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FALL 2009


EFM 8/10/09

Electronic Fetal Monitoring

The electronic fetal monitor (EFM) is a device that provides a graphic display
of the fetal heart rate (FHR) and monitoring of uterine activity by digital
readout and tracing. EFM can be either external, which is noninvasive or
internal, which requires the attachment of an electrode to the presenting
fetal part. Nursing staff may routinely initiate external monitoring; initiating
the internal route is generally performed by a physician or midwife. A nurse
may also be certified in this skill. Monitoring of uterine contractile activity
can also be executed by an external or internal method.

Continuous fetal monitoring is indicated when abnormalities occur with

intermittent auscultation and for use in high-risk clients.

A. External
1. Noninvasive
2. Two devices are secured to the maternal abdomen by belts and
connected to the monitoring machine.
a. Ultrasound Transducer
1. Detects fetal heart sounds
i. Water soluble conducting gel is placed on the
surface to the transducer.
ii. Transducer is placed on the maternal abdomen
where the fetal heart tones (FHT) are heard
iii. Ultrasound waves generated from this device
bounce back from the fetus.
iv. The ultrasound waves are then displayed on
the monitor paper and by digital readout.
b. Tocotransducer
1. Detects the relative strength of uterine contractions.
i. Placed over the uterine fundus and secured by a
ii. As the uterus contracts, pressure is exerted
against the transducer and is recorded.
iii. FHT and contractions pressure (intensity) cannot
be accurately recorded on obese clients or if there
are problems securing the belt.
B. Internal
1. Invasive
2. Provides the most accurate fetal heart monitoring and
monitoring of uterine pressure.
3. Two devices

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a. Fetal scalp electrode (FSE) is secured to the fetal

scalp by a small electrode and records FHR.

b. Intrauterine pressure catheter (IUPC) is

inserted directly into the uterine cavity and
records the intensity of contractions.

4. Prerequisites for internal monitoring

a. Membranes must be ruptured.
b. Cervix must be at least 2-3 centimeters dilated.
c. Careful insertion of FSE to avoid fetal face, fontanels
and genitals
d. Presenting part must be engaged.

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Both external and internal monitoring is accomplished by the same

electronic monitoring machine.

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Uterine contractions occur about every 3-5 minutes with a duration of 30-60
seconds and an intensity of 40-60 mm HG (contraction intensity is measured
by mm HG only when the internal method is utilized). Uterine contractions
are assessed in the following manner

A. Frequency-measured from the beginning on one contraction to the

beginning o the next contraction.

B. Duration-measured from the beginning of one contraction to the end of

the same contraction.

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C. Intensity-pressure of a contraction (called contraction pressure).

D. Resting pressure-pressure between contractions. Average resting

pressure is 5-15 mm Hg.

An example of FHR and uterine activity on chart paper.

The upper section of the chart paper is used to record the FHR by both the
external and internal modes of monitoring. The vertical scale is related to
FHR, which can be recorded between 30 and 240 beats/min (bpm). The
horizontal scale is divided into 1 millimeter sections, which are subdivided by
six sections representing 10 seconds of time. The lower section is used to
record uterine activity.


The baseline heart rate is the average rate when no contractions are
occurring. Note the baseline on the strip below. Also, note the variability of
the heart rate.

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The normal FHR is between 110 and 160 bpm. The baseline FHR is the mean
(average) FHR rounded to increments of 5-10 bpm in a 10 minute segment.
Need 2 minutes total over the entire 10 minute period to determine FHRB.
These 2 minutes do not need to be consecutive minutes! The evaluation
also must exclude periodic segments with periodic or episodic changes or
periods of marked FHR variability.

Accelerations are transient increases in FHR greater than 15 bpm for at least
15 seconds. Two accelerations in 20 minutes are considered to be a reactive
trace. Accelerations are reassuring patterns as they indicate fetal
responsiveness and the integrity of the mechanisms controlling the heart.

Beat to beat variability is the normal irregularity of the cardiac rhythm,

caused by continuous balancing interaction of the sympathetic
(cardioacceleration) and parasympathetic (cardiodeceleration) divisions of
the autonomic nervous system. Slowing is mediated by the vagus nerve.
The vagal stimulation becomes dominant as the fetus reaches term. After
birth, the vagus nerve also leads to a gradual slowing in the baseline of the
newborn’s heart rate.

Good variability is demonstrated by cyclic fluctuations and changes of heart

rate from the baseline. Decreases in variability indicate central nervous
system (CNS) depression. Causes of CNS include:
A. Medications (analgesics MgSO4)
B. Fetal sleep cycles (usually last no longer than 15-20 minutes)
C. Congenital anomalies
D. Preterm fetus (less than 28 weeks, usually normal after 32
E. Fetal hypoxia and acidosis

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F. Fetal tachycardia
G. Fetal brain damage

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The cause of increased beat-to-beat variability is unknown; however, this

usually signifies fetal well being. Baseline beat should vary 10-15 beats over
a 60 second period. Variability is described as long or short term. Short-
term variability is the variation from beat to beat and is difficult to detect
without internal monitoring to read the exact FHR during a minute period.
Long-term variability is the rhythmic fluctuation of the FHR from baseline
over a minute (usually 5-6 waves).

Variability is usually classified in the following manner:

No variability (0-2 bpm)
Minimal (3-5 bpm)
Average (6-10 bpm)
Moderate (11-25 bpm)
Marked (> 25 bpm)

Decreased variability in combination with late or variable decelerations indicates

and increased risk of fetal pre-acidosis (pH 7.20-7.25) or acidosis (pH < 7.20)
signifying the infant will be depressed at birth. The combination of late or variable
decelerations with loss of variability is particularly ominous. Late or worsening
variable decelerations in the presence of normal variability indicate a nonreassuring
pattern indicating the fetal distress is of recent origin or mild degree.

Baseline of 110-150 bpm with average variability

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Note the decreased variability of the above strip. If lasts for longer than 10
minutes this reflects a change in baseline FHR.

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Fetal tachycardia is usually considered to be a baseline FHR greater than 160

bpm. Suspicious tachycardia is between 150-170 bpm. A pathological
pattern is tachycardia is greater than 170 bpm. Causes of fetal tachycardia
A. Fetal hypoxia
B. Prematurity
C. Fetal or maternal infection (chorioamnionitis)
D. Maternal anxiety
E. Stimulation and activity
F. Maternal or fetal anemia
G. Paraysmpatholytic medications (atropine or Atarax
H. Sypathomimetic medications (Yutopar, {ritodrine }, Brecanyl,
I. Maternal hyperthyroidism
J. Idiopathic


Fetal bradycardia is considered to be a baseline of less than 100 bpm. A FHR

of 100-120 with normal variability is not associated with fetal difficulty. If
lasts longer than 10 minutes reflects a change in the baseline FHR.

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Causes of fetal bradycardia include the following:

A. Fetal hypoxia
B. Medications (anesthesics, analgesics)
C. Maternal hypotension or seizures
D. Rapid descent
E. Vigorous vaginal examination
F. Tetanic uterine contraction
G. Prolapse or prolonged compression of the umbilical cord
H. Fetal cardiac dysrhythmias
I. Hypothermia
J. Paracervial block
K. Epidural and spinal anesthesia


Decelerations (decals) are distinguished based on their waveforms. A

prolonged deceleration is greater than 15 bpm, lasting longer than 2 minutes
and with duration greater than 15 seconds but less than 2 minutes.
Recurrent decelerations occur with at least 50% of uterine contractions in
any 20 minute segment.

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Early Decelerations
A. Begins at the onset of the contraction and ends at the end of the
B. Cause of this type of deceleration is head compression and is
caused by vagal stimulation; may be prevented by avoiding
early rupture of membranes.
C. Is a reassuring pattern that is usually seen late in labor and
reinforces the fetus is moving downward in the birth canal.
D. No nursing intervention is necessary.

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Late Decelerations
A. Occurs after the peak of the contraction or late in the contraction
B. Transitory decreases in FHR caused by uteroplacental
compromised blood flow to the fetus does not deliver the amount
of oxygen necessary for the fetus to withstand the stress of
C. Regardless of the depth of the deceleration, all late decals are
considered potentially ominous.
D. Persistent late decals with decreased variability lead to an
ominous pattern (fetal hypoxia). Also associated with fetal
acidosis and low Apgar scores.
E. Nursing Intervetions:
1. Place in lateral position, preferably left side.
2. Administer O2 by tight face mask
3. Discontinue oxytocin, if hyperstimulation present consider
using terbutaline 0.25 mg SC
4. Correct maternal hypotension
5. Hydrate by bolus infusion of fluid
6. If persist > 30 minutes despite above, consider fetal scalp
pH and/or emergency procedure

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Variable Decelerations
A. Shown by an acute fall in the FHR with a rapid downslope and a
variable recovery phase.
B. Variable in duration, intensity and timing. They may not bear a
constant relationship to uterine contractions. Are caused by
umbilical cord compression
C. Resemble letter “U”, “V” or “W”
D. Occur frequently in women who have PROM and decreased
amniotic fluid volume.
E. As many as 50% of all monitored fetus experience variable
decels during labor.
F. If baseline FHR remains stable and variability remains good,
these decels are not associated with poor fetal outcome.
G. Nursing Interventions:
1. Change maternal position
2. Discontinue oxytocin if associated with poor variability
3. Assist with amnioinfusion

FHR patterns are called reassuring, non-reassuring and ominous.

A. Reassuring patterns are those associated with fetal well-being
and positive outcomes.
-normal baseline rate
-presence of accelerations

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-normal (moderate) variability

-absence of decelerations

B. Non-reassuring patterns, “warning patterns”, suggest decreasing

fetal capacity to cope with the stress of labor.
-absence of reassuring characteristics
*recurrent late or variable decelerations with absent
*substantial bradycardia with absent variablity

Assessment of Fetal Monitoring Strips

Suggested Approach

Baseline Fetal Heart Rate (FHRB)

1. What is FHRB?
2. Assess if it is average (110-160), tachycardia ( > 160), bradycardia
a. Tachycardia or bradycardia-what could be some possible causes
Baseline Variability
a. Absent, minimal, moderate, marked
1. Present or absent
2. Periodic (with fetal movement or stimulation)
3. Episodic (with uterine contractions)
4. Regular (30 seconds-2 minutes) or Prolonged (2-10 minutes)
5. Gestational age criteria
≥ 32 weeks ≥ 15 bpm x ≥ 15 seconds
≤ 32 weeks ≥ 10 bpm x ≥ 10 seconds
1. Early associated cause:
2. Late associated cause:
3. Variable associated cause:
4. Prolonged deceleration associated causes:
5. Periodic (with uterine contractions) or Episodic (not associated with
uterine contractions)
6. Recurrent decelerations: with 50% of uterine contractions in a 20
minute segment
7. Combination decelerations: choose one closet to definition to label
Uterine Activity
1. Frequency
2. Duration
3. Intensity
4. Resting tone
5. Resting time
6. Hyperstimulation-6 or more contractions in a 10 minute strip
Reassuring features present…..or non-reassuring???

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