00:00
APGO educational topic number 26
00:02
intrapartum fetal surveillance the goal
00:05
of intrapartum fetal surveillance is to
00:07
detect events that occur during labor
00:08
that could compromise fetal oxygenation
00:10
fetal heart rate monitoring is a
00:12
modality intended to determine if the
00:15
fetus is well oxygenated and will be the
00:16
focus of this video in the United States
00:19
85% of Labor’s involve electronic fetal
00:21
heart rate monitoring electronic fetal
00:23
monitoring may be performed externally
00:25
with a Doppler device or internally with
00:27
a fetal scalp electrode the objectives
00:30
of this video are to describe the
00:31
techniques of fetal surveillance and to
00:34
interpret electronic fetal heart rate
00:35
monitoring here is a fetal heart rate
00:38
tracing the top portion is the fetal
00:40
heart rate and the bottom portion
00:42
records uterine contractions the x-axis
00:45
is time and each thicker white line
00:48
signifies one minute and this blue line
00:50
is fetal heart rate this purple line is
00:53
maternal heart rate the green line
00:55
depicts uterine activity and this is a
00:57
uterine contraction it is important to
00:59
approach the interpretation of fetal
01:01
heart rate racing’s in a systematic and
01:03
stepwise fashion the first step is to
01:05
look at the baseline a normal baseline
01:08
is between 110 and 160 beats per minute
01:10
fetal bradycardia is when the heart rate
01:12
is less than 110 fetal tachycardia is
01:15
when the heart rate is greater than 160
01:17
we will move next to variability
01:19
variability is the beat to beat change
01:22
in the fetal heart rate there are four
01:24
terms used to describe variability
01:26
absent minimal moderate and marked with
01:28
absent variability there is no variation
01:31
in the fetal heart rate with minimal
01:33
variability the fetal heart rate varies
01:35
less than five from beat to beat with
01:37
moderate variability the fetal heart
01:38
rate varies from 6 to 25 from beat to
01:41
beat and with marked variability the
01:43
fetal heart rate varies greater than 26
01:45
from beat to beat moderate variability
01:47
is reassuring moderate variability is a
01:50
reassuring sign that reflects adequate
01:52
fetal oxygenation and normal brain
01:54
function here is a fetal heart rate with
01:56
moderate variability the heart rate
01:58
fluctuates between 6 to 25 beats
02:00
decreased variability is associated with
02:02
fetal hypoxia acid emia tachycardia or
02:05
fetal CNS and cardiac anomalies drugs
02:08
that depress the fetal CNS system such
02:11
as morphine or magnesium can also
02:13
decreased variability decreased
02:15
variability can also be from a prolonged
02:17
uterine contraction here is a fetal
02:19
heart rate tracing with minimal
02:21
variability the fetal heart rate
02:22
fluctuates less than five from beat to
02:24
beat the next step in the assessment of
02:26
fetal heart rate tracing is the
02:28
characterization of accelerations and
02:29
decelerations
02:30
an acceleration is an increase in the
02:32
fetal heart rate from the baseline
02:34
decelerations are visually apparent
02:36
decreases in the fetal heart rate this
02:38
clever veal chop acronym can help you
02:41
remember the different types and causes
02:42
of accelerations and decelerations v
02:46
stands for a variable deceleration this
02:48
is when there is an acute fall in the
02:49
fetal heart rate with a rapid downslope
02:52
and a rapid recovery back to baseline
02:54
they are characteristically variable in
02:56
duration intensity and timing they
02:58
resemble the letter V and may not have
03:00
any specific relationship to uterine
03:02
contractions v is associated with sea
03:05
variables are caused by cord compression
03:07
east ants for early deceleration and
03:10
early deceleration has a slow onset and
03:13
a slow recovery that corresponds to the
03:16
start and end of the contraction E is
03:20
associated with H early accelerations
03:22
are caused by head compression these are
03:24
favorable and reassuring when seen on a
03:26
fetal heart tracing a stands for
03:28
acceleration
03:29
these are transient increases in the
03:31
fetal heart rate they do not have any
03:33
specific relationship to uterine
03:34
contractions and an acceleration lasts
03:37
for more than 15 seconds with an
03:38
increase of at least 15 beats above the
03:40
baseline after 32 weeks estimated
03:42
gestational age a is associated with o
03:45
as an OK meaning that the presence of
03:47
accelerations is a reassuring sign of
03:49
fetal well-being l stands for a late
03:52
deceleration a late deceleration is a
03:54
symmetric fall and rise in the fetal
03:56
heart rate racing that begins at or
04:01
after the peak of the uterine
04:02
contraction has ended the descent and
04:05
return are gradual and smooth a pattern
04:09
of persistent late decelerations is non
04:11
reassuring L is associated with pea late
04:14
decelerations are caused by placental
04:16
insufficiency
04:17
here is another fetal heart rate tracing
04:19
and the arrows depict the accelerations
04:21
the heart rate goes above the baseline
04:23
greater than 15 beats and lasts more
04:25
than 15 seconds
04:26
this fetal heart rate has the
04:27
characteristic v-shaped variable
04:29
deceleration the heart rate goes rapidly
04:31
down and rapidly back up to baseline
04:34
here is an early deceleration with a
04:36
slow decrease and a slow increase back
04:38
to baseline and it occurs at the same
04:40
time as the contraction this late
04:42
deceleration has the same slow decrease
04:44
and slow increase back to baseline but
04:47
it occurs after the contraction has
04:48
occurred we’ve now reviewed the steps
04:51
for fetal heart rate interpretation we
04:53
use these tools to classify fetal heart
04:55
rate tracings into three categories 1 2
04:58
& 3 category 1 is a tracing that has a
05:01
baseline rate between 110 to 160 beats
05:03
per minute has moderate baseline
05:05
variability no late or variable
05:07
decelerations early decelerations may be
05:09
present or absent and accelerations may
05:11
be present or absent here is a category
05:14
1 fetal heart rate racing with a
05:15
baseline of 130 moderate variability at
05:18
a nice acceleration category 3 is a
05:20
tracing that has absent baseline fetal
05:22
heart rate variability and any of the
05:24
following recurrent late decelerations
05:26
recurrent variable decelerations
05:28
bradycardia or there is a sinusoidal
05:30
wave pattern a sinusoidal pattern is
05:33
very unusual and is ominous it is
05:35
characterized by visually apparent
05:36
smooth sine wave like undulating
05:38
patterns in the fetal heart rate
05:40
baseline with a cycle frequency or 3 to
05:42
5 per minute which persists for 20
05:44
minutes or more a sinusoidal pattern
05:46
requires immediate delivery category 2
05:48
tracings are everything in between
05:50
category 1 and 3 here is a category 2
05:53
fetal heart rate tracing there is
05:54
moderate variability but she is having
05:56
variable decelerations a category 3
05:59
tracing is an indication for immediate
06:01
delivery
06:01
this fetal heart rate tracing
06:03
demonstrates a category 3 tracing for
06:05
there is absent fetal heart rate
06:07
variability and recurrent late
06:08
decelerations
06:09
the team should be moving towards
06:10
immediate delivery this concludes the
06:12
aapko video on intrapartum fetal
06:14
surveillance we reviewed the techniques
06:16
for fetal surveillance and the steps for
06:18
interpreting electronic fetal heart rate
06:19
monitoring