Three -Tier Fetal Heart Rate Interpretation Applying the ......Case Studies In Fetal Monitoring II III I Normal Abnormal Indeterminate NICHD 2008 Three -Tier Fetal Heart Rate Interpretation

1

Michael D. Fox RN, BSN

Applying the NICHD Categories Case Studies In Fetal Monitoring II

III

INormal

Abnormal

Indeterminate

NICHD 2008Three - Tier Fetal Heart Rate Interpretation

System

NICHD 2008Three - Tier Fetal Heart Rate Interpretation

System

I

NICHD 2008NICHD 2008

““““Normal””””

Category I• Moderate Variability• FHR 110-160 bpm• No late or variable decelerations •±±±± early decelerations•±±±± accelerations

Category I• Moderate Variability• FHR 110-160 bpm• No late or variable decelerations •±±±± early decelerations•±±±± accelerations

NICHD 2008NICHD 2008Category III• Absent variability with recurrent:

• Late decelerations• Variable decelerations• Bradycardia OR• Sinusoidal pattern

Category III• Absent variability with recurrent:

• Late decelerations• Variable decelerations• Bradycardia OR• Sinusoidal pattern ““““Abnormal”III

2

NICHD 2008NICHD 2008

II““““Indeterminate””””

Category II Tracings

Everything else

Category II Tracings

Everything else

““““The Mess In the Middle””””““““The Mess In the Middle””””

II

III

I

““““Abnormal””””

Indeterminate


2008 NICHD 3 Tier System Fails To:


• Clearly identify the relationship between FHR patterns and significant acidemia.


• Simplify and make clear the framework for determining the choice and timing of our interventions








? Minimal FHR variability (with decelerations) should be considered as potentially indicative of fetal acidemia and should be managed accordingly.

Minimal FHR variability (with decelerations) should be considered as potentially indicative of fetal acidemia and should be managed accordingly.

Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.

Absent FHR variability with decelerations… is abnormal and conveys an increased risk of fetal acidemia at the time it is observed.


NONO

MaybeMaybe

PresumedPresumed

FHR Patterns and AcidemiaFHR Patterns and Acidemia

2008 NICHD Report EFM JOGNN, 37, 1-6; 2008. 2008 NICHD Report EFM JOGNN, 37, 1-6; 2008.

NICHD - ACOG Practice Bulletin #116 November 2010

NICHD - ACOG Practice Bulletin #116 November 2010NICHD - ACOG Practice Bulletin #116 November 2010

Simplify the Framework3 Clinical Categories

Simplify the Framework3 Clinical Categories

3



Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.

Absent FHR variability ((with decelerations…) is abnormal and conveys an increased risk of fetal acidemia at the time it is observed.

Absent FHR variability ((with decelerations…) is abnormal and conveys an increased risk of fetal acidemia at the time it is observed.

ACOG - AWOHNN - AACN Interpretive Principles

ACOG - AWOHNN - AACN Interpretive Principles

Factors Increase Likelihood for Significant Acidemia

Factors Increase Likelihood for Significant Acidemia

2008 NICHD Report EFM JOGNN, 37, 1-6; 2008. 2008 NICHD Report EFM JOGNN, 37, 1-6; 2008.

NICHD - ACOG Practice Bulletin #116 November 2010

NICHD - ACOG Practice Bulletin #116 November 2010NICHD - ACOG Practice Bulletin #116 November 2010

• Recurrent… decelerations

• That progress to a greater depth and longer duration

• Are more indicative of impending fetal acidemia.NICHD 2010- ACOG Practice Bulletin #116 November 2010NICHD 2010- ACOG Practice Bulletin #116 November 2010

Evolution of Significant Acidemia? Evolution of Significant Acidemia?

Typical and observable changes associated with an increased risk for birth in the presence of a significant fetal acidemia?

Typical and observable changes associated with an increased risk for birth in the presence of a significant fetal acidemia?

1. Evolutionary loss of FHR variability

2. In association with recurrent decelerations and/or bradycardia

3. That get deeper over time

In Association Decelerations That Get Deeper Over Time

Moderate

Absent

Minimal

Pattern EvolutionEvolutionary loss of Variability

Moderate

AbsentMinimal

No No Maybe

Presumed PresumedMake a Presumptive Diagnosis of the FHR Patterns Relationship to Significant Acidemia

Based On the Degree of Variability Accompanies the Decelerations

Maybe

4

In a fetus with an initially normal FHR pattern the development of significant acidemia evolves over a period of time, of the order of at least one hour. (60 –

90 minutes)

In a fetus with an initially normal FHR pattern the development of significant acidemia evolves over a period of time, of the order of at least one hour. (60 –

90 minutes)

Estimated time to deliveryEstimated time to delivery

Local realities = Event to delivery time


Choice and Timing of Interventions: Factors to Consider

Choice and Timing of Interventions: Factors to Consider

1 Hour Window of Opportunity ±±±±1 Hour Window of Opportunity ±±±±

Applying the NICHD Categories Case Studies In Fetal MonitoringApplying the NICHD Categories Case Studies In Fetal Monitoring

CASE 1CASE 1

Patient ProfilePatient Profile

• 25 y/o G1 P0 • Admitted @ 39 3/7weeks • Labor• Epidural

• 25 y/o G1 P0 • Admitted @ 39 3/7weeks • Labor• Epidural

10:1210:12

Continuous monitoring Yes☐☐☐☐ No ☐☐☐☐Continuous monitoring Yes☐☐☐☐ No ☐☐☐☐✔✔

Recurrent decelerations - 50% UC’s in 2 consecutive 10 minute windows

5

MD/CNM notification Yes☐☐☐☐ No ☐☐☐☐MD/CNM notification Yes☐☐☐☐ No ☐☐☐☐✔✔

10:1210:12

Bedside evaluation Yes☐☐☐☐ No ☐☐☐☐Bedside evaluation Yes☐☐☐☐ No ☐☐☐☐✔✔

10:1210:12

Preparation for Delivery Yes☐☐☐☐ No ☐☐☐☐Preparation for Delivery Yes☐☐☐☐ No ☐☐☐☐✔✔

10:1210:12

Delivery Yes☐☐☐☐ No ☐☐☐☐Delivery Yes☐☐☐☐ No ☐☐☐☐✔✔ MD SVE - Leaves room

10:12 10:12

Complete. Feels urge to push

10:17

6

10:30 13 minutes later10:30 13 minutes later 10:30 18 minutes later10:30 18 minutes later

Ensure ability to rescue fetus Yes☐☐☐☐ No ☐☐☐☐Ensure ability to rescue fetus Yes☐☐☐☐ No ☐☐☐☐✔✔

11:10 40 minutes later11:10 40 minutes later 12:00 50 minutes later12:00 50 minutes later

7

13:00 60 minutes later13:00 60 minutes later

Neonatal Resuscitation Available Yes☐☐☐☐ No ☐☐☐☐Neonatal Resuscitation Available Yes☐☐☐☐ No ☐☐☐☐✔✔

13:37 birth13:37 birth

Is this tracing associated with Significant Acidosis?

Y e s N o

M ay b e

4% 9%

87%

A. YesB. NoC. Maybe

A. YesB. NoC. Maybe

Delivery OutcomeDelivery Outcome• 3535 gm. female• By low forceps for prolonged second

stage and maternal exhaustion (3 hrs. 25 minutes)

• Apgar Score 9/9

• 3535 gm. female• By low forceps for prolonged second

stage and maternal exhaustion (3 hrs. 25 minutes)

• Apgar Score 9/9Cord GasesCUA: 7.31/22/49/-2CUV: 7.36/28/43/-1

Cord GasesCUA: 7.31/22/49/-2CUV: 7.36/28/43/-1

8

2006 - Fetal acidemia and electronic fetal heart rate patterns: Is there evidence of an association? J. T. Parer a;T. King a; S. Flanders a; M. Fox a; S. J. Kilpatrick b The Journal of Maternal-Fetal Medicine, Volume 19, Issue 5 May 2006

2006 - Fetal acidemia and electronic fetal heart rate patterns: Is there evidence of an association? J. T. Parer a;T. King a; S. Flanders a; M. Fox a; S. J. Kilpatrick b The Journal of Maternal-Fetal Medicine, Volume 19, Issue 5 May 2006

Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.2008 NICHD Report EFM JOGNN, 37, 1-6; 2008. 2008 NICHD Report EFM JOGNN, 37, 1-6; 2008.

• 98% of the fetuses with moderate FHR variability, with or without decelerations or second stage bradycardia will be born in the absence of a significant metabolic acidemia, and/or in the presence of neonatal vigor.

•When moderate FHR variability is present at the time of birth < 1% of neonates will be born with an Apgar score <7 at 5 minutes.

• 98% of the fetuses with moderate FHR variability, with or without decelerations or second stage bradycardia will be born in the absence of a significant metabolic acidemia, and/or in the presence of neonatal vigor.

•When moderate FHR variability is present at the time of birth < 1% of neonates will be born with an Apgar score <7 at 5 minutes.

CASE 2CASE 2



• 16 y/o G1 P0 @ 40 6/7 weeks arrives in triage contracting strongly

• SVE in triage 5/100/-2

• AROM – thick mec

• FSE/IUPC are placed - amnioinfusionbegun

• Complete within 3 hours admission

• 16 y/o G1 P0 @ 40 6/7 weeks arrives in triage contracting strongly

• SVE in triage 5/100/-2

• AROM – thick mec

• FSE/IUPC are placed - amnioinfusionbegun

• Complete within 3 hours admission

Time: 23:50 – complete and pushingTime: 23:50 – complete and pushing

9

00:20: 30 minutes later…00:20: 30 minutes later… 00:40: 20 minutes later…00:40: 20 minutes later…

01:20: 40 minutes later01:20: 40 minutes later 01:30: 10 minutes later01:30: 10 minutes later

10

01:50: 20 minutes later – decision C/S01:50: 20 minutes later – decision C/S 01:59: 9 minutes later Terbutaline given) 01:59: 9 minutes later Terbutaline given)

To OR

02:20: 21 minutes later 02:20: 21 minutes later 02:28: 4 minutes later delivery 02:28: 4 minutes later delivery

11


Y e s N o

M ay b e

83%

14%3%A. Yes

B. NoC. Maybe

A. YesB. NoC. Maybe

Delivery SummaryDelivery Summary

• 1 hr. 20 minutes of recurrent decelerations with minimal -absent variability

• Male

• Apgar score 3/7/8

Cord Gases: • CUA : 6.82/114/14/-13

• CUV : 6.93/84/27/-11

• 1 hr. 20 minutes of recurrent decelerations with minimal -absent variability

• Male

• Apgar score 3/7/8

Cord Gases: • CUA : 6.82/114/14/-13

• CUV : 6.93/84/27/-11


CASE 3CASE 3

• 29 y/o G 2 P1 @ 39 3/7 wks.• Spontaneous labor• 29 y/o G 2 P1 @ 39 3/7 wks.• Spontaneous labor


12

17:3017:30 22:20 AROM 22:20 AROM

Inadequate uterine monitoring

22:3022:30 02 and IV increased 02 and IV increased 22:5822:58

13

23:1023:10 23:2023:20

23:30 SVE 3/90%23:30 SVE 3/90% 23:4023:40

14

Category ☐☐☐☐ I ☐☐☐☐ II ☐☐☐☐ IIICategory ☐☐☐☐ I ☐☐☐☐ II ☐☐☐☐ III

Significant Acidemia Yes ☐☐☐☐ NO ☐☐☐☐ Maybe ☐☐☐☐Significant Acidemia Yes ☐☐☐☐ NO ☐☐☐☐ Maybe ☐☐☐☐

XX XX

XX XX

23:4623:46 23:5023:50

15

24:00 SVE 4 cm – plan C/S24:00 SVE 4 cm – plan C/S 00:03 SQ Terbutaline00:03 SQ Terbutaline To ORTo OR

00:09 Positioned for spinal 00:2000:20 00:28 delivery00:28 delivery

16

17

18

19


Y e s N o

M ay b e

12%

41%47%

A. YesB. NoC. Maybe

A. YesB. NoC. Maybe

• C/S for ““““fetal distress. ””””

• 1900 gm. Female • APGARS 5/8.

• C/S for ““““fetal distress. ””””

• 1900 gm. Female • APGARS 5/8.

Birth OutcomeBirth Outcome

Cord GasesCUA:7.17/62/9/-8CUV:7.22/52/16/-7

Cord GasesCUA:7.17/62/9/-8CUV:7.22/52/16/-7

20

(23:40 – 00:03) - 23 minutes minimal variability + recurrent late decelerations(some deep – 60

beats below baseline)

(23:40 – 00:03) - 23 minutes minimal variability + recurrent late decelerations(some deep – 60

beats below baseline)

Local realities = in house surgical team immediate C/S capabilities

Local realities = in house surgical team immediate C/S capabilities

Timing of Interventions: Factors to Consider Timing of Interventions: Factors to Consider


Estimated time to delivery – presumption remote delivery- 4 cm

Estimated time to delivery – presumption remote delivery- 4 cm

00:03 Restoration of moderate FHR variability immediately before delivery

00:03 Restoration of moderate FHR variability immediately before delivery

SummationSummation

1. FHR decelerations as an independent finding are poorly predictive of complicated outcomes.

1. FHR decelerations as an independent finding are poorly predictive of complicated outcomes.

2. The degree of variability is the most sensitive indicator of the adequacy of oxygen delivery to the fetus at any given moment in time.

2. The degree of variability is the most sensitive indicator of the adequacy of oxygen delivery to the fetus at any given moment in time.

4. A metabolic acidemia typically develops slowly in association with recurrent decelerations and an evolutionary reduction of FHR variability over time.

4. A metabolic acidemia typically develops slowly in association with recurrent decelerations and an evolutionary reduction of FHR variability over time.

3. The deeper the decelerations the > likelihood for developing a significant acidemia.

3. The deeper the decelerations the > likelihood for developing a significant acidemia.

4 Simple Guidelines FHR Monitoring4 Simple Guidelines FHR Monitoring

Fetal acidemia and electronic fetal heart rate patt erns: Is there evidence of an association? J. T.

PARER1, T. KING1, S. FLANDERS1, M. FOX1, & S. J. KI LPATRICK2

Evidence Based Indications For ActionBased on the degree of variability that accompanies the decelerations

MAYBE?

Make a presumptive Diagnosis

YES?NO?

Significant acidemia?

21

� Continuous Observation� Notification� Bedside Evaluation� Prepare for birth� Expedite Birth� Prepare For Neonatal Resuscitation� Prepare to Transfer/Transport

� Continuous Observation� Notification� Bedside Evaluation� Prepare for birth� Expedite Birth� Prepare For Neonatal Resuscitation� Prepare to Transfer/Transport

IntrauterineResuscitation In a fetus with an initially normal FHR pattern

the development of significant acidemia evolves over a period of time, of the order of at

least one hour. (60 – 90 minutes)

In a fetus with an initially normal FHR pattern the development of significant acidemia

evolves over a period of time, of the order of at least one hour. (60 – 90 minutes)

Estimated time to deliveryEstimated time to delivery



Timing of Interventions: Factors to Consider Timing of Interventions: Factors to Consider




Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.

Moderate FHR variability reliably predicts the absence of fetal metabolic acidemia at the time it is observed.



NONO

MaybeMaybe

PresumedPresumed

Interpretive PrinciplesInterpretive Principles

I

II

III

Relationship AcidemiaRelationship AcidemiaExample: 3 – Tiered System that Integrated Patterns Presumed Relationship Acidemia with the CategoriesExample: 3 – Tiered System that Integrated Patterns Presumed Relationship Acidemia with the Categories

II

III

I

““““Abnormal””””

Indeterminate


Integrated 3 Tier SystemIntegrated 3 Tier System• More clearly identify the relationship between FHR patterns and significant acidemia.

• More clearly identify the relationship between FHR patterns and significant acidemia.

•Better clarify how our presumptive diagnosis informs the choice and timing of our interventions.

•Better clarify how our presumptive diagnosis informs the choice and timing of our interventions.

Three -Tier Fetal Heart Rate Interpretation Applying the ......Case Studies In Fetal Monitoring II III I Normal Abnormal Indeterminate NICHD 2008 Three -Tier Fetal Heart Rate Interpretation

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