Give amnioinfusion for recurrent, moderate to severe variable decelerations, 9. 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. May 2, 2022. References. If delivery is imminent, even severe decelerations are less significant than in the earlier stages of labor. Normal. 1. Fetal heart tracing is also useful for eliminating unnecessary treatments. (f) Comment on the agreement between the answers to parts (a) and (e). It indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.24 It should be differentiated from the pseudosinusoidal pattern (Figure 11a), which is a benign, uniform long-term variability pattern. Are there accelerations present? C. Evaluate the patient's understanding of the monitoring methods and notify the practitioner. This web game uses NICHD terminology to identify tracing elements and categorize EFM tracings. b. apply a stressful stimulus to the fetus. Table 1 lists examples of the criteria that have been used to categorize patients as high risk. Recurrent variable decelerations are frequently seen in association with maternal expulsive efforts in the 2nd stage of labor. The practitioner has ordered continuous electronic monitoring, but the patient requests IA for the early part of labor. b) basalt plateau (They start and reach maximum value in less than 30 seconds.) 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). Baseline of 140 - 150 with decelerations to 120 noted beginning with the contraction and returning to baseline by the end of the contraction. What is the baseline of the FHT? This is associated with certain maternal and fetal conditions, such as chorioamnionitis, fever, dehydration, and tachyarrhythmias. Yes, and the strip is reactive. The baseline FHR is 135 bpm with moderate variability. A more recent article on intrapartum fetal monitoring is available. 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. A woman has just received pain medication in labor. https://www.ncbi.nlm.nih.gov/pubmed/19546798 On entering the room, the nurse sees the patient lying supine and notices that there has been abrupt slowing in the FHR to 90 bpm during the last two contractions, each episode lasting 30 seconds or less. The NCC EFM Tracing Game is just one of the valuable tools in this digital EFM toolkit. Obstetric Models and Intrapartum Fetal Monitoring in Europe NEW! 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. What is the peak voltage across the 3.0F3.0 \mu \mathrm{F}3.0F capacitor? Are contractions present? What is the baseline of the FHT? Table 4 lists recommended emergency interventions for nonreassuring patterns.4,14 These interventions should also be considered for ominous patterns while preparations for immediate delivery are initiated. The presence of at least two accelerations, each lasting for 15 or more seconds above baseline and peaking at 15 or more bpm, in a 20-minute period is considered a reactive NST. Management depends on the clinical picture and presence of other FHR characteristics.18, Overall Assessment (O). This content is owned by the AAFP. In the United States, an estimated 700 infant deaths per year are associated with intrauterine hypoxia and birth asphyxia.5 Another benefit of EFM includes closer assessment of high-risk mothers. 5 contractions in 10 minutes averaged over thirty minutes -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 Variability (V; Online Table B). -Positive Contraction Stress Test: Hasten fetal delivery. 3. A new nurse is asking an experienced nurse about interpreting a Category III FHR tracing. The nurse's first action should be which of the following? Increased variability in the baseline FHR is present when the oscillations exceed 25 bpm (Figure 2). -Accelerations my be present or absent. Hypoxia, uterine contractions, fetal head compression and perhaps fetal grunting or defecation result in a similar response. a) lapilli Fetal heart rate patterns are classified as reassuring, nonreassuring or ominous. Theyre empowered by these results to intervene and hopefully prevent an adverse outcome. "The test results are within normal limits.". The probe sends your babys heart sounds to a computer and shows FHR patterns. The key elements include assessment of baseline heart rate, presence or absence of variability, and interpretation of periodic changes. Health care professionals play the game to hone and test their EFM knowledge and skills. b. -Stress = uterine contractions Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing. Quizzes 6-10. Statistical analysis included univariate analyses with Student T-test, one-way ANOVA, chi-square and Fisher exact test. The experienced nurse tells the new nurse that a Category III FHR tracing may include which characteristic? We also searched the Cochrane Library, Essential Evidence Plus, and Clinical Evidence. Variable. Count FHR between contractions for 60 seconds to determine average baseline rate, 6. The fetal heart rate undergoes constant and minute adjustments in response to the fetal environment and stimuli. (SELECT ALL THAT APPLY), Baseline rate of 110-160 bpm Moderate variability. Collections are larger groups of tracings, 5 tracings are randomly. Presence of moderate fetal heart rate variability and accelerations with absence of recurrent pathologic decelerations provides reassurance that acidosis is not present. Your doctor can then take steps to manage the underlying medical problem. Category 1. Scroll down for another when you're done. 2. 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. If you have any feedback on our "Countdown to Intern Year" series, please reach out to Samhita Nelamangala at d4medstudrep@gmail.com. They resemble the letter U, V or W and may not bear a constant relationship to uterine contractions. Bradycardia of this degree is common in post-date gestations and in fetuses with occiput posterior or transverse presentations.16 Bradycardia less than 100 bpm occurs in fetuses with congenital heart abnormalities or myocardial conduction defects, such as those occurring in conjunction with maternal collagen vascular disease.16 Moderate bradycardia of 80 to 100 bpm is a nonreassuring pattern. https://www.acog.org/~/media/For%20Patients/faq015.pdf, Current version ( b) Recalculate the primary current, IpI _{ p }Ip. The nurse's action after turning the patient to her left side should be: Applying oxygen per face mask at 8-10 L/min. Powered by. Detection is most accurate with a direct fetal scalp electrode, although newer external transducers have improved the ability to detect variability. The nurse observes smooth, gradual decelerations to 135 bpm occurring with more than 50% of the contractions. 90-150 bpm B. Determine Risk (DR). Which of the following information should be included? No. The nurse notes a prolonged deceleration of the FHR to 80 bpm and begins intrauterine resuscitation. Postdate gestation, preeclampsia, chronic hypertension and diabetes mellitus are among the causes of placental dysfunction. Palpate the abdomen to determine the position of the fetus (Leopold maneuvers), 2. Compared with structured intermittent auscultation, continuous EFM showed no difference in overall neonatal death rate. Which of the following fetal heart responses would the nurse expect to see on the internal monitor tracing? Tachycardia is certainly not always indicative of fetal distress or hypoxia, but this fetal tracing is ominous. D. Determine the onset and end of each deceleration in relation to the onset and end of the contraction. 150 155 160 Interpretation of the FHR variability from an external tracing appears to be more reliable when a second-generation fetal monitor is used than when a first-generation monitor is used.3 Loss of variability may be uncomplicated and may be the result of fetal quiescence (rest-activity cycle or behavior state), in which case the variability usually increases spontaneously within 30 to 40 minutes.19 Uncomplicated loss of variability may also be caused by central nervous system depressants such as morphine, diazepam (Valium) and magnesium sulfate; parasympatholytic agents such as atropine and hydroxyzine (Atarax); and centrally acting adrenergic agents such as methyldopa (Aldomet), in clinical dosages.19. 7. Thus, it has the characteristic mirror image of the contraction (Figure 5). A patient is in active labor and is being continuously monitored with a fetal monitor. Baroreceptors influence the FHR through the vagus nerve in response to change in fetal blood pressure. A nurse is teaching a woman how to do "kick counts." The patient is being monitored by external electronic monitoring. For the letters on this figure, choose the likely cause of melting for Site B. While admitting a patient who is at 40 weeks' gestation, the nurse observes an FHR of 165 bpm with recurrent decelerations. Am J Obstet . DR C BRAVADO incorporates maternal and fetal risk factors (DR = determine risk), contractions (C), the fetal monitor strip (BRA = baseline rate, V = variability, A = accelerations, and D = decelerations), and interpretation (O = overall assessment). 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. Continuous EFM may adversely affect the labor process and maternal satisfaction by decreasing maternal mobility, physical contact with her partner, and time with the labor nurse compared with structured intermittent auscultation.7 However, continuous EFM is used routinely in North American hospitals, despite a lack of evidence of benefit. Notify your provider if the baby's movement slows down, The nurse explains to the student that increasing the infusion rate of non-additive intravenous fluids can increase fetal oxygenation primarily by, A pregnant woman's biophysical profile score is 8. selected each time a collection is played. d) volcanic neck The purpose of initiating contractions in a CST is to. et al. While caring for a patient in active labor at 39 weeks' gestation, the nurse interprets the FHR tracing as a Category III. Non-stress test PLUS -Monitoring for two 20-minute periods c) On the basis of your answers, is it desirable to have the resistance of the two 120 V loads be equal? Variability describes fluctuations in the baseline FHR, whether in terms of frequency, amplitude, or magnitude. The nurse notes that the fetal heart rate is 140-170 bpm and charts that the variability is which of the following? A term, low-risk baby may have higher reserves than a fetus that is preterm, growth restricted, or exposed to uteroplacental insufficiency because of preeclampsia. Identify pattern of uterine contractions, including regularity, rate, intensity, duration and baseline tone between contractions. 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 B. Reposition the patient, check blood pressure, and continue to monitor the FHR pattern. All Rights Reserved. a streams response to precipitation. Self Guided Tutorial. 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 . Non-Reactive NST: From this information, we wish to predict where the fringe for n=50n=50n=50 would be located. https://www.acog.org/Patients/FAQs/Fetal-Heart-Rate-Monitoring-During-Labor?IsMobileSet=false Copyright 2023 American Academy of Family Physicians. Your obstetrician reviews the fetal heart tracing at regular time intervals. -Moderate FHR variability. 2023 National Certification Corporation. distribution of tributaries influences Variability should be normal after 32 weeks.17 Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Fetal scalp sampling for pH is recommended if there is no acceleration with scalp stimulation.11. Baseline Rate (BRA; Online Table B). 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. The searches included systematic reviews, meta-analyses, randomized controlled trials, and review articles. Recurrent deep variable decelerations can be corrected with amnioinfusion. All Rights Reserved. She asks the nurse to explain the results. 140 145 150 155 160 FHT Quiz 1 Fetal Tracing Quiz Perfect! Practice Quizzes 6-10 - Electronic Fetal Monitoring. What should the nurse do in this situation? 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. 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. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. The nurse is caring for a patient in labor when repetitive late decelerations are noted on the external fetal monitor. Use a definite integral to find the number of animals passing the checkpoint in a year. Powered by. -Fetal Doppler: transmits small, high frequency sound waves that are reflected off of the fetal heart - measures heart rate -Normal fetal heart rate = 110-160 BPM Electronic Fetal Monitoring Determine whether accelerations or decelerations from the baseline occur. The nurse would chart this change in baseline as which of the following? Use a logarithmic transformation to find a linear relationship between the given quantities and graph the resulting linear relationship on a log-linear plot. Continuous electronic fetal monitoring was developed in the 1960s to assist in the diagnosis of fetal hypoxia during labor. A way to assess your babys overall health, fetal heart tracing is performed before and during the process of labor. 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. A. -Relative: Multiple Gestation, History of classic cesarean section, -Negative (Normal): Adequate contractions, No concerning rate changes with contractions (no late decelerations) The FHR baseline is 130 bpm with moderate variability. 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. 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. 140 145 Correct . Suppose the 4040 \Omega40 resistance in the distribution circuit is replaced by a 2020 \Omega20 resistance. Variable decelerations associated with a nonreassuring pattern, Late decelerations with preserved beat-to-beat variability, Persistent late decelerations with loss of beat-to-beat variability, Nonreassuring variable decelerations associated with loss of beat-to-beat variability, Confirmed loss of beat-to-beat variability not associated with fetal quiescence, medications or severe prematurity, Administer oxygen through a tight-fitting face mask, Change maternal position (lateral or knee-chest), Administer fluid bolus (lactated Ringer's solution), Perform a vaginal examination and fetal scalp stimulation, When possible, determine and correct the cause of the pattern, Consider tocolysis (for uterine tetany or hyperstimulation), Consider amnioinfusion (for variable decelerations), Determine whether operative intervention is warranted and, if so, how urgently it is needed, A blunt acceleration or overshoot after severe deceleration, Late decelerations or late return to baseline (. Strongly Predictive of normal acid-base status at the time of observation. The patient received an epidural bolus approximately 10 minutes ago. Powered by. A meta-analysis showed that if there is absent or minimal variability without spontaneous accelerations, the presence of an acceleration after scalp stimulation or fetal acoustic stimulation indicates that the fetal pH is at least 7.20.19, If the FHR tracing remains abnormal, these tests may need to be performed periodically, and consideration of emergent cesarean or operative vaginal delivery is usually recommended.15 Measurements of cord blood gases are generally recommended after any delivery for abnormal FHR tracing because evidence of metabolic acidosis (cord pH less than 7.00 or base deficit greater than 12 mmol per L) is one of the four essential criteria for determining an acute intrapartum hypoxic event sufficient to cause cerebral palsy.20, When using continuous EFM, tracings should be reviewed by physicians and labor and delivery nurses on a regular basis during labor. The patient's membranes ruptured 1 hour ago, and the fluid was clear. EFM Tracing Game. 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. The nurse understands that that if the woman has hypotension the fetal monitor tracing would indicate which of the following? About. Fetal tachycardia may be a sign of increased fetal stress when it persists for 10 minutes or longer, but it is usually not associated with severe fetal distress unless decreased variability or another abnormality is present.4,11,17. Adequate documentation is necessary, and many institutions are now employing flow sheets (e.g., partograms), clinical pathways, or FHR tracing archival processes (in electronic records). The main goal is to identify fetuses who are prone to injuries stemming from hypoxia (or a lack of oxygen for fetal tissues). A pattern of persistent late decelerations is nonreassuring, and further evaluation of the fetal pH is indicated.16 Persistent late decelerations associated with decreased beat-to-beat variability is an ominous pattern19 (Figure 7). 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. A more recent article on intrapartum fetal monitoring is available. to access the EFM tracing game and to take full advantage of all the resources available. T(t)=50+50cos(6t). Fetal monitoring. What should the nurse do next? Together with Flo, learn how fetal heart tracing actually works. A.True B.False According to the 2008 NICHD consensus report, the normal frequency of uterine contractions is which of the following? Relevant ACOG Resources. The Value of EFM Certification (One Team One Language), showcases the national PSA campaign Your Baby Communicates along with peer-to-peer video discussions on the value of EFM Board Certification. Do not automatically initiate continuous electronic fetal heart rate monitoring during labor for women without risk factors; consider intermittent auscultation first. -Amount of amniotic fluid The recommendations for the overall management of FHR tracings by NICHD, the International Federation of Gynecology and Obstetrics, and ACOG agree that interpretation is reproducible at the extreme ends of the fetal monitor strip spectrum.10 For example, the presence of a normal baseline rate with FHR accelerations or moderate variability predicts the absence of fetal acidemia.10,11 Bradycardia, absence of variability and accelerations, and presence of recurrent late or variable decelerations may predict current or impending fetal asphyxia.10,11 However, more than 50 percent of fetal strips fall between these two extremes, in which overall recommendations cannot be made reliably.10 In the 2008 revision of the NICHD tracing definitions, a three-category system was adopted: normal (category I), indeterminate (category II), and abnormal (category III).11 Category III tracings need intervention to resolve the abnormal tracing or to move toward expeditious delivery.11 In the ALSO course, using the DR C BRAVADO approach, the FHR tracing may be classified using the stoplight algorithm (Figure 19), which corresponds to the NICHD categories.9,11 Interventions are determined by placing the FHR tracing in the context of the specific clinical situation and corresponding NICHD category, fetal reserve, and imminence of delivery (Table 4).9,11, If the FHR tracing is normal, structured intermittent auscultation or continuous EFM techniques can be employed in a low-risk patient, although reconsideration may be necessary as labor progresses.2 If the FHR tracing is abnormal, interventions such as position changes, maternal oxygenation, and intravenous fluid administration may be used.
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fetal heart tracing quiz 10