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Intrapartum Fetal Heart Rate MonitoringCase Presentation
David A. Miller, M.D.Professor of Obstetrics, Gynecology and Pediatrics
Division of Maternal Fetal MedicineUniversity of Southern California Keck School of Medicine
Chief of Maternal Fetal MedicineChildren’s Hospital Los Angeles
28 year old G3 P2 at 39 5/7 weeks hospitalized in early labor, cervix 3 cm dilated, 60% effaced, ‐1 station
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When you encounter this FHR tracing, what is the very first step?
Intrapartum Fetal Heart Rate Management Decision Model©
Confirm FHR and uterine activityConfirm FHR and uterine activity
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After confirming FHR and uterine activity what is the next step?
1. Definition
2. Interpretation
3.Management
Definition…
What are the five components of a FHR tracing?
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How do you define baseline?
What is the baseline?
How do you define variability?
What is the variability here?
Variability is defined as ____________ in the ___________ that are ____________ in _____________ and ______________
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What is the clinical significance of the variability in this segment of tracing?
Moderate variability reliably predicts the absence of __________________
When?
Variability is defined as “fluctuations in the baseline that are
irregular in amplitude and frequency”
The sinusoidal pattern demonstrates “fluctuations in the
baseline that are regular in amplitude and frequency”
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Is there good beat‐to‐beat variability?
The terms “short‐term”, “beat‐to‐beat”and “long‐term variability are not included in the standard NICHD definitions because in actual practice, they are visually determined as a unit
Yeah, but what’s the harm in charting “beat‐to‐beat” variability?
Are there any accelerations?
How do you define an acceleration?
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Are there any decelerations?
Category?
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Intrapartum Fetal Heart Rate Management Decision Model©
Confirm FHR and uterine activityConfirm FHR and uterine activity
FHR Category?FHR Category?
Is the patient low‐risk?
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance
How frequently are nurses required to chart?How about midwives and doctors?
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There were four cesareans that night and three other laboring patients throughout the early evening and night.
While everyone was busy, the tracing was being watched intermittently by the charge nurse…it gradually changed.
When the last cesarean was being completed, the tracing was reviewed again…
What do you do now?
1. Definition
2. Interpretation
3.Management
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What is the baseline?
What is the variability?
Is it minimal?
Is it absent?
Either way, what is it NOT?
So what does it mean?
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Any accelerations?
How do you define acceleration?
What type of decelerations are these?
Are they abrupt?How do you define abrupt?Are they gradual?How do you define gradual?What do they mean?
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Is this a change from previously?
Is this a Category II FHR tracing?
Is it a Category III tracing?
If we can’t agree whether it is a Category II or III, can we at least agree what Category it is NOT?
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If the FHR tracing is not in “Category I”, what is the next step?
“ABCD”“ABCD”
Is the patient low‐risk?
“A” – Assess oxygen pathway
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance
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What are the steps in the “oxygen pathway”?
How do you assess each?
“A”
Assess Oxygen
Pathway
“B”
Begin Corrective
Measures if Indicated
“C”
Clear Obstacles to
Rapid Delivery
“D”
Determine Decision
to Delivery Time
Lungs Airway and breathing Supplemental oxygen FacilityOR availabilityEquipment
Facility response time
Heart Heart rate and rhythm
Position changesFluid bolusCorrect hypotension
Staff
NotifyObstetricianSurgical assistantAnesthesiologistNeonatologistPediatricianNursing staff
Consider staff:AvailabilityTrainingExperience
VasculatureBlood pressureVolume status
Mother
Informed consentAnesthesia optionsLaboratory testsBlood productsIntravenous accessUrinary catheterAbdominal prepTransfer to OR
Surgical considerations(prior abdominal or uterine surgery )Medical considerations(obesity, hypertension, diabetes, SLE)Obstetric considerations(parity, pelvimetry, placental location)
Uterus
Contraction strengthContraction frequencyBaseline uterine toneExclude uterine rupture Stop or reduce stimulant
Consider uterine relaxantFetus
ConfirmEstimated fetal weightGestational agePresentationPositionInfection
Consider factors such as:Estimated fetal weightGestational agePresentationPositionInfection
PlacentaPlacental separationBleeding vasa previa
CordVaginal examExclude cord prolapse
Consider amnioinfusion Labor Consider IUPC
Consider factors such as:Arrest disorderProtracted laborRemote from deliveryPoor expulsive efforts
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Some factors unrelated to fetal oxygenation can affect the appearance of the fetal heart rate tracing
Can you name some maternal factors?
How might they impact the fetal heart rate?
Fetal factors?
How would you expect them to impact the FHR?
Factors that influence the FHR tracing by mechanisms other than oxygenation
Maternal
FeverInfectionMedicationsHyperthyroidism
Fetal
FeverInfectionMedicationsAnemiaAnomaliesArrhythmiaExtreme prematurityPreexisting neurologic injurySleep cycle
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If your assessment of the oxygen pathway (“A”) suggests interruption of the oxygen pathway at one or more points, what is the next step?
(What letter follows “A”?)
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance
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What are 7 conservative corrective measures that should be considered in this setting?
Lungs Supplemental oxygen
Position changeFluid bolusCorrect hypotension
Stop or reduce uterine stimulantConsider uterine relaxant
Consider amnioinfusion
HeartVasculatureUterus
Placenta
Cord
What are two additional corrective measures than can relieve second stage decelerations?
Do all 7 conservative corrective measures need to be done in this setting?
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Despite conservative corrective measures, decelerations continue
After (“A”) assessing the oxygen pathway and (“B”) beginning conservative corrective measures as indicated, when do you plan to review the tracing again?
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Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance
What are the options here?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?IIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
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Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
How do you determine whether it is safe to continue labor?
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
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Exclude significant interruption of the oxygen pathway
How?
Exclude on‐going hypoxic injury…
How?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Presence of moderate variability or accelerationsand
Absence of clinically significant decelerations
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
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Are there clinically significant decelerations?
Is there moderate variability?
Are there any accelerations?
If conservative measures “A” and “B” do not resolve decelerations and result in moderate variability and/or accelerations to your satisfaction, what is the next step?
Make this EASY on yourself…
It does NOT have to be complicated…
If you have ANY question
Just proceed to the next step
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If you can’t say for sure that moderate variability is present
If you can’t say for sure that accelerations are present
If you can’t say for sure that there are no clinically significant decelerations….
Just move on to “C”
Clear common obstacles to rapid delivery
This does not commit you to delivery
This is nothing more than PLANNING AHEAD…
EMPHASIS:
When planning ahead for the possible need for rapid delivery, you should consider individual characteristics of…
Facility
Staff
Mother
Fetus
Labor
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What are some examples of common obstacles to rapid delivery?
Facility…?Staff…?Mother…?Fetus…?Labor…?
By the time you’ve reached the “C” stage of management, who should be notified?
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After addressing steps “A”, “B” and “C”, what is the next step?
Who needs to be making decisions for “D” and beyond?
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Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“C” – Clear obstacles to rapid delivery“D” – Determine decision to delivery time
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Presence of moderate variability or accelerationsand
Absence of clinically significant decelerations
No/Unsure
Yes
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
What factors need to be considered when estimating the time from decision to delivery?
FacilityStaffMotherFetusLabor
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What are some examples?
Facility…?Staff…?Mother…?Fetus…?Labor…?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“C” – Clear obstacles to rapid delivery“D” – Determine decision to delivery time
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Presence of moderate variability or accelerationsAnd
Absence of clinically significant decelerationsYes
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
No/Unsure
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After all conservative corrective measures have been considered and employed as deemed necessary (“ABCD”), what is the next step?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“C” – Clear obstacles to rapid delivery“D” – Determine decision to delivery time
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
Is vaginal delivery likely before the onset of metabolic acidemia and potential injury?
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Presence of moderate variability or accelerationsand
Absence of clinically significant decelerations
No
Yes
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
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The cervix 5 cm dilated, completely effaced. The fetal head is at +1 station
What should the physician you do here?
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“C” – Clear obstacles to rapid delivery“D” – Determine decision to delivery time
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No Yes
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
Is vaginal delivery likely before the onset of metabolic acidemia and potential injury?
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Moderate variability and/or accelerationsand
No clinically significant decelerationsYes
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
No/Unsure
No/Unsure
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Is vaginal delivery likely before the onset of metabolic acidemia and potential injury?
The most important aspect of this question is that it MUST be answered using the best information available
AVOID THIS PITFALL
The scientific name of this syndrome?
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Kickin’ the can down the road
60 minutes later
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If a standardized management protocol had been followed, do you think this would have ended long ago?
Considerably later, the patient was delivered by Cesarean
Would you be surprised by a low 5‐minute Apgar score?
By metabolic acidemia?
By neurologic injury?
Would a systematic “ABCD” approach have avoided this?
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Optimize outcomesMinimize medical‐legal risks
Standard of care
Reasonableness
Factual accuracy (Standard definitions and interpretation)Ability to articulate a plan (Standard management…“ABCD”)
Credibility
Is the patient low‐risk?
“A” – Assess oxygen pathway“B” – Begin corrective measures
“C” – Clear obstacles to rapid delivery“D” – Determine decision to delivery time
“ABCD”“ABCD”
Routine SurveillanceRoutine Surveillance
No Yes
Yes
Intrapartum Fetal Heart Rate Management Decision Model©
II or IIIII or III
FHR Category?FHR Category?
IIIIIIIIIIII
Is vaginal delivery likely before the onset of metabolic acidemia and potential injury?
•Every 30 min in the 1st stage of labor•Every 15 min in the 2nd stage of labor
Confirm FHR and uterine activityConfirm FHR and uterine activity
II
•Every 15 min in the 1st stage of labor•Every 5 min in the 2nd stage of labor
Moderate variability and/or accelerationsand
No clinically significant decelerationsYes
FHR Category?FHR Category?
Heightened SurveillanceHeightened Surveillance Expedite DeliveryExpedite Delivery
No/Unsure
No/Unsure
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Does a tracing like this guarantee normal newborn outcome?
Are there conditions other than interrupted oxygenation that can cause newborn depression?
Maternal
FeverInfectionMedications
Fetal
FeverInfectionMedicationsAnemiaAnomaliesExtreme prematurityPreexisting neurologic injury
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Does a tracing like this guarantee the absence of metabolic acidemia from ANY cause?
Are there conditions other than interrupted oxygenation that can cause metabolic acidemia?
Maternal
InfectionMedications
Fetal
InfectionMedicationsErrors of metabolism
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If this tracing is followed immediately by delivery of a newborn with metabolic acidemia and newborn depression, how do you explain your management?
Summary
A standardized approach to intrapartum FHR definition, interpretation and management demonstrates reasonableness
The essential element that defines the standard of care