Valerie Hill - Assessment

EFM - When it’s used

Electronic fetal monitoring, when first introduced, was thought to be more sensitive than auscultation, and prevent rates of mortality and neurological conditions, however, that is not the case. EFM is mostly only needed to be used for people with risk for adverse perinatal outcomes. EFM is shown to increase the rate of interventions in labor.

When to Assess Fetal Heart Rate (first and second stages + extra)

• In the latent part of the first stage of labor: Every hour

• In the active part of the first stage of labor, and the passive part of the second stage: Every 15-30 mins

• In the active part of the second stage: Every 5-15 mins

• Should be assessed before and after AROM, and when FHR is abnormal.

How to do Intermittent Asucultation (When, where, what and how)

• Done with a doptone, ultrasound stethoscope, or delee-hillis fetoscope. Doptone is most common, and converts FHR into an electrical signal. 

• When assessed, it should be described as a baseline number, and whether the rhythm is regular or irregular. If irregular, or abnormal, EFM may be initiated. 

• Done by palpating for the fetal back, putting the IA instrument on top of it, listening either for 60 seconds (during a time of rest), or shorter intervals added up. Once baseline rate and rhythm are obtained, listen to FHR for 60secs immediately following a contraction and ensure it is within the baseline range. Maternal pulse should be palpated when auscultating FHR to ensure the two aren’t conflated.

• UA and FHR should be assessed and documented together to get the whole picture.

External EFM

• Once the area of maximal intensity of FHR is located, conductive gel is applied to the abdomen and the transducer is put over that area to monitor FHR. Because it monitors changes in movement, maternal and fetal movement may affect FHR artificially. 

• A tocotransducer can be used to measure UA transabdominally and is placed over the fundus. Can be inaccurate before term.

• Both UA and FHR external monitoring can be affected by obesity. 

• External EFM limits patient mobility

Internal EFM

• More accurate than external.

• Membranes must be ruptured and cervix must be at least 2-3cm dilated

• A small spiral electrode is placed on the presenting part, and/or an IUPC is placed in the uterus. The electrode monitors FHR, and the IUPC monitors UA through detecting compression.

How to assess Uterine Activity (what are you assessing for, ranges/limits)

• Assessment should include frequency (# of contractions in 10 mins averaged over 30 mins), duration (length of contraction. Should not be longer than 90secs and is typically 45-80 secs) intensity (measured as mild, moderate or strong if measured by palpation, or in mmHg if measured by IUPC), and resting tone (described as soft by palpation, or <25mmHg by IUPC).

• Normal UAA is 5 or less contractions in 10 mins that last less than 90secs each, and a minimum of 30secs between each contraction. Contractions should be moderate to strong. 

• A mild contraction feels like the tip of your nose, a moderate like your chin, and a strong like your forehead. 

PROM

• PROM is the rupture of the amniotic sac and leakage of amniotic fluid before the onset of labor at any gestational age.

• Preterm PROM is PROM that occurs before 37 weeks.

• Infection is a major risk factor associated with preterm PROM, with chorioamnionitis being the most common. 

• Placental abruption, retained placenta, and hemorrhage can also occur.

PROM Management

• For people at term, or between 34-36 weeks, active pursuit of labor and birth is the recommended course for patients who experience PROM.

• Before 32 weeks, PROM is managed expectantly, and treated with corticosteroids for lung maturation, and antibiotics to prolong the time between rupture and birth, and reduce complications.

• If preterm PROM is being managed conservatively, patients should be taught to monitor fetal movements, and should feel 6 movements in 2 hours.

• Administering magnesium sulphate also provides fetal neuroprotection if the pt is less than 34 weeks.

Post Term Pregnancy

• Beyond 42 weeks gestation, or beyond 294 days from LMP.