The Peri-FACTS® Academy Presents

Fetal Heart Rate Monitoring:

Pathophysiology and Practice

Edited by
Loralei L. Thornburg, M.D.
Assistant Professor of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine

J. Christopher Glantz, M.D., M.P.H.

Professor of Obstetrics and Gynecology
Division of Maternal-Fetal Medicine

Carol Giffi, R.N.C., M.S.N.P.

Department of Obstetrics and Gynecology

and

James R. Woods, Jr., M.D.

Henry A. Thiede Professor and Chairman
Department of Obstetrics and Gynecology

Department of Obstetrics and Gynecology

The University of Rochester
Rochester, New York

Medical Editor: Leah Garnett

Indexer: Joanne Still

 University of Rochester 2013

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise,
without prior permission of the publisher.

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Contributors

Kimberlee A. Bliek, M.S., R.N.

Clinical Nurse Specialist
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Therese Caffery, R.N.C., M.S.N.P.

Nurse Practitioner
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Kathy Flynn, R.N.C., M.S.N.P.

Nurse Practitioner
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Dzhamala Gilmandyar, M.D.

Fellow of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Lisa Gray, M.D.

Fellow of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

David Hackney, M.D., M.S.

Assistant Professor
Division of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
University Hospitals Case Medical Center
MacDonald Women’s Hospital
Cleveland, OH

Monique Ho, M.D.

Assistant Professor of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

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Tulin Ozcan, M.D.
Associate Professor of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Eva K. Pressman, M.D.

James R. Woods, Jr., Professor, Director, and Associate Chair for Clinical Affairs of Obstetrics
and Gynecology
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Ruth Anne Queenan, M.D., M.B.A.

Associate Professor and Chief of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
Highland Hospital
Rochester, NY

Neil S. Seligman, M.D.

Assistant Professor of Obstetrics and Gynecology
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Shirley Warren, R.N.C., M.S.N.P.-BC

Clinical Nurse Specialist
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

Paula Zozzaro-Smith, D.O.

Fellow of Maternal-Fetal Medicine
Department of Obstetrics and Gynecology
The University of Rochester
Rochester, New York

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Preface
We are pleased to introduce the brand new Peri-FACTS® Academy textbook Fetal Heart
Rate Monitoring: Pathophysiology and Practice. The text has been completely revised
to update the terminology, and to include the most up-to-date information on maternal and
fetal physiology and its use in interpretation of fetal assessment.

The initial chapters in this book focus on physiologic adaptations of pregnancy and the
basic physiology of oxygen delivery to the fetus. In subsequent chapters, different aspects
of fetal assessment in various clinical scenarios are reviewed. The text has been
reorganized and expanded to fully discuss fetal monitoring and interpretation.

The case studies have been revised, and new fetal heart rate tracings and questions added,
accompanied by numerous examples. Many of the fetal heart rate tracings offer examples
of basic fetal heart rate monitoring interpretation; others have been selected specifically for
the advanced learner seeking a higher level of interpretation in more complicated fetal
assessment.

Fetal Heart Rate Monitoring: Pathophysiology and Practice is the core reference
textbook for the Peri-FACTS® Academy obstetric and fetal monitoring course. In addition
to this textbook, the Year in Review publications allow access to all of the reading
materials and clinical case studies presented throughout the prior year, compiled into an
indexed textbook.

For more information regarding all the offerings of the Peri-FACTS® Academy and our
other textbooks, online learning opportunities, videos, and newly added gynecology content,
visit our web site at http://www.urmc.rochester.edu/obgyn/Peri-FACTS. Input always is
welcome from those who utilize this textbook and we hope that it serves as a worthy
resource within your obstetric practice.

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Table of Contents

Preface ............................................................................................................................................... iii

Chapter 1
Maternal Physiology and Initiation of Parturition

Introduction ...................................................................................................................................... 3
Reproductive System ...................................................................................................................... 3
Cardiovascular System .................................................................................................................... 3
Hematologic Changes ...................................................................................................................... 5
Respiratory Changes ....................................................................................................................... 6
Renal Function ................................................................................................................................ 7
Labor and Myometrial Function ..................................................................................................... 8
Conclusion ....................................................................................................................................... 9
Related Readings .......................................................................................................................... 11
Review ............................................................................................................................................ 12

Chapter 2
Fluid Dynamics in Pregnancy

Introduction ................................................................................................................................... 17
Distribution of Fluids .................................................................................................................... 17
Keywords ....................................................................................................................................... 17
Measurements of Fluids, Electrolytes, and Concentrations ....................................................... 18
Osmosis .......................................................................................................................................... 18
Hemodynamic Changes in Pregnancy ......................................................................................... 19
Maintenance Hydration for Hospitalized Obstetric Patients ..................................................... 20
Volume Overload in Obstetric Patients ....................................................................................... 20
Conclusion ..................................................................................................................................... 21
Related Readings .......................................................................................................................... 23
Review ............................................................................................................................................ 24

Chapter 3
Fetal Circulation and the Impact on Heart Rate Monitoring

Introduction ................................................................................................................................... 29
Fetal Circulation ........................................................................................................................... 29
Fetal Brain Maturation and Fetal Circulation ........................................................................... 31
Transition to Newborn Circulation .............................................................................................. 32
Conclusion ..................................................................................................................................... 33
Related Readings .......................................................................................................................... 35
Review ............................................................................................................................................ 36

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Chapter 4
Fetal Oxygen and Acid-Base Metabolism

Introduction ................................................................................................................................... 41
Hemoglobin .................................................................................................................................... 41
Oxygen and Adult Hemoglobin .................................................................................................... 41
Fetal Hemoglobin .......................................................................................................................... 41
Factors Affecting Fetal Hemoglobin Function ............................................................................ 42
2,3-Diphosphoglyceric Acid (2,3-DPG or DPG) ............................................................................ 42
Oxygen Transportation ................................................................................................................. 43
Oxygen Delivery at the Placental Level ...................................................................................... 43
Fetal Elimination of Metabolic By-Products ............................................................................... 44
Fetal Acid-Base Balance ............................................................................................................... 44
Understanding Base Excess ......................................................................................................... 45
Types of Acidosis ........................................................................................................................... 45
Causes of Acidosis ......................................................................................................................... 46
Umbilical Blood Gas Assessment ................................................................................................. 46
Predictive Value of Umbilical Blood Gases ................................................................................. 47
Conclusion ..................................................................................................................................... 47
Related Readings .......................................................................................................................... 49
Review ............................................................................................................................................ 50

Chapter 5
Amniotic Fluid Physiology

Introduction ................................................................................................................................... 55
Composition of Amniotic Fluid ..................................................................................................... 55
Amniotic Fluid Volume Regulation .............................................................................................. 55
Evaluation of Amniotic Fluid Volume .......................................................................................... 56
Disorders of Amniotic Fluid Volume ............................................................................................ 57
Conclusion ..................................................................................................................................... 58
Related Readings .......................................................................................................................... 59
Review ............................................................................................................................................ 60

Chapter 6
Fetal Heart Rate Monitoring: Technology, Baseline, and Variability

External Fetal Monitoring Technology ......................................................................................... 65

Fetal Scalp Electrode .................................................................................................................... 65
The Logic of Fetal Monitors .......................................................................................................... 65
Baseline Fetal Heart Rate ............................................................................................................ 66
Baseline Fetal Heart Rate Tachycardia ...................................................................................... 67
Baseline Fetal Heart Rate Bradycardia ...................................................................................... 67
Wandering Baseline ...................................................................................................................... 70
Defining Fetal Heart Rate Variability ......................................................................................... 70
Evaluation of Minimal Fetal Heart Rate Variability .................................................................. 71
Marked Variability ....................................................................................................................... 72
Sinusoidal-Appearing Fetal Heart Rate Baseline ....................................................................... 72

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 Conclusion ..................................................................................................................................... 74
Related Readings .......................................................................................................................... 75
Review ........................................................................................................................................... 76
Chapter 7
Accelerations and Decelerations

Introduction ................................................................................................................................... 81
Accelerations ................................................................................................................................. 81
Decelerations ................................................................................................................................. 83
Early Decelerations ....................................................................................................................... 83
Variable Decelerations .................................................................................................................. 85
Late Decelerations ........................................................................................................................ 88
Prolonged Decelerations ............................................................................................................... 92
Conclusion ..................................................................................................................................... 93
Related Readings .......................................................................................................................... 95
Review ........................................................................................................................................... 96

Chapter 8
Assessment of Uterine Activity

Introduction ................................................................................................................................. 101

Normal Uterine Activity ............................................................................................................. 101
Intrapartum Amnioinfusion ....................................................................................................... 104
Related Readings ........................................................................................................................ 107
Review .......................................................................................................................................... 108

Chapter 9
Antepartum Fetal Assessment

Introduction ................................................................................................................................. 113

Nonstress Tests ........................................................................................................................... 113
Vibroacoustic Stimulation .......................................................................................................... 116
Biophysical Profile ...................................................................................................................... 117
Contraction Stress Tests ............................................................................................................ 121
Conclusion ................................................................................................................................... 125
Related Readings ........................................................................................................................ 126
Review ......................................................................................................................................... 128

Chapter 10
Fetal Heart Rate Monitoring Interpretation

Introduction ................................................................................................................................. 133

Systematic Evaluation of Electronic Fetal Monitoring ............................................................. 133
Utility of Fetal Heart Rate Tracings .......................................................................................... 133
Intrapartum Asphyxia ................................................................................................................ 134
Categorization of Fetal Heart Rate Tracings ............................................................................ 135
Interpretation of Fetal Heart Rate Tracing Categories ............................................................ 136
Interventions ............................................................................................................................... 136

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 Conclusion ................................................................................................................................... 138
Related Readings ........................................................................................................................ 139
Review .......................................................................................................................................... 140

Chapter 11
Fetal Assessment by Doppler Velocimetry

Introduction ................................................................................................................................. 145

Doppler Principle ........................................................................................................................ 145
Doppler Measurement Techniques: Doppler Ratios and Peak Systolic Velocity ...................... 146
Umbilical Artery Velocimetry ..................................................................................................... 147
Middle Cerebral Artery................................................................................................................ 147
Doppler of Fetal Veins ................................................................................................................ 147
Suspected Fetal Anemia and Middle Cerebral Artery Doppler ................................................ 148
Intrauterine Growth Restriction(IUGR) .................................................................................... 149
Preclinical Signs of Placental Dysfunction: Venous Redistribution ......................................... 150
Early Signs of IUGR: Arterial Redistribution ............................................................................ 150
Umbilical Artery Doppler ........................................................................................................... 150
Middle Cerebral Artery Doppler ................................................................................................ 150
Ductus Venosus Doppler ............................................................................................................. 151
Late Signs of IUGR: Critical Dopplers and Biophysical Profile Score Abnormalities ............ 151
Doppler Velocimetry for IUGR Monitoring ............................................................................... 152
Use of Doppler Velocimetry for Timing of Delivery in Early-Onset IUGR .............................. 153
Use of Doppler Velocimetry for Timing of Delivery in Late-Onset IUGR ............................... 154
Related Readings ........................................................................................................................ 155
Review ......................................................................................................................................... 158

Chapter 12
Fetal Monitoring in the Complex Patient

Introduction ................................................................................................................................. 163

Infection and Intrapartum Fetal Heart Rate Monitoring ......................................................... 163
Maternal Obesity ........................................................................................................................ 163
Multiple Gestation ...................................................................................................................... 164
Prematurity ................................................................................................................................. 164
Fetal Anomalies .......................................................................................................................... 166
Fetal Cardiac Defects .................................................................................................................. 167
Fetal Cardiac Arrhythmias ........................................................................................................ 167
Congenital Bradycardia .............................................................................................................. 169
Fetal Tachyarrhythmias ............................................................................................................. 170
Intraoperative Fetal Monitoring ................................................................................................ 171
The Medically Compromised Patient ......................................................................................... 173
Conclusion ................................................................................................................................... 174
Related Readings ........................................................................................................................ 175
Review ......................................................................................................................................... 176

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Chapter 13
Patient Safety and Team Communication:
Developing a Culture of Safety and Teamwork

Introduction ................................................................................................................................. 181

Source of Error ............................................................................................................................ 181
Teams and Their Role in Patient Safety .................................................................................... 181
Developing Successful Perinatal Teams .................................................................................... 182
Human Factors Engineering ...................................................................................................... 182
Team Communication ................................................................................................................. 183
Documentation ............................................................................................................................ 185
Communication Challenges ........................................................................................................ 186
Conclusion ................................................................................................................................... 188
Additional Resources .................................................................................................................. 189
Related Readings ........................................................................................................................ 191
Review ......................................................................................................................................... 192

Chapter 14
Putting It All Together:
Basic Fetal Heart Rate Monitor Interpretation Case Studies

Clinical Case Study 14.1 ............................................................................................................. 197

Clinical Case Study 14.2 ............................................................................................................. 201
Clinical Case Study 14.3 ............................................................................................................. 205
Clinical Case Study 14.4 ............................................................................................................. 210

Chapter 15
Putting It All Together:
Advanced Fetal Heart Rate Monitor Interpretation Case Studies

Clinical Case Study 15.1 ............................................................................................................. 217

Clinical Case Study 15.2
Clinical Case Study 15.3
Clinical Case Study 15.4
Clinical Case Study 15.5
Clinical Case Study 15.6
Clinical Case Study 15.7
............................................................................................................. 221
............................................................................................................. 225
............................................................................................................. 229
............................................................................................................. 233
............................................................................................................. 237
............................................................................................................. 241

Glossary of Terms ........................................................................................................................ 247

Appendix ....................................................................................................................................... 253

Index ............................................................................................................................................... 263

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