This pattern is sometimes called a saltatory pattern and is usually caused by acute hypoxia or mechanical compression of the umbilical cord. efm.com/fhm/files/quiz2.php?QiD=DCABCC 1/2Correct. External monitoring is performed using a hand-held Doppler ultrasound probe to auscultate and count the. Yes, and the strip is reactive. To learn what we do to deliver the best health and lifestyle insights to you, check out our content review principles. Baseline is calculated as a mean of FHR segments that are the most horizontal, and also fluctuate the least. Identify baseline fetal heart rate and presence of variability, both long-term and beat-to-beat (short-term). Fetal scalp sampling, which requires amniotomy, tests fetal pH for the presence of acidemia.16 However, because of a 10% inadequate sample rate and a prolonged sample-to-result time of 18 minutes on average, this test is rarely performed in the United States.20 Lactate fetal scalp sampling (direct measurement of lactate by a probe) is another option that boasts a sample-to-result time of two minutes; however, its use has not resulted in improved newborn outcomes.21 An internal real-time fetal pulse oximetry probe (similar to an intrauterine pressure catheter) may lower operative vaginal delivery rates during the second stage of labor but has no apparent effect on neonatal outcomes.22,23 Fetal electrocardiograms have also been studied because fetal acidosis can affect the ST interval. The EFM toolkit also offers EFM CE opportunities and C-EFM. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Determine Risk (DR). It may also be performed using an external transducer, which is placed on the maternal abdomen and held in place by an elastic belt or girdle. The nurse is instructing a new staff nurse on reassuring FHR patterns. 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. 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). Home. 10. It takes that professionals understanding of what the continuous tracings show to properly assess the fetal condition. 6. Statistical analysis included univariate analyses with Student T-test, one-way ANOVA, chi-square and Fisher exact test. Structured intermittent auscultation detects changes in FHR during contractions but not overall FHR variability (moment-by-moment fluctuations in FHR)4,5; therefore, continuous electronic fetal monitoring remains the more appropriate option in high-risk labor (Table 214,16,17). For example, fetuses with intrauterine growth restriction are unusually susceptible to the effect of hypoxemia, which tends to progress rapidly.4, A growing body of evidence suggests that, when properly interpreted, FHR assessment may be equal or superior to measurement of fetal blood pH in the prediction of both good and bad fetal outcomes.13 Fetuses with a normal pH, i.e., greater than 7.25, respond with an acceleration of the fetal heart rate following fetal scalp stimulation. Foremost, the entire fetal heart rate tracing requires evaluation, which includes assessing the uterine activity for tachysystole, presence or absence of variability, and accelerations. 1. T(t)=50+50cos(6t).T(t)=50+50 \cos \left(\frac{\pi}{6} t\right) . Delivery is indicated if tracing does not improve and acidemia suspected. This system can be used in conjunction with the Advanced Life Support in Obstetrics course mnemonic, DR C BRAVADO, to assist in the systematic interpretation of fetal monitoring. The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli. Internal is more accurate, measuring the beat to beat time since it has direct contact with the fetus. 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. Therefore, it is a vital clue in determining the overall fetal condition. Normal. INTRODUCTION. While caring for a patient in active labor at 39 weeks' gestation, the nurse interprets the FHR tracing as a Category III. Any written information on the tracing (e.g., emergent situations during labor) should coincide with these automated processes to minimize litigation risk.21, Table 5 lists intrauterine resuscitation interventions for abnormal EFM tracings.9 Management will depend on assessment of the risk of hypoxia and the ability to effect a rapid delivery, when necessary. 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. All Rights Reserved. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Air Force, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. government. The baseline FHR is 135 bpm with moderate variability. Fetal heart rate (FHR) may change as they respond to different conditions in your uterus. A. The FHR is controlled by the autonomic nervous system. If the new rate is below 110 BPM, the pattern is considered a bradycardia. -Related to fetal movement Non-Reactive NST: Internal vs external. 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. If one of the following is detected during structured intermittent auscultation for a low-risk patient, switch to continuous electronic fetal monitoring to assess the National Institute of Child Health and Human Development category and to determine necessary clinical management: Fetal tachycardia (> 160 beats per minute for > 10 minutes), Fetal bradycardia (< 110 beats per minute for > 10 minutes), Recurrent decelerations following contractions (> 50% of contractions) or prolonged deceleration (> 2 minutes but < 10 minutes). The patient's labor has been normal to this point. These require attachment of fetal head electrodes; a recent randomized controlled trial and meta-analysis showed no improvement in neonatal outcomes or rates of operative or cesarean delivery.24,25, The National Institute of Child Health and Human Development terminology (revised in 2008) classifies continuous electronic fetal monitoring tracings using a three-tiered system and is the accepted national standard for continuous electronic fetal monitoring interpretation.5 Labor management depends on the continuous electronic fetal monitoring category and overall clinical scenario (Table 3).4,5,7, Interpretation of continuous electronic fetal monitoring tracings must include comments on uterine contractions, baseline FHR, variability (fluctuations in the FHR around the determined baseline during a 10-minute segment), presence of accelerations and/or decelerations, and trends of continuous electronic fetal monitoring patterns over time.2,5. 3/10/2017 Fetal Heart Tracing Quiz 10 Correct. Table 1 lists examples of the criteria that have been used to categorize patients as high risk. Fetal Tracing Quiz Please answer each question. Late. Discontinue oxytocin (Pitocin) infusion, if in use, 4. b. C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. After discussion regarding the FHR tracing, the resident and attending practitioner on duty determine that the FHR tracing is a Category II. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. Any type of abnormality spotted in a fetal heart tracing could indicate an inadequate supply of oxygen or other medical issues. Recurrent deep variable decelerations can be corrected with amnioinfusion. Your doctor analyzes FHR by examining a fetal heart tracing according to baseline, variability, accelerations, and decelerations. The nurse still interprets the FHR tracing as a Category III. Variable decelerations may be classified according to their depth and duration as mild, when the depth is above 80 bpm and the duration is less than 30 seconds; moderate, when the depth is between 70 and 80 bpm and the duration is between 30 and 60 seconds; and severe, when the depth is below 70 bpm and the duration is longer than 60 seconds.4,11,24 Variable decelerations are generally associated with a favorable outcome.25 However, a persistent variable deceleration pattern, if not corrected, may lead to acidosis and fetal distress24 and therefore is nonreassuring. When you've finished these first five, here are five more. 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). 90-150 bpm B. Every piece of content at Flo Health adheres to the highest editorial standards for language, style, and medical accuracy. The primary reason for evaluating alpha-fetoprotein (AFP) levels in maternal serum is to determine if the fetus has. Identify changes in the FHR recording over time, if possible. JAMES J. ARNOLD, DO, AND BREANNA L. GAWRYS, DO. If delivery is imminent, even severe decelerations are less significant than in the earlier stages of labor. The FHR baseline is 125 bpm. What is the baseline of the FHT? Your doctor uses special types of equipment to conduct electronic fetal monitoring. -Amount of amniotic fluid https://www.mayoclinic.org/tests-procedures/nonstress-test/about/pac-20384577 Beta-adrenergic agonists used to inhibit labor, such as ritodrine (Yutopar) and terbutaline (Bricanyl), may cause a decrease in variability only if given at dosage levels sufficient to raise the fetal heart rate above 160 bpm.19 Uncomplicated loss of variability usually signifies no risk or a minimally increased risk of acidosis19,20 or low Apgar scores.21 Decreased FHR variability in combination with late or variable deceleration patterns indicates an increased risk of fetal preacidosis (pH 7.20 to 7.25) or acidosis (pH less than 7.20)19,20,22 and signifies that the infant will be depressed at birth.21 The combination of late or severe variable decelerations with loss of variability is particularly ominous.19 The occurrence of a late or worsening variable deceleration pattern in the presence of normal variability generally means that the fetal stress is either of a mild degree or of recent origin19; however, this pattern is considered nonreassuring. FHR baseline of 120-130 with V shaped decelerations to 100 noted before and after contractions. The American College of Obstetricians and Gynecologists (ACOG), the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the Society for Maternal-Fetal Medicine developed a new three-tiered classification of fetal heart rate abnormalities and a system for interpreting these abnormalities (1). 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. If the cause cannot be identified and corrected, immediate delivery is recommended. 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). 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. The patient received an epidural bolus approximately 10 minutes ago. A new nurse is asking an experienced nurse about interpreting a Category III FHR tracing. What is the peak voltage across the 3.0F3.0 \mu \mathrm{F}3.0F capacitor? Turn mother to her left side, Family Health (BSN2) Exam Three Sherpath/Quiz, ANTEPARTUM AND POSTPARTUM COMPLICATIONS QUIZ-, Julie S Snyder, Linda Lilley, Shelly Collins, Volume 1, Chapter 11 Human Lifespan Develop. Nonreassuring patterns such as fetal tachycardia, bradycardia and late decelerations with good short-term variability require intervention to rule out fetal acidosis. Baseline Rate (BRA; Online Table B). 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. -2 points for each normal, 0 for abnormal, -8-10: Normal result ,Repeat BPP weekly The descent and return are gradual and smooth. Have you tested your EFM skills lately? Faculty, Students, State Boards & Volunteers. 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 during active labor.13 Continuous electronic fetal monitoring was developed for widespread use in the 1970s as a screening test for fetal hypoxia/acidosis during labor, specifically to reduce hypoxic-ischemic encephalopathy, cerebral palsy, and fetal death.13, Fetal acidemia (pH < 7.15) is most accurately diagnosed via umbilical cord arterial sampling immediately after delivery.46 Because fetal acidosis can affect autonomic control and therefore variability of FHR, continuous electronic fetal monitoring is considered a surrogate marker for measurement.2,7 However, the very low prevalence of cerebral palsy (antepartum events are most likely causative agents), hypoxic-ischemic encephalopathy, and fetal death has led to a false-positive rate of 99%3 for continuous electronic fetal monitoring and a low predictive value.810 Additionally, continuous electronic fetal monitoring is falsely positive for fetal acidosis two-thirds of the time, with low sensitivity (57%) and specificity (69%).1,3 Furthermore, user variability in interpretation is high, with agreement between experts only half the time.11,12, Continuous electronic fetal monitoring includes external and internal monitoring.7 External monitoring involves placement of two monitors (one for FHR and the other for contractions) against the maternal abdomen. Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. May 2, 2022. Prolonged decelerations (15 beats per minute drop below baseline for more than 2 and less than 10 minutes) Minimal variability. c. Reassure the family the finding is normal. Copyright 1999 by the American Academy of Family Physicians. a) lapilli can you recognize these strip elements? The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. Instruct the woman to drink 1 to 2 quarts of water. Additionally, an Apgar score of less than 7 at five minutes, low cord arterial pH (less than 7.20), and neonatal and maternal hospital stays greater than three days were reduced.22, Tocolytic agents such as terbutaline (formerly Brethine) may be used to transiently stop contractions, with the understanding that administration of these agents improved FHR tracings compared with untreated control groups, but there were no improvements in neonatal outcomes.23 A recent study showed a significant effect of maternal oxygen on increasing fetal oxygen in abnormal FHR patterns.24. 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). This alone is not predictive of fetal acidosis unless accompanied by decreased variability and/or absent spontaneous or stimulated accelerations.2,5. The NCC EFM Tracing Game uses NICHD terminology. 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). Decelerations (D). Powered by. A normal fetal heart tracing would reassure both you and your obstetrician that it's safe to proceed with labor and delivery. This variability reflects a healthy nervous system, chemoreceptors, baroreceptors and cardiac responsiveness. The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. Differentiate maternal pulse from fetal pulse, 4. Because these events have a low prevalence, continuous electronic fetal monitoring has a false-positive rate of 99%. Palpate for uterine contraction during period of FHR auscultation to determine relationship, 5. d) volcanic neck b) Recalculate the primary current, IpI _{ p }Ip. Collections are larger groups of tracings, 5 tracings are randomly. 5 contractions in 10 minutes averaged over thirty minutes Practice Quizzes 1-5. 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 Use a definite integral to find the number of animals passing the checkpoint in a year. Describe the variability. Perform a vaginal examination (check for cord prolapse, rapid descent of the head, or vaginal bleeding suggestive of placental abruption), 6. The patient is scheduled for an amniocentesis at 16 weeks gestation. Self Guided Tutorial. Correct. Theyll wrap a pair of belts around your belly. Rarely done because of risks and ability to evaluate fetus with other technology Electronic Fetal Monitoring Practice Questions, Chapter 24: Newborn Nutrition and Feeding, Chapter 1: 21st Century Maternity Nursing, Julie S Snyder, Linda Lilley, Shelly Collins, An Introduction to Community and Public Health, Denise Seabert, James McKenzie, Robert Pinger, Placebos, OTC meds, Herbals for Pharm exam 4, Final Exam Set 2: BP/RR/Temperature/Instillat. selected each time a collection is played. The purpose of initiating contractions in a CST is to. Copyright 2009 by the American Academy of Family Physicians. Other maternal conditions such as acidosis and hypovolemia associated with diabetic ketoacidosis may lead to a decrease in uterine blood flow, late decelerations and decreased baseline variability.23. Per the practitioner's order and the patient's request, the nurse has been monitoring the fetal heart rate by IA. Determine whether accelerations or decelerations from the baseline occur. A student nurse is placing a tocotransducer on a woman for electronic fetal monitoring. 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 . : Your doctor will explain the steps of the procedure. Recently, second-generation fetal monitors have incorporated microprocessors and mathematic procedures to improve the FHR signal and the accuracy of the recording.3 Internal monitoring is performed by attaching a screw-type electrode to the fetal scalp with a connection to an FHR monitor. Table 3 lists examples of nonreassuring and ominous patterns. The nurse's action after turning the patient to her left side should be: Applying oxygen per face mask at 8-10 L/min. Palpate the abdomen to determine the position of the fetus (Leopold maneuvers), 2. 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. 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. 8. Professionals using Electronic Fetal Monitoring in their practice should also take advantage of: The EFM Resources page with linked papers and articles including the NCC monograph Fetal Assessment and Safe Labor Management authored by Kathleen Rice Simpson, PhD, RNC-OB, CNS-BC, FAAN. A woman has just received pain medication in labor. Recurrent variable decelerations are frequently seen in association with maternal expulsive efforts in the 2nd stage of labor. Amnioinfusion for umbilical cord compression in the presence of decelerations reduced: fetal heart rate decelerations (NNT = 3); cesarean delivery overall (NNT = 8); Apgar score < 7 at five minutes (NNT = 33); low cord arterial pH (< 7.20; NNT = 8); neonatal hospital stay > three days (NNT = 5); and maternal hospital stay > three days (NNT = 7).

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