I HAVE NOTHING TO Category II FHRT- A DISCLOSE Standardized - - PowerPoint PPT Presentation

Steven L. Clark, M.D. Texas Children’s Hospital/Baylor College of Medicine

Management of Category II FHRT- A Standardized Approach

I HAVE NOTHING TO DISCLOSE Rates of neonatal encephalopathy and cerebral palsy remain unchanged

“A disappointing story”

Roger Freeman, MD

New Eng J Med 1990

WHY?

• Maybe we have simply expected too much of

a single physiologic parameter – heart rate.

WHY?

• Maybe we have simply expected too much of

a single physiologic parameter – heart rate.

• Can we really expect analysis of heart rate

alone to give us a detailed window into CNS

• xygenation and acid/base balance of a baby
• ne minute before birth when we know it is of

virtually no value in monitoring these parameters one minute after birth?

WHY?

• Maybe the use and interpretation of FHRM is

so vastly disparate and inconsistent that this variation overwhelms and masks the intrinsic value of a highly effective tool.

WHY?

• Maybe the use and interpretation of FHRM is

so vastly disparate and inconsistent that this variation overwhelms and masks the intrinsic value of a highly effective tool.

• Because of this inconsistency, there has never

been a standard, testable hypothesis dealing with interpretation and management of FHRT.

Inconsistent application of a tool may mask its intrinsic value

Fetal Heart Rate Monitoring

A Device Introduced Without an Instruction Manual

Category I

Category III >80% of all FHRT exhibit category II patterns

No specific, authoritative guidelines for management of these patterns exist.

Category II FHRT

• Present in vast majority of patients.
• These are the cases that are missed and cause

preventable fetal injury.

• These are the cases that result in litigation.
• These are the cases that result in unnecessary

cesareans.

• Yet no clear management guidelines exist!

Management of Category II FHRT General Principles

• Goal is to delivery babies before they develop

severe acidemia – implications for variability and decelerations.

General Principles

• Goal is to delivery babies before they develop

severe acidemia – implications for variability and decelerations.

• Progress in labor must also be considered.

What Constitutes “Normal Progress”?

Mean 5th Percentile Nulliparas Rate of cervical dilatation 3 cm/hr 1.2 cm/hr Duration of 2nd stage 33 min 117 min Multiparas Rate of cervical dilatation 5.7 cm/hr 1.5 cm/hr Duration of 2nd stage 8.5 min 46.5 min

• E. Friedman: Progression of spontaneous labor at term: 1978

Suggested definition of “Normal Progress” Nulliparas Active phase: 1 cm/hr Second stage: 2 hours Multiparas Active phase: 1.5 cm/hr Second stage: 1 hour

General Principles

• Goal is to delivery babies before they develop

severe acidemia – implications for variability and decelerations.

• Progress in labor must also be considered.
• Moderate variability/accelerations remain the
• nly reliable sign that no damaging

hypoxia/acidemia is present

General Principles

• Sudden, catastrophic events can never be

eliminated

• Features such as fetal tachycardia are not

addressed: other patterns will emerge prior to need for delivery.

Definitions

Variability

• Variability = predominant pattern over 30 min.
• Marked variability = moderate variability
• Diminished variability = Absent variability

The algorithm treats absent and minimal variability as being equivalent despite the literature supporting the fact that only the former reliably reflects a high degree of correlation with severe fetal acidemia.

MINIMAL

Definitions

Significant Decelerations

• Variables: ≥60 bpm from baseline X ≥ 60 sec
• Variables: < 60 bpm X ≥ 60 seconds regardless
• f baseline
• Any late decelerations

Application of Algorithm

• May be delayed for up to 30 minutes to try

intrauterine resuscitation.

• Applied every 30 minutes while category II

pattern persists.

• When delivery is indicated, deliver within 30

minutes.

• Discontinue if pattern changes to category I or

III.

• Does not apply to extreme prematurity, VBAC
• r abruption.

Algorithm does not address prolonged decelerations

Clinical Context is All Important

A PROLONGED DECELERATION WITH TACHYSYSTOLE

Examples

IUGR FETUS WITH OLIGOHYDRAMNIOS

Additional Points

• This is not intended to represent THE exclusive

standard of care.

Additional Points

• This is not intended to represent THE exclusive

standard of care.

• This is intended to represent ONE approach

which complies with the standard of care, as we see it.

Additional Points

• This algorithm is not intended to represent

THE exclusive standard of care.

• This algorithm is intended to represent ONE

approach which complies with the standard of care, as we see it.

• This algorithm is derived from currently

available basic science, clinical evidence and expert opinion.

Additional Points

• This algorithm will allow prevention of

preventable intrapartum HIE.

• Future modifications may allow the same

results with less intervention (or maybe not.)

• Use of this algorithm should provide both
• ptimal care, and optimal safety.

Options for management of labor Use the algorithm that represents current evidence-based medicine Offer unmonitored labor as the way to best avoid cesarean Offer primary cesarean as the only way the only way to exclude intrapartum injury Offer labor only with continuous category I FHRT

The Future? Random, ever-changing, individual interpretation and management of abnormal FHRT is no longer an option

Such management only increases the cesarean rate and adds to litigation woes without significantly improving

• utcomes.