Intrapartum Fetal Monitoring All laboring patients should initially have initial a 20 minute period of continuous monitoring. If they meet criteria, they could have intermittent monitoring* (see intermittent monitoring SOP). Otherwise they should have continuous monitoring. Intermittent auscultation: 1 st stage active: heart tones q 30 min during contraction and for 60 seconds after with handheld doppler. 2 nd stage: q 15 min and q 5 min while pushing. ❑ Variability: Minimal < 5 bpm, Moderate 6 -25 bpm, Marked > 25 bpm ❑ Normal Baseline: approximate mean FHR rounded to 5 bpm increments during 10 min period excluding accels and decels that lasts at least 2 min. Normal is 110 -160 bpm. Methadone can lower baseline. Accelerations: Usually associated with spontaneous fetal activity, stimulation, or uterine contractions. A reassuring sign of fetal well being. > 32 weeks: > 15 bpm above baseline for > 15 seconds < 2 minutes < 32 weeks: > 10 bpm above baseline for > 10 seconds < 2 minutes ❑ ❑ Decelerations: Periodic changes in FHR during uterine contractions. Early: nadir coincides with contraction peak; nadir > 30 seconds from onset; head compression. Variable: rapid descent usually with good recovery; nadir < 30 seconds; cord compression. Late: nadir after contraction peak; nadir > 30 seconds; uteroplacental insufficiency. Recurrent: occur with > 50% of contractions in a 20 -minute period. Intermittent: occur with < than 50% of contractions. ❑ CATEGORIES Cat I: Has all of the following: - Baseline rate 110 -160 bpm - Moderate variability - Accelerations (+/-) - Early decels (+/-) - No late or variable decels Cat II �� Everything else. Cat III Has either: - Sinusoidal pattern > 20 minutes OR - Absent FHR baseline variability AND recurrent late or recurrent variable decel or > 10 min bradycardia. *** Address physiology, start intrauterine resusc, activate back up plan *** FHR: “Dr C Bravado” DR: Determine risk C: Contractions BRA: Baseline rate V: Variability A: Accelerations D: Decelerations O: Assessment and plan Decels: “VEAL CHOP” Variable = Cord Early = Head A = O Late = Placenta *HTN disorders, GDMA 2 or DM, Cholestasis, TOLAC, h/o IUFD, IUGR, Polyhydramnios, multiple gestation, preterm, > 41 completed weeks, major anomalies, epidural anesthesia, oxytocin administration, moderate to thick meconium, Triple I, vaginal Bleeding.
Intrapartum Fetal Monitoring ❑ All clinically significant decelerations (late, variable, prolonged) reflect interruption of the pathway of oxygen transfer from the environment to the fetus ❑ Improve fetal O 2 If prolapsed cord: (1) elevate presentation while (2) calling for help, (3) place in Trendelenburg, (4) back fill bladder - Maternal LL position. - IVF bolus while (5) prepping for delivery. - Discontinue Pitocin. Algorithm for Cat II Mgmt: - Oxygen 10 L / min - Check for prolapse, rapid descent, or bleeding / abruption. ❑ INTERVENTIONS Reduce uterine activity - IVF bolus - Maternal LL position. - Discontinue Pitocin. - Terbutaline. Treat cord compression - Maternal reposition - Amnioinfusion - Modify pushing Consider need for expedited delivery (vacuum, forceps, c/s) AClark. Category II FHRT. Am J Obstet Gynecol 2013. Advanced Life Support in Obstetrics Program, AAFP’’s Intrapartum Fetal Monitoring