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Updated: Jun 4 2024

Intrapartum Fetal Assessment

  • Snapshot
    • A 35-year-old woman at 42 weeks of gestation presents for an induction of labor due to postterm pregnancy. She reports positive fetal movement, and denies vaginal bleeding. After amniotomy is performed, a change in the fetal heart rate is noted, as seen in the tracing in the image. Maternal repositioning is performed. (Variable decelerations)
  • Introduction
    • Overview
      • intrapartum fetal assessments are performed to assess fetal well-being during labor and delivery
        • biophysical profile (BPP)
        • fetal heart rate (FHR) monitoring
          • electronic fetal monitoring (EFM) is the most common method to assess the fetus during labor
  • Biophysical Profile (BPP)
    • Five measurements of fetal well being, each rated on scale of 0 or 2
      • measurements
        • fetal breathing
        • gross body movements
        • fetal tone
          • extremity extension and flexion
        • amniotic fluid volume
        • nonstress test (NST)
    • Scoring
      • 8-10 is reassuring
      • 6 is equivocal
        • delivery if > 36 weeks
        • repeat BPP in 24 hours if < 36 weeks
      • ≤ 4 is abnormal
        • requires immediate intervention, prompt delivery
  • Fetal Heart Rate (FHR)
    • Normal FHR 120-160/min
    • Tachycardia is FHR > 160/min
      • causes include
        • maternal fever
        • fetal hypoxia
        • prematurity
        • anemia (maternal or fetal)
        • chorioamnionitis
        • hyperthyroidism
    • Bradycardia is FHR < 110/min for > 10 minutes
      • causes include
        • congenital heart block
        • maternal β-blockers
    • FHR variability
      • reliable indicator of fetal well being
      • causes of decreased variability include
        • fetal hypoxia
        • congenital heart anomalies
        • quiet fetal heart cycle 
  • Electronic Fetal Heart Rate Monitoring (EFM) Tracing Interpretation 
    • Accelerations
      • ↑ FHR at least 15/min above baseline for ≥ 15 seconds and < 2 minutes in a 20 minute period when gestational age is > 32 weeks or 10/min for ≥ 10 seconds when gestational age is < 32 weeks
        • considered a reactive NST (needs the presence of at least 2 accelerations)
      • suggests fetal well being
      • if this was a NST during pregnancy (not intrapartum), management would be routine-follow-up
    • Early decelerations
      • ↓ FHR (not below 100/min) that coincide with uterine contraction
        • nadir of the deceleration meets the apex of the uterine contraction
      • results from pressure on fetal head (fetal head compression) resulting in vagus nerve stimulation and reflex bradycardia
      • physiologic and not harmful to fetus
    • Variable decelerations
      • may not coincide with uterine contractions
      • rapid ↓ in FHR (often < 100/min) with variable recovery
      • reflex mechanism due to umbilical cord compression
        • rupture of membrane can lead to umbilical artery compression
      • correct by shifting maternal position or amnioinfusion if membranes ruptured
        • considered first-line
        • if maternal repositioning does not improve FHR tracing, amnioinfusion can be considered
    • Late decelerations
      • begins after uterine contraction has started
      • associated with uteroplacental insufficiency and viewed as potentially dangerous
      • potential causes
        • placental abruption
        • maternal diabetes
        • maternal anemia
        • maternal sepsis
        • postterm pregnancy
        • hyperstimulated uterus
      • repetitive late develerations require intervention
    • Sinusoidal tracing
      • sine-wave like pattern
      • associated with increased morbidity and mortality
      • indicative of severe fetal anemia
        • e.g., severe hypoxia and Rh disease
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