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Electronic Fetal Heart Rate Monitoring
AKA “reading strips” G1 OB skills workshop- July 31st 201
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Goals Become familiar looking at electronic fetal heart rate tracings
Learn a systematic approach to electronic fetal monitoring (EFM) interpretation
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Objectives List the three risk based categories of EFM interpretation
Demonstrate an organized approach to reading a strip Correctly identify early decelerations, variable decelerations, late decelerations
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EFM: The Basics Used to assess fetal well being
External vs. internal monitoring Intermittent vs. continuous monitoring Constant and minuute adjustments in response to the fetal environment and stimuli
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EFM: The Basics FHR tracings should be evaluated in the context of the clinical situation. This includes (but is not limited to): Gestational age Prior results of fetal assessment Medications Maternal medical conditions Fetal conditions
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External monitors
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Internal monitors-IUPC and FSE
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Systematic approach Baseline fetal heart rate and trend
variability Uterine contractions (frequency and duration) Periodic Heart Rate Changes Accelerations and Decelerations Changes or trends over time
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DRCBRAVADO (ALSO mnemonic)
Define Risk Contractions (in 10 mins) Baseline Rate (should be ) Variability (should be greater than 5) Accelerations Decelerations Overall (normal or not)
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Systematic Approach Final interpretation
Category I Category II Category III Develop an assessment and plan and DOCUMENT it
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Categories A new classification system from the National Institute of Child Health and Human Development Workshop Report Based on available evidence and consensus statements
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Key Guidelines FHR decels as an independent finding are poorly predictive of complicated outcomes The degree of variability is the MOST sensitive indicator of the adequacy of oxygen delivery to the fetus at any given moment in time
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Pattern Evolution Recognizing changes in the FHR tracing over time is the key element of FHR interpretation. A hypoxia-induced reduction in FHR variability develops gradually over about minutes
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Progress Note Example Subjective Objective Toco: baseline 130s, good variability reactive, occ. variable deceleration Ctx: q 3 min., regular, palpate moderate intensity Cervix: 5/80/-1 A/P: G3P2 at term. Category 1 tracing. Expectant management. Anticipate NSVD.
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Contractions The number of contractions present in a 10 minute window averaged over 30 minutes. Normal: less than or equal to 5 Tachysystole: more than 5 Avoid the terms “hyperstimulation” and “hypercontractility”
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Category I-Normal Baseline rate between 110-160 bpm
Moderate baseline variability May lose variabilty for minutes during fetal sleep cycles. This is OK. Accelerations present (or absent) Early decelerations may be present No late or variable decelerations
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Moderate Variability
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Variability Classifications-Detemined in a 10 min window excluding accelerations and decelerations Absent: amplitude range undetectable Minimal: amplitude more than undetectalbele and less than 5 bpm Moderate amplitude range 6-25 bpm Marked: amplitude range >25 bpm
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Accelerations
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Accelerations Reliably predict the absence of fetal maetabolic acidemia However…REMEMBER the absence off accelerations does NOT reliably predict fetal acidemia.
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Early Decelerations
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Early Decelerations
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Category II-The Messy Middle
Fetal tachycardia (>160 bpm) Fetal bradycardia (<110 bpm) With preserved baseline variability Minimal or Marked baseline variability Absence of induced accelerations after fetal stimulation
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Category II Variable decelerations associated with minimal or moderate variability Variable Decels with shoulders Late decelerations with preserved moderate baseline variability Prolonged decelerations (greater than 2 minutes, but less than 10)
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Category II Tracings If you have a category II tracing you need to do something to try and make it better. Oxygen, change in position, d/c pitocin, etc. Consider making the OB team aware of the situation as well.
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Category II INDETERMINATE
Not predictive of abnormal fetal acid base status, yet no adequate evidence to classify as Category I or III.
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Fetal Tachycardia
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Fetal Bradycardia
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Late Decelerations
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Variable Decelerations with Shoulders
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Saltatory variability
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Category III - Abnormal
Absent baseline varibility and any of the following: Recurrent late decelerations Recurrent variable decelerations Bradycardia Sinusoidal pattern
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Category III FHR tracing with persistent absent or minimal variability with recurrent decels or bradycardia hold the strongest association with fetal acidemia and/or the absence of neonatal vigor at birth
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Ominous tracings Usually requires IMMEDIATE delivery if the tracing is persistently a category III If vaginal delivery is close, move to operative vaginal delivery. If vaginal delivery not imminent, then a c-section is needed.
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Decreased Variability
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Late Decelerations with absent variability
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Sinusoidal pattern
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Now it’s your turn…..
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Practice Fetal tachycardia, loss of varibility, small variable decels
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Practice Reacitve strip, no contractions
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Practice
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Practice Pseudosinusoidal pattern- non-reassuring but not ominous
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Objectives List the three risk based categories of EFM interpretation
Demonstrate an organized approach to reading a strip Correctly identify early decelerations, variable decelerations, late decelerations
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