1. Electronic Fetal Heart Rate Monitoring
AKA “reading strips”
G1 OB skills workshop-
July 31st 201

2. Goals Become familiar looking at electronic fetal heart rate tracings
Learn a systematic approach to electronic fetal monitoring (EFM) interpretation

3. Objectives List the three risk based categories of EFM interpretation
Demonstrate an organized approach to reading a strip
Correctly identify early decelerations, variable decelerations, late decelerations

4. EFM: The Basics Used to assess fetal well being
External vs. internal monitoring
Intermittent vs. continuous monitoring
Constant and minuute adjustments in response to the fetal environment and stimuli

5. EFM: The Basics
FHR tracings should be evaluated in the context of the clinical situation. This includes (but is not limited to):
Gestational age
Prior results of fetal assessment
Medications
Maternal medical conditions
Fetal conditions

6. External monitors

7. Internal monitors-IUPC and FSE

8. Systematic approach Baseline fetal heart rate and trend
variability
Uterine contractions (frequency and duration)
Periodic Heart Rate Changes
Accelerations and Decelerations
Changes or trends over time

9. DRCBRAVADO (ALSO mnemonic)
Define Risk
Contractions (in 10 mins)
Baseline Rate (should be )
Variability (should be greater than 5)
Accelerations
Decelerations
Overall (normal or not)

10. Systematic Approach Final interpretation
Category I
Category II
Category III
Develop an assessment and plan and DOCUMENT it

11. Categories
A new classification system from the National Institute of Child Health and Human Development Workshop Report
Based on available evidence and consensus statements

12. Key Guidelines
FHR decels as an independent finding are poorly predictive of complicated outcomes
The degree of variability is the MOST sensitive indicator of the adequacy of oxygen delivery to the fetus at any given moment in time

13. Pattern Evolution
Recognizing changes in the FHR tracing over time is the key element of FHR interpretation.
A hypoxia-induced reduction in FHR variability develops gradually over about minutes

14. Progress Note Example
Subjective
Objective
Toco: baseline 130s, good variability
reactive, occ. variable deceleration
Ctx: q 3 min., regular, palpate moderate intensity
Cervix: 5/80/-1
A/P: G3P2 at term. Category 1 tracing. Expectant management. Anticipate NSVD.

15. Contractions
The number of contractions present in a 10 minute window averaged over 30 minutes.
Normal: less than or equal to 5
Tachysystole: more than 5
Avoid the terms “hyperstimulation” and “hypercontractility”

16. Category I-Normal Baseline rate between 110-160 bpm
Moderate baseline variability
May lose variabilty for minutes during fetal sleep cycles. This is OK.
Accelerations present (or absent)
Early decelerations may be present
No late or variable decelerations

17. Moderate Variability

18. Variability
Classifications-Detemined in a 10 min window excluding accelerations and decelerations
Absent: amplitude range undetectable
Minimal: amplitude more than undetectalbele and less than 5 bpm
Moderate amplitude range 6-25 bpm
Marked: amplitude range >25 bpm

19. Accelerations

20. Accelerations
Reliably predict the absence of fetal maetabolic acidemia
However…REMEMBER the absence off accelerations does NOT reliably predict fetal acidemia.

21. Early Decelerations

22. Early Decelerations

23. Category II-The Messy Middle
Fetal tachycardia (>160 bpm)
Fetal bradycardia (<110 bpm)
With preserved baseline variability
Minimal or Marked baseline variability
Absence of induced accelerations after fetal stimulation

24. Category II
Variable decelerations associated with minimal or moderate variability
Variable Decels with shoulders
Late decelerations with preserved moderate baseline variability
Prolonged decelerations (greater than 2 minutes, but less than 10)

25. Category II Tracings
If you have a category II tracing you need to do something to try and make it better.
Oxygen, change in position, d/c pitocin, etc.
Consider making the OB team aware of the situation as well.

26. Category II INDETERMINATE
Not predictive of abnormal fetal acid base status, yet no adequate evidence to classify as Category I or III.

27. Fetal Tachycardia

28. Fetal Bradycardia

29. Late Decelerations

30. Variable Decelerations with Shoulders

31. Saltatory variability

32. Category III - Abnormal
Absent baseline varibility and any of the following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern

33. Category III
FHR tracing with persistent absent or minimal variability with recurrent decels or bradycardia hold the strongest association with fetal acidemia and/or the absence of neonatal vigor at birth

34. Ominous tracings
Usually requires IMMEDIATE delivery if the tracing is persistently a category III
If vaginal delivery is close, move to operative vaginal delivery.
If vaginal delivery not imminent, then a c-section is needed.

35. Decreased Variability

36. Late Decelerations with absent variability

37. Sinusoidal pattern

38. Now it’s your turn…..

39. Practice
Fetal tachycardia, loss of varibility, small variable decels

40. Practice
Reacitve strip, no contractions

41. Practice

42. Practice
Pseudosinusoidal pattern- non-reassuring but not ominous

43. Objectives List the three risk based categories of EFM interpretation
Demonstrate an organized approach to reading a strip
Correctly identify early decelerations, variable decelerations, late decelerations