This guideline is intended for healthcare professionals, particularly those in training, who are working in hse. Intrapartum electronic fetal monitoring efm is used for most women who give birth in the united states. Nomenclature, interpretation, and general management principles july 2009. Hobel cj intrapartum clinical assessment of fetal distress. Intrapartum fetal heart rate monitoring sciencedirect. Although unexpected intrapartum fetal death has been largely eliminated. Since its introduction neonatal morbidity has been reduced but operative intervention has increased 2. Efm is used to assess fetal wellbeing ante partum and during labor 2, 3, 4. Figo news the guidelines are available at the links below, in the special ijgo free to view section and on the figo committee and working group publications page.
A normal tracing reliably predicts a welloxygenated fetus. Delphi consensus statement on intrapartum fetal monitoring in low. This updated guide describes the framework for core content of educational programs and clinical practicums for fetal heart rate monitoring in obstetric practice. Fetal heart rate monitoring 2018 queensland clinical guidelines.
Obstetrics at decisive crossroads regarding patternrecognition of. Cervix needs to be 45cm dilated and vx at 1 st or below ph 7. Jun 20, 2012 the objective of this study was to assess the fetal heart rate fhr signal quality of noninvasive abdominal fetal electrocardiogram fecg in comparison to the doppler ultrasound cardiotocogram ctg during the first and second stage of labour. Jul 09, 2009 this is going to be a long one, readers, so sit tight. Nomenclature, interpretation, and general management principles this practice bulletin was developed by the acog. A controlled trial of differential effects of intrapartum fetal monitoring. Nonreassuring fetal heart rate patterns intrapartum triple fetal. The goal of antepartum fetal surveillance is to prevent fetal death. This was a prospective observational study of noninvasive fecg using five abdominally sited electrodes against the traditional doppler ultrasound. The intent of intrapartum fetal surveillance is to assess uterine activity, fetal well. Given how thoroughly this practice has been embraced by obstetricians it was used in more than 85% of births in 2002, up from 45% in 1980 some readers may be surprised by the bulletin. Intrapartum fetal assessment and therapy clinical gate. This practice bulletin was devel oped by the acog committee on.
Standardisation of fetal heart rate monitoring fetal heart rate monitoring, whether by intermittent auscultation ia or electronic fetal monitoring efm, should be recommended to all women in labour. Despite intensive efforts directed at initial training in fetal heart rate. Freeman, md fetal heart rate fhr monitoring was introduced over 3 decades ago into clinical use and patient management. Low cerebroplacental ratio cpr at term is an independent predictor of intrapartum fetal compromise ifc 1, 2, poor acidbase status at birth 3, 4, increased risk of admission to the neonatal intensive care unit nicu 5 and increased risk of stillbirth 6, and is now believed to reflect failure of a fetus to reach its genetic growth potential at term 7. The fetal brain modulates the fetal heart rate through an interplay of sympathetic and parasympathetic forces. Purpose and scope the purpose of this guideline is to reduce adverse perinatal outcomes related to inappropriate or inadequate intrapartum fetal surveillance. Areas of competence for clinicians whose practice includes antepartum and intrapartum fetal heart rate monitoring are provided. The quality of intrapartum fetal heart rate monitoring. Intrapartum fetal heart rate monitoring obstetricsgynecology. Prior to its implementation, intrapartum fetal death rates were between 3 and 4 per. It covers the care of healthy women with uncomplicated pregnancies entering labour at lowrisk of developing intrapartum complications.
It continues to be the predominant method for intrapartum fetal surveillance despite questions about its ef. Relationship of prelabor fetal cardiac function with. In the us 75 percent of the deliveries are monitored by electronic fetal heart rate monitoring efm. Ctg acquisition can be performed by portable sensors that transmit signals wirelessly to a. Otherwise, the baseline for that segment is described as indeterminate. Fetal heart rate decelerations, memetics, intrapartum fetal monitoring, head. Evidence is lacking to develop an ideal intrapartum fetal monitoring system to improve perinatal outcomes. Intelligent systems are engineered with algorithms or neural networks designed to simulate expert knowledge.
American college of obstetricians and gynecologists acog. Computer analysis of the fetal heart rate is a technology of the information age commercially available for research and clinical practice. This guideline covers the care of healthy women who go into labour at term 3741 weeks. Intrapartum fetal monitoring a disappointing story nejm. Intrapartum management of category ii fetal heart rate. A randomized trial of intrapartum electronic fetal heart rate monitoring versus intermittent auscultation obstet. Fetal heart rate fhr decelerations are centerstage most important in. Intrapartum fetal heart rate monitoring case presentation.
Baseline fetal heart rate fhr is the mean level of the fhr when this is stable, excluding accelerations and decelerations. Computer analysis of the fetal heart rate journal of. Fetal scalp ph in women with abnormal fetal heart rate tracings. Rcog statement on revised nice intrapartum care guidelines. Automated analysis has provided objective, standardized, and reproducible data used to research fetal heart rate responses in the antepartum and. American college of obstetricians and gynecologists.
The third edition of antepartal and intrapartal fetal monitoring is an excellent tool to begin the process of understanding the basics as well as the more advanced aspects of fetal heart rate monitoring. Acog issues new practice bulletin on continuous electronic. The purpose of this document is to provide obstetric care providers with a framework for. Thus, fetal heart rate fhr monitoring can be used to determine if a fetus is well oxygenated. Electronic fetal heart rate monitoring efm was developed and introduced into clinical practice during the second half of the 20th century, with the expectation that it would provide information on the wellbeing of the fetus during labor. Dasguptas recent advances in obstetrics and gynecology 9, edition. Pdf persistent challenge of intrapartum fetal heart rate. Acog, 2009, usa, low, at least every 15 min, at least every 5 min, not stated. Nomenclature, interpretation, and general management principles practice bulletin no. Intrapartum electronic fetal heart rate monitoring and the prevention of perinatal brain injury. Intrapartum signal quality with external fetal heart rate. Management of intrapartum fetal heart rate tracings acog. Fetal heart rate changes environment lungs heart vasculature uterus placenta cord fetus hypoxemia hypoxia metabolic acidosis metabolic acidemia metabolic acidemia potential injury 1.
Intrapartum electronic fetal heart rate monitoring was introduced in the united states in the early 1970s after studies supported the existence of a correlation between patterns of fetal heart. It is determined over a time period of 510 minutes, expressed as beats per minute. Take the following into account when assessing baseline fetal heart rate. The threetiered fetal heart rate interpretation system should be used to assist in determining fetal status 1. The mean fetal heart rate rounded to increments of five beats per minute during a tenminute segment, excluding accelerations, deceleration and periods of marked fhr variability. Acog fetal heart rate monitoring information minnesota hospital. Risk factors should be identified and recorded see table 1. Antepartum and intrapartum fetal heart rate monitoring.
Problems with intrapartum fetal heart rate monitoring. Problems with intrapartum fetal heart rate monitoring interpretation and patient management roger k. Clinical management guidelines for obstetriciangynecologists, number 70, december 2005 replaces practice bulletin number 62, may 2005. Efmelectronic fetal heart rate monitoring can be done antepartum or intrapartum nstnon stress test cstcontraction stress test rarely used bppbiophysical profile afiamniotic fluid index iugrintrauterine growth restriction lgalarge for gestational age us or utsultrasound iufdintrauterine fetal demise. Structured intermittent auscultation is a technique that employs the systematic use of a doppler assessment of fetal heart rate fhr during labor at defined timed intervals table 1. Secondstage fetal heart rate abnormalities and type of neonatal acidemia. The limits of electronic fetal heart rate monitoring in the prevention of. Intrapartum fhr monitoring management decision model. Fetal scalp lactate testing during intrapartum pregnancy with abnormal fetal heart rate. Intermittent auscultation for intrapartum fetal heart rate surveillance. These factors may evolve through the course of labour.
Management of intrapartum fetal heart rate tracings. Canadian agency for drugs and technologies in health. It was used among 45% of laboring women in 1980, 62% in 1988, 74% in 1992, and 85% in 2002 1. Fhr fetal heart rate fse fetal scalp electrode gtn glyceryl trinitrate hb haemoglobin ia intermittent auscultation ifs intrapartum fetal surveillance iv intravenous mom multiples of median pappa pregnancy associated plasma proteina ranzcog royal australian and new zealand college of obstetricians and gynaecologists. The recommendations to leave the choice between intermittent auscultation and electronic fhr monitoring to the labouring woman and her attending clinician is based on the conclusions from metaanalyses summarizing the outcomes and interventions in randomized controlled trials see table 2. Management of intrapartum fetal heart rate tracings intrapartum electronic fetal monitoring efm is used for most women who give birth in the united states.
In general, electronic fhr monitoring, particularly if combined with fetal blood sampling fbs, leads to. Fetal heart monitoring journal of obstetric, gynecologic. Sep 12, 2017 prior to its implementation, intrapartum fetal death rates were between 3 and 4 per. Intrapartum management of nonreassuring fetal heart rate. As such, clinicians are faced daily with the management of fetal heart rate fhr tracings. Electronic fetal heart rate monitoring fhr is the routine.
Antepartum fetal surveillance techniques based on assessment of fetal heart rate fhr patterns have been in clinical use for almost four decades and are used along with realtime ultrasonography and umbilical artery doppler velocimetry to evaluate fetal wellbeing. Using audit methodology to identify areas for research and practice improvement. Premature rupture of membranes the 2008 national institute of child health and human development workshop report on electronic fetal monitoring. The american college of obstetricians and gynecologists acog has issued a new practice bulletin on continuous electronic fetal monitoring in labor. However, for lowrisk parturients who wish to avoid continuous monitoring during labor, scoring systems may demonstrate some benefit. Beginners will find this work extremely useful to master the endless patterns of fetal heart rate tracings. Intrapartum management of category ii fetal heart rate tracings. The baseline must be for a minimum of 2 minutes in a tenminute segment. Introduction fhr patterns are indirect markers of the fetal cardiac and medullary responses to blood volume changes, acidemia, and hypoxemia, all obstetrical organizations advise monitoring the fhr during labor a trial comparing auscultation with no monitoring found that. Intrapartum fetal heart rate assessment linkedin slideshare. Intrapartum fetal heart rate monitoring case presentation david a. In the most recent year for which data are available, approximately 3. Feb 08, 2014 fetal scalp ph in women with abnormal fetal heart rate tracings. Fetal heart monitoring includes initial and ongoing assessments of the woman and fetus.
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