This module provides concepts for nursing process interpretation of the FHR (fetal heart rate) characteristics. Interpretation includes the systematic analysis of collected assessment data necessary for collaborative diagnosis and intervention. Emphasis is placed on the physiologic basis of FHR characteristics found on electronic fetal monitoring tracings.
Much of the technology developed to improve perinatal outcomes focuses on indirect measures of fetal status because a direct examination of the fetus is difficult. Whether auscultated or electronically monitored, the fetal heart is the element that is most easily and frequently observed in fetal evaluation. Practitioners involved with interpreting FHR monitoring tracings agree on one aspect, that there is a lack of agreed upon reproducible definitions or terminology in clinical trails and clinical practice. That inconsistency challenges even the fetal monitoring experts.
Regardless of practice settings documentation whether on the tracing or in the medical record, reflects the standard of care provided. The more complete the documentation the higher the standard of care. The healthcare provider must be able to identify what is seen; understand the physiology of what is displayed and describe in consistent terms to other members of the healthcare team.
A. Uterine Activity – Clinicians should use consistent terms which have clearly defined meanings in order to “speak the same language” when communicating the interpretations of the FHR and uterine activity (UA) tracings.
Doubling: sometimes called “camel backs” is two contractions with the first contraction being longer and stronger than the second. The uterus rarely returns to resting tone and the interval between is usually less than 20 seconds. The interval between each set of contractions will be greater than 60 seconds.
Contractions are displayed in the UA channel on the tracing. Documentation of contractions may include frequency, duration, intensity and relaxation. Documentation should include the method of monitoring. More information can be obtained by a toco or IUPC than by palpation. The tracing is only one small but important part of the entire medical record. Although it was once thought that the tracing should be able to stand alone as evidence of labor events, thinking has changed. The tracing or strip provides limited evidence of events related to a woman’s care and the standard of practice. The nurse’s notes reflect assessment and observation, action, fetal and maternal responses and communications. Evidence of the standard of care provided should be found in the nurses' notes and need not be double-charted on the fetal monitor tracing. The nurses’ notes should provide enough information about the UA and FHR patterns that the tracing could be drawn if the strip were lost.
Assessment of UA might be documented in the nurses’ notes as follows:
Method of Assessment
UCs palpated q3 min X 60 sec, strong, uterus, soft between UCs.
Toco, UCs q 3-31/2 min X 60-80 Sec, strong, uterus soft between UCs
IUPC, UCs q 3-31/2 min X 60-80 sec, 75-85 mm Hg, rest, tone 20-25 mm Hg. (The ¯ reflects the peak IUP).
B. The Fetal Heart Rate
End-stage bradycardia or second stage bradycardia is a sustained drop of 15 to 30 bpm during the second stage of labor.It occurs in as many as 91% of fetuses. If end-stage bradycardia was preceded by a lack of accelerations, decreased variability or late decelerations, the fetus was Hypoxic. If there was thick meconium in the amniotic fluid prior to the second stage of labor, there is an increased risk of decreased variability, late decels, bradycardia and meconium aspiration syndrome. Therefore it is important to be prepared to intervene to improve fetal oxygenation or expedite delivery if hypoxia exists prior to the second stage of delivery.
Agonal pattern is the FHR of a decompensating fetus with a surge of catecholamines. The baseline is less than 100 beats per minute (bpm) with upward and downward swings that last 20 or more seconds and often precedes terminal bradycardia.
Terminal bradycardia is the FHR of a decompensated fetus with sinus node depression. The baseline is near 60 bpm and falling.
Stability - a well-oxygenated fetus should have short-term variability (STV), long-term variability (LTV), accels and a baseline level that fluctuates within a 25-bpm range. The baseline may flatten and rise over a period of minutes or hours. A rising baseline is abnormal and is usually a fetal response to infection or hypoxia. The baseline may abruptly or slowly drop. This happens in direct vagal response or in response to hypoxia. Abruption may cause an abrupt drop in the baseline. A smooth meandering baseline with absent STV and LTV is called wandering or unstable. It is ominous.
Early and late decels have clear physiologic implications: early decels are not related to hypoxia; late decels are related to hypoxia. Because of their clear significance, it is common to document “early decels” and “late decels” in addition to the rest of the systematic review.
Since variable decels vary in configuration, duration and depth, it is more common to use abbreviations to document a range of duration and depth. The duration and depth of variables should be described. For example, one variable decel might be documented as “variable decel X 25 sec. ¯ 90 bpm.”
It is appropriate to write on the tracing unless the tracing is copied onto an optical disk, in which case a computer keyboard is needed to make entries on the tracing. Circling or initialing heart rate changes such as decels is discouraged. If it is done it is essential that the interventions, which were immediately taken following the noted pattern, are also promptly recorded on the tracing or in the notes.
By circling a pattern, all eyes will focus on that aspect of the tracing particularly during retrospective review. This increases the potential of ignoring other important aspects of the tracing and makes it hard to be objective. JCAHO has suggested guidelines for charting in nurse’s notes should include the woman and/or her fetus’s needs, problems, capabilities and limitations; the nursing interventions and patient responses; and patient status at the time of transfer or discharge.
Below is a suggested list of items that may be documented on the strip:
In addition the notes should include the systematic review of FHR pattern and uterine activity; intake and output; and communications with the physician.
The importance of documentation on the patient’s medical record cannot be over emphasized. Adherence to standards of practice is essential and appropriate assessment; intervention and evaluation should be clearly documented. Nurses are cautioned against the use of terms such as “fetal distress,” ”fetal hypoxia,” or “uteroplacental insufficiency” in their charting because these terms are medical diagnosis.
Nurses should avoid the use of empty and meaningless charting phrases such as “physician notified of patient’s condition.” The chart should explain of what the physician was specifically notified (e.g. notified of ¯ B/P)
The overall goal of narrative medical record charting is to be accurate objective and free from editorial comment. A properly documented monitor strip should be able to stand alone with the information contained on it. However the medical record should also be able to stand alone.
Second-generation fetal monitors and some hand held Doppler devices use autocorrelation. It was determined that these ultrasound records “very closely” approach that of beat-to-beat variability (STV) generated from the scalp electrode. As long as you are using one of these second generation monitors you may document STV with an external toco.
When auscultation is used, the practitioner’s assessment is the sole source of information about the FHR. Careful listening and precise descriptions of auscultation findings can provide useful information of the status of the fetus. Auscultation detects:
Limitations exist with the auscultation method despite careful listening and descriptions of the FHR by practitioners. Auscultation does not:
Regardless of the practice setting all practitioners who work with fetal monitoring must know how their equipment works, what the information they receive means and how to convey that information to the rest of the healthcare team.
AWHONN Fetal Heart Monitoring Principles and Practice 2nd Edition
Kendall/Hunt Publishing Company. Dubuque (1993)
Murray, Michelle, Antepartal and Intrapartal Fetal Monitoring 4th Edition,
Learning Resources International Inc. Albuquerque (1997)
Tucker, Susan, Mosby’s Fetal Monitoring and Assessment 4th Edition,
St. Louis (2000)