fetal monitoring

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of or pertaining to a fetus or to the period of its development.
fetal acoustic stimulation test a test used to assess fetal health in compromised pregnancies; a vibroacoustic stimulus such as an electronic artificial larynx is applied either externally or directly to the fetus and resultant fetal movements, cardioacceleration, and alterations in respiration are compared to those of normal fetuses.
fetal alcohol syndrome a group of symptoms characterized by mental and physical abnormalities of the infant and linked to the maternal intake of alcohol during pregnancy. Clinical manifestations, which can be present in varying degrees, include prenatal and postnatal growth deficiency, mental retardation, irritability in infancy, hyperactivity in childhood, microcephaly, short palpebral fissures, smooth philtrum, thin vermilion border of upper lip, small distal phalanges, and ventricular septal defects. Although the exact amount of alcohol consumption that will produce fetal damage is unknown, the risk and extent of abnormalities are most likely to be increased when the daily intake of pure alcohol exceeds 2 ounces. The periods of gestation during which the alcohol is most likely to result in fetal damage are three to four and a half months after conception and during the last trimester. Abstinence from alcohol during pregnancy is recommended.
fetal assessment determination of the well-being of the fetus; techniques and procedures include: (1) medical and nursing histories and physical examination of the mother, (2) assays of amniotic fluid obtained by amniocentesis, (3) ultrasonography, (4) chemical assessment of placental function, (5) electronic and ultrasonic fetal heart rate monitoring, and (6) chorionic villus sampling. Extensive and thorough assessment of the health status of the fetus is indicated when maternal characteristics, obstetrical complications, and familial and genetic factors place the fetus at risk.

Amniotic fluid assay is most often done to establish the diagnosis of a genetic disorder, to monitor the fetus sensitized against the mother's rh factor, or to determine fetal lung maturity. Cells floating in the amniotic fluid sample can be examined to detect genetic disorders caused by chromosomal abnormalities and to detect certain metabolic aberrations. neural tube defects such as spina bifida and anencephaly are detected by analyzing the amniotic fluid for alpha-fetoprotein (AFP). When an open neural tube defect is present, the amount of alpha-fetoprotein can be increased as much as eight times the normal value.

The amniotic fluid also can be assayed for bilirubin, an indicator of the severity of Rh incompatibility between maternal and fetal blood. Fetal lung maturity can be assessed by evaluating the presence of pulmonary surfactant, a phospholipid protein, in the amniotic fluid. In normal fetal development the production of surfactant, a substance essential to lung expansion and adequate ventilation after birth, begins at about the 22nd week of gestation; however, surfactant is not present in sufficient quantities until 35 to 36 weeks. Two of its principal constituents, lecithin and sphingomyelin, can be evaluated by measuring the lecithin-sphingomyelin ratio (L/S ratio) in a sample of amniotic fluid. In general, a ratio greater than 2:1 indicates that the fetal lungs are mature and the newborn infant is not likely to develop respiratory distress syndrome of the newborn.

Ultrasonography is a noninvasive technique helpful in diagnosing unusual fetal presentations, placenta previa, multiple pregnancy, and fetal abnormalities such as hydrocephalus and hydronephrosis. It also can be used to trace fetal growth by periodic measurement of the biparietal diameter of the head of the fetus, femur length, or head:abdominal circumference ratio.

Chorionic villus sampling is a technique by which a small sample is obtained from the fetal portion of the placenta by aspiration through the cervical canal. It can be used for diagnosis of genetic abnormalities as early as the first trimester.

Chemical assessment of the nutritive and respiratory functions of the placenta can be accomplished by determining the amount of the hormone estriol in the maternal blood or urine. Throughout gestation a normally functioning placenta produces increasing amounts of estriol, the precursors for the production of which are provided by the fetal adrenal glands. Thus, a normal estriol value in maternal blood or urine indicates that both the placenta and the fetus are healthy.

Fetal monitoring using either ultrasound or direct electronic monitoring equipment to measure fetal heart rate and uterine contractions and the nonstress test to evaluate fetal heart rate changes in response to uterine contractions and fetal movements are discussed under fetal monitoring.
fetal circulation the circulation of blood from the placenta to and through the fetus and back to the placenta. Fetal circulation can be traced as follows: The oxygenated blood is carried from the placenta to the fetus via the umbilical vein. About half of this blood passes through the hepatic capillaries and the rest flows through the ductus venosus into the inferior vena cava. Blood from the vena cava is mostly deflected through the foramen ovale into the left atrium, then to the left ventricle, into the ascending aorta and on to the head and upper body. The arterial oxygenation of this blood is approximately 25 to 28 mm Hg; thus the fetal coronary circulation and brain receive the blood with the highest level of oxygenation.

Deoxygenated blood from the superior vena cava flows into the right atrium, right ventricle, and then into the pulmonary artery. Because of high pulmonary vascular resistance, only about 5 to 10 per cent of the blood in the pulmonary artery flows to the lungs, the majority of it being shunted through the patent ductus arteriosus and then down the descending aorta. The PaO2 of the blood in the descending aorta is about 22 mm Hg.
Postnatal Changes. After birth the changes in circulation involve closure of three fetal channels, the ductus venosus, the foramen ovale, and the ductus arteriosus. The ductus venosus closes with the clamping of the umbilical cord and inhibition of blood flow through the umbilical vein. The foramen ovale functionally closes after the first few breaths as pressure within the left atrium rises above that in the right atrium. The ductus arteriosus constricts partly in response to higher arterial oxygen levels that occur after the first few breaths. Other postnatal changes include a decrease in pulmonary vascular resistance and a decrease in pulmonary artery pressure. These changes result in the transport of 100 per cent of the cardiac output from the right heart to the lungs for oxygenation and then to the left heart and thence to the aorta.
A simplified scheme of the fetal circulation. From Betz et al., 1994.
fetal monitoring continuous intrapartal monitoring of the fetal heart rate and uterine contractions for the purpose of reducing preventable fetal and neonatal death by more accurate diagnosis and correction of problems related to fetal distress during labor, such as compression of the umbilical cord or placental insufficiency.
Noninvasive (Indirect) Monitoring. The fetal heart rate is measured using the techniques of ultrasonography or phonocardiography. Evaluations of this kind provide good data on the fetal heart rate and, unlike direct fetal monitoring, can be used while the amniotic membranes are still intact and the cervix has not yet dilated. These techniques are easier to use than invasive techniques but do not provide information as accurate and precise as that obtained by direct monitoring.

The duration and relative strength of uterine contractions and the length of intervals between them can be measured externally by placing a tokodynamometer on the mother's abdomen at the site of greatest uterine activity. The force of contractions is displayed on a screen. Layers of fat in obese patients and restlessness of the mother interfere with precise external monitoring of uterine contractions. Therefore high-risk patients can be more effectively monitored by internal techniques.
Invasive (Direct) Monitoring. Invasive techniques of fetal and maternal monitoring require direct access to the fetus and amniotic sac via the vagina and dilated cervix. Direct electrocardiography of the fetal heart is accomplished by attaching an electrode to the fetal presenting part. Proper placement of the electrode makes the risk to the mother and fetus negligible, and the data obtained are extremely accurate. Direct monitoring of uterine contractions uses an intrauterine amniotic fluid catheter to measure intrauterine pressure changes.

Simultaneous monitoring of the fetal heart rate and uterine contractions is essential to accurate interpretation of events taking place within the uterus during labor. Patterns of a slowing heart rate (deceleration) or increase in rate (acceleration) are examined in the context of the phase of the contraction in which the change in rate occurs. For example, decelerations that take place early during uterine contractions may indicate compression of the fetal head, a normal and expected event. However, a deceleration occurring late in the contraction may indicate placental pathology and uteroplacental insufficiency, a very serious and life-threatening condition. However, maternal hypotension and uterine hypotonus, both of which can be alleviated or corrected, may also cause late deceleration.
Contraction Stress Tests:Oxytocin Challenge Test. The purpose of this test, which is usually not done before the 28th week of gestation, is to assess the respiratory function of the placenta; that is, to determine whether the placenta and fetus will be able to withstand the stress of repetitive contractions during labor, and if they cannot, when and how delivery of the infant should be carried out. It is indicated for high-risk mothers, such as those with diabetes, hypertensive disease of pregnancy, history of a previous stillbirth, or anything else affecting the health status of the fetus. The oxytocin challenge test should not be attempted if placenta previa is present or if the mother has had a previous delivery by midline-incision cesarean section.

Oxytocin is given to stimulate enough uterine contractions to provide a sample of fetal response and determine whether there is adequate placental respiratory reserve to maintain the fetus for the remainder of the pregnancy and through labor. Data from the recorded fetal heart rate patterns during contractions are used to assess the status of the fetus and to make decisions about either allowing the pregnancy to continue until the fetus is more mature, or intervening promptly to avoid severe and perhaps fatal stress on the fetus.

Prior to the administration of the oxytocin, the fetal heart rate is monitored for 30 minutes or more to determine baseline variability and fetal movement. Spontaneous movement of the fetus without oxytocin may mean it is not necessary. However, if there is no spontaneous movement, oxytocin is given in quantities sufficient to trigger three or four contractions.
Nipple Stimulation. This involves the application of warm, moist washcloths to the breasts, followed by 10 minutes of massaging and rolling of the nipples. If it is successful in inducing uterine contractions, it obviates the need for an oxytocin challenge test.
Nonstress Test. This test relies on spontaneous fetal activity rather than on oxytocin-induced fetal movement to assess fetal response to uterine contractions. If there is no spontaneous fetal activity, it may be elicited by external rubbing or gentle pressure on the mother's abdomen. Fetal heart rate is monitored externally and correlated with fetal activity. Acceleration of the heart rate can also be induced by vibroacoustic stimulation using an external source of sound such as an artificial larynx applied to the maternal abdomen over the fetal head. Increased confidence in the validity and accuracy of the nonstress test has led to its widespread use and, in many cases, its preference over the more time-consuming and often contraindicated oxytocin challenge test.
Accelerations and Decelerations. Periodic heart rate changes are evaluated in reference to a fetal “baseline” that is determined when there is no stress present. Deviations from the baseline occur in response to uterine contractions and fetal activity that affect fetal oxygenation and transfer of carbon dioxide.

Accelerations are transient increases of the fetal heart rate, occurring at the same time as uterine contractions and coming at anytime during labor. They may be the earliest indicators of fetal distress; however, without other abnormalities of fetal heart rate pattern, they are thought to be reassuring when in response to manipulation, stimulation, or fetal movement.

Decelerations are decreases in the fetal heart rate. The three types are early, late, and variable. Early deceleration is believed to be caused by fetal head compression. The fetal heart rate returns to the baseline at or before the end of the uterine contraction and is not associated with an abnormality. Late deceleration occurs after the uterus has begun to contract and may not cease with the contraction. It is an ominous sign of fetal distress, is believed to be caused by uteroplacental insufficiency, and is frequently associated with high-risk pregnancy and with maternal hypotension or uterine hyperactivity. Variable deceleration occurs at various times in relation to uterine contractions. It could be associated with umbilical cord compression and may be relieved by changing the mother's position.

Early signs that suggest fetal distress include irregularity and mild variable decelerations. Early signs of fetal compromise that are more ominous include further decreased variability, heart rate increased over baseline, and variable or late decelerations. Late signs of fetal distress include no variability, severe variable or late decelerations with minimal variability, bradycardia in relation to baseline heart rate, and a sinusoid pattern to the fetal heart rate.
External fetal monitoring. The heart rate of the fetus is evaluated, particularly in response to uterine activity or contractions. From Malarkey and McMorrow, 2000.


constant checking on a patient's condition, either personally or by means of a mechanical monitor.
acid-base monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of patient data to regulate acid-base balance.
biological monitoring examination of materials such as blood or urine that come from living organisms, to determine if there has been exposure to given chemical substances.
electrolyte monitoring in the nursing interventions classification, a nursing intervention defined as collection and analysis of patient data to regulate electrolyte balance.
electronic fetal monitoring: antepartum in the nursing interventions classification, a nursing intervention defined as electronic evaluation of fetal heart rate response to movement, external stimuli, or uterine contractions during antepartal testing.
electronic fetal monitoring: intrapartum in the nursing interventions classification, a nursing intervention defined as electronic evaluation of heart rate response to uterine contractions during intrapartal care.
fetal monitoring see fetal monitoring.
fluid monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of patient data to regulate fluid balance.
health policy monitoring in the nursing interventions classification, a nursing intervention defined as surveillance and influence of government and organization regulations, rules, and standards that affect nursing systems and practices to ensure quality care of patients.
hemodynamic monitoring see hemodynamic monitoring.
intracranial pressure monitoring see intracranial pressure monitoring.
invasive hemodynamic monitoring in the nursing interventions classification, a nursing intervention defined as the measurement and interpretation of invasive hemodynamic parameters to determine cardiovascular function and regulate therapy as appropriate.
neurologic monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of patient data to prevent or minimize neurologic complications.
newborn monitoring in the nursing interventions classification, a nursing intervention defined as the measurement and interpretation of the physiologic status of the neonate in the first 24 hours after delivery.
nutritional monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of patient data to prevent or minimize malnourishment.
quality monitoring in the nursing interventions classification, a nursing intervention defined as the systematic collection and analysis of an organization's quality indicators for the purpose of improving patient care.
respiratory monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of patient data to ensure airway patency and adequate gas exchange.
transcutaneous oxygen monitoring see transcutaneous oxygen monitoring.
vital signs monitoring in the nursing interventions classification, a nursing intervention defined as the collection and analysis of cardiovascular, respiratory, and body temperature data to determine and prevent complications. See also vital signs.

fetal monitoring

Obstetrics A general term which can refer to any maneuver used to evaluate the fetus' status during pregnancy–eg, measurement of heartbeat and visual examination of the amniotic sac; however, as used, FM usually refers to the use of electronic devices during L&D to assess the baby's heartbeat and uterine contraction. See External fetal monitoring, Internal fetal monitoring.
Fetal monitoring*
Indirect FM–Electrodes are placed on abdominal skin over uterus, which detects fetal heart beats and uterine contractions
Direct FM involves the placing of an electrode directly on the fetus while it is in the uterus, which is done after the membranes around the fetus have ruptured
*Formerly limited to high risk pregnances, FM is a common procedure that been linked to a ↓ in labor-related death and disability; a consequence of FM is ↑ possibility of the obstetrician performing a C- section