Fetal Heart Rate Monitoring

Daphne Christy P. Rupisan

Ob-Gyne Resident
Fetal heart rate setting
mechanism
Simpatis:
In the myocardium
Ex: beta adrenegic, stress
Parasimpatis
Between atrium and ventrikel
Asetilkolin-> Stimulating n.vagus-> heart rate
Atropin-> Inhibiting n.vagus-> heart rate
Baroreceptor
Aortic arch and carotid sinus
pressing-> stimulate n.vagus and n.glosofaringeus->
heart rate
Chemoreceptor
Perifer: carotid and aortic corpus
Central: The medulla oblongata
O2 and CO2 heart rate
Hormonal
Stressasfiksiamed.adrenalepinefrin and
norepinefrinheart rate

Objectives
To be able to interpret systematically CTG
tracings.
To be able to correlate clinically the CTG
interpretations.
To be able to recognizeberkisar non reassuring
and ominous patterns on CTG tracings
and apply appropriate management.


Interpretation of the fetal heart rate
tracing
follow a systematic approach
Baseline rate
Baseline fetal heart rate (FHR) variability
Presence of accelerations
Periodic or episodic decelerations
Frequency and intensity of uterine contractions
Changes or trends of FHR patterns over time

Baseline Fetal Heart Rate (FHR)
heart rate during a 10 minute segment
rounded to the nearest 5 beat per minute
increment


Baseline Fetal Heart Rate (FHR)
Normal baseline: between 110 and
160bpm

Bradycardia :Mean FHR < 110 BPM

Tachycardia: Mean FHR>160 BPM

Baseline change: The decrease or increase
in heart rate lasts for longer than 10
minutes.
Baseline FHR Variability
Baseline Variability

An important index of cardiovascular function and
appears to be regulated largely by the autonomic
nervous system
Baseline FHR Variability
ABSENT: amplitude range undetectable
Baseline FHR Variability
MINIMAL: amplitude range detectable
but <5 beats per minute
Baseline FHR Variability
MODERATE: amplitude range 6-25
beats/min
Baseline FHR Variability
NICHD: Describing Accelerations
Abrupt increase in FHR
Onset to peak < 30 seconds
Peak: 15 bpm lasting 15 seconds from onset to
return to baseline
Prolonged acceleration: 2 min but < 10 min
Acceleration > 10 min = baseline change
Accelerations
At 32 weeks AOG
and beyondmelebihi
Before 32 weeks
AOG
Peak

15 beats per minute
or more above the
baseline
10 beats per minute
or more above the
baseline
Acceleration

Lasts 15 seconds or
more but <2 minutes
from the onset to
the return to the
previously
determined baseline
Lasts 10 seconds or
more, but < 2
minutes from the
onset to the return
to the previously
determined baseline
Prolonged acceleration:
Increase in heart rate lasts for 2 to < 10 minutes.
REACTIVITY
An increase of 15 BPM
above baseline for 15
second duration (from
baseline to baseline)
twice in a 20 minute
period.
Presence of 2
acceleration in a 20
minute period

Sinosoidal pattern
Visually apparent, smooth, sine wavelike undulating
pattern in FHR baseline with a cycle frequency of 3-
5 per minute which persists for 20 minutes or more
Sinusoidal pattern maybe observed with
Severe fetal anemia from Rh
isoimmunization
Feto-maternal hemorrhage
Twin-twin transfusion syndrome
Vasa previa w/ bleeding
Fetal intacranial hemorhage
Severe fetal asphyxia

Williams,23
rd
edition; Intrapartum Assessment
Decelerations
Periodic
Not associated with uterine contractions
Episodic
Associated with uterine contractions
Decelerations
Early deceleration
Gradual decrease in
FHR with onset of
deceleration to
nadir >30 seconds
nadir occurs with the
peak of a contraction.







Head compression
Causes vagal nerve activation as a result of dural
stimulation and that mediates fetal heart rate
deceleration
Williams,23
rd
edition; Intrapartum Assessment
Decelerations
Late Deceleration:
Onset of the
deceleration occursterjadi
after the beginning of
the contraction, and the
nadir of the deceleration
occurs after the peak of
the contraction.

Causes of late deceleration
Any process that causes maternal
hypotension (epidural analgesia)
Excessive uterine activity
Placental dysfunction
Maternal diseases
Hypertension
Diabetes
Collagen vascular disorder
Williams,23
rd
edition; Intrapartum Assessment
Decelerations
Variable:
Abruptmendadak decrease in
FHR of > 15 beats per
minute measured from
the most recently
determined baseline
rate.
The onset of
deceleration to nadir is
less than 30 seconds.
The deceleration
lasts > 15 seconds and
less than 2 minutes
Etiologies of variable deceleration
Umbilical cord occlusion
it reflects either blood pressure changes
due to interruptiongangguan of umbilical flow or
changes in oxygenation.


Williams,23
rd
edition; Intrapartum Assessment
American College of Obstetrician and Gynecologists
(1995) has defined significant variable decelerations as
those decreasing to less than 70 beats/min and lasting
more than 60 seconds





Williams,23
rd
edition; Intrapartum Assessment
Maternal hypotension
Uterine hyperactivity
Cord prolapse
Cord compression*
Prolonged Decelerations
A decrease in FHR of 15 beats per minute measured from
the most recently determined baseline rate. The
deceleration lasts 2 minutes but < 10 minutes.
Causes:
Rapid descent of fetal head
Abruption
Artifact (maternal heart rate)
Maternal seizure
Uterine Contractions
Normal: 5 or less contractions in 10
minutes averaged over a 30-minute
window




POGS CPG on CS, November 2012


Tachysystole
>5contractions in 10 minutes, averaged over
a 30-minute window
Always be qualified as to the presence or
absence of associated FHR decelerations
Applies to both spontaneous and stimulated
labor
POGS CPG on CS, November 2012
Uterine Contractions
THREE TIERED CATEGORIZATION OF
FHR INTERPRETATION






POGS CPG on Abnormal labor and Delivery,
November 2009

Category I II III
Baseline
FHR
110-160 beats per
minute
Bradycardia not accompanied by
absent baseline variability or
Tachycardia
Bradycardia
Baseline
variability
Moderate Minimal baseline variability
Absent baseline variability with
no recurrent decelerations
Marked baseline variability
Absent
Deceleratio
ns
Late or variable
decelerations:
Absent

Early
decelerations:
present or absent






Recurrent variable
decelerations accompanied by
minimal or moderate baseline
variability
Prolonged deceleration more
than 2 minutes but less than 10
minutes
Recurrent late decelerations
with moderate baseline
variability
Variable decelerations with
other characteristics such as
slow return to baseline,
overshoots, or shoulders
Recurrent late
decelerations
Recurrent
variable
decelerations
Acceleration
s
Present or absent Absence of induced
accelerations after fetal
stimulation
Sinusoidal pattern
Evaluate:
1. Cervical examination to determine umbilical cord
prolapse, rapid cervical dilatation or descent of fetal
head.
2. Uterine contraction frequency and duration (r/o
tachysystole)
3. Monitoring maternal blood pressure level for
evidence of hypotension, especially in those with
regional anesthesia

POGS CPG on Abnormal labor and Delivery,
November 2009






Management for Category II or
Category III tracing
Treat:
1. Discontinue any labor stimulating agent.
2. Change maternal position to left or right lateral
recumbent position, reducing compression of the
vena cava and improving uteroplacental blood
flow
3. If hypotensive, treat with volume expansion or
with ephedrine or both or phenylephrine may be
warranted



POGS CPG on Abnormal labor and Delivery,
November 2009



Management for Category II or
Category III tracing
Recommendations

Detection of an abnormal FHR pattern (Cat
III) is an indication for CS.
Presence of 3 consecutive Cat II abnormal
FHR patters, despite resuscitive measures is
an Indication for CS.

POGS CPG ON CS, NOVEMBER 2012

Optimal decision to delivery interval
If an emergency CS is warranted for an
abnormal FHR pattern or acute fetal
compromise, it should be started as quickly
as possible, ideally w/in 30 minutes.

POGS CPG ON CS, NOVEMBER 2012


LET US INTERPRET
Let us interpret!
Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression
1/17/14
145- 150
MODERATE
PRESENT
ABSENT
ABSENT
REACTIVE NST
3/17/14 1 PM
PU,32 weeks AOG CNIL IE: closed
Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression

145-150
ABSENT
ABSENT
ABSENT
uterine contractions every 2-3mins, 30-40 seconds,
moderate
CATEGORY III
Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression
145-150
MINIMAL
PRESENT
PRESENT
Every 2-3 minutes mild to moderate , 50-60
seconds
CATEGORY II, INDETERMINATE FOR MINIMAL
VARIABILITY
Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression
145-150
MODERATE
absent
PRESENT
STRONG q 3-4min
CATEGORY II

Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression
130-135
ABSENT
ABSENT
ABSENT
NONE
NON-REACTIVE NST
Baseline FHR
Variability
Acceleration
Deceleration
Uterine contractions
Impression
150-155
ABSENT
ABSENT
PRESENT
2 UTERINE CONTRACTIONS, 9 MINUTES APART
MODERATE
CATEGORY III
Meeting the Objectives
To be able to interpret systematically CTG
tracings.
To be able to correlate clinically the CTG
interpretations.
To be able to recognize non reassuring and
ominous patterns on CTG tracings and apply
appropriate management.


Its a lie to think you are not good enough...
Its a lie to think youre not worth anything...


Nick Vujicic, Life without limits