Intrapartum Fetal

Surveillance
Tim Fader MD
November 21, 2012

Learning Objectives
Role of continuous fetal heart
monitoring in Somaliland
Procedure and timing of Intermittent
Auscultation
Interpretation of Fetal Heart Rate
Patterns
Management of FHR Patterns
Intrauterine Resuscitation

Fetal Surveillance
Purpose: to identify and treat
hypoxemia and acidosis in the fetus,
during labor, to prevent a poor
outcome
Techniques
Continuous fetal heart monitoring
(CFHM)
Intermittent Auscultation (IA)

Continuous Fetal Heart

Monitoring
Expensive Equipment
Uncomfortable
Outcome: limited improvement demonstrated
No difference in 1-minute APGAR below 7
No difference in admissions to neonatal nursery
No difference in rate of cerebral palsy
No difference in perinatal death
Some decrease in neonatal seizures
Marked increase in C-sections and assisted vaginal
deliveries.

Intermittent Auscultation
Cheap
Requires investment in training

Nurses
Doctors

Requires 1:1 ratio of nurse to

laboring patient

IA Technique

Doppler with speaker

Position of fetus
Point of maximum intensity
Maternal versus fetal pulse
Palpate uterine contraction
Count FHR between contractions for
baseline
Count FHR during and immediately after
contraction

When do you Listen?

On admission
Every 15-30 minutes during active
phase of labor
Every 5-10 minutes during second
stage
Before any change in management
(drugs, augmentation, walking,
anesthesia, etc)
After rupture of membranes
With abnormal uterine activity

Continuous Fetal Heart

Monitoring

Basic Fetal Monitoring

Fetal Heart Tones

1 min

Uterine Contractions

Fetal Monitoring
DR C BRAVADO

Determine Risk
Contractions
Baseline Rate
Variability
Accelerations
Decelerations
Overall Assessment

Interpretation of Fetal Heart Rate:

Dr. C Bravado
Determine Risk
- Admission History and Physical
- Laboratory results
- Review partograph
- Talk with midwife

Contractions
Frequency
- Normal: 5 or less per 10 minutes
- Tachysystole: more than 5 per 10
minutes
Strength
Duration

Baseline Rate
Between contractions
Normal 110-160 over 10 minutes
Bradycardia (<110): postdates, OP
position, fetal heart disease, fetal acidosis
Tachycardia (>160):
Maternal causes: anxiety, fever, dehydration,
ketosis, terbutaline, thyrotoxicosis, anemia ,
infection
Fetal causes: prematurity, congenital heart
disease (>200)

Variability
Difficult to define with intermittent
auscultation

Beat-to-beat changes in heart rate

Absent
Minimal
Moderate
Marked
5-25 BPM is normal
Moderate: reassuring of active fetal CNS
Absent: sleep cycle, medications, hypoxia

Absent Variability
Undetectable variation from
baseline

Minimal

From undetectable to 5 bpm variabilit

Variability

Moderate Variability
from 6 to 25 bpm of
variation

Marked Variability

Greater than 25 bpm of variabi

Accelerations
Fetal heart rate change above the
baseline rate
Less than 32 weeks gestation:
Rise of 10 bpm for 10 seconds
Greater than 32 weeks gestation:
Rise of 15 bpm for 15 seconds
Changes longer than 10 minutes are
either tachycardia or bradycardia

Accelerations

Decelerations
Fetal heart rate change below the baseline
May describe as gradual or abrupt onset
Gradual - onset to low point > 30 sec
Abrupt - onset to low point < 30 sec
Type of deceleration
Compare lowest point of deceleration to
peak of contraction
Early, late, and variable decelerations

Decelerations
Early
Gradual decrease
Mirrors contraction (nadir at same time
as peak)
Onset to nadir>30 seconds
Head compression
benign

Early Deceleration

Decelerations
Variable
Abrupt decrease
Onset to nadir <30
seconds
Decrease >15 bpm,
Duration >15 seconds
to 2 minutes
V or W shaped
Variable in size,
shape, depth,
duration, and timing
relative to contraction

Cord compression
Watch out: late
onset following
contraction, slow
recovery, decreased
variability, baseline
tachycardia, loss of
accelerations,
increased depth,
repetitive

Variable Decelerations

Decelerations
Late
Gradual decrease in FHR
Onset to nadir >30 seconds
Nadir and recovery follow contraction
Caused by uteroplacental insufficiency,
fetal hypoxia, abruption, IUGR

Late Decelerations

Note low point of deceleration

occurs after peak of contraction;
however still looks U-shaped or like
an inverted contraction

Late Decelerations

Overall Assessment
Risk assessment + classification of
FHR pattern

Categorization of FHT
Patterns
Category I: normal fetal pH
Normal baseline, good variability, no late or
variable decelerations, may have early
decelerations or accelerations
Treatment: continue monitoring

Category II: Indeterminate

Everything not category I or III
Treatment: If accelerations and good variability:
resuscitate and follow; if no accelerations and
poor variability, resuscitate and consider
delivery

Categorization
Category III
- Sinusoidal pattern
- Absent variability with recurrent
late or
variable decelerations, or
bradycardia
- Treatment: resuscitate; if no
response, deliver

Intrauterine Resuscitation
First: check maternal vital signs and cervix
Then:
Lie on left or right side
Oxygen
Bolus NS or RL 500-1000
Stop oxytocin induction
D/C cervical ripening
Terbutaline (salbutamol?) for tachysystole
Prolapsed cord: elevate presenting part and C/S

Summary
Know when to use fetal monitoring
and SIA
Use DR. C BRAVADO mnemonic to
asses fetal heart rate
Intrauterine resuscitation for
nonreassuring fetal status

Practice

Questions?