Baseline & Variability
25-30%of exam
Periodic Patterns
20-25%of exam
Early DecelLate DecelVariable DecelProlonged DecelRecurrent vs Intermittent
Interpretation & Categories
15-20%of exam
Category ICategory IICategory IIISinusoidalThree-Tier
Uterine Activity & Physiology
15-20%of exam
TachysystoleMVUOxygen PathwayAutonomic ControlCause Picker
Interventions & Equipment
15-20%of exam
Quick Facts
- Exam
- C-EFM
- Body
- NCC
- Questions
- 100 scored
- Time
- 2 hours
- Format
- Multiple choice
- Result
- Pass/Fail
- Terminology
- 2008 NICHD
Variability Ladder
Absent < Minimal <=5 < Moderate 6-25 < Marked
Absent: 0Minimal: <=5Moderate: 6-25Marked: >25
Accel vs Decel
Acceleration
- Rate increases
- Well-being
- Intact CNS
Deceleration
- Rate decreases
- Possible compromise
- Needs context
Up reassures, down depends
Baseline Rate
- Normal
- 110-160 bpm
- Window
- 10-minute mean5 bpm
- Min duration
- 2 min identifiable
- Tachycardia
- >160 for 10 min
- Bradycardia
- <110 for 10 min
- Indeterminate
- <2 min baseline
Acceleration Rule
15x15 term | 10x10 preterm
Term: 15 bpm/15 sec<32 wk: 10 bpm/10 secProlonged: 2-10 min
Minimal vs Absent Variability
Minimal
- Detectable to 5 bpm
- Sleep, sedation
- Often Category II
Absent
- Undetectable
- Hypoxia/acidemia
- Cat III with decels
Some range vs none
Variability Tiers
- Absent
- Undetectable amplitude
- Minimal
- Detectable to 5 bpm
- Moderate
- 6-25 bpmReassuring
- Marked
- >25 bpm (saltatory)
- Reflects
- Autonomic oxygenation
- Moderate predicts
- No acidemia now
Key Ranges
110-160 baseline | <=5 per 10 min | 200 MVU
Baseline: 110-160Tachysystole: >5/10minAdequate: 200-250 MVU
Accelerations
- Term fetus
- 15 bpm x 15 sec
- <32 weeks
- 10 bpm x 10 sec
- Onset
- Abrupt <30 sec
- Prolonged
- 2 to <10 min
- Means
- Fetal well-being
- Scalp stim
- Predicts normal pH
Tachy / Brady Causes
- Tachy: fever
- Infection sign
- Tachy: drugs
- Terbutaline, atropine
- Tachy: hypoxia
- Early compensation
- Brady: hypoxia
- Late/acidemia
- Brady: cord
- Prolapse, descent
- Brady: block
- Fetal heart block
VEAL CHOP
Variable Early Accel Late = Cord Head OK Placenta
Variable: CordEarly: HeadAccel: OKLate: Placenta
Early vs Late Decel
Early
- Nadir at peak
- Head compression
- Benign, no action
Late
- Nadir after peak
- Uteroplacental
- Non-reassuring
Timing vs contraction peak
Early & Late Decels
- Early onset
- Gradual >=30 sec
- Early nadir
- At contraction peak
- Early cause
- Head compression
- Late onset
- Gradual >=30 sec
- Late nadir
- After contraction peak
- Late cause
- Uteroplacental insufficiency
Variable vs Late Decel
Variable
- Abrupt <30 sec
- Cord compression
- Varies in shape
Late
- Gradual >=30 sec
- Uteroplacental
- Uniform shape
Abrupt vs gradual onset
Variable & Prolonged
- Variable onset
- Abrupt <30 sec
- Variable depth
- 15 bpm x 15 sec
- Variable cause
- Cord compression
- Most common
- Variable in labor
- Prolonged
- 2 to <10 min
- >=10 min
- Baseline change
Decel Modifiers
- Recurrent
- >=50% contractions
- Intermittent
- <50% contractions
- Window
- 20-minute segment
- Overshoot
- Accel after variable
- Shoulder
- Brief pre-decel rise
- Significance
- Recurrent > intermittent
Category Stack
I normal -> II indeterminate -> III abnormal
I: moderate, no lateII: everything elseIII: absent + decels
Category II vs III
Category II
- Indeterminate
- Variability present
- Surveillance
Category III
- Abnormal acid-base
- Absent variability
- Urgent action
Indeterminate vs abnormal
Category to Action
- Moderate, no late/variable→Category I(Routine monitoring)
- Not I or III→Category II(Surveillance + resus)
- Absent + recurrent late→Category III(Urgent action)
- Sinusoidal present→Category III(Prepare delivery)
- Cat III unresolved→Expedite delivery(If resus fails)
Category Criteria
- Cat I baseline
- 110-160 bpm
- Cat I variability
- Moderate required
- Cat I decels
- No late/variable
- Cat II
- All not I/III
- Cat III: sinusoidal
- Or absent variability
- Cat III + decels
- Recurrent late/variable/brady
Category Meaning
- Cat I
- Normal acid-base
- Cat II
- Indeterminate, most common
- Cat III
- Abnormal acid-base
- Snapshot
- Single point in time
- Dynamic
- Moves between categories
- Cat II rule
- Needs clinical judgment
Special Patterns
- Sinusoidal
- 3-5 cycles/min
- Sinusoidal cause
- Severe fetal anemia
- Pseudosinusoidal
- Narcotics, fetal sucking
- Lambda
- Accel then small decel
- Arrhythmia
- Often benign PACs
- Marked
- Saltatory, post-hypoxic
Tachysystole vs Normal
Normal UA
- <=5 per 10 min
- Adequate recovery
- Routine
Tachysystole
- >5 per 10 min
- Reduce uterotonics
- Qualify by decels
Five or fewer is normal
Decel to Cause
- Gradual, mirrors peak→Early(Head compression)
- Gradual, after peak→Late(Uteroplacental)
- Abrupt, variable shape→Variable(Cord compression)
- 2 to <10 min→Prolonged(Mixed cause)
- Sine wave 20 min→Sinusoidal(Fetal anemia)
- >=10 min decrease→Bradycardia(Baseline change)
Uterine Activity
- Normal
- <=5 per 10 min
- Tachysystole
- >5 per 10 min
- Average over
- 30-minute window
- Frequency
- Start to start
- MVU
- Sum above resting tone
- Adequate labor
- 200-250 MVU
Fetal Physiology
- O2 pathway
- Uterus to fetus chain
- Vagal
- Lowers rate, variability
- Sympathetic
- Raises rate, accels
- Resting tone
- 5-25 mmHg (IUPC)
- Centralization
- Blood to brain/heart
- Acidemia
- Loss of variability
External vs Internal Monitor
External
- Doppler + toco
- Noninvasive
- Frequency only
Internal
- FSE + IUPC
- Needs ruptured membranes
- True intensity
Indirect vs direct signal
Pattern to Intervention
- Variable decels→Reposition(Relieve cord)
- Recurrent variables→Amnioinfusion(Oligohydramnios)
- Late decels→Lateral + IV(Improve perfusion)
- Tachysystole + decels→Stop oxytocin(Then tocolytic)
- Post-epidural hypotension→Bolus + vasopressor(Restore BP)
- Indeterminate tracing→Scalp stimulation(Provoke accel)
Intrauterine Resuscitation
- Reposition
- Lateral, relieve aortocaval
- IV bolus
- Restore perfusion
- Stop oxytocin
- Reduce tachysystole
- Tocolytic
- Terbutaline if persists
- Amnioinfusion
- Cushion cord
- Vasopressor
- Treat hypotension
Monitoring & Equipment
- External FHR
- Doppler ultrasound
- External UA
- Tocodynamometer frequency
- Internal FHR
- Fetal scalp electrode
- Internal UA
- IUPC true intensity
- MHR artifact
- Maternal pulse mimics fetal
- Paper speed
- 3 cm/min (US)
Common Traps
Early vs Late
Early nadir at peak ≠ Late nadir after peak
Variability vs Accelerations
Variability is fluctuation ≠ Accel is rate rise
Minimal vs Absent
Minimal detectable <=5 ≠ Absent is undetectable
Tachycardia vs Bradycardia
>160 ten min ≠ <110 ten min
Sinusoidal vs Pseudosinusoidal
Sinusoidal means anemia ≠ Pseudo from narcotics
Recurrent vs Intermittent
Recurrent >=50% ≠ Intermittent <50%
Prolonged vs Bradycardia
Prolonged 2 to <10 min ≠ >=10 min is baseline
Last Minute
- 1.Baseline = 110-160 bpm
- 2.Moderate variability = 6-25 bpm
- 3.Late = uteroplacental insufficiency
- 4.Variable = cord compression
- 5.Early = head compression, benign
- 6.Cat I needs moderate variability
- 7.Cat III = absent + recurrent
- 8.Sinusoidal = severe fetal anemia
- 9.Tachysystole = over 5 per 10 min
- 10.Recurrent = at least 50% contractions
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