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Case Review
From NeoReviews, Strip of the
Month: October 2015
Baseline FHR
• Baseline FHR
– Approximate mean FHR rounded to increments of
5 beats/min during a 10 minute segment,
excluding accelerations, decelerations, and
periods of marked FHR variability.
– The baseline must be for a minimum of 2 minutes
in any 10 minute segment.
– Normal baseline range is 110-160
Baseline (cont.)
• Definitions:
– Tachycardia: The baseline FHR is greater than 160
beats per minute.
– Bradycardia: The baseline FHR is less than 110
beats per minute.
Variability
• Fluctuations in the FHR baseline that are
irregular in amplitude and frequency,
measured from the peak to the trough.
• Absent- amplitude range is undetectable
• Minimal- amplitude range is detectable but
less than 5 beats/min
• Moderate- Amplitude range 6-25 beats/min
• Marked- Amplitude range is greater than 25
beats/min.
FHR Changes
• Accelerations
– Visually apparent abrupt increase in the FHR from the
baseline. The onset to the peak is less than 30 seconds.
– Before approximately 32 weeks, an acceleration has a peak
of at least 10 beats/min above the bassline and duration of
at least 10 seconds.
– After 32 weeks, an acceleration has a peak of at least 15
beats/min above the baseline and the duration is more
than 15 seconds.
– Prolonged acceleration lasts more than 2 min but less than
10 min
– If an acceleration is longer than 10 min, it is a baseline
change
Decelerations
• Early
– Occurs with a contractions, with a gradual onset (more than 30 seconds to nadir).
Generally the nadir occurs at the same time as the peak of the contraction.
• Late
– Occurs in association with a contraction with a gradual onset. The Onset, nadir, and
recovery occur after the beginning, peak, and end of the contraction.
• Variable
– An abrupt (onset to nadir is less than 30 seconds) decrease in the FHR. The
decrease is at least 15 beats/min and lasts at least 15 seconds but less than 2 min.
• Prolonged
– Decrease in FHR at least 15 beats/min below the baseline, lasting at least 2 min but
less than 10.
Three-tier FHR Classification System
• Category I
– Normal FHR tracing with all of the following
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baseline 110-160
FHR variability is moderate
Accelerations are present or absent
Without late or variable decelerations
Early decelerations may be present
• Category II
– Includes all FHR tracings not assigned to
Categories I or III
• Category III
– FHR tracing includes at least one of the following:
• Absent variability with late decelerations
• Absent variability with recurrent variable decelerations
• Absent variability with bradycardia for at least 10
minutes
• Sinusoidal pattern for at least 20 minutes
Contractions
• The number of contractions in a 10-minute
window and averaged over 30 min.
• Normal: 5 or less contractions in 10 minutes
• Tachysystole: More than 5 contractions in 10
minutes.
Presentation:
– 41 year-old G2P1 with type 2 diabetes mellitus at
37 5/7 weeks
– Admitted with early labor and SROM
– Denies vaginal bleeding
– Reports feeling frequent fetal movement
– Significant Hx:
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Type 2 DM
Advanced maternal age
Open angle glaucoma
Sickle cell trait
Further history
• Type 2 DM diagnosed 5 years before this
pregnancy.
• Prior medications: Metformin and an ACE
Inhibitor.
– At 8 weeks gestation, transitioned to insulin and
the ACE inhibitor was discontinued.
– Glucose has been well controlled with insulin
• All 3rd trimester ultrasounds and biophysical
profiles have been reassuring.
Progression
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Admission exam:
Blood pressure 126/66
HR 70
Blood glucose 115mg/dL
SROM confirmed
GBS negaive
Electronic fetal monitoring strip 1.
Emily Willner, and Brett C. Young Neoreviews
2015;16:e598-e605
©2015 by American Academy of Pediatrics
Progression
• Dilation 3 cm, 75% effaced, and -2 station
• Insulin drip started
One hour later…
Electronic fetal monitoring strip 2.
Emily Willner, and Brett C. Young Neoreviews
2015;16:e598-e605
©2015 by American Academy of Pediatrics
SBAR+R Report
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Situation
Background
Assessment
Recommendation
Read back
Progression
– Cervical exam: 4 cm, 100 % effaced, and at 0
station
– Variable decels resolve with position change and
IV fluids
– Epidural placed for pain relief
– 10 minutes later…
Electronic fetal monitoring strip 3.
Emily Willner, and Brett C. Young Neoreviews
2015;16:e598-e605
©2015 by American Academy of Pediatrics
SBAR+R Report
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Situation
Background
Assessment
Recommendation
Read back
Progression
• Dilation 10 cm, 100 % effaced, +2 station.
• Prolonged decel lasted 9 minutes, despite
interventions
• Decel resolved, and patient began pushing
with good effort.
Electronic fetal monitoring strip 4.
Emily Willner, and Brett C. Young Neoreviews
2015;16:e598-e605
©2015 by American Academy of Pediatrics
Progression
• Patient pushed for seven minutes and
delivered
• NICU team in room due to prolonged decel
What are your apgars?
• 1 minute :
9
– Color: acrocyanosis Pulse >100
Grimace: good cry
– Activity: arms and legs flexed with spontaneous movement
Resp: more than 50
• 5 minutes:
9
• Color: acrocyanosis Pulse > 100
Grimace: good cry
• Activity: arms and legs flexed with spontaneous movement
• Resp: more than 50
Outcome
– Vigorous female at 37 5/7 weeks was delivered by
vaginal delivery
– Wt: 2,615g
– Uncomplicated neonatal course and was
discharged 2 days after birth in stable condition
Discussion
– 6%-7% of pregnancies are complicated by
Diabetes (gestational and Pregestational)
– Infants of diabetic mothers (IDMs) increased risks:
• Macrosomia
– May result in postpartum hemorrhage, cesarean delivery, and
extensive perineal damage
• Shoulder dystocia
Fetal Risks
• Stillbirth
• Congenital anomalies
– Cardiac defects
– Neural tube defects
Pregestational diabetes increases risks
of OB complications:
– Preeclampsia and other hypertensive disorders of
pregnancy
– Worsening end-organ damage
– Retinopathy and nephropathy worsen during
pregnancy
– Increased risk of MI
– Increased risk of diabetic ketoacidosis
– Placental insufficiency
Neonatal complications
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Hypoglycemia
Respiratory distress
Polycythemia
Hyperbilirubinemia
Increased risk of childhood obesity and
development of type 2 diabetes
Risks can be minimized
• Good control of glucose before and during
pregnancy
• Preconception counseling
• Ultrasounds monitoring size and fetal wellbeing
References:
• Strip of the Month: October 2015. Emily
Willner and Brett C. Young. NeoReviews
2015;16;e598. DOI: 10.1542/neo.16-10-e598.
Retrieved from
http://neoreviews.aapublications.org/ by
Teriesa Pleyo on May 12, 2016