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. Fetal bradycardia (FHR less than 110 bpm for at least 10 minutes) is more concerning than fetal tachycardia, and interventions should focus on intrauterine resuscitation and treating reversible maternal or fetal causes (Table 62,5,7 and eFigure C). View questions only 3/10/2017 Fetal Heart Tracing Quiz 2 Correct. 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). Early decelerations are caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. 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. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. AMIR SWEHA, M.D., TREVOR W. HACKER, M.D., AND JIM NUOVO, M.D. It takes that professionals understanding of what the continuous tracings show to properly assess the fetal condition. Are there accelerations present? Continuous EFM reduced neonatal seizures (NNT = 661), but not the occurrence of cerebral palsy. 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. All Rights Reserved. Baseline Rate (BRA; Online Table B). Which of the following information should be included? What is the baseline of the FHT? The use of amnioinfusion for recurrent deep variable decelerations demonstrated reductions in decelerations and cesarean delivery overall. 2023 National Certification Corporation. Accelerations represent a sudden increase in FHR of more than 15 bpm in bandwidth amplitude. The FHR normally exhibits variability, with an average change of 6 to 25 bpm of the baseline rate, and is linked to the fetal central nervous system. Are contractions present? A normal fetal heart tracing would reassure both you and your obstetrician that it's safe to proceed with labor and delivery. Give intravenous fluids if not already administered; consider bolus, 7. to access the EFM tracing game and to take full advantage of all the resources available. Your doctor can then take steps to manage the underlying medical problem. -Daily Fetal Kick Counts Correct. None. Category III tracings have been associated with fetal hypoxia, acidosis, and encephalopathy.2,5,26,37, Fetal tachycardia (FHR of more than 160 bpm for at least 10 minutes) can be caused by maternal or fetal factors (Table 52,5,7 and eFigure B). EFM In-Depth. 5. Document in detail interpretation of FHR, clinical conclusion and plan of management. Health care professionals play the game to hone and test their EFM knowledge and skills. It is important to review the pressure tracing before assessing the fetal tracing to accurately interpret decelerations. What is the baseline of the FHT? Powered by. A patient is in active labor and is being continuously monitored with a fetal monitor. : -Monitoring for two 20-minute periods Baseline is calculated as a mean of FHR segments that are the most horizontal, and also fluctuate the least. Variable and inconsistent interpretation of tracings by clinicians may affect management of patients. On a drawing of the body locate the major body regions containing lymph nodes. Which of the following steps are included in this intervention? The NCC EFM Tracing Game is just one of the valuable tools in this digital EFM toolkit. The patient received an epidural bolus approximately 10 minutes ago. Category II tracings are indeterminate, are present in the majority of laboring patients, and can encompass monitoring predictive of clinically normal to rapidly developing acidosis. Cochrane review of low-quality evidence and practice guidelines from the American College of Obstetricians and Gynecologists, Guidelines, with one small disease-oriented randomized controlled trial and one Cochrane review focusing on tocolytics aspect of intrauterine resuscitation. 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. Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. 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. A normal fetal heart tracing would reassure both you and your obstetrician that its safe to proceed with labor and delivery. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. where ttt is time in months, with t=0t=0t=0 corresponding to July. You scored 6 out of 6 correct. -May have early decelerations. Fetal Tracing Quiz Please answer each question. You scored 6 out of 6 correct. Health care professionals play the game to hone and test their EFM knowledge and skills. NCC EFM Tracing Game. 4. Ominous patterns require emergency intrauterine fetal resuscitation and immediate delivery. Search dates: December 2018, July 2019, and March 2020. 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. Discontinue oxytocin (Pitocin) infusion, if in use, 4. -0-2: Deliver promptly, -Assesses fetal tolerance of stress 1. Management includes further investigation into and correction of possible stressors.14,33, Variable decelerations are recurrent when they occur with greater than 50% of contractions in any 20-minute period2,5 (Figure 57). Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. The main goal is to identify fetuses who are prone to injuries stemming from hypoxia (or a lack of oxygen for fetal tissues). is part of the free online EFM toolkit at. 150 155 160 Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. The experienced nurse tells the new nurse that a Category III FHR tracing may include which characteristic? et al. What Do Contractions Feel Like? 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. What is the baseline of the FHT for Twin A (Black)? The nurse observes smooth, gradual decelerations to 135 bpm occurring with more than 50% of the contractions. Evaluate recordingis it continuous and adequate for interpretation? C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. The nurse notes a prolonged deceleration of the FHR to 80 bpm and begins intrauterine resuscitation. Treat placental fetal perfusion through intrauterine resuscitation before proceeding to immediate delivery for all Category II or III tracings with concern for fetal acidosis. All rights reserved. Copyright 2023 American Academy of Family Physicians. Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! Category I tracings reflect a lack of fetal acidosis and do not require intervention. The organization's practice allows for IA if 1:1 nursing staff is available. -Fetal breathing movements Per the practitioner's order and the patient's request, the nurse has been monitoring the fetal heart rate by IA. What is the baseline of the FHT? The onset, nadir, and recovery of the deceleration usually coincide with the beginning, peak, and ending of the contraction, respectively.11 Early decelerations are nearly always benign and probably indicate head compression, which is a normal part of labor.15, Variable decelerations (Online Figure I), as the name implies, vary in terms of shape, depth, and timing in relationship to uterine contractions, but they are visually apparent, abrupt decreases in FHR.11 The decrease in FHR is at least 15 bpm and has a duration of at least 15 seconds to less than two minutes.11 Characteristics of variable decelerations include rapid descent and recovery, good baseline variability, and accelerations at the onset and at the end of the contraction (i.e., shoulders).11 When they are associated with uterine contractions, their onset, depth, and duration commonly vary with successive uterine contractions.11 Overall, variable decelerations are usually benign, and their physiologic basis is usually related to cord compression, with subsequent changes in peripheral vascular resistance or oxygenation.15 They occur especially in the second stage of labor, when cord compression is most common.15 Atypical variable decelerations may indicate fetal hypoxemia, with characteristic features that include late onset (in relation to contractions), loss of shoulders, and slow recovery.15. Starting with a high dose is a more effective way to kill cancer cells. Gene amplification in cancer cells has been shown to lead to resistance to cancer-killing medications when the dose of medication is increased gradually. A term, low-risk baby may have higher reserves than a fetus that is preterm, growth restricted, or exposed to uteroplacental insufficiency because of preeclampsia. Variability describes fluctuations in the baseline FHR, whether in terms of frequency, amplitude, or magnitude. While admitting a patient who is at 40 weeks' gestation, the nurse observes an FHR of 165 bpm with recurrent decelerations. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine if the fetus has. Powered by. Ultrasound assessment x 30 minutes This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Mucus plug: What is it and how do you know you've lost it during pregnancy? A. Continuous EFM may adversely affect the labor process and maternal satisfaction by decreasing maternal mobility, physical contact with her partner, and time with the labor nurse compared with structured intermittent auscultation.7 However, continuous EFM is used routinely in North American hospitals, despite a lack of evidence of benefit. Late decelerations are associated with uteroplacental insufficiency and are provoked by uterine contractions. If the cause cannot be identified and corrected, immediate delivery is recommended. A pattern of persistent late decelerations is nonreassuring, and further evaluation of the fetal pH is indicated.16 Persistent late decelerations associated with decreased beat-to-beat variability is an ominous pattern19 (Figure 7). Marked. 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). Determine Risk (DR). -Positive Contraction Stress Test: Hasten fetal delivery. To provide a systematic approach to interpreting the electronic fetal monitor tracing, the National Institute of Child Health and Human Development convened a workshop in 2008 to revise the accepted definitions for electronic fetal monitor tracing. 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. Periodic changes in FHR, as they relate to uterine contractions, are decelerations that are classified as recurrent if they occur with 50 percent or more of contractions in a 20-minute period, and intermittent if they occur with less than 50 percent of contractions.11 The decrease in FHR is calculated from the onset to the nadir of the deceleration. The nurse understands that this pattern is related to which of the following? -NST efm.com/fhm/files/quiz2.php?QiD=DCABCC 1/2Correct. Another area of interest is the use of computer analysis for key components of the fetal tracing,29 or decision analysis for the interpretation of the EFM tracing.30 These have not been demonstrated to improve clinical outcomes.29,30 Fetal pulse oximetry was developed to continuously monitor fetal oxygenation during labor by using an internal monitor, requiring rupture of membranes.31 Trials have not demonstrated a reduction in cesarean delivery rates or interventions with the use of fetal pulse oximetry.31. Variable. Fetal Assessment in Non-Obstetric Settings 9. Describe a hypothesis that explains these results. A.>6 contractions in 10 minutes averaged over twenty minutes B. This content is owned by the AAFP. What action by the student indicates to the registered nurse that the student understands the procedure? Table 1 lists examples of the criteria that have been used to categorize patients as high risk. The nurse is administering a contraction stress test and notes the presence of late decelerations corresponding to three contractions in a ten-minute period of time. They are the most commonly encountered patterns during labor and occur frequently in patients who have experienced premature rupture of membranes17 and decreased amniotic fluid volume.24 Variable decelerations are caused by compression of the umbilical cord. Monochromatic light of wavelength \lambda is incident on a GP pair of slits separated by 2.40104m2.40 \times 10^{-4} \mathrm{~m}2.40104m and forms an interference pattern on a screen placed 1.80m1.80 \mathrm{~m}1.80m from the slits. d) volcanic neck -Try to get 3 uterine contractions within 10-minute period, -Absolute: Placenta Previa, Cerclage, Incompetent cervix B. distribution of tributaries influences Structured intermittent auscultation can be used for low-risk labor because it statistically decreases cesarean and operative vaginal delivery rates without increasing cerebral palsy or fetal death. The patient is being monitored by external electronic monitoring. 140 145 150 155 160 2. Assessments. Fetal heart tracing allows your doctor to measure the rate and rhythm of your little ones heartbeat. Challenge yourself every tracing collection is FREE! Turn the patient to the left side, stop the oxytocin infusion, and assess maternal vital signs. The electronic fetal monitor uses an external pressure transducer or an intrauterine pressure catheter (IUPC) to measure amplitude and frequency of contractions. The nurse will chart the variability as which of the following? The presence of a saltatory pattern, especially when paired with decelerations, should warn the physician to look for and try to correct possible causes of acute hypoxia and to be alert for signs that the hypoxia is progressing to acidosis.21 Although it is a nonreassuring pattern, the saltatory pattern is usually not an indication for immediate delivery.19. The normal range for baseline FHR is defined by NICHD as 110 to 160 beats per minute (bpm; Online Figure A). -Fetal muscle tone . Some clinicians have argued that this unproven technology has become the standard for all patients designated high risk and has been widely applied to low-risk patients as well.9 The worldwide acceptance of EFM reflects a confidence in the importance of electronic monitoring and concerns about the applicability of auscultation.10 However, in a 1996 report, the U.S. Preventive Services Task Force7 did not recommend the use of routine EFM in low-risk women in labor. The clinician and the patient with a low-risk pregnancy discuss the benefits of structured intermittent auscultation vs. continuous electronic fetal monitoring; patient agreement to structured intermittent auscultation is documented in medical record; labor team ensures appropriate nurse staffing (1:1), Labor nurse determines current fetal position and best location to place Doppler handheld probe (usually over the fetal back) with Leopold maneuvers; transabdominal ultrasonography (passive mode) can be used to identify the location of the fetal heart if manual palpation proves difficult, With one hand holding the probe in place, the other hand palpates the uterine fundus to detect maternal contractions, Following contractions, baseline fetal heart rate is assessed by counting the number of beats during a 30- to 60-second interval, For a minimum of 1 minute following contraction onset, fetal heart rate is reassessed at 6- to 10-second intervals to detect accelerations or decelerations in heart rate, American College of Obstetricians and Gynecologists, Association of Women's Health, Obstetric and Neonatal Nurses, At least hourly (< 4 cm cervical dilation), 15 to 30 minutes (4- to 5-cm cervical dilation), Any condition in which placental insufficiency is suspected, Maternal preeclampsia/gestational hypertension, Use of oxytocin (Pitocin) or other uterine stimulants for labor induction or augmentation. A.True B.False According to the 2008 NICHD consensus report, the normal frequency of uterine contractions is which of the following? Recurrent variable decelerations are frequently seen in association with maternal expulsive efforts in the 2nd stage of labor. Ordinarily, your babys heart beats at a faster rate in the late stage of pregnancy, when theyre especially active. The figure in the next column shows a graph of TTT. Normal. 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. Because these events have a low prevalence, continuous electronic fetal monitoring has a false-positive rate of 99%. The FHR is under constant variation from the baseline (Figure 1). Heres how to tell if youre experiencing them. Every 15 to 30 minutes in active phase of first stage of labor; every 5 minutes in second stage of labor with pushing, Assess FHR before: initiation of labor-enhancing procedure; ambulation of patient; administration of medications; or initiation of analgesia or anesthesia, Assess FHR after: admission of patient; artificial or spontaneous rupture of membranes; vaginal examination; abnormal uterine activity; or evaluation of analgesia or anesthesia, 1. A patient is in active labor with spontaneous contractions occurring every 2 minutes and lasting 90 to 100 seconds. Remember, the baseline is the average heart rate rounded to the nearest five bpm. Auscultation of the fetal heart rate (FHR) is performed by external or internal means. This content is owned by the AAFP. 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. What would be an appropriate next action by the nurse? Your doctor analyzes FHR by examining a fetal heart tracing according to baseline, variability, accelerations, and decelerations. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the FHR during a uterine contraction and for 30 seconds thereafter to identify fetal response. Moderate. -Moderate FHR variability. The reporting nurse states that the FHR baseline is 150 bpm with moderate variability, no decelerations are present, and episodic accelerations are occurring. The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. Therefore, it is a vital clue in determining the overall fetal condition. electronic fetal heart monitoring trivia quiz questions web mar 22 2022 questions and answers 1 according to awhonn the normal baseline fetal heart rate fhr is a 90 150 -Related to fetal movement All Rights Reserved. a. The clinical risk status (low, medium, or high) of each fetus is assessed in conjunction with the interpretation of the continuous EFM tracing. b. apply a stressful stimulus to the fetus. The fetal heart rate baseline increases 15 beats per minute after vibroacoustic stimulation. They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation.15 The presence of accelerations is considered a reassuring sign of fetal well-being. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended (Figure 6). -Accelerations my be present or absent. 5. Intraobserver variability may play a major role in its interpretation. 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. Differentiating between a reassuring and nonreassuring fetal heart rate pattern is the essence of accurate interpretation, which is essential to guide appropriate triage decisions. DR C BRAVADO incorporates maternal and fetal risk factors (DR = determine risk), contractions (C), the fetal monitor strip (BRA = baseline rate, V = variability, A = accelerations, and D = decelerations), and interpretation (O = overall assessment). A student nurse is placing a tocotransducer on a woman for electronic fetal monitoring. They resemble the letter U, V or W and may not bear a constant relationship to uterine contractions. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the. A. An increase in risk status during labor, such as the diagnosis of chorioamnionitis, may necessitate a change in monitoring from structured intermittent auscultation to continuous EFM. May 2, 2022. The true sinusoidal pattern is rare but ominous and is associated with high rates of fetal morbidity and mortality.24 It is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles per minute and an amplitude range of five to 15 bpm. Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. Prolonged decelerations (Online Figures K and L) last longer than two minutes, but less than 10 minutes.11 They may be caused by a number of factors, including head compression (rapid fetal descent), cord compression, or uteroplacental insufficiency. Most patients who undergo internal fetal monitoring during labor accept monitoring as a positive experience.6. 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). 2. Continuous EFM increased cesarean delivery rates overall (NNH = 20) and instrumental vaginal births (NNH = 33). -Stress = uterine contractions EFM Tracing Game. One hour later, the nurse notices that the FHR baseline is 145 bpm with minimal variability. How an individual's senses are elevated by arousing the central nervous system? Yes, and the strip is reactive.
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