The effect of continuous EFM monitoring on malpractice liability has not been well established. Other rare risks associated with EFM include fetal scalp infection and uterine perforation with the intra-uterine tocometer or catheter. Intrapartum fetal monitoring was developed in the 1960s to identify events that might result in hypoxic ischemic encephalopathy, cerebral palsy, or fetal death. The patient's labor has been normal to this point. - When considering the effectiveness of Electronic Fetal Monitoring, it comes down to the experience and knowledge of the person identifying the tracings. Intrapartum Fetal Monitoring | AAFP Perform a vaginal examination (check for cord prolapse, rapid descent of the head, or vaginal bleeding suggestive of placental abruption), 6. -Contractions started by: IV pitocin or Nipple stimulation Fetal heart rate. Prolonged FHR decelerations from baseline (more than two minutes but less than 10 minutes) may represent rapid cervical change and/or fetal descent, maternal hypotension, placental abruption, umbilical cord prolapse, or uterine rupture2,5,26 (Figure 77). Fetal scalp sampling, which requires amniotomy, tests fetal pH for the presence of acidemia.16 However, because of a 10% inadequate sample rate and a prolonged sample-to-result time of 18 minutes on average, this test is rarely performed in the United States.20 Lactate fetal scalp sampling (direct measurement of lactate by a probe) is another option that boasts a sample-to-result time of two minutes; however, its use has not resulted in improved newborn outcomes.21 An internal real-time fetal pulse oximetry probe (similar to an intrauterine pressure catheter) may lower operative vaginal delivery rates during the second stage of labor but has no apparent effect on neonatal outcomes.22,23 Fetal electrocardiograms have also been studied because fetal acidosis can affect the ST interval. Relevant ACOG Resources. Data Sources: PubMed searches were completed using the key terms intrapartum fetal heart monitoring, cardiotocography, structured fetal heart monitoring, National Institute of Child Health and Human Development classifications, amnioinfusion, and advanced life support in obstetrics. Health care professionals play the game to hone and test their EFM knowledge and skills. Remember, the baseline is the average heart rate rounded to the nearest five bpm. After discussion regarding the FHR tracing, the resident and attending practitioner on duty determine that the FHR tracing is a Category II. -Reassuring for fetal well being Tracing patterns can and will change! Give intravenous fluids if not already administered; consider bolus, 7. The organization's practice allows for IA if 1:1 nursing staff is available. What should the nurse do next? Use a definite integral to find the number of animals passing the checkpoint in a year. Evaluation of fetal well-being using fetal scalp stimulation, pH measurement, or both, is recommended for use in patients with nonreassuring patterns.11,12 Evaluation for immediate delivery is recommended for patients with ominous patterns. The patient is scheduled for an amniocentesis at 16 weeks gestation. The figure in the next column shows a graph of TTT. Management of late decelerations includes intrauterine resuscitation and identifying and treating reversible causes, with immediate delivery recommended if they do not resolve2,5,7 (Figure 67). Results in this range must also be interpreted in light of the FHR pattern and the progress of labor, and generally should be repeated after 15 to 30 minutes. Continuous electronic fetal monitoring has been shown to reduce the incidence of neonatal seizures, but there has been no beneficial effect in decreasing cerebral palsy or neonatal mortality. Health care professionals play the game to hone and test their EFM knowledge and skills. Fetal Heart Tracing Quiz 2 - 3/10/2017 - Course Hero The electronic fetal monitor uses an external pressure transducer or an intrauterine pressure catheter (IUPC) to measure amplitude and frequency of contractions. A patient is in active labor with spontaneous contractions occurring every 2 minutes and lasting 90 to 100 seconds. If the new rate is below 110 BPM, the pattern is considered a bradycardia. The patient received an epidural bolus approximately 10 minutes ago. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Remember, the baseline is the average heart rate rounded to the nearest five bpm. The FHR baseline is 130 bpm with moderate variability. We also searched the Cochrane Library, Essential Evidence Plus, and Clinical Evidence. Select the answer that doesn't belong with the others: Fetal Heart tracings (FHR) Flashcards | Quizlet Differentiate maternal pulse from fetal pulse, 4. Electronic fetal monitoring is performed in a hospital or doctors office. They resemble the letter U, V or W and may not bear a constant relationship to uterine contractions. Gene amplification in cancer cells has been shown to lead to resistance to cancer-killing medications when the dose of medication is increased gradually. Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. is part of the free online EFM toolkit at. The use of amnioinfusion for recurrent deep variable decelerations demonstrated reductions in decelerations and cesarean delivery overall. Shows FHR as well as uterine contractions. The periodic review includes ensuring that a good quality tracing is present and that abnormalities are appropriately communicated. 1. The main goal is to identify fetuses who are prone to injuries stemming from hypoxia (or a lack of oxygen for fetal tissues). Are there accelerations present? https://www.ncbi.nlm.nih.gov/pubmed/19546798 Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm. Fetal Tracing Quiz Please answer each question. 90-150 bpm B. The recommendations for the overall management of FHR tracings by NICHD, the International Federation of Gynecology and Obstetrics, and ACOG agree that interpretation is reproducible at the extreme ends of the fetal monitor strip spectrum.10 For example, the presence of a normal baseline rate with FHR accelerations or moderate variability predicts the absence of fetal acidemia.10,11 Bradycardia, absence of variability and accelerations, and presence of recurrent late or variable decelerations may predict current or impending fetal asphyxia.10,11 However, more than 50 percent of fetal strips fall between these two extremes, in which overall recommendations cannot be made reliably.10 In the 2008 revision of the NICHD tracing definitions, a three-category system was adopted: normal (category I), indeterminate (category II), and abnormal (category III).11 Category III tracings need intervention to resolve the abnormal tracing or to move toward expeditious delivery.11 In the ALSO course, using the DR C BRAVADO approach, the FHR tracing may be classified using the stoplight algorithm (Figure 19), which corresponds to the NICHD categories.9,11 Interventions are determined by placing the FHR tracing in the context of the specific clinical situation and corresponding NICHD category, fetal reserve, and imminence of delivery (Table 4).9,11, If the FHR tracing is normal, structured intermittent auscultation or continuous EFM techniques can be employed in a low-risk patient, although reconsideration may be necessary as labor progresses.2 If the FHR tracing is abnormal, interventions such as position changes, maternal oxygenation, and intravenous fluid administration may be used. This pattern is most often seen during the second stage of labor. This alone is not predictive of fetal acidosis unless accompanied by decreased variability and/or absent spontaneous or stimulated accelerations.2,5. Minimal variability during the hour preceding fetal bradycardic events has been shown to be most predictive of fetal acidosis and need for emergent delivery.23 During periods of minimal variability, accelerations produced by scalp stimulation offer reassurance.15,23,26,41 Management of minimal variability includes intrauterine resuscitation and identifying and treating reversible causes (Table 7).2,7,16, Marked variability is defined as more than 25 bpm fluctuations in FHR around the determined baseline for more than 10 minutes and may represent hypoxic stress5,33 (eFigure E). The incoming nurse enters the patient's room to complete an initial assessment and sees that the FHR has been 80 bpm for the last 3 minutes and that variability is minimal to absent. Intermountain Healthcare - Interprofessional Continuing Education, Third Annual Advanced Fetal Heart Rate Interpretation Conference, 10/27/2023 12:00:00 PM - 10/27/2023 5:00:00 PM, This conference will discuss fetal heart rate variability including: pathophysiology of variability; extreme abnormalities of variability; variability in the Category II Fetal Heart Tracing Algorithm; and case . Place the Doppler over the area of maximal intensity of fetal heart tones, 3. Internal is more accurate, measuring the beat to beat time since it has direct contact with the fetus. Electronic fetal monitoring is performed in a hospital or doctors office. Copyright 1999 by the American Academy of Family Physicians. Compared with structured intermittent auscultation, a period of EFM on maternity unit admission results in a lack of improved neonatal outcomes and increased interventions, including epidural analgesia (NNH = 19), continuous EFM (NNH = 7), and fetal blood scalp testing (NNH = 45). Variability should be normal after 32 weeks.17 Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Issues such as hypoxia, however, might slow their heart rate. Fetal heart rate monitoring can be done either externally or internally. Author disclosure: No relevant financial affiliations. While assessing the FHR, the nurse notices a pattern of uniform decelerations that have an abrupt onset with a nadir down to 90 bpm for 30 seconds. See permissionsforcopyrightquestions and/or permission requests. Is perinatal asphyxia predictable? - PMC - National Center for You have to lie down or sit in a reclined position for the test, which lasts about 20 minutes. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. Fetal Tracing Quiz . This content is owned by the AAFP. Yes, and the strip is reactive. What is the baseline of the FHT? The nurse is caring for a low-risk primipara at 40 weeks' gestation and in active labor. JAMES J. ARNOLD, DO, AND BREANNA L. GAWRYS, DO. Chemoreceptors located in the aortic and carotid bodies respond to hypoxia, excess carbon dioxide and acidosis, producing tachycardia and hypertension.15 The FHR is under constant and minute adjustment in response to the constant changes in the fetal environment and external stimuli. Count FHR between contractions for 60 seconds to determine average baseline rate, 6. A change in baseline FHR is said to occur when the change persists for 10 minutes or longer. They last for longer than 15 seconds. This content is owned by the AAFP. The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Severe prolonged bradycardia of less than 80 bpm that lasts for three minutes or longer is an ominous finding indicating severe hypoxia and is often a terminal event.4,11,16 Causes of prolonged severe bradycardia are listed in Table 6. You have to lie down or sit in a reclined position for the test, which lasts about 20 minutes. Identify type of monitor usedexternal versus internal, first-generation versus second-generation. The NCC EFM Tracing Game uses NICHD terminology. Challenge yourself every tracing collection is FREE! One benefit of EFM is to detect early fetal distress resulting from fetal hypoxia and metabolic acidosis. Category II tracings are defined as indeterminate, are common, and represent all tracings that do not fall into the Category I or III groups.2,5 They vary widely in level of concern for acidosis, so the family physician must determine the severity of the Category II tracing and take the appropriate action.2,5,7,35, There is a direct association between fetal acidosis, recurrent decelerations, and depth of decelerations2,5,34,36; however, the presence of moderate variability and/or accelerations offers reassurance in Category II tracings because the presence is predictive of a lack of fetal acidosis.2,4,26,27,34,3638 For Category II tracings without spontaneous or provoked accelerations, minimal/absent variability, or deep decelerations (i.e., FHR drops to 70 bpm or less), immediate action is needed.3,4, A management algorithm30 (eFigure A) has been developed that is based on the suspected degree of fetal acidosis and ideally minimizes unnecessary interventions.7, A five-tiered classification/management scheme for management of Category II tracings has been developed (http://www.obapps.org).7,37,39 Each continuous electronic fetal monitoring tracing is color coded to represent the threat of acidosis based on the National Institute of Child Health and Human Development definitions, and Category II is broken into three separate severity and intervention subcategories based on the presence of accelerations and/or moderate variability.7,37 This classification has been shown to improve identification of fetal acidosis and newborns requiring immediate intervention after delivery.37, Category II management should focus on first correcting reversible causes, including stopping uterotonic agents and placental fetal perfusion, through intrauterine resuscitation(Figure 1).2,7,16,21,27,3033 Lateral recumbent maternal positioning reduces compression of the maternal vena cava and aorta and the fetal umbilical cord.2,32,33 Intravenous fluid boluses up to 1 L have been shown to improve fetal oxygenation up to 30 minutes after administration.32,33 Maternal oxygen may be administered after other maneuvers, but it can be discontinued after tracing improvement because there is no evidence to support its routine use.2,32,33 Modification in maternal pushing efforts, such as initiating only with the urge to push and allowing for fetal recovery by pushing with every second or third contraction, can improve maternal and fetal oxygenation.40, Category III tracings, defined by a sinusoidal FHR pattern (Figure 37) or absent FHR variability (Figure 47) with recurrent late and/or variable decelerations or fetal bradycardia (see the Fetal Bradycardia section), require immediate intrauterine resuscitation and intervention.2,5,8,14,27,30,32,33,38,39 If the Category III tracing does not rapidly improve, expedited delivery is recommended.