AWHONN Advanced
Fetal Monitoring
Course
Disclosure
The Instructors of this course report
either conflicts of interests or relevant
financial relationships, or lack thereof.
The nurse planners for this course
report no conflicts of interests.
Disclosure
The Instructors will be discussing an
off-label use of the medication
terbutaline but will not be discussing
the off-label use of any medical
devices.
Course Objectives
1. Describe physiologic principles of maternal and fetal
oxygen transfer and acid-base balance.
2. Identify physiologic principles underlying fetal heart
monitoring.
3. Describe concepts in antenatal testing including
analysis and interpretation of biophysical profiles
and complex antenatal fetal heart monitoring
tracings.
4. Relate physiologic principles to the goals and
interventions of antenatal testing.
5. Evaluate interventions for patients undergoing
antenatal testing.
Course Objectives (cont.)
6. Analyze fetal cardiac arrhythmia patterns
and describe outcomes associated with
these patterns
7. Analyze complex fetal heart monitoring
patterns utilizing current NICHD/ACOG FHM
terminology and categories
8. Apply perinatal risk management principles,
communication techniques and
documentation strategies related to complex
and challenging patient care scenarios.
Fetal Oxygenation
Maternal circulation
Uterine circulation
Placental circulation
Umbilical circulation
Fetus
Maternal Transfer of Oxygen to
Fetus
Transport from atmosphere to alveoli
Diffusion across alveolar membrane
Transport from lungs to placenta
Diffusion across the placenta
Transport from placenta to fetus
Diffusion into fetal tissues
Adapted from Meschia, G. (1979). Supply of oxygen to the fetus. J Reproductive Medicine, 23, 160.
Four Components of
Oxygen Transport
Oxygen content
Oxygen affinity
Oxygen delivery
Oxygen consumption
Maternal Oxygen
Transport
Maternal oxygen content:
The total amount of oxygen in the
maternal arterial blood
Amount of oxygen dissolved in plasma
(PaCo2)
Percent of oxygen carried on the
hemoglobin (SaO2)
Maternal Oxygen
Transport (cont.)
PaO2 helps bind oxygen molecules to
hemoglobin.
Saturated hemoglobin molecule
carries four molecules of oxygen.
SaO2 is a more precise measure of
oxygen content than PaO2
Maternal Oxygen
Transport (cont.)
Oxygen affinity:
Gain and release of oxygen
molecules from hemoglobin
Can change with variations in pH,
CO2 or maternal temperature
Reflected on oxyhemoglobin
dissociation curve
Maternal Oxyhemoglobin
Dissociation Curve
Maternal Oxygen
Transport (cont.)
Oxygen delivery:
Amount of oxygen delivered to the
tissues each minute
Two components are:
Oxygen content
Cardiac output
Maternal Oxygen
Transport (cont.)
Oxygen consumption:
Amount of oxygen consumed by the
body and tissues each minute
Interventions to Decrease
Maternal Oxygen Consumption
Promote maternal relaxation
Coach with helpful breathing techniques
Manage pain
Maintain acceptable uterine activity (in
some cases decreasing uterine activity)
Use antipyretics to reduce fever
Reposition the mother
Provide appropriate management of
second stage labor
Fetal Oxygen Transport
Includes oxygen content, affinity,
delivery, and consumption
Is directly dependent on maternal
oxygen transport
Is affected by:
Blood flow to the uterus and placenta
Integrity of the placenta
Blood flow through the umbilical cord
Fetal Oxygen Transport
(cont.)
Fetal oxygen content:
Amount of oxygen dissolved in
plasma (PaO2)
Amount of oxygen carried on the
hemoglobin (SaO2)
Fetal PaO2 is approximately 30 mmHg
Adult is 100 mmHg
Fetal Oxygen Transport
(cont.)
Fetal oxygen tension is bout 25% of
an adults
Fetal hemoglobin:
Has an increased oxygen affinity
Has a higher concentration than
maternal (approximately 17 gm/dL at
term)
(Freeman et al., 2003; Harvey & Chez, 1997)
Fetal Oxygen Transport
(cont.)
Fetal Circulation
Fetal Oxygen Transport
(cont.)
Fetal oxygen consumption:
Amount of oxygen consumed by the
tissues each minute
Fetal response to decrease oxygen
consumption:
Alteration in behavioral state
Decreased fetal movement
Change in variability
Change in reactivity
Fetal Response to
Decreased Oxygen
Redistribution of blood to vital organs
Oxygen consumption decreases:
Myocardium uses less oxygen
Changes in FHR
Aerobic to anaerobic metabolism
Aerobic vs. Anaerobic
Metabolism
Technology for Analysis of Fetal
Hypoxia
Fetal ECG analysis
ST-segment analysis
Definitions of Key Terms
Base deficit: HCO3 concentration
lower than normal
Base excess: HCO3 concentration
higher than normal
Academia: concentration of
hydrogen ions
in the blood
Acidosis: concentration of
hydrogen ions
in the tissue
Definitions of Key Terms
(cont.)
Hypoxemia: oxygen content in
blood
Hypoxia: level of oxygen in the
tissue
Asphyxia: Hypoxia, acidemia, and
metabolic acidosis
Neonatal Encephalopathy and
Cerebral Palsy
Neonatal encephalopathy:
A clinically defined syndrome of
disturbed neurologic function in the
earliest days of life in the term infant,
manifested by difficulty with initiating
and maintaining respiration, depression
of tone and reflexes, subnormal level of
consciousness, and often by seizures
(ACOG, 2003, p. 84)
Neonatal Encephalopathy and
Cerebral Palsy (cont.)
Four criteria define an acute
intrapartum event sufficient to cause
cerebral palsy
(ACOG, 2003 p. xviii):
Evidence of metabolic acidosis in
fetal umbilical arterial blood obtained
at delivery (ph <7 and base deficit
12 mmol/L)
Neonatal Encephalopathy and
Cerebral Palsy (cont.)
Criteria continued:
Early onset of severe or moderate
neonatal encephalopathy in infants
born at 34 or more weeks of
gestation
(ACOG, 2003)
Neonatal Encephalopathy and
Cerebral Palsy (cont.)
Criteria continued:
Cerebral palsy of spastic quadriplegic
or dyskinetic type
(ACOG, 2003)
Types of Cerebral Palsy
(CP)
Spastic Cerebral Palsy
Impacts 70-80% of individuals with CP
Characteristics by stiff muscles
Spastic quadriplegia, the most severe
form, is associated with mental retardation
Types of Cerebral Palsy
(cont.)
Athetoid/Dyskinetic
Impacts 10-20% of individuals with CP
Characterized by fluctuations in muscle
tone and uncontrolled movement
Associated with sucking, swallowing, and
speech impediments
Neonatal Encephalopathy and
Cerebral Palsy (cont.)
Criteria continued:
Exclusion of other identifiable
etiologies such as trauma,
coagulation disorders, infectious
conditions or genetic disorders
(ACOG, 2003)
Absence of Metabolic
Acidemia
Systematic Assessment
of FHR Tracings
Baseline rate
Variability
Periodic/episodic changes
Uterine activity
Pattern evolution
Accompanying clinical characteristics
urgency
NICHD FHR Interpretation System
Normal Fetal Acid-Base
Status: Well-Oxygenated
Fetus
All the following:
Baseline rate 110-160
bpm
Baseline variability
moderate
Late or variable decels:
Absent
Early Decels present or
absent
Accels: present or absent
Category I
Indeterminate:
Compensatory
Response
Examples:
Moderate variability with
recurrent late or variable
decels
Minimal variability with
recurrent variable decels
Absent variability without
recurrent decels
Bradycardia with moderate
variability
Prolonged decels and
Tachycardia
Category II
Abnormal Fetal AcidBase Status
Either:
Absent variability with:
Recurrent late decels, or
Recruuent variable decels,
or
Bradycardia
OR
Sinusoidal pattern
Category III
Managing Strategies
Tracing may evolve between categories
Category I:
Followed in routine manner
Category II:
Requires evolution, continued surveillance and
interventions guided by the clinical picture
Category III:
Requires prompt evaluation
Use interventions
Systematic Decision
Making
Includes:
Intrapartum goals
Ongoing assessment
Physiologic interventions
Clinical evaluation
JoAnn, 17 years old,
G1 P0, 40 5/7 Weeks Gestation
Family history: none provided
Medical history
Car accident one year ago; broken arm
and facial lacerations
Previous pregnancies: denies
Psychosocial history:
In an abusive relationship
Not in school
Not living with parents
JoAnn (cont.): Current
Pregnancy
Four prenatal visits; two different
providers
First trimester substance abuse
Current tobacco use
Normal prenatal lab values
JoAnn (cont.): Admission
Data
SROM 0655:
Large amount of pooling clear fluid
Fern positive
SVE: 1-2/80%/-1; cephalic
presentation
VS: BP 119/73, P 75, R 20, afebrile
JoAnn (cont.): 1005
JoAnn (cont.): 1640
JoAnn (cont.): 1640
JoAnn (cont.): 1715
Effects of Ephedrine
Maternal:
Cardiac output
Heart rate
Blood pressure
Fetal:
Tachycardia
FHR variability
Accelerations
JoAnn (cont.): 1800
JoAnn (cont.): 1925
JoAnn (cont.): 1938
JoAnn (cont.) Outcome
Cesarean birth with epidural
anesthesia
Male infant, 6 lb, 7 oz (2,920) grams)
Apgar scores 1/6/7
Moderate clot in uterine cavity,
partial abruption
Very thin nuchal cord x2
Grade III placenta with calcification
The Physiological Basis for
Advanced Fetal Heart Monitoring
Physiologic principles underlying
fetal heart monitoring
Advanced physiologic principles of
maternal and fetal oxygen transfer
and acid-base balance
Clinical decision making when
utilizing fetal heart monitoring.
