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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


>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


  • 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


Late decelerations
Late Decelerations


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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