Management of nonreassuring FHR patterns during labor

1. Determine the cause of the abnormality (eg, cord prolapse, maternal medication, abruption placenta)

2. Attempt to correct the problem or initiate measures to improve fetal oxygenation (eg, change maternal position, ad min ister oxygen and intravenous fluids, consider amnioinfusion or tocolysis)

3. If the nonreassuring pattern does not resolve within a few minutes, perform ancillary tests to determine the fetal condition

4. Determine whether operative intervention is needed

B. The presence of accelerations almost always assures the absence of fetal acidosis. Therefore, if such accelerations are not observed, they should be elicited by manual or vibroacoustic stimulation. There is a 50 percent risk of fetal acidosis in fetuses in whom accelerations cannot be elicited, so further evaluation by fetal scalp sampling for pH is indicated to help clarify the fetal acid-base status. Serial evaluation every 20 to 30 minutes is necessary if the FHR pattern remains nonreassuring. Expeditious delivery is indicated for persistent nonreassuring FHR patterns.

Management of Variant Fetal Heart Rate Patterns

FHR Pattern

Diagnosis

Action

Normal rate normal variability, accelerations, no decelerations

Fetus is well oxygenated

None

Normal variability, accelerations, mild nonreas-suring pattern (bradycardia, late decelerations, variable decelerations)

Fetus is still well oxygenated centrally

Conservative management.

Normal variability, ± accelerations, moderate-severe nonreassuring pattern

(bradycardia, late decelerations, variable decelerations)

Fetus is still well oxygenated centrally, but the FHR suggests hypoxia

Continue conservative management. Consider stimulation testing. Prepare for rapid delivery if pattern worsens

Decreasing variability,

± accelerations, moderate-severe nonreassuring patterns

(bradycardia, late decelerations, variable decelerations)

Fetus may be on the verge of decompensation

Deliver if spontaneous delivery is remote, or if stimulation supports diagnosis of decompensation. Normal response to stimulation may allow time to await a vaginal delivery

Absent variability, no accelerations, moderate/severe nonreassuring patterns

(bradycardia, late decelerations, variable decelerations)

Evidence of actual or impending asphyxia

Deliver. Stimulation or in-utero management may be attempted if delivery is not delayed

References: See page 184.

References: See page 184.

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