Obstetrics Marrow Pg 345-354 (Normal Pregnancy & ANC)
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What is a consequence of fetal hypoxia during labor?

  • Decreased umbilical blood flow
  • Improved fetal heart rate
  • Metabolic acidosis (correct)
  • Increased placental blood flow

    • Intermittent fetal heart sounds auscultation is not recommended for high-risk cases.

    False

    What is indicated by a drop in fetal heart rate during labor?

    Compromise of the fetus

    Uterine contractions decrease __________ blood flow, which can lead to intermittent fetal oxygenation issues.

    <p>uteroplacental</p> Signup and view all the answers

    Match the stages of labor with the recommended monitoring frequency for low-risk cases:

    <p>First stage - Low risk = Every 30 minutes Second stage - Low risk = Every 15 minutes</p> Signup and view all the answers

    What is the normal range for fetal heart rate (FHR) during a normal pregnancy?

    <p>110-160 bpm</p> Signup and view all the answers

    Absent variability in fetal heart rate is a reassuring sign.

    <p>False</p> Signup and view all the answers

    What is required in addition to decreased variability to categorize CTG into category 3?

    <p>One more comorbid finding</p> Signup and view all the answers

    Normal baseline variability of FHR is between _____ bpm.

    <p>6 to 25</p> Signup and view all the answers

    Match the following fetal heart rate interpretations with their corresponding definitions:

    <p>Bradycardia = FHR less than 110 bpm Normal variability = Fluctuations of FHR between 6 to 25 bpm Absent variability = Indicates potential fetal hypoxia Baseline FHR = The average FHR over a period of time</p> Signup and view all the answers

    What is indicated by a Non-Stress Test (NST) showing < 2 accelerations in 40 minutes?

    <p>Compromised fetus</p> Signup and view all the answers

    A reactive NST can predict fetal hypoxia with a high level of accuracy.

    <p>False</p> Signup and view all the answers

    What scoring is done by ultrasound scan over 30 minutes to assess fetal well-being?

    <p>Biophysical Score (BPS)</p> Signup and view all the answers

    NST can be performed ____ times a week, depending on the risk assessment.

    <p>twice</p> Signup and view all the answers

    Match the following parameters assessed in the Biophysical Score (BPS) with their criteria:

    <p>Fetal tone = ≥ 1 episode of extension &amp; flexion Fetal breathing movement = ≥ 1 episode of breathing movement for &gt; 30sec. Gross body movement = ≥ 3 body movements in 30 mins Amniotic fluid = Single deepest pocket (vertical) ≥ 2cm</p> Signup and view all the answers

    What indicates fetal acidemia during a biophysical profile score (BPS)?

    <p>Decreased BPS score</p> Signup and view all the answers

    Immediate delivery is indicated for a BPS score of 2/10 or 0/10.

    <p>True</p> Signup and view all the answers

    What is the primary purpose of the vibro-acoustic stimulation test?

    <p>To rule out fetal sleep on non-reactive NST</p> Signup and view all the answers

    In cases of fetal hypoxia, the first parameter affected is the __________.

    <p>NST</p> Signup and view all the answers

    Match the biophysical profile management scores with the appropriate actions:

    <p>10/10 or 8/10 with (N) AFV = Reassurance (&lt; Risk of fetal hypoxia) 8/10 with normal AFV = Follow based on period of gestation 4/10 = Delivery if POG ≥ 32WKS 2/10 or 0/10 = Immediate delivery</p> Signup and view all the answers

    What is a possible cause of a sinusoidal FHR pattern?

    <p>Fetal anemia</p> Signup and view all the answers

    Sinusoidal fetal heart rate patterns can occur in conditions such as twin-to-twin transfusion syndrome.

    <p>True</p> Signup and view all the answers

    What is the frequency range of a sinusoidal FHR pattern?

    <p>2 to 5 cycles per minute</p> Signup and view all the answers

    FHR is considered abnormal if there is _____ or less variability.

    <p>absent</p> Signup and view all the answers

    Match the following fetal heart rate patterns to their definitions:

    <p>Deceleration = Drop in FHR by 15 bpm lasting for 15 seconds to 2 minutes Sinusoidal = Wave pattern with 2 to 5 cycles per minute for ≥ 20 mins Normal FHR = FHR between 120-160 bpm with variability Prolonged Deceleration = Isolated deceleration lasting ≥ 2 minutes</p> Signup and view all the answers

    What is the first step in the procedure for fetal scalp pH monitoring?

    <p>Make an incision through the fetal scalp</p> Signup and view all the answers

    A fetal pH of 7.15 indicates acidosis and requires immediate actions.

    <p>True</p> Signup and view all the answers

    What fetal heart rate (FHR) response indicates a pH greater than 7.2 during a scalp stimulation test?

    <p>Increase of &gt; 10 bpm for 15 seconds</p> Signup and view all the answers

    The normal pH value in fetal scalp monitoring is greater than ______.

    <p>7.25</p> Signup and view all the answers

    Match the fetal monitoring procedures with their purposes:

    <p>Fetal Scalp pH Monitoring = Confirm fetal acidosis/hypoxemia Fetal Scalp Stimulation = Assess fetal condition based on heart rate response Fetal Pulse Oximetry = Measure fetal oxygen saturation levels Cervical dilation requirements = Cervix ≥ 4 to 10 cms dilated</p> Signup and view all the answers

    What is the primary hormone responsible for the changes observed in the uterus during pregnancy?

    <p>Progesterone</p> Signup and view all the answers

    The linea nigra is a line that appears due to decreased levels of melanocyte stimulating hormone (MSH) during pregnancy.

    <p>False</p> Signup and view all the answers

    What are stretch marks associated with during pregnancy?

    <p>They are associated with the skin's stretching due to the growing fetus and typically appear as pink striae gravidarum and silvery-gray striae albicans.</p> Signup and view all the answers

    During pregnancy, the uterus typically increases in weight to __________ grams.

    <p>1100</p> Signup and view all the answers

    Match the skin changes during pregnancy with their correct descriptions:

    <p>Linea nigra = A dark line on the abdomen Stretch marks = Pink striae gravidarum and silvery-gray striae albicans Pregnancy mask = Pigmentation on the face Palmar erythema = Redness on the palms</p> Signup and view all the answers

    Which of the following statements best describes late deceleration in CTG monitoring?

    <p>A gradual decrease in FHR that begins after a uterine contraction.</p> Signup and view all the answers

    Variable deceleration in fetal heart rate monitoring is directly related to uterine contractions.

    <p>False</p> Signup and view all the answers

    What is the normal range for fetal heart rate (FHR) during a normal pregnancy?

    <p>110-160 bpm</p> Signup and view all the answers

    The management of non-reassuring CTGs may include emergency C-section and ________ resuscitation.

    <p>in-utero</p> Signup and view all the answers

    Match the CTG category with its description:

    <p>Category 1 = FHR is 110-160 bpm with moderate variability Category 2 = Suspicious CTG reading Category 3 = Non-reassuring with potential compromises Category 1A = FHR &lt; 110 bpm with decreased variability</p> Signup and view all the answers

    Which of the following factors can lead to variable deceleration in fetal heart rate?

    <p>Oligohydramnios</p> Signup and view all the answers

    A sinusoidal FHR pattern is considered a reassuring indicator in CTG monitoring.

    <p>False</p> Signup and view all the answers

    Persistent variable deceleration can indicate a poor prognosis when FHR falls below _____ bpm.

    <p>60</p> Signup and view all the answers

    What is the primary function of the mucus plug in the cervix during pregnancy?

    <p>To prevent ascent of infections</p> Signup and view all the answers

    The presence of Chadwick sign indicates an increase in blood flow to the cervix and is associated with pregnancy.

    <p>True</p> Signup and view all the answers

    What are the two types of epithelium present in the cervix?

    <p>Endocervix and Exocervix</p> Signup and view all the answers

    The most common type of vaginitis in pregnancy is __________.

    <p>Candidiasis</p> Signup and view all the answers

    Match the following hormonal changes with their effects during pregnancy:

    <p>Progesterone = Supports decidua and suspends ovulation Estrogen = Increases blood flow to reproductive organs LH = Decreases due to negative feedback FSH = Decreases as ovulation is suspended</p> Signup and view all the answers

    What is the most common cause associated with early deceleration in FHR?

    <p>Head compression</p> Signup and view all the answers

    Late deceleration is characterized by a gradual decrease in FHR that coincides with uterine contractions.

    <p>False</p> Signup and view all the answers

    What is the recommended position for a pregnant woman experiencing issues with fetal heart rate?

    <p>Left lateral position</p> Signup and view all the answers

    The sudden decrease in FHR during variable deceleration indicates __________ stimulation.

    <p>vagal</p> Signup and view all the answers

    Match the type of deceleration with its characteristic.

    <p>Early deceleration = Gradual decrease in FHR coinciding with contractions Late deceleration = Sudden decrease in FHR beginning at peak of contraction Variable deceleration = Sudden decrease in FHR without a clear pattern</p> Signup and view all the answers

    What should be done if there is no recovery of fetal heart rate after initial management?

    <p>Administer Terbutaline</p> Signup and view all the answers

    A dip in fetal heart rate lasting more than 10 minutes indicates a change in baseline fetal heart rate.

    <p>True</p> Signup and view all the answers

    What characterizes a late deceleration on a CTG graph?

    <p>Onset and end of dip later than uterine contractions</p> Signup and view all the answers

    Gradual decrease in FHR is described as a __________ dip on the CTG graph.

    <p>U-shaped</p> Signup and view all the answers

    What is the primary characteristic of variable deceleration?

    <p>V-shaped dip on a CTG graph</p> Signup and view all the answers

    Study Notes

    Intrapartum Fetal Surveillance

    • Uterine contractions reduce uteroplacental blood flow, leading to intermittent fetal oxygenation.
    • A well-oxygenated fetus can tolerate insults to oxygenation without experiencing hypoxia.
    • A compromised fetus, especially those with intrauterine growth restriction or prematurity, cannot tolerate insults to oxygenation, resulting in fetal hypoxia, brain injury, and decreased fetal heart rate (FHR).
    • Deceleration in FHR is a sign of a compromised fetus.
    • Consequences of fetal hypoxia include metabolic acidosis, neonatal encephalopathy, hypoxic ischemic encephalopathy, and long-term sequelae such as cerebral palsy.

    Intermittent Auscultation of Fetal Heart Sounds (FHS)

    • The World Health Organization (WHO) recommends routine intermittent FHS auscultation.
    • Low-risk cases should have FHS checked every 30 minutes during the first stage of labor and every 15 minutes during the second stage.
    • High-risk cases should have FHS checked every 15 minutes during the first stage of labor and every 5 minutes during the second stage.
    • Monitoring methods include handheld Doppler and stethoscope.

    Cardiotocography (CTG)

    • Used for high-risk pregnancies.
    • Provides a continuous recording of FHR and uterine contractions.
    • Other monitoring methods include scalp pH monitoring, scalp stimulation, and pulse oximetry.
    • FHS is plotted on the partogram only after 30 minutes of monitoring.

    Normal FHR and Variability

    • Normal FHR range is 110-160 beats per minute (bpm).
    • Bradycardia is a heart rate below 110 bpm.
    • Tachycardia is a heart rate above 160 bpm.
    • Baseline variability of FHR is the irregular fluctuations in FHR, excluding accelerations and decelerations.
    • Normal variability is 6 to 25 bpm, indicating normal umbilical cord pH.
    • Absent or decreased variability is a reliable sign of fetal hypoxia and is associated with fetal acidemia.

    Non-Stress Test (NST)

    • NST assesses fetal well-being by monitoring FHR for 20 minutes.
    • A reactive NST shows ≥ 2 accelerations in 20 minutes, indicating a normal fetus.
    • A non-reactive NST shows < 2 accelerations in 20 minutes and requires further evaluation.
    • NST predicts fetal status for the upcoming week and can be done twice weekly or daily.
    • NST cannot predict sudden onset events.

    Causes of Non-Reactive NST

    • Fetal prematurity.
    • Fetal hypoxia/acidosis.
    • Fetal sleep.

    Biophysical Score (BPS)

    • Also known as the Manning score.
    • A diagnostic test done weekly in high-risk cases.
    • Evaluates five fetal parameters: fetal tone, breathing movement, gross body movement, amniotic fluid volume, and NST.
    • Each parameter is scored 0 or 2, with a total score of 10.

    Interpretation of BPS

    • BPS correlates to fetal pH with a lower score indicating fetal acidemia.
    • In fetal hypoxia, the first parameter affected is NST, and the last parameter affected is fetal tone.

    Management Based on BPS

    • A score of 10/10 or 8/10 with normal amniotic fluid volume (AFV) indicates reassurance.
    • A score of 8/10 with normal AFV requires management based on the period of gestation.
    • A score of 8/10 or 6/10 with decreased AFV suggests fetal hypoxia.
    • A score of 4/10 requires delivery if the period of gestation (POG) is ≥ 32 weeks.
    • A score of 2/10 or 0/10 requires immediate delivery.

    Vibro-acoustic Stimulation Test

    • Used to rule out fetal sleep on a non-reactive NST.
    • A short burst of sound is given to the fetus.
    • An acceleration in FHR indicates a response.

    Contraction Stress Test

    • An outdated method.
    • Contractions are induced with oxytocin in the antenatal period.
    • The FHR is monitored during the contractions.

    Modified Biophysical Score

    • A screening test that combines NST, amniotic fluid index (AFI), and BPS.
    • NST represents acute hypoxia in the fetus.
    • AFI represents chronic hypoxia in the fetus.

    Causes of Abnormal FHR Patterns

    • Maternal causes: analgesics, sedatives, magnesium sulfate.
    • Fetal causes: fetal compromise, hypoxia, acidemia, prematurity.

    Sinusoidal FHR Pattern

    • A characteristic wave pattern on the CTG.
    • Frequency of 2 to 5 cycles per minute for ≥ 20 minutes.
    • Seen in fetal anemia, Rh incompatibility, parvovirus B19 infection, vasa previa, and twin-to-twin transfusion syndrome.

    Decelerations

    • A drop in FHR by 15 bpm lasting for 15 seconds to 2 minutes.
    • Absent variable deceleration.
    • Oscillation of sinus wave (above/below baseline).
    • No use of drugs/narcotics.

    Prolonged Deceleration

    • An isolated deceleration lasting ≥ 2 minutes.

    Fetal Scalp pH Monitoring

    • Used to confirm fetal acidosis or hypoxemia.
    • Prerequisites: cervix dilated ≥ 4 to 10 cm, vertex at least at -1.5 station.
    • Procedure: incision made through fetal scalp, blood collected, and pH measured.
    • Interpretation:
      • pH > 7.25 is normal.
      • pH 7.20 to 7.25: repeat after 20 to 30 minutes.
      • pH < 7.2: immediately repeat scalp pH; < 7.2 requires emergency C-section.

    Fetal Scalp Stimulation

    • Procedure: Fetal scalp pinched using Allis forceps before taking scalp blood.
    • Interpretation: If FHR increases by > 10 bpm for 15 seconds after digital scalp stroking, the pH is > 7.2.

    Fetal Pulse Oximetry

    • A sensor introduced transcervically and positioned against the fetal face.
    • Measures fetal SpO2.

    CTG Graph Analysis

    • The document outlines various CTG graph patterns.
    • Variable decelerations are sudden decreases in FHR not directly related to uterine contractions.
    • Early decelerations are gradual decreases in FHR that begin before a uterine contraction.
    • Late decelerations are gradual decreases in FHR that begin after a uterine contraction.

    Categories of CTG

    • The document outlines the various categories of CTG readings (according to ACOG):
      • Category 1: Reassuring (Normal).
      • Category 2: Suspicious.
      • Category 3: Non-reassuring.

    Management of Non-Reassuring CTGs

    • Emergency C-section + In-utero resuscitation.
      1. Stop oxytocin.
      1. Lie in left lateral position.
      1. O2 inhalation by mask.
      1. IV fluids (if required).
      1. Terbutaline (if uterine contractions must be stopped).

    Maternal Adaptations in Pregnancy

    • Cutaneous Changes

      • Increased estrogen during pregnancy leads to increased melanocyte stimulating hormone (MSH).
        • Linea nigra: A darkly pigmented line from the xiphisternum to the pubic symphysis.
        • Stretch marks:
          • Pink striae gravidarum (stretch marks of current pregnancy)
          • Silvery-gray striae albicans (stretch marks of previous pregnancy)
        • Pregnancy mask/chloasma gravidarum: Pigmentation on the face.
        • Palmar erythema: Redness on the palms.
        • Spider naevae: Dilated veins below the skin.

    • Changes in Reproductive Organs

      • Uterus
        • Weight: Increases to 1100g.
        • Cause: Primarily due to hypertrophy (enlargement) of the uterine tissue.
        • Other contributing factor: Hyperplasia (increase in number) of uterine cells.
        • Hormone responsible: Progesterone.
        • Uterine Blood Flow: Increased.
        • Utero-placental Blood Flow: Increased to 500-750 ml/min.
        • Position: Dextrorotated (rotated to the right) to accommodate the sigmoid colon.

    • Cervix:

      • Bluish discoloration: Chadwick sign/Jacquemier's sign.
      • Closed by mucus plug to prevent ascent of infections.
      • Release of show: Blood and mucus expelled in true labor pain.
      • Hypertrophy & hyperplasia: Enlarging and abnormal cell growth of the cervix.
      • Length of cervix: 4 to 5 cm.
      • Ectropion/Eversion: Columnar epithelium of the endocervix grows over the squamous epithelium of the exocervix, often presenting as post-coital bleeding.
      • Endocervix: Inner lining
      • Exocervix: Outer lining

    • Vagina:

      • Increased Lactobacilli/Doderlein bacilli.
      • ↑ Conversion of glycogen to lactogen.
      • ↓ PH (Acidic: 3.5).
      • ↓ Pathogenic bacteria.
      • m/c vaginitis in pregnancy: Candidiasis: Candida can survive in acidic pH.
      • Bluish discoloration (Chadwick/Jacquemier sign).

    • Endocrine Changes

      • Pregnancy is a progesterone-dependent condition.
      • Progesterone:
        • Suspension of ovulation.
        • Supports decidua.
      • ↑ Estrogen & progesterone: From placenta.
      • Negative Feedback: ↓LH & FSH.
      • Ovulation: Suspended in pregnancy.
      • Amenorrhea:
        • ↑ progesterone

    Management of Non-Reassuring CTGs

    • Stop oxytocin
    • Oxygen inhalation by mask
    • Lie in left lateral position
    • If no improvement: Terbutaline (to relax the uterus)

    Types of Decelerations

    Type CTG graph Characteristics Cause
    Early deceleration Gradual decrease in FHR reaching its nadir in 30 seconds.Onset and end of FHR coincides with uterine contractions.Nadir (lowest point) coincides with highest point of uterine contraction.Usually benign (Not associated with fetal hypoxia/acidemia). Gradual decrease in FHR (U-shaped dip on CTG).Onset & end of dip coincides with contractions.Usually benign. Head compression
    Late deceleration Onset/end of dip later than uterine contraction, usually begins at peak of contraction, most ominous. Sudden decrease in FHR (V-shaped dip on CTG).Onset and end of dip later than uterine contractions, usually begins at peak of the contraction.Most ominous. Uteroplacental insufficiency
    Variable deceleration Sudden decrease in FHR (V-shaped dip on CTG). Vagal stimulation.

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    Test your knowledge on intrapartum fetal surveillance and the implications of fetal hypoxia. This quiz covers topics such as uterine contractions, fetal heart rate monitoring, and recommendations from the WHO for intermittent auscultation. Learn about the signs of a compromised fetus and the importance of timely interventions.

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