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Principles of Fetal

Monitoring Interpretation

Christina Westveer, MSN, RNC-MNN, CCE

Katie Leon Guerrero, RN, RNC-OB, C-EFM

• Review NICHD definitions and practice application of definitions

• Apply a standardized approach to EFM management

• Learn key strategies for communication

• Review key elements of documentation

NICHD Terminology

• NICHD-1997 • Identified standard

• ACOG-2005 terminology

• AWHONN-2005 • Developed three-tier fetal

heart rate interpretation
• ACNM-2006
• NICHD reaffirmed-2008
• All should be using the same
NICHD Terminology

The purpose of describing FHR characteristics according to NICHD

categories is:

• “To communicate effectively in the event that an abnormal CTG exists

and invoke an appropriate level of concern,”

• To use standardized, quantitative nomenclature “in order to reduce

miscommunication among providers caring for the laboring patient,
[and] propagate consistent, evidence-based responses to CTG
- Barrett Robinson, MD, MPH, Latasha Nelson, MD
Maternal Fetal Medicine, Northwestern Memorial Hospital, Chicago, IL
FHR Tracing Evaluation

Qualitative and quantitative description:

• Baseline rate

• Baseline variability

• Presence of accelerations

• Periodic or episodic decelerations

• Changes/trends over time

• Uterine contraction evaluation

Baseline FHR

• Baseline range is 110-160

• Baseline FHR is the approximate mean rounded to increments
of 5 bpm during a 10 minute segment
• Baseline is documented as a single number
• There must be ≥ 2minutes of identifiable baseline segments
(not necessarily contiguous) in a 10-minute window to
determine baseline
• Definition excludes:
• Periodic or episodic changes
• Marked variability

• Undetectable from baseline

• Visually detectable, <5bpm

• 6-25 bpm

• >25 bpm

• Excluded from definition of variability

• Smooth sine wave-like pattern with regular frequency and amplitude
• 3-5 cycles per minutes
• Must be present for 20 minutes for diagnosis
• Severe fetal anemia, amnionitis, fetal sepsis, narcotics
• Can we use terminology “pseudo-sinusoidal”?

• Visually apparent abrupt increase from baseline

• Term fetus
• Onset to peak <30 seconds
• Peak > 15 bpm
• Duration > 15 seconds <2 minutes
• Preterm fetus
• Onset to peak <30 seconds
• Peak >10 seconds
• Duration >10 seconds
• Prolonged acceleration
• > 2 minutes, <10 minutes
• > 10 minutes is a baseline change
Critical thinking: Are these accels?
Critical thinking: Are these accels?
Critical Thinking: Accels

If FHR accelerations only occur during contractions, should

you be suspicious?

• Increasing the heart rate is the only way a fetus can increase cardiac
output in the setting of hypoxemia.

• Increased heart during contractions is also a pattern consistent with

maternal fetal signal ambiguity
Early Decelerations

• Usually symmetrical, gradual decrease in fetal heart rate and

return to baseline associated with uterine contractions
• Onset to nadir is > 30 seconds
• The nadir of the deceleration usually occurs at the same time
of the peak of the contraction.
Earlies v. Variables
Variable Decelerations

• An abrupt decrease in fetal heart rate below the baseline

which may or may not be associated with uterine contractions
• Onset to beginning of nadir is < 30 seconds
• The decrease in fetal heart rate below the baseline is > 15
beats per minute, lasting 15 seconds or more, but less than 2
Variable Decelerations – Incorrect Terms
Late Decelerations

• Based on visual assessment.

• Gradual decrease in fetal heart rate and return to baseline
associated with uterine contractions
• Onset to nadir ≥ 30 seconds. The nadir of the deceleration
usually occurs after the peak of the contraction
Lates with Moderate Variability
Prolonged Deceleration

Prolonged Deceleration
• Decrease of >15 bpm from baseline
• Duration >2 minutes
• Less than 10 minutes
• Change of baseline >10 minutes
• Gradual or abrupt onset
Prolonged Deceleration

Points of NICHD

• Moderate variability reliably predicts the absence of metabolic acidemia

at the time of the observation
• Converse not true: Absence of moderate variability does not mean abnormal
acid-base status

• Accelerations, stimulated or spontaneous, reliably predicts the absence

of metabolic acidemia at the time of the observation
• Converse not true: Absence of accelerations does not reliably predict fetal
Normal Uterine Activity

Normal: < 5 contractions in 10 minutes, averaged over a

30 minute window
How is an abnormal contraction pattern

• Tachysystole: >5 contractions in 10 minutes, averaged over a

30 minute window

• Tachysystole should always be qualified as to the presence or

absence of associated FHR decelerations
• This does not mean we wait until there are FHR decelerations to

• The term tachysystole applies to both spontaneous AND

stimulated labor.
Normal Uterine Activity

Normal: < 5 contractions in 10 minutes, averaged

over a 30 minute window

Resting time between contractions should be ≥ 60

seconds in the 1st stage of labor and ≥ 45 seconds in
the 2nd stage of labor
Interventions-Physiologic Goals

• Support maternal coping and labor progress

• Maximize uterine blood flow
• Late
• Position changes, IV fluids, reduce uterine activity, reduce anxiety/pain
• Maximize umbilical circulation
• Variable
• Position changes, Amnioinfusion
• Maximize oxygenation
• Minimal or absent variability
• Position changes, IV fluids, oxygen
• Maintain appropriate uterine activity
• Tachysystole
• Position changes, fluids, reduce uterine activity
Fetal Scalp Stimulation

• Noninvasive procedure for evaluating acid-base status

• Used for Category II FHR (indeterminate)

• i.e. no spontaneous acceleration, minimal variability

• Performed during segments of baseline

• Not during decelerations or bradycardia

• NOT a method of intrauterine resuscitation

Signal Ambiguity
Category II
• Cat II Algorithm PeriGen
Category II
Significant Decelerations

• Variables lasting longer than 60 seconds and reaching a nadir more

than 60 bpm below the baseline

• Variables lasting longer than 60 seconds and reaching a nadir of less

than 60 bpm regardless of the baseline

• Any late decelerations of any depth

• Any prolonged decelerations

Caveat – NICHD Category III

• Category III does not require “significant” decelerations. Only

absent variability with recurrent decelerations.

Categories – Critical Thinking

Does a reactive NST = a Category 1 tracing?

Does a Category 1 tracing = reactive NST?


So why do we have categories and algorithms?


• Essential to ensure safety

• All providers on the team should contribute
• Effective patient-centered communication can contribute to reduction in
medical-legal exposure
• Clear, direct, explicit, timely
• Use NICHD definitions
• Debrief-essential after events
• What went well
• What could we improve upon
• Was everyone aware of their role

• Joint Commission Sentinel Event Alert #30 – 2004: “Preventing infant

death and injury during delivery”
• Of the studied cases, TJC found communication issues as the top root cause in
72% of poor outcomes

• We are teaching the nurses to communicate with NICHD terminology -

insist they use it!

Clear, direct, explicit, timely

• Use Parameters for actions, interventions, and callbacks

• Ask for clarification

• Use readback/repeat back when verbal or telephone orders are


• State what you need or expect. Do not make assumptions.

• ”Close the loop” in emergencies


Use NICHD Terminology


• Streamlined, factual, and objective

• Timely

• Clinically relevant information

• Detailed descriptions not needed-use NICHD terminology


Streamlined, factual, and objective

• Use a systematic approach to evaluating EFM and labor

• Cover every component – Baseline, variability, accels, decels (recurrent or
intermittent), contractions frequency, duration, strength, resting tone, MVUs

• Don’t neglect evolution of the pattern

• Be sure your templates incorporate the critical components


Streamlined, factual, and objective

“Reassuring” ≠ Category 1. Please don’t chart it if there are decels.


Streamlined, factual, and objective

Documentation and Communication

• Did the nurse documenting ”no decels or fetal heart tones problems”
mean there were none?

• On the flip side, had it been a category 1 strip and the nurse
documented variable and late decelerations, would that have made any
difference in the outcome of the baby?

• What if a nurse documents a late deceleration or minimal variability and

you disagree?
Documentation and Communication

Use NICHD definitions to discuss the strip with the RN

• Evaluate lates vs variables: Is the onset to nadir > or < 30 seconds?

• Is it a variable or variability? Is the depth at least 15 bpm off the baseline

and at least 15 second long?

• Evaluates variables vs. Earlies: is the onset to nadir > or < 30 seconds?

• What was the variability before and after the FHR change? Were there
Elements of Medical Malpractice

1. Duty

2. Breach of Duty

3. Causation

All three must be identified for successful plaintiff litigation.


When reviewing a labor chart for legal purposes, one wants to see:
• The FHR strip was accurately assessed and interpreted
• *More importantly,* if required, appropriate and timely interventions
were employed, i.e.
• Continue to monitor (EFM, vital signs, labs, etc)
• Notify MD
• Maternal lateral positioning
• IVF bolus
• Decrease/DC pitocin/tocolysis
• Some assessment of fetal acid/oxygenation status – NST, BPP, Scalp stim
• These interventions were evaluated for effectiveness within a timely
• If ineffective, the next interventions were carried out within a timely manner


Evaluation Plan

10 Rules of Labor Eval for Attorneys

1. Is labor progressing normally? Are you confident the baby will be

safely vaginally delivered?
2. Is safe vaginal delivery remote?
3. Is FHR variability decreasing or worsening?
4. Is there oxytocin induced tachysystole?
5. Obstetric threats to fetal reserve?
6. Rising or falling baseline?
7. Deterioration? More decels or loss of accels?
8. Was resuscitation started and is it working?
9. Is it fetal or maternal heart rate?
10. Is the OR & delivery team available?
-Dov Apfel, President Birth Injury Litigation Group AAJ, Janet, Janet & Suggs
Future Topics?

• Operative Vaginal Delivery

• Advanced Concepts in FHM, Fetal Oxygenation and Pathophysiology

• Updates on Hypertensive Disorders and Postpartum Hemorrhage

• What would you like to know more about? We want to hear your

• AWHONN. (2015). Fetal Heart Monitoring Principles and Practices (5th

ed.). Washington, DC: Kendall Hunt.
• Clark, L. C., Mageotte, M. P., Garite, T. J., Freeman, R. K., Miller, D. A.,
Simpson, K. R., . . . Hankins, G. D. (2013). Intrapartum management of
category II fetal heart rate tracings: Towards standardization of care.
American Journal of Obstetrics & Gynecology, 89-97.
• Macones, G. A., Hankins, G. D., Spong, C. Y., Hauth, J., & Moore, T.
(2008). The 2008 national institute of child health and human
development workshop report on electronic fetal monitoring: Update on
definitions, interpretation, and research guidelines. JOGNN, 37, 510-
Thank You

Thank you for attending!