SUBJECT:

Obstetrics and Gynecology Transcriber: Miles Fernandez TOPIC: High Risk Pregnancy/ Antepartum Editor: Sarah Sy-Santos and Intrapartum Assessment Lecturer: Jenny Lynn Y. Vidanes, MD, DPOGS,FPSMFM Number of Pages: 11
Legend:

Things she stressed na most likely lalabas

High Risk Pregnancy Description: Pregnancies where there is an increased risk of maternal of fetal morbidity and mortality Perinatal events have significant role in infant mortality Fetal deaths may occur during antepartum and intrrapartum Attributed by: 30% Asphyxia (IUGR, Prolonged Gestation) 30% Maternal Complications 15% Congenital Anomalies 20% UNKNOWN etiology 5% Infection High Risk Factors A. Maternal Factors Maternal Age o Age is less than 18 years old Lack of physical or emotional maturity for pregnancy o Multipara > 35 years old Greater exposure to infections/diseases; increased risk for developmental abnormalties o Woman greater than or equal to 35 years of age had a 2 fold greater risk for fetal death (Fretts, et al.) o Fetal deaths are highest in teenagers (< 18 years old) and women (> 35 years old) (Denmark data) Maternal Height o 60 inches (153 cm) or less Increased risk for cephalo pelvic disproportion o Increased rate for birth trauma, caesarean section, congenital anomalies, and prematurity o 42% contracted pelvis Maternal Weight o Obesity/Abnormal BMI causes: Increased fetal growth Medical Complications (hypertension and diabetes mellitus) Increased need for operative delivery Increased still birth and neonatal death Obesity increases propensity for cardiovascular disease Social Factors o Smoking Teratogenic Intrauterine Growth Restrictions It would induce vascular damage, leading to placental insufficiency o Drugs Opium, Barbiturates, Amphetamines, and Methadone: Low birth weight Tetracyclinw: Brownish staining of deciduous teeth Chloramphenicol: Gray's Syndrome Ash gray cyanosis of baby due to vascular collapse; RDS Streptomycin: Congenital Deafness o Alcohol Fetal mental retardation Delerium Tremens Craniofacial defect Limb defects Cardiovascular defects IUGR

B. Obstetric History Multiparity (>5) Abruptio Placenta Placenta Previa displacement of placenta anterior to fetal head; the placenta "blocks" the birth canal Postpartum Haemorrhage Uterine Rupture Twinning Dysfunctional Labor Congenital anomalies C. PROM and Preterm Birth Cord prolapsed Intrauterine amniotic infection Respiratory distress syndrome Intraventricular haemorrhage preterm Necrotizing enterocolitis preterm D. Fetal Growth Disorders IUGR o Prematurity, Death Fetal Macrosomia o Asphyxia o Fetal distress o Trauma o Vaginal lacerations o Uterine atony decreased contractions due to over stretched uterus E. F. Amniotic fluid abnormalities Polyhydramnios (> 24 cm) Oligohydramnios (< 5 cm) Post-term pregnancy Sharp rise in both fetal and neonatal mortality Fetal injury from fetopelvic disproportion Asphyxial damage from fetal distress with increased chance of mental subnormality and neurologic deficit

G. Maternal Medical Conditions Renal diseases increased risk for fetal pulmonary edema Diabetes Mellitus macrosomic baby Thyroid disorders o Hyperthyroidism tachycardia, hepatosplenomegaly, IUGR, craniosyntosis o Hypothyroidism Neurologic abnormalities, respiratory difficulty, dysmorphic facies, hypotonia Cardiovascular disorders predisposition to eclampsia Respiratory disorders Hematologic disorders Anemia Malnutrition LBW infant

High Risk Clinic Pregnancies at extremes of reproductive age o 17 years and below o Primigravida 35 years and above Placenta Previa increased chance of bleeding preterm

@ Poor Obstetrical History 2 Consecutive Abortions 3 or more Repeated Abortions Previous Preterm Delivery Previous Fetal and/or Neonatal Death Previous birth with Congenital anomaly
Diagnosed medical conditions Hypertension, Diabetes Generative tract disorders Co-existing trophoblastic diseases or had a trophoblastic disease within the last year Psychiatric conditions Problems in fetal, aging, structure, or size Malignancies (genital and extragenital) Polyhydramnios or Oligohydramnios Low Risk Pregnancy Monitor every 30 minutes Monitor every 15 minutes High Risk Pregnancy Monitor every 15 minutes Monitor every 5 minutes

Fetal Well Being Goal of Fetal Surveillance Prevent fetal death Assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions as well as those in which complications have developed Fetal Response to Hypoxemia a. Increase Oxygen Supply Includes increase in baseline heart rate, haemoglobin concentration, improved cardiac contractility or efficiency, and increased oxygen extraction This phase in unlikely to suffice in the case of placental insufficiency *Increase in placental resistance by increasing fetal blood pressure (Fetal Hypertensive State) b. Control Oxygen Distribution Preservation of oxygenation in vital centers of the brain, heart, adrenals, and placenta Reduction of flow to the mesenteric, renal, and distal aortic outflow tracts Causes assymetrical IUGR brought about by brain sparing effect c. Reduce Oxygen Consumption Initiates minor increase in time between activity cycles and may extend all the way to complete abolition of fetal activity Fetus may not move to conserve O2 consumption; therefore, less movement leads to more conserved O2 Fetal oxygen consumption may fall more than 15% during inactivity

@ Intermittent Auscultation
1st stage of labor 2nd stage of labor

Electronic Fetal Monitoring Done only for high risk patients Types: a. External (Indirect) Ultrasound Doppler Principle b. Internal (Direct) Electrode attached to fetal scalp Increased the overall CS rate (relative risk [RR], 1.66; 95% confidence interval, 1.30-2.13) and the CS rate for abnormal Fetal Heart Rate (FHR) or acidosis or both Increased the risk of both vacuum and forceps operative vaginal delivery The use of Electronic Fetal Monitoring (EFM) a. Reduces the risk of neonatal seizures (RR, 0.50; 95% CI, 0.31 - 0.80) Only advantage b. Does not reduce the perinatal mortality (RR, 0.85; 95% CI, 0.59 - 1.23) c. Does not reduce the risk of cerebral palsy (RR 1.74; 95% CI, 0.97 - 3.11) Continuous EFM should be offered and is recommended for High Risk Pregnancies Current evidence does not support the use of admission tocogram in low risk pregnancy (Leve III, C) From the book: Although maternal heart tones are 5x higher than the babys, the machine selectively picks up the fetal heart tone. So one way for the phycisan to know if the baby is dead is if the machine already picks up the maternal heart tone.
Antepartum Surveillance focuses on fetal physical activites (well being) Intrapartum Surveillance focuses on fetal heart rate analysis

@ Fetal Asphyxia
a. Immediate adaptive response Inhibition of Heart rate acceleration Fetal breathing movements Gross body movements Occurs within minutes of insult CNS center regulating Non Stress Test (NST) most sensitive Fetal respiratory center almost as sensitive Centers regulating fetal tone and movement least sensitive Chronic adaptive response Reflexive in origin Mediated by aortic arch and carotid chemoreceptors Redistribution in cardiac output Increased supply to brain, heart, adrenals, and placenta Decreased supply to other organs e.g. Decrease in renal output due to oligohydramnios Effects of redistribution of cardiac output develop slowly Magnitude of responses mimic severity of insult Response is progressive Response is not reversible

b.

Fetal Hypoxemia (Asphyxia) CNS Cellular Dysfunction Aortic body chemoreceptor stimulation

Hypotonia Absent fetal breathing Absent fetal movement Non Reactive NST

Reflex redistribution of cardiac output

Reflex Late deceleration

Increased blood flow to: Fetal Brain (? IVH) Adrenals Heart Placenta

Decreased blood flow to: Fetal Kidneys (Oliguria) Lung (Respiratory Distress Syndrome - RDS) Gut (NEC) Liver Carcass

Regulation of Fetal Heart Rate Sympathetic Regulation a. Releases catecholamine from sympathetic nerve endings and from chromaffin tissues of the adrenal glands b. Causes cardiac acceleration c. Induce fetal vasoconstriction and fetal hypertension Parasympathetic Regulation a. b.

@ Most important controlling mechanism of the FHR

Travels from the cardioregulatory center in the ventral surface of the brainstem to the heart via the cardiac fibers of the vagus nerve Releases acetylcholine in the region of SA and AV node

Aspects of Fetal Condition that Might be Influenced by Antepartum Testing Perinatal death IUGR Non reassuring fetal status Neonatal asphyxia Postnatal motor and intellectual impairment Congenital anomalies Need for specific therapy When to do Antepartum Assessment? (ACOG) For most at risk patients 32 - 34 weeks For multiple or worrisome conditions 26 - 28 weeks Fetal Movement Counting Fetal activity that can be appreciated as early as 7 weeks different from quickening. Beyond 8 weeks, fetal body movements are never absent for periods exceeding 13 minutes At 36 weeks the fetal behaviour status is already established Since 1973, case reports of decreased fetal activity preceded fetal death Quantify fetal movement as a way to assess and prognosticate fetal well-being Several protocols: Examples Perception of 10 movements in 2 hours Counting of fetal movements in 1 hour 3-4x a day Time needed to feel 10 movements 6 movements in 1 hour Decreased fetal movements a. Decreased amniotic fluid: due to redistribution of blood in response to asphyxia b. Drugs c. Sedatives: Maternal sedative or anesthesia can pass through placenta d. Sleep state in the fetus e. Fetal compromise

c.

Antepartum Fetal Assessment Indication for Antepartum Fetal Monitoring 1. For patients at high risk for uteroplacental insufficiency a. Prolonged pregnancy b. Diabetes Mellitus c. Hypertension d. Previous stillbirth e. Suspected IUGR f. Advanced Maternal Age g. Multiple gestations with discordant growth h. Antiphospholipid syndrome Antibodies attack phospholipids which leads to increased risk of spontaneous abortion 2. When other tests suggest fetal compromise a. Suspected IUGR b. Decreased fetal movement c. Oligohydramnios 3. Routine antepartum surveillance Obstetric Conditions and Management influenced by Anterpartum Testing Preterm delivery Route of delivery Bed rest Observation Drug therapy Operative intervention in labor Neonatal intensive care Termination of pregnancy for a congenital anomaly

Pros and Cons of Fetal Movement Counting

PROS Simple Can be Done at Home No human or material resources needed CONS Intrude on the woman's time Unnecessary anxiety to the mother Staff overload as additional investigations may have to be done exclusive to fetal compromise Might increase antenatal admissions, obstetric interventions, and prematurity

@ Neural Control of Fetal Biophysical Activities

Biophysical Parameter Fetal Tone Fetal Movement Fetal Breathing Fetal Heart Reactivity CNS Center Cortex Subcortical Area Cortex-Nuclei Ventral surface of 4th ventricle Medulla and Posterior Hypothalamus AOG 7.5 - 8.5 weeks 9 weeks 20 - 21 weeks 24 - 26 weeks

Related Studies: a. Four studies, involving 71,370 women, were incuded in this review; 68,654 in one cluster-randomised trial b. Not enough evidence to influence practice c. No trials compared fetal movement counting with no fetal movement counting d. Results neither confirm nor refute the effectiveness of fetal movement counting as a method of fetal surveillance e. Not enough evidence to recommend or not to recommend formal fetal movement counting f. Insufficient data to assess stillbirths accurately g. Woman to count distinct fetal movements on a daily basis after 28 weeks AOG h. Perception of 10 distinct movements in up to 2 hours is considered reassuring i. The counting can be discontinued for that day after 10 movements

Correlate with other significant fetal developments para masmadali magmemorize ng AOG J 8 weeks: About the time na pelvic organ pa ang uterus 9 weeks: Abdominal organ na ang uterus 20 weeks: Fundic height is around the umbilicus 24weeks: Same ang AOG with the fundic height in cm

@ Hypoxia Cascade Theory

Cascade of hypoxia first affects the last neural center to be developed. Kasi if it is last to be developed, meaning it is more immature and took less time being developed than an area was formed first Fetal Heart Rate Activity
(Medulla and Posterior Hypothalamus)

Fetal Breathing Movement

(Ventral Surface of 4th ventricle)

Fetal Behavioral States 1F: Quiescence (quiet sleep) 2F: Frequent gross body movements, Continuous eye movements, and Oscillation of FHR (REM sleep) 3F: Continuous eye movements, Without body movements, No increase in FHR 4F: Vigorous body movements, Continuous eye movements (Awake state) Fetuses spend most of their time in states 1F and 2F Sleep Awake Cycles a. Independent of maternal sleep awake cycles b. 20 - 75 minutes (mean: 40 minutes)

Fetal Movement
(Cortex Nuclei)

Fetal Tone
(Cortex Subcortical Area) **Hear Bachs Movement and Tone. Haha. I tried. Sana gumana J

Biophysical Profile Non-invasive test that combines data from 2 sources: a. Ultrasound imaging b. Fetal heart rate monitoring It predicts the presence or absence of fetal asphyxia and the risk of death during the antenatal period Parameters a. Fetal breathing movements b. Fetal movement c. Fetal tone d. Fetal heart rate activity e. Amniotic fluid volume Markers f. Acute Markers Fetal breathing movements Fetal movement Fetal tone Fetal heart rate activity b. Chronic Marker Amniotic fluid volume

Parameters of Biophysical Profile a. Fetal Breathing Initial inward movement of the thorax with descent of the diaphragm and abdominal contents, followed by a return to the original position Fetal "hiccups" (a variant of normal fetal breathing) Paradoxical chest wall movement Two types of Respiratory Movement: Gasps or Sighs o Occurs at a frequency of 1 to 4 minutes Irregular bursts of breathing o Occurred at rates up to 240 cycles per minute Has diurnal variation, diminishes during night (paradoxical breathing) Variables that affect fetal respiratory movements Hypoxia Labor Hypoglycemia Sound stimuli Cigarette smoking Amniocentesis Impending PTL Gestational age FHR (Fetal Heart Rate)


b. Fetal Tone Limb or trunk extension with return to flexion Opening of hand with finger and thumb extension with return to closed-fist formation Hand remains in flexed formation for the entire 30 minute period Amniotic Fluid Volume Largest single vertical pocket Chronic Marker Amniotic fluid index Oligohydramnios: < 5 cm Low normal: 5 - 7.9 cm Normal: 8 - 18 cm High Normal: 18.1 - 24 cm Polyhydramnios: > 24 cm Factors Influencing BPP Performance a. Drugs Sedatives Decrease activity Cocaine Bizarre fetal movement Indomethacin Oligohydramnios b. Maternal cigarette smoking Fetal breathing movement abolished or attenuated Fetal movement reduced Causes decrease 02deliver by placenta c. Maternal Hypoglycemia Abnormal behaviour Features of Electronic Fetal Monitoring A. Baseline Fetal Heart Rate *Please read the attached page on how to read fetal heart tones first J pictures are also included at the back para kita J Causes of Fetal Tachycardia Fetal Hypoxia Fetal Anemia Fetal Sepsis Fetal Heart Failure Fetal Tachyarrythmia Maternal Fever Maternal Hyperthyroidism Beta-Sympathomimetic drugs Parasympatholytic drugs: Atropine, Hydroxyzine HCl (Iterax), Phenothiazines Fetal hypopituitarism with brainstem injury Maternal hypothermia Prolonged hypoglycaemia Beta blocker therapy Second stage of labor Maternal heart rate being recorded in a case of fetal demise B. Baseline Variability Fluctuations in the baseline FHR that are irregular in amplitude and frequency Visually quantified as the amplitude of peak to trough in beats per minute Types: o Absent: Amplitude range undetectable

c.

@ Biophysical Profile Scoring

Component Fetal Breathing Fetal Movement Fetal tone Score = 2
>1 episode of rhythmic breathing lasting > 30 seconds within 30 minutes > 4 discrete body or limb movements within 30 minutes > 1 episode of extension of a fetal extremity with return to flexion, or opening or closing hand Single vertical pocket > 2 cm

Score = 0
< 30 seconds of breathing in 30 minutes < 4 movements in 30 seconds No movement or no extension/flexion

Amniotic Fluid Volume Non Stress Test Score 10 8/10

(Normal AFV)

> 2 acceleration of > 15 beats/minute for > 15 minutes in 20 - 40 minutes

Largest single vertical pocket < 2 cm 0 or 1 acceleration in 20 to 40 minutes

Interpretation
Normal, non asphyxiated fetus Normal, nonasphyxiated fetus

Management
Repeat testing weekly For diabetics 2x a week Repeat testing weekly For diabetics 2x a week

8/8
(if NST is not done)

8/10
(Decreased AFV)

Chronic Asphyxia Suspected

Deliver

Possible fetal asphyxia

4 0-2

Probable fetal asphyxia Almost certain fetal asphyxia

If AFV abnormal Deliver If AFV normal at > 36 weeks with favourable cervix Deliver If repeat test is < 6 Deliver If repeat test is > 6 Observe Repeat test on same day, if < 6 Deliver Deliver

Minimal: Amplitude range detectable but 5 beats per minute or fewer

BPP Score 0 2-4 6 8 or 10

Associated with fetal acidemia Progressively moreaccurate predictor of abnormal outcome Equivocal test was a poor predictor of abnormal outcome Associated with normal pH

Moderate (Normal) Amplitude ranges 6 - 25 beats per minute

Marked: Amplitude range greater than 25 beats per minute

Categories a. Early deceleration (Head Compression) Visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine contraction The nadir of the deceleration occurs at the same time as the peak of the contraction The onset, nadir, and recovery of the deceleration are coincident with the beginning peak, and ending of the contraction, respectively (mirror image) Generally seen in active labor between 4 and 7 cm dilatation Not associated with fetal hypoxia, academia, or low APGAR scores Symmetrical gradual decrease and return of the FHR associated with a uterine contraction Onset to nadir: greater than or equal to 30 seconds Nadir occurs at the same time as the peak of the contraction

Causes of Decreased FHR variability Fetal sleep cycles Hypoxia/Acidosis Extreme prematurity Congenital anomalies Fetal tachycardia Pre-existing neurological abnormality Drugs: CNS depressants, parasympatholytics (atropine), Beta Blockers C. Periodic Changes Acceleration Abrupt increase in FHR: Onset to peak in < 30 seconds Peak: > 15 bpm lasting 15 seconds from onset to return to baseline Prolonged acceleration: > 2 minutes but less than 10 minutes Acceleration > 10 minutes = Baseline change A visually apparent abrupt increase (onset to peak in less than 30 seconds) in the FHR 32 weeks of gestation and beyond Peak of 15 beats per minute or more above baseline, with duration of 15 seconds or more but less than 2 minutes from onset to return Before 32 weeks of gestations Acceleration has a peak of 10 beats per minute or more above baseline, with duration of 10 seconds or more but less than 2minutes from onset to return Prolonged acceleration Lasts for 2 minutes or more but less than 10 minutes in duration Baseline change Acceleration lasts 10 minutes or longer Deceleration Transient episode of slowing of the fetal heart rate beow the baseline level of more than 15 bpm and lasting 15 seconds or more If rate is below 110 bpm and duration is > 10 minutes bradycardia b. Variable deceleration (Cord Compression) Visually abrupt decrease in FHR Onset, depth, and duration vary with successive contraction Usually due to umbilical cord compression Abrupt decrease in FHR Onset to nadir: < 30 seconds Decrease in FHR is greater than or equal to 15 bpm, lasting greater than or equal to 15 seconds, and less than 2 minutes in duration

(B) Variable Deceleration


c. Late deceleration (Uteroplacental Insufficiency) Onset, nadir, and recovery of the contraction occur AFTER the beginning, peak and ending of the contraction, respectively Any process that causes maternal hypotension, excessive uterine activity or placental dysfunction Epidural anesthesia Oxytocin stimulation Direct myocardial depression in severe cases Onset to nadir: Greater than or equal to 30 seconds Nadir of the deceleration occurs after the peak of the contraction D. Uterine Contractions Types: Interval Duration Intensity Montevideo Units It is the product of the intensity (increased uterine pressure above baseline tone) of a contraction in mmHg multiplied by contraction frequency per 10 minutes E.g. 3 contractions in 10 minutes, each 50 mmHg intensity would equal to 150 montevideo units Patterns of uterine activity First stage of labor Increased uterine contraction intensity from 25 mmHg at commencement of labor to 50 mmHg at the end Frequency increases from 3 to 5 contractions per minute Uterine baseline tone from 8 - 12 mmHg Second stage of labor Contractions of 80 - 100 mmHg are typical Increase frequency to 5 to 6 per 10 minutes

To help visualize what happens to the fetus heart rate when contractions occur.

a.

Other Categories Prolonged deceleration Visually apparent decrease in the FHR below the baseline, 15 beats per minute or more, lasting 2 minutes or more but less than 10 minutes in duration

b.

Sinusoidal pattern Visually apparent smooth, sine wae-like undulating pattern in FHR baseline with a cycle frequency of 3-5 beats per minute which persists for 20 minutes or more Causes: Severe fetal anemia, analgesics (Demerol), amnionitis

Origin and Propagation Originates near the uterine end of one of the fallopian tubes (Pacemakers) Right pacemaker usually predominates over the left and starts most contractile waves Contractions spread from the pacemaker area throughout the uterus at 2 cm/sec, depolarizing the organ within 15 seconds Depolarization wave propagates downward towards the cervix Intensity is greatest in the fundus and it diminishes in the lower uterus

Non Stress Test (NST) Done without uterine contractions Fetal heart rate of a fetus that is not acidotic or neurologically depressed will temporarily accelerate with fetal movements Heart rate reactivity thought to be a good indicator of normal fetal autonomic function Diurnal rhythm in mature fetuses: Acme (145 bpm): midday Nadir (120 bpm): early morning hours
Parameter Baseline

@ Normal
(Reactive) 100 - 160

Atypical (Nonreactive) 100-110 >160, < 30 minutes Rising Baseline < 5 for 40 - 80 minutes

Abnormal (Nonreactive) < 100 >160, >30 minutes Erratic baseline < 5 for > 80 minutes > 25 for > 10 minutes Sinusoidal Variable for > 60 seconds Late decelerations < 2 at > 15 bpm for 15 seconds > 80 minutes

Variability

6 - 25 < 5 for < 40 minutes

Decelerations

Accelerations Term

Accelerations < 32 weeks

Action

None or occasional but < 30 seconds > 6 at > 15 bpm for 15 seconds < 40 minute testing > 2 at > 10 bpm for 10 seconds < 40 minute testing Further assessment optional

Variable deceleration 30 60 seconds < 2 at > 15 bpm for 15 seconds in 40 - 80 minutes

< 2 > 10 bpm for 10 seconds in 40 - 80 minutes

< 2 > 10 bpm for 10 seconds in > 80 minutes

Contraction Stress Test (CST) Used to determine if there is Late deceleration Uteroplacental insufficiency Detection of presence or absence of FHR decelerations in response to either spontaneous or induced uterine contraction Fetus with reduced placental reserve will develop transient fetal hypoxemia in association with the interruption of uteroplacental blood flow caused by contractions CST Method Mother in semi-recumbent position or in a left lateral tilt Initial trace of 15 minutes to determine baseline FHR and to note for spontaneous contractions Induction of contraction: Intravenous oxytocin 10 'u'/1 L saline titrated (not to exceed 60 m'u'/min) Goal: 3 contractions in 10 minutes Manual Nipple Stimulation Not to exceed 2 minutes in duration, not less than 5 minutes apart Goal 3 contractions in 10 minutes Contraindications for CST Absolute Placenta previa Chronic fetal abruption Proven or suggested cord presentation Upper uterine segment scar Relative Pregnancy at risk for premature delivery E.g. Multiple gestation, Incompetence

@ Interpretation
Category Normal or Negative Positive Equivocal-suspicious Interpretation No late or significant variable decelerations Late decelerations following 50% or more of contractions Intermittent late decelerations or significant variable decelerations Fetal heart rate decelerations with contractions > every 2 minutes or lasting longer than 90 seconds Fewer than three contractions in 10 minutes or an uninterpretable tracing

Further assessment required

Urgent action required

Reactive VS Non Reactive NST REACTIVE BFHR 130-135 bpm Variability Moderate Accelerations + Decelerations -

NON-REACTIVE 150 bpm Minimal to absent -

Equivocal hyperstimulatory Unsatisfactory

Loss of reactivity may be associated: Fetal Sleep Cycles Fetal Acidosis Central nervous system depression Indications It is initiated at 32 weeks AOG on a weekly basis or earlier or more frequent in very high risk situations Twice weekly for women with post term pregnancy, multifetal gestation, type 1 diabetes, IUGR, and PIH Causes of FALSE NEGATIVE NST Prematurity Maternal smoking and stress Malnutrition Glycemic levels Fetal sleep states Causes of FALSE POSITIVE NST Caffiene Cocaine Morphine Sedatives Alcohol

*Take Note: Negative CST Good indicator of fetal health Positive CST Relatively poor predictor of fetal compromise CST Best used in combination with other tests of fetal well-being

Intrapartum Fetal Assessment Done when the patient is already in labor Fetal Heart Rate Analysis The primary means in which a fetus is evaluated for adequacy of oxygenation


Factors affecting FHR a. Gross body movement Associated with increase in FHR, starting at 20 - 26 weeks AOG Large, combined limb and trunk movement versus isolated limb or rolling trunk movement Passive fetal movements produced by palpation DOES NOT elicit increase in FHR b. Fetal breathing movements Variability may be increased with breathing movements Increased variability and breathing movements during REM sleep c. Pain Early 2nd trimester: FHR deceleration 22 weeks onwards: increase in FHR d. Temperature Increase in maternal temperature (i.e. infection): Gradual increase in FHR Lowering of maternal temperature: Fetal bradycardia e. Viroacoustic stimulation Technique: Placement of electronic artificial larynx placed approximately 1 cm from or directly onto the maternal abdomen Normal response: Fetal heart rate acceleration of at least 15 bpm for at least 15 seconds after the stimulation and prolonged fetal movements f. Measurements: < 30 weeks Single sustained increase in FHR > 33 weeks Increase in FHR may take > 10 minutes from stimulation Term Elevation of the FHR may persist up to 1 hour g. Sleep/Wake Cycles Affects mainly variability rather than FHR Variability organized into episodes of high and low variability (lasting about 20 minutes each) wide variability in duration REM sleep: Increased variability Quiet sleep: Reduced to absent variability h. Drugs In general, drugs affect the baseline fetal heart rate and has less effect on the fetal reflex responses Mechanisms of drug effects on the fetal heart rate: Primary Mechanisms Examples Increased Beta adrenergic stimulation Ritodrine, Isoxsuprine, Heart Rate Terbutaline Alpha Adrenergic Blockade CNS stimulants /Dysarrhythmics (general) Parathecol stimulants Catechol release Increased metabolic rate Vagal blockade Vagal stimulation/SA depression Beta-sympathetic blockade Alpha-sympathetic stimulation CNS depressant Myocardial depressant Phenotalamine Cocaine, Ketamine Ephedrine Nicotine Caffeine, Thyroxine Atropine Digoxin Propanolol Dopamine General Anaesthetics Lidocaine

Decreased Heart Rate

Classification of FHR Tracings (Three tiered system) Category FHR Definitions Trackings I Normal Normal acid base status at the time of observation II Indeterminate Not predictive of abnormal fetal acid base status, yet presently there is no adequate evidence to classify as Category I or III III Abnormal Associated with abnormal fetal acid base status Category I : Normal Category II Not predictive of normal fetal acid-base status Require evaluation Continued surveillance and reevaluation Ancillary tests or intrauterine resuscitative measures may be used. Ancillary (Supplementary) tests may include: Fetal scalp pH sampling Allis clamp fetal scalp stimulation Digital scalp stimulation Vibroacoustic stimulation Category III Associated with abnormal feta acid base status Clinical evaluation Expeditiously resolve abnormal pattern: Maternal oxygen Maternal position change Discontinuation of labor stimulation Treatment of maternal hypotension Treatment of tachysystole (Uterine hyperstimulation) If abnormal FHR pattern does not resolve DELIVER!

@ 2008 NICHD Workshop on Electronic Fetal Monitoring

Baseline FHR Baseline FHR Variabiity Category I (Normal) 110 - 160 bpm Moderate (6 - 25 bpm) Present or Absent Present or Absent Absent Category II (Indeterminate) <110 bpm Bradycardia >160 bpm Tachycardia Minimal (< 5 bpm) Absent (not accompanied by recurrent decelerations) Marked (> 25 bpm) Absent *Recurrent variable *Prolonged deceleration > 2 minutes but < 10 minutes *Recurrent late decelerations with moderate variability *Variable decelerations with other characteristics Category III (Abnormal)

Absent baseline variability and any of the following: *Recurrent late decelerations *Recurrent variable decelerations *Bradycardia (< 110 bpm) OR Sinusoidal Patterns

Accelerations Early Decelerations Late or Variable Decelerations

*Take Note: Acceleration may not be an important factor since it is absent in both Category II and III but may be present or absent in Category I Intrauterine Resuscitation Discontinuation of any labor stimulating agent Cervical examination to determine umbilical cord prolapsed, rapid cervical dilatation, or descent of the fetal head Changing maternal position to left lateral recumbent position Monitoring maternal blood pressure level for evidence of hypotension, especially those with regional anaesthesia Assessment of patient for uterine tachysystole Fetal Scalp Sampling
ACOG 1995 measurements of the pH in capillary scalp blood may help to identify the fetus in serious distress Uncommonly used Only performed in select cases of deliveries in which the fetal heart rate tracing other conditions raise some concern regarding fetal status

Possible complications a. Haemorrhagic or infection complications b. Numerous samples can result in soft tissue trauma to the fetus Interpretations:
Recommended action Labor is observed FSS is repeated within 30 minutes FSS is collected immediately and the mother is taken to an operating room and prepared for delivery

Fetal blood sample result (pH) >7.25 7.20 - 7.25 <7.20

Principle:
a. During period of hypoxia, the fetus will use anaerobic metabolic pathways, thus increasing lactate levels Evidence of severe fetal or maternal distress Concern for vertical transmission of maternal infection Minimal cervical dilatation or excessive fetal caput (edema)

Contraindications
a. b. c.

Scalp stimulation a. Clark and associates (1984) suggested that scalp stimulation is an alternative to scalp blood sampling b. This is based on the observation that acceleration of the heart rate in response to pinching of the scalp with an Allis clamp just prior to obtaining blood was invariably associated with normal pH

______________________________________________________________________________________________________________________ End of Transcription

How to read fetal heart tones 101 Acme: Peak/ Highest point Nadir: Trough/ Lowest point Baseline Heart Rate Criteria: Mean fetal heart rate rounded to increments of 5 beats per minute during a 10 minute segment excluding: a. Periodic or episodic changes (e.g. acceleration,deceleration) b. Periods of marked FHR variability (e.g. absent, minimal, marked) c. Segments of baseline that defer by more than 25 beats per minute (only increments of 5) The baseline must be for a minimum of 2 minutes in any 10 minute segment. Here is a picture of normal FTH recording. Take note that 1 square=10 seconds. 6 squares = 1 min. The thickened line will mark 1 minute.The vertical numbers correspond to the number of beats/minute. Each horizontal line= 10 beats. The baseline should follow the 2nd criteria. So dapat, medyo steady/constant yung line at certain number of beats for at least 2 squares. The baseline you see in a 10 minute segment can be reported as the range with increments of 5. So for this example, the FTR is 140-145 bpm.

Findings: Normal FHR baseline: 110 - 160 beats per minute Tachycardia: FHR baseline values > 160 beats per minute Bradycardia: FHR baseline values< 110 beats per minute

Acceleration

Deceleration