#116 Management of Intrapartum Fetal Heart Rate Tracings

Question 1

What is the management of a Category I fetal heart rate tracing?

Answer 1

Routine management

Question 2

What characteristics of a category II fetal heart rate tracing allows for continued surveillance plus intrauterine resuscitative measures?

Answer 2

FHR accelerations of moderate FHR variability

Question 3

What characteristics of a category II fetal heart rate tracing make you consider delivery?

Answer 3

Absent FHR accelerations and absent/minimal FHR variability

Question 4

How do you manage a category III FHR tracing?

Answer 4

Prepare for delivery while performing intrauterine resuscitative measures, proceed to delivery if not improved

Question 5

What is the most common FHR abnormality occuring during labor?

Answer 5

Intermittent variable decels

Question 6

What is the management of intermittent variable decels?

Answer 6

Most often do not require any treatment and associated with normal perinatal outcomes

Question 7

What features of a FHR tracing with recurrent variable decels can reassure you that the fetus is not current acidemic?

Answer 7

Moderate FHR variability or a spontaneous or induced acceleration

Question 8

What causes recurrent late decelerations?

Answer 8

Transient or chronic uteroplacental insufficiency. Common causes: maternal hypotension, uterine tachysystole, maternal hypoxia

Question 9

What is the initial management for recurrent late decels?

Answer 9

Maneuvers to promote uteroplacental perfusion: maternal lateral positioning, IVF bolus, maternal oxygen administration, evaluation for tachysystole

Question 10

What is definition of fetal tachycardia

Answer 10

FHR >160bpm for at least 10 mins

Question 11

What are identifiable underlying causes of fetal tachycardia

Answer 11

Infection (eg chorio, pyelo), medications (eg terb, cocaine, stimulants) maternal medical disorders (eg hyperthyroid), ob conditions (eg placental abruption, fetal bleeding), fetal tachyarrhythmias (usually w/ FHR > 200bpm)

Question 12

Is tachycardia predictive of fetal acidemia?

Answer 12

Poorly predictive unless accompanied by minimal or absent FHR variability or recurrent decels or both

Question 13

What is fetal bradycardia

Answer 13

FHR <110bpm for at least 10- minutes

Question 14

What are identifiable causes of fetal bradychardia or prolonged decels?

Answer 14

Maternal hypotension, umbilical cord prolapse/occlusion, rapid fetal descent, tachysystole, placental abruption, uterine rupture. Rarely in fetus with congenital heart abnormalities or myocardial conduction defects (maternal collagen vascular disease), congenital heart block (usually occurs in 2nd trimester)

Question 15

How long is a fetal sleep cycle?

Answer 15

Generally lasts 20 mins, but can persist up to 60mins.

Question 16

How long after maternal opioid administration should FHR variability improve?

Answer 16

Within 1-2 hours

Question 17

Patient with tachysystole on pitocin without associated fetal heart changes, how should you manage pitocin?

Answer 17

Consider decreasing oxytocin if Category 1.

Question 18

What intervention should be done for a women in spontaneous labor with tachysystole without associated fetal heart changes (cat 1)?

Answer 18

No intervention required

Question 19

How should you manage a patient in spontaneous labor with tachysystole with Cat II or III FHR tracing?

Answer 19

Intrauterine resuscitative measures. If no resolution, consider tocolytic.

Question 20

How should you manage a patient with induced or augmented labor with tachysystole and category II or III FHR tracing?

Answer 20

Decrease or stop uterotonics. Intrauterine resuscitative measures. If no resolution, consider tocolytic.

Question 21

What have category III tracings been associated with?

Answer 21

Increased risk for neonatal encephalopathy, cerebral palsy, and neonatal acidosis

Question 22

Is a category III tracing a good predictor for abnormal neurologic outcomes?

Answer 22

Predictive value is poor

Question 23

What is the decision-to-incision time for cesarean delivery in the setting of abnormal FHR pattern? What does the evidence say about this time line?

Answer 23

30 minutes. Multiple studies show lack of association between adverse outcomes and incision >30 mins