Brian Levine, MD, MS, is board-certified in obstetrics and gynecology as well as in reproductive endocrinology and infertility. Am J Obstet Gynecol. The variable deceleration, prolonged deceleration, and sinusoidal fetal heart rate. He completed medical school at AIN Shams University in Cairo, Egypt, and completed a residency in family practice and a faculty development fellowship at the University of California, Davis, School of Medicine.... TREVOR W. HACKER, M.D., is associate medical director of the family practice residency program at Mercy Healthcare Sacramento and assistant clinical professor at the University of California, Davis, School of Medicine. AMIR SWEHA, M.D., is residency director and medical director at the family practice residency program at Mercy Healthcare Sacramento and assistant clinical professor at the University of California, Davis, School of Medicine. 7. 19. [2017] 1.10.48 Use the following classifications for fetal blood sample results: If you are having a non-stress test at the end of pregnancy, you can hear the fluctuations. Imagine what it would sound like if you had ongoing audio of your heart rate as you were starting to exercise and then cooling down. The variable deceleration, prolonged deceleration, and sinusoidal fetal heart rate. 1982;15:35–42. Nochimson DJ, 1971;78:865–81. Ⓒ 2021 About, Inc. (Dotdash) — All rights reserved. The presence of a saltatory pattern, especially when paired with decelerations, should warn the physician to look for and try to correct possible causes of acute hypoxia and to be alert for signs that the hypoxia is progressing to acidosis.21 Although it is a nonreassuring pattern, the saltatory pattern is usually not an indication for immediate delivery.19. 3. The effects of 5% Dextrose in Lactated Ringer's Injection on the duration of labor or delivery, on the possibility that forceps delivery or other intervention or resuscitation of the newborn will be necessary, and on the later growth, development, and functional maturation of the child are unknown. 1978;78:2110–2. Thus, it has the characteristic mirror image of the contraction (Figure 5). ACOG technical bulletin no. The true sinusoidal pattern is rare but ominous and is associated with high rates of fetal morbidity and mortality.24 It is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles per minute and an amplitude range of five to 15 bpm. 4. A pattern of persistent late decelerations is nonreassuring, and further evaluation of the fetal pH is indicated.16 Persistent late decelerations associated with decreased beat-to-beat variability is an ominous pattern19 (Figure 7). A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Notice that the onset and the return of the deceleration coincide with the start and the end of the contraction, giving the characteristic mirror image. Electronic fetal monitoring during labor. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow. Tachycardia greater than 200 bpm is usually due to fetal tachyarrhythmia (Figure 4) or congenital anomalies rather than hypoxia alone.16  Causes of fetal tachycardia are listed in Table 5. Assessment of fetal and newborn acid-base status. Reassuring pattern. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. Aust N Z J Obstet Gynaecol. Clin Perinatol. Lake M, However, during the process of labor, your baby may show signs of needing more intense monitoring or your labor or interventions may require increased monitoring to help boost the safety of procedures. Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. Roberts GM. It indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.24 It should be differentiated from the “pseudosinusoidal” pattern (Figure 11a), which is a benign, uniform long-term variability pattern. The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. This deceleration pattern also may be interpreted as a variable deceleration with late return to the baseline based on the early onset of the deceleration in relation to the uterine contraction, the presence of an acceleration before the deceleration (the “shoulder”) and the relatively sharp descent of the deceleration. Mean FHR rounded to increments of 5 bpm during a 10 min window, excluding: 1. This tracing probably represents cord compression and uteroplacental insufficiency. Administer oxygen through a tight-fitting face mask, Change maternal position (lateral or knee-chest), Administer fluid bolus (lactated Ringer's solution), Perform a vaginal examination and fetal scalp stimulation, When possible, determine and correct the cause of the pattern, Consider tocolysis (for uterine tetany or hyperstimulation), Consider amnioinfusion (for variable decelerations), Determine whether operative intervention is warranted and, if so, how urgently it is needed. The FHR tracing should be interpreted only in the context of the clinical scenario, and any therapeutic intervention should consider the maternal condition as well as that of the fetus. Unfortunately, precise information about the frequency of false-positive results is lacking, and this lack is due in large part to the absence of accepted definitions of fetal distress.7 Meta-analysis of all published randomized trials has shown that EFM is associated with increased rates of surgical intervention resulting in increased costs.8 These results show that 38 extra cesarean deliveries and 30 extra forceps operations are performed per 1,000 births with continuous EFM versus intermittent auscultation. Advanced Life Support in Obstetrics Course Syllabus. The second uterine contraction is associated with a shallow and subtle late deceleration. : American Academy of Family Physicians 1996:97–106, Adapted with permission from Wolkomir MS. Understanding and interpreting intrapartum fetal heart rate monitoring. 127. Beard RW, / By using Verywell Family, you accept our, Reading a Fetal Monitor Can Help You See How the Baby Is During Labor, 13 Milestones for Your Pregnancy After Miscarriage, The Options Parents Have When Being Sent Home After a False Labor, How to Tell Whether You're Having a Missed Miscarriage, 5 Simple Reasons Why You May Not Hear the Heartbeat Right Away, Tools You Can Use for Listening to Your Baby's Heartbeat at Home, Slowed Fetal Heartbeat During Pregnancy Can Be a Concern. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm. Fields LM, However, if your doctor notices that your baby's heartbeat is off by a week or more, it can indicate that a miscarriage is more likely. Boehm FH, 18. 9. Hon EH. 11. 1995;85:149–55. Be sure to talk to your midwife or doctor about the concerns that you have with your baby's heart rate. Copyright © 2020 American Academy of Family Physicians. SMFM Consult Series #36: Prenatal Aneuploidy Screening using Cell Free DNA. A Clinical Update on Prevention, Home Paul RH, Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline Goodlin RC, Immediate, unlimited access to all AFP content. Simply ask your practitioner for advice if you are concerned. Baltimore: Williams & Wilkins, 1996:433–42. The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. The normal heart rate for a fetus is anywhere between 120 and 160 beats per minute.This is a rare condition, occurring in only 1-2% of pregnancies, … 21. Determine whether accelerations or decelerations from the baseline occur. Martin CB Jr. 11. Jordaan HV, Weissman A, Hon EH. Kurse J. Fields LM, This use of a doppler in the home is not recommended for most mothers. Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis. The labor prior was latent on the precipice of converting to active labor. Clinical fetal monitoring. Persistent tachycardia greater than 180 bpm, especially when it occurs in conjunction with maternal fever, suggests chorioamnionitis. National Center for Health Statistics. : Public Health Service, 1995. Jordaan HV, Intrapartum fetal heart rate monitoring. 2018;28:3-16. doi:10.1016/j.spen.2018.05.002, ACOG Practice Bulletin No. 42, no. Intrapartum fetal heart rate monitoring. Lake M, Antepartum fetal heart rate monitoring. Bowen AW, 10. In the United States, an estimated 700 infant deaths per year are associated with intrauterine hypoxia and birth asphyxia.5 Another benefit of EFM includes closer assessment of high-risk mothers. Recently, second-generation fetal monitors have incorporated microprocessors and mathematic procedures to improve the FHR signal and the accuracy of the recording.3 Internal monitoring is performed by attaching a screw-type electrode to the fetal scalp with a connection to an FHR monitor. Clin Perinatol. Druzin ML. Some clinicians have argued that this unproven technology has become the standard for all patients designated high risk and has been widely applied to low-risk patients as well.9 The worldwide acceptance of EFM reflects a confidence in the importance of electronic monitoring and concerns about the applicability of auscultation.10 However, in a 1996 report, the U.S. Preventive Services Task Force7 did not recommend the use of routine EFM in low-risk women in labor. Milwaukee: Center for Ambulatory Teaching Excellence, Department of Family and Community Medicine, Medical College of Wisconsin, 1995:1–19. Monthly vital statistics report; vol. Washington, D.C.: ACOG, 1989. Bissonnette JM. 9(May 1, 1999) Suidan AK, Other maternal conditions such as acidosis and hypovolemia associated with diabetic ketoacidosis may lead to a decrease in uterine blood flow, late decelerations and decreased baseline variability.23. : American Academy of Family Physicians, 1996:97–106. Assessment of fetal and newborn acid-base status. Document in detail interpretation of FHR, clinical conclusion and plan of management. Clin Obstet Gynecol. Byrd JE. The significance of the changes in the continuous fetal heart rate in the first stage of labour. Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. If a Category III tracing does not resolve with these measures, delivery should be under-taken. Guzman ER, VII. Although detection of fetal compromise is one benefit of fetal monitoring, there are also risks, including false-positive tests that may result in unnecessary surgical intervention. Beat-to-beat or short-term variability is the oscillation of the FHR around the baseline in amplitude of 5 to 10 bpm. 1. Accelerations in the fetal heart rate of 10 beats/min above baseline 4. Adapted with permission from Byrd JE. The FHR is controlled by the autonomic nervous system. 1979;133:762–72. 1.10.45 Do not take a fetal blood sample during or immediately after a prolonged deceleration. A nurse is checking the external fetal monitor of a client in active labor. 1985;153:717–20. The transducer uses Doppler ultrasound to detect fetal heart motion and is connected to an FHR monitor. Beard RW, Table 1 lists examples of the criteria that have been used to categorize patients as high risk. Advance report of maternal and infant health data from the birth certificate, 1991. The normal FHR range is between 120 and 160 beats per minute (bpm). Management should include treatment of the uterine hyperstimulation. Nonreassuring pattern of late decelerations with preserved beat-to-beat variability. Insler V. The descent and return are gradual and smooth. Am J Obstet Gynecol. Prematurity, maternal anxiety and maternal fever may increase the baseline rate, while fetal maturity decreases the baseline rate. Some moms feel better when they can monitor the baby's heartbeat from home. The electronic evaluation of the fetal heart rate. Fetal heart rate patterns are classified as reassuring, nonreassuring or ominous. Obstet Gynecol. Society for Maternal-Fetal Medicine (SMFM) Consult Series #38: Hepatitis B in Pregnancy- Screening, Treatment and Prevention of Vertical Transmission. Note the onset at the peak of the uterine contractions and the return to baseline after the contraction has ended. 42, no. Lowe EW. Reversal of fetal distress following intensive treatment of maternal diabetic ketoacidosis. However, variability is preserved. The fetal membranes must be ruptured, and the cervix must be at least partially dilated before the electrode may be placed on the fetal scalp. Gimovsky ML, Fetal tachycardia with possible onset of decreased variability (right) during the second stage of labor. 1974;43:22–30. Clin Perinatol. Conclude whether the FHR recording is reassuring, nonreassuring or ominous. [2017] 1.10.47 Use either pH or lactate when interpreting fetal blood sample results.
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