Fetal Heart Rate Monitoring

Fetal monitoring is the way to displays the fetal heart rate (FHR). Fetal heart rate is monitored in relation to maternal contraction. The baseline FHR is measured between contraction and the normal FHR at term is 120-160 beats per minute. The device that monitors uterine activity can assess frequency, duration and intensity of contractions.

There are two types of fetal monitoring: external fetal monitoring and external fetal monitoring.

External Fetal Monitoring
It is noninvasive procedure and is performed using a tocotransducer or Doppler ultrasonic tranducer. The ultrasound transducer is placed over the area in which the fetal back is located and fasten with a belt. The tocotransducer is placed over the fundus of uterus where contractions feel stronger and fasten with a belt. This external fetal monitoring will allow the client to get position comfortably.


Internal Fetal Monitoring It is invasive procedure and requires rupturing of the membranes and the electrode is attached to the presenting part of the fetus. For being available of internal fetal monitoring, the mother must be dilated 2-3 cm.

FETAL HEART RATE PATTERN

Fetal Bradycardia:
The FHR is less than 120 beats per minute for 10 minutes of more

Fetal Tachycardia:
The FHR is greater than 160 beats per minute for 10 minutes or more.

Acceleration
Accelerations are temporary increases of FHR at least 15 beats greater than the baseline and lasting at least 15 seconds, reflect a responsive nonacidotic fetus. Acceleration may occur with fetal movement, uterine contraction, vaginal examinations, or when the fetus is in a breech presentation.

Early Decelerations
In early decelerations, the fetal heart rate is below baseline and return to the baseline by the end of the contraction. It usually occurs during contractions and not associated with fetal compromise and requires no interventions. A uniform shape and mirror image of uterine contraction are showed.

Late Decelerations
In late decelerations, the fetal heart rate looks similar to early deceleration but begin well after the contraction begins and return to baseline after the contraction ends. Late decelerations reflect impaired placental exchange or uteroplacental insufficiency. The intervention includes improving placental blood flow and fetal oxygenation by placing patient on side, administer oxygen by tight face mask, discontinue oxytocin (if any), hydration, and correct hypertension (if any).

Variable Deceleration
In variable decelerations, the fetal heart rate does not have the uniform appearance. Shape, duration and degree of FHR fall below baseline are variable. Variable decelerations are significant when the FHR repeatedly decreases to less than 7- beats per minutes and persists at the level for at least 60 seconds before returning to the baseline. The cause of variable decelerations is the conditions that restrict flow through the umbilical cord (compressed umbilical cord). Interventions include change position (trendelenburg may be helpful), discontinue oxytocin (if any), check for cord prolapsed or imminent delivery by vaginal exam, consider amnioinfusion, and administer 100% oxygen by tight face mask.

Breathing in Labor

Breathing technique during labor and delivery will promote relaxation and oxygenation.

FIRST STAGE LABOR BREATHING

Cleancing Breath
Each contraction begins and ends with a deep inspiration and expiration.

Slow Paced Breathing
It is used as long as possible during labor, and promotes relaxation

Modified Paced Breathing
Breathing is shallow and fast, and it is used when slow paced breathing is no longer effective.
Pattern Paced Breathing (pant blow)
After a certain number of breaths, the client exhales with a slight emphasis or blow, and then begins the modified paced breathing.


Breathing to Prevent Pushing
Encourage client to blow repeatedly using short puffs when the urge to push is strong.

SECOND STAGE LABOR BREATHING

Traditional Pushing
The client takes on or more cleansing breaths at the beginning of a contraction and then hold it, pushing as hard as she can for as long as possible. Then quickly exhales, takes another breath and pushes again, repeating the process until the contraction is over.

Other Pushing Methods
The client exhales small amounts of air through an open glottis during pushing.
The client pushes in short bursts only when the urge is strong instead of using prolonged expulsive efforts.

Leopold’s Maneuvers

Leopold’s Maneuvers are methods to determine position, presentation and engagement of fetus.

They will include:

1. Determination of what is in the fundus
2. Evaluation of the fetal back and extremities
3. Palpation of the presenting part above the symphysis, and
4. Determination of the direction and degree of flexion of the head.

How to Perform Leopold’s Maneuver

Before performing Leopold’s Maneuver, ask the mother to empty the bladder, warm hands, and apply them to the mother’s abdomen with firm and gently pressure.

First Leopold’s Maneuver:

1. It will determine which part of the fetus is in the fundus.
2. Place pals on each side of the upper abdomen and palpate around the fundus
3. You would feel a hard, round, movable object if the head is in the fundus
4. You would feel soft and have an irregular shape and are more difficult to move if the buttock is in the fundus

Second Leopold’s Maneuver:

1. Move hand downward over each side of the abdomen, applying firm, even pressure.
2. The fetus’s back which is a smooth, hard surface should be felt on one side of the abdomen.
3. The hands, feet, elbows, and knees which are as irregular knobs and lumps will be felt on the opposite side of the abdomen.

Third Leopold’s Maneuver:

1. It will determine fetal position
2. Place hand above the symphysis pubis
3. Bring thumb and fingers together and grasp the part of fetus between them that may be the head or the buttocks

Fourth Leopold’s Maneuver:

1. It is used in the late stage of pregnancy to determine how far the fetus has descended into the pelvic inlet.
2. Place hand on the sides of the lower abdomen close to the midline
3. Slide hands downward and press inward
4. If you have determined that the buttocks are in the fundus, then feel for the head
5. If you cannot feel the head, it probably has descended

Mechanism of Labor

There are eight classical steps in the normal mechanism of labor as following here:

Engagement

• This is also called lightening or dropping
• The fetus nestles into the pelvis

Descent

• This process starts from the time of engagement until birth and is assessed by the station.
• The fetal head undergoes as it begins its journey through the pelvis.

Flexion

• The fetal head’s nodding forward toward the fetal chest
• While descending through the pelvis, the fetal head flexes so that the fetal chin is touching the fetal chest. This functionally creates a smaller structure to pass through the maternal pelvis

Internal Rotation

• With further descent, the occiput rotates anteriorly and the fetal head assumes an oblique orientation. In some cases, the head may rotate completely to the occiput anterior position.

Extension

• It begins after the head crowns
• This means that the fetal chin is no longer touching the fetal chest.
• It enables the head to emerge when the fetus is in a cephalic position
• The extension of labor is completed when the head passes under the symphysis pubis and occiput and the anterior fontanel, brow, face and chin pass over the sacrum and coccyx and are over the perineum

Restitution

• After the head emerges, the fetal head becomes in a realignment

External Rotation

• The shoulder of fetus externally rotates after head emerging and restitution
  
• The shoulder is in the anteroposterior diameter of the pelvis.

Expulsion

• This is the birth of entire body.

Fetal Presentation

Fetal position is defined as designation of landmark of fetal presenting part (occiput, mentum, sacrum, scapula) to right or left, and anterior, posterior, or transverse portion of the woman's pelvis.

A three-letter abbreviation is used to describe the relationship of the presenting part to the maternal pelvis.

• Sides of presenting part facing in the pelvis are described as: R (right) or L (left).
• Landmarks of presenting part are described as: O (occiput, or head), S (sacrum), Sc (scapula, or shoulders), M (mentum, or chin).
• Directions of presenting part facing in the pelvis are descreibe as: A (anterior, or front), P (posterior, or back), or T (transverse).

The first and third letters relate to the pelvis, and the second letter relates to the fetus.


Common possible fetal presentations are :

VERTEX / OCCIPITAL PRESENTATION
LOA = Left Occipital Aterior
LOT = Left Occipital Transverse
LOP = Left Occipital Posterior
ROA = Right Occipital Anterior
ROT = Right Occipital Transverse
ROP = Right Occipital Posterior

FACE PRESENTATION
LMA = Left Mentum Anterior
LMT = Left Mentum Transverse
LMP = Left Mentum Posterior

BREECH PRESENTATIONS
LSA = Left Sacrum Anterior
LST = Left Sacrum Transverse
LSP = Left Sacrum Posterior


Here are images of fetal presentation :



click image to enlarge.

Labor: True and False

There are pleliminary events to labor :

• Backache
• Cervix becomes soft and effaced and may begin to dilate
• Braxton Hicks contraction increase
• Lightening or dropping
• Membranes may rupture spontaneously
• Vaginal secretions increase
• Urinary frequency increases
• Passage of mucous plug occurs
• Weight loss of 1 – 3 lb
• “Bloody show” occurs
• Mother has a sudden burst of energy

How to differentiate between true labor and false labor?

True Labor:

• Contractions are in the back and abdomen
• Contractions are regular with decreasing intervals
• Contractions increase over time and increase with walking, and little or no effect from sedation
• Cervical dilation and effacement are progressive

False Labor:

• Contractions are in lower abdomen
• Contractions are irregular with unchanging or increasing intervals
• Contractions remain the same, unaffected by, or decrease with walking and relieved by sedation
• No dilation or effacement or cervix

COMPLICATION OF PREGNANCY

ABRUPTIO PLACENTAE
Abruptio Placentae is premature detachment of a normally situated placenta. Patient with abruption placentae will have bleeding, abdominal pain, boardlike uterus, maternal hypotension and tachycardia and fetal distress. Nursing managements will include: bed rest, monitor bleeding and shock, monitor fetal heart rate continuously.

ECLAMPSIA
Complication with seizures between 20th week of pregnancy and first postpartal week. Eclampsia can be happened with or following pregnancy-induced hypertension. Management of eclampsia will include giving magnesium sulfate, frequently assess vital signs, restrict fluid intake hourly to a total of 125 mL/h, and urinary output should be at least 30 mL/h.

GESTATIONAL DIABETES
Gestational diabetes occurs in 3–6% of all pregnancies, and although it typically resolves after delivery, it increases the risk of maternal pyelonephritis and of certain congenital anomalies, and is often associated with polyhydramnios and fetal macrosomia, with resultant dystocia. Patient will have polyuria, polydipsia and polyphagia. Gestational diabetes can be diagnosed with 3 hours Glucose Tolerance Test after 100 grams load. Management: exercise, dietary management, insulin (if needed), monitoring of weight, and teach and to assess glucose monitoring and diet.


PLACENTA PREVIA
Placenta previa is the condition in which the placenta is implanted in the lower segment of the uterus, extending to the margin of the internal os of the cervix or partially or completely obstructing the os. Clinical sign of placenta previa is painless vaginal bleeding. Management: monitor maternal vital signs, bed rest, monitor fetal heart rate, and not performing vaginal examination if placenta previa is suspected.

GROUP B STREPTOCOCCAL INFECTION
It would be 10-30% of pregnant women are colonized which are asymptomatic. It is recommended screening by rectovaginal swab at 37 weeks of gestation.

PREGNANCY-INDUCED HYPERTENSION (PIH)
PIH is a syndrome of hypertension, edema, and proteinuria that can occurs after 20th week of pregnancy. This patient will have headache, blood pressure of 140/90 or greater, or an increase of 30 mm Hg systolic or 15 mm Hg diastolic at two readings and edema that not relieved by bed rest, proteinuria, weight gain above 2 lb / weeks, visual disturbance, and epigastric pain. Patient who has pregnancy-induced hypertension will be managed by bed rest, control blood pressure, antihypertensive medicines, monitor intake and output, daily weight, and check urine for protein.

HELLP SYNDROME
This is a type of severe preeclampsia involving hemolysis, elevated liver function, and low platelets. Patient should delivery soon.

PRETERM LABOR
Preterm labor is a labor between 20 and 37 weeks of gestation.