For instance, FHR decelerations may show an abrupt decline from the baseline value, with a nadir after the peak of the contraction followed by a slow recovery to the baseline level.
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The measures for intrauterine resuscitation described above for fetal bradycardia can also be effective interventions for fetal tachycardia.
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Originally Posted by BobP Hi, I thought I would toss in my 2 cents with some observations of someone who has only followed him Manny for a couple of weeks now. I just started using real money the last 3 days with a small of shares I know, not enough time for a decent evaluation: First day - still getting used to Interactive Broker's platform and couldn't take the trade.
Seemed to work mainly because the price came back to the original entry, a minute later, and I was able to get a good fill. Of course this is only one day so too early to tell long term results. His "chat" room is run by a moderator that only allows positive thoughts.
If you try and post that you lost money, it will never see the light of day. It is hoped that this initiative will ultimately yield data that facilitate FHR monitor strip interpretation in an evidence-based manner. Currently, intrapartum EFM is best viewed as a screening test to confirm fetal well-being rather than a diagnostic test confirming fetal compromise. Clinical factors, stage of labor, evolution of a particular pattern, and the characteristics of the entire FHR monitor strip must influence any given interpretation.
No single method of classification or interpretation, regardless of its complexity, can be expected to provide clear guidelines for the management of borderline or difficult-to-classify patterns. Finally, because the status of the fetus during the labor process is dynamic, the data produced by intrapartum EFM are continuous, and the FHR strips must be examined on an ongoing basis.
Analysis of intrapartum EFM strips must be approached in an organized, systematic manner to optimize the value of the information obtained, to avoid overwhelming the practitioner with the volume of data obtained, and to prevent the practitioner from overlooking important clinical events.
In general, the following six characteristics should be included in any thorough analysis: The technical quality of the monitor strip, to ensure that artifact does not make interpretation impossible inadequate data must not be interpreted; instead, the quality of the data obtained must be improved Determination of whether external or internal monitoring methods are being employed Evaluation of the FHR baseline rate Analysis of the FHR reactivity external monitor or beat-to-beat variability internal monitor Inspection for the presence of FHR accelerations Consideration of periodic FHR decelerations associated with uterine contractions During the analytic process, multiple abnormalities in a particular FHR tracing are more significant than isolated findings.
Fetal scalp pH determination or evoked fetal response to scalp stimulation or vibroacoustic stimulation may be helpful in the accurate assessment of fetal status in the face of nonreassuring FHR data. Uterine Contractions The intrauterine baseline pressure is defined simply as the pressure extant between contractions.
An approximation of this variable can be obtained only by means of an intrauterine pressure catheter monitoring system. The upper limits of normal baseline intrauterine pressure may be defined according to the stage of labor: Baseline pressures greater than these levels may represent uterine hypertonicity and sometimes are associated with abruptio placentae, uterine hyperstimulation with oxytocin, fetal malposition e. Uterine hyperstimulation has been defined as a similar contraction frequency or a series of contractions lasting more than 2 minutes in combination with potentially worrisome FHR changes e.
Similarly, if oxytocin induction or augmentation becomes complicated by tachysystole, the oxytocin should be discontinued or the rate of infusion decreased, at least temporarily, to avoid uterine hyperstimulation.
The graphic representations of normal uterine contractions on intrapartum EFM strips tend to be bell-shaped i. Experienced clinicians recognize, however, that some patients may have an irregular contraction pattern throughout labor with an entirely normal progress of labor.
The potential issue of apparently inadequate uterine contraction frequency is of no concern as long as satisfactory labor progress is occurring.
Similarly, there is no simple relationship between the intensity of uterine contractions and the rate of cervical dilatation. External tocodynamometry provides no information regarding the strength or intensity of uterine contractions.
Even with an intrauterine pressure catheter system, the deflection on the intrapartum EFM strips is not necessarily an accurate indicator of the quality of labor. Nonetheless, contractions that occur less frequently than every 5 minutes and have a peak amplitude of less than 25 mmHg seldom are associated with a normal labor curve, particularly in the active phase of labor.
Once again, however, a detailed analysis of the frequency and intensity of uterine contractions is necessary only when the rate of cervical change is abnormal. The normal range is — bpm. Baseline rates below this range less than bpm are considered bradycardia, whereas fetal baseline tachycardia is defined by a FHR greater than bpm for two contraction cycles or longer than 5 minutes.
Deviations from this normal baseline range are not necessarily indicative of fetal compromise. For example, a baseline rate of — bpm, if not associated with other FHR abnormalities or a significant decrease from a previously higher baseline rate, may be associated with an entirely reassuring intrapartum EFM strip. Severe FHR baseline bradycardia less than bpm is more likely to be associated with fetal jeopardy, although fetal congenital heart block can produce an identical FHR tracing that is not associated with acute compromise, and should be excluded when patients present with a fetal bradycardia in the mid- or early third trimester prior to proceeding with an emergency delivery, when practical.
Clearly, there are instances where there is evidence for another cause of fetal bradycardia such as vaginal bleeding, cord prolapse, etc. Delivery should not be delayed in these cases. Also, there are conditions where the technology such as M-mode or Doppler ultrasound or the expertise to exclude congenital heart block as a cause of fetal bradycardia are not available. It may be similarly unwise to delay delivery in these cases.
Finally, near term, the additional risk of delivery is low enough that the risk-benefit ratio may favor delivery over delay. Fetal tachycardia may not be as clear an indicator of potential fetal compromise as severe baseline bradycardia. Fetal baseline tachycardia is classified as mild from to bpm and as severe when greater than bpm. The differential diagnosis for the etiology of fetal tachycardia includes fetal compromise, maternal fever, prematurity, fetal infection, fetal arrhythmia more common with fetal heart rates greater than bpm , maternal thyrotoxicosis, fetal anemia, and maternal drug ingestion prescribed or illicit.
After excluding these potential confounding etiologies, and if combined with other FHR abnormalities, the index of suspicion for fetal compromise should be increased. For example, the combination of fetal tachycardia with diminished variability and late decelerations would be nonreassuring, as would the combination of fetal tachycardia with severe variable decelerations.
The measures for intrauterine resuscitation described above for fetal bradycardia can also be effective interventions for fetal tachycardia. In general, regardless of the type of nonreassuring FHR pattern, steps should be taken and documented to optimize fetal status. Fetal heart rate variability is defined as fluctuations in the baseline FHR of two cycles per minute or greater. Fetal heart rate pattern with baseline tachycardia and minimal variability.
Clearly, accurate assessment of the intrapartum fetal status requires an overview of the entire clinical scenario, not the simple categorization of isolated, perhaps even transient, FHR tracing characteristics. This so-called saltatory pattern may be observed early in labors complicated by fetal malposition or disproportion and on occasion deteriorates into a pattern characterized by significant variable decelerations. Also infrequent is the sinusoidal FHR pattern.
Characterized by the smooth, undulating oscillation of the baseline mimicking a sine wave , short-term variability is absent in this pattern. The amplitude of the long-term baseline variability ranges from 5 to 15 bpm, and the frequency of the cycles generally is three to five cycles per minute. This FHR pattern must be present for at least 10 minutes to avoid overdiagnosing this rare pattern, which classically is associated with severe fetal anemia e. When persistent, a true sinusoidal pattern may signify significant fetal compromise, and appropriate diagnostic or therapeutic maneuvers should be initiated.
More commonly, however, a sinusoidal-like pattern is not of clinical significance. Fetal Heart Rate Accelerations: Spontaneous and Evoked Periodic intrapartum FHR accelerations more than 14 bpm above baseline lasting more than 14 seconds and less than 2 minutes 14 may be spontaneous, associated with uterine contractions, or related to fetal movements. As in the setting of antenatal surveillance e. The presence of spontaneous FHR accelerations clearly is a reassuring sign. The converse, however, is not true; the absence of such accelerations is not necessarily worrisome, and other FHR tracing characteristics should be used to evaluate fetal status.
Intrapartum FHR accelerations also can be evoked with either scalp stimulation of vibroacoustic stimulation. Clark and associates 20 reported that the presence of FHR accelerations 15 bpm for at least 15 seconds after digital or instrumental fetal scalp stimulation uniformly was associated with a fetal scalp pH greater than 7.
On a practical basis, the fetal scalp stimulation test is useful for evaluation of the fetus showing a nonreassuring FHR pattern, particularly when the cervix is not sufficiently dilated to permit fetal scalp sampling for pH determination. Smith and associates 21 observed that similar FHR accelerations evoked by transabdominal vibroacoustic stimulation in the setting of nonreassuring FHR data were associated with a fetal scalp pH of greater than 7.
The presence of evoked FHR accelerations is an excellent predictor of fetal well-being, although scattered reports have described isolated instances of fetal acidemia in fetuses with a reactive response to intrapartum vibroacoustic stimulation.
Despite the myriad of classification systems proposed, we prefer to categorize these decelerations typically, but not always, decreases of at least 10—15 bpm from the baseline value simply as early, variable, or late in character. Most authentic disagreements about the analysis of FHR decelerations stem from differing assessments of the FHR baseline value. One unifying generalization typifies the discussion: The types of FHR decelerations are described in what most authorities agree is the order of increasing potential concern.
Early decelerations display an onset, nadir, and recovery that is synchronous with the onset, peak, and end of the uterine contraction. In short, early decelerations mirror the uterine contraction pattern.
Generally ascribed to fetal head compression with resultant vagal stimulation , early FHR decelerations are the least common variety of intrapartum FHR deceleration observed and usually are of no clinical significance. Variable FHR decelerations are variable in shape as well as in timing with respect to the uterine contraction pattern. Characterized by an abrupt decline defined as onset of deceleration to beginning of nadir less than 30 seconds 14 from the FHR baseline value and an equally abrupt recovery, variable decelerations display a variety of waveforms, such as V, U, W, or combinations Fig.
The decline in FHR below baseline is more than 14 bpm, lasting more than 14 seconds and less than 2 minutes from onset to return to baseline.
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