OBSTETRICS

ANTEPARTUM FETAL
SURVEILLANCE &
4S-1 | CEU-SOM A & B
INTRAPARTUM MONITORING
Maynila E. Domingo, MD, DPOGS, FPSMFM, FPSUOG November 16, 2018

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
V. REFERENCES

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 2 Progressive deterioration in fetal cardiovascular and behavioral states.
recommends that prenatal sonography be performed in all 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 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: Test of uteroplacental function
In Vitro Fertilization Pregnancy Premise: uterine contractions uterine vessels constrict
Previous Stillbirth transiently restrict oxygen delivery to the fetus and that a hypoxic
Teratogen Exposure fetus will demonstrate recurrent late decelerations.
In normal pregnancy, physiologic mechanisms are
COMPONENTS OF ANTEPARTUM SURVEILLANCE able to protect the baby from transient restrictions in
oxygen delivery, thus fetus will not demonstrate late
a. Fetal Movement Assessment decelerations.
b. Contraction Stress Test
c. Nonstress Test INDICATIONS:
d. Acoustic Stimulation Test Used when the fetus is at risk for consequences of
e. Biophysical Profile uteroplacental pathology, in conditions such as
f. Doppler Velocimetry diabetes, hypertension, IUGR, and in postdates to
assess if the woman can safely undergo labor and
So far for 1-4 FHR muna yung inaassess natin. vaginal delivery.
May be useful when a fetus with other abnormal
A. FETAL MOVEMENT ASSESSMENT testing parameters is to be delivered that might be a
candidate for vaginal delivery if contractions are
tolerated.
Fetal movement decreases in response to hypoxemia
If at least 3 contractions with 40 sec duration or longer in 10
Diminished fetal activity may be an indication of impending fetal
minutes no uterine stimulation is necessary.
death.
Contractions are induced with either oxytocin or nipple
Movement counting increased detection of IUGR
stimulation if fewer than 3 in 10 minutes.
Decreased movement was associated with a variety of placental
Oxytocin: dilute intravenous infusion is initiated at a rate of
abnormalities.
0.5mU/min and doubled every 20 minutes until a satisfactory
Primigravid: quickening is felt at 24-26th week
contraction pattern is established.
Multigravid: quickening is felt at an earlier period
Mechanical nipple stimulation: instruct woman to rub one
Maternal perception of distinct fetal kicks is dependent
nipple through clothing for 2-5 minutes until a contraction
on age of gestation and gravidity.
begins. If desired contraction is not achieved after a 5-minute
interval, she is instructed to retry nipple stimulation
Counts:
Interpretation
Count to 10 method (Proposed by ACOG): perception of 10
distinct movements in 2 hours – considered reassuring
2-hour-period corresponds to the sleep-wake cycle of Negative:
babies that is about 60-80mins. no late or significant variable decelerations
Monitor 3-4x per day after every meal.
Mas active si baby, pag busog si mommy (due to Positive:
increased oxygen and sugar towards the baby) late decelerations following 50% or more of contractions
Pag less than 10 go to the clinic immediately for further (even if the contraction frequency is fewer than three in
testing 10 minutes)

Baseline method: count fetal movement for 1hr 3x per Equivocal-suspicious:

week, count is considered reassuring if it equaled or intermittent late decelerations or significant variable
exceeded the woman’s previously established baseline. decelerations
Tailored for the patient
If there is decrease in baseline, the mother should be Equivocal-hyperstimulatory:
alert, and consult with her health care practitioner for fetal heart rate decelerations that occur in the presence of
further investigation. contractions more frequent than every 2 minutes or
Do not allow the patient to wait for several days na lasting longer than 90 seconds
hindi nararamdaman si baby.
Unsatisfactory:
Although several fetal movement counting protocols have fewer than three contractions in 10 minutes or an
been used, neither the optimal number nor ideal duration for uninterpretable tracing
counting have been defined. Table 1 Criteria for Interpretation of the Contraction Stress Test

RELATIVE CONTRAINDICATIONS:
B. CONTRACTION STRESS TEST
Preterm labor or certain patients at high risk of preterm labor
Preterm membrane rupture
History of extensive uterine surgery or classic caesarian
delivery
Known placenta previa
Placenta is located low in the uterine segment, or within the
cervical canal, or foremost than the fetal presenting part or
“mababa yung inunan”

C. NONSTRESS TEST

Fetal heart rate acceleration in response to fetal movement as a

sign of fetal health

Figure 3 Contraction stress test Test of fetal condition

Premise: Heart rate of fetus that is not acidotic or neurologically
Evaluates response of the fetal heart rate to induced depressed will temporarily accelerate with fetal movement
contractions, was designed to unmask poor placental function Assessment of fetal condition w/o stress (i.e.
contraction)
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 Involves the use of Doppler detected fetal heart rate acceleration Variations:
coincident with fetal movements perceived by the mother. Silent oscillatory pattern: consisted of a fetal heart rate
Done on the 28th week baseline that oscillated less than 5 bpm and presumably
indicated absent acceleration and beat-to-beat variability

Figure 4 Non stress test

Interpretation Figure 7 FHR tracing (upper panel) and accompanying contraction tracing
(second panel). Tracing, obtained during maternal and fetal acidemia,
Reactive shows absence of accelerations, diminished variability, and late
Nonreactive
decelerations with weak spontaneous contractions
≥2 fetal heart rate accelerations of Test lacks sufficient fetal
Terminal cardiotocogram: baseline deceleration of less
15 beats, above baseline lasting heart rate acceleration over
than 5 bpm, absent accelerations and late decelerations
for 15 sec within 20min, with or a 40 minute period
with spontaneous uterine contractions (may indicate
without fetal movement discernible (maximum of 80 minutes)
impending fetal death)
by the woman

For fetuses <32 weeks: 10 beats

above baseline, lasting at least 10
seconds
Table 2 Criteria for the Interpretation of Nonstress Test

Figure 8 Cardiotocogram

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
condition remains stable.
Figure 5 Reactive nonstress test. In the upper panel, notice the increase of 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

Figure 9 Acoustic stimulation test

Figure 6 Nonreactive nonstress test (left side of tracing) followed by contraction A commercially available acoustic stimulator is positioned on
stress test showing mild, late decelerations (right side of tracing). Cesarean the maternal abdomen, and a stimulus of 1 to 2 seconds is
delivery was performed, and the severely acidemic fetus could not be
applied
resuscitated.
This may be repeated up to three times for up to 3 seconds
If not high risk: Do NST on the 28th week (CNS development)
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 A positive response is defined as the rapid appearance of Component Score 2 Score 0
a qualifying acceleration following stimulation
In Williams, it is vibro-acoustic stimulation ≥2 accelerations of 0 or 1
a ≥15 beats/min for acceleration
Nonstress test
E. BIOPHYSICAL PROFILE ≥15 sec within 20– within 20–40 min
40 min
Manning and colleagues (1980) proposed the combined use ≥1 episode of <30 sec of
of five fetal biophysical variables as a more accurate means rhythmic breathing breathing
Fetal breathing
of assessing fetal health than a single element lasting ≥30 sec within 30 min
Test is performed for 30 minutes within 30 min
≥3 discrete body or <3 discrete
Components (Mind The Baby, mAN) Fetal
limb movements movements
1. Movement movement
within 30 min
2. Tone ≥1 episode of 0
3. Breathing extremity extension extension/flexion
4. Amniotic fluid volume Fetal tone
and subsequent events
5. Acceleration (Nonstress test) return to flexion
A pocket of Largest single
Appearance of the components of the biophysical profile amnionic fluid that vertical
across gestational age: measures at least pocket ≤2 cm
2 cm in two planes
Fetal tone: cortex-subcortical area 8 weeks AOG perpendicular to
Fetal movement: cortex 9 weeks AOG each other (2 × 2
Closely related yung tone and movement Amnionic fluid
cm pocket)
Tone: 1 flexion and extension volumeb
Movement: at least 3 in 30 min At least 5 cm in
Breathing movements – ventral surface of the 4th 4 quadrant
ventricle 21 weeks AOG method
At least 1 episodic rhythmic breathing
diaphragmatic movement lasting/sustained for
≥ 30 seconds in 30 min Table 3 Components and Scores for the Biophysical Profile aMay be omitted
if all four sonographic components are normal.
b
Further evaluation warranted, regardless of biophysical composite score, if
largest vertical amnionic fluid pocket ≤2 cm.

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
If normal fluid at
> 36 weeks with
favorable cervix,
6
deliver
If repeat test ≤
Figure 10 Paradoxical chest movement with fetal respiration. 6, deliver
During inspiration (A), the chest wall paradoxically collapses and If repeat test >
the abdomen protrudes, whereas during expiration (B), the chest 6, observe and
wall expands.
repeat per
protocol
FHR – hypothalamus and medulla 2nd to early 3rd
Probable fetal Repeat testing
trimester
asphyxia same day; if
In terms of Development: Tone, Movement 4
biophysical profile
Breathing NST
Deterioration: NST Breathing Tone, Movement score ≤ 6, deliver
Amniotic fluid- based on fetal urine output, chronic Almost certain fetal Deliver
indicator of stress. 0 to 2 asphyxia

Table 4 Interpretation of Biophysical Profile Score

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 F. DOPPLER VELOCIMETRY

Measurement of blood flow velocities in the maternal and fetal

vessels gives information about uteroplacental blood flow and fetal
responses to physiologic challenges
To check maternal and fetal circuit.
Results are important to detect fetal acidosis
Three fetal vascular circuits assessed to determine fetal health and
to aid in the decision to intervene for growth-restricted fetuses:

Umbilical Artery – main supply to the fetus

Middle Cerebral Artery – main supply to the fetal brain
Ductus Venosus
Maternal circuit:
Uterine artery

Figure 13 Doppler velocity waveforms. A. Normal waveform with normal S/D

ratio. B., Decreased EDF, 30% obliteration of villous vessels, increased UA
Figure 11 Common Doppler Indices. resistance weak predictor of adverse outcome, delivery at ≥ 37 weeks. C. Absent
Hindi daw makatarungang i-memorize ito sabi ni doc. end-diastolic flow, 70% abnormality of villous vessels, poor fetal prognosis,
corticosteroids, delivery at ≥ 34 weeks. D. Reversed end-diastolic flow.

UMBILICAL ARTERY Umbilical artery reversed diastolic flow

(In ppt, but not discussed: it’s too complex na daw)
Low impedance circulation 1 to 2% improvement in survival each day in utero
in the amount of EDF with advanced gestation between 26 to 29 weeks
Reflects Placental Circulation, and resistance perfusion to Use Doppler flow of ductus venosus supports the
delivery of fetoplacental unit. decision to extend pregnancy to 32 weeks of BPP/NST
Progression of damage: remain reassuring
1. increased resistance Absent/reversed ductus venosus α wave:
2. absent end-diastolic flow Ominous finding
3. reversal
Sign of impending fetal academia
Systolic-diastolic (S/D) ratio is considered abnormal if it is above
the 95th percentile for gestational age or if diastolic flow is either
absent or reversed
MIDDLE CEREBRAL ARTERY
Implication: Absent or reversed end-diastolic flow signifies
increased impedance to umbilical artery blood flow
Reversed diastolic flow is associated with >70% placental arterial
obliteration.
AEDF/REDF associated with IUGR and Oligohydramnios
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
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
High Morbidity and mortality related to preterm delivery
before 32 weeks AOG

Figure 14 Middle cerebral artery

Middle Cerebral Artery

Most accessible cerebral vessel
Carries 80% of blood flow
High impedance circulation
Complement umbilical artery results assess severity of
hypoxia & predict neonatal outcome
Compute using cerebroplacental ratio: MCA Pulsatility Index /
UA Pulsatility Index
UA should have lower resistance.
CP ratio of >1 is preferred.
Low CP ratio <1 indicates brain sparing effect.
Figure 12 Umbilical artery doppler

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 Prospective Observational trial to optimize pediatric health in UTERINE ARTERIES
IUGR (PORTO) study: serious adverse neonatal outcome:
low CPR ,1 (18%) compared to CPR >1 (2%) impedance with advancing gestation
Pag previously may brain sparing tapos pag recheck mo >1 Notch and impedance after 22 weeks is Abnormal
na that is a sign of decompensation. Persistent impedance can lead to:
PTL
IUGR
Preeclampsia
NRFS

Figure 15 Brain sparing effect

Obliteration of
Dilatation and
placental vascular
Fetal Hypoxemia redistribution of
channel increases
MCA Flow
afterload

Figure 18 Flowchart of fetal assessment

Figure 16 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

Figure 19 Flow chart for the management of suspected IUGR

Figure 17 Ductus venosus

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 Low Risk High Risk
SURVEILLANCE
Pregnancies Pregnancies
Intermittent
Yes Yes
auscultations
Acceptable
Continuous
Methods
Electronic Yes Yes
Monitoring
1st Stage Every 30 Every 15
Evaluation Labor minutes minutes
Intervals 2nd Stage Every 15 Every 5
Labor minutes minutes
Table 6 Recommendations for the intermittent auscultation.

Figure 20 Progression of placental insufficiency and sequence of abnormal Antenatal and Intrapartum conditions associated with increased
Doppler results. End of sequence BPP score falls, Late decelerations, abnormal
results of BPP and CTG occur late.
risk of adverse fetal outcome where intrapartum electronic fetal
surveillance may be beneficial
SUMMARY OF INTERVENTIONS FOR THE CASE (HIGH RISK) Maternal
Advise patient to do daily fetal kick count o Vaginal bleeding in labor
Doppler Studies o Intrauterine infection/chorioamnionitis
Start NST at 26 weeks o Previous Caesarian section
Monitor NST twice weekly o Prolonged membrane rupture 24 hours at term
Monitor BPP weekly o Induced labor
Adjust BPP and NST frequency depending on Doppler results o Augmented labor
o Hypertonic uterus
IV. INTRAPARTUM MONITORING o Preterm labor
o Post-term pregnancy (42 weeks)
Cardiotocography Fetal
The technique of recording (“graph”) the fetal heart rate o Meconium staining of the amniotic fluid
(“cardio”) and the uterine contractions (‘toco”) with the use of o Abnormal fetal heart rate on auscultation
cardiotocograph, aka electronic fetal monitor
Aka Electronic Fetal Monitoring (EFM) Continuous EFM
Premise: Labor is a stressful event for the fetus: uterine Widely used method of intrapartum fetal surveillance in high-
contractions decreased uteroplacental blood flow reduced risk labor
oxygen delivery to the fetus may lead to the following events hence Continuous recording of fetal heart rate combined with a
monitoring is important. recording of uterine activity

STEPS IN SYSTEMATIC INTERPRETATION

1. Assess the quality of the signal acquisition.

o The quality of the tracing of both the FHR and uterine activity
channel must allow for accurate interpretation.
o If there is insufficient duration, breaks in the recording, artifact,
Hypoxic Metabolic Neonatal or a general poor quality tracing, then it must be continued
Cerebral palsy
acidemia acidosis encephalopathy until interpretable data are obtained.

Possible Causes of Inadequate Tracings for Interpretation

High BMI (abdominal adipose tissue)
Polyhydramnios
Maternal factors Oligohydramnios
Detecting maternal pulse
Maternal movement
Figure 21 Clinical Sequelae of Hypoxic Acidemia
Very active fetus
Fetal factors Fetal position (e.g., posterior position)
Intermittent Auscultation
Active phase
Cardiac dysrhythmias
Obstetrical Active phase Table 7 Causes of inadequate tracings
Latent (second
Societies (first stage)
stage)
Recommended 2. Determine the paper speed and graph range.
Society of
at the time of o There is no evidence suggesting a particular paper speed.
Obstetricians and
Gynaecologists of
assessment Every 15-30 Every 5 o 1 cm/min and 3 cm/min
minutes minutes
Canada (SOGC,
Approximately 3. Assess the uterine activity pattern.
Canada)
every 1 hour
o NORMAL uterine contractions – ≤5 contractions in 10
National Institute
for Health and Care Every 15 Every 5 minutes, averaged over a 30-minute window
- o TACHYSYSTOLE – >5 contractions in 10 minutes, averaged
Excellence (NICE, minutes minutes
UK) over a 30-minute window
Royal College of o Usage of such terms as hyperstimulation and
Obstetricians and Every 15 Every 5 hypercontractility are without meaning and should be
-
Gynaecologists minutes minutes abandoned
(RCOG, UK)
American College
4. Define the fetal heart rate patterns.
of Obstetricians Every 15 Every 5
- o Baseline fetal heart rate
and Gynecologists minutes minutes
(ACOG, US) o Variability
Table 5 Recommendations for the intermittent auscultation by different o Accelerations
obstetrical societies o Decelerations
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 BASELINE FETAL HEART RATE

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

Figure 23 Graphs illustrating variability or fluctuations of the fetal heart rate

Sinusoidal 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

Figure 22 Bradycardic and tachycardic FHT graphs

VARIABILITY

Fluctuations in the baseline FHR that are irregular in amplitude and

inconstant frequency
Visually quantified as the amplitude of peak-to-trough in bpm Figure 24 Graph illustrating sinusoidal fetal heart rate pattern
Determined in a 10 minute window and excludes accelerations and
decelerations Causes of Decreased to Absent Variability
Physiological variability is a normal characteristic of the fetal heart o Medications (e.g., narcotics, sedatives, beta-blockers,
rate betamethasone)
Variability of the fetal heart is largely controlled by the effect of the o Prematurity
vagus nerve of the heart o Fetal tachycardia
Persistent hypoxia causing acidosis may lead to a decrease in fetal o Congenital anomalies
heart rate variability
Moderate variability suggests that the fetal acid-base status is ACCELERATION
acceptable
Fetal heart rate variability is episodic because of fetal sleep cycles. Apparent abrupt increase (onset to peak in < 30 sec) in the FHR.
Variability will therefore be minimal intermittently, even in the The increase is measured from the most recently determined
healthy fetus. portion of the baseline
a peak of 15 bpm or more above baseline, with a duration of 15 sec
Classification Amplitude Range or more but less than 2 min from onset to return to the previously
Absent Undetectable determined baseline
Minimal Detectable but ≤5 bpm or fewer < 32 weeks of gestation, accelerations are defined as having a
Moderate (normal) 6-25 bpm peak of 10 bpm or more above baseline, with a duration of ≥10 sec
Marked >25 bpm but <2 min from onset to return
Table 8 Baseline fetal heart rate variability fluctuation classification Prolonged acceleration lasts ≥ 2 min, but <10 min
If an acceleration lasts 10 min, it is a baseline change

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 DECELERATION

The quantification of deceleration magnitude is based on the depth

of the deceleration’s nadir in bpm below the baseline, excluding
any transient spikes or electronic artifact.
The duration of the deceleration is quantitated from the start of the
deceleration to the end of the deceleration.
Recurrent – ≥50% of uterine contractions in any 20-minute
segment.

EARLY DECELERATION

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.
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 onset, nadir, and recovery of the deceleration are coincident Figure 27 Graph illustrating variable deceleration with onset, nadir, and recovery,
with the beginning, peak, and ending of the contraction, as well as contraction
respectively

Figure 28 Graph illustrating variable decelerations

Figure 25 Graph illustrating early deceleration with onset, nadir, and recovery, as
well as contraction

They are associated with fetal head compression during labor and
are generally considered benign and inconsequential
This FHR pattern is not normally associated with fetal acidemia

Figure 29 Graph illustrating recurrent variable decelerations

LATE DECELERATION
Figure 26 Graph illustrating early decelerations occurring simultaneously with the
contractions
Utero-placental insufficiency
VARIABLE DECELERATION Gradual decrease and return of the FHR associated with a uterine
contraction with the time of onset of the deceleration to its nadir
Cord compression as ≥30 sec
Abrupt decrease in the FHR with the onset of deceleration to the The decrease is typically symmetrical in shape and is measured
nadir of <30 seconds. The deceleration should be at least 15 bpm from the most recently determined portion of the baseline to the
nadir of the deceleration.
below the baseline, lasting for at least 15 seconds but <2 minutes
The deceleration is delayed in timing, with the nadir of the
in duration.
deceleration occurring after the peak of the contraction
When variable decelerations occur in conjunction with uterine
•In most cases the onset, nadir, and recovery of the deceleration
contraction, their onset, depth, and duration commonly vary with
occur after the beginning, peak, and ending of the contraction,
successive uterine contractions
respectively

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 Categories and Interventions

CATEGORY 1 (ALL OF THE FOLLOWING)

Baseline rate: 110–160 bpm

Variability: moderate

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

Figure 30 Graph illustrating late deceleration with onset, nadir, and recovery, as
well as contraction CATEGORY 2 (ANY OF THE FOLLOWING)

NICHD: CLASSIFYING DECELERATIONS Baseline rate:

Bradycardia not accompanied by absent
Decelerations Onset Shape Nadir Tachycardia
Early Gradual Symmetrical Matches UC peak
Variable Abrupt Assymetrical ≥15 bpm lasting Variability:
Minimal / marked baseline variability
≥15 sec but <2
If Absent , should have no recurrent
min
decelerations
Late Gradual Symmetrical After UC peak
Table 9 NICHD classifying decelerations
Accelerations:
Absence of induced accelerations after fetal
THREE-TIER SYSTEM FHR INTERPRETATION SYSTEM (2008) stimulation
Category 1 FHR: NORMAL TRACINGS Decelerations:
o Strongly predictive of normal fetal acid-base status at the time Periodic or episodic decelerations
of observation and can be followed in a routine manner Recurrent variable decelerations accompanied
without any specific action required, include all of the by minimal or moderate baseline variability
following: Prolonged deceleration ≥2 min but <10 min
Recurrent late decelerations with moderate
Parameter Category I baseline variability
Baseline 110-160 bpm Variable decelerations with other characteristics,
Variability Moderate such as slow return to baseline, “overshoots,” or
Decelerations Absence of any late or variable decelerations “shoulders”
Early decelerations may or may not be present
Acceleration May or may not be present Interpretation:
Table 10 Category 1 FHR Interpretation Indeterminate; 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)

Figure 31 Graph illustrating Category 1 FHR with interpretation 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 11 Three-Tier Fetal Heart Rate Interpretation System and Resuscitative

Measures for Category II or Category III Tracings
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 Table 13 Some Resuscitative Measures for Category II or Category III
Tracings (from Williams)

Table 12 Three-Tier Fetal Heart Rate Interpretation System (from Williams)

V. REFERENCES

Chapters 10, 17, 24 of Williams Obstetrics 25th Edition

(Cunningham et. al)
Dr. Domingo’s PPT Lecture (November 16, 2018)
Notes and recordings of OB Trans Team (November 16, 2018)

“Konti na lang, kayang-kaya n’yo ‘to. Konting-konti na lang, be strong.”

˜Dr. Maynila Domingo

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