Nonreassuring Fetal Status

Aka: Nonreassuring Fetal Status, Fetal Distress, Fetal Hypoxia, Birth Asphyxia

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II. Causes

  1. Uterine Rupture
  2. Uterine Hyperstimulation
  3. Placental Abruption
  4. Umbilical Cord accident
  5. Uteroplacental Insufficiency

III. Definitions

  1. Nonreassuring Fetal Status (preferred term)
    1. Fetal Heart Tracing suggestive of Fetal Hypoxia or acidosis

IV. Evaluation

  1. Fetal status
    1. Confirm findings with alternative monitoring
      1. Consider fetal scalp electrode
    2. Response to acoustic or scalp stimulation
    3. Consider Fetal Scalp pH (pH < 7.20 is abnormal)
  2. Maternal status
    1. Maternal Vital Signs
      1. Temperature
      2. Blood Pressure
      3. Heart Rate
    2. Vaginal examination
      1. Vaginal Bleeding (e.g. Placental Abruption)
      2. Cervical examination
        1. Cervical dilation
        2. Rapid head descent
        3. Umbilical Cord Prolapse

V. Management: Based on Fetal Monitoring

  1. See NICHD Category
  2. NICHD Category 1: Normal
    1. Reassuring Fetal Heart Tracing
    2. Fetal Heart Rate 110-160 bpm with moderate variability and no variable or Late Decelerations
    3. Continue current management
  3. NICHD Category 2: Indeterminate
    1. Non-reassuring Fetal Heart Tracing (lacking category 1 criteria without category 3 criteria)
    2. Variability or accelerations present
      1. Perform interventions as below
      2. Reassess after 30 minutes, and resume close monitoring
      3. Cesarean delivery (or Vaginal Delivery if progressing in active labor) Indications
        1. Significant decelerations with >50% of contractions for 60 minutes
    3. Variability of accelerations absent
      1. Perform interventions as below
      2. Reassess after 30 minutes, and resume close monitoring
      3. Cesarean delivery (or Vaginal Delivery if progressing in active labor) Indications
        1. Significant decelerations with >50% of contractions for 30 minutes
        2. Persistent NICHD Category 2 tracing with poor variability or accelerations >1 hour
        3. Deep Decelerations to Heart Rate <70 bpm
  4. NICHD Category 3: Abnormal
    1. Ominous Fetal Heart Tracing
    2. Recurrent variable or Late Decelerations, Fetal Bradycardia or sinusoidal pattern with loss of FHT Variability
    3. See interventions below
    4. Expedite delivery

VI. Management: Interventions for Non-reassuring Fetal Heart Tracing

  1. Maternal position change
    1. Lateral recumbent or
    2. Hands and Knees
  2. Evaluate maternal Vital Signs for serious findings
    1. Hypotension
    2. Fever
    3. Tachycardia
  3. Oxygen 8-10 liters per minute by Non-Rebreather Mask
  4. Intravenous Fluid Resuscitation with 1 Liter crystalloid
  5. Suppress labor
    1. Remove Cervadil
    2. Discontinue Oxytocin
    3. Consider holding pushing
    4. Consider Terbutaline SQ 0.25 mg
  6. Vaginal examination for acute cause
    1. Placental Abruption
    2. Umbilical Cord Prolapse
    3. Rapid Fetal Descent
  7. Consider Amnioinfusion
    1. Indicated in repeat Variable Decelerations
  8. Consider expedited delivery
    1. Vacuum Assisted Delivery
    2. Forceps Assisted Delivery
    3. Cesarean Section
  9. Consultation
    1. Obstetrics for expedited delivery
    2. Neonatology or Pediatrics

VII. References

  1. (2009) Obstet Gynecol 114(1):192-202 +PMID:19546798 [PubMed]
  2. Arnold (2020) Am Fam Physician 102(3): 158-67 [PubMed]
  3. Bailey (2009) Am Fam Physician 80(12): 1388-98 [PubMed]

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