UNIVERSITY OF WISCONSIN MEDICAL FOUNDATION
CLINICAL POLICY AND PROCEDURE
TITLE: MEASURING FETAL HEART TONES
Effective Date: January, 2003 Approval: See Authorization
Supersedes Protocol: None Contact: Clinical Staff Educator
Reviewed March, 2005 March, 2008 May 2009 January 2012 August 2014
PURPOSE: To provide guidelines for the measurement of fetal heart tones at the University of Wisconsin Medical
Foundation (UWMF) and Department of Family Medicine (DFM) clinics.
DEFINITION: Fetal heart tones may be measured to obtain baseline data and to detect changes in the physical condition
of the unborn child. Fetal heart tones are audible with a Doppler approximately 10 to 12 weeks after the woman’s last
ξ Normal range for fetal heart tone rate is 110 to 160 beats per minute
ξ Bradycardia is less than 110 beats per minute
ξ Tachycardia is greater than 160 beats per minute
POLICY: The clinical staff will utilize the following guidelines to measure fetal heart tones in UWMF and DFM
SUPPLIES: Doppler, Transmission gel, Provider’s order, Patient’s record
1. Wash hands and gather equipment.
2. Introduce yourself, identify the patient. Include date of birth.
3. Explain procedure and purpose of measuring fetal heart tones to the patient.
4. Provide privacy and make the patient comfortable.
5. If available, review the previous recording of the fetal heart rate.
6. Use Leopold’s maneuvers to locate the position of the fetus in the patient’s abdomen by gently palpating the upper
and lower borders of the uterus and the lateral borders of the uterus. Fetal heart tones are most easily heard over the
area of the uterus where the back/spine of the fetus is located.
7. Using a Doppler to measure the heart tones:
ξ Apply transmission gel to area where you will attempt to hear fetal heart tones
ξ Turn on the Doppler
ξ Gently move it along the skin of the mother’s abdomen.
ξ Listen for the sound of blood flowing through the heart
ξ Count the fetal heart rate for one full minute
ξ Clean transmission gel off patient’s abdomen and Doppler unit
ξ NOTE: If fetal heart rate is LESS THEN 110 beats per minute, compare fetal heart rate against the
mother’s apical heart rate.
8. Wash your hands using soap and water or hand sanitizer.
9. If fetal bradycardia or tachycardia is present, notify provider immediately.
10. Discuss the findings with the mother and assist her to comfortable position.
11. If fetal bradycardia or tachycardia is present, document notification of provider and actions taken in Progress Notes
section of HealthLink in patient’s record.
12. Document the fetal heart rate in the Prenatal Vitals & Notes section of HealthLink in patient’s record.
WRITTEN BY: Ronnie Peterson, R.N., M.S., Manager of Clinical Support
REVISED BY: LaVay Morrison, RN, BSN, Clinical Staff Educator
REVIEWED BY: Catherine Hubbard, Nurse Practitioner, OB/GYN, West Towne
Denise Maves UWMF OB/GYN, 20 S Park Street
12.09 Fetal Heart Tones - OB/GYN, Midwives, Women's Health Center-East/West
Young, B.K. Intrapartaum fetal heart rate assessment. In:UpToDate, Basow,DS(Ed),UpToDate,Waltham,MA,2013
AUTHORIZED BY: Richard Welnick, MD, Medical Director, Ambulatory Clinic Operations, UWMF
Sandra A. Kamnetz M.D., Vice Chair, Department of Family Medicine
Medical Director, UWMF Date
Vice Chair, Department of Family Medicine Date