for marked FHR variability?

Identify cause, change maternal position to lateral, increase IV fluids, administer O2 at $8\text{--}10\,\text{L/min}$, if concerned about uterine hyperstimulation we can stop oxytocin, notify provider, and prepare for potential C-section.

Are isolated minimal or marked variability patterns ominous on their own?

No; isolated findings warrant close observation, but they become ominous when combined with recurrent decelerations or persistent baseline changes.

What is uterine hyperstimulation (tachysystole) and what commonly causes it?

Excessive uterine contraction frequency; most commonly caused by oxytocin (Pitocin) infusion.

What is placental abruption and why is it an obstetric emergency?

Premature separation of the placenta from the uterine wall, leading to severe maternal hemorrhage and fetal hypoxia/death; requires emergency C-section.

How is an FHR acceleration defined?

A visually apparent, abrupt increase in FHR above baseline with onset-to-peak time of less than $30\,\text{seconds}$. (Considered reassuring, indicates fetal well-being)

What is the $15 \times 15$ rule for fetal heart rate accelerations at term?

Peak must be $\ge 15\,\text{bpm}$ above baseline and last for $\ge 15\,\text{seconds}$ (from onset to return), lasting less than $2\,\text{minutes}$.

What do FHR accelerations signify physiologically?

Fetal movement, intact neuromuscular system, and fetal well-being (reassuring sign requiring no intervention).

How is an FHR deceleration defined?

A transient decrease in FHR below baseline caused by parasympathetic nervous system stimulation.

How are FHR decelerations classified and described?

Classified by visual shape and timing relative to uterine contractions into three main types: Early, Late, and Variable.

What visual characteristics define an early deceleration?

Gradual, symmetrical decrease and return of FHR that mirrors the uterine contraction; the lowest point (nadir) coincides exactly with the contraction peak.

Early decelerations are okay, but…

variable and late decelerations may indicate distress; monitoring is essential.

How far below baseline do early decelerations typically drop?

Visually apparent, usually symmetrical, and have a gradual decrease in FHR, Rarely drop more than $30\text{--}40\,\text{bpm}$ below baseline. Mirrors contractions.

When during labor do early decelerations most commonly occur?

During active labor, when mom is pushing, or as the baby's head descends or any use of forceps or vacuum extraction to help the baby out

What is the physiological cause of early decelerations?

Transient fetal HEAD COMPRESSION, which stimulates a vagal response.

Are early decelerations indicative of fetal distress or hypoxia?

No; early decelerations are benign and do not require intervention.

What nursing action is indicated upon observing early decelerations?

Perform a vaginal exam to assess cervical progress/station and inspect for crowning; prepare for birth if mom is about to deliver.

What visual characteristics define a late deceleration?

Gradual, symmetrical FHR decrease where the nadir occurs AFTER the peak of the contraction, and FHR returns to baseline only after the contraction ends.

Anytime you have a late deceleration, what category strip is the baby going to have?

Category II or III (Never a category l)

What is the primary physiological cause of late decelerations?

Uteroplacental insufficiency, causing reduced maternal-fetal blood flow and oxygen exchange during contractions.

What clinical conditions are frequently associated with late decelerations?

Maternal hypotension, gestational hypertension, post-term pregnancy/placental aging (babies 40 weeks and beyond), oxytocin tachysystole, maternal smoking ( can cause decreased perfusion to the placenta), anemia, and cardiac disease.