Antenatal Fetal Surveillance

Antenatal fetal surveillance involves various testing modalities to assess fetal well-being before labor begins. These methods are particularly important for high-risk pregnancies but may be utilized in any pregnancy where concerns about fetal health arise.

Method	Description	Nursing Considerations
Maternal Perception of Fetal Movement (Kick Counts)	Patient monitors and records fetal movements, typically aiming for at least 10 movements within a 2-hour period	Educate mothers to contact healthcare provider if fewer than 10 movements in 2 hours or significant decrease in movement patterns
Nonstress Test (NST)	Electronic monitoring of fetal heart rate response to fetal movement over at least 20 minutes	Reactive NST shows at least two accelerations of 15 beats/min lasting 15 seconds within a 20-minute period
Biophysical Profile (BPP)	Combines NST with ultrasound assessment of fetal breathing movements, fetal body/limb movements, fetal tone, and amniotic fluid volume	Score of 8-10/10 is considered normal; scores below 6 may indicate need for delivery
Modified BPP	Combines NST with assessment of amniotic fluid volume (deepest vertical pocket)	Simplified version of BPP; normal result includes reactive NST and AFI ≥5 cm
Contraction Stress Test (CST)	Evaluates FHR response to uterine contractions to detect late decelerations	Negative CST (no late decelerations) is reassuring; positive CST may indicate uteroplacental insufficiency
Umbilical Artery Doppler Velocimetry	Ultrasound assessment of blood flow in umbilical artery	Primarily used in suspected fetal growth restriction; assesses placental function

Intrapartum Fetal Monitoring

During labor, fetal monitoring becomes critical for assessing how the fetus is tolerating the stress of contractions and the birth process. There are two primary approaches to intrapartum fetal monitoring:

1. Intermittent Auscultation (IA)

Intermittent auscultation involves periodically listening to the fetal heart rate using a fetoscope, Doppler device, or ultrasound transducer. This method is recommended for low-risk pregnancies by many organizations including the World Health Organization (WHO).

• Frequency:
  • First stage (latent phase): Every 30 minutes
  • First stage (active phase): Every 15-30 minutes
  • Second stage: Every 5-15 minutes
• Assessment timing: Listen before, during, and after a contraction for at least 60 seconds
• Documentation: Record baseline rate, rhythm, and presence of accelerations or decelerations

2. Electronic Fetal Monitoring (EFM)

Electronic fetal monitoring, or cardiotocography (CTG), provides continuous recording of both the fetal heart rate and uterine contractions. This approach is commonly used in high-risk pregnancies and in many hospital settings for all laboring women.

External vs. Internal Fetal Monitoring

Feature	External Monitoring	Internal Monitoring
Method	Ultrasound transducer placed on maternal abdomen	Fetal scalp electrode attached directly to fetal scalp
Requirements	No specific prerequisites	Requires ruptured membranes and cervical dilation
Accuracy	May lose contact with movement; can confuse maternal and fetal heart rates	More accurate and continuous signal; direct fetal ECG
Invasiveness	Non-invasive	Invasive; small risk of infection or scalp injury
Mobility	Allows more mobility; wireless options available	Restricts mobility
Best for	Early labor, intact membranes, maternal obesity	When external monitoring is inadequate or precise data is needed

Fetal Heart Rate Interpretation

Proper interpretation of fetal heart rate patterns is crucial for assessing fetal well-being during labor. The NICHD (National Institute of Child Health and Human Development) terminology is used to standardize FHR interpretation.

Key Components of FHR Assessment:

1. Baseline Rate: The average FHR rounded to increments of 5 beats per minute during a 10-minute window
   • Normal: 110-160 beats per minute (bpm)
   • Tachycardia: >160 bpm
   • Bradycardia: <110 bpm
2. Baseline Variability: Fluctuations in the baseline FHR
   • Absent: Undetectable
   • Minimal: ≤5 bpm
   • Moderate (normal): 6-25 bpm
   • Marked: >25 bpm
3. Accelerations: Transient increases in FHR
   • ≥15 bpm above baseline for ≥15 seconds
   • Reassuring sign of fetal well-being
4. Decelerations: Transient decreases in FHR
   • Early: Uniform, gradual decrease with onset and return that mirrors contraction timing
   • Late: Gradual decrease with onset, lowest point, and recovery occurring after the beginning, peak, and end of contraction
   • Variable: Abrupt decrease with rapid onset and return; variable in duration and timing
   • Prolonged: Decrease from baseline for >2 minutes but <10 minutes

FHR Category	Characteristics	Management Implications
Category I (Normal)	Normal baseline (110-160 bpm) Moderate variability No late or variable decelerations Early decelerations may be present Accelerations may be present	Routine monitoring; no specific action needed
Category II (Indeterminate)	All patterns not categorized as I or III Examples: minimal variability, absent accelerations, prolonged decelerations	Continued observation, evaluation, and surveillance; consider corrective measures
Category III (Abnormal)	Absent variability with recurrent late decelerations, recurrent variable decelerations, or bradycardia Sinusoidal pattern	Prompt evaluation and intervention; prepare for possible rapid delivery if pattern doesn’t resolve

Phases of First Stage Labor

The first stage of labor begins with the onset of regular uterine contractions that cause cervical change and ends with full cervical dilation to 10 cm. This stage is divided into two phases:

Phase	Cervical Dilation	Characteristics	Duration
Latent Phase	0 cm to 6 cm	Slower cervical change Contractions may be irregular Less predictable duration	Nulliparous: Up to 20 hours Multiparous: Up to 14 hours
Active Phase	6 cm to 10 cm	More rapid cervical dilation Regular, stronger contractions More predictable progression	Nulliparous: 0.5-1.0 cm/hr Multiparous: 1.5-2.0 cm/hr

Nursing Interventions During First Stage Labor

The nurse’s role during the first stage of labor is multifaceted, including assessment, monitoring, support, and documentation.

Initial Assessment and Admission

• Obstetric Triage: Obtain presenting symptoms, vital signs, FHR, and contraction patterns
• Review Prenatal Record: Medical, surgical, obstetric history and laboratory results
• Admission History: Complete thorough assessment including medical, surgical, obstetric/gynecologic, and psychosocial history
• Physical Examination:
  • General survey and vital signs
  • Heart, lung, and extremity assessment
  • Obstetric examination: FHR, contractions, membrane status
  • Vaginal examination: cervical dilation, effacement, position, station, and presenting part

Ongoing Monitoring During First Stage

Assessment Parameter	Frequency (Latent Phase)	Frequency (Active Phase)
Maternal Vital Signs	Every 60 minutes	Every 30-60 minutes
Fetal Heart Rate (Intermittent)	Every 30 minutes	Every 15-30 minutes
Fetal Heart Rate (Continuous)	Continuous with evaluation every 30 minutes	Continuous with evaluation every 15 minutes
Contraction Pattern	Every 30-60 minutes	Every 15-30 minutes
Cervical Examination	As indicated by labor progress	Every 2-4 hours or as indicated
Pain Assessment	Hourly or as needed	Every 30 minutes or as needed
Bladder Status	Every 2 hours	Every 1-2 hours

Documentation Requirements

• Maternal vital signs and condition
• FHR baseline, variability, accelerations, and decelerations
• Contraction frequency, duration, and intensity
• Cervical changes and fetal descent
• Interventions and patient response
• Pain level and comfort measures provided
• Intake and output
• Medications administered

Comfort Measures During First Stage Labor

Providing comfort during the first stage of labor is essential for promoting a positive birth experience and supporting physiologic birth processes.

Non-Pharmacological Pain Management

• Breathing Techniques: Patterned breathing helps with relaxation and distraction from pain
• Hydrotherapy: Shower or bath can reduce pain perception and promote relaxation
• Massage: Counter-pressure on the sacrum can alleviate back pain during contractions
• Heat/Cold Therapy: Warm compresses for back pain, cool cloths for face/neck
• Relaxation Techniques: Guided imagery, music therapy, or meditation
• Birthing Ball: Promotes optimal fetal positioning and relieves pressure
• TENS (Transcutaneous Electrical Nerve Stimulation): May reduce pain perception in early labor
• Sterile Water Injections: For severe back pain, can provide 60-90 minutes of relief

Pharmacological Pain Management

• Systemic Analgesics: Opioids like fentanyl or morphine for short-term relief
• Nitrous Oxide: Self-administered 50/50 mixture with oxygen
• Regional Anesthesia:
  • Epidural: Most common method; continuous infusion of local anesthetic
  • Combined Spinal-Epidural: Faster onset than epidural alone

Position Changes and Mobility

Promoting mobility and frequent position changes during the first stage of labor has numerous benefits including enhanced comfort, improved maternal-fetal circulation, and more efficient labor progress.

Benefits of Upright Positions and Mobility

• Uses gravity to assist fetal descent
• Reduces pain perception
• Improves uterine blood flow
• Increases intensity and efficiency of contractions
• May shorten first stage labor duration
• Reduces need for augmentation
• Facilitates fetal rotation through pelvis

Recommended Positions During First Stage

• Walking/Standing: Uses gravity; can lean on partner or wall during contractions
• Sitting: On birthing ball, chair, or bed; promotes relaxation between contractions
• Hands and Knees: Relieves back pain; aids rotation of occiput posterior positions
• Side-lying: Promotes rest while maintaining good uterine perfusion
• Semi-sitting: Comfortable position that still uses some gravity advantage
• Leaning Forward: Standing or kneeling while leaning on bed/partner reduces back pain
• Squatting: Increases pelvic diameter; may be used intermittently