Fetal Well-being and Electronic Fetal Monitoring

1. Fetal Well-being and Electronic Fetal Monitoring Fetal Tests Fetal Heart Rate Decelerations Variability Fetal Movement Counts

2. Ultrasound • Confirmation of pregnancy and fetal presentation • Evaluation of fetal heartbeat and fetal respiration • Identification of more than one embryo/fetus • For examination of anatomical fetal structures • To estimate gestational age, fetal weight, and growth • Location of the placenta and amniotic fluid volume • Accompanying invasive procedures

3. Fetal Activity • Vigorous fetal activity - provides reassurance of fetal well-being • Marked decrease or cessation in activity • May indicate possible fetal compromise • May require immediate follow-up • Assessment of fetal activity (from week 28 to week 38) - noninvasive method of monitoring the fetus

4. Fetal Movement Counts • Daily record beginning at 27 weeks gestation • Count at same time each day – 1 hour after meals • Lie in side-lying position • Contact health care provider when: • <10 movements in 3 hours using Cardiff card • < 3 movements in 8 hours using daily movement record • No fetal movement in AM • Fetal movements becoming slower

5. Electronic Fetal Monitoring • Provides continuous data and is routine for high-risk clients • Also used for women experiencing an induction of labor • May be done externally or with an internal monitor

6. Electronic Fetal Monitoring • - Indications for: • Previous history of stillborn • Presence of complication • Induction of labor, preterm labor • Decreased fetal movement • Non-reassuring fetal status • Meconium staining of amniotic fluid • Trial of labor following a C-section

7. Electronic Fetal Monitoring • Fetal Heart Rate – 110 – 160 bpm • Fetal Tachycardia • Sustained rate of 161 bpm or above • If rate is 180 bpm or above, is marked tachycardia • Causes • Early fetal hypoxia • Maternal fever • Maternal dehydration • Chorioamnionitis • Maternal hyperthyroidism • Beta-sympathomimetic drugs • Fetal anemia

8. Fetal Tachycardia • Ominous sign if tachycardia is accompanied by • Late decelerations • Severe variable decelerations • Decreased variability

9. Fetal Bradycardia • Fetal Bradycardia • less than 110 bpm during a 10-minute period or longer • Causes • Profound hypoxia in fetus • Maternal hypotension • Prolonged umbilical cord compression • Fetal arrhythmias • Uterine hyperstimulation • Abruptio placentae • Uterine rupture • Vaginal stimulation in second stage of labor

10. Evaluate Fetal Monitoring • Is baseline within normal limits? • Is there tachycardia or bradycardia? • Is variabilitypresent or absent? • If present, is variability Minimal (≤ 5 bpm)? Moderate (6-25 bpm)? Marked (> 25 bpm)? • Are there accelerations or decelerations(early, late, variable, prolonged) (prolonged = decrease ≥ 15 bpm for ≥ 2 min but < 10 min)?

13. EFM Categories • Category 1 - Normal • FHR 110 – 160 • No late or variable decelerations • May see early decelerations • Category 3 – Abnormal • Absent variability and any of following: • Recurrent and variable decelerations • Bradycardia • Sinusoidal pattern (cycle frequency 3 – 5 minutes for >= 20 minutes)

14. EFM Categories • Category 2 – Indeterminate • Any fetal heart rate pattern not in Category 1 or Category 2

15. Nursing Interventions for Nonreassuring FHR • Optimize maternal positioning – side-lying • Discontinue oxytocin if indicated • Give supplemental oxygen if indicated • Notify physician or midwife • Administer IV fluids as needed • Monitor maternal v/s for hypotension and treat • Elevate HOB 30 degrees • Initiate continuous monitoring

16. Nursing Interventions for Nonreassuring FHR • Assist with internal monitors as appropriate • Perform vaginal exam to assess for prolapsed cord or labor progress • Assist physician with fetal blood sampling • Prepare for expeditious birth • Provide client and family with explanation • Administer tocolytic as ordered

18. Biophysical Profile

19. Non-Stress Test • Used to assess fetal status using an electronic fetal monitor • Based on the knowledge • Well-oxygenated fetus has adequate oxygenation • Intact central nervous system • Increase in fetal heart rate (FHR) with fetal movement • Reactive NST: Two accelerations of FHR over 20 minutes • Nonreactive: Less than 2 accelerations over 40 minutes • Unsatisfactory: Cannot be interpreted

20. Non-Stress Test Example of a reactive nonstress test (NST). Accelerations of 15 beats per minute lasting15 seconds with each fetal movement (FM).

21. Non-Stress Test Example of a nonreactive NST. There are no accelerations of FHR with FM.

22. Contraction Stress Test Example of a positive contraction stress test (CST). Repetitive late decelerations occurwith each contraction. Note that there are no accelerations of FHR with three fetal movements (FM).

23. Amniocentesis • Nursing care: Assist the physician during amniocentesis • Support the woman undergoing the procedure • Obtain informed consent • Clarify the physician’s instructions or explanations • Obtain baseline vital signs • Obtain baseline fetal heart rate • After procedure, review reportable side effects • Assess vital signs and fetal heart rate

24. L/S Ratio 16–6 Lecithin / Sphingomyelin (L/S) Ratio and Phophatidylglycerol (PG)

25. NCLEX Question • A biophysical profile result of 4 is reported to the physician. Which intervention should the nurse plan to do? • Schedule a repeat BPP for later today. • Schedule a contraction stress test. • Instruct in fetal movement counts. • Prepare for delivery of fetus.