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Fetal Heart Rate Monitoring. Paul G. Tomich , M.D. Department of Obstetrics and Gynecology University of Nebraska College of Medicine . Learning Objectives. Evolution Examples Descriptions Reassuring patterns Concerning patterns Definitions of Category I, II, and III tracings

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fetal heart rate monitoring

Fetal Heart Rate Monitoring

Paul G. Tomich, M.D.

Department of Obstetrics and Gynecology

University of Nebraska College of Medicine

learning objectives
Learning Objectives
  • Evolution
  • Examples
  • Descriptions
    • Reassuring patterns
    • Concerning patterns
  • Definitions of Category I, II, and III tracings
    • Discuss action needed
  • Non-stress Test (NST)
  • Biophysical Profile (BPP)
evolution of fhr monitoring
“Evolution” of FHR Monitoring
  • Monitoring fetus in labor
  • FHR patterns
    • Good outcomes
    • Poor outcomes
  • Contraction Stress Test (CST)
  • Non Stress Test (NST)
  • Biophysical profile (BPP)
  • Categorization of FHR Tracing into Category I, II, and III
categorization of fhr tracings
Categorization of FHR Tracings
  • Recommendation of three-tiered system
    • April 2008
    • More standardized interpretation
  • Concept: Interpretation of a FHR monitor strip is a dynamic process, with determination of whether a particular strip is reassuring and what action plans should be taken… and then to evaluate at a later time
ways to monitor
Ways to Monitor

Uterine contractions

Fetal heart rate (FHR)

ways to monitor1
Ways to Monitor

Uterine contractions

Fetal heart rate (FHR)

features to describe
Features to Describe
  • Fetal heart rate (FHR)
    • Top line on monitor strip
  • Uterine contractions
    • Bottom line on

monitor strip

features to describe1
Features to Describe

Baseline

Variability

Accelerations

Decelerations

Trends over time

Interpret into 1 of 3 categories

baseline
Baseline
  • Mean fetal heart rate
    • Rounded to increments of 5
    • During a 10 minute period
    • Excluding accelerations and decelerations
  • Normal baseline
    • 100-160 BPM
baseline1
Baseline
  • Bradycardia

<100 BPM

  • Tachycardia

>160 BPM

  • Indeterminate
    • less than 2 minutes of baseline is present
fetal tachycardia
Fetal Tachycardia
  • Normal variant
    • prematurity
  • Intra-amniotic infection
  • Fetal anemia
  • Fetal cardiac arrhythmia (SVT)
  • Fetal hypoxia
features to describe2
Features to Describe

Baseline

Variability

Accelerations

Decelerations

Trends over time

Interpret into 1 of 3 categories

variability
Variability
  • Fluctuations in FHR
    • Over 10 minutes
  • Descriptors are:
    • Absent: undetectable amplitude range
    • Minimal: undetectable up to 5 BPM
    • Moderate: amplitude range 6 to 25 BPM
    • Marked: amplitude range greater than 25 BPM
features to describe3
Features to Describe

Baseline

Variability

Accelerations

Decelerations

Trends over time

Interpret into 1 of 3 categories

accelerations
Accelerations
  • Abrupt increase in FHR
    • At least 15 BPM above baseline
  • Duration
    • Must last 15 seconds to 2 minutes
  • Prolonged accelerations
    • Last 2 minutes to 10 minutes
  • Baseline change
    • Acceleration lasting 10 mins or longer
slide22

>15 beats above baseline

15 seconds to 2 minutes in length

features to describe4
Features to Describe

Baseline

Variability

Accelerations

Decelerations

Trends over time

Interpret into 1 of 3 categories

decelerations
Decelerations
  • Decrease in baseline
  • 3 Types
    • Early
    • Variable
    • Late
deceleration
Deceleration

Decrease in FHR

early deceleration
Early Deceleration
  • Symmetrical to contraction
  • Mirror image of contraction
  • Gradual decrease in FHR
    • 30 secs or more from onset to nadir
slide29

EARLY DECELERATION

  • Gradual FHR decrease
  • Onset to nadir 30 seconds or more
  • Nadir of deceleration occurs with peak of contraction
  • Mirror contraction
late d ecelerations
Late Decelerations
  • Deceleration is delayed in timing
    • Occurs after the contraction
  • A gradual FHR decrease
    • Onset to nadir > 30 second
variable decelerations
Variable Decelerations
  • Abrupt decrease in fetal heart rate
    • Onset to nadir less than 30 seconds
  • Decrease in FHR
    • 15 BPM or more
    • Lasting 15 seconds to 2 mins
variable declerations
VariableDeclerations
  • Pathophysiology
    • umbilical cord compression
decelerations1
Decelerations
  • Prolonged deceleration
    • Decrease of 15 BPM
    • Lasts 2-10 minutes
  • Baseline change
    • Deceleration lasting at least 10 mins
  • Description
    • Intermittent
      • Less than 50% of contractions in 20 minutes
    • Recurrent
      • More than 50 % of contractions in 20 minutes
sinusoidal pattern
Sinusoidal Pattern

Smooth sin-wave pattern

Cycle frequency 3-5 mins

Persists for 20 minutes or longer

uterine contractions
Uterine Contractions
  • Number of contractions in 10 minutes
    • averaged over thirty minutes
  • Document
    • Frequency
    • Intensity
    • Duration
    • Relaxation
      • time between contractions
tachysystole
Tachysystole
  • >5 contractions in 10 mins
    • Averaged over 30 mins
categorization of fhr patterns
Categorization of FHR Patterns

An evaluation of the fetus at a particular point in time

Categories I, II, and III

category i
Category I
  • Normal baseline
    • 110-160 BPM
  • FHR Variability
    • moderate
  • Late or Variable decelerations
    • none
category ii
Category II

Not enough evidence to place into either Category I or III

category iii
Category III

Abnormal tracing

Predictive of abnormal fetal acid-base status

Requires prompt intervention

non stress test

Non-Stress Test

Reactive

2 or more accelerations in 20 mins

Acceleration

At least 15 beats above baseline

Lasting for at least 15 seconds

Non-reactive

biophysical profile bpp
Biophysical Profile (BPP)

NST + ultrasound markers

Score linearly correlated with fetal pH

Risk of fetal death within one week of normal BPP is 1:1300

biophysical profile

Biophysical Profile

Zero or 2 points for each

Fetal heart beat monitor

Fetal breathing

Fetal movements

Amniotic Fluid Volume

Flexion/Extension

Fetal Monitoring 4 accelerations in 40 minutes

Fetal Breathing 30 seconds

Fetal Movements Truncal

Flexion/Extension Arm/leg activity

Amniotic Fluid AFI > 5.0 cm

BPP of 8/10 or 10/10 is “normal” or “reassuring”

BPP of 6/10 requires some sort of intervention

modified biophysical profile

Modified Biophysical Profile

Combination of NST and AFI only

If less than 4/4

more evaluation is done

guidelines for reviewing fhr monitoring
Guidelines for Reviewing FHR Monitoring
  • normal patient
    • reviewed every 30 min in the first stage of labor
    • every 15 minutes in the second stage
  • complicated patients
    • every 15 minutes in first stage
    • Every 5 mins in second stage
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