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NeoReviews Vol.7 No.2 2006 e109
© 2006 American Academy of Pediatrics

Strip of the Month

February 2006

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

* Charles B. and Ann L. Johnson Professor of Obstetrics; Chief, Division of Materna-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
 Suggested Reading
 
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 Table 1.


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

     Assumptions from the NICHD Workshop

     Definitions
Baseline Fetal Heart Rate

Baseline Variability

Accelerations

Late Decelerations

Early Decelerations

Variable Decelerations

Prolonged Decelerations

Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.

We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.


   Case Presentation
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 Electronic Fetal Monitoring Case...
 Case Presentation
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     History
A 29-year-old G 3 P 2002 woman presents to the labor and delivery unit at 39 2/7 weeks’ gestation with painful uterine contractions. Findings on personal, medical, and obstetrical histories are unremarkable. This pregnancy has been uncomplicated.

     Progression of Labor
The woman is placed on EFM. The obstetrician who is in the labor room determines that the cervix is dilated 7 cm, and there is an increased amount of bloody show. EFM Strip #1 is shown in Figure 1.


Figure 1
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  		Figure 1. EFM Strip #1.

 
Findings on EFM Strip #1 are:

Membranes are ruptured artificially, and slightly bloody amniotic fluid is noted. A fetal scalp electrode is placed. An anesthesia consult is obtained, and specimens for admission laboratory tests are drawn. Ten minutes later, EFM Strip #2 is obtained (Fig. 2).


Figure 2
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  		Figure 2. EFM Strip #2.

 
Findings on EFM Strip #2 are:

Because of the persistent decelerations, the patient is moved to the operating room emergently for potential cesarean delivery. Ten minutes later, EFM Strip #3 is obtained (Fig. 3).


Figure 3
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  		Figure 3. EFM Strip #3.

 
Findings on EFM Strip #3 are:

Evaluation of the cervix in the operating room reveals that cervical dilation is complete, effacement is complete, and the presenting part is at -1 station. A spinal epidural is placed for pain management. Ten minutes later, EFM Strip #4 is obtained (Fig. 4).


Figure 4
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  		Figure 4. EFM Strip #4.

 
Findings on EFM Strip #4 are:

     Outcome
A viable female infant weighing 3,304 g is delivered by emergent cesarean section due to a low FHR that did not respond to intrauterine resuscitative actions (position change, correction of hypotension). Nuchal cord x 2, thick meconium, and placenta suspicious for abruption are noted at delivery. Apgar scores are 6 at 1 minute and 8 at 5 minutes. The infant is resuscitated with suction, oxygen, and intubation. She is admitted to the well baby nursery. Arterial cord gas findings in relation to normal findings and those of acidosis are shown in Table 2.


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 7.13 80 9 –2.6

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


   Footnotes
 
Author Disclosure

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


   Suggested Reading
Top
 Electronic Fetal Monitoring Case...
 Case Presentation
 Suggested Reading
 
ACOG Practice Bulletin #62. Intrapartum Fetal Heart Rate Monitoring.May 2005.

Freeman RK. Problems with intrapartum fetal heart rate monitoring interpretation and patient management. Obstet Gynecol. 2002;100 :813 –826[Abstract/Free Full Text]

National Institute of Child Health and Human Development Research Planning Group. Electronic fetal heart rate monitoring: research guidelines for interpretation. Am J Obstet Gynecol. 1997;177 :1385 –1390.[Medline]





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Right arrow Articles by Druzin, M. L.
Right arrow Articles by Arafeh, J. M.R.

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