They are characteristically variable in duration, intensity and timing. Recurrent variable decelerations are frequently seen in association with maternal expulsive efforts in the 2nd stage of labor. The NICHD has stated that it is no longer useful to distinguish between short-term and long-term variability and has categorized variability into the following classifications, depending on the amplitude of the FHR tracing: absent (Online Figure C), minimal (Online Figure D), moderate (Online Figure E), and marked (Online Figure F).11, Sleep cycles of 20 to 40 minutes or longer may cause a normal decrease in FHR variability, as can certain medications, including analgesics, anesthetics, barbiturates, and magnesium sulfate.15 Loss of variability, accompanied by late or variable decelerations, increases the possibility of fetal acidosis if uncorrected.15, Sinusoidal pattern is a smooth, undulating sine wave pattern defined by an amplitude of 10 bpm with three to five cycles per minute, lasting at least 20 minutes.11 This uncommon pattern is associated with severe fetal anemia and hydrops, and it usually requires rapid intervention in these settings.15 Similar appearing benign tracings occasionally occur because of fetal thumb sucking or maternal narcotic administration, and generally these will persist for less than 10 minutes.15. Your doctor evaluates the situation by reviewing fetal heart tracing patterns. A. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. The patient is being monitored by external electronic monitoring. Evaluate recordingis it continuous and adequate for interpretation? A nurse is teaching a woman how to do "kick counts." The experienced nurse tells the new nurse that a Category III FHR tracing may include which characteristic? What is the baseline of the FHT? The nurse has no other patients to care for at this time. May 2, 2022 The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing. Copyright 2020 by the American Academy of Family Physicians. The five components of the biophysical profile are as follows: (1) nonstress test; (2) fetal breathing movements (one or more episodes of rhythmic fetal breathing movements of 30 seconds or. Instruct the woman to drink 1 to 2 quarts of water. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. The probe sends your babys heart sounds to a computer and shows FHR patterns. This content is owned by the AAFP. Accelerations (A). Normal. This pattern is sometimes called a saltatory pattern and is usually caused by acute hypoxia or mechanical compression of the umbilical cord. A concern with continuous EFM is the lack of standardization in the FHR tracing interpretation.5,811 Studies demonstrate poor inter-rater reliability of experts, even in controlled research settings.12,13 A National Institute of Child Health and Human Development (NICHD) research planning workshop was convened in 1997 to standardize definitions for interpretation of EFM tracing.14 These definitions were adopted by the American College of Obstetricians and Gynecologists (ACOG) in 2002,5 and revisions were made in a 2008 workshop sponsored by NICHD, ACOG, and the Society for Maternal-Fetal Medicine.11 The Advanced Life Support in Obstetrics (ALSO) curriculum developed the mnemonic DR C BRAVADO (Table 3) to teach a systematic, structured approach to continuous EFM interpretation that incorporates the NICHD definitions.9,11. After discussion regarding the FHR tracing, the resident and attending practitioner on duty determine that the FHR tracing is a Category II. Give intravenous fluids if not already administered; consider bolus, 7. can you recognize these strip elements? The fetal membranes must be ruptured, and the cervix must be at least partially dilated before the electrode may be placed on the fetal scalp. Your obstetrician reviews the fetal heart tracing at regular time intervals. Detection is most accurate with a direct fetal scalp electrode, although newer external transducers have improved the ability to detect variability. What are the two most important characteristics of the FHR? Interpretation of the FHR variability from an external tracing appears to be more reliable when a second-generation fetal monitor is used than when a first-generation monitor is used.3 Loss of variability may be uncomplicated and may be the result of fetal quiescence (rest-activity cycle or behavior state), in which case the variability usually increases spontaneously within 30 to 40 minutes.19 Uncomplicated loss of variability may also be caused by central nervous system depressants such as morphine, diazepam (Valium) and magnesium sulfate; parasympatholytic agents such as atropine and hydroxyzine (Atarax); and centrally acting adrenergic agents such as methyldopa (Aldomet), in clinical dosages.19. The American College of Obstetricians and Gynecologists (ACOG), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society for Maternal-Fetal Medicine developed a new three-tiered classification of fetal heart rate abnormalities and a system for interpreting these abnormalities (1). Bradycardia in the range of 100 to 120 bpm with normal variability is not associated with fetal acidosis. -No late or variable decelerations. a) lapilli The patient in labor is having multiple deep variable decelerations down to 60-70 bpm. Fetal heart rate. A systematic approach is recommended when reading FHR recordings to avoid misinterpretation (Table 2). Early decelerations (mirror contraction, with nadir at peak of contraction, likely fetal head compression) and accelerations (FHR increase of 15 bpm or more over at least 15 seconds) may be present.2,5,7,34 No intervention is required for Category I tracings. 1. Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm (Figure 2). Ultrasound assessment x 30 minutes It indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.24 It should be differentiated from the pseudosinusoidal pattern (Figure 11a), which is a benign, uniform long-term variability pattern. -6:Suspect lack of adequate oxygen, Repeat BPP in 24 hours & deliver if <= 6 On entering the room, the nurse sees the patient lying supine and notices that there has been abrupt slowing in the FHR to 90 bpm during the last two contractions, each episode lasting 30 seconds or less. Early. Try your hand at the following quizzes. All Rights Reserved. Although these decelerations are not associated with fetal distress and thus are reassuring, they must be carefully differentiated from the other, nonreassuring decelerations. Non-reactive: The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. What is the most appropriate nursing response? If you have any feedback on our "Countdown to Intern Year" series, please reach out to Samhita Nelamangala at d4medstudrep@gmail.com. Finally, the recovery phase is due to the relief of the compression and the sharp return to the baseline, which may be followed by another healthy brief acceleration or shoulder (Figure 8). The resulting printout is known as a fetal heart tracing, which will be read and analyzed. Therefore, it is a vital clue in determining the overall fetal condition. A patient is in active labor and is being continuously monitored with a fetal monitor. 100-170 bpm C. 110-160 bpm D. 120-140 bpm 2. The baseline FHR is 135 bpm with moderate variability. These segments help establish an estimated baseline (for a duration of 10 minutes) which is expressed in beats per minute. Practice Quizzes 6-10 - Electronic Fetal Monitoring. 5. What action by the nurse is most appropriate? 7. Statistical analysis included univariate analyses with Student T-test, one-way ANOVA, chi-square and Fisher exact test. She asks the nurse to explain the results. A patient at 41 weeks' gestation arrives on the unit for labor induction. 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. Challenge yourself every tracing collection is FREE! Your doctor can confirm the likelihood of hypoxic injury using fetal heart tracing. Continuous electronic fetal monitoring was developed in the 1960s to assist in the diagnosis of fetal hypoxia during labor. Challenge yourself every tracing collection is FREE! 9. -Contractions started by: IV pitocin or Nipple stimulation Every piece of content at Flo Health adheres to the highest editorial standards for language, style, and medical accuracy. The NCC EFM Tracing Game is part of the free online EFM toolkit at NCC-EFM.org. What action by the student indicates to the registered nurse that the student understands the procedure? Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. The descent and return are gradual and smooth. 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. 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). 8. This content is owned by the AAFP. The nurse understands that the test will be read as which of the following? See permissionsforcopyrightquestions and/or permission requests. Variability describes fluctuations in the baseline FHR, whether in terms of frequency, amplitude, or magnitude. Copyright 2023 American Academy of Family Physicians. Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia (Figure 4) or congenital anomalies rather than hypoxia alone.16 Causes of fetal tachycardia are listed in Table 5. Gene amplification in cancer cells has been shown to lead to resistance to cancer-killing medications when the dose of medication is increased gradually. Fetal bradycardia is defined as a baseline heart rate less than 120 bpm. In the United States, an estimated 700 infant deaths per year are associated with intrauterine hypoxia and birth asphyxia.5 Another benefit of EFM includes closer assessment of high-risk mothers. For the letters on this figure, choose the likely cause of melting for Site B. ), What do Braxton Hicks contractions feel like? The nurse understands that this NST will be read as: A woman in active labor has just received an epidural. Turn the patient to the left side, stop the oxytocin infusion, and assess maternal vital signs. -Fetal Doppler: transmits small, high frequency sound waves that are reflected off of the fetal heart - measures heart rate -Normal fetal heart rate = 110-160 BPM Electronic Fetal Monitoring -Fetal body movements Baseline of 140 - 150 with decelerations to 120 noted beginning with the contraction and returning to baseline by the end of the contraction. The monitor calculates and records the FHR on a continuous strip of paper. What is the baseline of the FHT? Continuous EFM increased cesarean delivery rates overall (NNH = 20) and instrumental vaginal births (NNH = 33). A baseline of less than 110 bpm is defined as bradycardia.11 Mild bradycardia (100 to 110 bpm) is associated with post-term infants and occipitoposterior position.15 Rates of less than 100 bpm may be seen in fetuses with congenital heart disease or myocardial conduction defects.15 A baseline greater than 160 bpm is defined as tachycardia11 (Online Figure B). Mucus plug: What is it and how do you know you've lost it during pregnancy? Identify changes in the FHR recording over time, if possible. The patient is now 7 cm dilated, 100% effaced, and at +1 station. Variable. A. The incoming nurse is receiving a report regarding a laboring patient whose cervix is 7 cm dilated, who has a fetal spiral electrode in place, and who is receiving IV oxytocin for augmentation of labor. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. If you want to see how you are doing overall, try the comprehensive assessment: Prematurity, maternal anxiety and maternal fever may increase the baseline rate, while fetal maturity decreases the baseline rate. External monitoring (unless noted differently), paper speed is 3cm/min. About. You have to lie down or sit in a reclined position for the test, which lasts about 20 minutes. It is also characterized by a stable baseline heart rate of 120 to 160 bpm and absent beat-to-beat variability. b. What information about this assessment is most appropriate? A meta-analysis showed that if there is absent or minimal variability without spontaneous accelerations, the presence of an acceleration after scalp stimulation or fetal acoustic stimulation indicates that the fetal pH is at least 7.20.19, If the FHR tracing remains abnormal, these tests may need to be performed periodically, and consideration of emergent cesarean or operative vaginal delivery is usually recommended.15 Measurements of cord blood gases are generally recommended after any delivery for abnormal FHR tracing because evidence of metabolic acidosis (cord pH less than 7.00 or base deficit greater than 12 mmol per L) is one of the four essential criteria for determining an acute intrapartum hypoxic event sufficient to cause cerebral palsy.20, When using continuous EFM, tracings should be reviewed by physicians and labor and delivery nurses on a regular basis during labor. a streams response to precipitation. 2023 National Certification Corporation. Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. Continuous electronic fetal monitoring, compared with structured intermittent auscultation, has been shown to increase the need for cesarean delivery (number needed to harm = 56; RR = 1.63; 95% CI, 1.29 to 2.07; n = 18,861) and operative vaginal delivery (number needed to harm = 41; RR = 1.15; 95% CI, 1.01 to 1.33; n = 18,615), with no statistical decrease in fetal death or cerebral palsy.1 Continuous electronic fetal monitoring has also led to a 50% reduction in the incidence of neonatal seizure vs. structured intermittent auscultation, but this has no effect on long-term outcomes.1, Several adjuncts have been studied to overcome the high false-positive rate of continuous electronic fetal monitoring. 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). Determine whether accelerations or decelerations from the baseline occur. To learn what we do to deliver the best health and lifestyle insights to you, check out our content review principles.
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