Fetal Heart Rate (FHR) Monitoring during labor

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2. Fetal Assessment During Labor
We asses:
1. Amniotic fluid
2. Fetal Heart Rate (FHR): the
primary assessment
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3. 1. Amniotic fluid analysis:
• Amniotic fluid should be clear, colorless
or pale yellow, when the membranes
rupture.
• Cloudy fluid with foul smell → Infection
• Green Fluid → Fetal Hypoxia due to
meconium (the first stool of the baby)
• Blood streak → Hemorrhage
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4. 2. Fetal Heart Rate (FHR) Monitoring
• Is the measuring of the fetus’s heart rate
during the labor by using a special
instruments.
• Types and methods of fetal heart
monitoring:
1. Intermittent auscultation
2. Electronic fetal monitoring (EFM)
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1. Intermittent Auscultation technique:
• Auscultation is a method of listening
to the fetal heartbeat for about 60
seconds by using a fetal stethoscope
(fetoscope or Pinard), or a hand-held
Doppler ultrasound device.

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• While listening to the heartbeat, the
doctor also palpates the mother’s uterus
by placing a hand on the abdomen to
measure the contractions.
• Intermittent auscultation should be done:
− Every 15-30 minutes during the active
phase of 1st stage,
− Every 5-15 minutes during the pushing
phase of 2nd stage.

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Fetoscope Pinard Hand-held
Doppler

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2. Electronic fetal monitoring (EFM)
• EFM is an electronic monitor used to
continuously measures the fetus’s heart
rate and using a pressure sensor to
monitor the mother’s contractions at the
same time.
• There are 2 types of EFM:
• External monitoring
• Internal monitoring

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Indications for EFM
• Pregnancy complications (Diabetes, preeclampsia…)
• Pre-term labor.
• Previous caesarean.
• The baby is smaller than expected.
• Multiple fetuses.
• Overweight mother.
• Prolonged 1st stage of labor.
• The amniotic fluid contains significant amounts of
meconium (The baby's first poo).
• Induction of labor.
• A high temperature mother.

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External monitoring:
• Measuring the heart rate through an
ultrasound device, and measuring the
contractions by using a pressure sensor;
both devises are held against the
mother's belly with a belt.
• The reading of external monitoring is
affecting by changing position.

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Internal monitoring:
• Measure the heart rate through a wire called
(electrode) contains a needle, inserted
through the vagina and cervix, and placed
under the baby's scalp. And measuring the
contractions with a thin tube inserted into the
uterus.
• Internal monitoring can be done only after the
cervix has dilated to at least 2cm and the
amniotic sac has ruptured.

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FHR patterns
• Normal Pattern:
Baseline FHR = 120 – 160 bpm (Beat/min.)
• Tachycardia:
Baseline FHR above 160 bpm
• Bradycardia:
Baseline FHR less than 120 bpm
*Baseline FHR = 10 minutes*

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Contraction Pattern
• Normal contractions:
5 or fewer contractions in 10 minutes
lasting about 60 seconds in the active
phase.
• Contraction intensity:
30 mmHg in early labor to 70 - 90 mmHg
in the second stage.

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Normal fetal heart rate with moderate variability
Normal Contraction

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Causes of Tachycardia
Tachycardia is a FHR above
160 bpm that lasts for at least
10 minutes
• Mother fever
• Mother and fetus infection
• Mother dehydration
• Mother and fetus anemia
• Fetus hypoxemia
• Fetal tachyarrhythmia
• Fetus cardiac abnormalities
Causes of Bradycardia
Fetal bradycardia is a
baseline FHR of less than 110
bpm that lasts for at least 10
minutes
• Mother Dehydration
• Mother Hypotension
• Rupture of uterus or vasa
previa
• Placental abruption
• Medications such as anesthetics
• Fetal hypoxia
• Late or profound hypoxemia
• Umbilical cord occlusion
• Fetal bradyarrythmias

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Baseline FHR Variability
• The normal fetal heart rate baseline is from
120 to 160 BPM and has variability usually
with a range of 3-5 bpm from the baseline.
• Characteristics:
1. Undetectable (less than 5 bpm)
2. Minimal (up to 5 bpm)
3. Moderate (6 to 25 bpm)
4. Marked (more than 25 bpm)
Abnormal if lasts
over 60 min.

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Periodic changes
Periodic changes are accelerations or
decelerations in the FHR that are in relation
to uterine contractions and persist over
time.

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Accelerations
• Accelerations are transient increases in the FHR
about (15 bpm) above baseline for about (15 sec. to
less than 2 min.) and then return normally to the
base line.
• Prolonged acceleration: Increase in heart rate lasts
for 2 to 10 minutes.
• The presence of accelerations is a sign of normal
fetus, because they are usually associated with
fetus stimulation, such as fetal movement, vaginal
examinations, and contractions.

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Fetal heart rate accelerations

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Decelerations
Transitory decrease in the FHR from the
baseline.
1. Early decelerations: the onset and return of a
deceleration is match to the contraction
2. Variable decelerations: variable in the time,
intensity, and duration of a deceleration
3. Late decelerations: the fetal heart rate return
to the baseline after the end of the
contraction

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Management
1. Early decelerations: No intervention is necessary,
just keep watching. It happen due to uterine
contractions.
2. Variable decelerations: Reposition of the mother,
oxygen mask, and stop oxytocin. It happen due to
Umbilical cord occlusion and problems.
3. Late decelerations: Reposition of the mother,
oxygen mask, stop oxytocin, give IV. It happen
due to reduction in O2

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Early decelerations

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Variable decelerations

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Late decelerations

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What happens if the fetal heart rate pattern
is abnormal?
• An abnormal fetal heart rate may mean that the fetus is
not getting enough oxygen or that there are other
problems.
• We should first try to find the cause.
• Steps can be taken to help the baby get more oxygen,
such as change the position of the mother, and giving her
an oxygen mask.
• If the procedures do not work, and the fetus still has a
problem, we should deliver the baby immediately.
• In this case, the delivery of the baby is more likely to be
by cesarean birth or with forceps or vacuum delivery.

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Forceps delivery
Vacuum delivery