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Persistent, nonreactive fetal heart rate patterns indicate that permanent neurologic injuries have occurred.

Meconium staining provides additional information about the timing of a neurologic injury. Staining of the placenta and/or membranes takes 3-6 hours; the vernix, 12-14 hours; and the skin and changes on a chest x-ray, 24 hours. This timetable often coincides with a woman's report of decreased or absent fetal movement.

Preadmission fetal brain injury is associated with a fixed baseline heart rate 71% of the time; a "stair step to heaven" pattern 18% of the time; and prolonged deceleration 10% of the time.

The "stair step to heaven" pattern indicates a loss of autonomic control in a dying fetus, he said. The heartbeat slows in 10-beat increments at varying intervals.

Many clues--a "fixed" baseline heart rate or persistent nonreactivity, old meconium or meconium sequelae, and oligohydramnios all point to static encephalopathy, Dr. Phelan said.

"You can't make something better after it's broken, especially when it comes to neurologic cells," he said.

On the other hand, some fetal heart rate patterns broadcast an ongoing crisis in the womb, where intervention could make a difference.

In particular, Dr. Phelan urged colleagues to become familiar with the Hon fetal heart rate pattern.

The fetal heart rate begins as normal. Later, the baseline heart rate begins to rise to a level of tachycardia in association with repetitive decelerations and usually a loss of variability. "The pattern reflects on-going asphyxia," he said.

According to [Dr. Edward H.] Hon, the inventor of fetal monitoring, hypoxia begins before you see tachycardia, he stressed.

In about half of such fetuses, there is no change in the pattern; the tachycardia and repetitive fetal heart rate decelerations continue unabated.

But in 35% of cases, a sudden, rapid, and sustained deterioration of the fetal heart rate develops; profound brain damage leads to loss of autonomic control and the "stair steps to heaven," presaging death in 14%.

"These children are usually devastated," he said.

Optimally, delivery should occur at the time of tachycardia, before the fetus can "crash," Dr. Phelan said at the meeting.

"My advice to all of you is, don't forget this pattern. Don't mess with this pattern," Dr. Phelan continued. Intervention is necessary.

Afebrile mothers should be delivered. Febrile mothers should be treated with antibiotics and antipyretics. If the fetal heart rate pattern does not return to normal within an hour, deliver the fetus.

"Get the [fetus] out of the environment," he said. "Do it before [it] crashes."

A less subtle indication of an intrapartum brain injury is sudden and sustained bradycardia, generally after a sentinel hypoxic event preceded by a normal fetal heart rate tracing. Such events include uterine rupture, oligohydramnios, shoulder dystocia, cord prolapse, and abruption.

These fetuses may crash from a heart rate of 120 beats per minute to 60 without warning. If the fetus is unresponsive to remedial measures and terbutaline, deliver immediately. In a study of 107 cases, the onset of the deceleration to delivery interval was 14-81 minutes, with a mean of 32 minutes.

"If you can get in, you can hopefully preserve CNS function," Dr. Phelan said.

"That's why we should do crash [C-] section drills," he said.

Hon Fetal Heart Rate Pattern: Characteristics

* Admission fetal heart rate (FHR) pattern reactive.

* Subsequent nonreactivity.

* Substantial rise in baseline FHR.

* Prolonged FHR tachycardia.

* Repetitive FHR decelerations.

BY BETSY BATES

Los Angeles Bureau

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