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Table of Contents


1	A Brief History of Fetal Monitoring	1
	Historical Overview	1
	Randomized Trials of Electronic Fetal Monitoring	2
	Fetal Heart Rate Monitoring Research at the End of the Twentieth Century	4
	Fetal Assessment at the Beginning of the Twenty-First Century	4
2	Physiologic Basis for Monitoring	9
	Transfer of Oxygen from Environment to Fetus	9
	External Environment	10
	Maternal Lungs	10
	Maternal Blood	11
	Maternal Heart	12
	Maternal Vasculature	13
	Uterus	14
	Placenta	14
	Fetal Blood	19
	Umbilical Cord	20
	Fetal Response to Disrupted Oxygen Transfer	22
	Mechanisms of Injury	22
	Injury Threshold	23
	Summary	25
3	Instrumentation for Fetal Heart Rate and Uterine Activity Monitoring	28
	Auscultation of Fetal Heart Rate	28
	Description	28
	Leopold�s Maneuvers	30
	Frequency of Auscultation	32
	Documentation of Auscultated Fetal Heart Rate	33
	interpretation of Auscultated Fetal Heart Rate	33
	Benefits and Limitations of Auscultation	34
	Electronic Fetal Monitoring	35
	Overview	35
	Converting Raw Data into a Visual Display	37
	External Mode of Monitoring	39
	Ultrasound Transducer	39
	Tocotransducer	42
	Advantages and Limitations of External Transducers	45
	Internal Mode of Monitoring	45
	Spiral Electrode	45
	Intrauterine Pressure Catheter	49
	Advantages and Limitations of Internal Monitoring	51
	Display of Fetal Heart Rate, Uterine Activity, and Other Information	52
	Monitor Tracing Scale	54
	Monitoring Twins and Multiples	57
	Artifact Detection	58
	Troubleshooting the Monitor	58
	Telemetry	60
	Central Displays	62
	Computer-Based Information Systems	63
	Data-Input Devices	67
	ST Segment Analysis	69
4	Evaluation of Uterine Activity	73
	Assessment Methods: Palpation and Electronic Monitoring	73
	Palpation	73
	Electronic Monitoring	74
	Stages of Normal Labor	77
	Defining Normal Uterine Activity	77
	Defining Excessive Uterine Activity	79
	Common Underlying Causes of Excessive Uterine Activit	85
	Interventions to Decrease Excessive Uterine Activity	85
	Diagnosis and Management of Labor Abnormalities	85
	Latent Phase Abnormalities	86
	Active Phase Abnormalities	87
	Second Stage Abnormalities	88
	Uterine Activity and Oxytocin Use	88
	Summary	91
5	Pattern Recognition and Interpretation	95
	The Evolution of Standardized Fetal Heart Rate Terminology	95
	Evidence-Based Interpretation of Fetal Heart Rate Patterns	96
	National Institute of Child Health and Human Development Terminology: General Considerations	99
	Five Basic Components of a Fetal Heart Rate Tracing	701
	Terminology, Physiology, and Interpretation of Specific Fetal Heart Rate Patterns	101
	Baseline Rate	101
	Definition	101
	Physiology	103
	Categories of Baseline Rate	103
	Tachycardia	103
	Definition	103
	Interpretation	104
	Bradycardia	106
	Definition	106
	Interpretation	106
	Baseline Fetal Heart Rate Variability	107
	Definition	107
	Physiology	108
	Categories of Baseline Variability	109
	Absent Variability	109
	Minimal Variability	110
	Moderate Variability	112
	Marked Variability	113
	Sinusoidal Pattern	114
	Accelerations	114
	Definition	114
	Physiology	115
	Interpretation	115
	Decelerations	116
	Definition	116
	Physiology	116
	Late Decelerations	117
	Definition	117
	Interpretation	117
	Early Decelerations	119
	Definition	119
	Interpretation	120
	Variable Decelerations	121
	Definition	121
	Interpretation	121
	Prolonged Decelerations	123
	Definition	123
	Interpretation	124
	Patterns Not Defined by the National Institute of Child Health and Human Development	125
	�Wandering Baseline�	125
	�Lambda� Pattern	126
	�Shoulder(s)�	127
	�Checkmark� Pattern	128
	�End-Stage� Bradycardia and �Terminal� Bradycardia	128
	�Uniform� Accelerations	129
	�Atypical� Variable Decelerations	129
	�Good Variability within the Deceleration�	132
	Summary	134
6	Management of the Intrapartum Fetal Heart Rate Tracing	139
	Management	139
	General Considerations	139
	Fundamental Principles	140
	Evaluate the Fetal Heart Rate Tracing	141
	Evaluation of Five Essential Fetal Heart Rate Components	141
	A - Assess the Oxygen Pathway	142
	B - Begin Corrective Measures	142
	Supplemental Oxygen	143
	Maternal Position Changes	143
	Intravenous Fluid Administration	146
	Correcting Maternal Blood Pressure	146
	Reducing Uterine Activity	147
	Alter Second-Stage Pushing Technique	147
	Amnioinfusion	147
	Re-evaiuate Fetal Heart Rate After Corrective Measures	14f
	C - Clear Obstacles to Rapid Delivery	148
	D - Decision to Delivery Time	149
	Time Until Vaginal Delivery	149
	Time Until Possible Onset of Metabolic Acidemia	150
	Responding to Acute Events	150
	Other Methods of Fetal Monitoring	151
	Intrapartum Fetal Scalp pH Determination	151
	Fetal Scalp Stimulation and Vibroacoustic Stimulation	151
	Computer Analysis of Fetal Heart Rate	152
	Fetal Pulse Oximetry	152
	ST Segment Analysis	153
	Umbilical Cord Acid-Base Determination	154
	Approximate Normal Values for Cord Blood	154
	Types of Acidemia	155
	Summary	156
7	Influence of Gestational Age on Fetal Heart Rate	163
	The Preterm Fetus	163
	Baseline Fetal Heart Rate in the Preterm Fetus	164
	Periodic and Episodic Heart Rate Changes in the Preterm Fetus	164
	Behavior States in the Preterm Fetus	165
	Preterm Uterine Activity	165
	Tocolytic Agents and Effect on Fetal Heart Rate	168
	Monitoring the Preterm Fetus	169
	The Postterm Fetus	170
	Risks Associated with Postterm Pregnancy	171
	Intrapartum Management	172
	Summary	172
8	Fetal Assessment in Non-Obstetric Settings	176
	Emergency Services Department Assessment and Care	178
	Pregnant Trauma Victim Assessment and Care	181
	Maternal-Fetal Transport Assessment and Care	186
	Non-Obstetric Surgery: Maternal-Fetal Assessment and Care	186
	Surgery When Gestation is More than 24 Weeks	187
	Federal Law and Triage	188
	Summary	189
9	Antepartum Fetal Assessment	191
	Fundamental Determinations	191
	Contraction Stress Test and Oxytocin Challenge Test	193
	Interpretation and Management	193
	Advantages and Limitations	194
	Procedures for Contraction Stress Testing	194
	The Nonstress Test	196
	Interpretation and Management	197
	Advantages and Disadvantages	197
	The Biophysical Profile	198
	Interpretation and Management	T98
	Advantages and Limitations	199
	The Modified Biophysical Profile	200
	Interpretation and Management	200
	Advantages and Limitations	201
	Fetal Movement Counts	202
	Interpretation and Management	202
	Umbilical Artery Doppler Velocimetry	203
	Biochemical Assessment	203
	Amniocentesis for Feta! Lung Maturity	203
	Summary	206
10	Patient Safety, Risk Management, and Documentation	210
	Occurrence of Errors	210
	Human Error	211
	Prevention of Errors and Risk Reduction	214
	High-Reliability Perinatal Units	214
	Creating a Circle of Safety�	215
	Guidelines to Promote Safety and Reduce Risks	220
	Management of Risks and Adverse Outcomes	224
	Disclosure of Unanticipated Outcomes	225
	Elements of Malpractice	225
	Notification and Clinical Review	226
	Reporting of Sentinel Events	226
	Failure Mode, Effect, and Criticality Analysis	227
	Documentation	227
	Components of Care: Assessment, Communication, Documentation	229
	Documentation Issues Specific to Electronic Fetal Monitoring	232
	Electronic Medical Records and Information Systems	237
	Summary	241
Appendix A	Amnioinfusion	246
Appendix B	Selected Pattern Interpretations at 1 cm/min Paper Speed	249
	Glossary of Terms and Abbreviations	266