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Fetal Surveillance in Labor

Goal of intrapartum surveillance

To detect potential fetal decomposition and to allow timely and effective intervention to prevent
perinatal/neonatal morbidity and mortality
Rationale for fetal heart rate monitoring

Not clinically feasible to assess the function of the fetal brain during labor. FH characteristics can be
assessed

Changes in fetal heart rate precede brain injury

Timely response to abnormal fetal heart patterns might be effective in preventing brain injury.

Appropriate Monitoring in an Uncomplicated Pregnancy


Intermittent Auscultation (IA) following an established protocol and response is the recommended fetal
surveillance method during labor for healthy women without risk factors for adverse perinatal outcome.
For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation
should be offered and recommended in labor to monitor fetal well-being.
Assessment with Intermittent Auscultation (IA) (SOGC, 2007)

Requires the ability to differentiate sounds generated by the device used

Material pulse should be checked during auscultation to differentiate maternal and fetal heart rates

If the fetal heart is technically inaudible, the EFM should be commenced

Variety of techniques can be used for listening and counting the fetal heart rate

Baseline fetal heart rate

Assessed by listening and counting between uterine contractions

Greatest accuracy results when the FHR is counted for 60 seconds

Rhythm

Presence of dysrhythmias or irregular heart rate not associated with contractions (fast, slow, irregular)

Further assessment with UTZ or echocardiography may be necessary

Heart rate changes

Accelerations or decelerations
First stage-latent
phase
For the latent phase of
labor, there are very
limited data on which
to base a
recommendation
ACOG
SOGC

RCOG

Recommended at the
time of assessment,
approximately q 1 h

First stage active


phase

Active second stage

q 15 mins
q 15-30 mins

q 5 mins
q 5 mins

q 15 mins

q 5 mins

Intermittent Auscultation (IA)


What is not assessed?

Baseline variability and classification of decelerations


Benefits

Less costly, less constricting, freedom of movement is increased


Limitations

Difficult to hear a fetal heart rate in very large women when using a fetoscope

Women may feel the technique to be intrusive

ADMISSION CARDIOTOCOGRAPHY (CTG)


Admission fetal heart tracings are not recommended for healthy women at term in labor in the absence of risk
factors for adverse perinatal outcome, as there is no evident benefit. (SOGC, 2007)
Current evidence does not support the use of the admission CTG in low-risk pregnancy and it is therefore not
recommended (RCOG, 2001)

FETAL SURVEILLANCE IN LABOR


Electronic fetal monitoring (EFM) compared with Intermittent Auscultation (IA) has not been shown to improve
long-term fetal or neonatal outcomes as measured by a decrease in morbidity or mortality

Continuous EFM during labor is associated with a reduction in neonatal seizures but no significant
differences in long-term sequelae, including cerebral palsy, infant mortality and other standard measures
of neonatal well-being.
EFM is associated with an increase in interventions, including cesarean section, vaginal operative delivery and
the use of anesthesia.
EFM is recommended for pregnancies at risk of adverse perinatal outcome.
Antenatal and intrapartum conditions associated with increased risk of adverse fetal
outcome when intrapartum electronic fetal surveillance may be beneficial
ANTENATAL
INTRAPARTUM
Maternal
Maternal
Hypertensive disorders of pregnancy
Vaginal bleeding in labor
Pre-existing DM/gestational diabetes
Intrauterine infection/chorioamnionitis
Maternal medical diseases: cardiac,
Previous cesarean section
Prolonged membrane rupture >24 hours
anemia, hyperthyroidism, vascular
at term
diseases and renal diseases
Induced labor
Maternal MVA/trauma
Augmented labor
Morbid obesity
Preterm labor
Post-term pregnancy
Fetal
Fetal
IUGR
Meconium staining of the amniotic fluid
Prematurity
Abnormal fetal heart rate on auscultation
Oligohydramnios
Abnormal umbilical artery Doppler
Velocimetry
Isoimmunization
Abnormal umbilical artery Doppler
velocimetry
Isoimmunization
Multiple pregnancy
Breech presentation

INTERPRETATION OF ELECTRONIC FETAL MONITORING

Fundamental principles when using 2008 NICHD terminology:


The definitions are primarily developed for visual interpretation of FHR patterns. However, it is recognized that
computerized interpretation is developed and the definitions must also be adaptable to such applications
The definitions apply to the interpretations of patterns produced from either a direct fetal electrode detecting
the fetal electrocardiogram or an external Doppler device detecting the fetal heart rate events with use of the
autocorrelation technique
ELECTRONIC FETAL HEART RATE MONITORING
INTERNAL

Attach a bipolar spiral electrode directly to the fetal scalp

Electrical fetal cardiac signal is amplified and fed into a cardiotachometer for heart rate calculation

FHR tracing results from the signal processor, counts every R-R interval of the ECG
EXTERNAL

Ultrasound Doppler principle

Signals are edited electronically before data is printed onto the bedside monitor tracing paper

Signals are put through a microprocessor that compares incoming signals with the most recent previous
signal: auto-correlation.
INTERPRATATION OF ELECTRONIC FETAL MONITORING
Fundamental principles when using 2008 NICHD terminology:

The record of both the FHR and uterine activity should be of adequate quality for visual interpretation

The prime emphasis is intrapartum pattern. The definitions may also be applicable to ante partum
observation.

The features of FHR patterns are categorized as either baseline, periodic, or episodic. Periodic patterns
are those associated with uterine contractions, and episodic patterns are those not associated with
uterine contractions.
The periodic patterns are distinguished on the basis of waveform, currently accepted as either abrupt or
gradual onset.
Accelerations and decelerations are generally determined in reference to the adjacent baseline FHR.
No distinction is made between short-term variability and long-term variability -> definition of
variability is based visually in the amplitude of the complexes, with exclusion of the sinusoidal pattern.
There is good evidence that a number of characteristics of FHR patterns are dependent upon fetal
gestation age and physiologic status as well as maternal physiologic status -> FHR tracings should be
evaluated in the context of many clinical conditions including gestational age, prior results of fetal
assessment, medications, maternal medical conditions and fetal conditions.
The individual components of defined FHR patterns do not occur independently and generally
evolve over time.
A full description of an EFM tracing requires a qualitative and quantitative description of:
1. Uterine contractions
2. Baseline fetal heart rate
3. Baseline FHR variability
4. Presence of accelerations
5. Periodic or episodic decelerations
6. Changes or trends of FHR patterns over time

UTERINE CONTRACTIONS
Quantified as the number of contractions present in a 10-minute window, averaged over 30 minutes.
Duration, intensity and relaxation time between contractions are equally important in clinical practice
A. Normal:

5 contractions in 10 minutes, averaged over a 30-minute window

B. Tachysystole: >5 contractions in 10 minutes, averaged over a 30-minute window


C. Characteristics of uterine contractions:
Tachysystole should always be qualified as to the presence or absence of associated FHR
decelerations
The term tachysystole applies to both spontaneous or stimulated labor. The clinical response may
differ.
The terms hyperstimulation and hypercontractility are not defined and should be abandoned.

BASELINE FETAL HEART RATE


1. Determined by approximating the mean FHR rounded to increments of 5 bpm during a 10-minute window

Excluding accelerations and decelerations

Excluding periods of marked FHR variability (>25 bpm)


2. There must be at least 2 minutes of identifiable baseline segments (not necessarily contiguous)in any 10minute window, or the baseline for that period is indeterminate
3. Abnormal baseline

Bradycardia: baseline FHR is <110 bpm

Tachycardia: baseline FHR is >160 bpm


4. Baseline fetal heart rate becomes more physiologically fixed, as the baseline fetal heart rates increases

BASELINE FHR VARIABILITY


1. Fluctuations in the baseline FHR that are irregular in amplitude and frequency

Determined in a 10-minute window, excluding accelerations and deceleration

Visually quantitated as the amplitude of the peak to trough in beats per minute
2. Classification:

Absent FHR variability amplitude range undetectable

3.

Minimal FHR variability amplitude range >undetectable and

Moderate FHR variability amplitude range 6-25 bpm

Marked FHR variability range

5 bpm

25 bpm

FETAL HEART RATE VARIABILITY

SHORT-TERM VARIABILITY

Beat-to-beat fluctuations in heart rate that arises from the slight difference in the period between R
waves of the ECG of a normal fetus

Determined to be normally present when electrocardiac cycles are measured directly with a scalp
electrode

Normal beat-to-beat variability at 6-25 bpm


LONG-TERM VARIABILITY

Oscillatory changes that occur during the course of 1 minute and result in the waviness of the baseline

Normal frequency of 3-5 cycles per minute

NICHD Fetal Monitoring Workshop (2008) did not recommend differentiating between short and longterm variability, visually determined as a unit.
Increased variability

Fetal breathing

Fetal body movements

Advancing gestation
Decreased variability

Indicates a seriously compromised fetus

Single most reliable sign of fetal compromise

Associated with fetal acidemia, maternal acidemia

Common causes:
Analgesic drugs during labor
Narcotics, barbiturates, phenothiazines, tranquilizers
Magnesium sulfate

ACCELERATION
1. Visually apparent abrupt increase in FHR

Increase from the onset of acceleration to the peak <30 seconds

15 bpm and last

2.

Peak must be

3.

Prolonged accelerations is

4.

Baseline change is an acceleration lasting

5.

Before 32 weeks gestation, accelerations are defined as having a peak

15 seconds from the onset to return

2 minutes but <10 minutes in duration

10 minutes

10 bpm and a duration of

10

seconds

EARLY DECELERATION
1. Visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with a uterine
contraction

Gradual FHR decrease is defined as one from the onset of the FHR to the FHR nadir of

30 seconds

2. The decrease in FHR is calculated from the onset to the nadir of the deceleration
3. The nadir of the deceleration occurs at the same time as the peak of the contraction
4. In most cases the onset, nadir, and recovery of the deceleration are COINCIDENT WITH the
beginning, peak and ending of the contraction, respectively.

LATE DECELERATION
1. Visually apparent, usually symmetrical, gradual decrease and return of the FHR associated with a uterine
contraction

Gradual decrease is defined as one from the onset to the FHR nadir of

30 seconds

2. The decrease in FHR is calculated from the onset to the nadir of the deceleration
3. The deceleration is delayed in timing, with the nadir of the deceleration occurring AFTER the peak
of the contraction
4. In most cases the onset, nadir, and recovery of the deceleration are coincident AFTER the
beginning, peak and ending of the contraction, respectively
5. Caused by uteroplacental insufficiency
6. Oxygen sensors in the fetal brain detect a drop in fetal oxygen tension -> increase in sympathetic neuronal
response -> elevation in fetal BP -> detected by baroreceptors -> slowing of FHR
7. Reflex late decelerations

Seen with an acute insult is superimposed on a previously normally oxygenated fetus in the
presence of contractions

Caused by a decrease in uterine blood flow beyond the capacity of the fetus to extract sufficient
oxygen

Carried from the fetal placenta to the heart and distributed

Low oxygen tension is sensed by chemoreceptors, neuronal activity results in a vagal discharge results
in transient decelerations


Accompanied by normal FHR, signify normal CNS integrity
8. Nonreflex Late Decelerations

Same mechanism except that the blood from the placenta is insufficient to support myocardial
action

Direct myocardial hypoxic depression

Seen without variability signifying fetal decompensation

Hypoxia continues to become severe, decelerations no longer vagally mediated

Not proportional in depth to the severity of the hypoxia

May become more shallow as the hypoxia becomes more severe


9. Causes of late decelerations:

Excessive uterine contractions single most common cause

Conduction anesthesia (spinal/epidural) can cause systemic/local hypoperfusion/hypotension

Postmaturity, maternal hypertension, collagen vascular disease, diabetes mellitus

Abruptio placenta

Severe maternal anemia / maternal hypoxemia

Chronic fetal anemia

VARIABLE DECELERATION
1. Visually apparent abrupt decrease in FHR

Abrupt FHR decrease is defined from the onset of deceleration to the beginning of the FHR nadir of <30
seconds
2. The decrease in FHR is

15 bpm, lasting

15 seconds, and <2 minutes in duration

3. When variable decelerations are associated with uterine contractions, their onset, depth and duration
commonly vary with successive uterine contractions
4. Other characteristics:

Slow return of the FHR after the end of the contraction

Biphasic decelerations

Tachycardia after variable decelerations

Accelerations preceding and/or following, sometimes called shoulders or overshoots

Fluctuations in the FHR in the trough of the deceleration


5. Umbilical cord is compressed -> umbilical vein collapses first -> dec cardiac return, fetal hypotension,
baroreceptor reflex -> accelerate fetal heart to maintain cardiac output
6. Continuing compression -> umbilical artery compressed -> increased vascular resistance detected by
baroreceptors ->heart rate slows
7. As the cord vessels open, arteries open first -> heart rate return to baseline -> acceleration occurs
MILD

Deceleration of a duration of <30 seconds, regardless of depth

Decelerations not below 80 bpm, regardless of duration


MODERATE

Deceleration with a level <80 bpm


SEVERE

Deceleration to a level <70 bpm for >60 seconds

PROLONGED DECELERATION
1. Visually apparent decrease in FHR from the baseline that is
minutes
2. A deceleration that lasts

15 bpm, lasting

2 minutes but <10

10 minutes is a baseline change

SINUSOIDAL HEART RATES


1. Observed with serious fetal anemia, due to D-isoimmunization, ruptured vasa previa, fetomaternal
hemorrhage, twin-twin transfusion
2. Amnionitis, fetal distress, umbilical cord occlusion
3. Administration of meperidine, morphine, alphaprodine, butophanol
4. Not generally associated with fetal compromise
5. Modanlou and Freeman (1982) definition:

Stable baseline heart rate of 120-160 bpm with regular oscillations

Amplitude of 5-15 bpm

Frequency of 2-5 cycles/min long term variability

Fixed or flat short-term variability

Oscillation of the sinusoidal waveform above or below a baseline

Absence of accelerations

QUANTITATION OF DECELERATIONS
1. Magnitude of a deceleration is quantitated by the depth of the nadir in beats per minute (excluding transient
spikes or electronic artifact)
2. Duration is quatitated in minutes and seconds from the beginning to the end of the deceleration
3. Accelerations are quantitated similarly

DECELERATIONS
Recurrent

Occur with

50% of uterine contractions in any 20-minute window

Intermittent

Occur with <50% of uterine contractions in any 20-minute segment

GENERAL CONSIDERATIONS FOR THE INTERPRETATION OF FHR PATTERNS


1. The presence of FHR accelerations (either spontaneous or stimulated) reliably predicts the absence of fetal
metabolic academia

The absence of accelerations does not reliably predict fetal academia

FHR accelerations can be stimulated by different methods (vibroacoustic stimulation, transabdominal


halogen, light, and direct fetal scalp stimulation)
2. Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia

Minimal or absent FHR variability alone does not reliably predict the presence of fetal hypoxemia or
metabolic acidemia

The significance of marked FHR (salutatory) variability is unclear.

THREE-TIER FETAL HEART RATE INTERPRETATION SYSTEM


1. CATEGORY I

Category I FHR tracings include ALL of the following:

Baseline rate 110-160 bpm

Baseline FHR variability: moderate

Late/variable decelerations: absent

Acceleration: present/absent

NORMAL tracings

Strongly predictive of normal fetal acid-base status at the time of observation

May be followed in a routine manner

NO specific action is required


2. CATEGORY II

Category II FHR tracings include ALL FHR tracings not categorized as Category I or III. Category II tracings
may represent an appreciable fraction of those encountered in clinical care. Include any of the following:

Baseline rate
Bradycardia not accompanied by absent baseline variability
Tachycardia

Baseline FHR variability:


Minimal baseline variability
Absent baseline variability nor accompanied by recurrent decelerations
Marked baseline variability

Accelerations
Absence of induced accelerations after fetal stimulation

Periodic or episodic decelerations


Recurrent variable decelerations accompanied by minimal or moderate baseline variability

Prolonged deceleration

2 minutes but <10 minutes

Recurrent late decelerations with moderate baseline variability


Variable decelerations with other characteristics, such as slow return to baseline, overshoots or
shoulders
Indeterminate
Not predictive of abnormal fetal acid-base status
No adequate evidence at present to classify these as Category I or Category III
Require evaluation and continued surveillance and reevaluation, taking into account the entire associated
clinical circumstances

3. CATEGORY III

Category III FHR tracings include either:

Absent baseline FHR variability and any of the following:


Recurrent late decelerations
Recurrent variable decelerations
Bradycardia

Sinusoidal pattern

Abnormal

Predictive of abnormal fetal acid-base status at the time of observation

Require prompt evaluation

Efforts to expeditiously resolve abnormal FHR include, but are not limited to:

Provision of maternal oxygen

Change in maternal position

Discontinuation of labor stimulation

Treatment for maternal hypotension

INTRAPARTUM SURVEILLANCE OF UTERINE ACTIVITY


1. INTERNAL UTERINE PRESSURE MONITORING

Use intrauterine pressure catheters


2. EXTERNAL MONITORING

Uterine transducer held against the abdominal wall

PATTERNS OF UTERINE ACTIVITY


Origin and propagation of contractions

Originates near the uterine end of one of the fallopian tubes, a pacemaker

Right pacemaker dominates over the left

Contractions spread from the pacemaker throughout the uterus at 2cm/sec, depolarizing the uterus within
15 seconds

Depolarization waves propagates downward to the cervix; intensity greatest at the fundus and diminishes
in the lower uterus

Descending gradient would direct fetal descent toward the cervix and efface the cervix

ALL parts of the uterus are synchronized and reach their peak pressure almost simultaneously, resulting in
a curvilinear waveform

SYSTEMIC INTERPRETATION OF EFM


1. Assess the quality of the signal acquisition
2. Determine the paper speed and graph range

No evidence suggesting a particular universal paper speed

Consistency within each institution and ideally within regions


3. Determine whether the mode of recording is external or internal
4. Assess the uterine activity pattern, including frequency, duration and intensity of contraction and uterine
resting tone
5. Assess the baseline fetal heart rate
6. Assess baseline variability
7. Assess fetal heart rate accelerations
8. Assess periodic or episodic decelerations
9. Classify EFM tracing
10. Evaluate overall clinical picture