interpretation and management of intrapartum fetal heart
TRANSCRIPT
경북의대 성원준
Interpretation and management of
intrapartum fetal heart rate monitoring
External & Internal FHR monitoring
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Why is FHR monitoring important?
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BP
O2
HR
Efficacy of EFM
*EFM vs intermittent auscultation
• Cesarean section rate ↑ (RR:1.66, CI:1.30-2.13)
• Operative vaginal delivery ↑ (RR:1.16, CI:1.01-1.32)
• Neonatal seizure ↓ (RR:0.50, CI:0.31-0.80)
• Perinatal mortality ≒ (RR:0.85, CI:0.59-1.23)
• Cerebral palsy ≒ (RR:1.74, CI:0.97-3.11)
• PPV of nonreassuring pattern to predict CP: only 0.14%
-ACOG practice bulletin 106, 2009
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Interobserver and intraobserver variability
Comparisons of guidelines
• ACOG NICHD practice bulletin106, 2009
• FIGO updated consensus guideline, 2015
• RCOG NICE guideline CG190, 2017
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Paper speed
• Most countries: 1cm/min
• Netherlands: 2cm/min
• North America and Japan: 3cm/min
• At 3cm/min, variability appears reduced to a clinician familiar with 1cm/min scale
1min
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Baseline• Mean FHR rounded to increments of 5bpm during 10min
(>2min, no periodic or episodic change or marked variability) -ACOG 2009
• Mean level of most horizontal and less oscillatory for 10min -FIGO 2015
ACOG 2009,FIGO 2015
RCOG 2017
Normal 110-160 Reassuring 110-160
Tachycardia >160 Nonreassuring 100-109, 161-180
Bradycardia <110 Abnormal <100, >180
Baseline change
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Tachycardia
• Preterm fetus
• Maternal pyrexia
• Intrauterine infection
• Epidural analgesia
• Initial stage of nonacute fetal hypoxemia
• Beta-agonist, parasympathetic blockers
• Fetal supraventricular tachycardia, atrial flutter -ACOG 2009
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Bradycardia
• Postdate fetus (usually 100-110)
• Maternal hypothermia
• Beta-blockers
• Fetal AV block -ACOG 2009
• 100-110 of normal variability and no variable, late decelerations: Continue usual care -RCOG 2017
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Variability• Fluctuations in baseline FHR, quantified as amplitude of peak to trough
– ACOG 2009
• Oscilliation in FHR, average bandwidth amplitude in 1min segments
– FIGO 2015
ACOG 2009 FIGO 2015 RCOG 2017
Absent undetect
Minimal ≤5 Reduced <5 for 50min Reassuring 5-25
Moderate (normal)
6-25 Normal 5-25 Nonreassuring <5 for 30-50min>25 for 15-25min
Marked >25 Increased(Saltatory)
>25 for 30min Abnormal <5 for 50min>25 for 25min
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Variability
Moderate : 6-25 bpm
Marked : > 25 bpm
Minimal : ≤ 5bpm
Absent : undetectable
-ACOG 200911/42
Reduced variability
• Ongoing CNS hypoxia/acidosis
• Previous cerebral injury
• Infection
• Parasympathetic blockers
• Deep sleep: lower range of normality
• Following initially normal CTG, reduced variability due to hypoxia is
very unlikely to occur during labor without decelerations and rise in
baseline -FIGO 2015
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Increased variability
• Unknown pathophysiology
• Recurrent decelerations? with very acute hypoxia/acidosis
• Fetal autonomic instability -FIGO 2015
Not always benign
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Accelerations
• Abrupt (<30sec onset to peak)
≥32weeks, ≥15bpm for ≥15sec
<32weeks, ≥10bpm for ≥10sec
-ACOG 2009
• Neurologically responsive fetus without hypoxia/acidosis
• Absence of accelerations in normal CTG is unlikely to indicate hypoxia/acidosis -FIGO 2015
• Presence of accelerations with reduced variability is a sign that the baby is healthy -RCOG 2017
>15
>15
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Decelerations
• Early
• Variable
• Late
• Prolonged
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Early decelerations
• Symmetrical gradual decrease
(onset to nadir ≥30sec)
coincident with contraction
-ACOG 2009
• Shallow
• Benign
• Fetal head compression
-FIGO 2015
>30
shallow
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Variable decelerations
• Abrupt decrease
(onset to nadir<30sec)
≥15bpm for ≥15sec (<2min)
• Onset, depth and duration vary
with contractions
• Umbilical cord compression
-ACOG 2009
• Baroreceptor mediated response
to increased arterial pressure
-FIGO 2015
<30s
≥15b
≥15s, <2min
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• Concerning characteristics of variable decelerations -RCOG 2017
- >60sec
- reduced variability within deceleration
- failure to return to baseline
- biphase (W) shape
- no shouldering
& U shape by FIGO 2015
• Intermittent vs recurrent variable decelerations -ACOG 2009
if, ≥50% of contractions: impending fetal acidemia
Variable decelerationsa
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Late decelerations
• Symmetrical gradual decrease
(onset to nadir ≥30sec)
• Delayed in timing, nadir after
peak of contraction -ACOG 2009
• Starts >20sec after onset of
contraction -FIGO 2015
• Uteroplacental insufficiency
• Chemoreceptor mediated
response to fetal hypoxemia
-FIGO 2015
≥30s
≥15b
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Prolonged decelerations
• FHR decrease of ≥15bpm for ≥2min & <10min –ACOG 2009
• FHR decrease >3min –FIGO 2015, –RCOG 2017
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Prolonged decelerations
• Maternal hypotension (postepidural)• Umbilical cord prolapse or occlusion• Rapid fetal descent• Tachysystole• Placental abruption• Uterine rupture -ACOG 2009, RCOG 2017
• Hypoxemia and chemoreceptor mediated• >5min, <80bpm and reduced variability within deceleration
: acute hypoxia/acidosis- emergent intervention -FIGO 2015
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Sinusoidal pattern• Regular, smooth, undulating signal with amplitude of 5-15bpm,
3-5cycles/min, without acceleration, >30min -FIGO 2015
• Apparent smooth, undulation pattern, 3-5cycles/min, ≥20min
-ACOG 2009
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Sinusoidal pattern
• Fetal anemia
• Acute fetal hypoxia
• Infection
• Cardiac malformation
• Hydrocephalus
• Gastroschisis -FIGO 2015
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Uterine tone
• Only frequency of contractions can be reliable
• Intensity and duration also contribute to FHR -FIGO 2015
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Tachysystole
• >5 contractions in 10min (averaged over 30min)
–ACOG 2009
• >5 contractions in 10min (two successive periods or averaged over 30min)
–FIGO 2015
• Hyperstimulation or hypercontractility
: abandoned terms –ACOG 2009
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Normal fetal acid-base status? No CP!
• Accelerations: fetus is not acidemic
• Variability: no consensus (fetus is not academic usually)
study 1. Moderate variability: cord pH>7.15
2. Variable or late decelerations with normal variability
: cord pH>7.0 in 97%
3. Most cases of adverse neonatal outcomes
: normal variability -ACOG 2009
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Interpretation of EFM
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3 tier systemACOG Category I Category II Category III
FIGO Normal Suspicious Pathological
RCOG Normal Suspicious Pathological
1 nonreassuring 2 nonreassuring or1 abnormal pattern
All reassuring
ACOG practice bulletin 106, 2009
Category I Category II Category III
All of the following:
Baseline FHR: 110-160 Variability: moderate
Late or variable decel: -
Early decel: +/-Accel: +/-
Examples:
Bradycardia with no absent variabilityTachycardia
Minimal variabilityAbsent variability with no recurrent
decelerationsMarked variability
Absence of induced accelerations after stimulation
Recurrent variable decelerations with minimal or moderate variabilityRecurrent late decelerations with
moderate variabilityProlonged decelerations (2-10min)Variable decelerations with other
characteristics (slow return, overshoots, shoulders)
Either:
Absent variability with-Recurrent late decel
-Recurrent variable decel-Bradycardia
Sinusoidal pattern
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FIGO classification 2015aa
Normal Suspicous Pathological
Baseline 110-160 bpm
Lacking at least one of normality, but no pathological features
<100 bpm
Variability 5-25 bpm<5bpm, >50min>25bpm, >30minSinusoidal pattern
Decelerations No repetitive (<50%)
Repetitive (>50%) late decel >30min,Single prolonged
deceleration >5min
Interpretation No hypoxia/acidosis Low probability High probability
Management No intervention Action to correct Expedite delivery
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Reassuring Nonreassuring Abnormal
Baseline 110-160 100-109 or 161-180 <100 or >180
Variability 5-25<5 (30-50min)>25 (15-25min)
<5 (>50min)>25 (>25min)
Sinusoidal
DecelerationsNone or early,
Variable decel with no concern <90min
All others
Recurrent variabledecel with
concern >30min,Late decel >30min,
Bradycardia,Prolonged decel
RCOG guidelines CG 190
Concerning characteristics of variable decelerations:
>60sec, reduce variability within decelerations, failure to return to baseline, W shape, no shouldering
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RCOG guidelines CG 190aa
Category Definition Management
Normal All features reassuring Continue CTG
Suspicious 1 nonreassuring
Correct underlying causeFull set of observationsInform an obstetrician or a senior midwifeDocument a plan for reviewingTake her preferences into account
Pathological2 nonreassuring or1 abnormal
Review by an obstetrician and a senior midwifeExclude acute event and correct underlying causeOffer digital scalp stimulationConsider fetal blood samplingConsider expediting birthTake the woman’s preferences into account
Urgent intervention
bradycardia, or prolonged decel
All the aboves, prepare for urgent birthExpedite the birth if bradycardia >9min
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Management of EFM
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Management of ACOG
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Intervention effect should be apparent within 30 minutes of application
Intrauterine resuscitation
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Clarks et al, AJOG 2013Timmins et al, OGCNA 2015
How to approach category II, Clarks et al.
Significant decel: Variable decel over
60sec, <60bpm: Any late decel
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Management of intrapartum FHR tracing
ManagementIntrauterine
resuscitation & Delivery
InterpretationACOG Category IIIFIGO PathologicalRCOG Pathological
30min
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Management of intrapartum FHR tracing
ManagementACOG IUR & Surveillance
FIGO RCOG IUR & DeliveryClarks et al. Consider delivery if abnormal
progress or remote from delivery
InterpretationACOG Category IIFIGO PathologicalRCOG Pathological
IUR: Intra Uterine Resuscitation
60min
Management of intrapartum FHR tracing
InterpretationACOG Category IIFIGO Suspicious
RCOG Pathological
ManagementACOG FIGO IUR & Surveillance
RCOG IUR & DeliveryClarks et al. Consider delivery if abnormal
progress or remote from delivery
IUR: Intra Uterine Resuscitation
60min
Over 50 min
Management of intrapartum FHR tracing
InterpretationACOG Category IIFIGO PathologicalRCOG Pathological
ManagementACOG FIGO RCOG IUR & Delivery
Clarks et al. Observe 1 hr & Delivery
IUR: Intra Uterine Resuscitation
Interobserver and intraobserver variability
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Take home messages
• FHR monitor: medical device without instruction manual
• Interobserver and intraobserver variability
• Efforts for standardization
• Consider labor progress before making actions
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