This document discusses intrapartum fetal heart rate monitoring. It defines normal and abnormal fetal heart rate patterns and categories. Category I indicates a normal tracing. Category II is indeterminate, while Category III tracings are abnormal, showing absent variability and late or variable decelerations. The document outlines intrauterine resuscitation measures to improve fetal oxygenation if abnormalities arise, such as giving oxygen, IV fluids, changing position and reducing contractions. Fetal scalp blood sampling to check pH can guide management in equivocal cases. Overall, the document provides guidance on interpreting and responding to fetal heart rate tracings during labor and delivery.

1. Intrapartum monitoring
DR. AHMED MOHAMED ABBAS, MD
Assistant Professor of OB-GYN
Faculty of Medicine- Assiut University

2. FETAL HEART RATE MONITORING
 Normal fetal heart rate (FHR) findings are highly reassuring of fetal
well-being.
 Abnormal FHR findings are poor predictors of fetal compromise.
 Wide usage of electronic FHR monitoring has not lowered the rate
of cerebral palsy (CP) because the antecedents of CP appear not to
be intrapartum events, but rather antenatal events.
 So, the false-positive rate for electronic FHR monitoring for
predicting CP is >99%.
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4. Intermittent auscultation devices
Pinard stethoscope DeLee stethoscope
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5. EXTERNAL MONITORING
 External devices (most common) are placed on the uterine
fundus.
 Advantage used before significant cervical dilation and
membrane rupture.
 Disadvantages are poor quality tracing with maternal
obesity and maternal discomfort from the device belts.
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6. EXTERNAL MONITORING
 Fetal. A continuous ultrasound transducer picks up fetal cardiac
motion but also can register maternal great vessel pulsations.
 Contractions. A tocographic transducer device senses the change
in uterine wall muscle tone. It can measure the beginning and
ending of contractions but cannot precisely assess contraction
intensity.
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7. Cardiotocography External Monitoring
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8. INTERNAL DEVICES
 Internal devices are placed through the dilated cervix.
 Advantages include optimum signal quality, which is unaffected by
maternal obesity.
 Disadvantages include limitation to labor when cervical dilation and
membrane rupture have occurred.
 Fetal. A direct scalp electrode precisely senses each QRS complex of the
fetal cardiac cycle. Complications can include fetal scalp trauma and
infection.
 Contractions. An intrauterine pressure catheter (IUPC) placed into the
uterine cavity precisely registers intrauterine hydrostatic changes with
each contraction.
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10. INTRAPARTUM FETAL HEART RATE
MONITORING
DEFINITIONS
 Baseline Fetal Heart Rate (FHR): The mean FHR rounded
to increments of 5 beats/min during a 10-minute segment.
 Normal FHR baseline is 110–160 beats/minute.
 Tachycardia: FHR baseline is >160 beats/min.
 Bradycardia : FHR baseline is <110 beats/min.
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11.  Baseline variability: describes fluctuations in the baseline
FHR that are irregular in amplitude and frequency. It is a
reflection of the autonomic interplay between the sympathetic
and parasympathetic nervous system.
 Absent: amplitude range undetectable
 Minimal: amplitude range detectable but ≤5 beats/min
 Moderate (normal): amplitude range 6–25 beats/min
 Marked: amplitude range >25 beats/min
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12. Variability 12
Normal/ increased variability or irregularity of a cardiac rhythm.
Absence or decreased variability, or a smooth flat baseline, is a sign
of fetal compromise

13. FETAL HEART RATE CATEGORIES
 A three-tiered system for the categorization of FHR patterns is
recommended.
 Categorization evaluates the fetus at that point in time; tracing
patterns can and will change.
 FHR tracing may move back and forth between the categories
depending on the clinical situation and management strategies.
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14. Category I: FHR tracings are normal
Criteria include all of the following:
 Baseline rate: 110–160 beats/min
 Baseline FHR variability: moderate
 Late or variable decelerations: absent
 Early decelerations: present or absent
 Accelerations: present or absent
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15. Baseline Fetal Heart rate
Normal Pattern
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16. Category II: FHR tracings are
indeterminate
 These include all FHR tracings not categorized as category I
or III and may represent a great portion of those encountered
in clinical care.
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17. Category III: FHR tracings are
abnormal
 Criteria include absent baseline FHR variability and any of the
followings:
 Recurrent late decelerations
 Recurrent variable decelerations
 Bradycardia
 Sinusoidal pattern
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18. Poor or absent variability
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20. INTRAUTERINE RESUSCITATION
 Decrease uterine contractions: Turn off any IV oxytocin
infusion or administer terbutaline 0.25 mg subcutaneously to
enhance intervillous placental blood flow.
 Augment IV fluid volume: Infuse 500 mL bolus of intravenous
normal saline rapidly to enhance uteroplacental infusion.
 Administer high-flow oxygen: Give the parturient 8–10 L of
oxygen by facemask to increase delivery of maternal oxygen
to the placenta.
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21.  Amnioinfusion is useful for reducing the severity of variable
decelerations.
 Change position: Removing the parturient from the supine position
decreases inferior vena cava compression and enhances cardiac
return, thus cardiac output to the placenta. Turning the parturient
from one lateral position to the other may relieve any umbilical cord
compression that may be present.
 Vaginal examination: Perform a digital vaginal examination to rule
out possible prolapsed umbilical cord.
 Scalp stimulation: Perform a digital scalp stimulation observing for
accelerations, which would be reassuring of fetal condition.
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INTRAUTERINE RESUSCITATION

22. FETAL PH ASSESSMENT
 Intrapartum: Fetal scalp blood pH may be used in labor if the EFM strip is
equivocal.
 Prerequisites include cervical dilation, ruptured membranes, and
adequate descent of the fetal head.
 Contraindications are suspected fetal blood dyscrasia.
 A small, shallow fetal scalp incision is made resulting in capillary
bleeding.
 The blood is collected in a heparinized capillary tube and sent to the
laboratory for blood gas analysis.
 Normal fetal pH is ≥7.20.
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23. CASE SCENARIO
 A 20-year-old primigravida at 39 weeks’ gestation is in active
labor at 7 cm of cervical dilation.
 The EFM strip shows a baseline heart rate of 175 beats/min,
and variability is absent, but repetitive late decelerations are
seen after each contraction. No accelerations are noted.
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24.  Examine the EFM strip carefully looking for baseline FHR, degree of
variability, and presence of periodic changes (accelerations,
decelerations).
 Confirm abnormal findings using criteria discussed (category II or
III).
 Identify nonhypoxic causes present that could explain the abnormal
findings.
 Initiate the intrauterine resuscitation measures described previously
to enhance placental perfusion and fetal oxygenation.
 Observe for normalization of the EFM tracing.
 Prepare for delivery promptly if resuscitation measures do not
normalize EFM tracing.
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25. Specific interventions if immediate delivery Is indicated:
 In stage 1 of labor, the only option is emergency cesarean
section.
 In stage 2 of labor, an operative vaginal delivery (e.g.,
vacuum extractor
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