Intrapartum Fetal Surveillance PDF

intrapartum fetal monitoring The goal of intrapartum fetal assessment is to prevent fetal mortality or morbidity, primarily resulting from asphyxia. Perinatal asphyxia is estimated to affect 2–5 per 1000 live births. 1 The outcomes of perinatal asphyxia are poor; in high- income countries up to 40...

intrapartum fetal monitoring The goal of intrapartum fetal assessment is to prevent fetal mortality or morbidity, primarily resulting from asphyxia. Perinatal asphyxia is estimated to affect 2–5 per 1000 live births. 1 The outcomes of perinatal asphyxia are poor; in high- income countries up to 40% of infants will die and 30% will have significant long-term neurodisability.1 These outcomes are not only tragic for the families involved, but they place a significant burden on the country as children with hypoxic–ischaemic- encephalopathy (HIE) may develop cerebral palsy with lifelong consequences for that family. Case : Fetal Assessment Intrapartum Athmar is a 27 year old G3P1A1 pregnant of 37wks gestation, presented at 8:00 am on the day of your call to the labour ward with abdominal pain.She is a known case of hypertension on treatment since second trimester. She is a teacher. Family history is positive to hypertension and diabetes mellitus. The family asked you whether she is in labour or not. 1- What are the criteria of labor pain to differentiate it from other types of pain? 2 - After taking full history from Athmar, you performed general, abdominal and pelvic examination. Her vital signs were normal and she was not in labour; however, she was worried about her baby as she is having hypertension. You admitted her for further assessment. How can you assess her fetal condition?  Athmar called you at 2:00 pm and informed you that her pain is increasing and she is starting to pass clear watery discharge per vagina.O/E: PR= 88/min, BP=140/90 mmHg, T= 37c. Fetal HR= 130/min. She is having 3 uterine contractions per 10 min, head is engaged. P/V examination: cervical dilatation is 2 cm, cephalic presentation, membranes are ruptured and the liquor is clear. 1-At what stage of labour Athmar is? 2- Plot these findings on a portogram 4 How would you monitor her fetal condition during labour? 5 The patient asked you that she want to eat and drink, what is your advice? 6 How frequent you want to perform pelvic examination? 7- At 8:00 pm you examined Athmar and found that she is in the second stage of labour. She asked you at which position she can deliver. Do you prefer certain position? At 8:15 pm Athmar started to push down, you examined her and found that the head is crowni g 8- What the meaning of crowning? 9- Can you prevent perineal tears at this stage? How? 10 -Athmar delivered a live male baby of 3.250kg body weight spontaneously. At the first min. the delivered baby is pink with blue extremities, his heart rate is 95bpm, and well- flexed limbs, with strong cry and normal respiration. He responded to sole stimulation by a grimace. Athmar asked you about the condition of her baby. What is APGAR SCORE of this newborn baby? Athmar asked you whether she finished her labour or not and you informed her that the placenta is not yet delivered. You are waiting for delivery of the placenta. 11 What are the signs of placental separation? 12 If the placenta is separated how would you deliver the placenta?. 13 The placenta was delivered within 10min. Is this labour regarded as normal? What are the criteria of normal labour? 14 Give five reasons why a low risk woman in labour might be commenced on electronic fetal monitoring (EFM). 15 What four fetal features are assessed when interpreting a cardiotocogram? 16 You perform a fetal blood sample (FBS) on the basis of abnormal CTG and the result shows a PH of 7.22. Outline your plane management.  intrapartum fetal monitoring Methods of intrapartum fetal monitoring  Intermittent auscultation listening to the FHR either by a Pinard stethoscope Or a hand-held Doppler device Intermittent auscultation(IA) is recommended as a minimum for women who, at the onset of labor, are identified as low risk of developing fetal compromise. FHR should be auscultated every 15 minutes for duration of one minute soon after a contraction During the first stage of labor and every 5 minutes or after every other contraction during the second stage of labor.  Intrapartum fetal monitoring  continuous electronic fetal monitoring This is the most widely used method of intrapartum fetal surveillance in high-risk labor. This is achieved by using a Doppler ultrasound transducer placed on the mother’s abdomen (external CTG) or a scalp electrode (internal CTG) to monitor the baby’s heart rate. A pressure gauge transducer is placed on the abdomen between the uterine fundus and the umbilicus to monitor uterine contractions. CTG is a continuous recording of the fetal heart rate combined with a recording of uterine activity. Continuous electronic fetal monitoring  Interpretation of the CTG FHR pattern recognition should be in relationship to the uterine contractions. The four features of the heart rate the baseline rate, baseline variability, accelerations and Decelerations Normal FHR pattren  Fetal compromise in labour Fetal compromise in labour may be due to a variety of pathology, including  placental insufficiency,  uterine hyper stimulation,  maternal hypotension,  cord compression and  placental abruption. Identification of any reversible cause of abnormality and initiation of appropriate action (correction of maternal hypotension, cessation of oxytocin and/or tocolysis for excess of uterine activity) has been shown to be useful to correct FHR abnormality.  Tachycardia Mean FHR>160 BPM Causes: Maternal fever Fetal hypoxia, Fetal anemia, Ammonites, Fetal tachyarrhythmia) and SVT (200- 240 BPM) Fetal heart failure Drugs Beta sympathomimetic  Bradycardia Mean FHR < 110 BPM Causes – Heart block (little or no variability) – Occiput posterior or transverse position – Serious fetal compromise. – hypoxia  Grades of fluctuation are based on amplitude range (peak to trough): Absent variability = Amplitude range undetectableMinimal = < 5 BPM Moderate = 6 to 25 BPM Marked = > 25 BPMThe tracing tshows an amplitude range of ~ 10 BPM (moderate variability ).  variability Persistently minimal or absent FHR variability appears to be the most significant intrapartum sign of fetal compromise. Causes of Decreased Variability Fetal metabolic acidosis Pre existing neurologic abnormality CNS depressants Fetal sleep cycles Congenital anomalies Prematurity Fetal tachycardia Normal variant Betamethasone A pre-terminal trace with no accelerations, markedly reduced baseline variability and shallow late decelerations  deceleration  Early decelerations are characterized by a slowing of the fetal heart rate starting at t he beginning of the contraction, and returning to the baseline by the end of the contraction  A late deceleration is a slowing of the fetal heart rate during a contraction, with the rate only returning to the baseline 30 seconds or more after the contraction has ended.  Variable decelerations have no fixed time relationship to uterine contractions. Therefore, the pattern of decelerations changes from one contraction to another.  Fetal scalp blood sampling Fetal blood sampling (FBS) is an invasive procedure. A sample of blood is taken from the fetal scalp using an amnioscope and is subjected to blood gas analysis. Contraindications for FBS include  maternal infections such as HIV, hepatitis B or C, herpes  fetal bleeding disorders such as hemophelia  and premature gestation(