From NeoReviews Strip of the Month June 2014 Case Review From NeoReviews Strip of the Month June 2014

Baseline FHR Baseline FHR Approximate mean FHR rounded to increments of 5 beats/min during a 10 minute segment, excluding accelerations, decelerations, and periods of marked FHR variability. The baseline must be for a minimum of 2 minutes in any 10 minute segment. Normal baseline range is 110-160

Baseline (cont.) Definitions: Tachycardia: The baseline FHR is greater than 160 beats per minute. Bradycardia: The baseline FHR is less than 110 beats per minute.

Variability Fluctuations in the FHR baseline that are irregular in amplitude and frequency, measured from the peak to the trough. Absent- amplitude range is undetectable Minimal- amplitude range is detectable but less than 5 beats/min Moderate- Amplitude range 6-25 beats/min Marked- Amplitude range is greater than 25 beats/min.

FHR Changes Accelerations Visually apparent abrupt increase in the FHR from the baseline. The onset to the peak is less than 30 seconds. Before approximately 32 weeks, an acceleration has a peak of at least 10 beats/min above the bassline and duration of at least 10 seconds. After 32 weeks, an acceleration has a peak of at least 15 beats/min above the baseline and the duration is more than 15 seconds. Prolonged acceleration lasts more than 2 min but less than 10 min If an acceleration is longer than 10 min, it is a baseline change

Decelerations Early Late Variable Prolonged Occurs with a contractions, with a gradual onset (more than 30 seconds to nadir). Generally the nadir occurs at the same time as the peak of the contraction. Late Occurs in association with a contraction with a gradual onset. The Onset, nadir, and recovery occur after the beginning, peak, and end of the contraction. Variable An abrupt (onset to nadir is less than 30 seconds) decrease in the FHR. The decrease is at least 15 beats/min and lasts at least 15 seconds but less than 2 min. Prolonged Decrease in FHR at least 15 beats/min below the baseline, lasting at least 2 min but less than 10.

Three-tier FHR Classification System Category I Normal FHR tracing with all of the following baseline 110-160 FHR variability is moderate Accelerations are present or absent Without late or variable decelerations Early decelerations may be present

Category II Category III Includes all FHR tracings not assigned to Categories I or III Category III FHR tracing includes at least one of the following: Absent variability with late decelerations Absent variability with recurrent variable decelerations Absent variability with bradycardia for at least 10 minutes Sinusoidal pattern for at least 20 minutes

Contractions The number of contractions in a 10-minute window and averaged over 30 min. Normal: 5 or less contractions in 10 minutes Tachysystole: More than 5 contractions in 10 minutes.

PT: 26 yr old G2 P1 at 39 2/7 weeks arrives complaining of contractions and decreased fetal movement x 24 hours Denies leaking fluid Hx: Previous delivery was a c/section for breach presentation 4 years ago. Prenatal: normal, GBS Negative Cervix: 2-3 cm with bulging BOW. Plan: Pt is planning for a repeat c/s

EFM Strip #1. EFM Strip #1. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Maurice L. Druzin, and Nancy Peterson Neoreviews 2014;15:e249-e256 ©2014 by American Academy of Pediatrics

Interpretation Variability: Minimal to absent Baseline: 150 Episodic Patterns: None Periodic Patterns: Recurrent late decelerations Uterine Contractions: Every 2-4 min Interpretation: Category II to III

SBAR+R Report Situation Background Assessment Recommendation Read back

Actions Taken Physician notification Biophysical Profile Umbilical Artery Doppler study Klehauer-Betke test Positioned left lateral IV fluid bolus 500 mL Oxygen One hour later…

EFM Strip #2. EFM Strip #2. Maurice L. Druzin, and Nancy Peterson Neoreviews 2014;15:e249-e256 ©2014 by American Academy of Pediatrics

Interpretation Variability: Minimal to absent Baseline: 150 Episodic Patterns: None Periodic Patterns: Recurrent late decelerations Uterine Contractions: Every 2-4 min Interpretation: Category II to III

Actions taken Continued to monitor… 20 minutes later…

EFM Strip #3. EFM Strip #3. Maurice L. Druzin, and Nancy Peterson Neoreviews 2014;15:e249-e256 ©2014 by American Academy of Pediatrics

Interpretation Variability: Minimal Baseline: 155 Episodic Patterns: None Periodic Patterns: Recurrent late decelerations Uterine Contractions: Every 2-5 min Interpretation: Category II One hour later…

EFM Strip #4. EFM Strip #4. Maurice L. Druzin, and Nancy Peterson Neoreviews 2014;15:e249-e256 ©2014 by American Academy of Pediatrics

Interpretation Variability: Minimal Baseline: 155 Episodic Patterns: None Periodic Patterns: Recurrent late decelerations Uterine Contractions: Every 2-5 min Interpretation: Category II Patient prepared for repeat c/section.

What are your apgars? 1 1 6 1 minute 5 minutes 10 minutes Color: pale Pulse: <100 Grimace: no response Activity: Absent Resp: Absent 5 minutes 10 minutes Color: Acrocyanosis Pulse: >100 Grimace: some response Activity: some flexion Resp: Absent 1 1 6

Outcome Viable female 3.14 kg Apgar 1, 1, 6, & 8 at 1, 5, 10, & 15 min Velamentous insertion Meconium fluid Transported to NICU on ventilator Infant H/H 3/11 + Klehauer-Betke Estimated Fetal Blood loss 400mL

References: Druzin, M.L. & Peterson, N. (June 2014) Strip of the Month Review, NeoReviews 2014:15:e249, AAP Publications. Retrieved from neoreviews.aappublications.org Miller, L. A., Miller, D. A., & Tucker, S. M. (2013). Mosby’s Pocket Guide to Fetal Monitoring: A Multidisciplinary Approach (7th ed.). (St. Louis, MO). Elsevier, Mosby.