OBSTETRICS

ANTEPARTUM FETAL
SURVEILLANCE &
4S-1 | CEU-SOM A & B
INTRAPARTUM MONITORING
MAYNILA E. DOMINGO, MD, DPOGS, FPSMFM,
FPSUOG
OUTLINE
 Survival depends on AOG and weight.
I. INTRODUCTION  Basis: a fetus whose oxygenation in utero is challenged will
II. CASE respond to a series of detectable physiologic adaptive or
III. ANTEPARTUM FETAL SURVEILLANCE decompensatory signs as hypoxemia or frank metabolic
a. Fetal Movement Assessment acidemia develop
b. Contraction Stress Test  if physiologic adaptations are not corrected, pathologic
c. Nonstress Test adaptations will ensue and may rapidly progress into
d. Acoustic Stimulation Test decompensation.
e. Biophysical Profile
f. Doppler Velocimetry
IV. INTRAPARTUM MONITORING

I. INTRODUCTION

 Fetal assessment
∞ One component is ultrasound/imaging which is done to
know the characteristics of the fetus such as gestational
age, fetal number, viability, presentation, position,
biometry (measurement of the different parts of the
fetus) and placental location
∞ is not limited to imaging, the other component requires
looking at the fetal well-being by observation of fetal
behavior to infer fetal neurologic function and aid
diagnosis of many fetal abnormalities.
∞ Involves monitoring the fetus during
Antepartum/Antenatal period (1st, 2nd, & 3rd trimester) as
well as monitoring of the baby in the Intrapartum period
(during labor and delivery).
 American College of Obstetricians and Gynecologists Figure 3.2 Progressive deterioration in fetal cardiovascular and behavioral
recommends that prenatal sonography be performed in all states. Metabolic status is directly proportional to CNS and CVS status
pregnancies and considers it an important part of obstetrical
care (2016). INDICATIONS FOR ANTEPARTUM SURVEILLANCE

II. CASE  Maternal:

 Previous obstetric history
 43 y/o  Hypertension
 Present BP: 140/ 100; with Chronic hypertension  Placental abruption
 G5P4 (4003)  Pre-pregnancy diabetes
 Uterine Pregnancy: 26 2/7 weeks, cephalic, not in labor  Insulin-requiring gestational diabetes
 Fundic Height: 19cm, Estimated Fetal Weight: 400-600 grams  Advanced maternal age
 Poor obstetric history for one full term fetal death in utero  Cyanotic heart disease
 Chronic renal disease
How will you advice this patient regarding fetal monitoring?  Marked uterine anomalies
 Morbid obesity
III. ANTENATAL FETAL SURVEILLANCE  Isoimmunization
 Preterm premature rupture of membranes
 Why Perform Antenatal Fetal Surveillance?  Vaginal bleeding
 Basic goal: Improve Perinatal Outcome  Abnormal maternal serum screening (hCG of AFP
 Main goal: To put into effect timely interventions to prevent >2.0 MOM) in the absence of confirmed fetal
perinatal or maternal morbidities anomaly
 Premise: to catch early insults to the fetus to provide timely  Motor vehicular accident during pregnancy
interventions and prevent sequelae such as:  Fetal:
a. Fetal: stillbirth, metabolic acidosis at birth
 Previous obstetric history
b. Neonatal: mortality, metabolic acidosis, hypoxic renal
 Congenital anomalies
damage, necrotizing enterocolitis, intracranial
 Decreased fetal movement
hemorrhage, seizures, neonatal encephalopathy,
cerebral palsy  Suspected oligohydramnios/polyhydramnios
 Multiple pregnancy
Prevention  Preterm labor
of fetal death  Small for gestational age
 Intrauterine Growth Restriction
 Stillbirth
 Placenta:
Avoidance of  APAS (Antiphospholipid Antibody Syndrome)
unnecessary  SLE (Systemic Lupus Erythematosus).
interventions
 Thrombophilia
Figure 1.1 Goals of Antenatal Fetal Surveillance. There should be balance  Marked placental abnormalities
between the 2 factors to avoid incurring other morbidities.

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  Miscellaneous:  May be useful when a fetus with other abnormal
 In Vitro Fertilization Pregnancy testing parameters is to be delivered that might be a
 Previous Stillbirth candidate for vaginal delivery if contractions are
 Teratogen Exposure tolerated.
 If at least 3 contractions with 40 sec duration or longer in 10
COMPONENTS OF ANTEPARTUM SURVEILLANCE minutes no uterine stimulation is necessary.
 Contractions are induced with either oxytocin or nipple
a. Fetal Movement Assessment stimulation if fewer than 3 in 10 minutes.
b. Contraction Stress Test  Oxytocin: dilute intravenous infusion is initiated at a rate of
c. Nonstress Test 0.5mU/min and doubled every 20 minutes until a satisfactory
d. Acoustic Stimulation Test contraction pattern is established.
e. Biophysical Profile  Mechanical nipple stimulation: instruct woman to rub one
f. Doppler Velocimetry nipple through clothing for 2-5 minutes until a contraction
begins. If desired contraction is not achieved after a 5-minute
 So far for 1-4 FHR muna yung inaassess natin. interval, she is instructed to retry nipple stimulation

A. FETAL MOVEMENT ASSESSMENT Interpretation

 Fetal movement decreases in response to hypoxemia Negative:

 Diminished fetal activity may be an indication of impending fetal no late or significant variable decelerations
death.
 Movement counting increased detection of IUGR Positive:
 Decreased movement was associated with a variety of placental late decelerations following 50% or more of contractions
abnormalities. (even if the contraction frequency is fewer than three in
 Primigravid: quickening is felt at 24-26th week 10 minutes)
 Multigravid: quickening is felt at an earlier period
 Maternal perception of distinct fetal kicks is dependent Equivocal-suspicious:
on age of gestation and gravidity. intermittent late decelerations or significant variable
decelerations
 Counts:
Equivocal-hyperstimulatory:
 Count to 10 method (Proposed by ACOG): perception of 10 fetal heart rate decelerations that occur in the presence of
distinct movements in 2 hours – considered reassuring contractions more frequent than every 2 minutes or
 2-hour-period corresponds to the sleep-wake cycle of lasting longer than 90 seconds
babies that is about 60-80mins.
 Monitor 3-4x per day after every meal. Unsatisfactory:
 Mas active si baby, pag busog si mommy (due to fewer than three contractions in 10 minutes or an
increased oxygen and sugar towards the baby) uninterpretable tracing
 Pag less than 10 go to the clinic immediately for further Table 3.B.1 Criteria for Interpretation of the Contraction Stress Test
testing
 RELATIVE CONTRAINDICATIONS:
 Baseline method: count fetal movement for 1hr 3x per  Preterm labor or certain patients at high risk of preterm
week, count is considered reassuring if it equaled or labor
exceeded the woman’s previously established baseline.  Preterm membrane rupture
 Tailored for the patient  History of extensive uterine surgery or classic caesarian
 If there is decrease in baseline, the mother should be delivery
alert, and consult with her health care practitioner for  Known placenta previa
further investigation.  Placenta is located low in the uterine segment, or within the
 Do not allow the patient to wait for several days na cervical canal, or foremost than the fetal presenting part or
hindi nararamdaman si baby. “mababa yung inunan”

 Although several fetal movement counting protocols have C. NONSTRESS TEST

been used, neither the optimal number nor ideal duration for
counting have been defined.  Fetal heart rate acceleration in response to fetal movement as a
sign of fetal health
B. CONTRACTION STRESS TEST  Test of fetal condition
IV. INSERT CST PIC  Premise: Heart rate of fetus that is not acidotic or neurologically
depressed will temporarily accelerate with fetal movement
 Evaluates response of the fetal heart rate to induced  Assessment of fetal condition w/o stress (i.e.
contractions, was designed to unmask poor placental function contraction)
 Test of uteroplacental function  Involves the use of Doppler detected fetal heart rate acceleration
 Premise: uterine contractions uterine vessels constrict coincident with fetal movements perceived by the mother.
transiently restrict oxygen delivery to the fetus and that a hypoxic  Done on the 28th week
fetus will demonstrate recurrent late decelerations.
 In normal pregnancy, physiologic mechanisms are INSERT NST PIC
able to protect the baby from transient restrictions in
oxygen delivery, thus fetus will not demonstrate late
decelerations.
 INDICATIONS:
 Used when the fetus is at risk for consequences of
uteroplacental pathology, in conditions such as
diabetes, hypertension, IUGR, and in postdates to
assess if the woman can safely undergo labor and
vaginal delivery.

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 Interpretation

Reactive Nonreactive

≥2 fetal heart rate accelerations of Test lacks sufficient fetal

15 beats, above baseline lasting heart rate acceleration over
for 15 sec within 20min, with or a 40 minute period
without fetal movement discernible (maximum of 80 minutes)
by the woman

For fetuses <32 weeks: 10 beats

above baseline, lasting at least 10
seconds
Table 3.C.1 Criteria for the Interpretation of Nonstress Test

Figure 3.C.3 FHR tracing (upper panel) and accompanying contraction

tracing (second panel). Tracing, obtained during maternal and fetal
acidemia, shows absence of accelerations, diminished variability, and late
decelerations with weak spontaneous contractions

 Terminal cardiotocogram: baseline deceleration of less

than 5 bpm, absent accelerations and late decelerations
with spontaneous uterine contractions (may indicate
umpending fetal death)
INSERT TERMINAL CARDIOTOCOGRAM PIC

 There is no good evidence on which to base a

recommendation for frequency of non-stress testing.

 In most cases, a normal NST is predictive of good perinatal

outcome for the one week, provided the maternal-fetal
Figure 3.C.1 Reactive nonstress test. In the upper panel, notice the increase of condition remains stable.
fetal heart rate by more than 15 beats/min for longer than 15 seconds following
fetal movements, which are indicated by the vertical marks (lower panel). D. ACOUSTIC STIMULATION TEST

INSERT ACOUSTIC STIMULATION TEST PIC

 A commercially available acoustic stimulator is positioned on

the maternal abdomen, and a stimulus of 1 to 2 seconds is
applied
 This may be repeated up to three times for up to 3 seconds
 A positive response is defined as the rapid appearance of
a qualifying acceleration following stimulation
 In William’s it is vibro-acoustic stimulation

E. BIOPHYSICAL PROFILE

 Manning and colleagues (1980) proposed the combined use

of five fetal biophysical variables as a more accurate means
Figure 3.C.2 Nonreactive nonstress test (left side of tracing) followed by of assessing fetal health than a single element
contraction stress test showing mild, late decelerations (right side of tracing).
 Test is performed for 30 minutes
Cesarean delivery was performed, and the severely acidemic fetus could not be
resuscitated.
 Components (Mind The Baby, mAN)
 If not high risk: Do NST on the 28th week (CNS development) 1. Movement
2. Tone
 Variations: 3. Breathing
 Silent oscillatory pattern: consisted of a fetal heart rate 4. Amniotic fluid volume
baseline that oscillated less than 5 bpm and presumably 5. Acceleration (Nonstress test)
indicated absent acceleration and beat-to-beat variability
Appearance of the components of the biophysical profile
across gestational age:

 Fetal tone: cortex-subcortical area  8 weeks AOG

 Fetal movement: cortex  9 weeks AOG
 Closely related yung tone and movement
 Tone: 1 flexion and extension
 Movement: at least 3 in 30 min
 Breathing movements – ventral surface of the 4th
ventricle  21 weeks AOG
 At least 1 episodic rhythmic breathing
diaphragmatic movement lasting/sustained for
≥ 30 seconds in 30 min

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 Biophysical Interpretation Recommended
Profile Score Management
Normal, No fetal indication
nonasphyxiated for intervention;
fetus repeat test weekly
except in diabetic
10
patients and
postterm
pregnancy
(twice weekly)
Normal, No fetal indication
8/10 (Normal
nonasphyxiated for intervention;
AFV)
fetus repeat testing per
8/8 (NST not done)
protocol
Chronic fetal Deliver
8/10 (Decreased
asphyxia
AFV)
suspected

Possible fetal  If amnionic fluid

asphyxia volume
abnormal,
deliver
Figure 3.E.1 Paradoxical chest movement with fetal respiration.  If normal fluid at
During inspiration (A), the chest wall paradoxically collapses and > 36 weeks with
the abdomen protrudes, whereas during expiration (B), the chest
favorable cervix,
wall expands. 6
deliver
 FHR – hypothalamus and medulla  2 to early 3nd rd  If repeat test ≤
trimester 6, deliver
 In terms of Development: Tone, Movement  If repeat test >
Breathing NST 6, observe and
 Deterioration: NSTBreathingTone, Movement repeat per
 Amniotic fluid- based on fetal urine output, chronic protocol
indicator of stress. Probable fetal Repeat testing
asphyxia same day; if
4
Component Score 2 Score 0 biophysical profile
score ≤ 6, deliver
≥2 accelerations of 0 or 1 Almost certain fetal Deliver
a ≥15 beats/min for acceleration 0 to 2 asphyxia
Nonstress test
≥15 sec within 20– within 20–40 min
40 min Table 2.E.2 Interpretation of Biophysical Profile Score
≥1 episode of <30 sec of
rhythmic breathing breathing F. DOPPLER VELOCIMETRY
Fetal breathing
lasting ≥30 sec within 30 min
within 30 min  Measurement of blood flow velocities in the maternal and fetal
≥3 discrete body or <3 discrete vessels gives information about uteroplacental blood flow and fetal
Fetal responses to physiologic challenges
limb movements movements
movement  To check maternal and fetal circuit.
within 30 min
≥1 episode of 0  Results are important to detect fetal acidosis
extremity extension extension/flexion  Three fetal vascular circuits assessed to determine fetal health and
Fetal tone to aid in the decision to intervene for growth-restricted fetuses:
and subsequent events
return to flexion
 Umbilical Artery – main supply to the fetus
A pocket of Largest single
 Middle Cerebral Artery – main supply to the fetal brain
amnionic fluid that vertical
 Ductus Venosus
measures at least pocket ≤2 cm
 Maternal circuit:
2 cm in two planes
 Uterine artery
perpendicular to
each other (2 × 2
Amnionic fluid
cm pocket)
volumeb
 At least 5 cm in
4 quadrant
method

Table 2.E.1 Components and Scores for the Biophysical Profile aMay be
omitted if all four sonographic components are normal. Figure 3.F.1. Common Doppler Indices. Hindi daw makatarungang i-memorize
b
Further evaluation warranted, regardless of biophysical composite score, if ito sabi ni doc.
largest vertical amnionic fluid pocket ≤2 cm.

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 MIDDLE CEREBRAL ARTERY
UMBILICAL ARTERY
INSERT MCA PIC
 Low impedance circulation
  in the amount of EDF with advanced gestation  Most accessible cerebral vessel
 Reflects Placental Circulation, and resistance perfusion to  Carries 80% of blood flow
delivery of fetoplacental unit.  High impedance circulation
 Progression of damage:  Complement umbilical artery results assess severity of
1. increased resistance hypoxia & predict neonatal outcome
2. absent end-diastolic flow  Compute using cerebroplacental ratio: MCA Pulsatility Index /
3. reversal UA Pulsatility Index
 Systolic-diastolic (S/D) ratio is considered abnormal if it is above  UA should have lower resistance.
the 95th percentile for gestational age or if diastolic flow is either  CP ratio of >1 is preferred.
absent or reversed  Low CP ratio <1 indicates brain sparing effect.
 Implication: Absent or reversed end-diastolic flow signifies  Prospective Observational trial to optimize pediatric health in
increased impedance to umbilical artery blood flow IUGR (PORTO) study: serious adverse neonatal outcome:
 Reversed diastolic flow is associated with >70% placental arterial low CPR ,1 (18%) compared to CPR >1 (2%)
obliteration.  Pag previously may brain sparing tapos pag recheck mo >1
 AEDF/REDF associated with IUGR and Oligohydramnios na that is a sign of decompensation.
 At placental end, more EDF (lower RI, S/D)
 The perinatal mortality rate for absent end-diastolic flow was
approximately 10 percent, and for reversed end-diastolic flow, it INSERT BRAIN SPARING EFFECT PIC
approximated 33 percent.
 REDF and AEDF sign of impending fetal cardiovascular and
metabolic deterioration.
 Perinatal and neonatal mortality >5x higher with REDF than AEDF
 Delivery Decision based on AOG if with normal daily BPP/NST
 Reversed diastolic flow delivery at ≥32 weeks AOG Obliteration of
 High Morbidity and mortality related to preterm delivery placental
Dilatation and
before 32 weeks AOG vascular Fetal
redistribution of
channel Hypoxemia
MCA Flow
increases
Insert UA Doppler pic afterload

 Figure 3. F. Brain sparing effect occurs when there is progressive

deterioration of fetoplacental unit (high pressure in umbilical artery)
causing hypoxemia. The middle cerebral artery compensates by
reducing cerebrovascular impedance to increase blood flow to the
brain.

DUCTUS VENOSUS

 Branches from the portal vein

 High velocity flow
 High turbulence
 Biphasic
 Ventricular Systole
 Early diastole (nadir of 2nd phase to late diastole or atrial
kick)
 Used to evaluate decompensation

INSERT DUCTUS VENOSUS PIC

Figure 3.F.2 Doppler velocity waveforms. A. Normal waveform with normal
S/D ratio. B., Decreased EDF, 30% obliteration of villous vessels, increased UA
resistance weak predictor of adverse outcome, delivery at ≥ 37 weeks. C. Absent
UTERINE ARTERIES
end-diastolic flow, 70% abnormality of villous vessels, poor fetal prognosis,
corticosteroids, delivery at ≥ 34 weeks. D. Reversed end-diastolic flow.  impedance with advancing gestation
 Notch and impedance after 22 weeks is Abnormal
Insert UA Doppler pic  Persistent impedance can lead to:
 PTL
 Umbilical artery reversed diastolic flow  IUGR
(In ppt, but not discussed: it’s too complex na daw)  Preeclampsia
 1 to 2% improvement in survival each day in utero  NRFS
between 26 to 29 weeks
 Use Doppler flow of ductus venosus supports the  For the case above (high risk): advise patient to do daily fetal
decision to extend pregnancy to 32 weeks of BPP/NST kick count, start NST at 26 weeks, do NST twice weekly,
remain reassuring monitor BPP weekly, Adjust BPP and NST frequency
 Absent/reversed ductus venosus α wave: depending on Doppler results
 Ominous finding
 Sign of impending fetal academia

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  Premise: Labor is a stressful event for the fetus: uterine
contractionsdecreased uteroplacental blood flowreduced
oxygen delivery to the fetus may lead to the following events hence
monitoring is important.

Hypoxic Metabolic Neonatal

Cerebral palsy
acidemia acidosis encephalopathy

 Intermittent Auscultation
Figure 3.C.4 Flowchart of fetal assessment.
Latent Active Active phase
phase (second stage)
(first
stage)
Recommended Every Every 5 minutes
at the time of 15-30
assessment minutes
SOGC
Approximately
every 1 hr.
Every 15 Every 5 minutes
NICE
minutes
Every 15 Every 5 minutes
RCOG minutes

Every 15 Every 5 minutes

ACOG minutes

Figure 3. F Flow chart for the management of suspected IUGR.

Table 4.1 Recommendations for the intermittent auscultation.

Insert antenatal and intrapartum conditions associated with…

 Continuous EFM
 Widely used method of intrapartum fetal surveillance in high-
risk labor
Figure 3. F Proggresion of placental insufficiency and sequence of
abnormal Doppler results. End of sequence BPP score falls, Late  Continuous recording of fetal heart rate combined with a
decelerations, abnormal results of BPP and CTG occur late. recording of uterine activity

IV. INTRAPARTUM MONITORING INSERT STEPS IN SYSTEMATIC INTERPRETATION 8 SLIDES

 Cardiotocography
 The technique of recording (“graph”) the fetal heart rate
(“cardio”) and the uterine contractions (‘toco”) with the use of
cardiotocograph, aka electronic fetal monitor
 Aka Electronic Fetal Monitoring (EFM)

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 BASELINE FETAL HEART RATE EARLY DECELERATION

 Approximate mean FHR rounded to increments of 5 bpm during a
10-min segment, excluding: Periodic or episodic changes,
segments of baseline that differ by more than 25 bpm or periods of
marked FHR variability
 In documenting, the baseline must be in any 10 minute window, the
minimum baseline duration must be at least 2 min or the baseline
for that timeperiod is indeterminate.
 Normal FHR baseline: 110–160 bpm
 Tachycardia: FHR baselines >160 bpm
 Bradycardia: FHR baseline< 110 bpm
 Signifies head compression
 A gradual FHR decrease and return to the baseline FHR
associated with a uterine contraction from the onset of the
deceleration to its nadir of ≥ 30 seconds.
 Decrease is typically symmetrical in shape and is measured from
the most recently determined portion of the baseline to the nadir
of the deceleration
 The onset, nadir, and recovery of the deceleration are coincident
with the beginning, peak, and ending of the contraction,
respectively

Insert pic and addtl definition 2 slides

INSERT 2 slides

VARIABILITY VARIABLE DECELERATION

 Fluctuations in the baseline FHR that are irregular in amplitude and  cord compression
inconstant frequency  Abrupt in the FHR as from the onset to the nadir of < 30 seconds.
 Visually quantified as the amplitude of peak-to-trough in bpm The deceleration should be at ≥ 15 bpm, lasting≥ 15 sec, and <2
 Determined in a 10 minute window and excludes accelerations and min in duration.
decelerations  When variable decelerations occur in conjunction with uterine
contraction, their onset, depth, and duration commonly vary with
Classification Amplitude range successive uterine contractions
 Insert 5 slides/pic
undetectable
Absent

detectable but ≤ 5
Minimal
bpm or fewer
6–25 bpm
Moderate (normal)
>25 bpm
Marked
Table 4.2 Baseline fetal heart rate variability fluctuation classification
INSERT pics of amplitude changes 4 slides
 Sinosoidal fetal heart rate pattern:
 Visually apparent, smooth, sine wave-line undulating
pattern in FHR baseline with a cycle frequency of 3–5 per
minute which persists for 20 minutes or more.
 Incompatible with the definition of variability
Insert pic + 3 slides
INSERT pics of graph + variability 3 slides
LATE DECELERATION
 uteroplacental insufficiency
 Gradual decrease and return of the FHR associated with a uterine
contraction with the time of onset of the deceleration to its nadir
as ≥30 sec
 •The decrease is typically symmetrical in shape and is measured
from the most recently determined portion of the baseline to the
nadir of the deceleration.
 The deceleration is delayed in timing, with the nadir of the
deceleration occurring after the peak of the contraction
 •In most cases the onset, nadir, and recovery of the deceleration
occur after the beginning, peak, and ending of the contraction,
respectively

ACCELERATION

 Apparent abrupt increase (onset to peak in< 30 sec) in the FHR.

 The increase is measured from the most recently determined
portion of the baseline
 a peak of 15 bpm or more above baseline, with a duration of
15 sec or more but less than 2 min from onset to return to the
previously determined baseline
 INSERT pics

 < 32 weeks, accelerations are defined as having a peak of 10

bpm or more above baseline, with a duration of ≥10 sec but <2
min from onset to return

•Prolonged acceleration lasts≥ 2 min, but <10 min•If an

acceleration lasts 10 min, it is a baseline change
 INSERT pics

DECELERATION
 INSERT definition 1 slide

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 Categories and Interventions V.REFERENCES
CATEGORY 1 (ALL OF THE FOLLOWING)  Chapters 10, 17, 24 of Williams Obstetrics 25th Edition
(Cunningham et. al)
Baseline rate: 110–160 bpm  Dr. Domingo’s PPT Lecture (11/16/18)
 Notes and recordings of OB Trans Team (11/16/18)
Variability: moderate
“Konti na lang, kayang-kaya n’yo ‘to. Konting-konti na lang, be strong.”
˜Dr. Maynila Domingo
Late or variable decelerations: absent

Early decelerations: present or absent

Accelerations: present or absent

Interpretation: Strongly predictive of normal acid-base

status

Clinical Management: Routine Management

CATEGORY 2 (ANY OF THE FOLLOWING)

Baseline rate:
 Bradycardia not accompanied by absent
 Tachycardia

Variability:
 Minimal / marked baseline variability
 If Absent , should have no recurrent
decelerations

Accelerations:
Absence of induced accelerations after fetal
stimulation

Decelerations:
 Periodic or episodic decelerations
 Recurrent variable decelerations accompanied
by minimal or moderate baseline variability
 Prolonged deceleration ≥2 min but <10 min
 Recurrent late decelerations with moderate
baseline variability
 Variable decelerations with other characteristics,
such as slow return to baseline, “overshoots,” or
“shoulders”

Interpretation:
 Indeterminated; not reflective of abnormal acid-
base status

Clinical Management: continued surveillance and

reevaluation

CATEGORY 3 (ANY OF THE FOLLOWING)

Absent baseline FHR variability and any of the

following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern

Interpretation: Abnormal; predictive of abnormal fetal

acid-base status (ACIDEMIA in ¼ fetuses)

Clinical Management: prompt evaluation, expeditious

attempts to resolve abnormal FHR pattern such as
maternal oxygen, change in maternal position,
discontinuation of labor stimulation, treatment of maternal
hypotension or additional efforts

Table 1. Three-Tier Fetal Heart Rate Interpretation System and Resuscitative

Measures for Category II or Category III Tracings

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