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Fetal Heart Rate Monitoring Paul G. Tomich, M.D. Department of Obstetrics and Gynecology University of Nebraska College of Medicine.

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Presentation on theme: "Fetal Heart Rate Monitoring Paul G. Tomich, M.D. Department of Obstetrics and Gynecology University of Nebraska College of Medicine."— Presentation transcript:

1 Fetal Heart Rate Monitoring Paul G. Tomich, M.D. Department of Obstetrics and Gynecology University of Nebraska College of Medicine

2 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)

3 “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

4 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

5 Uterine contractions Fetal heart rate (FHR) Ways to Monitor

6 Uterine contractions Fetal heart rate (FHR) Ways to Monitor

7 Features to Describe Fetal heart rate (FHR) – Top line on monitor strip Uterine contractions – Bottom line on monitor strip

8 Features to Describe Baseline Variability Accelerations Decelerations Trends over time Interpret into 1 of 3 categories

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

10 Baseline is RED LINE

11 Bradycardia <100 BPM Tachycardia >160 BPM Indeterminate – less than 2 minutes of baseline is present Baseline

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13 Fetal Tachycardia Normal variant – prematurity Intra-amniotic infection Fetal anemia Fetal cardiac arrhythmia (SVT) Fetal hypoxia

14 Features to Describe Baseline Variability Accelerations Decelerations Trends over time Interpret into 1 of 3 categories

15 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

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17 Variability

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20 Features to Describe Baseline Variability Accelerations Decelerations Trends over time Interpret into 1 of 3 categories

21 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

22 >15 beats above baseline 15 seconds to 2 minutes in length

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25 Features to Describe Baseline Variability Accelerations Decelerations Trends over time Interpret into 1 of 3 categories

26 Decelerations Decrease in baseline 3 Types – Early – Variable – Late

27 Deceleration Decrease in FHR

28 Early Deceleration Symmetrical to contraction Mirror image of contraction Gradual decrease in FHR – 30 secs or more from onset to nadir

29 EARLY DECELERATION  Gradual FHR decrease  Onset to nadir 30 seconds or more  Nadir of deceleration occurs with peak of contraction  Mirror contraction

30 Late Decelerations Deceleration is delayed in timing – Occurs after the contraction A gradual FHR decrease – Onset to nadir > 30 second

31 Late Decelerations

32 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

33 Variable Declerations Pathophysiology – umbilical cord compression

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37 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

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43 Sinusoidal Pattern Smooth sin-wave pattern Cycle frequency 3-5 mins Persists for 20 minutes or longer

44 Sinusoidal Pattern

45 Uterine Contractions Number of contractions in 10 minutes – averaged over thirty minutes Document – Frequency – Intensity – Duration – Relaxation time between contractions

46 Monitoring of Contractions

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48 Tachysystole >5 contractions in 10 mins – Averaged over 30 mins

49 Categorization of FHR Patterns An evaluation of the fetus at a particular point in time Categories I, II, and III

50 3 Categories

51 Category I Normal baseline – 110-160 BPM FHR Variability – moderate Late or Variable decelerations – none

52 Category II Not enough evidence to place into either Category I or III

53 Category III Abnormal tracing Predictive of abnormal fetal acid-base status Requires prompt intervention

54 The ABCD’s of Fetal Monitoring

55 Examples of Tracings

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63 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

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65 Reactive NST

66 NST + ultrasound markers Score linearly correlated with fetal pH Risk of fetal death within one week of normal BPP is 1:1300 Biophysical Profile (BPP)

67 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

68 Modified Biophysical Profile Combination of NST and AFI only If less than 4/4 more evaluation is done

69 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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