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

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. 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

11. 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 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

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

13. 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

14. 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

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

16. 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 seconds
Interpretation Category: III
Rui Wang, and Toni Golen Neoreviews 2016;17:e47-e54
©2016 by American Academy of Pediatrics

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

18. 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…

19. 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

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

21. 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

22. 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%

23. 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.