You should talk to your doctor or midwife about how to best monitor your baby if you are concerned. Don't miss a single issue. These can include tachycardia–an increased heart rate–or bradycardia, which is a slowed heartbeat. Fetal heart rate patterns are classified as reassuring, nonreassuring or ominous. Stroke: Part I. 11. Annual summary of births, marriages, divorces, and deaths: United States, 1993. Postdate gestation, preeclampsia, chronic hypertension and diabetes mellitus are among the causes of placental dysfunction. Any decrease in uterine blood flow or placental dysfunction can cause late decelerations. The transducer uses Doppler ultrasound to detect fetal heart motion and is connected to an FHR monitor. Fetal scalp sampling for pH is recommended if there is no acceleration with scalp stimulation.11. Dr. Nuovo received his medical degree from the University of Vermont College of Medicine, Burlington, and completed a residency in family practice at Madigan Army Medical Center, Tacoma, Wash. ACOG technical bulletin no. Schifrin BS, 1975;82:24–8. 13. VII. Sign up for the free AFP email table of contents. A pseudosinusoidal pattern shows less regularity in the shape and amplitude of the variability waves and the presence of beat-to-beat variability, compared with the true sinusoidal pattern (Figure 11b). Boehm FH, A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. 6. 2d ed. This pattern is most often seen during the second stage of labor. Kurse J. Variable and inconsistent interpretation of tracings by clinicians may affect management of patients. Byrd JE. Reversal of fetal distress following intensive treatment of maternal diabetic ketoacidosis. 7. : Public Health Service, 1994. Krebs HB, Clin Perinatol. Hypoxia, uterine contractions, fetal head compression and perhaps fetal grunting or defecation result in a similar response. The FHR tracing should be interpreted only in the context of the clinical scenario, and any therapeutic intervention should consider the maternal condition as well as that of the fetus. Fetal arrhythmia is a term that refers to any abnormality in the heart rate of your baby. Washington, D.C.: ACOG, 1995. Jordaan HV, 207. Medicolegal ramifications of electronic fetal monitoring during labor. Most patients who undergo internal fetal monitoring during labor accept monitoring as a positive experience.6. Late deceleration with loss of variability. Understanding Fetal Heart Rate Patterns That May Predict Antenatal and Intrapartum Neural Injury. Knuppel RA, Tachycardia is considered mild when the heart rate is 160 to 180 bpm and severe when greater than 180 bpm. Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. 7. The significance of the changes in the continuous fetal heart rate in the first stage of labour. 1985;153:717–20. The fetal heart rate should be between 110 and 160 beats per minute during late pregnancy and labor, according to Johns Hopkins Medicine Health Library. A systematic approach is recommended when reading FHR recordings to avoid misinterpretation (Table 2). Hyattsville, Md. 1994;11:430–2. The effects of 5% Dextrose in Lactated Ringer's Injection on the duration of labor or delivery, on the possibility that forceps delivery or other intervention or resuscitation of the newborn will be necessary, and on the later growth, development, and functional maturation of the child are unknown. Severe prolonged bradycardia of less than 80 bpm that lasts for three minutes or longer is an ominous finding indicating severe hypoxia and is often a terminal event.4,11,16  Causes of prolonged severe bradycardia are listed in Table 6. Bissonnette JM. It indicates severe fetal anemia, as occurs in cases of Rh disease or severe hypoxia.24 It should be differentiated from the “pseudosinusoidal” pattern (Figure 11a), which is a benign, uniform long-term variability pattern. 17. / afp The inhibitory influence on the heart rate is conveyed by the vagus nerve, whereas excitatory influence is conveyed by the sympathetic nervous system. 2d ed. Weissman A, If you are having a non-stress test at the end of pregnancy, you can hear the fluctuations. ACOG/SMFM Obstetric Care Consensus. Thank you, {{form.email}}, for signing up. Persistent tachycardia greater than 180 bpm, especially when it occurs in conjunction with maternal fever, suggests chorioamnionitis. Finally, the recovery phase is due to the relief of the compression and the sharp return to the baseline, which may be followed by another healthy brief acceleration or shoulder (Figure 8). Am J Obstet Gynecol. ACOG technical bulletin no. In general, low-risk women will need less monitoring in labor. : American Academy of Family Physicians 1996:97–106, Adapted with permission from Wolkomir MS. Understanding and interpreting intrapartum fetal heart rate monitoring. Gimovsky ML, Progressive vagal dominance occurs as the fetus approaches term and, after birth, results in a gradual decrease in the baseline FHR. 1.10.45 Do not take a fetal blood sample during or immediately after a prolonged deceleration. Auscultation of the fetal heart rate (FHR) is performed by external or internal means. Kansas City, Mo. Baltimore: Williams & Wilkins, 1996:433–42. This is a question that you probably have from the first time you hear your baby's heartbeat. I. Identify pattern of uterine contractions, including regularity, rate, intensity, duration and baseline tone between contractions. Kansas City, Mo. Birth asphyxia occurs when the baby does not have adequate amounts of oxygen before, during, or after labor. Hyattsville, Md. The American College of Obstetricians and Gynecologists (ACOG) states that with specific intervals, intermittent auscultation of the FHR is equivalent to continuous EFM in detecting fetal compromise.4 ACOG has recommended a 1:1 nurse-patient ratio if intermittent auscultation is used as the primary technique of FHR surveillance.4 The recommended intermittent auscultation protocol calls for auscultation every 30 minutes for low-risk patients in the active phase of labor and every 15 minutes in the second stage of labor.4  Continuous EFM is indicated when abnormalities occur with intermittent auscultation and for use in high-risk patients. Maternal hypotension and uterine hyperstimulation may decrease uterine blood flow. The monitor calculates and records the FHR on a continuous strip of paper. Hutson JM, Fetal heart rate patterns: monitoring, interpretation, and management. Movement, sleeping, and other activities can cause normal variation. The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes. The evaluation and significance of intrapartum baseline FHR variability. Assessment of fetal and newborn acid-base status. Want to use this article elsewhere? Clark SL, Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. Physiology and clinical use of fetal heart rate variability. 127. Identify changes in the FHR recording over time, if possible. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Fetal heart rate is 150 to 160 beats per minute, and beat-to-beat variability is preserved. Beta-adrenergic agonists used to inhibit labor, such as ritodrine (Yutopar) and terbutaline (Bricanyl), may cause a decrease in variability only if given at dosage levels sufficient to raise the fetal heart rate above 160 bpm.19 Uncomplicated loss of variability usually signifies no risk or a minimally increased risk of acidosis19,20 or low Apgar scores.21 Decreased FHR variability in combination with late or variable deceleration patterns indicates an increased risk of fetal preacidosis (pH 7.20 to 7.25) or acidosis (pH less than 7.20)19,20,22 and signifies that the infant will be depressed at birth.21 The combination of late or severe variable decelerations with loss of variability is particularly ominous.19 The occurrence of a late or worsening variable deceleration pattern in the presence of normal variability generally means that the fetal stress is either of a mild degree or of recent origin19; however, this pattern is considered nonreassuring. [2017] 1.10.48 Use the following classifications for fetal blood sample results: Fetal tachycardia that is due to fetal tachyarrhythmia associated with congenital anomalies, in this case, ventricular septal defect. Since variable and inconsistent interpretation of fetal heart rate tracings may affect management, a systematic approach to interpreting the patterns is important. National Center for Health Statistics. 3. They are the most commonly encountered patterns during labor and occur frequently in patients who have experienced premature rupture of membranes17 and decreased amniotic fluid volume.24 Variable decelerations are caused by compression of the umbilical cord. Address correspondence to Amir Sweha, M.D., 7500 Hospital Dr., Sacramento, CA 95823. Byrd JE. / However, if your doctor notices that your baby's heartbeat is off by a week or more, it can indicate that a miscarriage is more likely. Schifrin BS. Schneider EP, At about five weeks gestation, your baby's heart begins to beat. 22. Am J Obstet Gynecol. Relationship between continuous fetal heart rate patterns and Apgar score in the newborn. National Center for Health Statistics. Evaluation of fetal well-being using fetal scalp stimulation, pH measurement, or both, is recommended for use in patients with nonreassuring patterns.11,12  Evaluation for immediate delivery is recommended for patients with ominous patterns. 16. Schifrin BS, Insler V. The significance of the changes in the continuous fetal heart rate in the first stage of labour. Evaluate recording—is it continuous and adequate for interpretation? Am J Nurs. This tracing probably represents cord compression and uteroplacental insufficiency. This use of a doppler in the home is not recommended for most mothers. Goodlin RC, In the United States, an estimated 700 infant deaths per year are associated with intrauterine hypoxia and birth asphyxia.5 Another benefit of EFM includes closer assessment of high-risk mothers. Lake M, 5. The FHR is under constant variation from the baseline (Figure 1). Get diet and wellness tips to help your kids stay healthy and happy. Early decelerations are caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. During the first Match Day celebration of its kind, the UCSF School of Medicine class of 2020 logged onto their computers the morning of Friday, March 20 to be greeted by a video from Catherine Lucey, MD, MACP, Executive Vice Dean and … Which fetal heart pattern indicates cord compression? If a Category III tracing does not resolve with these measures, delivery should be under-taken. 1. Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. Hon EH. Dunn LJ, A graduate of the UCLA School of Medicine, he completed a residency in family practice at the Shasta-Cascade Family Practice Residency Program in Redding, Calif., and completed a faculty development fellowship at the University of California, San Francisco, School of Medicine. Bradycardia of this degree is common in post-date gestations and in fetuses with occiput posterior or transverse presentations.16 Bradycardia less than 100 bpm occurs in fetuses with congenital heart abnormalities or myocardial conduction defects, such as those occurring in conjunction with maternal collagen vascular disease.16 Moderate bradycardia of 80 to 100 bpm is a nonreassuring pattern. Intrapartum fetal surveillance: the role of fetal scalp blood sampling. 8. The FHR is controlled by the autonomic nervous system. The indirectly obtained fetal heart rate: Comparison of first- and second-generation electronic fetal monitors. Obstet Gynecol. Electronic fetal heart rate monitoring is commonly used to assess fetal well-being during labor. Fetal tachycardia with possible onset of decreased variability (right) during the second stage of labor. The descent and return are gradual and smooth. Druzin ML. A more recent article on intrapartum fetal monitoring is available. Get Permissions, Access the latest issue of American Family Physician. Your baby has the same reaction. The significance of overshoot. Hon EH. Clinical fetal monitoring. Hyattsville, Md. Whither electronic fetal monitoring? The indirectly obtained fetal heart rate: Comparison of first- and second-generation electronic fetal monitors. An acceleration pattern preceding or following a variable deceleration (the “shoulders” of the deceleration) is seen only when the fetus is not hypoxic.15 Accelerations are the basis for the nonstress test (NST). [2017] 1.10.46 Take fetal blood samples with the woman in the left-lateral position. Br J Obstet Gynecol. Fetal Distress: Diagnosis, Conditions & Treatment. Fetal heart rate is 180 bpm. Variability should be normal after 32 weeks.17 Fetal hypoxia, congenital heart anomalies and fetal tachycardia also cause decreased variability. Fetal and maternal monitoring: maternal reactions to fetal monitoring. : Public Health Service, 1994. Am J Obstet Gynecol. Guide to clinical preventive services. Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis. Jordaan HV, There are other ways to listen to your baby's heartbeat. Severe variable deceleration with overshoot. Hon EH. Though there are many words to describe the moment that you first hear your baby's heartbeat, most people use words like galloping to describe how the heart rate sounds. Labor and Delivery If vasopressor drugs are either used to correct hypotension or added to the local anesthetic solution, the obstetrician should be cautioned that some oxytocic drugs may cause severe persistent hypertension and that even a rupture of a cerebral blood vessel may occur during the postpartum period (see WARNINGS). Variable deceleration with pre- and post-accelerations (“shoulders”). Table 1 lists examples of the criteria that have been used to categorize patients as high risk. Advanced Life Support in Obstetrics Course Syllabus. State of the art. 13. Gabbe, S, Niebyl, J, Simpson, JL. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. If the cause cannot be identified and corrected, immediate delivery is recommended. Knight CA, Sandmire HF. Or you can have continuous fetal monitoring with either external monitoring or internal fetal monitoring.. A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended (Figure 6). This deceleration pattern also may be interpreted as a variable deceleration with late return to the baseline based on the early onset of the deceleration in relation to the uterine contraction, the presence of an acceleration before the deceleration (the “shoulder”) and the relatively sharp descent of the deceleration. The heart rate goes up and down within a certain framework of normal. : American Academy of Family Physicians, 1996:97–106. Interpretation of the Electronic Fetal Heart Rate During Labor. National Center for Health Statistics. Treatment of sickle cell disease during pregnancy is complex. Differentiating between a reassuring and nonreassuring fetal heart rate pattern is the essence of accurate interpretation, which is essential to guide appropriate triage decisions. 2009;114(1):192-202. doi:10.1097/aog.0b013e3181aef106. Note the onset at the peak of the uterine contractions and the return to baseline after the contraction has ended. Recently, second-generation fetal monitors have incorporated microprocessors and mathematic procedures to improve the FHR signal and the accuracy of the recording.3 Internal monitoring is performed by attaching a screw-type electrode to the fetal scalp with a connection to an FHR monitor. Schifrin BS. Baltimore: Williams & Wilkins, 1996:433–42. Vaginal administration of Cytotec, outside of its approved indication, has been used as a cervical ripening agent, for the induction of labor and for treatment of serious postpartum hemorrhage in the presence of uterine atony. National Center for Health Statistics. Accelerations are transient increases in the FHR (Figure 1). Filshie GM, Weissman A, Intrapartum electronic fetal heart rate monitoring (EFM) and amnioinfusion. A Clinical Update on Prevention. Reassuring pattern. At this point, a normal fetal heart rate is about the same as the mother's: 80–85 beats per minute (bpm). 26. Lastly, late decelerations and fetal hypoxia during the second stage of labor could be the result of your pushing. 21. 2. 10. Bradycardia in the range of 100 to 120 bpm with normal variability is not associated with fetal acidosis. 12. 1989;16:627–42. 11. Immediate, unlimited access to all AFP content. Am J Perinatol. Caritis SN. Bowen AW, Martin CB Jr. 24. Fetal and maternal monitoring: maternal reactions to fetal monitoring. Mild variable decelerations are present. Most people are not prepared for how quickly a baby's heart beats in pregnancy. Fetal heart rate is 170 to 180 bpm. Read our, Medically reviewed by Brian Levine, MD, MS, FACOG, Medically reviewed by Andrea Chisholm, MD, Verywell Family uses cookies to provide you with a great user experience. Painful crises should be treated aggressively. Table 7 lists signs associated with variable decelerations indicating hypoxemia4,11,26 (Figures 9 and 10). ACOG technical bulletin no. Previous: Stroke: Part I. 1990;76:1130–4. Identify type of monitor used—external versus internal, first-generation versus second-generation. Prematurity decreases variability16; therefore, there is little rate fluctuation before 28 weeks. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Note the prolonged contraction pattern with elevated uterine tone between the peaks of the contractions, causing hyperstimulation and uteroplacental insufficiency. Petres RE, Unfortunately, precise information about the frequency of false-positive results is lacking, and this lack is due in large part to the absence of accepted definitions of fetal distress.7 Meta-analysis of all published randomized trials has shown that EFM is associated with increased rates of surgical intervention resulting in increased costs.8 These results show that 38 extra cesarean deliveries and 30 extra forceps operations are performed per 1,000 births with continuous EFM versus intermittent auscultation. 1975;123:206–10. Beat-to-beat variability is preserved. Physiology and clinical use of fetal heart rate variability. Obstet Gynecol. At this point, it begins a rapid deceleration to the normal fetal heart rate for mid-pregnancy to about 120–180 bpm. By the beginning of the ninth week of pregnancy, the normal fetal heart rate is an average of 175 bpm. Thus, it has the characteristic mirror image of the contraction (Figure 5). 8. The second uterine contraction is associated with a shallow and subtle late deceleration. Although these decelerations are not associated with fetal distress and thus are reassuring, they must be carefully differentiated from the other, nonreassuring decelerations. Lurie S, Roberts GM. Pressure on the cord initially occludes the umbilical vein, which results in an acceleration (the shoulder of the deceleration) and indicates a healthy response. / Vol. Sandmire HF. Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. Regardless of the depth of the deceleration, all late decelerations are considered potentially ominous. Milwaukee: Center for Ambulatory Teaching Excellence, Department of Family and Community Medicine, Medical College of Wisconsin, 1995:18, Address correspondence to Amir Sweha, M.D., 7500 Hospital Dr., Sacramento, CA 95823. How do you know if your baby's heart rate is normal? The true sinusoidal pattern is rare but ominous and is associated with high rates of fetal morbidity and mortality.24 It is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles per minute and an amplitude range of five to 15 bpm. Kansas City, Mo. Stamatopoulos N, Lu C, Casikar I, Reid S, Mongelli M, Hardy N, Condous G. Prediction of subsequent miscarriage risk in women who present with a viable pregnancy at the first early pregnancy scan. Am J Obstet Gynecol. Abrupt decreases in fetal heart rate that are unrelated to the contractions 3. Adapted with permission from Byrd JE. Vaughn WK. -Use with caution during labor and delivery; avoid use during second stage of labor.-Avoid use in obstetrics when maternal blood pressure exceeds 130/80 mmHg.-According to some authorities, this drug is considered first choice for anaphylaxis treatment during pregnancy; use in the same manner as for non-pregnant patients. Milwaukee: Center for Ambulatory Teaching Excellence, Department of Family and Community Medicine, Medical College of Wisconsin, 1995:18. Petres RE, Classification and prognosis of fetal heart rate patterns. To see the full article, log in or purchase access. Nochimson DJ, Note the decreased regularity and the preserved beat-to-beat variability, compared with a true sinusoidal pattern (B). Antepartum fetal heart rate monitoring. Vaughn WK. Wolkomir MS. Understanding and interpreting intrapartum fetal heart rate monitoring. Suidan AK, Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm and is considered a nonreassuring pattern (Figure 3). 1971;78:865–81. The effect of continuous EFM monitoring on malpractice liability has not been well established. Hutson JM, Paul RH. Choose a single article, issue, or full-access subscription. However, variability is preserved. U.S. Preventive Services Task Force. Management should include treatment of the uterine hyperstimulation. Copyright © 2020 American Academy of Family Physicians. Early deceleration in a patient with an unremarkable course of labor. Clin Perinatol. Seventh Edition; 2016. Mean FHR rounded to increments of 5 bpm during a 10 min window, excluding: 1. VII. Shields D. : Public Health Service, 1995. Some moms feel better when they can monitor the baby's heartbeat from home. There are also options for monitoring baby's heart rate during labor. Some parents may wonder if monitoring the baby's heart rate from day to day while at home is a smart idea. Adapted with permission from Wolkomir MS. Understanding and interpreting intrapartum fetal heart rate monitoring. With regard to the labor and delivery, our expert indicated the decision to perform a cesarean section was timely made. Chemoreceptors located in the aortic and carotid bodies respond to hypoxia, excess carbon dioxide and acidosis, producing tachycardia and hypertension.15 The FHR is under constant and minute adjustment in response to the constant changes in the fetal environment and external stimuli. AMIR SWEHA, M.D., and TREVOR W. HACKER, M.D., Mercy Healthcare Sacramento, Sacramento, California, JIM NUOVO, M.D., University of California Davis, School of Medicine, Davis, California. Baroreceptors influence the FHR through the vagus nerve in response to change in fetal blood pressure. Correlate accelerations and decelerations with uterine contractions and identify the pattern. Other rare risks associated with EFM include fetal scalp infection and uterine perforation with the intra-uterine tocometer or catheter. They are usually associated with fetal movement, vaginal examinations, uterine contractions, umbilical vein compression, fetal scalp stimulation or even external acoustic stimulation.15 The presence of accelerations is considered a reassuring sign of fetal well-being. Long-term variability is a somewhat slower oscillation in heart rate and has a frequency of three to 10 cycles per minute and an amplitude of 10 to 25 bpm. Am J Obstet Gynecol. Hon EH. 1982;15:35–42. 3. However, during the process of labor, your baby may show signs of needing more intense monitoring or your labor or interventions may require increased monitoring to help boost the safety of procedures. Electronic fetal monitoring during labor. JIM NUOVO, M.D., is residency director of the University of California, Davis, Family Practice Residency Program. Cytotec can induce or augment uterine contractions. The normal FHR range is between 120 and 160 beats per minute (bpm). Your heart rate would go up and down as well. Reassuring patterns correlate well with a good fetal outcome, while nonreassuring patterns do not. Fields LM, 15. 42, no. / Journals Notice that the onset and the return of the deceleration coincide with the start and the end of the contraction, giving the characteristic mirror image. There is also a slowing of the normal fetal heart rate in the last 10 weeks of pregnancy, though the normal fetal heart rate is still about twice the normal adult's resting heart rate. This pattern is sometimes called a saltatory pattern and is usually caused by acute hypoxia or mechanical compression of the umbilical cord. Imagine what it would sound like if you had ongoing audio of your heart rate as you were starting to exercise and then cooling down. Lowe EW. Medicolegal ramifications of electronic fetal monitoring during labor. While the heart rate in pregnancy is faster than an adult's heart rate, the truth is that a normal fetal heart rate changes during the stages of pregnancy and throughout the day.. Caritis SN. Late deceleration related to bigeminal contractions. Monthly vital statistics report; vol. By using Verywell Family, you accept our, Reading a Fetal Monitor Can Help You See How the Baby Is During Labor, 13 Milestones for Your Pregnancy After Miscarriage, The Options Parents Have When Being Sent Home After a False Labor, How to Tell Whether You're Having a Missed Miscarriage, 5 Simple Reasons Why You May Not Hear the Heartbeat Right Away, Tools You Can Use for Listening to Your Baby's Heartbeat at Home, Slowed Fetal Heartbeat During Pregnancy Can Be a Concern. Obstet Gynecol. Talk to your doctor or midwife for advice on which is best for you. The presence of a saltatory pattern, especially when paired with decelerations, should warn the physician to look for and try to correct possible causes of acute hypoxia and to be alert for signs that the hypoxia is progressing to acidosis.21 Although it is a nonreassuring pattern, the saltatory pattern is usually not an indication for immediate delivery.19. Ominous patterns require emergency intrauterine fetal resuscitation and immediate delivery. State of the art. Clinical fetal monitoring. tion, discontinuation of labor stimulation, treatment of maternal hypotension, and treatment of tachysystole with FHR changes.
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