06.04 Fetal Heart Monitoring (FHM)

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Overview

  1. Purpose: determine fetal well being by measuring FHR, fetal response to contractions.

Nursing Points

General

  1. Two kinds of monitoring
    1. External: noninvasive
      1. Monitor placed on mother’s abdomen over the fetal back
    2. Internal: invasive
      1. Requires rupture of membranes and mother to be dilated 2-3 cm
      2. Electrode placed under fetal scalp
  2. Reassuring vs. nonreassuring
    1. Reassuring – good, healthy fetal response
    2. Nonreassuring – Not okay, needs intervention and notify MD

Assessment

  1. What we’re assessing for (VEAL-CHOP mnemonic)
    1. Variability
      1. Variable decelerations→  Cord compression
        1. Abrupt decreases from cord compression
      2. Early decelerations→ Head compression
        1. Deceleration that occurs at the start of the contraction and returns to baseline at the end of the contraction, happens with head compression and is ok
      3. Accelerations→ oxygenated
        1. FHR increases, Oxygenated and good
      4. Late decelerations→ Placental insufficiency
        1. Deceleration that occurs after the start of the contraction, caused by fall in O2 to the fetus
  2. Nonstress test → 20 minutes of noninvasive fetal monitoring
    1. Reactive if there are 2+ accelerations in a 20 min period
      1. Desired outcome
    2. Nonreactive if less than 2 accelerations in a 20 min period
  3. FHR patterns to watch out for
    1. Bradycardia (< 110 for 10+ min)
    2. Tachycardia (> 160 for 10+ min)
    3. Late decelerations ( issues with placenta)
    4. Prolonged decelerations
    5. Hypertonic uterine activity (uterus not resting in between contractions, which decreases uterine circulation and therefore O2 supply to fetus)
    6. Absent or decreasing variability
    7. Variable decelerations lasting longer than 1 minute with a FHR less than 70
  4. We want accelerations and healthy variability
    1. Not acidotic

Therapeutic Management

  1. What to do when these abnormal  FHR’s occur
    1. ID cause
      1. Prolapsed cord
      2. Check mom’s vitals for hyper/hypotension, fever
    2. Stop oxytocin, if infusing (this can worsen the nonreassuring pattern)
    3. Change mother’s position (preferably to left side-lying if not already there)
    4. Give oxygen at 8-10 L via face mask
    5. Prepare to initiate appropriate monitoring (i.e. internal monitoring)
    6. Notify provider of potential cause, interventions, mother and baby’s response and prepare for further potential intervention

Nursing Concepts

  1. Perfusion
  2. Safety
  3. Clinical Judgment

Patient Education

  1. Press button on the monitor when you feel the baby move during a NST
  2. Signs of infection for internal monitor

Reference Links

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Video Transcript

In this lesson I will explain when fetal monitoring is used, how to perform, and your role in monitoring.

There are two kinds of monitoring. There is external and internal. External is noninvasive and a monitor is placed over the fetal back on the mother’s abdomen. You can see in this image the fetus in the uterus. So here on the fetal back side of the uterus is where the external monitor would be placed. An internal monitor is invasive is placed under fetal scalp. It is called a fetal scalp electrode. This is a little wire placed under the fetal skin on the sculpt. These monitoring tools are going to assess the fetal heart rate which should be 110-160.
Now let’s look at some of this monitoring. So first let’s talk about what is happening on these monitor strips.There is a mnemonic I want to share with you to help. This is something known as VEAL-CHOP. The V stands for variable decelerations. This is when there are abrupt decreases in the fetal heart rate and occurs because of cord compression. That is the “C”. Next are early decelerations and these are associated with a contractions that cause head compression as we are close to delivery. These are normal and ok. For this the fetal heart rate will decrease when the contraction starts and return to baseline at the end. It is a mirror image. Accelerations is the “A” and means there is Oxygenation so this is good. The “L” is late decelerations and are bad. The “P” is placental insufficiency”. So this is associated with a contraction, caused by fall in O2 level. The heart rate drops after the start of the contraction.

A test that can be used to assess is the Nonstress test. This is noninvasive and is 20 minutes of monitoring. The testing results are either reactive or nonreactive. The mother will hit a button every time she feels the fetus move. The fetal heart rate should increase or accel with movement. Reactive occurs if there are 2 or more accelerations in a 20 min period. Nonreactive is when there is less than 2 accelerations in a 20 min period. This is not a good thing and shows that the fetus is not living in a healthy environment.

So what do we do when there is an abnormal fetal heart rate. We first want to figure out the cause. Is it a prolapsed cord? That occurs when the cord is delivered prior to the fetus. Never good! So for this the patient should be put either in trendelenburg or knees to chest as she is rushed to the operating room for delivery. Or is the reason from mom. Check mom’s vitals for hyper or hypotension or fever. If the mom is getting pitocin then it needs to be stopped. The fetus isn’t responding well to labor so we need to stop adding to the contractions. We need to change the mother’s position preferably to left side-lying if not already there. This will increase blood flow into the placenta. Oxygen can be given at 8-10 L via face mask. Even if maternal oxygen level is ok. The extra oxygen will flow to the baby and increase the fetal heart rate. We had a patient once that the physician broke the patient’s bag of water and the fetal head was not well engaged in the pelvis. Because of this the cord prolapsed because the head wasn’t there to act as a “cork” so the physician said she had the cord in her hand and she stayed at the foot of the bed holding the head off of the cord while the nurse put the patient with her knees to chest and several nurses rolled her emergently to the OR. The labor nurse became what we call the “mole” and put a sterile glove and sleeve on and switched places with the physician. The labor nurse has to remain in this position in between the patient’s legs lifting the head off the cord until it is delivered. So the baby was delivered in this case in under 8 minutes. It is very quick because it is emergent! Patients also have decelerations all the time and it can seem like you are in and out of their room all day. So the patient has a late decelerations and you constantly stop the pitocin, turn the patient and put oxygen on her. All sort of at the same time. Constant battle flip flopping to hopefully make the baby happy and tolerate labor. Sometimes unfortunately all of the flip flopping still ends with a c-section because the fetus cannot tolerate labor but have to always try.

Our education for this patient will just revolve around telling the patient to press the button when she feels the baby move during a non stress test. And any signs of infection for internal monitor. Infection is a risk anytime something from outside is entering the uterus.

Perfusion, safety, and clinical Judgment will be concepts for fetal monitoring. A good fetal heart rate shows that there is good perfusion through the placenta and to the fetus. Safety is involved because we need to ensure that there is a good fetal heart rate meaning that the fetus is safe in the uterus. And nurses have to make good clinical judgement to act fast if the heart rate is not in good range or reacting well to labor.
Our key points for review are that the monitoring can be invasive with a fetal scalp electrode or, noninvasive with an internal monitor. A non stress test is a way to look at fetal status and the heart rate should increase with movement. We should see 2 accelerations in 20 mins and rise for 15 BPM. If the fetal heart rate is not responding well to labor then we can turn, reposition, give oxygen, and stop the pitocin. We want to see accelerations and good variability.

Make sure you check out the resources attached to this lesson and review the mnemonic VEAL-CHOP.. Now, go out and be your best selves today. And, as always, happy nursing.

Read more

  • Question 1 of 10

A nurse is caring for a client who is in labor. The nurse has applied external fetal monitoring and notes that the baby’s heart rate is having late decelerations. Which of the following actions should the nurse perform? Select all that apply.

  • Question 2 of 10

A nurse is caring for a client who is in labor. The client has an external fetal heart monitor in place and the nurse is watching the baby’s heart rate. The nurse notes that the infants heart rate increases to 180 beats per minute and stays elevated for 10 minutes before returning to 140 bpm again. Which of the following nursing actions is most appropriate?

  • Question 3 of 10

While checking a fetal heart rate (FHR) on a pregnant client who is in labor, a nurse notes that the fetal heart rate slows below the baseline each time the mother has a contraction. By the end of the contraction, the FHR has returned to a normal rate. Which of the following best describes this phenomenon?

  • Question 4 of 10

A nurse is caring for a client who is in labor at the hospital. The nurse prepares to apply an external fetal monitor but the client is morbidly obese and the monitor does not fit well. What should the nurse do? Select all that apply.

  • Question 5 of 10

A nurse is caring for a patient who is in labor and who needs fetal heart monitoring. Which of the following is considered a non-reassuring sign seen during fetal heart rate monitoring? Select all that apply.

  • Question 6 of 10

The nurse is performing fetal heart monitoring (FHM) on a client who is 39-weeks along and has been in labor for 14 hours. Which of the following findings is the LEAST concerning?

  • Question 7 of 10

A nurse caring for a pregnant client is checking fetal heart tones using a Doppler stethoscope. Which of the following interventions would the nurse employ during this process? Select all that apply.

  • Question 8 of 10

A nurse is caring for a pregnant client in labor and notices the fetal heart rate has decelerations that start after the contraction starts. What are the priority nursing interventions at this time? Select all that apply.

  • Question 9 of 10

A pregnant client arrives to labor and delivery unit and the nurse places a fetal monitor on her. The fetal heart rate is assessed to be 123. What is the most appropriate action by the nurse?

  • Question 10 of 10

A nurse notes late decelerations on a fetal heart monitor. What possible situations could be causing this? Select all that apply

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