Cheat sheet
C-EFM Electronic Fetal Monitoring Cheat Sheet
Baseline & Variability
- 25-30% of exam
- Baseline Rate Variability Tiers Accelerations Tachy vs Brady
Periodic Patterns
- 20-25% of exam
- Early Decel Late Decel Variable Decel Prolonged Decel Recurrent vs Intermittent
Interpretation & Categories
- 15-20% of exam
- Category I Category II Category III Sinusoidal Three-Tier
Uterine Activity & Physiology
- 15-20% of exam
- Tachysystole MVU Oxygen Pathway Autonomic Control Cause Picker
Interventions & Equipment
- 15-20% of exam
- Intrauterine Resuscitation Amnioinfusion Monitoring Modes NICHD Documentation
Quick Facts
- Exam C-EFM
- Body NCC
- Questions 100 scored
- Time 2 hours
- Format Multiple choice
- Result Pass/Fail
- Terminology 2008 NICHD
Variability Ladder BA
- Absent < Minimal <=5 < Moderate 6-25 < Marked
- Absent: 0 Minimal: <=5 Moderate: 6-25 Marked: >25
Accel vs Decel BA
Acceleration
- Rate increases
- Well-being
- Intact CNS
Deceleration
- Rate decreases
- Possible compromise
- Needs context
- Up reassures, down depends
Baseline Rate BA
- Normal 110-160 bpm
- Window 10-minute mean 5 bpm
- Min duration 2 min identifiable
- Tachycardia >160 for 10 min
- Bradycardia <110 for 10 min
- Indeterminate <2 min baseline
Acceleration Rule BA
- 15x15 term | 10x10 preterm
- Term: 15 bpm/15 sec <32 wk: 10 bpm/10 sec Prolonged: 2-10 min
Minimal vs Absent Variability BA
Minimal
- Detectable to 5 bpm
- Sleep, sedation
- Often Category II
Absent
- Undetectable
- Hypoxia/acidemia
- Cat III with decels
- Some range vs none
Variability Tiers BA
- Absent Undetectable amplitude
- Minimal Detectable to 5 bpm
- Moderate 6-25 bpm Reassuring
- Marked >25 bpm (saltatory)
- Reflects Autonomic oxygenation
- Moderate predicts No acidemia now
Key Ranges BA
- 110-160 baseline | <=5 per 10 min | 200 MVU
- Baseline: 110-160 Tachysystole: >5/10min Adequate: 200-250 MVU
Accelerations BA
- Term fetus 15 bpm x 15 sec
- <32 weeks 10 bpm x 10 sec
- Onset Abrupt <30 sec
- Prolonged 2 to <10 min
- Means Fetal well-being
- Scalp stim Predicts normal pH
Tachy / Brady Causes BA
- Tachy: fever Infection sign
- Tachy: drugs Terbutaline, atropine
- Tachy: hypoxia Early compensation
- Brady: hypoxia Late/acidemia
- Brady: cord Prolapse, descent
- Brady: block Fetal heart block
VEAL CHOP DE
- Variable Early Accel Late = Cord Head OK Placenta
- Variable: Cord Early: Head Accel: OK Late: Placenta
Early vs Late Decel DE
Early
- Nadir at peak
- Head compression
- Benign, no action
Late
- Nadir after peak
- Uteroplacental
- Non-reassuring
- Timing vs contraction peak
Early & Late Decels DE
- Early onset Gradual >=30 sec
- Early nadir At contraction peak
- Early cause Head compression
- Late onset Gradual >=30 sec
- Late nadir After contraction peak
- Late cause Uteroplacental insufficiency
Variable vs Late Decel DE
Variable
- Abrupt <30 sec
- Cord compression
- Varies in shape
Late
- Gradual >=30 sec
- Uteroplacental
- Uniform shape
- Abrupt vs gradual onset
Variable & Prolonged DE
- Variable onset Abrupt <30 sec
- Variable depth 15 bpm x 15 sec
- Variable cause Cord compression
- Most common Variable in labor
- Prolonged 2 to <10 min
- >=10 min Baseline change
Decel Modifiers DE
- Recurrent >=50% contractions
- Intermittent <50% contractions
- Window 20-minute segment
- Overshoot Accel after variable
- Shoulder Brief pre-decel rise
- Significance Recurrent > intermittent
Category Stack CA
- I normal -> II indeterminate -> III abnormal
- I: moderate, no late II: everything else III: absent + decels
Category II vs III CA
Category II
- Indeterminate
- Variability present
- Surveillance
Category III
- Abnormal acid-base
- Absent variability
- Urgent action
- Indeterminate vs abnormal
Category to Action CA
- Moderate, no late/variable → Category I ( Routine monitoring )
- Not I or III → Category II ( Surveillance + resus )
- Absent + recurrent late → Category III ( Urgent action )
- Sinusoidal present → Category III ( Prepare delivery )
- Cat III unresolved → Expedite delivery ( If resus fails )
Category Criteria CA
- Cat I baseline 110-160 bpm
- Cat I variability Moderate required
- Cat I decels No late/variable
- Cat II All not I/III
- Cat III: sinusoidal Or absent variability
- Cat III + decels Recurrent late/variable/brady
Category Meaning CA
- Cat I Normal acid-base
- Cat II Indeterminate, most common
- Cat III Abnormal acid-base
- Snapshot Single point in time
- Dynamic Moves between categories
- Cat II rule Needs clinical judgment
Special Patterns CA
- Sinusoidal 3-5 cycles/min
- Sinusoidal cause Severe fetal anemia
- Pseudosinusoidal Narcotics, fetal sucking
- Lambda Accel then small decel
- Arrhythmia Often benign PACs
- Marked Saltatory, post-hypoxic
Tachysystole vs Normal PH
Normal UA
- <=5 per 10 min
- Adequate recovery
- Routine
Tachysystole
- >5 per 10 min
- Reduce uterotonics
- Qualify by decels
- Five or fewer is normal
Decel to Cause PH
- Gradual, mirrors peak → Early ( Head compression )
- Gradual, after peak → Late ( Uteroplacental )
- Abrupt, variable shape → Variable ( Cord compression )
- 2 to <10 min → Prolonged ( Mixed cause )
- Sine wave 20 min → Sinusoidal ( Fetal anemia )
- >=10 min decrease → Bradycardia ( Baseline change )
Uterine Activity PH
- Normal <=5 per 10 min
- Tachysystole >5 per 10 min
- Average over 30-minute window
- Frequency Start to start
- MVU Sum above resting tone
- Adequate labor 200-250 MVU
Fetal Physiology PH
- O2 pathway Uterus to fetus chain
- Vagal Lowers rate, variability
- Sympathetic Raises rate, accels
- Resting tone 5-25 mmHg (IUPC)
- Centralization Blood to brain/heart
- Acidemia Loss of variability
External vs Internal Monitor IN
External
- Doppler + toco
- Noninvasive
- Frequency only
Internal
- FSE + IUPC
- Needs ruptured membranes
- True intensity
- Indirect vs direct signal
Pattern to Intervention IN
- Variable decels → Reposition ( Relieve cord )
- Recurrent variables → Amnioinfusion ( Oligohydramnios )
- Late decels → Lateral + IV ( Improve perfusion )
- Tachysystole + decels → Stop oxytocin ( Then tocolytic )
- Post-epidural hypotension → Bolus + vasopressor ( Restore BP )
- Indeterminate tracing → Scalp stimulation ( Provoke accel )
Intrauterine Resuscitation IN
- Reposition Lateral, relieve aortocaval
- IV bolus Restore perfusion
- Stop oxytocin Reduce tachysystole
- Tocolytic Terbutaline if persists
- Amnioinfusion Cushion cord
- Vasopressor Treat hypotension
Monitoring & Equipment IN
- External FHR Doppler ultrasound
- External UA Tocodynamometer frequency
- Internal FHR Fetal scalp electrode
- Internal UA IUPC true intensity
- MHR artifact Maternal pulse mimics fetal
- Paper speed 3 cm/min (US)
Common Traps
Early vs Late
- Early nadir at peak ≠ Late nadir after peak
Variability vs Accelerations
- Variability is fluctuation ≠ Accel is rate rise
Minimal vs Absent
- Minimal detectable <=5 ≠ Absent is undetectable
Tachycardia vs Bradycardia
- >160 ten min ≠ <110 ten min
Sinusoidal vs Pseudosinusoidal
- Sinusoidal means anemia ≠ Pseudo from narcotics
Recurrent vs Intermittent
- Recurrent >=50% ≠ Intermittent <50%
Prolonged vs Bradycardia
- Prolonged 2 to <10 min ≠ >=10 min is baseline
Last Minute
- 1. Baseline = 110-160 bpm
- 2. Moderate variability = 6-25 bpm
- 3. Late = uteroplacental insufficiency
- 4. Variable = cord compression
- 5. Early = head compression, benign
- 6. Cat I needs moderate variability
- 7. Cat III = absent + recurrent
- 8. Sinusoidal = severe fetal anemia
- 9. Tachysystole = over 5 per 10 min
- 10. Recurrent = at least 50% contractions
C-EFM Certified in Electronic Fetal Monitoring
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