All those with complete AV block by maternal autoantibodies positivity survived, but 42.8% needed a pacemaker. Qin J, Deng Z, Tang C, Zhang Y, Hu R, Li J, Hua Y, Li Y. Yellow Raft unfolds with a distinctive rhythm as the reader moves backwards and forwards in time, encountering first the story of Rayona, then the story of her mother Christine, and finally the story of Aunt Ida, whose real relationship to the first two becomes one of the novels more powerful revelations. However, depending on the monitor and the existing maternal R wave, amplification of the incoming signal may continue until, on occasion, counting of the maternal heart rate (MHR) from the scalp of the dead fetus results (, FETAL HEART RATE DERIVED BY INDIRECT (EXTERNAL) DOPPLER ULTRASOUND, In the antepartum period, and often during the intrapartum period, it is neither feasible nor always necessary to use the direct fetal ECG signal to record the FHR. An ECG signal consists of P, . The majority of fetal arrhythmias are premature contractions. In addition, the actual signal created by the fetal cardiac motion is greatly affected by the position and movement of the transducer with respect to the fetus. Most of the PACs are benign, and do not have a genetic cause, while a few PACs can be associated with congenital heart defects or as a manifestation of Costello syndrome caused by HRAS mutations [20]. if you have areas where it's uniform aka a fully colored in area, no breaks, like a big block of spikes . [40] and a median of 12days for Jaeggi et al. Thesis. Moreover, fetal cardiac arrhythmias can have an effect on FHR signals. Refaat M, El Dick J, Sabra M, Bitar F, Tayeh C, Abutaqa M, Arabi M. J Neonatal Perinatal Med. [13] reported that they used a two-dimensional scan head with M-mode recordings for the diagnosis of fetal arrhythmias. Figure 4.4. To remove noise and artifacts, the . PubMedGoogle Scholar. Immediate postnatal pacemaker implantation is warranted in refractory cases. official website and that any information you provide is encrypted Both methods have advantages and disadvantages, and one or the other is more applicable in certain clinical situations. Sustained fetal arrhythmias associated with major structural heart disorders, hydrops fetalis, and fetal heart failure warrant intrauterine pharmaceutical conversion of heart rhythm or early pacemaker implant in order to avoid fetal demise. J Matern Fetal Neonatal Med. Fetal direct intramuscular injection of digoxin with maternal amiodarone use is an effective alternative. The .gov means its official. [36] reported that the successful rate was 81.2% (26/32) when treated with flecainide as a first-line therapy. Successful in utero transesophageal pacing for severe drug-resistant tachyarrhythmia. Front Pharmacol. Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics, https://doi.org/10.1186/s13052-020-0785-9, https://radiopaedia.org/articles/fetal-premature-ventricular-contractions, https://doi.org/10.1136/bmjopen-2017-016597, http://medcraveonline.com/JCCR/JCCR-09-00322.php, http://creativecommons.org/licenses/by/4.0/, http://creativecommons.org/publicdomain/zero/1.0/. ____ denotes the spontaneous, rhythmic depolarization of cardiac cells. M-mode ultrasound can detect the AV and ventriculoatrial (VA) intervals, fetal heart rate, AV conduction, and even ejection fraction [11], but detection qualities may be compromised by early detection in first trimester, unfavorable fetal position, hydrops fetalis, fetuses with cardiac contractile dysfunction and obese pregnant women [12]. 2017;9:00322 http://medcraveonline.com/JCCR/JCCR-09-00322.php. Moreover, fetal cardiac arrhythmias can have an effect on FHR signals. AlSoufi M. Successful treatment of fetal tachycardia by sotalol. In this study, a machine learning framework for fetal arrhythmia detection. Ekiz A, Kaya B, Bornaun H, Acar DK, Avci ME, Bestel A, et al. Miyoshi T, Maeno Y, Sago H, Inamura N, Yasukochi S, Kawataki M, et al. The mechanisms of fetal bradycardia were complete AV block (14/29, 48.3%), second-degree AV block (8/19, 42.1%). If maternal transplacental treatment fails, direct administrations, such as intraumbilical, intraperitoneal, or intramuscular injection of antiarrhythmic agents can be considered as alternative approaches. Fetal tachycardia is a faster heart rate than expected. 2018;31:260510. Instead of hearing a "thump-THUMP-thump-THUMP" rhythm, the doctor might hear "thump THUMP-THUMP thump." There are three types of fetal arrhythmias: Bradyarrhythmia: The heart rate is too slow. Hydrostatic pressure within the uterus should be equal at all points. A transducer innovation employed by second-generation monitors is pulsed Doppler. 1,7. The original electrode was a modified skin clip, but now a spiral electrode is used. Ueda K, Maeno Y, Miyoshi T, Inamura N, Kawataki M, Taketazu M, on behalf of Japan Fetal Arrhythmia Group, et al. 2013;42:28593. In one of these, the heart rate of the mother was obtained from a dead fetus. In 2 cases, maternal QRS complexes which were detectable at the fetal scalp electrode were counted, resulting in misleading recordings. By detecting flow imaging frequency spectrum of the pulmonary arteries and pulmonary veins, the pulse Doppler echocardiography can determine the rhythm changes between the spectra and the arrhythmic patterns. Although US clinicians find 1 cm/minute tracings are harder to read than the same tracings at 3 cm/minute, the slower rate of tracing is commonly used in Europe, South America, and certain centers in this country. The outcomes of intrauterine therapy of fetal tachyarrhythmias depend on the types or etiology of fetal arrhythmias and fetal conditions. Cardiac arrhythmias and artifacts in fetal heart rate signals: detection and correction. Assessment of fetal arrhythmia by simultaneous Doppler recording of flow patterns in the ascending aorta and superior vena cava. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Prenatal Diagnosis of Fetal Heart Failure. fetal arrhythmia vs artifact. statement and 2002;17:757. Eng. PubMed Central Therefore, prenatal treatment is warranted for improving the fetal survival rate. [41] Freedom from arrhythmia on maintenance therapy was 93 and 90% at 1 and 3months, respectively. 2011;124:174754. and Reproductive Biology, 54:103108, M. L. Cabaniss, D. Karetnikov. CAS IFMBE Proceedings, vol 16. Fetal arrhythmias are a common phenomenon with rather complicated etiologies. Fetal arrhythmia is a term that refers to any abnormality in the heart rate of your baby. Friday, June 10, 2022posted by 6:53 AM . 2006;25:47781. Postma AV, van de Meerakker JB, Mathijssen IB, Barnett P, Christoffels VM, Ilgun A, et al. Fetal bradycardias may be due to sinus bradycardia, blocked PACs, or high degree AV block [46]. fetal arrhythmia vs artifactdiscretionary housing payment hackney. If the electrodes are changed more often - especially for overweight people or people, who sweat very intensely - the occurrence of artifacts are avoided. by | Jun 10, 2022 | how to charge a kangvape without a charger | when do live oaks drop their leaves in florida | Jun 10, 2022 | how to charge a kangvape without a charger | when do live oaks drop their leaves in florida The primary goal of fetal therapy is the prevention or resolution of hydrops. Fetal complete AV block with structural heart disease often shows a worse prognosis, such as fetal demise or pacemaker implant requirement. With combined flecainide and digoxin therapy, conversion to sinus rhythm occurred within 5days (range, 014days). Crisan CD, Lighezan I, Lazar E, Moscu AV. Digoxin is more suitable for rhythm conversion of fetal AF and SVT in fetuses free of hydrops fetalis, while sotalol shows better effects for those with hydrops fetalis. Fetal bradycardia has shown limited therapeutic efficacy, and early treatment with steroids and/or plasmapheresis remains controversial. Bethesda, MD 20894, Web Policies Arrhythmias are discovered in about 1% of fetuses. 2003;29:S85. 8600 Rockville Pike The electronic circuitry of the fetal monitor senses this frequency change and converts it to an electronic signal. In comparison to flecainide or digoxin, sotalol was less effective to convert SVT to sinus rhythm. The transient fetal bradycardia is benign and often need no fetal treatment. 2 years ago. Bravo-Valenzuela NJ, Rocha LA, Machado Nardozza LM, Jnior EA. A healthy fetus has a heartbeat of 120 to 160 beats per minute, beating at a regular rhythm. Lippincott Company, D. N. Lebrun (2003) Analysis of neonatal heart rate variability and cardiac orienting responses. Debates remain regarding prenatal diagnosis and treatment of fetal arrhythmias. PubMed Fetal arrhythmias: prenatal evaluation and intrauterine therapeutics. The occurrence of paroxysmal AF can be a result of TBX5 gain-of-function mutations and overexpressions of Nppa, Cx40, Kcnj2 and Tbx3 genes [7]. 2012 Jun 1;109(11):1614-8. doi: 10.1016/j.amjcard.2012.01.388. One potential source of error occurs when the Doppler signal is actually maternal and not FHR (. Cardiol Young. The institutional Review Board approves this study. Ann Pediatr Cardiol. According to an article in the Indian Pacing and Electrophysiology Journal , the normal fetal heart rate ranges between 110 and 160 beats . 8,12,16 The use of fetal echocardiography, M-mode and pulse-wave Doppler has lead to improved diagnosis of fetal arrhythmias, and remains the cornerstone of diagnosis. The possibility for signal loss, doubling, halving, or recording of MHR or other movements must be kept in mind when reading changes in FHR monitor strips (, ABDOMINAL FETAL ELECTROCARDIOGRAPHIC-DERIVED FETAL HEART RATE TRACINGS, Abdominal fetal ECG signals were first recorded by Cremer in 1906 (. Most of the rapid fetal arrhythmia is a nonorganic lesion, mostly transient. An official website of the United States government. Application of this knowledge may prevent fetal injury and death. Despite various electronic logic and filtering processes, this often results in an apparent increase in short-term variability due to a false reproduction of the actual interval from one heart beat or R wave (contraction) to the next (, Although not new in concept, the application of autocorrelation to FHR technology has been made possible by the introduction of high-speed microprocessor integrated circuitry. Fetal Diagn Ther. The highest point of the waveform is detected and recorded as a heart beat, even though it may not appear at the same time in each waveform. Fetal arrhythmias are a common phenomenon with rather complicated etiologies. Fetal arrhythmia is rare. Accessibility PubMed Central The intrauterine or neonatal mortality rate in hydropic fetuses treated with flecainide was much lower than that treated with digoxin (0% vs. 43%, P=0.06). Europ. It can be helpful in making prenatal diagnoses of a variety of fetal arrhythmias, such as complete AV block, premature contractions, paroxysmal SVT and Wolff-Parkinson-White syndrome and long QT syndrome [19]. First-generation monitors calculate heart rate by electronic integration and peak detection of the returning Doppler signal. Prog Pediatr Cardiol. This is a preview of subscription content, access via your institution. 2000;11:117. The main drawback to phonocardiographically derived FHR systems is that they are extremely sensitive to ambient noise such as maternal bowel sounds, voices in the room, certain air-conditioning systems, and, especially, noise produced by any motion of the microphone or of the bed clothing against the microphone. 2013;42:28593. ; Disney Surprise Drinks Clinical presentation, management, and postnatal outcomes of fetal tachyarrhythmias: a 10-year single-center experience. Sotalol is usually well-tolerated and has little or no negative inotropic effect on the fetal heart. This mechanical energy may be sensed by a microphone and amplified, producing an electrical signal that may then be reconverted to sound or used to produce a phonocardiogram, an oscillographic tracing of the heart sounds. The modes of administration, intraumbilical, intraamniotic, intraperitoneal, intramuscular and intracardiac, have been selected as routes of administration. Lin AE, O'Brien B, Demmer LA, Almeda KK, Blanco CL, Glasow PF, et al. Cardiotocography is the most commonly used noninvasive diagnostic technique that provides physicians information about fetal development (in particular about development of autonomous nervous system - ANS) and wellbeing. Ultrasound Obstet Gynecol. 2009;3:2537. Heart Rhythm. 1981;88:124638. Therefore, the fetal electrocardiogram (ECG) signal provides the clinician with a measure of the electrical activity of the fetal heart. This article reviews heart rate monitoring . This can help us confirm the diagnosis and discuss possible options for . Jaeggi ET, Friedberg MK. 2016;5:e003673. [54] described percutaneous transvenous intracardiac cardiac pacing performed in a case of fetal AV block via the fetal umbilical vein under ultrasound guidance. Article Epub 2012 Mar 22. Transl Pediatr. In 2 fetuses of their patient setting, the arrhythmias were diagnosed using two-dimensional echo alone. D Maternal fever. As the fetal heart beats, closure of the valves may be detected by listening with a suitable stethoscope through the mothers abdominal wall. Fetal monitors obtain the FHR indirectly by use of Doppler ultrasound. Arrhythmia. Hosono T, Kanagawa T, Chiba Y, Neki R, Kandori A, Tsukada K. Fetal atrial flutter recorded prenatally by magnetocardiography. Sotalol as first-line treatment for fetal tachycardia and neonatal follow-up. It is important to understand that with Doppler technology, it is not the actual fetal heart being heard but rather a sound that is created by the device in response to frequency changes generated by a moving interface. Terms and Conditions, Intraperitoneal, intraamniotic, and intramuscular injections allow instant delivery of the drugs while the fetuses carry less traumatic injuries [27]. Phonocardiography was the first method used to record FHR electronically. This section will deal with the methodology involved in the clinical application of these techniques. For more information or to schedule an appointment, call Texas Children's Fetal Center at 832-822-2229 or 1-877-FetalRx (338-2579) toll-free. When the transmitted ultrasonic beam encounters an interface of increased density, a portion of the signal is reflected. Arrhythmia means no regular rhythm and dysrhythmia means abnormal rhythm. Want to learn about Fetal Arrhythmia from a Pediatric cardiologist's perspective? To understand the significance of the FHR display, it is important to understand what the monitor can and cannot count. The time to conversion to sinus rhythm for sotalol varied from 1 to 5days (median 1day) for Shah et al. Fetal arrhythmias are diagnosed in 13% of pregnancies [1], and account for 1020% of the referrals to fetal cardiology [2]. Kardia Advanced Determination "Sinus with Supraventricular Ectopy (SVE)" indicates sinus rhythm with occasional irregular beats originating from the top of the heart. Ann Pediatr Cardiol. J Am Heart Assoc. Privacy 3, Department of Electronic and Telecommunication, University "Federico II", Via Claudio, 21, Naples, Italy, Mario Cesarelli,M. Romano,P. Bifulco&A. Fratini, You can also search for this author in Fetal Diagn Ther. (From Klapholz H, Schifrin BS, Myrick R et . (8 wk-egg, 10wk-orange, 12wk-grapefruit against pelvic brim, allows to hear fetal HR) o Earliest ultrasounds are most accurate in dating. J Arrhythm. eCollection 2022. Ginekol Pol. Artifact is the interference seen on the monitor or strip which may look like a wandering or fuzzy baseline. Of these arrhythmias, 10% are considered potential sources of morbidity. Blocked atrial bigeminy also resembles 2:1 AV block and causes fetal bradycardia. This biphasic signal is immersed in noise created by fetal movements, arterial blood flow, maternal movements, and random muscle contractions. Despite apparent improvement in signal interpretation, autocorrelation is still not a true measure of short-term variability. D. Maternal fever. 2016;48(Suppl. Fetal bradycardia is a slower heart rate than expected. The fetuses with benign arrhythmias, such as PACs <11 beats per minute (bpm) and sinusal tachycardias, did not need any treatment before or after birth, whereas those with postnatal arrhythmias associated with hemodynamic fluctuations require interventions, as they may lead to preterm delivery in some occasions [9]. Sridharan S, Sullivan I, Tomek V, Wolfenden J, kovrnek J, Yates R, et al. The aim of the present study is to discuss the complex and challenging issue concerning the prenatal evaluation and intrauterine therapeutics of fetal arrhythmias. A 10-year observational study on the pregnant women demonstrated 29 cases of fetal arrhythmias: 12 (41.4%) of which were fetal tachycardias (10 cases with SVT, 2 cases with atrial flutter (AF)), 5 (17.2%) were fetal bradyarrhythmias (all 5 cases with AV block), and 12 (41.4%) were fetal irregular cardiac rhythms (premature atrial beats) [4]. Capuruo et al. With older monitors, the quality of the Doppler-created FHR tracing is directly related to the orientation of the signal to the fetal heart, the amount of fetal movement, and the degree of constant attention by nursing personnel of maintaining an adequate signal while caring for the patient. In the United States, the standard factors are 30 BPM/cm on the vertical scale and 3 cm/minute on the horizontal scale. Manage cookies/Do not sell my data we use in the preference centre. It also extracts 16 significant features from multiple domains, including (time, frequency, and time-frequency features. Hajdu J, Pete B, Harmath A, Varadi V, Papp Z. Fetal arrhythmias: a clinical review. It is within this group of rhythm disturbances that the majority of fetal . Fetal PVCs were less common than PACs. Doppler waveforms detected from the inferior vena cava and the descending aorta helps in obtaining information of atrial and ventricular systoles simultaneously. Article 2008;4:17248. Unable to display preview. 1985;8:110. Diagnosis and management of fetal bradyarrhytmias. Immediate postnatal pacemaker implantation is warranted in refractory cases. An arrhythmia is an irregular rhythm of the heart in which abnormal electrical signals through the heart muscle may cause the heart to beat too fast (tachycardia), too slowly (bradycardia), or in an erratic pattern. ; 33 (3): 2415, O. Sibony, J. P. Fouillot, M. Benaoudia, A. Benhalla, J. F. Oury, C. Sureau, P. Blot (1994) Quantification of the heart rate variability by spectral analysis of fetal well-being and fetal distress. Fetal tachyarrhythmia - part II: treatment. Fetal echocardiography has been the mainstay of fetal arrhythmia diagnosis; however, fetal magnetocardiography (fMCG) has recently become clinically available. Although most fetal arrhythmias are benign, some cause fetal hydrops and can lead to fetal death. FETAL HEART RATE DERIVED BY DIRECT (INTERNAL) FETAL ELECTROCARDIOGRAPHY. Re: Sotalol as first-line treatment for fetal tachycardia and neonatal follow-up. Clinical and genetic spectrum of neonatal arrhythmia in a NICU. Fetal complete heart block. This can be caused by patient movement, improper grounding, loose or defective electrodes or faulty ECG equipment. The transplacental administration of combined digoxin and flecainide is an effective regimen for SVT with long VA interval [32]. Springer Nature. Google Scholar. Therefore, when fetal arrhythmia, in particular fetal bradycardia, is found, special attention should be paid to whether cardiac structural abnormalities is present [55]. Ultrasound waves of sufficient intensity will generate heat. 2022 Jul 15;12(7):1722. doi: 10.3390/diagnostics12071722. Italian Journal of Pediatrics on Biom. 2008;102:143342. In the other, the instrument produced an incomprehensible record as a result of counting both maternal and fetal complexes. For fetuses with hydrops and fetal SVT with long VA interval, digoxin is rarely effective. It is often temporary and . It is more effective than digoxin, especially for hydropic fetal tachycardia, with no adverse fetal outcomes found [14]. The transplacental administration of antiarrhythmic agents, including digoxin, flecainide, sotalol, and amiodarone, is applied for fetal tachycardia in many centers [25]. Genetic studies have shown that GATA4, NKX2-5, TBX3, and TBX5 genes are responsible for cardiac structural development, whereas mutations of these genes may lead to congenital heart diseases and conduction disorders [6]. The site is secure. Ultrasonic signals can penetrate human tissue. [39], 135days (median 7.5days) for van der Heijden et al. 2003;53:2869. These arrhythmias do not represent an expression of the physiological behavior of the ANS. The "a" prefix in arrhythmia means a lack or an absence of something. Carpenter RJ Jr, Strasburger JF, Garson A Jr, Smith RT, Deter RL, Engelhardt HT Jr. Fetal ventricular pacing for hydrops secondary to complete atrioventricular block. to use this representational knowledge to guide current and future action. Pacing Clin Electrophysiol. The role of echocardiography in fetal tachyarrhythmia diagnosis. Artifact vs arrhythmia. A ventricular rate<55bpm, fetal cardiac dysfunction and hydrops fetalis (P=0.04) were significant predictive risk factors of a higher mortality rate. (eds) 11th Mediterranean Conference on Medical and Biomedical Engineering and Computing 2007. A similar shift is created if the Doppler signal is being reflected by any movement such as fetal blood, maternal vessels, or fetal movement. Google Scholar. Instrumentation and Artifact Detection Including Fetal Arrhythmias. SVT mechanism was classified by mechanical VA time intervals as short VA or long VA. Burne - Jones ) Rhythm II. . Ultrasound Obstet Gynecol. The overall mortality was 8%, only 4% of which was arrhythmia-related. Benign fetal arrhythmias, including premature contractions and sinus tachycardia, do not need any treatment before and after birth. Effectiveness of sotalol as first-line therapy for fetal supraventricular tachyarrhythmias. No Comments . The clinical outcome and prognosis of patients are usually determined by the type and extent of cardiac malformation [55]. Fetal tachyarrhythmias are usually SVT (63.4%), AF (28.0%) and VT (8.5%). If your doctor suspects an arrhythmia after reviewing your routine ultrasound, he or she may request a fetal echocardiogram (echo), an ultrasound of the fetal heart. Currently, ultrasound is the only widely used method of studying fetal anatomy and physiology, but it has significant limitations for assessment of cardiac rhythm. Up-to-date . Fetal premature ventricular contractions https://radiopaedia.org/articles/fetal-premature-ventricular-contractions. Intrauterine therapy of fetal tachyarrhythmias has been carried out by the transplacental route. Stirnemann et al. M.G. Aim: We aim to report a case of an enlarged fetal thymus causing arrhythmia. This form of short-term memory is supported by the prefrontal cortex (PFC) and is believed to rely on the ability of selectively tuned pyramidal neuron networks to persist in firing even after a to-be-remembered stimulus is removed from the environment. These can include tachycardia-an increased heart rate-or bradycardia, which is a slowed heartbeat. Keywords. Saileela R, Sachdeva S, Saggu DK, Koneti NR. fetal arrhythmia vs artifact. Amiodarone, propafenone, and combined therapies are reserved for refractory fetal tachycardias [30]. The overall incidence of malignant fetal arrhythmias, such as complete AV block and SVT, are relatively rare, found in 1:5000 pregnancies [5]. Both, artifacts and cardiac arrhythmias represent outliers of the FHR signals, so they affect both time domain and time frequency signal analysis. Fetal arrhythmia is a term that refers to any abnormality in the heart rate of your baby. 2018;11:349. Provided by the Springer Nature SharedIt content-sharing initiative, Over 10 million scientific documents at your fingertips. Fetal bradycardias may occur in the presence of fetal hypoxia [48], associated congenital structural disorders [49], maternal connective tissue disorders [50], positivity of maternal SSA/Ro and/or SSB/La autoantibodies [50], or due to an unknown cause [51]. Am J Cardiol. Crowley et al. With ventricular systole, the closure of the atrioventricular (AV) valves produces the first heart sound. Most are curable to a transplacental treatment by the first-line antiarrhythmic agents. 2009;2:195207. Circulation. Shah et al. Due to the weakness of the fetal ECG signal before 30 weeks gestation, the interference created by the electromyographic muscle noise of the maternal abdominal wall, and the frequency of coincidence of maternal and fetal ECG signals, abdominal ECG plays little role in modern FHR monitoring other than in arrhythmia detection. 11th Mediterranean Conference on Medical and Biomedical Engineering and Computing 2007 pp 789792Cite as, Part of the IFMBE Proceedings book series (IFMBE,volume 16). Sustained fetal arrhythmias that predispose to the occurrence of hydrops fetalis, cardiac dysfunction, or even fetal demise require early treatments. 2005;10:50414. Benign fetal arrhythmias, such as premature contractions and sinus tachycardia, do not need any perinatal treatments. Maeno Y, Hirose A, Kanbe T, Hori D. Fetal arrhythmia: prenatal diagnosis and perinatal management. This direct treatment is indicated in cases of tachyarrhythmia with hydrops fetalis as an adjunctive to the higher dose of maternal transplacental therapy [28]. With such a system, both technical and logistic problems exist, such as catheter occlusion by solid matter, kinking or entrapment of catheter between the uterus and the fetus, as well as introduction of artifact secondary to maternal movement and catheter manipulation (, The pressure within the uterine cavity is directly proportional to the uterine wall tension and inversely proportional, Insertion of the uterine pressure catheter is accomplished by introducing it, while within the sterile introducer tube, just inside the uterine cervix and next to the presenting part (, Another modification of the intrauterine pressure catheter allows for amnioinfusion while simultaneously recording contraction strength directly (see, Click to share on Twitter (Opens in new window), Click to share on Facebook (Opens in new window), Click to share on Google+ (Opens in new window), on Instrumentation and Artifact Detection Including Fetal Arrhythmias, Liability and Risk Management in Fetal Monitoring, Clinical Management of Abnormal Fetal Heart Rate Patterns, Alternative and Backup Methods to Improve Interpretation of Concerning FHR Patterns, Fetal Heart Rate Patterns Associated with Fetal Central Nervous System Dysfunction, Evaluation and Management of Fetal Heart Rate Patterns in Premature Gestation, Antepartum Management of the High-Risk Patient.

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