Fetal Monitoring and Nursing Care

Nursing Care for Fetal Monitoring

Fetal Monitoring a Part of Prenatal Care,Devices for Fetal Monitoring,How Fetal Care Introduced In Health Care,How Fetal Heart Is Important to Monitor,Importance,Reliability and Validity.

Fetal Monitoring a Part of Prenatal Care

    Fetal assessment is part of the process of providing prenatal care. It involves early identification of real or potential problems and enables the achievement of the best possible obstetric outcomes. 

    Fetal assessment involves low tech and high tech modalities such as fetal movement counting (kick counts), intermittent auscultation (IA), electronic fetal monitoring (EFM), nonstress tests (NST), vibroacoustic stimulation (VAS), auscultated acceleration (AAT), contraction stress tests (CST), amniotic fluid index (AFI), biophysical profiles (BPP), and Doppler velocimetry. 

    The basis for all of these testing modalities is evaluation of certain biophysical parameters related to the developmental and health-related patterns of fetal behavior in utero. Adequate uteroplacental function is necessary for these patterns of healthy behavior. 

    Uteroplacental insufficiency (UPI) has been shown to be the cause of at least two thirds of antepartal fetal deaths (Gegor & Paine, 1992).

Devices for Fetal Monitoring 

    Electronic fetal monitoring is the basic intervention used in fetal assessment. Electronic fetal monitoring as an electronic data-gathering and data-processing device was developed during the 1960s. By the end of the 1970s. 

    Almost all major obstetrical units had at least one monitor, and 70% of all women in labor in the United States were monitored (Bassett, K., 1996). K. R. Simpson (2000) reported that the use of EFM increased from 22.5% of women in labor in 1975 to 84.0% by 1998. 

    In addition to its use in monitoring fetal status during labor, modifications of EFM have been developed for antepartal fetal assessment to determine optimal fetal development and diagnose conditions of actual or potential fetal compromise (e.g., NST, CST, VAS, and BPP).

How Fetal Care Introduced In Health Care

    Controversies still continue over the appropriate place of EFM in obstetric care. It was introduced into clinical practice on the basis of animal studies and became widely used, with no controlled assessment of its effectiveness in improving the outcome of delivery (Smith, M. A., Ruffin, & Green, 1993). 

    It was supposed to provide more accurate fetal assessment with the accompanying prompt identification of fetal compromise. Early retrospective studies suggested that EFM was associated with fewer infants born with low Apgar scores, lower neonatal mortality rates, and better neurological outcomes (Smith et al.).

How Fetal Heart Is Important to Monitor

    Schmidt and McCartney (2000) presented a thorough historical review and discussion of the development of fetal heart rate assessment. They found that expectations of the benefits of EFM exceeded and preceded re- search on outcomes, efficacy and safety. 

    As knowledge accumulated through research and practice, the theories of correlation of causation and intraportal events has changed. What were once considered to be significant intraportal events cannot now be linked as conclusively to brain damage in neonates.     

Current research and improvements continue to report benefits of EFM: a decrease in neo-natal seizures and decreased operative intervention for fetal distress, with improved analysis.

Importance 

    The major problem is still the risk of misinterpretation of the EFM tracing. Schmidt and McCartney (2000) included study results that, with a reassuring pattern, EFM can be a sensitive tool for identifying the well oxygenated fetus. 

    But it is not a specific tool for identifying the compromised fetus when a no reassuring pattern is seen. Current concerns are focused on the best ways to prevent or reduce inappropriate use of EFM and develop the best ways to assess and monitor fetal development and safety in labor.

    McCartney (2000) discussed the proposed benefits of automated EFM assessment (computer analysis): it is objective, standardized, and reproducible. She discusses the use of artificial intelligence (AI) and how it may prove to be of great value along with smart monitors and electronic databases in improving interpretation of EFM. 

    M. L. Porter (2000) reported that the use of fetal pulse oximetry was approved by the FDA for clinical use in May, 2000 to provide more information about fetal oxygen status, especially in cases of no reassuring fetal heart rate pat- terns.

    The American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetrical, and Neonatal Nurses (AWHONN) have developed standards and guidelines for practice concerning fetal assessment and the use of EFM and other modalities of fetal heart rate assessment. 

    As cited in Schmidt and McCartney (2000), the ACOG Technical Bulletin No. 207 entitled Fetal heart rate patterns: Monitoring, interpretation, and management states that intermittent auscultation is a safe technique for monitoring low-risk births. 

    AWHONN issued Basic, High Risk and Critical Care Intrapartum Nursing: Clinical Competencies and Education Guide in 1999 and the 2000 Position Statement entitled the use of fetal monitoring in support of laboring women. These standards of practice deter- mine the accepted conduct of antepartal and intraportal care and provide the core of safe practice. 

    It is the responsibility of all nursing and medical health care providers to be proficient in the use and interpretation of EFM and other intervention modalities employed in perinatal health care delivery. Other recommendations include using EFM as a diagnostic rather than a screening tool and not as a substitute for supportive health care personnel. 

    Additionally, specific indications, such as oxytocin induction or augmentation of labor, an abnormal fetal heart rate by auscultation, twin gestation, hypertension or pre eclampsia, dysfunctional labor, meconium staining, vaginal breech delivery, diabetes, or prematurity, as noted by Smith and others (1993), are still applicable.

Reliability and Validity

    Haggerty (1999) presented an extensive overview of the reliability, validity, and efficacy of EFM. Her work looks at both sides of the controversy, and includes the recommendations of ACOG, the United States Preventive Services Task Force (1996), and AWHONN that EFM and IA both have a place in fetal monitoring. 

    Feinstein (2000) also researched the efficacy of IA, especially with low-risk pregnant women. Miltner (2002) concluded that integrating supportive care provided by labor nurses with other direct and indirect care interventions (such as monitoring modalities) may offer the best model for providing high-quality intrapartum nursing care.

    Further prospective studies should be conducted to try to determine the optimal balance of intermittent or continuous EFM and auscultation and the other modalities of fetal assessment and pregnancy management. 

    Rigorous study protocols and close attention to the principles of scientific inquiry are needed so that study results will be reliable and valid. The major concerns of perinatal care should be optimal and cost effective outcomes for mother and infant, without concern for protection of the caregiver from litigious actions.