Electronic Fetal Monitoring

Electronic Fetal Monitoring

Indications for continuous EFM

Any pregnancy considered high risk· Induction or augmentation of labor·Decreased fetal movement·Premature labor·Premature rupture of membranes

• Oligohydramnios• Hypertension• Abnormal fetal heart rate• Fetal malpresentation in

labor• IDDM• Multiple Gestation• Previous C/S• Trauma• Meconium

ACOG & AAP

• When EFM is the method selected for fetal assessment. The MD & obstetrical personnel should be qualified to identify and interpret abnormalities. These guidelines also state that it is appropriate for MD & Nurse to use the descriptive terms that have been given to fetal monitoring patterns in charting and reporting

• Those not qualified or are unsure of the

interpretation in FHR patterns should seek other professionals to assist in this evaluation and interpretations

• The nurse should document the presence of MD and nurse, pt position and changes in cervix,

• Therapeutic interventions such as O2 and medications

• Increased or decreased BP• Febrile• Amniotomy, AROM,SROM, color amt.

consistency• Is the patient complete/pushing• All of these descriptive details give a picture

that indicates what is going on with the patient and possible cause of change in FHR pattern

• AAP/ACOG

Guidelines emphasize that when there is a change in the FHR pattern all of those things should be documented as well as a return to baseline

Each tracing should include Pt NameID #Date, Time of admission/deliveryEDC, Gravida Para and any other identifying information

ACOG• Has not identified core competencies in FHR

monitoringStandard guidelines Norm 110-160

»Fetal tachycardia»Mod 161-180»Marked “ 181-more»Fetal Bradycardia»Mod 100-119»Marked” 90 or less

4 Basic Features of Fetal Heart tracing

4 Basic Features• Baseline • Variability• Bradycardia <110 bpm • Tachycardia >160 bpmPeriodic changes: FHR accelerations or

decelerations that occur with contractions. Decelerations are routinely described as early,

late, or variable.

Non-periodic changes (no changes in variability)

Nonperiodic changes can occur spontaneously, without contraction activity, and are also described as accelerations or decelerations.

Variable decelerations can appear during a Non-stress test and may be a sign ofcord compression or oligohydramnios, both of which can have adverse effects on the fetus.

· Baseline Variability

· Normal FHR 5 bpm greater than or equal to 5 bpm, between contractions

Nonreassuring FHR less than 5 bpm or less, but less than 30 min of tracing

Abnormal FHR less than 5 bpm for 90 min or more.

Baseline variability

• The minor fluctuations on baseline FHR at 3-5 cycles p/m will reflect baseline variability

• Examine 1 min segment and estimate highest peak and lowest trough

• Normal is more than or equal to 5 bpm

Factors affecting Baseline variability

• Para-Sympathetic affects short term variability

• Sympathetic affects long term

• CNS Drugs reduces Variability

• Increased gestational age may increase variability

• Mild Hypoxia may cause both Sympathetic and Parasympathetic stimulation

Accelerations• Accelerations transient increase in FHR of

15 bpm or more lasting for 15 sec

• Absence of accelerations on an otherwise normal Fetal heart tracing remains unclear

• Presence of FHR Accelerations usually have good outcome

Accelerations

• Head compression

Begins on the onset of contraction and returns to baseline as the contraction ends

Should not be disregarded if it appears early in labor or in the antenatal period

Early Decelerations

EARLY DECELERATION

Early Decelerations

Late Decelerations• Uniform periodic slowing of FHR with

the on set of the contraction Reduced baseline variability together

with late decelerations and repetitive late deceleration increases risk of fetal acidosis and an Apgar score of less than 7 at

5/min with an increased risk of adverse outcome

Late Deceleration

Late Deceleration

Late DecelerationsDue to acute and chronic utero-placental insufficiency

· Occurs after the peak and past the length of uterine contraction, often with slow return to the baseline

· Is precipitated by hypoxemia

· Associated with respiratory and metabolic acidosis

· Common in patients with PIH, DM, IUGR or other forms of placental insufficiency

Variable Decelerations• Variable intermittent periodic slowing of

FHR with rapid onset recovery and isolation

• They can resemble other types of deceleration in timing and shape

• Atypical associated with an increased risk of umbilical artery acidosis and Apgar score less than 7 at 5 min

Additional components

Loss of 1 or 2 degree rise in baseline rate• Slow return to baseline FHR after and end of

contraction• Prolonged secondary rise in Base FHR • Biphasic deceleration• Loss of variability during deceleration • Continuation of the baseline at a lower rate

Variable Deceleration (Vagal activity) Inconsistent in configuration

• No uniform temporal r-ship to the onset of contraction, are variable and occur in isolation

• Worrisome when Rule of 60 is exceeded (i.e. decrease of 60 bpm,or rate of 60 bpm and longer than 60 sec)

• Caused by compression of the umbilical cord

• Often associated with Oligo-hydramnios with or without rupture of membranes

• Acidosis if prolonged and recurrent

Variable Decelerations

Variable Decelerations

Drop in FHR of 30 bpm or more lasting for at least 2 mins

• Is pathological when it crosses 2 contractions in 3 mins• Results in reduced of O2 transfer to placenta• Associated with poor neonatal outcome

Prolonged Deceleration

Prolonged DecelerationsCAUSES

• Cord prolapse

• Maternal hypertension/hypotension

• Uterine hypertonia

• Epidural/spinal or pudendal anesthesia

• Can follow a vag exam, AROM or SROM with high presenting part

Prolonged Deceleration

Intrauterine Resuscitation

Have the mother lie on her left/right side

or in a knee chest positionTo alleviate possible cord compression

Reduce or stop any oxytocin Initiate tocolysisTo decrease uterine activity and increase

placental blood flowIncrease IV fluidTo increase maternal blood/fluid volume 

    Give oxygen @ 10-12 L/min via mask   

• Physician may apply an internal monitor to verify the accuracy of external monitor reading 

• Physician may administer amnioinfusion   to decrease pressure on cord or dilute mec.

• If the heart rate is not restored to normal within 30 minutes, prompt delivery is needed.  Cesarean section may then become necessary. Goal is to deliver ASAP

Causes of Baseline Change

• Postdates• Drugs• Idiopathic• Arrhythmias• Hypothermia• Increased vagal tone• Cord CompressionManagement depends on the clinical situation

Causes of Bradycardia• Asphyxia• Drugs• Prematurity• Maternal Fever• Maternal thyrotoxicosis• Maternal Anxiety• Idiopathy

Management depends on the clinical situation

Baseline Tachycardia

· Asphyxia· Drugs· Prematurity· Maternal fever· Maternal thyrotoxicosis· Maternal Anxiety· Idiopathy

Sinusoidal Pattern

• Regular Oscillation of the Baseline long-term Variability resembling a Sine wave fixed cycle of 3-5 p min with amplitude of 5-15bpm and above but not below the baseline

• Should be viewed with suspicion as poor outcome has occurred (maternal/fetal hemorrhage)

Sinusoidal pattern

Sinusoidal pattern - distinctive smooth undulating

Sine-wave baselineCord compression• Hypovolemia• Ascites• Idiopathic (fetal thumb sucking)• Analgesics• Anemia• AbruptionManagement depends on clinical situation

Summary of tracing• Normal with all 4 Features

• Suspicious one non reassuring category and remainder are reassuring

• Pathological 2 or more non-reassuring categories or one or more abnormal categories.