Strip of the Month: December 2016 Lena Braginsky, MD,* Beth A. Plunkett, MD* *Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston Hospital, Evanston, IL. ELECTRONIC FETAL MONITORING CASE REVIEW SERIES Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, the terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Plan- ning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring, and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate (FHR) patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1. Assumptions from the NICHD Workshop • Definitions are developed for visual interpretation, assuming that both the FHR and uterine activity recordings are of adequate quality • Definitions apply to tracings generated by internal or external monitoring devices • Periodic patterns are differentiated based on waveform, abrupt or gradual (eg, late decelerations have a gradual onset and variable decelerations have an abrupt onset) • Long- and short-term variability are evaluated visually as a unit • Gestational age of the fetus is considered when evaluating patterns • Components of FHR do not occur alone and generally evolve over time DEFINITIONS Baseline Fetal Heart Rate • Approximate mean FHR rounded to increments of 5 beats per minute in a 10- minute segment of tracing, excluding accelerations and decelerations, periods of marked variability, and segments of baseline that differ by >25 beats per minute • In the 10-minute segment, the minimum baseline duration must be at least 2 minutes (not necessarily contiguous) or the baseline for that segment is indeterminate • Bradycardia is a baseline of <110 beats per minute; tachycardia is a baseline of >160 beats per minute AUTHOR DISCLOSURE Drs Braginsky and Plunkett have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Vol. 17 No. 12 DECEMBER 2016 e753 Strip of the Month by 165225 on October 21, 2018 http://neoreviews.aappublications.org/ Downloaded from
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Strip of the Month: December 2016Lena Braginsky, MD,* Beth A. Plunkett, MD*
*Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston Hospital,
Evanston, IL.
ELECTRONIC FETAL MONITORING CASE REVIEW SERIES
Electronic fetal monitoring (EFM) is a popular technology used to establish fetal
well-being. Despite its widespread use, the terminology used to describe patterns
seen on the monitor has not been consistent until recently. In 1997, the National
Institute of Child Health and Human Development (NICHD) Research Plan-
ning Workshop published guidelines for interpretation of fetal tracings. This
publication was the culmination of 2 years of work by a panel of experts in the
field of fetal monitoring, and was endorsed in 2005 by both the American
College of Obstetricians and Gynecologists (ACOG) and the Association of
Women’s Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG,
NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated
the definitions for fetal heart rate (FHR) patterns, interpretation, and research
recommendations. Following is a summary of the terminology definitions and
assumptions found in the 2008 NICHD workshop report. Normal values for
arterial umbilical cord gas values and indications of acidosis are defined in
Table 1.
Assumptions from the NICHD Workshop• Definitions are developed for visual interpretation, assuming that both the FHR
and uterine activity recordings are of adequate quality• Definitions apply to tracings generated by internal or external monitoring
devices• Periodic patterns are differentiated based on waveform, abrupt or gradual (eg,
late decelerations have a gradual onset and variable decelerations have an
abrupt onset)
• Long- and short-term variability are evaluated visually as a unit
• Gestational age of the fetus is considered when evaluating patterns• Components of FHR do not occur alone and generally evolve over time
DEFINITIONS
Baseline Fetal Heart Rate• Approximate mean FHR rounded to increments of 5 beats per minute in a 10-
minute segment of tracing, excluding accelerations and decelerations, periods
of marked variability, and segments of baseline that differ by >25 beats per
minute
• In the 10-minute segment, the minimum baseline duration must be at least
2 minutes (not necessarily contiguous) or the baseline for that segment is
indeterminate
• Bradycardia is a baseline of <110 beats per minute; tachycardia is a baseline of
>160 beats per minute
AUTHOR DISCLOSURE Drs Braginskyand Plunkett have disclosed no financialrelationships relevant to this article. Thiscommentary does not contain a discussion ofan unapproved/investigative use of acommercial product/device.
Vol. 17 No. 12 DECEMBER 2016 e753
Strip of the Month
by 165225 on October 21, 2018http://neoreviews.aappublications.org/Downloaded from
3. Society for Maternal Fetal Medicine (SMFM) PublicationsCommittee; Sinkey RG, Odibo AO, Dashe JS. # 37: diagnosis andmanagement of vasa previa. Am J Obstet Gynecol. 2015;213(5):615–619
4. Oyelese KO, Turner M, Lees C, Campbell S. Vasa previa: anavoidable obstetric tragedy. Obstet Gynecol Surv. 1999;54(2):138–145
5. Oyelese Y, Catanzarite V, Prefumo F, et al. Vasa previa: the impact ofprenatal diagnosis on outcomes. Obstet Gynecol. 2004;103(5 Pt1):937–942
6. Creasy RK, Resnik R, Iams JD, Lockwood CJ, Moore TR,Greene MF. Creasy and Resnik’s Maternal-Fetal Medicine:Principles and Practice. 7th ed. Philadelphia, PA: Saunders/Elsevier; 2014
7. Vintzileos AM, Ananth CV, Smulian JC. Using ultrasound in theclinical management of placental implantation abnormalities. Am JObstet Gynecol. 2015;213(4 Suppl):S70–S77
8. Bronsteen R, Whitten A, Balasubramanian M, et al. Vasa previa:clinical presentations, outcomes, and implications formanagement.Obstet Gynecol. 2013;122(2 Pt 1):352–357
9. Eddleman KA, Lockwood CJ, Berkowitz GS, Lapinski RH,Berkowitz RL. Clinical significance and sonographic diagnosis ofvelamentous umbilical cord insertion. Am J Perinatol. 1992;9(2):123–126
10. Ruiter L, Kok N, Limpens J, et al. Systematic review of accuracy ofultrasound in the diagnosis of vasa previa.Ultrasound Obstet Gynecol.2015;45(5):516–522
11. Robinson BK, Grobman WA. Effectiveness of timing strategies fordelivery of individuals with vasa previa. Obstet Gynecol. 2011;117(3):542–549
American Board of PediatricsNeonatal–Perinatal ContentSpecification• Know the diagnosis and management of maternal/fetal bloodloss such as placenta previa, placenta abruption, vasa previa, andmaternal-fetal hemorrhage
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Lena Braginsky and Beth A. PlunkettStrip of the Month: December 2016
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