Safe Deliveries Project Management of Indeterminate (Category II) Intrapartum Fetal Heart Rate Tracings Kathleen Simp

1. Safe Deliveries Project Management of Indeterminate (Category II) Intrapartum Fetal Heart Rate Tracings Kathleen Simpson, PhD, RNC November 19, 2013 Presented at Washington State Hospital Association Safe Table 11/19/2013

2. Presented at Washington State Hospital Association Safe Table 11/19/2013

3. Assuring Fetal Wellbeing • Supporting a woman in giving birth vaginally within the upper normal limits of labor duration must be in the context of a well fetus • Assessment of fetal status should be considered relative to the likelihood and timing of vaginal birth Presented at Washington State Hospital Association Safe Table 11/19/2013

4. Labor Progress: Nulliparous Women Harper et al., 2012 Normal progress of induced labor. Obstetrics and Gynecology 119(6),1113–8 Presented at Washington State Hospital Association Safe Table 11/19/2013

5. Assuring Fetal Wellbeing • Birth of the fetus, when possible, prior to the development of damaging degrees of hypoxia/ acidemia Presented at Washington State Hospital Association Safe Table 11/19/2013

6. Presented at Washington State Hospital Association Safe Table 11/19/2013

7. Fetal Status Fluctuations during Labor • Most fetuses (84%) will demonstrate FHR pattern characteristics that are both normal (category I) and indeterminate (category II) over the course of labor • Abnormal (category III) FHR patterns are rare (0.1%) • On average, the duration of category I is about 78% of labor, category II; 22% and category III; 0.004% • Ideally, if the FHR pattern is category II, there is moderate variability and/or accelerations to support the presumption of a non-acidotic fetus • Jackson et al. (2011). Frequency of fetal heart rate categories and • short-term neonatal outcome. Obstet Gynecol. 118(4):803–808. Presented at Washington State Hospital Association Safe Table 11/19/2013

8. Frequency of FHR Categories/Short-Term Neonatal Outcome • Babies of women whose last 2 hrs were exclusively normal (category I) did well • only 0.6% had 5-min Apgar scores less than 7 • 0.2% had low Apgar scores with NICU admission • When >75% of last 2 hrs was indeterminate (category II) • low 5-min Apgar score increased to 1.3% of patients • low 5-min Apgar score with NICU admission increased to 0.7% • Jackson et al. (2011). Frequency of fetal heart rate categories and • short-term neonatal outcome. Obstet Gynecol. 118(4):803–808. Presented at Washington State Hospital Association Safe Table 11/19/2013

9. Indeterminate (Category II) • Wide range of clinical implications associated with various types of FHR patterns within category II • Imprecise nature of category II as it relates to fetal wellbeing makes it challenging / not always useful for clinical decisions during labor Presented at Washington State Hospital Association Safe Table 11/19/2013

10. Indeterminate (Category II) Presented at Washington State Hospital Association Safe Table 11/19/2013

11. Presented at Washington State Hospital Association Safe Table 11/19/2013

12. Assumptions/Clarifications • Marked variability is considered same as moderate variability • Significant decelerations are defined as any of the following: • Variable decelerations lasting >60 sec and >60 bpm below baseline. • Variable decelerations lasting >60 sec and <60 bpm regardless of baseline. • Late decelerations of any depth • Prolonged deceleration • Clark et al., (2013). Intrapartum management of category II fetal heart rate tracings: • Towards standardization of care. Am J Obstet Gynecol;209(2):89–97. Presented at Washington State Hospital Association Safe Table 11/19/2013

13. Assumptions/Clarifications • Application of algorithm may be initially delayed for up to 30 min while attempts are made to alleviate category II pattern with conservative therapeutic interventions (e.g., correction of hypotension, position change, amnioinfusion, tocolysis, reduction or discontinuation of oxytocin) • Once a category II FHR pattern is identified, FHR is evaluated and algorithm applied q 30 min • Any significant change in FHR parameters should result in reapplication of algorithm • Clark et al., (2013). Intrapartum management of category II fetal heart rate tracings: • Towards standardization of care. Am J Obstet Gynecol;209(2):89–97. Presented at Washington State Hospital Association Safe Table 11/19/2013

14. Assumptions/Clarifications • For category II FHR patterns in which algorithm suggests cesarean birth is indicated, birth should ideally be initiated within 30 min of decision • Clark et al., (2013). Intrapartum management of category II fetal heart rate tracings: • Towards standardization of care. Am J Obstet Gynecol;209(2):89–97. Presented at Washington State Hospital Association Safe Table 11/19/2013

15. Assumptions/Clarifications • If at any time tracing reverts to category I status, or deteriorates for even a short time to category III status, the algorithm no longer applies • Clark et al., (2013). Intrapartum management of category II fetal heart rate tracings: • Towards standardization of care. Am J Obstet Gynecol;209(2):89–97. Presented at Washington State Hospital Association Safe Table 11/19/2013

16. Moderate variability and accelerations, thus excluding clinically significant acidemia • Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate • If the fetus is remote from birth, expediting birth would be appropriate Presented at Washington State Hospital Association Safe Table 11/19/2013

17. Moderate variability and accelerations, thus excluding clinically significant acidemia • Significant variable decelerations suggest umbilical cord compression during contraction, which could, over time, lead to significant acidemia • Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate; if the fetus is remote from birth, expediting birth would be appropriate Presented at Washington State Hospital Association Safe Table 11/19/2013

18. Minimal to absent variability without decelerations, despite regular contractions • Medication effect has been excluded clinically as part of the initial period of intrauterine resuscitation attempts • While the fetus may have experienced prelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus • However, since such fetuses may not tolerate labor without sudden deterioration and demise, cesarean birth would be appropriate, per algorithm, if pattern persists for 1 hour Presented at Washington State Hospital Association Safe Table 11/19/2013

19. Minimal to absent variability/late decelerations occurring with >50% of contractions • Per algorithm, expedited birth is indicated regardless of labor progress Presented at Washington State Hospital Association Safe Table 11/19/2013

20. Summary • It is reasonable to initiate management of a category II FHR pattern with an assessment of variability and accelerations, thus allowing the clinician to immediately rule out the presence of clinically significant metabolic acidemia • For nonacidemic fetuses, the focus then shifts to assessing the likelihood of developing significant acidemia prior to birth • Clark et al., (2013). Intrapartum management of category II fetal heart rate tracings: • Towards standardization of care. Am J Obstet Gynecol;209(2):89–97. Presented at Washington State Hospital Association Safe Table 11/19/2013