Essentials of fetal and uterine monitoring

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Contents
List of Reviewers
Introduction
Share Essentials of Fetal and Uterine Monitoring, Fifth Edition
Section 1: Systematic Assessment of the Pregnant Woman
	Systematic Assessment
		Initial Maternal/Fetal Assessment
	Leopold Maneuvers
	Estimate the Fetal Weight or Size and Palpate FM
	Evaluate the FHR by Auscultation
	Confirm Fetal Life
	Apply the Monitor
	ECG and EMG Signals
	Electromyography
	Determine the Presence of Fetal Well-Being
	Auscultation: Abnormal Findings
	Assess Maternal Vital Signs and Risk Factors
	Respiratory Rate
	Temperature
	Perform a Maternal Head-to-Toe Assessment
	Completing the Assessment
	Determine Fundal Height and Fetal Growth
	Determine Uterine Activity
	Determine the Presence of Labor and Status of the Membranes
	Placement of the TOCO
	Assess the Cervix
	Summary
	Questions
Section 2: The Paper Output and the Computer Image
	The Paper Output and the Computer Image
	The Paper Output
	The Computer Image
	Archiving
	Benefits and Limitations
	Read the Operator’s Manual
	Paper Speed
	Heat-Sensitive (Thermal) Paper
	U.S. FHR Grid
	International FHR Grid
	Grid Colors
	Review Question
	Loading the Paper
	Documentation
		Documentation When You Begin Monitoring
		Strip and Initial Documentation
	Number the Paper Tracing
	Testing the Fetal Monitor
	Manual Test of the Fetal Monitor
	The Clock
	Exercises
	Maternal Heart Rate
	Twin Monitoring
	Cross-Channel Verification
	Baseline Offset
	Documentation of Twins
	MHR Doubling and FHR Halving
	Maternal Accelerations
	Answers to Exercises
	Summary
	Questions
	References
Section 3: External and Internal Fetal Monitoring
	Ultrasound Technology
	Confirm Fetal Life
	Test the US Transducer
	Apply Coupling Gel
	First-Generation US Technology: Peak Detection
	First-Generation Monitor Sayings
	Autocorrelation
	US Principles
	Second-Generation Monitor Sayings
	US Transducer
	Automatic Gain Control
	Artifact
	Testing the Tocotransducer
	Noninvasive Monitoring of the FHR, MHR, and UA
	FSE and Reference Electrode
	Benefits and Risks of Spiral Electrode Use
	Dysrhythmias
	Artifact
	Leg Plate
	Determining the FHR
	Logic, ECG Artifact Elimination Switch
	ECG Plot
	Internal Monitoring of Uterine Contractions With an IUPC
	Intrauterine Pressures
	Extraovular Insertion
	Cable Offset
	Hydrostatic Pressure
	Elastic Recoil/Resting Tone
	Peak IUP
	IUPC Potential Risks
	Summary
	Questions
	References
	Recommended Reading
Section 4: Maternal Heart Rate Patterns
	Simultaneous FHR and MHR Monitoring
	Machine Doubling of the MHR
	Dual Monitoring
	Maternal Smart BP Feature
	Maternal Decelerations
	US Monitoring of the MHR and FHR
	Dual Monitoring to Enhance Situational Awareness
	Maternal Accelerations in the Second Stage of Labor
	Cross-Modal Processing and Cognitive Errors
	Summary
	Questions
	References
Section 5: Uterine Contractions
	Uterine Contraction Physiology
	Pacemakers
	Impulse Path
	Labor Contraction Features
		Effective Contractions That Facilitate Childbirth
	Difficult Labor (Dystocia) Features
	Labor Curve
	Fear Creates Ineffective, Frequent Contractions
	Ketones Decrease Effective Contractions
	Uterotonics Increase Contractions
	Characteristics of Contractions Frequency
	Duration
	Interval
	Resting Tone
	Assessment of Contractions
		Palpation
	Strength/Quality
	Fundal Pressure
	Peak IUP
	Intensity (Active Pressure)
	Equipment That Records UA
		Benefits of Using the TOCO
		The Meaning of Images Produced by the TOCO
	TOCO Limitations
	IUPC Indications
		Indications for Intrauterine Pressure Monitoring
	Montevideo Units
	Exercises
	MVUs and Fetal pH
	UA Waveforms
	Uterine Irritability
	Coupling
	Hyperstimulation
	Tachysystole
	Actions to Decrease UA
		IV Bolus to Decrease UA
	Terbutaline to Decrease UA
	Hypertonus
	Uterine Reversal
	Tetanic Contractions
	Exercises
	Answers to Exercises
	Summary
	Questions
	References
Section 6: Abnormal Uterine Activity
	Precipitate Labor
	Excessive UA
	Characteristics of XSUA
	Excessive Frequency of Contractions
	Hypercontractility
	Hyperstimulation
	Tachysystole
	Excessive Contraction Duration
	Skewed Contractions
	Coupling
	Excessive Contraction Strength
	Intrauterine Pressure Catheter
	Excessive Resting Tone
	Excessively Short Resting Intervals
	Hypotonic UA
	Hypertonic UA
	Constriction Ring
	Analysis of the Labor Curve (Partogram)
	The Fetal Cranium and Brain
	Brain Oxygen and Substrate
	Intracranial Pressure
	The Supratentorial Brain
	The Infratentorial Brain
	Tentorium Cerebelli and Falx Cerebri
	Spinal Cord
	Extracranial Pressure
	Variable Decelerations Related to Increased ICP
	Cerebral Blood Flow
	Cerebral Vascular Autoregulation
	Cerebral Perfusion Pressure
	Cerebral Critical Closing Pressure
	Caput
	Molding
	Skull Fracture and Lacerations
	Cerebral Energy and Oxygen Consumption
	Cushing Mechanism
	Cushing Reflex (Response)
	Cerebral Ischemic Encephalopathy
	Cranial Compression Ischemic Encephalopathy
	The Nursing Process to Optimize Maternal and Fetal Outcomes
		Assessment
	Nursing Diagnosis
	Plan of Care
	Actions in Response to Abnormal UA
	Summary
	Questions
	References
Section 7: The Baseline
	Systematic Review of the Fetal Heart Rate
	Systematic Review of Uterine Activity
	Baseline Level
	Normal Cycles of the Baseline
	Sinusoidal Pattern: Abnormal Cycles
	The Absence of Cycles
	Tachycardia
	Fetal Tachyarrhythmia
	Bradycardia
	Rising Baseline
	Falling Baseline
	End-Stage, Second-Stage, or Birth Bradycardia
	Wandering Baseline
	Agonal Pattern
	Terminal Bradycardia
	Actions in Response to an Agonal Pattern or Terminal Bradycardia
	Documentation of the Baseline
	Summary
	Questions
	References
Section 8: Baseline Variability
	Sine Wave, Cycle, Complex, Fluctuation, Oscillation
	Bandwidth, Amplitude, Range
	Categorize Variability (LTV)
	Five Categories of LTV
	Document Variability
	Variability (LTV) Physiology
	Absent Variability (LTV)
	Factors Related to Absent Variability (LTV)
	Prolonged Hypoxia and Fetal IUGR
	Possible Actions When Variability (LTV) is Absent
	Evaluate the Tracing, and Investigate the Duration of Absent Variability
	What Medications Were Administered?
	Find Accelerations and Decelerations
	Attempt to Evoke an Acceleration
	Apply a Spiral Electrode
	Intervene to Increase Fetal Oxygenation
	Notify the Provider
	Wandering Baseline With Absent LTV
	Minimal Variability (LTV)
	Physiology of Minimal LTV (3–5 BPM)
	Average LTV
	Physiology of Average LTV (6–10 BPM bandwidth/amplitude)
	Moderate LTV
	Physiology of Moderate LTV (11–25 BPM)
	Marked Variability (LTV)
	Physiology of Marked Variability (Marked LTV, Bandwidth/Amplitude > 25 BPM)
	Interventions to Optimize Fetal Perfusion and Oxygenation
	Hyperoxygenation Benefits
	Pathologic (True) Sinusoidal Pattern
		Cause(s)/Physiology of a Pathologic Sinusoidal Pattern
		Characteristics of a Pathologic Sinusoidal Pattern
		AVP (Antidiuretic Hormone)
	Benign Sinusoidal Pattern
	Sinusoidal Pattern: Suggested Actions
	Benign Sinusoidal Pattern: No Actions Required
	Exercises
	Answers to Exercises
	Summary
	Questions
	References
Section 9: Short-Term Variability
	Visualization of STV
	STV and the Ultrasound Transducer
	Acquisition of the Fetal ECG
	Measurement of Beat-to-Beat Variability
	Physiology of STV
		The Parasympathetic Nervous System: The Vagus
		The Sympathetic Nervous System
	Physiologic Significance of STV
	Documentation of STV
	Marked STV
	Exercises
	Actions in Response to Absent STV
	PACs and PVCs
	Sawtooth Pattern: Respiratory Sinus Arrhythmia
	Supraventricular Tachycardia
	Complete Heart Block
	Summary
	Questions
	References
Section 10: Accelerations
	Accelerations
	Acceleration Definition
	Acceleration Recognition Criteria
	Acceleration Types
	Spontaneous Accelerations and the Absence of Metabolic Acidosis
	Reactive Accelerations
	Reactivity
	Antenatal Accelerations
	Accelerations and the Preterm Fetus
	Prolonged Accelerations
	Uniform Accelerations
	Antepartal Acoustic Stimulation
	Intrapartal Acoustic Stimulation
	Intrapartal Accelerations
	Fetal Scalp Stimulation
	Accelerations Related to Fetal Brain Damage and Seizures
	The Loss of Accelerations Related to Fetal Brain Damage
	Summary
	Questions
	References
Section 11: Early Decelerations
	Recognition Criteria
	Physiology of Early Decelerations
	Early Decelerations and CPD
	Caput
	Molding
	Severe Head Compression and Injury
	Actions in Response to Early Decelerations
	Documentation
	Summary
	Questions
	References
	Recommended Reading
Section 12: Late and Spontaneous Decelerations
	Late Deceleration Recognition Criteria
	Physiology Related to Late Decelerations
		The Continuum From Hypoxia to Asphyxia
	Actions to Increase Fetal Perfusion and Oxygenation
	Evaluate Fetal Status
	Documentation
	Spontaneous Decelerations
	Summary
	Questions
	References
Section 13: Variable Decelerations and the Checkmark Pattern
	Composition of the Umbilical Cord
	Variable Decelerations
	Variable Deceleration Recognition Criteria
	Physiology of Shoulders and Physiology of Uniform Accelerations Related to Umbilical Cord Compression
	Physiology of Variable Decelerations Related to Umbilical Cord Compression
	Vagal Arrests
	Significance of Variable Decelerations
	The Frequency of Variable Decelerations
	The Shape of Variable Decelerations
	The Depth and Duration of Variable Decelera
	Moderate Variable Decelerations
	Severe Variable Decelerations
	Second-Stage Variable Decelerations
	Meconium
	Variable Decelerations Related to Fetal Cranial (Brain and Blood Vessel) Compression
	Antepartal Variable Decelerations
	Intrapartal Variable Decelerations
	Actions in Response to Variable Decelerations
	Reduce the Number of Contractions
	Administer Oxygen
	Avoid Pushing
	Short Umbilical Cord
	Artificial Rupture of the Membranes (AROM) Resulting in an Umbilical Cord Prolapse
	Tight Nuchal Cord and Shoulder Dystocia
	Documentation
	Checkmark Pattern
		Recognition Criteria
		Fetal Asphyxia as a Cause of a Checkmark Pattern and Fetal Seizures
	Actions in Response to a Checkmark Pattern
	Summary
	Questions
	References
Section 14: Prolonged Decelerations
	Prolonged Deceleration Definition
	Prolonged Deceleration Recognition Criteria
	Prolonged Deceleration Causes
	Physiology of a Prolonged Deceleration
	Neonatal Seizures
	Umbilical Cord Vessel and/or Head Compression
	Uteroplacental Insufficiency
	Maternal Seizure
	Antenatal Prolonged Decelerations
	Intrapartal Prolonged Decelerations During the First Stage of Labor
	Actions in Response to a Prolonged Deceleration
	Second Stage of Labor
	Actions in Response to a Prolonged Deceleration
	Act to Increase Fetal Perfusion and Oxygenation
		Decrease UA
		Change the Maternal Position to Maximize Cardiac Output and Uterine Perfusion
		Determine the Likelihood of an Imminent Vaginal Birth Versus a Need for a Cesarean Section
		Communicate With the Patient and the Obstetric Team
	Plan for Delivery
	Fetal Scalp Stimulation Is Not an Intervention
	Evaluate Fetal Status and Document
	Continue to Document
	Summary
	Questions
	References
Section 15: Fetal Hypoxia, Acidosis, and Asphyxia
	Antepartal Testing
	Prolonged Antepartal Fetal Hypoxia
	Spontaneous Decelerations
	Antepartal Fetal Tachycardia
	Prolonged Hypoxia and Total Asphyxia
	Monitoring Fetal Movement
	The High-Risk Intrapartum Patient
	Intrapartum Hypoxia, Ischemia, and Asphyxia
	Oxytocin Administration
	The Impact of Pushing on Fetal Acid–Base Balance
	Spontaneous Decelerations
		Acute Asphyxia During Labor
	Fetal Gasping
	Agonal Pattern
	Cord Blood Gases
	Collection of Umbilical Cord Blood
	Cord Blood Gas Results
	Base Excess
	Medical–Legal Implications
	The Standard of Care
	Negligence, Duty, Causation, and Damages
	Advocacy
	Chain of Command
	Summary
	Questions
	References
Section 16: Strip Evaluation and Categorization of Fetal Heart Rate Patterns
	Visual Inspection Precedes Categorization
	Visual Inspection: Strip Evaluation Exercises
	Answers to Strip Evaluation
		Strip 1
		Strip 2
		Strip 3
		Strip 4
		Strip 5
		Strip 6
		Strip 7
		Strip 8
		Strip 9
		Strip 10
	Category Systems
	Framing (Anchoring) Bias
	Confirmation Bias
	Optimize Outcomes
	Two-Category System
	Three-Category System
	FIGO Category: Normal
	FIGO Category: Suspicious
	FIGO Category: Pathological
	SOGC Category: Atypical Nonstress Test
	SOGC Category: Abnormal NST
	Five-Category System
	Summary
	References
Section 17: Fetal Monitoring Workshops Sponsored by the National Institute of Child Health and Human Development
	The NICHD Fetal Monitoring Workshop Nomenclature
	Years 1993 to 1997
	No Improvement in Agreement in Interpretation Using NICHD Nomenclature
	NICHD Workshop—2008
	NICHD Research Guidelines for Interpretation
	Bradycardia
	Tachycardia
	Short-Term Variability
	Baseline Variability
	Categories of Variability
	Categories of the FHR Pattern
	Sinusoidal Pattern
	Episodic and Periodic Changes
	Accelerations
	Early Deceleration
	Late Deceleration
	Limited Research Using the NICHD Nomenclature
	Peak-to-Nadir Lag Time
	Variable Deceleration
	Prolonged Deceleration
	Tachysystole
	Professional Bulletins—2009
	Issues Related to Category II
	Issues Related to Category III
	Tachycardia, Acute Chorioamnionitis, and Cerebral Palsy
	Summary
	Questions
	References
Section 18: Skills Validation
	Skills Validation Sheet for External Fetal Monitor Application
		Levels
	Skills Validation Sheet for Auscultation of Fetal Heart Rate and Palpation of Uterine Activity
		Levels
	Troubleshooting Electronic Fetal Monitor Equipment
		Levels
	Spiral Electrode (SE) Application
		Levels
	Fetal Monitor Scavenger Hunt
Glossary
Index