Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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
Timely response to abnormal fetal heart patterns might be effective in preventing brain injury.
Material pulse should be checked during auscultation to differentiate maternal and fetal heart rates
Variety of techniques can be used for listening and counting the fetal heart rate
Rhythm
Presence of dysrhythmias or irregular heart rate not associated with contractions (fast, slow, irregular)
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
q 15 mins
q 15-30 mins
q 5 mins
q 5 mins
q 15 mins
q 5 mins
Difficult to hear a fetal heart rate in very large women when using a fetoscope
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
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
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:
Visually quantitated as the amplitude of the peak to trough in beats per minute
2. Classification:
3.
5 bpm
25 bpm
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
Oscillatory changes that occur during the course of 1 minute and result in the waviness of the baseline
NICHD Fetal Monitoring Workshop (2008) did not recommend differentiating between short and longterm variability, visually determined as a unit.
Increased variability
Fetal breathing
Advancing gestation
Decreased variability
Common causes:
Analgesic drugs during labor
Narcotics, barbiturates, phenothiazines, tranquilizers
Magnesium sulfate
ACCELERATION
1. Visually apparent abrupt increase in FHR
2.
Peak must be
3.
Prolonged accelerations is
4.
5.
10 minutes
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
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
Abruptio placenta
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
3. When variable decelerations are associated with uterine contractions, their onset, depth and duration
commonly vary with successive uterine contractions
4. Other characteristics:
Biphasic decelerations
PROLONGED DECELERATION
1. Visually apparent decrease in FHR from the baseline that is
minutes
2. A deceleration that lasts
15 bpm, lasting
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
Intermittent
Minimal or absent FHR variability alone does not reliably predict the presence of fetal hypoxemia or
metabolic acidemia
Acceleration: present/absent
NORMAL tracings
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
Accelerations
Absence of induced accelerations after fetal stimulation
Prolonged deceleration
3. CATEGORY III
Sinusoidal pattern
Abnormal
Efforts to expeditiously resolve abnormal FHR include, but are not limited to:
Originates near the uterine end of one of the fallopian tubes, a pacemaker
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