NICHD: Fetal Monitoring

Definitions/Classifications
Fetal Heart Rate Baseline: The FHR is rounded to increments of 5 beats per min during a 10 min segment excluding accelerations and decelerations, periods of marked
variability, or baseline segments that differ by more than
25 beats.
In any given 10 min window, the minimum baseline duration must be at least 2 min (not necessarily contiguous).
Otherwise, it is considered indeterminate. In these instances, review of the previous 10 min segments should be
the basis on which to determine the baseline.
The fetal baseline rate is classified as follows:
Normal: 110-160 beats per min
Bradycardia: Less than 110 beats per min
Tachycardia: Over 160 beats per min

NICHD: Fetal Monitoring

Definitions/Classifications
Fetal Heart Rate Patterns: Determination of baseline
fetal heart rate variability is based on visual assessment
and excludes sinusoidal patterns.
Variability: defined as fluctuations in the fetal heart rate
baseline that are irregular in amplitude and frequency.
Absent variability: amp. range undetectable
Minimal variability: amp. range 5 bpm
Moderate variability: amp. range from 6-25 bpm
Marked variability: amplitude range > 25 bpm
Sinusoidal FHR Pattern: specific FHR pattern, described
as a smooth, sine-wave-like undulating pattern with a cycle frequency of 3 to 5 bpm that continues for at least 20
min or more

NICHD: Fetal Monitoring

Definitions/Classifications
Accelerations: An abrupt increase of at least 15 bpm in
FHR above the baseline. Onset to peak is less than 30 seconds and duration is equal to or more than 15 seconds and
less than two minutes from onset to return to baseline.
(15x15)
In pregnancies less than 32 weeks gestation, accelerations
are defined as an increase of 10 bpm or more above baseline which lasts 10 seconds or more. (10x10)
An acceleration is classified as prolonged if the duration is
2 min or more, but less than 10 min. A prolonged acceleration that is sustained for 10 min or more is a baseline
change.
Late Decelerations: A usually symmetrical, gradual decrease in FHR and return to baseline associated with uterine contractions. Onset to nadir is equal to or greater than
30 seconds. The nadir of the deceleration usually occurs
after the peak of the contraction.

NICHD: Fetal Monitoring

Definitions/Classifications
Early Decelerations: A usually symmetrical, gradual decrease in FHR and return to baseline associated with uterine contractions. Onset to nadir is equal to or greater than
30 seconds. The nadir of the deceleration usually occurs at
the same time of the peak of the contraction.
Variable Decelerations: An abrupt decrease in FHR below the baseline which may or may not be associated with
uterine contractions. Onset to the beginning of the nadir is
less than 30 seconds. The decrease in FHR below the
baseline is equal to or more than 15 bpm, lasting 15 seconds or more, but less than 2 min in duration from onset to
return to baseline. When variable decelerations occur in
conjunction with uterine contractions, the onset, depth,
and duration vary with each succeeding uterine contraction.

NICHD: Fetal Monitoring

Definitions/Classifications
Prolonged Deceleration: A decrease in FHR below the
baseline. The decrease in the FHR is 15 bpm or more and
lasts for at least 2 min but less than 10 min from onset to
return to baseline. A prolonged deceleration that is sustained for 10 min or more is a baseline change.
The duration of decelerations is quantified in minutes and
seconds from the beginning to the end of the deceleration.
The same principles apply to accelerations as well.
Decelerations are identified as intermittent if they occur
with less than 50% of contractions in any 20 min segment.
Decelerations are identified as recurrent if they occur with
50% or more uterine contractions in a 20 min segment.

NICHD: Fetal Monitoring

Definitions/Classifications
Uterine Activity: Uterine activity is assessed based on the
number of contractions that are occurring in a 10 min segment averaged over a 30 min period. Normal uterine activity is described as 5 or less contractions in a 10 min
segment, averaged over a 30 min period.
Excessive uterine activity is termed tachysystole and is
described as more than 5 contractions in a 10 min segment
averaged over a 30 min period. Tachysystole can be spontaneous or from stimulated labor.

NICHD: Fetal Monitoring

Definitions/Classifications
Category I: Tracings in this category are strongly predictive of normal acid-base status at the time of observation.
Baseline rate 110-160 bpm
Moderate variability
Late/Variable decelerations absent
Early decelerations present or absent
Category II: Tracings in this category are not predictive
of abnormal acid-base status; however, there are insufficient data to classify them as either category I or category
III.
Baseline rate
Bradycardia not accompanied by recurrent decelerations
Tachycardia
Baseline FHR Variability
Minimal baseline variability
Absent baseline variability not accompanied by
recurrent decelerations
Marked baseline variability

NICHD: Fetal Monitoring

Definitions/Classifications
Category II Cont.
Accelerations
Absence of induced acceleration after fetal
stimulation
Recurrent variable deceleration accompanied by
minimal or moderate baseline variability
Prolonged decelerations with moderate baseline
variability
Variable deceleration with other characteristics,
such as slow return to baseline,.
Category III: Tracings in this category are predictive or
abnormal acid-base status at the time of observation.
Absent baseline FHR variability and any of the
following
Recurrent decelerations
Recurrent variable decelerations
Bradycardia
Sinusoidal pattern

NICHD: Fetal Monitoring

Definitions/Classifications
Clinical Situation and/or FHR Characteristics:
Minimal or absent variability. Recurrent late decels. Recurrent variable decels. Prolonged decels. Tachycardia.
Bradycardia. Variable, late, or prolonged decels occurring
with maternal pushing efforts.
Goal of Treatment: Promote fetal oxygenation
Techniques/Measures to Improve Situation:
Lateral positioning (either left or right).
IV fluid bolus of LR. If appropriate for pt
O2 administration via mask at 10 L/min. Considered
if: minimal to absent variability and/or recurrent late
decels or prolonged decels (discontinue asap based on
fetal status).
Modification of pushing efforts; pushing with every
other or every third contraction or discontinuation of
pushing temporarily
Decrease/Discontinuation of oxytocin
Remove cervidil/withhold next dose of cytotec

NICHD: Fetal Monitoring

Definitions/Classifications
Clinical Situation and/or FHR Characteristics:
Tachysystole
Goal of Treatment: Reduce uterine activity
Techniques/Measures to Improve Situation:

IV fluid bolus of LR (if appropriate for pt)

Lateral positioning (either left or right)
Decrease in oxytocin rate
Discontinuation of oxytocin/removal of cervidil insert/
withholding next dose of misoprostol
If no response, terbutaline 0.25 mg subcutaneously
may be considered.

NICHD: Fetal Monitoring

Definitions/Classifications
Clinical Situation and/or FHR Characteristics:
Recurrent variable decelerations
Goal of Treatment: Alleviate umbilical cord compression
Techniques/Measures to Improve Situation:
Repositioning
Amnioinfusion (during first stage of labor)
Pushing with every other or every third contraction or discontinuation of pushing temporarily
Clinical Situation and/or FHR Characteristics:
Maternal hypotension
Goal of Treatment: Correct maternal hypotension
Techniques/Measures to Improve Situation:
Lateral positioning (either left or right)
IV fluid bolus of LR (if appropriate for pt)
Notify Anesthesia

NICHD: Fetal Monitoring

Definitions/Classifications
The following are suggested aspects of professional communication regarding fetal status when the fetal heart pattern is indeterminate or abnormal:

Baseline rate, variability, presence/absence of accelerations and decelerations

Clinical context (e.g. Pit rate and recent titration;
timing/amount of misoprostol; uterine activity;
bleeding; timing/amount IV pain meds; recent initiation or dosage range in regional anesthesia/
analgesia; hypotension; rapid labor progress; umbilical cord prolapsed; trial of labor attempting
vaginal birth after c/s)
Intrauterine resuscitation measures initiated and
the maternal-fetal response
HR evolution (how long been evolving?)
Sense of urgency (e.g. ASAP, w/in 30)
Who was notified and their response
Next steps if there is no resolution of FHR pattern

NICHD: Fetal Monitoring

Definitions/Classifications

Prematurity: increase in baseline, decrease in

variability, reduced frequency and amplitude of
accelerations
Sleep cycle: decrease in variability, reduced frequency and amplitude of accelerations
Spontaneous fetal movement: accelerations
Scalp stimulation: accelerations
SVE: accelerations
Maternal fever: increase in baseline, decrease in
variability
Intramniotic infection/Chorioamnionitis: increase in baseline, decrease in variability
Maternal hyperthyroidism: tachycardia, decrease
in variability
Maternal hypothermia: bradycardia
Maternal supine hypotension: late decelerations,
bradycardia
Maternal hypoglycemia: bradycardia
Maternal drugs or substances (caffeine, nicotine, cocaine, methamphetamine): tachycardia,
decrease in variability

NICHD: Fetal Monitoring

Definitions/Classifications

Maternal pushing efforts: variable decelerations,

prolonged decelerations, increase in baseline
Excessive uterine activity: late decelerations, increase in baseline FHR, decrease in variability
Oligohydramnios: variable decelerations
Fetal anemia: Sinusoidal pattern, tachycardia
Fetal heart block: Bradycardia, decrease in variability
Fetal cardiac failure: tachycardia, bradycardia,
decrease in variability
Fetal heart structure defects: bradycardia
Fetal tachyarrhythmia: tachycardia, decrease in
variability
Fetal viral infection (cytomeg): bradycardia
Fetal congenital anomaly: decrease in variability,
decelerations
Preexisting fetal neuro abnormality: decrease in
variability, absent accelerations