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NeoReviews Vol.9 No.1 2008 e42
© 2008 American Academy of Pediatrics

Strip of the Month

January 2008

Maurice L. Druzin, MD*
Julie M.R. Arafeh, RN, MSN{dagger}

* Charles B. and Ann L. Johnson Professor of Obstetrics; Chief, Division of Maternal-Fetal Medicine; Co-Medical Director, Mid-Coastal California Perinatal Outreach Program, Stanford University School of Medicine, Palo Alto, Calif
{dagger} Coordinator of Perinatal Outreach, Mid-Coastal California Perinatal Outreach Program, Stanford University, Palo Alto, Calif


   Electronic Fetal Monitoring Case Review Series
Top
 Electronic Fetal Monitoring Case...
Case Presentation
 
Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the Table .


Table 1. Arterial Umbilical Cord Gas Values

pH Pco2 (mm Hg) Po2 (mm Hg) Base Excess
Normal* ≥7.20 (7.15 to 7.38) <60 (35 to 70) ≥20 ≤–10 (–2.0 to –9.0)
Respiratory Acidosis <7.20 >60 Variable ≤–10
Metabolic Acidosis <7.20 <60 Variable ≥–10
Mixed Acidosis <7.20 >60 Variable ≥–10

* Normal ranges from Obstet Gynecol Clin North Am. 1999;26:695


Table 2. Arterial Umbilical Cord Gas Values

pH Pco2 (mm Hg) Po2 (mm Hg) Base Excess
Normal* ≥7.20 (7.15 to 7.38) <60 (35 to 70) ≥20 ≤–10 (–2.0 to –9.0)
Respiratory Acidosis <7.20 >60 Variable ≤–10
Metabolic Acidosis <7.20 <60 Variable ≥–10
Mixed Acidosis <7.20 >60 Variable ≥–10
Patient 7.17 66 6 –6

* Normal ranges from Obstet Gynecol Clin North Am. 1999;26:695

     Assumptions from the NICHD Workshop

     Definitions
Baseline Fetal Heart Rate

Baseline Variability

Accelerations

Late Decelerations

Early Decelerations

Variable Decelerations

Prolonged Decelerations


   Case Presentation
Top
 Electronic Fetal Monitoring Case...
 Case Presentation
 
     History
A 19-year-old G1P0 woman is admitted to labor and delivery for induction at 38 weeks’ gestation because of preeclampsia. Past medical and social histories are unremarkable, and the pregnancy was uncomplicated until 36 weeks’ gestation, when urine dipstick measurement for protein was 3+, and the woman’s blood pressure was 100/60 mm Hg. A 24-hour urine collection for protein measured 385 mg. She was followed closely as an outpatient, and at 38 weeks’ gestation, her blood pressure was 129/91 mm Hg and repeat 24-hour urine collection documented increased protein to 847 mg. Other laboratory findings were normal. Upon admission to labor and delivery, the woman’s blood pressure is 127/91 mm Hg, and she reports headache and visual changes. Vaginal examination shows the cervix to be a fingertip dilated, thick, and high. Misoprostol is administered vaginally to ripen the cervix to facilitate induction of labor, and an initial fetal tracing is obtained (Fig. 1).


Figure 1
Figure 1
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  		Figure 1. EFM Strip #1.

 
Findings on EFM Strip #1 are:

     Progression of Labor
Approximately 2 hours later, the patient begins to feel contractions and another tracing is obtained (Fig. 2).


Figure 2
Figure 2
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  		Figure 2. EFM Strip #2.

 
Findings on EFM Strip #2 are:

Within 20 minutes, the tracing improves (Fig. 3).


Figure 3
Figure 3
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  		Figure 3. EFM Strip #3.

 
Findings on EFM Strip #3 are:

Approximately 6 hours later, the patient is 6 cm dilated and is requesting an epidural. A fetal tracing (Fig. 4) is obtained as epidural placement is completed.


Figure 4
Figure 4
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  		Figure 4. EFM Strip #4.

 
Findings on EFM Strip #4 are:

Oxytocin therapy is started to augment uterine contractions after epidural placement. A fetal tracing (Fig. 5) is obtained approximately 1.5 hours later.


Figure 5
Figure 5
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  		Figure 5. EFM Strip #5.

 
Findings on EFM Strip #5 are:

The previously noted actions are taken without resolution of the decelerations, and the decision is made to deliver the fetus by emergent cesarean section. The patient is taken to the operating suite in an urgent but controlled fashion. A fetal tracing (Fig. 6) is obtained in the operating suite.


Figure 6
Figure 6
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  		Figure 6. EFM Strip #6.

 
Findings on EFM Strip #6 are:

     Outcome
A viable female infant weighing 2,543 g and having Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, is delivered. She is taken in stable condition to the nursery for observation during maternal recovery. Both mother and infant do well.


   Footnotes
 
Author Disclosure

Dr Druzin and Ms Arafeh did not disclose any financial relationships relevant to this article.


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This Article
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Right arrow Articles by Druzin, M. L.
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