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ACOG Pub Review > PB#116: Management of Intrapartum Fetal Heart Rate Tracings > Flashcards

PB#116: Management of Intrapartum Fetal Heart Rate Tracings Flashcards

1
Q

Definition of FHR baseline

A

Mean FHR rounded to increments of 5 bpm over 10 min segment, excluding periodic/episodic changes, periods of marked variability, and/or segments of baseline that differ by >25 bpm

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2
Q

Minimum time requirement for FHT to be considered a baseline

A

2 mins in any 10 min segment, or else baseline for that period is indeterminate (in which case one may refer to prior 10 min window for determining baseline)

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3
Q

Normal baseline

A

110-160 bpm

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4
Q

Fetal tachycardia

A

> 160 bpm

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5
Q

Fetal bradycardia

A

<110 bpm

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6
Q

Definition of FHR variability

A

Fluctuations in baseline FHR that are irregular in amplitude and frequency, visually quantitated as amplitude of peak-to-trough in bpm

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7
Q

Absent variability

A

Undetectable amplitude range

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8
Q

Minimal variability

A

Amplitude range detectable but <5 bpm

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9
Q

Moderate variability

A

Amplitude range 6-25 bpm

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10
Q

Marked variability

A

Amplitude range >25 bpm

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11
Q

Definition of accels

A

Visually apparent abrupt increase (onset to peak <30 secs) in FHR

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12
Q

Criteria for accels at 32+wga; criteria for accels at <32wga

A

Peak >15 bpm above baseline, w/ duration of >15 secs but <2 mins from onset to return; peak >10 bpm above baseline, w/ duration of >10 secs but <2 mins from onset to return

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13
Q

Definition of prolonged accel

A

Lasting >2 mins but <10 mins in duration

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14
Q

What is it considered if an accel lasts >10 mins?

A

Baseline change

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15
Q

Definition of early decels

A

Visually apparent usually symmetrical gradual decrease and return of FHR associated w/ ctx, wherein onset to nadir is >30 secs, and nadir of decel occurs at same time as ctx peak

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16
Q

Timing of onset/nadir/recovery of early decel as it relates to ctx (in most cases)

A

Coincident w/ beginning/peak/ending of ctx, respectively

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17
Q

Definition of late decels

A

Visually apparent usually symmetrical gradual decrease and return of FHR associated w/ ctx, wherein onset to nadir is >30 secs, and nadir of decel occurring after peak of ctx

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18
Q

Timing of onset/nadir/recovery of late decel as it relates to ctx (in most cases)

A

Occur after beginning/peak/ending of ctx, respectively

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19
Q

Definition of variable decels

A

Visually apparent abrupt decrease in FHR, wherein onset to nadir is <30 secs, decrease is >15 bpm, and lasts >15 secs but <2 mins in duration

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20
Q

Are onset/depth/duration of variable decels consistent across ctxs?

A

No, they commonly vary w/ successive ctxs

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21
Q

How is decrease in FHR calculated when evaluating decels?

A

From onset to nadir

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22
Q

Definition of prolonged decels

A

Visually apparent decrease in FHR, wherein decrease is >15 bpm, and lasts >2 mins but <10 mins in duration

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23
Q

What is it considered if a decel lasts >10 mins?

A

Baseline change

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24
Q

Definition of sinusoidal pattern

A

Visually apparent, smooth, sine wave-like undulating pattern in FHR baseline w/ cycle frequency of 3-5 per min, which persists for >20 mins

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25
Q

Definition of normal contractility

A

5 or fewer ctxs in 10 mins averaged over 30 min period

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26
Q

Definition of tachysystole

A

> 5 ctxs in 10 mins averaged over 30 min period

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27
Q

How should tachysystole always be qualified?

A

In the presence/absence of decels

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28
Q

Criteria for Cat 1 FHTs

A

Include all of the following: normal baseline, mod variability, absent late/variable decels, present/absent early decels, present/absent accels

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29
Q

General classification, acid-base status prediction, and recommended monitoring for Cat 1 FHTs

A

Normal, strongly predictive of normal fetal acid-base status at time of obs, can be monitored in routine manner (no specific action required)

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30
Q

How often should FHT be reviewed in a pt w/o complications in first stage of labor, in second stage of labor?

A

q30mins, q15mins

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31
Q

When is management necessary for FHT that is Cat I?

A

Only if evolution to Cat II or Cat III

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32
Q

Criteria for Cat 2 FHTs

A

Brady not accompanied by absent variability; tachy; min variability; absent variability w/o recurrent decels; marked variability; absence of induced accels after fetal stim; recurrent variable decels accompanied by min/mod variability; prolonged decel; recurrent late decels w/ mod variability; variable decels w/ other characteristics (ie slow return to baseline, overshoots, “shoulders”)

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33
Q

General classification, recommended monitoring, potential considerations for Cat 2 FHTs

A

Indeterminate, require evaluation and continued surveillance/reevaluation, may require ancillary testing of fetal wellbeing and/or intrauterine resuscitative measures

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34
Q

Features of a Cat II FHT that are reassuring and highly predictive of normal fetal acid-base status (2)

A

Accels (either spontaneous or elicited by scalp/vibroacoustic stim), mod variability

35
Q

Definition of intermittent variable decels

A

Variable decels occurring w/ <50% of ctxs

36
Q

Most common FHT abnormality during labor

A

Intermittent variable decels

37
Q

Are intermittent variable decels associated w/ abnormal perinatal outcomes?

A

Most often not

38
Q

Definition of recurrent variable decels

A

Variable decels occurring w/ >50% of ctxs

39
Q

Feature of recurrent variable decels that is more indicative of impending fetal acidemia

A

Decels that progress to greater depth and longer duration

40
Q

FHT features w/ recurrent variable decels that require evaluation (5)

A

Frequency, depth, duration, ctx pattern, other FHT characteristics (ie variability)

41
Q

Features of FHT tracings w/ recurrent variable decels that suggest that fetus is not currently acidemic (2)

A

Mod variability, spontaneous/induced accels

42
Q

Goal of management of recurrent variable decels

A

Relieving cord compression

43
Q

Initial maneuver used in management of recurrent variable decels

A

Maternal repositioning

44
Q

Intervention shown to decrease recurrence of variable decels and rate of C/S for suspected fetal distress

A

Amnioinfusion

45
Q

Poss FHT manifestations of cord compression (2)

A

Recurrent variable decels, prolonged decels/brady

46
Q

Poss interventions to alleviate cord compression (3)

A

Maternal repositioning, amnioinfusion, elevation of presenting fetal part while preparations are made for C/S (if cord prolapse noted)

47
Q

What are recurrent late decels thought to reflect?

A

Transient/Chronic uteroplacental insufficiency

48
Q

Common causes of uteroplacental insufficiency (3)

A

Maternal hypotension (ie post-epidural), tachysystole, maternal hypoxia

49
Q

Management options of recurrent late decels (4)

A

Maternal lateral positioning, IVF bolus, O2 administration, eval for tachysystole

50
Q

Poss FHT manifestations of fetal hypoxia and uteroplacental insufficiency (3)

A

Recurrent late decels, prolonged decels/brady, min/absent variability

51
Q

General principle of management of Cat II FHT w/ recurrent late decels?

A

Intrauterine resuscitation and reevaluation to determine whether adequate improvement in fetal status has occurred

52
Q

What FHT features are suggestive of fetal acidemia (and need for expedited delivery) in setting of recurrent late decels?

A

Min variability and absent accels despite intrauterine resuscitative measures

53
Q

When does an FHT w/ recurrent variable decels become Cat III?

A

If variability becomes absent

54
Q

Poss underlying causes for fetal tachy (5)

A

Infection, drugs, maternal medical disorders, OB conditions, fetal tachyarrhythmias

55
Q

Common infections leading to fetal tachy (3)

A

IAI, pyelo, other maternal infections

56
Q

Common drugs leading to fetal tachy (3)

A

Terb, cocaine, other stimulants

57
Q

Maternal medical disorder that can lead to fetal tachy

A

Hyperthyroidism

58
Q

OB conditions that can manifest as fetal tachy (2)

A

Abruption, fetal bleeding

59
Q

Common FHT features of an underlying fetal tachyarrhythmia

60
Q

Is tachy predictive for fetal hypoxemia/acidemia?

A

Poorly predictive in isolation (unless accompanied by min/absent variability and/or recurrent decels)

61
Q

Common causes of prolonged decels/brady (6)

A

Maternal hypotension (ie post-epidural), cord prolapse/occlusion, rapid fetal descent, tachysystole, abruption, uterine rupture

62
Q

Rare fetal causeses of brady (2)

A

Congenital heart abnormalities, myocardial conduction defects (ie those associated w/ maternal collagen vascular disease)

63
Q

When does onset of brady associated w/ congenital heart block typically begin?

A

2nd tri (extremely unlikely to have new onset intrapartum brady 2/2 congenital heart block)

64
Q

When is prompt delivery recommended in setting of brady/prolonged decels?

A

If brady/prolonged decels do not resolve and/or presence of min/absent variability

65
Q

Common poss causes of min variability (3)

A

Meds, fetal sleep cycle, fetal acidemia

66
Q

Common meds that may cause min variability (2)

A

Opioids, mag sulfate

67
Q

When does min variability typically improve to mod variability following opioid administration?

A

Within 1-2h

68
Q

Length of most fetal sleep cycles; max length of fetal sleep cycle

A

20 mins; 60 mins

69
Q

Management of min variability suspected to be 2/2 decreased fetal oxygenation (3)

A

Maternal repositioning, supp O2, IVF bolus

70
Q

Next step if initial resuscitation measures do not improve min variability and there are no accels

A

Digital scalp/vibroacoustic stim

71
Q

Poss indication of continued min variability in absence of accels that cannot be explained/resolved w/ resuscitation

A

Fetal acidemia

72
Q

When does tachy require eval/tx?

A

For pts in spontaneous labor w/ associated recurrent decels

73
Q

General intervention for laboring pts receiving pit w/ tachysystole

A

Reduction of uterine activity (to minimize risk of evolving fetal hypoxemia/acidemia)

74
Q

Management of tachysystole in presence of Cat I FHT in setting of IOL/AOL

A

Decrease in pit

75
Q

Management of tachysystole in present of Cat II/III FHT (2)

A

Decrease/stop pit, intrauterine resuscitation

76
Q

Next step if tachysystole-induced FHT abnormalities do not resolve w/ initial maneuvers

A

Tocolytic meds (ie terb)

77
Q

Intervention options for uterine hyperactivity (2)

A

Discontinuation of pit/cervical ripening agents, administration of tocolytic meds (ie terb)

78
Q

Criteria for Cat III FHTs

A

Include either: absent variability + recurrent late decels/recurrent variable decels/brady, or sinusoidal pattern

79
Q

General classification, acid-base status prediction, and recommended monitoring for Cat III FHTs

A

Abnormal, associated w/ abnormal fetal acid-base status at time of obs, require prompt evaluation

80
Q

Fetal risks associated w/ Cat III FHTs (3)

A

Neonatal encephalopathy, CP, neonatal acidosis

81
Q

How strong is predictive value of Cat III FHTs for abnormal neurological outcomes?

82
Q

How quickly should delivery occur after decision is made for OVD in setting of Cat III FHT?

A

As expeditiously as feasible

83
Q

How should one determine mode of delivery in setting of Cat III FHT?

A

Based on consideration of maternal and fetal risks/benefits

84
Q

Logistical considerations in preparation for OVD in setting of Cat III FHT (7)

A

Provision of informed consent (verbal or written as feasible), surgical team assembly (including surgeon/scrub tech/anesthesia), assessment of pt transit time/location, confirmation of IV access, review of lab results (ie CBC, T&S) and assessment of need for availability of blood products, assessment of need for preop Foley catheter placement, assembly of personnel for neonatal resuscitation

ACOG Pub Review (18 decks)

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