Fetal Monitor Documentation, Charting Frequency, and the 3-Tier Fetal Heart Rate Interpretation System (Nursing)

00:01 So, as nurses, one of our responsibilities when we're conducting any sort of testing or any intervention is documentation.

00:08 So what does the nurse need to document about the fetal heart rate tracing? Well, we need to document frequency, we need to document duration, and we're speaking of the contractions.

00:19 We need to document the type of monitoring that we're doing whether its internal or external, because that has an impact on what we do with the results.

00:29 We also want to document the presence or absence of accelerations and/or decelerations, so what do we see.

00:36 Of course we want to document the baseline fetal heart rate, is it normal? Is it between 110 and 160? And we also want to document the variability or the movement of that line.

00:48 So with every chart, we want to make sure that we are documenting this information about the labor progression and what we see on the fetal heart rate monitor.

00:57 One of the important things we do at nursing is to document what's going on with the patient.

01:02 Remember, if we don't write it down, it didn't happen, so it's very important that we know how often we need to chart our monitoring of the fetal heart rate.

01:10 So one of the things that we have to do is know that whether taking care of a client that's considered low risk or high risk and this determination will be made by the provider.

01:19 If you're taking care of a low risk patient, then changes are you're going to monitor them less frequent than a high risk patient, but let's look at the guidelines and what they say.

01:29 During the early phase of labor, we can document fetal heart rate and contraction pattern about every hour for the low risk patient and about every 30 minutes for the high risk patient, so you can see, it's a little bit faster, almost usually half the time.

01:44 Once we get in to the active phase of labor, past six centimeters, we're going to document about every 30 minutes, so we're going to go into the room, hopefully, we're in there most of the time with the client and we're going to write down what's going on, what's the baby doing, what are the contractions look like? If we're taking care of a high risk patent, that's going to be done every 15 minutes, once we get to the active phase of labor.

02:07 Once we get to second stage, remember at this point, we're usually doing some pushing, we're going to monitor the contractions and the fetal heart rate at least every 15 minutes for the low risk patient and then every 5 minutes for the high risk patient.

02:22 Sometimes we're monitoring the contractions and the fetal heart rate after every single contraction depending on what's going on and what we see, but these are the guidelines generally to follow when we think about how often we should chart.

02:35 One of the things that we have to also do as providers is know how to respond and how quickly we need to respond, and NICHD actually came up with a 3-tier category system that sort of a way that we know we need to watch this client and see that they're doing okay or we need to move immediately to a caesarian delivery.

02:56 So this 3-tier system helps us out and it's helpful to kind of think of the stop sign, the green means good, the yellow means caution, the red means stop; as we moved through these categories.

03:07 So category one is normal and what we know that that means is that the fetal acid-base or the oxygenation is perfect, everything is good.

03:16 And in order to be category one, we have to have a heart rate that's between 110 and 160 so normal, we have to have moderate variability, we shouldn't see any late or variable decelerations and we should have accelerations or early decelerations because we know those are normal and okay.

03:33 Moving on to the caution, the yellow light, this is category two and it indicates that there's some compensation by the fetus for something that's going on.

03:44 The babies are doing okay right now, but things could change so when we get to the yellow category or category two, then we need to really be monitoring the patient.

03:55 The patient's kinda moving into that high risk category so we're not going to wait an hour to go back and chart.

04:00 We might actually be by the bedside, really checking to make sure that things are okay.

04:05 So let's look at some of the criteria for category two.

04:08 So if we have moderate variability, that part is good, but we have recurrent late or variable decelerations meaning that with every single contraction we're seeing lates, we're seeing variable deceleration.

04:22 It might be okay right now, but that's not sustainable.

04:26 If we don't do anything about it, it might progress to minimal variability.

04:30 So remember variability has to do with the movement of that line, we've gone from normal now to a decreased variability, so we have minimal variability with either recurrent variable or late decelerations.

04:42 If we have absent variability and if we have absent variability period that's not good, so whether we have contractions or we don't, having absent variability means that there's no play between the parasympathetic and sympathetic nervous system and it implies there's decrease oxygenation.

04:59 If we have decelerations that last longer than two minutes, that's called a prolonged deceleration and that's indicative of the problem or if we have tachycardia so remember, the normal fetal heart rate is between 110 and 160, so a heart rate that's 170, 180 anything above of 160 for a long time is going to stress the fetus and also is not sustainable, which leads us to the red category and this means that we need to intervene immediately, so either hopefully the baby's coming out vaginally in the next few minutes, but if that's not the case, then we need to consider moving to an emergent or an emergency caesarian birth.

05:39 This is going to mean that the acid-base levels of the fetus are severely compromised and we need to do something or we could lose the baby.

05:47 So in this case, what we might see is absent variability completely, we have a smooth line and we have recurrent lates, or we have recurrent lates and variables, or we have a fetal heart rate that's less than a 110 or we're experiencing a sinusoidal pattern, and again a sinusoidal pattern is going to indicate that we don't have good oxygenation and usually it's a result of fetal blood loss, so we can't sustain a blood pressure or heart rate without adequate levels of blood flow, so we may see a sinusiodal pattern, and it look something like this.