From NeoReviews Strip of the Month January 2016 Case Review From NeoReviews Strip of the Month January 2016

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.

Presentation: Pt: 30 yr old G1 P0 at 38 3/7 weeks goes to OB office with c/o spontaneous ROM. + meconium Cervical exam: dilation 1cm, 40% effaced, -2, midposition. + fetal movements No bleeding GBS Negative Sent to hospital for admission

Electronic fetal monitoring strip 1. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Moderate Baseline rate: 145 Episodic patterns: None Periodic patterns: None Uterine contractions: Every 2 minutes, lasting 30-45 seconds Interpretation: Category I Normal fetal acid-base status Rui Wang, and Toni Golen Neoreviews 2016;17:e47-e54 ©2016 by American Academy of Pediatrics

SBAR+R Report Situation Background Assessment Recommendation Read back

Actions Taken Misoprostol 25 mcg placed vaginally. Three hours later: Cervix 2 cm dilated, 80 % effaced and -2 station Vital signs normal No vaginal bleeding Contractions increasing in strength

Electronic fetal monitoring strip 2. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Minimal to moderate Baseline: 150 Episodic patterns: Variable deceleration (Peak to nadir in <30 seconds) Periodic patterns: None Uterine contractions: Every 2-3 minutes Interpretation: Category II Rui Wang, and Toni Golen Neoreviews 2016;17:e47-e54 ©2016 by American Academy of Pediatrics

Actions taken Repositioned to improve uterine blood flow and fetal oxygenation IV bolus Continuous fetal monitoring One hour later…

Electronic fetal monitoring strip 3. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: Minimal to absent Baseline 150 Episodic Patterns: None Periodic patterns: Oscillations of the sinusoidal wave form above and below the baseline with amplitude of oscillations of 5 beats per minute and frequency of oscillations of 3 cycles per minute Uterine contractions: Every 3 minutes, lasting 60-80 seconds Interpretation Category: III Rui Wang, and Toni Golen Neoreviews 2016;17:e47-e54 ©2016 by American Academy of Pediatrics

SBAR+R Report Situation Background Assessment Recommendation Read back

Actions Taken Sinusoidal FHR pattern may be due to chronic fetal anemia, acute intrapartum asphyxia, fetal-maternal hemorrhage, or fetal in utero hemorrhage Emergency C/Section discussed 10 min later…

Electronic fetal monitoring strip 4. Contractions present? Normal or tachysystole? FHR Baseline? Variability? Accels or Decels? Category? Interpretation: Variability: absent Baseline 150 Episodic Patterns: Variable decelerations present Periodic patterns: Sinusoidal wave form with amplitude of oscillations of 5 beats per minute and frequency of oscillations of 3 cycles per minute Uterine contractions: Every 2 minutes, lasting 60 seconds Interpretation Category: III Rui Wang, and Toni Golen Neoreviews 2016;17:e47-e54 ©2016 by American Academy of Pediatrics

Outcome Emergency C/Section Delivery within 20 minutes of decision No signs of abruption seen

What are your apgars? 6 8 1 minute : 5 minutes: Color: Pale Pulse >100 Grimace: weak cry Activity: arms and legs flexed with slow movement Resp: irregular respirations 5 minutes: Color: Pale Pulse > 100 Grimace: vigorous cry Activity: arms and legs flexed with slow movement Resp: regular respirations 8 1 minute Color: pale Pulse: <100 Grimace: no response Activity: Absent Resp: Absent 5 minutes

Outcome Viable female 2675 g Apgar 6 & 8 at 1 & 5 minutes Pale, despite blow by oxygen Meconium fluid Transported to NICU Infant Hematocrit 14.9% Kleihauer-Betke on mom 3% Transfusion 30mL/kg PRBC Repeat Hematocrit on day one: 44.3%

References: Wang, R. & Golen, T. (January 2016) Strip of the Month Review, NeoReviews 2016: 17 (1) e47-e54, AAP Publications. Retrieved from neoreviews.aappublications.org on March 30, 2016. 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.