Fetal Heart Rate Monitoring Paul G. Tomich, M.D. Department of Obstetrics and Gynecology University...
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Transcript of Fetal Heart Rate Monitoring Paul G. Tomich, M.D. Department of Obstetrics and Gynecology University...
Fetal Heart Rate Monitoring
Paul G. Tomich, M.D.
Department of Obstetrics and Gynecology
University of Nebraska College of Medicine
Learning Objectives
EvolutionExamplesDescriptions
– Reassuring patterns– Concerning patterns
Definitions of Category I, II, and III tracings– Discuss action needed
Non-stress Test (NST)Biophysical Profile (BPP)
“Evolution” of FHR Monitoring
Monitoring fetus in laborFHR patterns
– Good outcomes– Poor outcomes
Contraction Stress Test (CST)Non Stress Test (NST)Biophysical profile (BPP)Categorization of FHR Tracing into Category I, II, and III
Categorization of FHR Tracings
Recommendation of three-tiered system– April 2008– More standardized interpretation
Concept: Interpretation of a FHR monitor strip is a dynamic process, with determination of whether a particular strip is reassuring and what action plans should be taken… and then to evaluate at a later time
Uterine contractionsFetal heart rate (FHR)
Ways to Monitor
Uterine contractionsFetal heart rate (FHR)
Ways to Monitor
Features to DescribeFetal heart rate (FHR)
– Top line on monitor stripUterine contractions
– Bottom line on
monitor strip
Features to DescribeBaselineVariabilityAccelerationsDecelerationsTrends over timeInterpret into 1 of 3 categories
Baseline
Mean fetal heart rate– Rounded to increments of 5– During a 10 minute period– Excluding accelerations and decelerations
Normal baseline– 100-160 BPM
Baseline is RED LINE
Bradycardia<100 BPM
Tachycardia>160 BPM
Indeterminate– less than 2 minutes of baseline is present
Baseline
Fetal Tachycardia
Normal variant– prematurity
Intra-amniotic infectionFetal anemiaFetal cardiac arrhythmia (SVT)Fetal hypoxia
Features to DescribeBaselineVariabilityAccelerationsDecelerationsTrends over timeInterpret into 1 of 3 categories
Variability
Fluctuations in FHR– Over 10 minutes
Descriptors are:– Absent: undetectable amplitude range– Minimal: undetectable up to 5 BPM– Moderate: amplitude range 6 to 25 BPM– Marked: amplitude range greater than 25 BPM
Variability
Features to DescribeBaselineVariabilityAccelerationsDecelerationsTrends over timeInterpret into 1 of 3 categories
Accelerations
Abrupt increase in FHR– At least 15 BPM above baseline
Duration– Must last 15 seconds to 2 minutes
Prolonged accelerations – Last 2 minutes to 10 minutes
Baseline change– Acceleration lasting 10 mins or longer
>15 beats above baseline15 seconds to 2 minutes in length
Features to DescribeBaselineVariabilityAccelerationsDecelerationsTrends over timeInterpret into 1 of 3 categories
Decelerations
Decrease in baseline3 Types
– Early– Variable– Late
Deceleration
Decrease in FHR
Early Deceleration
Symmetrical to contraction
Mirror image of contraction
Gradual decrease in FHR– 30 secs or more from
onset to nadir
EARLY DECELERATION
Gradual FHR decrease Onset to nadir 30 seconds or more Nadir of deceleration occurs with peak of
contraction Mirror contraction
Late Decelerations
Deceleration is delayed in timing – Occurs after the contraction
A gradual FHR decrease– Onset to nadir > 30 second
Late Decelerations
Variable Decelerations
Abrupt decrease in fetal heart rate– Onset to nadir less than
30 secondsDecrease in FHR
– 15 BPM or more– Lasting 15 seconds to 2
mins
Variable Declerations
Pathophysiology– umbilical cord
compression
DecelerationsProlonged deceleration
– Decrease of 15 BPM– Lasts 2-10 minutes
Baseline change – Deceleration lasting at least 10 mins
Description– Intermittent
Less than 50% of contractions in 20 minutes– Recurrent
More than 50 % of contractions in 20 minutes
Sinusoidal Pattern
Smooth sin-wave patternCycle frequency 3-5 minsPersists for 20 minutes or
longer
Sinusoidal Pattern
Uterine Contractions
Number of contractions in 10 minutes– averaged over thirty minutes
Document– Frequency– Intensity– Duration– Relaxation
time between contractions
Monitoring of Contractions
Tachysystole
>5 contractions in 10 mins– Averaged over 30 mins
Categorization of FHR Patterns
An evaluation of the fetus at a particular point in time
Categories I, II, and III
3 Categories
Category I
Normal baseline– 110-160 BPM
FHR Variability – moderate
Late or Variable decelerations– none
Category II
Not enough evidence to place into either Category I or III
Category III
Abnormal tracingPredictive of abnormal fetal acid-base statusRequires prompt intervention
The ABCD’s of Fetal Monitoring
Examples of Tracings
Non-Stress Test
•Reactive•2 or more accelerations in 20 mins•Acceleration
•At least 15 beats above baseline•Lasting for at least 15 seconds
•Non-reactive
Reactive NST
NST + ultrasound markersScore linearly correlated with fetal pHRisk of fetal death within one week of normal
BPP is 1:1300
Biophysical Profile (BPP)
Biophysical Profile
•Zero or 2 points for each•Fetal heart beat monitor•Fetal breathing•Fetal movements•Amniotic Fluid Volume•Flexion/Extension
•Fetal Monitoring 4 accelerations in 40 minutes•Fetal Breathing 30 seconds•Fetal Movements Truncal•Flexion/Extension Arm/leg activity•Amniotic Fluid AFI > 5.0 cm
•BPP of 8/10 or 10/10 is “normal” or “reassuring”•BPP of 6/10 requires some sort of intervention
Modified Biophysical Profile
•Combination of NST and AFI only•If less than 4/4
•more evaluation is done
Guidelines for Reviewing FHR Monitoring
normal patient– reviewed every 30 min in the first stage of labor– every 15 minutes in the second stage
complicated patients– every 15 minutes in first stage– Every 5 mins in second stage