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ELECTRONIC FETAL MONITORING (EFM)

AKA CARDIOTOCOGRAM (CTG)

Things you need:


1. EFM Machine
2. Gel
3. Ruler
4. Paper and Pencils

Procedures:
1. Non stress Test (NST)
2. Contraction Stress Test (CST)

NON STRESS TEST PROCEDURE (NST)


1. Introduce and Give Consent
2. Px in supine position
3. Perform L1 and L2
4. Attach the TOCO/UTERINE TRANSDUCER on the fundus (do not put gel)
5. Attach the USD TRANSDUCER to the area of the fetal back (put gel)
6. Give the FETAL EVENT MARKER to mom, and tell her to push button every time she
perceived fetal movement
7. Perform procedure in 20 min

Results of NST
1. NORMAL NST or “REACTIVE NST”
a. 2 OR MORE fetal acceleration that beaks at 15 bpm lasting for 15 seconds (Rule of 15s)
b. All occuring within 20 min period
c. With or without fetal movement
2. ABNORMAL NST or “NONREACTIVE NST”
a. Fetal heart rate baseline that oscilliates LESS THAN 5 bpm
b. Absent accelearation and beat-to-beat variablility
c. Over a 40 min period

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CONTRACTION STRESS TEST PROCEDURE(CST)


NIPPLE STIMULATION TEST
1. Introduce and give consent
2. Inform mom to rub 1 nipple for 2 min or when contraction begins
3. Restart after 5 min if first rubbing is unsuccessful
4. If at least 3 uterine contractions are present in 10 min, the FHT and UC are recorded
simulatenously with the EFM

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INTERPRETATION OF ELECTRONIC FETAL MONITORING


“DR C BRAVADO“

DR - DEFINE RISK
C - CONTRACTIONS
BRA - BASELINE RATE
V - VARIABILITY
A - ACCELERATION
D - DECELERATION
O - OVERALL IMPRESSION
1. DEFINE RISK: CHECK HX AND PE
2. CONTRACTIONS
Descriptors Feels Like EFM
Mild Chin ~20 mmHg
Moderate Tip of Nose ~20-80 mmHg
Strong Forehead >80 mmHg

Normal: </= 5 contraction in 10 min


Tachysystole: >5 contractions in 10 min

Obtain: Interval, Frequency and Intensity (IFI)


Interval: From the beginning of one contraction to the beginning of the next contraction

“Contractions every __ min, lasting __ seconds, mild/moderate/strong”

3. BASELINE HEART RATE


Mean FHR in span of 10 min
Tip: Find the flat segment or the segment with not much activity

Normal: 110-160 bpm


Indeterminate: If BHR is taken <2 min
Bradycardia: <110

“Within Normal Baseline FHT range of ___ — ____ bpm” OR


“Fetal Bradycardia, with FHT range of ___ — ____ bpm”
“Fetal Tachycardia, with FHT range of ___ — ____ bpm”

4. VARIABILITY
Fluctuations with irregular amplitude

Absent: Undetectable
Minimal: <5 bpm
Moderate: 6-25 bpm
Marked: >25 bpm
“Variability absent/minimal/moderate/marked”

5. ACCELERATIONS (ACCELS)
Abrupt increase in FHR above baseline
“Rule of 15s”: > 15 seconds, >15 bpm (if >/= 32 wks AOG)
“Rule of 10s”: > 10 seconds, > 10 bpm (if <32 wks AOG)

Prolonged accels: Lasts >/= 2 min but < 10 min


Change in baseline: Lasts > 10 min

“With or Without Acceleration”

6. DECELERATIONS (DECELS)
Gradual decels - gradual decrease and return of FHR, >/= 30 seconds
Early - HEAD COMPRESSION
Late - UTEROPLACENTAL INSUFFICIENCY
(Maternal Hypotension, excessive uterine activity, placental dysfxn, HPN, DM,
CTD)

Variable Decels - ABRUPT decease in FHR, <30 seconds = CORD COMPRESSION


7. OVERALL IMRESSION: 3 TIER SYSTEM FHR INTERPRETATION SYSTEM

CATEGORY I: Normal
BRA: 110-160 bpm
V: Moderate
A: (+/-)
D: (-) Late or Variable Decels; (+/-) Early Decels

Mgt: Expectant/Observe

CATEGORY II: Indeterminate


BRA: >160 bpm or <110 bpm
V: Minimal, Absent, Mild
A: (-) after fetal stim
D: Recurrent Variable Decels + minimal or moderate var
Prolonged Decels 2-10 min
Recurrent Late Decels + Moderate Var

Mgt: Extend Monitoring + Resuscitate

CATEGORY III: Abnormal


BRA: As below
V: Absent + any of the ff:
Recurrent Late Decels
Recurrent Variable Decels
Bradycardia
Sinusoidal pattern
D: As above

Mgt: Immediate Delivery (Depends on situtation, AVD or C-section)


CATEGORY III

SINUSOIDAL:

RESUSCITATION:
1. Left Lateral Decubitus Position
2. Oxygen support
3. D/C Oxytocin
4. IVF bolus (200 cc)
REPORT SAMPLE

Patient XY, Age, OB Score


Complete Dx
LMP
Latest VS
Latest IE Findings
Current Meds

EFM Reading
Fetal Bradycardia, with FHR range of 95-100 bpm
Absent Variability
No acceleration
With Late Deceleration to as low as 70 bpm
Strong contractions every 2-3 min, lasting for 60-90 seconds

Impression
Category III
Uteroplacental Insufficiency

Proposed Management
Immediate Delivery thru C-section at 2 cm dilation, station -3 or
Immediate Delivery thru Forceps Assisted Vaginal Delivery at 10 cm dilation,
station +3

SAMPLE 2

Patient XY, Age, OB Score


Complete Dx
LMP
Latest VS
Latest IE Findings
Current Meds

EFM Reading
Normal Baseline FHR at range of 135-140 bpm
Mild Variability
With acceleration
With Late Decelerations to as low as 100 bpm
Mild to moderate contractions every 2-3 min, lasting for 60-90 seconds

Impression
Category II

Proposed Management
Position patient to LL Decubitus
Plain NSS bolus (200 cc)
Discontinue Oxytocin
Administer Oxygen
Extend Fetal Monitoring