-Positive: Repetitive; persistent late decelerations, Decelerations with more than half of contractions, Not due to uterine hyperstimulation, -Negative Contraction Stress Test: Reassuring for fetal well being, Follow daily Fetal Kick Counts You scored 6 out of 6 correct. DR C BRAVADO (determine risk, contractions, baseline rate, variability, accelerations, decelerations, overall assessment) is a mnemonic that serves as a standardized tracing interpretation and reporting tool14 (Table 44,5,7,14,16,26). Which of the following steps are included in this intervention? Determine Risk (DR). Category I is defined by an FHR baseline of 110 to 160 beats per minute (bpm), moderate variability (six- to 25-bpm fluctuation in FHR from baseline), with no late decelerations (onset and nadir after peak of contraction, decrease of more than 15 bpm from baseline, likely uteroplacental insufficiency) and no variable decelerations (onset variable to contraction and slow [i.e., more than 15 seconds and less than two minutes] return to baseline, likely from cord compression) present5 (Figure 27). 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. 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. Questions and Answers 1. Electronic fetal heart rate monitoring (EFM) was first introduced at Yale University in 1958.1 Since then, continuous EFM has been widely used in the detection of fetal compromise and the assessment of the influence of the intrauterine environment on fetal welfare. The FHR tracing should be interpreted only in the context of the clinical scenario, and any therapeutic intervention should consider the maternal condition as well as that of the fetus. Prolonged. 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). Continuous electronic fetal monitoring is the continuous monitoring of fluctuations of the fetal heart rate (FHR) in relation to maternal contractions and is considered standard practice. -Positive Contraction Stress Test: Hasten fetal delivery. - When considering the effectiveness of Electronic Fetal Monitoring, it comes down to the experience and knowledge of the person identifying the tracings. 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. 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. A more recent article on intrapartum fetal monitoring is available. Quizzes 6-10. Which nursing intervention is necessary before a second trimester transabdominal ultrasound? Tracing patterns can and will change! The fetal heart rate tracing shows EITHER of the following: Sinusoidal pattern OR absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia. 6. 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. Patient Safety, Risk Management, and Documentation 11. 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). Am J Obstet . Abrupt increases in the FHR are associated with fetal movement or stimulation and are indicative of fetal well-being11 (Online Table B, Online Figure G). The nurse is reviewing a non-stress test (NST) and notes the following: FHR baseline of 120-130 bpm with increase in FHR noted to 150 for 15 seconds and an increase of FHR noted to 135 for 10 seconds over a 20 minute time frame. Uterine tachysystole is defined as more than five contractions in any 10-minute period, averaged over 30 minutes.2 Each normal uterine contraction causes a temporary decrease in uterine blood flow and fetal oxygenation, which is generally well tolerated.26,27 However, tachysystole increases the risk of acidosis.26,27 To correct tachysystole, physicians must reduce or stop uterine stimulants or add tocolytics.2,2729, Goals of intrapartum fetal monitoring include rapid identification and intervention for suspected fetal acidosis as well as reassurance and avoidance of unnecessary interventions in cases of adequate fetal oxygenation.4,26 Figure 1 provides an algorithm for suggested management.2,7,16,21,27,3033. Depending on your health status and your babys, nonstress tests (one to two times a week, if not daily) might be a good idea. -Monitoring for two 20-minute periods a. The nurse's best response is, b. Powered by. Non-reactive: 100-170 bpm C. 110-160 bpm D. 120-140 bpm 2. The effect of continuous EFM monitoring on malpractice liability has not been well established. Remember, the baseline is the average heart rate rounded to the nearest five bpm.120 125 130 135 140 FHT Quiz 2 Fetal Tracing Quiz Perfect! 7. -How? c) On the basis of your answers, is it desirable to have the resistance of the two 120 V loads be equal? Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! The nurse observes smooth, gradual decelerations to 135 bpm occurring with more than 50% of the contractions. 1. https://www.mayoclinic.org/tests-procedures/nonstress-test/about/pac-20384577 2023 National Certification Corporation. Structured intermittent auscultation is a technique that employs the systematic use of a Doppler assessment of fetal heart rate (FHR) during labor at defined timed intervals (Table 1).4 It is equivalent to continuous EFM in screening for fetal compromise in low-risk patients.2,3,5 Safety in using structured intermittent auscultation is based on a nurse-to-patient ratio of 1:1 and an established technique for intermittent auscultation for each institution.4 Continuous EFM should be used when there are abnormalities in structured intermittent auscultation or for high-risk patients (Table 2).4 An admission tracing of electronic FHR in low-risk pregnancy increases intervention without improved neonatal outcomes, and routine admission tracings should not be used to determine monitoring technique.6. Health care professionals play the game to hone and test their EFM knowledge and skills. Challenge yourself every tracing collection is FREE! -0-2: Deliver promptly, -Assesses fetal tolerance of stress Moderate. The workshop introduced a new classification scheme for decision making with regard to tracings. This is followed by occlusion of the umbilical artery, which results in the sharp downslope. A patient at 41 weeks' gestation arrives on the unit for labor induction. If any problems arise, reviews are done more frequently. Study with Quizlet and memorize flashcards containing terms like The nurse is caring for a patient in labor when repetitive late decelerations are noted on the external fetal monitor. The nurse's action after turning the patient to her left side should be: Applying oxygen per face mask at 8-10 L/min. Table 7 lists signs associated with variable decelerations indicating hypoxemia4,11,26 (Figures 9 and 10). The nurse's first action should be which of the following? Continuous monitoring of your babys heart rate is conducted during labor and delivery as well. If you want to see how you are doing overall, try the comprehensive assessment: The nurse understands that the primary intervention is to: The nurse notes that the fetal heart rate baseline is 120-130 with an increase in FHR to 145 bpm lasting 15 seconds. Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. Almost any stressful situation in the fetus evokes the baroreceptor reflex, which elicits selective peripheral vasoconstriction and hypertension with a resultant bradycardia. This alone is not predictive of fetal acidosis unless accompanied by decreased variability and/or absent spontaneous or stimulated accelerations.2,5. 04 November 2020 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. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. In 1991, the National Center for Health Statistics reported that EFM was used in 755 cases per 1,000 live births in the United States.2 In many hospitals, it is routinely used during labor, especially in high-risk patients. For more information on the use, interpretation and management of patients based on Fetal Heart Tracings check out the resources below. Presence of moderate fetal heart rate variability and accelerations with absence of recurrent pathologic decelerations provides reassurance that acidosis is not present. It means your fetus is neurologically responsive and doesnt have an oxygen deficiency. Health care professionals play the game to hone and test their EFM knowledge and skills. -Neither period yields adequate accelerations What is the baseline of the FHT for Twin A (Black)? Recurrent variable decelerations can be treated with amnioinfusion, the placement of isotonic fluids into the intrauterine cavity, with the same requirement and risks as the intrauterine pressure catheter and fetal scalp electrode mentioned previously.7 Amnioinfusion has been shown to reduce cord compression, leading to resolution of FHR decelerations (RR = 0.53; 95% CI, 0.38 to 0.74; n = 1,000) and lowering the likelihood of cesarean delivery (RR = 0.62; 95% CI, 0.46 to 0.83; n = 1,400).26,42. 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, Category II management should focus on first correcting reversible causes, including stopping uterotonic agents and placental fetal perfusion, through intrauterine resuscitation, Amnioinfusion has been shown to reduce cord compression, leading to resolution of FHR decelerations (RR = 0.53; 95% CI, 0.38 to 0.74; n = 1,000) and lowering the likelihood of cesarean delivery. 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. 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 decelerations show a symmetric gradual decrease in the FHR, which begins at the peak of each contraction and ends 10 to 15 seconds after the contraction has returned to resting baseline. The use of amnioinfusion for recurrent deep variable decelerations demonstrated reductions in decelerations and cesarean delivery overall. When continuous EFM tracing is indeterminate, fetal scalp pH sampling or fetal stimulation may be used to assess for the possible presence of fetal acidemia.5 Fetal scalp pH testing is no longer commonly performed in the United States and has been replaced with fetal stimulation or immediate delivery (by operative vaginal delivery or cesarean delivery). Fetal Tracing Quiz . A pseudosinusoidal pattern shows less regularity in the shape and amplitude of the variability waves and the presence of beat-to-beat variability, compared with the true sinusoidal pattern (Figure 11b). Contractions are classified as normal (no more than five contractions in a 10-minute period) or tachysystole (more than five contractions in a 10-minute period, averaged over a 30-minute window).11 Tachysystole is qualified by the presence or absence of decelerations, and it applies to spontaneous and stimulated labor. The baseline FHR is 135 bpm with moderate variability. You scored 6 out of 6 correct. The patient is having contractions every 4 minutes, each lasting 50 seconds. 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. Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. Fetal heart tracing is also useful for eliminating unnecessary treatments. While caring for a patient who is gravida 2 para 1 being induced for oligohydramnios, the nurse notices a pattern of recurrent abrupt decelerations down to 70 bpm with contractions lasting for 1 minute. Detection is most accurate with a direct fetal scalp electrode, although newer external transducers have improved the ability to detect variability. 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. 1. A woman has just received pain medication in labor. Intraobserver variability may play a major role in its interpretation. -2 points for each normal, 0 for abnormal, -8-10: Normal result ,Repeat BPP weekly All Rights Reserved. B. Any type of abnormality spotted in a fetal heart tracing could indicate an inadequate supply of oxygen or other medical issues. 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. Nonreassuring patterns such as fetal tachycardia, bradycardia and late decelerations with good short-term variability require intervention to rule out fetal acidosis. A scalp pH less than 7.25 but greater than 7.20 is considered suspicious or borderline. Turn off oxytocin (Pitocin) Typically performed in the later stages of pregnancy and during labor, fetal heart tracing results can say a lot about the health of your baby. (f) Comment on the agreement between the answers to parts (a) and (e). The descent and return are gradual and smooth. Although continuous EFM remains the preferred method for fetal monitoring, the following methodologies are active areas of research in enhancing continuous EFM or developing newer methodologies for fetal well-being during labor. They last for longer than 15 seconds. The EFM toolkit also offers EFM CE opportunities and C-EFM. Ordinarily, your babys heart beats at a faster rate in the late stage of pregnancy, when theyre especially active. Normal. -Try to get 3 uterine contractions within 10-minute period, -Absolute: Placenta Previa, Cerclage, Incompetent cervix Interpretation of intrapartum electronic fetal heart rate (FHR) tracings has been hampered by interobserver and intraobserver variability, which historically has been high [].In 2008, the American College of Obstetricians and Gynecologists (ACOG), the Society for Maternal-Fetal Medicine (SMFM), and the United States National Institute of Child Health and Human Development (NICHD . -Fetal muscle tone 2. Fetal scalp sampling for pH is recommended if there is no acceleration with scalp stimulation.11. Membranes have to be rupture in order to establish direct contact. -4: Suspect lack of adequate oxygen, If >36 wks: deliver, If < 36 wks: Lung Maturity Test The nurse understands that that if the woman has hypotension the fetal monitor tracing would indicate which of the following? This content is owned by the AAFP. 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. The NCC EFM Tracing Game uses NICHD terminology. Suppose the 4040 \Omega40 resistance in the distribution circuit is replaced by a 2020 \Omega20 resistance. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. -Fetal breathing movements 5. Select the answer that doesn't belong with the others: 5. Shows all of the following: -Baseline FHR 110-160 BPM. Most patients who undergo internal fetal monitoring during labor accept monitoring as a positive experience.6. See permissionsforcopyrightquestions and/or permission requests. Bradycardia in the range of 100 to 120 bpm with normal variability is not associated with fetal acidosis. Identify type of monitor usedexternal versus internal, first-generation versus second-generation. The resulting printout is known as a fetal heart tracing, which will be read and analyzed. A way to assess your babys overall health, fetal heart tracing is performed before and during the process of labor. What is the baseline of the FHT? The patient is being monitored by external electronic monitoring. 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. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow. The nurse is instructing a new staff nurse on reassuring FHR patterns. Copyright 2020 by the American Academy of Family Physicians. The presence of moderate variability and/or accelerations is predictive of a lack of fetal acidosis. Baroreceptors influence the FHR through the vagus nerve in response to change in fetal blood pressure. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine if the fetus has. The number of migratory animals (in hundreds) counted at a certain checkpoint is given by. 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. (SELECT ALL THAT APPLY). The periodic review includes ensuring that a good quality tracing is present and that abnormalities are appropriately communicated. Count FHR after uterine contraction for 60 seconds (at 5-second intervals) to identify fetal response to active labor (this may be subject to local protocols), Abnormal umbilical artery Doppler velocimetry, Maternal motor vehicle collision or trauma, Abnormal fetal heart rate on auscultation or admission, Intrauterine infection or chorioamnionitis, Post-term pregnancy (> 42 weeks' gestation), Prolonged membrane rupture > 24 hours at term, Regional analgesia, particularly after initial bolus and after top-ups (continuous electronic fetal monitoring is not required with mobile or continuous-infusion epidurals), High, medium, or low risk (i.e., risk in terms of the clinical situation), Rate, rhythm, frequency, duration, intensity, and resting tone, Bradycardia (< 110 bpm), normal (110 to 160 bpm), or tachycardia (> 160 bpm); rising baseline, Reflects central nervous system activity: absent, minimal, moderate, or marked, Rises from the baseline of 15 bpm, lasting 15 seconds, Absent, early, variable, late, or prolonged, Assessment includes implementing an appropriate management plan, Visually apparent, abrupt (onset to peak < 30 seconds) increase in FHR from the most recently calculated baseline, Peak 15 bpm above baseline, duration 15 seconds, but < 2 minutes from onset to return to baseline; before 32 weeks gestation: peak 10 bpm above baseline, duration 10 seconds, Approximate mean FHR rounded to increments of 5 bpm during a 10-minute segment, excluding periodic or episodic changes, periods of marked variability, and segments of baseline that differ by > 25 bpm, In any 10-minute window, the minimum baseline duration must be 2 minutes, or the baseline for that period is indeterminate (refer to the previous 10-minute segment for determination of baseline), The nadir of the deceleration occurs at the same time as the peak of the contraction, The nadir of the deceleration occurs after the peak of the contraction, Abrupt decrease in FHR; if the nadir of the deceleration is 30 seconds, it cannot be considered a variable deceleration, Moderate baseline FHR variability, late or variable decelerations absent, accelerations present or absent, and normal baseline FHR (110 to 160 bpm), Continue current monitoring method (SIA or continuous EFM), Baseline FHR changes (bradycardia [< 110 bpm] not accompanied by absent baseline variability, or tachycardia [> 160 bpm]), Tachycardia: medication, maternal anxiety, infection, fever, Bradycardia: rupture of membranes, occipitoposterior position, post-term pregnancy, congenital anomalies, Consider expedited delivery if abnormalities persist, Change in FHR variability (absent and not accompanied by decelerations; minimal; or marked), Medications; sleep cycle; change in monitoring technique; possible fetal hypoxia or acidemia, Change monitoring method (internal monitoring if doing continuous EFM, or EFM if doing SIA), No FHR accelerations after fetal stimulation, FHR decelerations without absent variability, Late: possible uteroplacental insufficiency; epidural hypotension; tachysystole, Absent baseline FHR variability with recurrent decelerations (variable or late) and/or bradycardia, Uteroplacental insufficiency; fetal hypoxia or acidemia, 2.

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