Fetal Heart Rate Monitoring

Paul G. Tomich, M.D.
Department of Obstetrics and Gynecology
University of Nebraska College of Medicine

Learning Objectives
 Evolution
 Examples
 Descriptions
– 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 labor
 FHR 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

with determination of whether a particular strip is reassuring and what action plans should be taken… and then to evaluate at a later time . 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.

Ways to Monitor  Uterine contractions  Fetal heart rate (FHR) .

Ways to Monitor  Uterine contractions  Fetal heart rate (FHR) .

Features to Describe  Fetal heart rate (FHR) – Top line on monitor strip  Uterine contractions – Bottom line on monitor strip .

Features to Describe  Baseline  Variability  Accelerations  Decelerations  Trends over time  Interpret 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 .

Baseline  Bradycardia <100 BPM  Tachycardia >160 BPM  Indeterminate – less than 2 minutes of baseline is present .

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Fetal Tachycardia  Normal variant – prematurity  Intra-amniotic infection  Fetal anemia  Fetal cardiac arrhythmia (SVT)  Fetal hypoxia .

Features to Describe  Baseline  Variability  Accelerations  Decelerations  Trends over time  Interpret 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 .

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Variability .

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Features to Describe  Baseline  Variability  Accelerations  Decelerations  Trends over time  Interpret 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 baseline 15 seconds to 2 minutes in length .

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Features to Describe  Baseline  Variability  Accelerations  Decelerations  Trends over time  Interpret into 1 of 3 categories .

Decelerations  Decrease in baseline  3 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 seconds  Decrease in FHR – 15 BPM or more – Lasting 15 seconds to 2 mins .

Variable Declerations  Pathophysiology – umbilical cord compression .

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Decelerations  Prolonged 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 .

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Sinusoidal Pattern  Smooth sin-wave pattern  Cycle frequency 3-5 mins  Persists 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 .

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Tachysystole  >5 contractions in 10 mins – Averaged over 30 mins .

II. and III . Categorization of FHR Patterns  An evaluation of the fetus at a particular point in time  Categories I.

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 tracing  Predictive of abnormal fetal acid-base status  Requires prompt intervention .

The ABCD’s of Fetal Monitoring .

Examples of Tracings .

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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 .

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Reactive NST .

Biophysical Profile (BPP)  NST + ultrasound markers  Score linearly correlated with fetal pH  Risk of fetal death within one week of normal BPP is 1:1300 .

Biophysical Profile •Zero or 2 points for each •Fetal heart beat monitor •Fetal breathing •Fetal movements •Amniotic Fluid Volume •Flexion/Extension .

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 .