Managing an Indeterminate (Category II) Fetal Heart Rate Tracing During Labor Kathleen Rice Simpson, PhD, RNC, FAAN
ne of the purposes of categorizing fetal heart rate (FHR) tracings was to delineate types of FHR tracings that provide good evidence of fetal status at the time observed (Macones, Hankins, Spong, Hauth, & Moore, 2008). This goal is generally achieved when FHR tracings meet criteria for categories I (normal) and III (abnormal). Fetuses displaying characteristics of category I tracings can be assumed to be doing well and have normal acid-base status. Fetuses with FHR tracings consistent with category III criteria are predictive of an increased risk of abnormal acidbase status at the time of observation (American College of Obstetricians and Gynecologists [ACOG], 2010). Therefore, if the category III FHR pattern cannot be resolved with the usual intrauterine resuscitation measures, plans for expeditious birth are warranted (ACOG, 2010).
ventions and develop a management plan that promotes a positive outcome. When assessing fetal status in the context of a category II FHR tracing, it is also important to consider the likelihood of birth occurring within a reasonable time frame to avoid progressive deterioration of fetal status (Clark et al., 2013). For example, a FHR tracing with tachycardia, moderate variability, and recurrent variable decelerations in a nulliparous woman with the cervix 2 centimeters (cm) and 50% effaced and the fetus at −2 station has a completely different clinical implication than that same tracing of a fetus of a multiparous woman whose cervix is 8 cm and 80% effaced. The imprecise nature of category II as it relates to fetal well-being creates challenges and is not always useful for clinical decision making during labor. Clark and colleagues
The imprecise nature of category II as it relates to fetal well-being creates challenges and is not always useful for clinical decision making during labor.
• Review the recommendations from Clark and colleagues (2013) for managing indeterminate (category II) FHR tracings during labor. • Apply the algorithm to category II FHR tracings during interdisciplinary electronic fetal monitoring rounds as a preliminary step in incorporating them into clinical practice.
administration of oxygen at 10 liters per nonrebreather facemask, amnioinfusion during Þrst-stage labor, and/ or modiÞcation of maternal pushing efforts during second-stage labor (ACOG, 2010; Clark et al., 2013). The goal is to attempt to resolve any clinical situations that are impeding adequate fetal oxygenation, allow labor to continue, and support the birth of a vigorous baby. ✜ Kathleen Rice Simpson is a Perinatal Clinical Nurse Specialist in St. Louis, MO, and the Editor-in-Chief of MCN. Dr. Simpson can be reached via e-mail at [email protected]
The author declares no conflict of interest. DOI:10.1097/NMC.0000000000000038 References
In contrast, the criteria for category II is so broad physiologically and includes many types of FHR characteristics associated with various degrees of concern for fetal wellbeing that the value of identifying a FHR tracing as category II is limited. All decelerations do not have the same meaning related to likely fetal status. Further, the presence or absence of moderate variability is a key factor in determining fetal wellbeing. More information about the FHR tracing is needed beyond the designation of category II to determine potentially appropriate inter212
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(2013) offer common sense recommendations for interpreting and managing intrapartum category II FHR tracings. A management algorithm is provided for ease of understanding and numerous examples of various types of intrapartum FHR tracings are offered to exemplify important points. Intrauterine resuscitation measures are based on the speciÞc FHR pattern and generally include one or more of the following interventions: lateral maternal repositioning, an intravenous ßuid bolus, reduction in uterine activity, correction of maternal hypotension,
American College of Obstetricians and Gynecologists. (2010). Management of intrapartum fetal heart rate tracings (Practice Bulletin No. 116). Washington, DC: Author. doi:10.1097/AOG.0b013e3182004fa9 Clark, S. L., Nageotte, M. P., Garite, T. J., Freeman, R. K., Miller, D. A. Simpson, K. R., …, Hankins G. D. (2013). Intrapartum management of category II fetal heart rate tracings: Towards standardization of care. American Journal of Obstetrics and Gynecology, 209(2), 89-97. doi:10.1016/j. ajog.2013.04.030 Macones, G. A., Hankins, G. D. , Spong, C. Y., Hauth, J., & Moore, T. (2008). The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: Update on definitions, interpretation, and research guidelines. Obstetrics and Gynecology, 112(3), 661-666. doi:10.1097/AOG.0b013e 3181841395
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