9. CONDITION: Intrapartum Fetal Distress
A. Introduction:
The goal of Intrapartum Fetal Heart Rate (FHR) Monitoring is to detect signs that warn of potential adverse fetal events in time to permit intervention. Another way to state this is that intrapartum fetal heart rate monitoring tries to identify fetal distress in its early stages. While fetal distress is a widely used term, it is poorly defined in the medical literature. This document defines fetal distress, using a combination of national medical literature and local (State of Maine) definitions.
B. Definitions:
(1) Variable deceleration: Decreases in FHR from the baseline rate that are non-uniform periodic changes that bear little relationship to uterine contractions. Onset may come at any phase of the contraction, and the wave form is usually different from that of the uterine contraction.
(2) Severe variable deceleration: FHR of less than 70 beats per minute (b.p.m.) that persists longer than60 seconds duration.
(3) Persistent severe variable deceleration: Severe variable declarations that persists for longer than 30 minutes.
(4) Late deceleration: Decrease in FHR from the baseline rate with a lag time of greater than 20 seconds from the peak of the contraction to the nadir of FHR deceleration.
(5) Persistent and nonremediable late deceleration: Late declarations that do not respond to the usual obstetrical interventions and occur repeatedly over a 10-15 minute time period.
(6) Severe bradycardia: FHR less than 80 b.p.m.
(7) Persistent severe bradycardia: Severe bradycardia that persists for longer than 5 minutes.
C. Confirmation of Diagnosis. For a diagnosis of fetal distress to be made, one or more of the following must be present:
(1) Persistent severe variable deceleration.
(2) Persistent and nonremediable late declarations.
(3) Persistent severe bradycardia.
D. The following actions should have been performed and documented prior to expediting delivery for fetal distress:
(1) Reposition patient.
(2) Administer oxygen by mask.
(3) Perform vaginal examination to check for prolapsed cord; and
(4) Ensure that qualified personnel are in attendance for resuscitation and care of the newborn.
Note: each institution shall define in writing the term qualified personnel for resuscitation and care of the newborn.
E. Each of the following actions should be performed and documented prior to starting a Cesarean section for fetal distress:
(1) Perform vaginal exam to rule out imminent vaginal delivery;
(2) Initiate preoperative routines;
(3) Monitor fetal heart tones (by continuous fetal monitoring or by auscultation) immediately prior to preparation of the abdomen; and
(4) Ensure that qualified personnel are in attendance for resuscitation and care of the newborn (each institution shall define in writing the term qualified personnel for resuscitation and care of the newborn).
F. When a diagnosis of fetal distress is made, consideration should be given to performing:
(1) Umbilical cord acid-base studies;
(2) Pathologic examination of the placenta.
References:
(1) ACOG Technical Bulletin: Intrapartum, Fetal Heart Rate Monitoring. #132 - September 1989.
(2) Quality Assurance in Obstetrics and Gynecology: ACOG Obstetrical Criteria Status, Cesarean Delivery for Fetal Distress. May 1989, p. 23.
(3) Danforth's Obstetrics and Gynecology 6th Edition. Chapter 16 Clinical Evaluation of Fetal Status. Intrapartum Fetal Monitoring, pp. 319-327 c.1990.
(4) Obstetric, Neonatal, and Gynecologic Care (A Practical Approach for the Indian Health Service) 5th Edition, 1989.
(5) Manual of Obstetrics, Diagnosis and Therapy: 3rd edition, Chapter 24, Fetal Heart Rate Monitoring, pp. 301-314.
(6) Parer and Livingston, What Is Fetal Distress: AM. J. OBSTET. GYNECOL, 1990; 162: 1421-7.
(7) Classification of Fetal Patterns from Dr. Albert D. Haverhamp, M.D.: City and County of Denver, Department of Health and Hospitals: Handout for House Officers, 1979.
(8) Obstetrical Pearls: A Practical Guide For the Efficient Resident, Care of the Laboring Patient, Fetal Monitoring pp. 45-50. c.1989.
Note: Each institution shall define-in writing the term qualified personnel for resuscitation and care of the newborn.
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