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

2. 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

3. 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.

4. 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.

5. 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

6. 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.

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

8. 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

9. 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.

10. 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

11. 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

12. 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

13. SBAR+R Report
Situation
Background
Assessment
Recommendation
Read back

14. 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…

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

16. 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

17. Actions taken
Continued to monitor…
20 minutes later…

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

19. 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…

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

21. 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.

22. 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

23. 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

24. 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.