FETAL MONITORING

REASONS TO MONITOR THE FETUS

ANTENATAL:

1. MATERNAL INDICATIONS e.g. obstetric cholestasis

2. FETAL INDICATIONS e.g. reduced fetal movements,
3. PLACENTAL INDICATIONS e.g. placental insufficiency /
growth restriction

IN LABOUR:

1. LOW RISK PATIENT

2. HIGH RISK PATIENT
 ANTENATAL FETAL MONITORING

BIOPHYSICAL PROFILE
USS:
1. Breathing - Does the baby have breathing movements at least once in 30 minutes?
2. Body Movement - Does the baby move at least three times in 30 minutes?
3. Muscle Tone - Does the baby have at least one flexion-extension (open-close)
movement of arms, legs or hands in 30 minutes?
4. Amount of amniotic fluid - Is there enough fluid around the baby?

5. CTG: Is it reactive?

AMNIOTIC FLUID
The Amniotic Fluid Index (AFI) can be used to determine fetal well-being.
Most of the fluid in amniotic fluid is contributed to by fetal urine.
This is then resorbed by the membranes and umbilical cord
Rapid turnover - possible to measure amniotic fluid from one day to the next
 BIOPHYSICAL PROFILE SCORE
OBSERVATION NORMAL (2 POINTS) ABNORMAL (0 POINTS)
CTG (NON-STRESS TEST) REACTIVE NON-REACTIVE
ONE BREATHING PERIOD
FETAL BREATHING NO BREATHING OBSERVED
LASTING AT LEAST 60 SEC
3 DISCRETE AND
LESS THAN 3 DISCRETE
FETAL MOVEMENTS DEFINTE MOVEMENTS OF
MOVEMENTS
ARMS LEGS OR BODY
ARMS & LEGS FLEXED.
FETAL TONE ONE DEFINITE EXTENSION / NO FLEXION
RETURN TO FLEXION
LARGEST POCKET OF FLUID LARGEST POCKET OF FLUID
AMNIOTIC FLUID MORE THAN 1cm WITHOUT LESS THAN 1cm WITHOUT
LOOPS OF CORD LOOPS OF CORD

8-10 = maximal score

0-4 = severe fetal compromise; delivery indicated
 Doppler blood flow velocity waveforms
Non-invasive velocity measurements of blood flow

Fetus is completely dependent on the supply of oxygen and nutrients from the placenta

Examination of the blood flow through the umbilical circulation can assess fetal health

Increased placental vascular resistance, reduces velocity of the end-diastolic flow in

the umbilical cord artery

Several Doppler indices have been used to quantify abnormalities in umbilical artery
Doppler flow waveforms: A/B ratio, the resistance index, the pulsatility index

Placental insufficiency can be quantified based on the reduction of end-diastolic

Doppler flow velocity into
(1) reduced enddiastolic flow velocity,
(2) absent end-diastolic flow velocity, and
(3) reversed end-diastolic flow velocity.
DOPPLER WAVEFORMS
 Doppler blood flow velocity waveforms

Middle cerebral artery peak-systolic flow velocity (MCA-

PSV) use
Doppler to detect fetal anaemia
 Ductus Venosus Dopplers
May be used as a trigger for delivery of IUGR fetus.
Late sign of CV decompensation
Reflects decreased ability to handle venous return.
Precedes FHR decels
Present in 79/211 (37%) of preterm IUGR, useful >
29wks
Predictive of pH<7.2

Baschat, O&G, 2007

 MONITORING IN LABOUR

Intermittent auscultation recommended for low-risk women

in established labour

INDICATIONS FOR continuous EFM:

1. meconium-stained liquor,
2. abnormal FHR detected by intermittent auscultation
3. maternal pyrexia
4. fresh bleeding in labour
5. oxytocin use for augmentation
6. the womans request.
 FETAL PHYSIOLOGY
1. The fetal heart pumps deoxygented blood to the placenta via the two umbilical arterie
2. At the placenta there is a free exchange of blood gases
(there's no mixing of foetal/maternal blood)
3. The blood is pumped back to the fetus via a single umbilical vein
 FETAL HEART RATE
The fetal heart is regulated by:
1. Nerve supply
i.e. HR is reduced by vagus nerve (parasympathetic), increased by sympathetic supply
2. Circulating catecholamines
3. Central nervous system activity

These are influenced by changes in:

1. fetal BP
2. fetal blood gas levels
(O2, CO2, pH)
3. Hypoxia
4. Pyrexia
5. Drugs
6. Gestation
7. Cord compression
8. Cerebral activity
A: Fetal heartbeat;
B: Indicator showing movements felt by mother (caused by pressing a button);
C: Fetal movement;
D: Uterine contractions
 Classification of FHR trace features
Baseline
(bpm) Variability
(bpm) Decelerations Accelerations
Feature

Reassuring 110160 5 None Present

Typical variable
decelerations with
100109 over 50% of contractions,
Non- < 5 for occurring for over 90 minutes
reassuring 161180 4090 minutes
Single prolonged deceleration
for up to 3 minutes The absence
of accelerations
with otherwise
normal trace is
Either atypical variable
decelerations with over of uncertain
< 100 50% of contractions or significance
> 180 < 5 for late decelerations, both
Abnormal Sinusoidal 90 minutes for over 30 minutes
pattern Single prolonged
10 minutes
deceleration for more
than 3 minutes
 Definition of normal, suspicious
and pathological FHR traces

Category Definition

An FHR trace in which all four features are classified as reassuring

Normal

An FHR trace with one feature classified as non-reassuring and

Suspicious the remaining features classified as reassuring

An FHR trace with two or more features classified as non-reassuring

Pathological or one or more classified as abnormal
Classifications of CTGS
1) Normal: Implies fetal well-being
2) Suspicious: Indicates continued observation
/additional tests
3) Pathological: Mandatory Action.
SMALL GROUP / PAIR WORKSHOP

using

FRESH EYES LABELS

 DR. C BRAVADO

Define Risk: Low or High

Contractions: Frequency, Length
Baseline Rate: Bradycardia, Normal,
Tachycardia
Variability: 5-10bpm/min
Accelerations: Present or Absent
Decelerations: Present or Absent, Type
Outcome: Normal, Suspicious. Pathological.
Management Plan
 The classification of fetal blood sample (FBS) results

FBS result Interpretation

(pH)

7.25 Normal FBS

7.217.24 Borderline FBS

7.20 Abnormal FBS

 APGAR SCORES
DESIGNED TO ASSESS WHICH BABIES NEED RESUSCITATION;

IT DOESN'T TELL US WHY A BABY NEEDS RESUSCITATION

0 1 2

Blue extremities, No cyanosis,

colour blue/pale all over body pink Body/extremities
pink

HR 0 <100 >100

Reflex irritability No response grimace/feeble cry/pull away

cry when stimulated

Flexed arms &

Tone none Some flexion legs, resist
extension

Breathing absent Irregular, gasping Strong, lusty cry

 CORD GASES
Indication of:

1. how well the oxygen supply has been maintained to the fetus during labour

2. How well the fetus has eliminated the waste product CO2

Gives an indication of the efficiency of placental gas exchange during labour

Cord gases can suggest a baby has been deprived of oxygen during labour
but it cannot tell us if the baby has suffered harm as a result

A baby could have good Apgars despite abnormal cord gases

A baby that has been deprived of oxygen during labour may have
compensated well but is still at risk of of e.g. hypoglycaemia
 SMALL GROUP WORKSHOP

Divide up into 4 groups

Read through the case history

Using DR C BRAVADO review the CTG at the times indicated in BOLD

THANK YOU