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Assessment of the fetus: intermittent auscultation, electronic fetal heart rate tracing, and fetal pulse oximetry.

Intrapartum assessment of fetal well-being has evolved over the last 40 years, with the primary focus being fetal heart rate assessments. Despite widespread use and initial enthusiasm for the potential for heart rate monitoring to reduce fetal and neonatal mortality and morbidity, conclusive evidence of improvement in long-term outcomes is lacking. Its use is associated with an increase in operative obstetric interventions and may increase morbidity associated with such interventions. Current investigation includes fetal pulse oximetry and further analysis of specific fetal electrocardiographic changes associated with hypoxic stress. Currently it is likely that fetal heart rate monitoring will maintain its role as a common intervention in obstetric units.

Auscultation↗

The relation between fetal heart rate accelerations and fetal movements.

Fetal heart rate (FHR) accelerations associated with fetal movements is considered a sign of fetal well-being. Fetal movements as felt by the pregnant woman and visualized by real-time ultrasonography were correlated to FHR accelerations in 52 normal and high-risk pregnant women. All fetal movements felt by the mother or seen in the real-time ultrasonography were associated with large FHR accelerations (more than 15 beats per minute lasting 15 seconds or more) or small accelerations (fewer than 15 beats per minute). The large accelerations were associated with 78.6% of fetal movements felt by the mother and 99.6% of fetal movements seen by real-time ultrasonography. The small accelerations were associated with 52.9% of fetal movements felt by the mother and 82.4% of fetal movements seen by ultrasonography. Mothers felt 75.7% of fetal movements seen by real-time ultrasonography. It was concluded that fetal movements could be verified by existence of large accelerations on the FHR tracing.

Female↗

The relevance of antenatal and intrapartum fetal heart rate patterns to fetal outcome.

Antenatal fetal heart rate (FHR) as an indicator of fetal status was evaluated in two separate studies. The first attempted to determine, in 30 minutes of continuous recording from each of 50 antenatal patients, relationships between spontaneous FHR changes and fetal condition before and after birth. No significant association was found between observed FHR patterns and antenatal or neonatal fetal status. The second study used induction of labour as a stress test, because similar conditions to that required for oxytocin stress testing were present and there was the advantage of direct FHR recording. In 150 induced and monitored labours, FHR changes associated with the first six suitable contractions seldom related to Apgar scores at birth or development of fetal distress in active labour. Fetuses showing no response to contractions tended to have better Apgar scores than those which showed FHR decelerations. Results from these studies do not substantiate reports that FHR changes arising spontaneously, or in response to induced contractions, reflect satisfactorily the existing or subsequent fetal status.

Apgar Score↗

[Changes in the automatically analyzed features of fetal heart rate patterns and fetal movements as influenced by atropine sulfate].

The influence of atropine sulphate (0.01 mg/kg body weight of pregnant women i.v.) on several parameters of fetal heart rate was investigated with automatic analysis of FHR. Fetal movements were counted, too. After administration of atropine, there was a first period with an "inverse" effect of atropine in all fetuses: decrease in baseline FHR (5.1%, minimum after 4.5 min) and increase in the amplitude of FHR fluctuation (44.6%). Thereafter, in a second period the "true" atropine effect appeared: increase in baseline FHR (15.5% above the level before atropine maximum after 25.1 min) and decrease in the amplitude of fluctuation (64.5%). In the third period baseline FHR returned to normal values but the amplitude of FHR fluctuation as well as the beat-to-beat irregularity remained small in 12 from 14 fetuses. Fetal movements registered by the mothers decreased significantly in this time. The results demonstrate a dualistic effect of atropine in the fetus. Moreover, the amplitude of FHR fluctuation (amplitude of macrofluctuation) and the beat-to-beat irregularity (microfluctuation) changed in an equal manner and appear to be influenced by similar regulatory processes. The divergence in the reaction of the baseline FHR and the amplitude of fluctuation together with a decrease in fetal movements might be caused by a central nervous effect with a change in the behaviour of the fetus.

Atropine↗

Simplified antepartum fetal heart assessment.

Antepartum fetal heart rate monitoring based on the association of fetal heart rate accelerations with fetal movements (non-stress test) is a standard method for fetal surveillance. Application of this method requires a continuous fetal heart rate recording monitor. Audible detection of heart rate accelerations was compared with recorded accelerations in 100 tests. A listening observer detected 77.7 per cent of all accelerations with an amplitude of at least 15 beats/minute. This allowed the detection of 94.2 per cent (82 out of 87) reactive non-stress tests. In no case was a non-reactive test called falsely reactive by the listening observer. This method may be useful for assessing fetal condition when continuous fetal heart rate monitors are not available.

Female↗

Evaluation of non-reassuring fetal heart rate patterns with fetal pulse oximetry combined with vibratory acoustic stimulation.

OBJECTIVE: To determine the value of fetal pulse oximetry and vibratory acoustic stimulation in the presence of non-reassuring fetal heart rate patterns during labor. DESIGN: Prospective study in women monitored by cardiotocography and fetal pulse oximetry during labor. MATERIALS AND METHODS: During a period of 18 months, 907 consecutive parturients in labor were monitored by cardiotocography. Out of these women, 63 were selected on the basis of a non-reassuring fetal heart rate tracing during the first stage of labor. In these cases, fetal pulse oximetry was applied. Vibratory acoustic stimulation was applied in fetuses without spontaneous reactivity in order to evaluate the fetal status. RESULTS: Our cases were classified into three groups, according to the lower fetal oxygen saturation levels, from the time of oximetry application until delivery. Group A consisted of 29 cases where fetal oxygen saturation levels were > or = 41%, group B (20 cases) with fetal oxygen saturation of 31-40% and group C (14 cases) with levels of < 30%. Spontaneous reactivity was observed in 15 fetuses of group A and seven of group B, while no case of reactivity was noted in group C. Vibratory acoustic-induced reactivity was associated with low fetal oxygen saturation levels. The mean umbilical artery pH levels were 7.29 +/- 0.051 in group A, 7.21 +/- 0.057 in group B and 7.04 +/- 0.05 in group C. CONCLUSION: Fetal pulse oximetry should be indicated not only in fetuses without any reactivity but also in those with induced reactivity, after the application of vibratory acoustic stimulation.

Acoustic Stimulation↗

The clustering of fetal heart rate changes and fetal movements in pregnancies between 20 and 30 weeks of gestation.

The temporal organization (nonrandomness) of fetal heart rate (FHR), fetal movement, and their association was evaluated in 20 normal pregnancies at 20 to 22 or 28 to 30 weeks of gestation with the use of external electronic fetal monitoring and statistical analysis with the runs test. At 20 to 22 weeks, significant clustering was found in one of 10 pregnancies for FHR change, two of 10 pregnancies for fetal movement, and one of 10 pregnancies for FHR changes associated with fetal movement. At 28 to 30 weeks, significant clustering was found in eight of 10 pregnancies for FHR change, eight of 10 pregnancies for fetal movement, and all 10 pregnancies of FHR change associated with fetal movement. There was significantly more clustering of FHR change, fetal movement, and FHR change associated with fetal movement at 28 to 30 weeks of gestation than at 20 to 22 weeks of gestation. Clustering of FHR changes was highly correlated with clustering of fetal movement.

Female↗

Influence of maternal heart rate and gross fetal body movements on the daily pattern of fetal heart rate near term.

Continuous measurements of fetal heart rate (FHR), gross fetal body movements, fetal breathing movements, and maternal heart rate (MHR) were made for 24-hour observation intervals in 11 pregnant women at 38 to 40 weeks. There was a significant positive correlation between each mother's daily mean MHR and her fetus' daily mean FHR. There was a trough in mean hourly FHR between 0200 and 0600 hours and a trough in mean hourly MHR between 2400 and 0700 hours. Mean hourly FHR both during and between times of gross fetal body movements was significantly correlated to mean hourly MHR. At term, the mean FHR is strongly influenced by the mean MHR and the presence or absence of gross fetal body movements.

Circadian Rhythm↗

Fetal heart rate patterns and fetal distress in fetuses with congenital anomalies.

Over a 3-year period at the Long Beach Women's Hospital, where electronic FHR (fetal heart rate) monitoring was routine, there were 8622 live births, including 41 infants born with major congenital malformations. The neonatal death rate in these malformed infants was 44%; 17 were delivered by cesarean section, 11 of which were performed because of fetal distress. There were no characteristic FHR patterns that would specifically identify major congenital malformations. There was a significantly increased incidence of prematurity, breech presentation, and cesarean section delivery in the congenital malformation group as compared to the overall population delivering at the Women's Hospital. The clinical implications of these observations are discussed.

Adult↗

[The relationship between gestational weeks and fetal breathing movements in each pattern of the fetal heart rate].

Fetal breathing movement (FBM) was analysed in each fetal heart rate (FHR) pattern and the gestational 2 weeks. FHR pattern was divided in automated FHR analysis into 3 groups; active, intermediate and resting patterns. The patients consisted of 102 pregnant women at 30-41 weeks, including 13 complicated pregnancies. 1) The active pattern percentage was 52.7% at 32-33 weeks and it decreased gradually. That of the resting pattern was 25.5% at 32-33 weeks and it increased gradually. 2) The percentages of positive FBM in the active pattern were significantly larger than those in the resting pattern in each 2 weeks. 3) The duration of continuous FBM ranged from 3 to 202 sec. FBM of long duration tended to exist in the resting pattern rather than in the active pattern. 4) The percent time ratio of FBM ranged from 1.0 to 92.7% and showed no definite relationship with the FHR patterns or gestational weeks. 5) The FBM rates in each FHR pattern showed no significant differences. Their sequential differences after 36 weeks were significant; that is, FBM in the resting pattern was more regular than that in the active pattern. 6) In high risk pregnancy, the resting pattern percentage was 52.3% and the ratio of positive FBM in the resting pattern was significantly smaller than that in active pattern.

Echocardiography↗

Sinusoidal fetal heart rate pattern following intrauterine fetal transfusion.

Two patients with severe rhesus isoimmunization had sinusoidal fetal heart rate patterns following intrauterine fetal transfusion. A consistent temporal relationship between fetal transfusion and sinusoidal fetal heart rate pattern was observed. Survival of a fetus who had a sinusoidal fetal heart rate pattern after each of three transfusions suggests that this pattern may not be ominous when observed transiently after fetal transfusion.

Adult↗

[Intrapartum fetal heart rate patterns and fetal outcome: prediction of newborn depression (author's transl)].

A statistically significant correlation exists between patterns of fetal heart rate (FHR) and neonatal state. However, the prognostic value of alterations of FHR for the individual has not been established. In 812 deliveries, we analyzed FHR tracings of the 30 minutes preceding delivery and correlated 6 characteristics of baseline, 10 of floating line and 6 of oscillation type with the incidence of severe acidosis (pH of umbilical cord artery less than or equal to 7.10) and low Apgar scores (one minute Apgar score less than or equal to 6). The exact risk for neonatal depression was calculated for each pattern of FHR. A high rate of depressed infants could be expected when the following alterations of FHR were seen during the last 30 minutes before delivery:--mild tachycardia, severe bradycardia,--severe variable decelerations, uniform late decelerations,--oscillation frequency less than 2 per minute independent of oscillation amplitude.

Acidosis↗

Spectral analysis of antepartum fetal heart rate variability from fetal magnetocardiogram recordings.

Fetal heart rate variability was derived from fetal magnetocardiogram recordings in ten subjects at gestation ages 32-38 weeks. Maternal interference was negligible and R-wave detection was highly reliable. Oscillations suggestive of respiratory sinus arrhythmia (RSA) were prominent in many of the heart rate tracings. Spectral analysis was used to quantify heart rate variability and to examine the influence of the RSA-like oscillations on heart rate variability. The oscillations were associated with increased power in the frequency range 0.4-1.0 Hz (P < or = 0.05). Magnetic recording appears to offer significant advantages for investigation of beat-to-beat fetal heart rate throughout the latter stages of pregnancy.

Adult↗

Fetal heart rate patterns and fetal distress in patients with preterm premature rupture of membranes.

Two hundred sixty-seven consecutive patients with preterm premature rupture of membranes (PROM) and 130 consecutive patients with idiopathic premature labor and intact membranes between 28 and 35 weeks' gestation were compared. A significantly higher incidence of cesarean section for fetal distress was found in patients with PROM (7.9%) compared with patients with premature labor (1.5%) (P less than .05). Fetal distress occurred with similar frequency in patients with and without chorioamnionitis. Analysis of electronic fetal heart rate patterns in patients with fetal distress revealed that 16 of 21 patients (76%) with PROM had patterns consistent with umbilical cord compression. A significant difference was found in neonatal mortality rates between the PROM group (4.5%) and the premature labor group (0) (P less than .05). The neonatal death rate in patients with fetal distress (three of 12) was significantly higher than in patients without distress (nine of 385) (P less than .01). It is suggested that the increased incidence of fetal distress in patients with preterm PROM may represent the loss of the protection of the umbilical cord that amniotic fluid normally provides.

Female↗

Effect of epidural analgesia on the fetal heart rate.

Fetal heart rate (FHR) changes occasionally follow the use of labor epidurals. Most studies of the phenomenon have focused on specific techniques, but similar timing and appearance suggest a common cause. Induction of analgesia may transiently alter the balance between factors encouraging and inhibiting uterine contractions with subsequent changes of FHR patterns. Regardless the etiology, these changes are transient and do not produce maternal or fetal morbidity. However, they must be promptly recognized and treated if necessary.

Analgesics, Opioid↗

Transient non-autoimmune fetal heart block.

OBJECTIVES: Fetal heart block is a rare and irreversible condition associated with structural heart defects or maternal autoantibodies (SS-A/Ro and SS-B/La) resulting in permanent damage of the atrioventricular (AV) node. This is the first report of 4 cases with a transient fetal heart block in structurally normal hearts without maternal autoantibodies. METHODS: A report on 4 patients seen within a 14-year period at one center with fetal heart block without intracardiac abnormalities or maternal autoantibodies. RESULTS: Three patients were referred to our center with a fetal bradycardia (heart rate 70-85 bpm), between 20 and 33 weeks' gestational age, and 1 for a 'triple' test at 16 weeks' gestational age. Echocardiography showed a complete heart block in 2 fetuses, and a second-degree AV block in the other 2. Heart block had completely resolved at all following visits. Postnatal ECG recordings showed normal sinus rhythm in all patients. Echocardiographic evaluation at presentation and follow-up showed normal cardiac anatomy, without signs of hydrops or cardiac decompensation in all patients. All mothers tested negative on SS-A/Ro and SS-B/La autoantibodies. CONCLUSIONS: Fetal heart block can occur in the absence of structural heart defects and maternal autoantibodies to SS-A/Ro and SS-B/La. The origin of such heart block is unknown, but its course seems benign: none of the patients ever showed ventricular heart rates <55 bpm, signs of congestive heart failure or fetal hydrops. Heart block resolved spontaneously in all patients.

Bradycardia↗

Fetal heart rate responses to fetal movements.

A classification of fetal heart rate (FHR) responses to fetal movements is based on the study of 210 hours of antepartum cardiotocographic tracings in clinically normal pregnant patients between 30 and 42 weeks gestation. The physiological mechanism underlying the FHR responses to fetal movement are discussed.

Female↗

Computer assessed fetal heart rate patterns and fetal scalp pH. A preliminary study.

From the beginning of biophysical and biochemical monitoring of the fetus during labor, a continuing attempt has been made to determine if a reliable correlation exists between these measurements and the well-being of the fetus. If such a correlation did indeed exist, the combined use of the two approaches would permit efficient, relatively simple fetal monitoring. This preliminary report describes the use of computer processed fetal heart rate patterns to predict fetal scalp blood pH. Initial results show a 90% overall accuracy in predictions; when corrected for some of the bias of retrospective predictions, the accuracy is 91% for high pH and 72% for low pH.

Blood Chemical Analysis↗