FAL assessment J labor is extremely important fatal assessment involves the use of a fatal Monitor and this is the only way that nurses can actually know what is going on with the fetus by placing the mother as soon as possible on a fetal monitor so fetal monitoring is done during labor and it depends on the doctor's order it can be intermittent it can also be continuous so it depends on what is order please review the objectives to ensure that these objectives are met at the end of this particular topic also some of your exam questions can actually come from the objectives so feton monitoring is uh electronic fetal monitoring that's done it is important to note that it helps it's a valuable tool that helps with a visualization of the fetal heart rate and it is used over 80% it is used to monitor laboring patients years ago they used the fetoscope and a stetoscope but in 1970 the fetal monitoring was introduced and the hope is that it will reduce longterm neurological effects research is still continuing but the majority of laboring women have some form of fetal monitoring so the basic it helps to monitor the fetal heart heart rate and it also is able to indicate how baby is doing during labor also it can it's able to identify contractions it also helps to identify if the fetus is compromised so in in order to place the cables for the electronic fetal monitoring you have to do your leopol you have to identify what is at the funest of the uterus if it's a hard Rong Mass you know it's a head and baby it's lying in the breach presentation but if it's a soft wrong mass at the fundus you know that may is saic there are two types of um fetal monitoring external and internal fetal monitoring so the first one we're going to actually talk about is external fetal monitoring so in identifying what is going on with baby you have to be able to have at least the basic knowledge of reading the tracing so each box it's 10 seconds long and each highlighted lines that contain six boxes is 1 minute long so after doing the layer poles identifying what is the presentation then you go down the side if it's a smooth side then it's Baby's back and the bumpy side is going to be the small parts the upper and lower extremities and so you want to place the ultrasound which must have the transducer gel in order for the fetal heart rate to be transmitted onto the paper so you want to place it over the upper side if Mom is lying on her left then it'll be on the right and once you have identified how the baby is lying you can actually place the ultrasound on on the mom's abdomen so the first thing you need to identify is the Baseline and the Baseline the average the normal rate is 110 to 160 so the first thing that needs to be identified and you can do that in the first two to 3 minutes what the Baseline is once the line is on a steady number because the paper is calibrated up and so you'll see 110 120 130 all the way up so the first thing that is important to identify is is the basine within the normal limit which is 110 to 11 16 once that is established then the variability which is the irregular wave in regular waves or fluctuation of the heart rate there are four categories when it comes to the variability and the variability tells or indic indicates that baby's neurological system is intact so the varability it has four different classifications or characteristics and the variability is the fluctuation of the heart rate or the regular waves so it goes above the Baseline so the first one that you're going to identify and you need a 20 minute tracing to get the entire picture in terms of what is the fetus doing so the first 3 minutes or so you can identify only the Baseline and the normal Baseline is 110 to 160 the variability indicates if baby's neurological system is intact and the variability is The Irregular waves or fluctuation of the heart rate and so the first variability we're going to talk about is absent when there is no fluctuation and nobody wants to see that because it can indicate that the fetus is pass it's similar to the EKG you do not want to see a straight line so absent variability is not a good indication because we know the baby is probably not alive then the second type or Cor istic of variability is minimal and minimal can be identified when the wave waves the fluctuation of the heart rate goes as high as 5 beats above the Bas line so if the Baseline is 120s then minimal variability the heart rate will fluctuate or increase to at least five Beats above 120 so it goes up to 125 come back down it can go up by 1 two three or five beats so the minimal variability can be described as five 0 to five beats above the Baseline and that minimal variability can IND weate baby is probably taken a nap or if Mom was given narcotics so in taking report it is important to ask if the mother was given narcotics if the answer is yes then it's important to ask what time because every narcotic that is administered during labor or if T woman one that is pregnant is very short it's a small dose and it's very short acting so if no narcotics was given and baby is just taking a nap then you can reposition the mother or you use an acoustic stimulator it's a buzzer and the fetus in responding to the buz heart rate should increase so minimal variability you want to make sure that baby is doing well either sleeping or if not context was given you can reposition and use an acoustic stimulator to and the heart rate should increase to indicate if baby's neurological system is intact so you're looking for a positive response so we've done absent and minimal the third type of variability that every OB provider and nurse will like to see is moderate variability where the heart rate fluctuates 5 to 25 beats above the Baseline and it indicates that baby's neurological system is intact baby is doing well in the present environment so moderate variability is reassuring that baby is well very happy in the environment they're in so moderate variability again can be described as 5 to 25 FTS above the Baseline so if the Baseline is more 120 baby's heart rate can go 125 130 135 it's 5 to 25 beats above the Baseline where it fluctuates then the last one we're going to talk about is marked variability and this is when the heart rate goes above 25 beats per minute the significant is unclear they're still doing research but it indicates that baby could be very very happy so the four types of variability when it comes to the Fatal monitoring are absent where there is a straight line it is not a good indication nobody wants to see that then minimal variability when the heart rate fluctuates 0 to 5 beats above the Baseline mother rate is what is reassuring and that's when the heart rate fluctuates 5 to 25 beats above the Baseline and the last one it is marked variability and this is when the heart rate goes 25 beats or more above of the Baseline so remember the first thing you want to look at is the Baseline and the normal Baseline is 110 to 160 then the second thing you're observing for is the variability which tells us if baby's neurological system is intact it's working well then another reassuring characteristic of the fetal tracing are accelerations and acceleration is the definition is 15 beats above the Baseline for 15 at least it could be longer but at least 15 seconds and so accelerations are the baby's heart rate the Fatal heart rate goes 15 beats Above This Baseline and it stays up for at least 15 seconds before returning to the Baseline that gives additional reassurance that baby is doing well so three things you're looking for that will ass assure you that baby's neurological system is intact baby is doing great in their present environment are the Baseline 110 to 160 moderate variability where the heart rate fluctuates 5 to 25 minutes above the Baseline and accelerations where the heart rate increases at least by 15 bits above the Baseline and it stays increase or elevated for at least 15 seconds that gives additional reassurance that baby is doing great so now that you've had some of the definitions and characteristics in terms of what is being looked at when a fetal monitor is applied and the tracing is displayed so you look at the Baseline and we know it's calibrated up 110 to 160 is normal you're looking at the variability and you need at least a 10 to 20 minute tracing 20 minute to document 20 minutes you cannot document moderate variability with a 2 minute or 3 minute tracing so in order for you to document moderate variability you should you must have a 20 minute tracing so you're looking at the Baseline you're looking at the variability and you're looking to see if aels are present so that's the top line that you see on this paper the bottom line indicates uterine contractions and in order to measure the uterine in contractions we're still on external monitoring you have to place the Toco transducer on top of the fundus that's where contractions start that is how you going to measure it but in using an external monitor the Toco transducer you can only measure the frequency and the duration it does not measure the strength of the contraction you are required to palpate and in palpating you have to discuss this with your patient cuz not every pregnant woman wants to be touched during a contraction so in order for you not for you to note the strength of the contraction because the external monitor does not give you the strength you have to pile pate and you can use this analogy they say um mild contractions are as the tip of your nose moderate is as firm as your chin and strong you can compare it to your forehead so you palpate you know how strong it is and then you can use the analogy mild is as the tip of your nose form as strong as as um moderate is as your chin and strong is as your forehead so again the only way you're going to know the strength of the contraction with an external monitor is by palpating but it does give you the duration and the duration starts from the beginning of the contraction to the end of that same contraction so remember every little box measures 10 seconds so you're going to count from the time the contraction start 10 20 30 40 50 until it ends of that same contraction and it gives you the duration of the contraction how long did the contraction last for you can also measure the frequency and in measuring the frequency it's the beginning of the contraction to the beginning of the following contraction so in measuring the frequency you start counting 10 20 30 40 50 60 70 18 19 100 10 20 so the beginning of the first to the beginning of the swollowing contraction and that gives you the frequency if it's 1 to 2 minutes apart two to three minutes so in order for you to know the frequency and talk documented you need a 10 minute tracing to do so so the external monitor we just reviewed it does require the ultrasound which needs the gel the transducer gel so that the heart rate can be transmitted to the paper and then the Toco transducer which is placed at the top of the fundus remember it does not measure the strength of the contraction you have to palate so that was the external monitor the internal monitor now it does require for the patient to be ruptured so the membranes whether spontaneously rupture or artificially done so you cannot Place internal monitor unless the patient is raptured the bag of waters is broken so that's the first thing and nurses cannot rupture patients it is practicing above your school so it has to be a provider so if the membranes are rupture depending on which state your practice iing for example if you're practicing in the state of Arizona as a nurse you are allowed to place an internal monitor which is known as a scalp electrode or a spiral electrode it is applied directly on the fetal head the bony prominence of the fetal head and it's able to measure the fetal heart rate it's a more effective measure measurement and so it is read the same way the Baseline the variability and if accelerations are present those are reassuring once they fall within the normal range so again the internal monitoring the membranes must be ruptured and it depends on the state you're practicing for example I I mentioned Arizona nurses are allowed to place internal scalp electrod in the state of New York they're not allowed so it is good to know your scope of practice depending on the state you're practicing in so the internal monitor for contractions is different it does require the in ic which is into uterine IC into uterine um catheter so the iupc is placed directly on top of the fundus and again in the state of Arizona only the providers are allowed to do so so the interuterine pressure catheter iupc is placed directly on the fundus on the uterus and only the providers are allowed to do so if you're practicing in the state of Texas nurses are allowed to do that but it is important whoever is plac in the iupc they must know what they're doing because you can easily puncture or rupture the uterus so it's very important that you know your scope of practice so the iupc the inter uterine pressure cetor is placed directly on top of the uterus def fundus this internal monitor can give you the exact strength of the contraction so you don't have to palpate if a patient has an iupc it gives you the exact strength and if you look on the paper it is calibrated like 0 five 10 15 20 so wherever the peak rests on of the contraction that's the strength of the contraction and so it is important to note the highest point which is called the peak of the contraction which line it is resting on and that is the strength of the contraction the duration is measured the same way and the frequency the same way as the external monitor with the iupc in place the doctors and nurses they can calculate what is called the multi units so the multi units measures the effectiveness or it measures the strength in terms of the contractions how is it calculating you have to look at the resting tone of the contractions and the resting tone when the contraction is completed the rest in tone allows baby to be resuscitated because during a contraction babies the fetus they squeezed and and so when the contraction is over they have an opportunity to resuscitate to slow down their heart rate get some oxygen and blood and so the resting tone is significant and to calculate the multi foro units the mvus you have to look at the peak of the contraction in a 10 minute tracing so for example if you have two contractions in 10 minutes and the highest point it got to is 50 that's the strength and then the resting tone is zero so two contractions they both peaked at 50 and the res in tone is zero so the mvus for that 10 minute tracing is going to be 100 so in being 100 it is not adequate enough to cause cervical dilation so the anticipated order will be that the doctor is going to order pin so that the mvus can get to 200 at least so if a mar is not Contracting adequately then it does affect cervical dilation multi units can only be calculated with an iupc in place and it does help the doctors in terms of knowing why is lab not progressing so if you have the envus equal in 100 then the anticipated order is going to be petosen to strengthen that contraction and to get the mvus to at least 200 so again to calculate the mvus you will have to get the peak of the contraction and the rest in tone and you need a 10 minute tracing so another example is if you have three contractions in 10 minutes one the first one peaked at 50 the resting tone was Zero the second one peaked at 60 but the res in tone is 10 you have to subtract the resting tone from the peak so the second contraction is going to be 50 even though the peak is 60 you have to subtract the res in tone which was 10 and then the last contraction you had at 70 but the rest in tone was 20 so you have to subtract 20 from 70 and that is going give you the peak so you'll have three contractions at 50 each 50 multip by 3 is 150 for the m v and the anticipated need will be that the doctor will order pin pin helps increase the strength and the frequency of contraction and it also helps in the progression of of Labor so the envus has to do with the peak and the resting tone the resting tone has to be subtracted from the peak and then you're able to calculate the mvus you also need a 10 minute tracing to be able to calculate the mvus so the Baseline for fetal monitoring is important to note it is from the normal range is 110 to 160 if the Baseline is above 160 then it indicates fetal Tachi cardia and one of the leading causes for fetal Tachi cardas maternal fever Brady Garder is if the Baseline is below 110 and one of the causes uh radi card could be cord fetal cord prolapse so it is important to note the Baseline of the fetal heart rate and this can be noted within 1 to 3 minutes so they are four categories of variability and variability is mentioned before it's actually the fluctuation of the heart rate that goes above the Baseline so the very first tracing there is no fluctuation detected so this is absent variability minimal the heart rate fluctuates 1 to 5 beats above the base line and minimal variability can be caused from mom being given narcotics or baby is just taken a app moderate variability which every provid and labor and delivery nurse will like to see is on the third C tracing and this is when the heart rate goes 6 to 25 beats above the Baseline Mark variability it's the heart rate increasing at least 25 beats above the Baseline there is no clinical significance but moderate variability [Music] does um gives assurance that baby's neurological system is intact baby is happy in the present environment sinusoidal pattern is you're unable to determine the Baseline and this is a Category 3 tracing when we talk about how the documentation for fetal monitoring is completed so sinus soidal the two main causes signus soidal it's either narcotics was given to Mom or fetal anemia severe fetal anemia so it means baby is the fetal is compromised it's not doing well and we have to rescue immediately in order to save the fetal life so accelerations are an Abrupt increase in the fetal heart rate at least 15 beats above the Baseline and it stays elevated for 15 seconds before returning to Baseline accelerations give additional reassurance that baby is doing well along with moderate variability it tells you that baby's neurological system is intact the fetus is happy in the current environment so we're going to look at decelerations and decelerations are the opposite to accelerations so these cells can be defined as a decrease in the heart rate 15 beats 15 beats below the Baseline and it stays down for 15 seconds before returning to Baseline so de accelerations are the opposite of accelerations and we have to intervene so these accelerations can be with or without contractions so periodic or episodic changes and the first one we're going to talk about is early decelerations early decelerations the characteristic is that it mirrors the contraction so when a contraction starts that's when the fetal heart rate decreases and it returns to Baseline when the contraction is completed so the deceleration early deceleration it mirrors the contraction this indicates that the fetal head is being compressed and it is uh early D cells nurses tend to be happy about if the patient is in labor because it tells you that the fetus is about to be born you still have to verify that the mother is completely dilated by doing a sterile vaginal exam and no cervix will be felt around the head so early these cells the characteristic it mirrors the contraction and it indicates head compression which is a good sign when a mother is in labor then the second Dell we're going to talk about is late decelerations and late decelerations are caused by utero placenta insufficiency so what is indicating is that the percenta is not working well and if the percenta is not working well then baby is deprived of oxygen and blood so the characteristics of late decelerations is that at the peak of the contraction the highest point of the contraction baby's heart rate starts to decrease and there is a slow return to Baseline after the contraction is completed I always encourage students to take a pencil ruler paper whatever and you want to measure when the heart rate when the fetal heart rate starts to decrease and if it's at the peak of the contraction the highest point of the contraction then it indic Ates that it is a late deceleration most times after late deceleration the variability is minimal because baby is deprived of oxygen and blood so late these cells we must intervene right away to save the fetal life then the next Dil we're going to talk about is fairy variable decelerations and a lot of students tend to get mixed up with variability and variable D cells with variable D cells it is an Abrupt onset and an Abrupt recovery to Baseline it can either be u v or W shaped and it indicates it's cord compression so the cord is being compressed and we must intervene as soon as possible to save the baby's life variable decelerations can occur with or without contractions so again variable D cells they are either V or w shape the it's an Abrupt onset in terms of decrease in the fetal heart rate with an Abrupt return to Baseline it can occur with or without contractions and it indicates that the cord the umbilical cord the fetal umbilical cord is being compressed and we must intervene to save the fetal life then the last deceleration we're going to look at is prolonged D cells the characteristics of prolonged D cells is that it the heart rate the fetal heart rate stays down for more than 2 minutes but less than 10 if it goes beyond 10 minutes then it indicates Brady card here so prolong deceleration the heart rate decreases and it stays down it stays de crease for less than 10 minutes so if we look at this tracing you can see the heart rate started decreasing and then it stays down but it goes back up after one two 3 4 minutes so it is less than 10 and we are required to intervene a lot of times prolonged D cell can indicate fetal descent so baby descended lower into the pelvic cavity so a easy way to remember when it comes to fetal monitoring is to use the the pneumonic ve chop so V in V stands to variable and we know that indicates cord compression the E stand so early and that indicates head compression accelerations are okay because it gives us additional reassurance that baby is doing well the fetus is happy in its present environment and late decelerations tells us something is not going well in terms of the procenta function and so to remember easily the acren the ne nomic ve chop can be used how do we intervene so it is important that we intervene using poison and poison is another nomic that helps in terms of intervention so p is a positional change so if the patient is lying on the right side you can reposition them to the left o is the oxygen which is given via face mask and it's 10 lers we cannot use a nasal can you look because it's 10 L that must be administered then I is to increase the ivy fluid so the patient can get a bolus and S is for sterile vaginal exam and O is to turn the PTO in off and N is to notify the physician and we're going to talk about this further along but those are some of the interventions that can be done when it comes to documentation it is standardized and so documenting category one everyone knows that is interpreting it what it means so there are three categories that are used the first category is category one the Baseline must be within the normal limit 110 to 160 for you to document category one and you need a 20 minute tracing to see the entire picture of the fetus what the fetus is doing to make that documentation so category one the Baseline is 110 to 160 the variability is moderate and this is when the heart rate fluctuates from 5 to 25 beats above the Baseline and there is no late or no variable decelerations accelerations can be present or absent it is still reassuring because of the moderate variability and early these cells are present if the patient is in labor so category one the tracing is reassuring it tells you it indicates that baby's neurological system is intact so document in category one anyone that's interpreting it knows that the Baseline is 110 to 160 the variability is moderate the accelerations are present or absent there is no late or variable decelerations so category one is reassuring category 2 now the Baseline can either be Brady cardic below 110 or it could be tacki cardic above 160 also the variability it could be minimal variability and you can have an absence of variability and there is Mark there is marked variable in terms of there is no marked variability so category two we know it's not reassuring because there is either Brady cardia or Taki cardia the variability could be absent also you can have variable desels or late deceleration so something is not right baby is not happy and we must intervene so Category 2 tells you that a tracing is not reassuring because there is a presence of either Brady cardia or tacki cardia or minimal variability or late D cells or variable D cells so category two is not reassuring and we must intervene category three now the sinusoidal tracing if it's present where the Baseline cannot be determined and as we've discussed before sinusoidal could either be caused by fetal anemia or narcotics and we must intervene right away so if there's a sinusoidal tracing it is a category 3 it is not reassuring and it requires stack intervention to save the fetal life also there could be absent variability along with recurrent late desels or recurrent variable decelerations so absent variability and either recurrent and when the term recurrent is used it means there are three or more episodes of late D cels variable D cels in a 10 minute tracing so absent variability with any one of those will automatically be a category three tracing that needs requires stat intervention so we've gone over the three categ ories in terms of documentation category one is reassuring category two is not reassuring category three is not reassuring and requires that intervention so it is important when you're going to document that you have a 20 minute tracing so that you can see the entire picture of what is going on with the fetus and as I mentioned earlier it's standardized anyone interpreting the documentation of category one knows that that tracing is reassuring so the management as I did mention earlier about poison how do we intervene so interventions includes poison which is an easy way to remember it doesn't mean that it has to be in the same order and a lot of times labor delivery nurses they work as a team and so you will have a lot of people coming into help so that they can see work together to save the fetal life so you want to reposition the patient give oxygen increase the IV fluid rate giving them Aus do a sterile vaginal exam turn the pin off if the patient is on pit document because in nursing if it's not documented it's considered not done and in Maternal Child Health the parents have 18 years to sue so you want to document well and of course notify the provider as to what is actually going on so poison is the acran or neonic that is um going to help you in terms of remembering how do you intervene so interventions other interventions include administering or giving an Amo infusion and an Amo infusion is simply give put in fluid back into the uterus the two indications of am infusion are oigo hydrus when the there is low fluid and this can be caus if the amtico is 300 Ms or less this can be caused from any defect in terms of the fetus having one artery and one vein so it tells you that there is some problem with the kidney and the Amo fluid volume is increased from the Fe urinating so if there is any issue with that then it is important to note that um there is going to be low fluid Amic fluid so oigo hydrus is an indication for administering a Amo infusion and Amo infusion is also used if there is variable decelerations so two indications are an AM infusion one for oligo hydrus where the TIC fluid is less than 300 and it can also be used in variable decelerations where we know that the umbilical cord is compressed so by putting fluid back into the uterus it can relieve that compression then other interventions includes giv tocolytics and the two most common tocolytics that are used in OB are magnesium sulfate which must always go on on a pump IV piggy bag and the antio calcium gluconate must be ordered so magnesium sulfate can be given and terbutaline terbutaline is never given Ivy push but it's given subcutaneously and it is important to note Mom's heart rate prior to administration because if the heart rate is greater is 140 or higher then terbutaline which is given subq or po never IV push cannot be administered because it increases the heart rate maternal heart rate forther so those are the two most used tocolytics how do tocolytics work they relax the smooth muscles of the UT and by relaxing the smooth muscle it helps baby to be resuscitated so documentation is important also documenting the contractions are important if you you have any questions please feel free to reach out to your course professor