Fetal Heart Rate Monitoring

Paul G. Tomich, M.D.

Department of Obstetrics and Gynecology
University of Nebraska College of Medicine
 Learning Objectives
Evolution
Examples
Descriptions
Reassuring patterns
Concerning patterns
Definitions of Category I, II, and III tracings
Discuss action needed
Non-stress Test (NST)
Biophysical Profile (BPP)
 Evolution of FHR Monitoring
Monitoring fetus in labor
FHR patterns
Good outcomes
Poor outcomes
Contraction Stress Test (CST)
Non Stress Test (NST)
Biophysical profile (BPP)
Categorization of FHR Tracing into Category I, II, and III
 Categorization of FHR Tracings

Recommendation of three-tiered system

April 2008
More standardized interpretation
Concept: Interpretation of a FHR monitor strip is a
dynamic process, with determination of whether a
particular strip is reassuring and what action plans
should be taken and then to evaluate at a later time
 Ways to Monitor

Uterine contractions
Fetal heart rate (FHR)
 Ways to Monitor

Uterine contractions
Fetal heart rate (FHR)
 Features to Describe
Fetal heart rate (FHR)
Top line on monitor strip
Uterine contractions
Bottom line on
monitor strip
 Features to Describe
Baseline
Variability
Accelerations
Decelerations
Trends over time
Interpret into 1 of 3 categories
 Baseline

Mean fetal heart rate

Rounded to increments of 5
During a 10 minute period
Excluding accelerations and decelerations
Normal baseline
100-160 BPM
Baseline is RED LINE
 Baseline
Bradycardia
<100 BPM
Tachycardia
>160 BPM
Indeterminate
less than 2 minutes of baseline is present
 Fetal Tachycardia
Normal variant
prematurity
Intra-amniotic infection
Fetal anemia
Fetal cardiac arrhythmia (SVT)
Fetal hypoxia
 Features to Describe
Baseline
Variability
Accelerations
Decelerations
Trends over time
Interpret into 1 of 3 categories
 Variability
Fluctuations in FHR
Over 10 minutes
Descriptors are:
Absent: undetectable amplitude range
Minimal: undetectable up to 5 BPM
Moderate: amplitude range 6 to 25 BPM
Marked: amplitude range greater than 25 BPM
Variability
 Features to Describe
Baseline
Variability
Accelerations
Decelerations
Trends over time
Interpret into 1 of 3 categories
 Accelerations
Abrupt increase in FHR
At least 15 BPM above baseline
Duration
Must last 15 seconds to 2 minutes

Prolonged accelerations
Last 2 minutes to 10 minutes
Baseline change
Acceleration lasting 10 mins or longer
>15 beats above baseline
15 seconds to 2 minutes in length
 Features to Describe
Baseline
Variability
Accelerations
Decelerations
Trends over time
Interpret into 1 of 3 categories
 Decelerations

Decrease in baseline
3 Types
Early
Variable
Late
 Deceleration

Decrease in FHR
 Early Deceleration
Symmetrical to
contraction
Mirror image of
contraction
Gradual decrease in
FHR
30 secs or more from
onset to nadir
 EARLY DECELERATION
Gradual FHR decrease
Onset to nadir 30 seconds or more
Nadir of deceleration occurs with peak of
contraction
Mirror contraction
 Late Decelerations

Deceleration is delayed in timing

Occurs after the contraction
A gradual FHR decrease
Onset to nadir > 30 second
Late Decelerations
 Variable Decelerations

Abrupt decrease in fetal

heart rate
Onset to nadir less than
30 seconds
Decrease in FHR
15 BPM or more
Lasting 15 seconds to 2
mins
 Variable Declerations

Pathophysiology
umbilical cord
compression
 Decelerations
Prolonged deceleration
Decrease of 15 BPM
Lasts 2-10 minutes
Baseline change
Deceleration lasting at least 10 mins
Description
Intermittent
Less than 50% of contractions in 20 minutes

Recurrent
More than 50 % of contractions in 20 minutes
 Sinusoidal Pattern

Smooth sin-wave pattern

Cycle frequency 3-5 mins
Persists for 20 minutes or
longer
Sinusoidal Pattern
 Uterine Contractions

Number of contractions in 10 minutes

averaged over thirty minutes
Document
Frequency
Intensity
Duration
Relaxation
time between contractions
Monitoring of Contractions
 Tachysystole

>5 contractions in 10 mins

Averaged over 30 mins
 Categorization of FHR Patterns

An evaluation of the fetus at a particular point in

time
Categories I, II, and III
3 Categories
 Category I

Normal baseline
110-160 BPM
FHR Variability
moderate
Late or Variable decelerations
none
 Category II

Not enough evidence to place into

either Category I or III
 Category III

Abnormal tracing
Predictive of abnormal fetal acid-base status
Requires prompt intervention
The ABCDs of Fetal Monitoring
Examples of Tracings
 Non-Stress Test

Reactive
2 or more accelerations in 20 mins
Acceleration
At least 15 beats above baseline

Lasting for at least 15 seconds

Non-reactive
Reactive NST
 Biophysical Profile (BPP)
NST + ultrasound markers
Score linearly correlated with fetal pH
Risk of fetal death within one week of normal
BPP is 1:1300
 Biophysical Profile

Zero or 2 points for each

Fetal heart beat monitor
Fetal breathing
Fetal movements
Amniotic Fluid Volume
Flexion/Extension
 Modified Biophysical Profile

Combination of NST and AFI only

If less than 4/4
more evaluation is done
Guidelines for Reviewing FHR Monitoring

normal patient
reviewed every 30 min in the first stage of labor
every 15 minutes in the second stage
complicated patients
every 15 minutes in first stage
Every 5 mins in second stage