1. From NeoReviews, Strip of the Month: October 2015
Case Review
From NeoReviews, Strip of the Month: October 2015

2. Baseline FHR Baseline FHR
Approximate mean FHR rounded to increments of 5 beats/min during a 10 minute segment, excluding accelerations, decelerations, and periods of marked FHR variability.
The baseline must be for a minimum of 2 minutes in any 10 minute segment.
Normal baseline range is

3. Baseline (cont.) Definitions:
Tachycardia: The baseline FHR is greater than 160 beats per minute.
Bradycardia: The baseline FHR is less than 110 beats per minute.

4. Variability
Fluctuations in the FHR baseline that are irregular in amplitude and frequency, measured from the peak to the trough.
Absent- amplitude range is undetectable
Minimal- amplitude range is detectable but less than 5 beats/min
Moderate- Amplitude range 6-25 beats/min
Marked- Amplitude range is greater than 25 beats/min.

5. FHR Changes Accelerations
Visually apparent abrupt increase in the FHR from the baseline. The onset to the peak is less than 30 seconds.
Before approximately 32 weeks, an acceleration has a peak of at least 10 beats/min above the bassline and duration of at least 10 seconds.
After 32 weeks, an acceleration has a peak of at least 15 beats/min above the baseline and the duration is more than 15 seconds.
Prolonged acceleration lasts more than 2 min but less than 10 min
If an acceleration is longer than 10 min, it is a baseline change

6. Decelerations Early Late Variable Prolonged
Occurs with a contractions, with a gradual onset (more than 30 seconds to nadir). Generally the nadir occurs at the same time as the peak of the contraction.
Late
Occurs in association with a contraction with a gradual onset. The Onset, nadir, and recovery occur after the beginning, peak, and end of the contraction.
Variable
An abrupt (onset to nadir is less than 30 seconds) decrease in the FHR. The decrease is at least 15 beats/min and lasts at least 15 seconds but less than 2 min.
Prolonged
Decrease in FHR at least 15 beats/min below the baseline, lasting at least 2 min but less than 10.

7. Three-tier FHR Classification System
Category I
Normal FHR tracing with all of the following
baseline
FHR variability is moderate
Accelerations are present or absent
Without late or variable decelerations
Early decelerations may be present

8. Category II Category III
Includes all FHR tracings not assigned to Categories I or III
Category III
FHR tracing includes at least one of the following:
Absent variability with late decelerations
Absent variability with recurrent variable decelerations
Absent variability with bradycardia for at least 10 minutes
Sinusoidal pattern for at least 20 minutes

9. Contractions
The number of contractions in a 10-minute window and averaged over 30 min.
Normal: 5 or less contractions in 10 minutes
Tachysystole: More than 5 contractions in 10 minutes.

11. Presentation:
41 year-old G2P1 with type 2 diabetes mellitus at 37 5/7 weeks
Admitted with early labor and SROM
Denies vaginal bleeding
Reports feeling frequent fetal movement
Significant Hx:
Type 2 DM
Advanced maternal age
Open angle glaucoma
Sickle cell trait

12. Further history Type 2 DM diagnosed 5 years before this pregnancy.
Prior medications: Metformin and an ACE Inhibitor.
At 8 weeks gestation, transitioned to insulin and the ACE inhibitor was discontinued.
Glucose has been well controlled with insulin
All 3rd trimester ultrasounds and biophysical profiles have been reassuring.

13. Progression Admission exam: Blood pressure 126/66 HR 70
Blood glucose 115mg/dL
SROM confirmed
GBS negaive

14. Electronic fetal monitoring strip 1.
Contractions present? Normal or tachysystole?
FHR Baseline?
Variability?
Accels or Decels?
Category?
Interpretation:
Variability: Moderate
Baseline rate: 140
Episodic patterns: none
Periodic patterns: none
Uterine contractions: every 4 minutes
Interpretation: Category 1
Action: continue monitoring labor progression
Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605
©2015 by American Academy of Pediatrics

15. Progression Dilation 3 cm, 75% effaced, and -2 station
Insulin drip started

16. Electronic fetal monitoring strip 2.
One hour later…
Electronic fetal monitoring strip 2.
Electronic fetal monitoring strip 2.
Contractions present? Normal or tachysystole?
FHR Baseline?
Variability?
Accels or Decels?
Category?
Interpretation:
Variability: Moderate
Baseline rate: 135
Episodic patterns: none
Periodic patterns: Variable Decelerations
Uterine contractions: Irregular every 1-4 minutes
Interpretation: Category II
Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605
©2015 by American Academy of Pediatrics

17. SBAR+R Report Situation Background Assessment Recommendation Read back
Nurse calls to MD to evaluate strip:
Differential diagnosis: Umbilical cord compression, uteroplacental insufficiency, umbilical cord prolapse
Action: Change maternal position, administer IV fluids, SVE to evaluate for umbilical cord prolapse.

18. Progression Cervical exam: 4 cm, 100 % effaced, and at 0 station
Variable decels resolve with position change and IV fluids
Epidural placed for pain relief
10 minutes later…

19. Electronic fetal monitoring strip 3.
What are you thinking???
Electronic fetal monitoring strip 3.
What are you thinking???
Contractions present? Normal or tachysystole?
FHR Baseline?
Variability?
Accels or Decels?
Category?
Interpretation:
Variability: Moderate
Baseline rate: 130
Episodic patterns: Prolonged deceleration
Periodic patterns: none
Uterine contractions: Irregular every 1-2 minutes
Interpretation: Category II
Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605
©2015 by American Academy of Pediatrics

20. SBAR+R Report Situation Background Assessment Recommendation Read back
Nurse calls to MD to evaluate strip:
Differential diagnosis: Umbilical cord compression, maternal hypotension resulting in uterine hypoperfusion
Action: Resuscitative manoeuvres: change maternal position, IV fluids, perform SVE

21. Progression Dilation 10 cm, 100 % effaced, +2 station.
Prolonged decel lasted 9 minutes, despite interventions
Decel resolved, and patient began pushing with good effort.

22. Electronic fetal monitoring strip 4.
Variability: Moderate
Baseline rate: 110
Episodic pattern: none
Periodic pattern: Early and variable decelerations
Uterine contractions: every 2 minutes
Interpretation: Category II
Differential diagnosis: Umbilical cord compression, fetal head compression
Action: if delivery is not imminent and the category II tracing continues, the obstetrician may choose to expedite the delivery with forceps or vacuum assisted delivery or proceed with an urgent caesarean delivery.
Emily Willner, and Brett C. Young Neoreviews 2015;16:e598-e605
©2015 by American Academy of Pediatrics

23. Progression Patient pushed for seven minutes and delivered
NICU team in room due to prolonged decel

24. What are your apgars? 9 9 1 minute : 5 minutes:
Color: acrocyanosis Pulse >100 Grimace: good cry
Activity: arms and legs flexed with spontaneous movement Resp: more than 50
5 minutes:
Color: acrocyanosis Pulse > 100 Grimace: good cry
Activity: arms and legs flexed with spontaneous movement
Resp: more than 50 9

25. Outcome
Vigorous female at 37 5/7 weeks was delivered by vaginal delivery
Wt: 2,615g
Uncomplicated neonatal course and was discharged 2 days after birth in stable condition

26. Discussion
6%-7% of pregnancies are complicated by Diabetes (gestational and Pregestational)
Infants of diabetic mothers (IDMs) increased risks:
Macrosomia
May result in postpartum hemorrhage, cesarean delivery, and extensive perineal damage
Shoulder dystocia

27. Fetal Risks Stillbirth Congenital anomalies Cardiac defects
Neural tube defects

28. Pregestational diabetes increases risks of OB complications:
Preeclampsia and other hypertensive disorders of pregnancy
Worsening end-organ damage
Retinopathy and nephropathy worsen during pregnancy
Increased risk of MI
Increased risk of diabetic ketoacidosis
Placental insufficiency

29. Neonatal complications
Hypoglycemia
Respiratory distress
Polycythemia
Hyperbilirubinemia
Increased risk of childhood obesity and development of type 2 diabetes

30. Risks can be minimized
Good control of glucose before and during pregnancy
Preconception counseling
Ultrasounds monitoring size and fetal well-being
“Risks to both the mother and fetus can be minimized by optimization of glucose control before and during pregnancy combined with close monitoring of maternal and fetal well-being. Preconception counseling should include an emphasis on prevention and treatment of end-organ complications of diabetes; avoidance of teratogenic medications, such as angiotensin-converting enzyme inhibitors; and the importance of euglycemia. The rate of fetal congenital anomalies is not significantly increased in the general population when glycosylated hemoglobin levels are within 1% (0.01) of normal (approximately 5%–6%); however, when the glycosylated hemoglobin level is close to 10% (0.10), the rate of congenital anomalies in these pregnancies is 20% to 25%. (2) Short- and long-acting insulin is routinely used for glycemic control. Ultrasonography is used to confirm early pregnancy dating and assess fetal anatomy at 18 to 20 weeks’ gestation. Fetal echocardiography can be considered given the increased risk of congenital cardiac anomalies. Given the increased risk of fetal demise in pregnancies affected by pregestational diabetes, the American College of Obstetricians and Gynecologists supports the use of antenatal fetal surveillance, including fetal movement counting, nonstress testing, and twice-weekly biophysical profile beginning at 32 to 34 weeks’ gestation, with the addition of Doppler velocimetry of the umbilical artery in pregnancies with poor fetal growth. (2)(4)”

31. References:
Strip of the Month: October Emily Willner and Brett C. Young. NeoReviews 2015;16;e598. DOI: /neo e598. Retrieved from by Teriesa Pleyo on May 12, 2016