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Fetal Assessment During Labor

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Fetal Assessment During LaborWe asses:

1. Amniotic fluid2. Fetal Heart Rate (FHR): the

primary assessment

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1. Amniotic fluid analysis:• Amniotic fluid should be clear, colorless

or pale yellow, when the membranes rupture.

• Cloudy fluid with foul smell → Infection• Green Fluid → Fetal Hypoxia due to

meconium (the first stool of the baby) • Blood streak → Hemorrhage

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2. Fetal Heart Rate (FHR) Monitoring

• Is the measuring of the fetus’s heart rate during the labor by using a special instruments.

• Types and methods of fetal heart monitoring:

1. Intermittent auscultation2. Electronic fetal monitoring (EFM)

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1. Intermittent Auscultation technique:

• Auscultation is a method of listening to the fetal heartbeat for about 60 seconds by using a fetal stethoscope (fetoscope or Pinard), or a hand-held Doppler ultrasound device.

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• While listening to the heartbeat, the doctor also palpates the mother’s uterus by placing a hand on the abdomen to measure the contractions.

• Intermittent auscultation should be done: − Every 15-30 minutes during the active

phase of 1st stage,− Every 5-15 minutes during the pushing

phase of 2nd stage.

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Fetoscope Pinard Hand-held Doppler

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2. Electronic fetal monitoring (EFM)• EFM is an electronic monitor used to

continuously measures the fetus’s heart rate and using a pressure sensor to monitor the mother’s contractions at the same time.

• There are 2 types of EFM:• External monitoring• Internal monitoring

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Indications for EFM• Pregnancy complications (Diabetes, preeclampsia…) • Pre-term labor.• Previous caesarean. • The baby is smaller than expected.• Multiple fetuses.• Overweight mother.• Prolonged 1st stage of labor.• The amniotic fluid contains significant amounts of

meconium (The baby's first poo).• Induction of labor.• A high temperature mother.

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External monitoring:• Measuring the heart rate through an

ultrasound device, and measuring the contractions by using a pressure sensor; both devises are held against the mother's belly with a belt.

• The reading of external monitoring is affecting by changing position.

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Internal monitoring:• Measure the heart rate through a wire called

(electrode) contains a needle, inserted through the vagina and cervix, and placed under the baby's scalp. And measuring the contractions with a thin tube inserted into the uterus.

• Internal monitoring can be done only after the cervix has dilated to at least 2cm and the amniotic sac has ruptured.

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FHR patterns• Normal Pattern: Baseline FHR = 120 – 160 bpm (Beat/min.)

• Tachycardia: Baseline FHR above 160 bpm

• Bradycardia: Baseline FHR less than 120 bpm

*Baseline FHR = 10 minutes*

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Contraction Pattern• Normal contractions: 5 or fewer contractions in 10 minutes lasting about 60 seconds in the active phase.

• Contraction intensity: 30 mmHg in early labor to 70 - 90 mmHg in the second stage.

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Normal fetal heart rate with moderate variability

Normal Contraction

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Causes of TachycardiaTachycardia is a FHR above 160 bpm that lasts for at least 10 minutes• Mother fever • Mother and fetus infection• Mother dehydration• Mother and fetus anemia• Fetus hypoxemia• Fetal tachyarrhythmia• Fetus cardiac abnormalities

Causes of BradycardiaFetal bradycardia is a baseline FHR of less than 110 bpm that lasts for at least 10 minutes• Mother Dehydration• Mother Hypotension• Rupture of uterus or vasa

previa• Placental abruption• Medications such as anesthetics • Fetal hypoxia• Late or profound hypoxemia• Umbilical cord occlusion• Fetal bradyarrythmias

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Baseline FHR Variability• The normal fetal heart rate baseline is from

120 to 160 BPM and has variability usually with a range of 3-5 bpm from the baseline.

• Characteristics:1. Undetectable (less than 5 bpm)2. Minimal (up to 5 bpm)3. Moderate (6 to 25 bpm)4. Marked (more than 25 bpm)

Abnormal if lasts over 60 min.

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Periodic changes

Periodic changes are accelerations or decelerations in the FHR that are in relation to uterine contractions and persist over time.

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Accelerations• Accelerations are transient increases in the FHR

about (15 bpm) above baseline for about (15 sec. to less than 2 min.) and then return normally to the base line.

• Prolonged acceleration: Increase in heart rate lasts for 2 to 10 minutes.

• The presence of accelerations is a sign of normal fetus, because they are usually associated with fetus stimulation, such as fetal movement, vaginal examinations, and contractions.

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Fetal heart rate accelerations

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DecelerationsTransitory decrease in the FHR from the baseline.1. Early decelerations: the onset and return of a

deceleration is match to the contraction2. Variable decelerations: variable in the time,

intensity, and duration of a deceleration3. Late decelerations: the fetal heart rate return

to the baseline after the end of the contraction

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Management1. Early decelerations: No intervention is necessary,

just keep watching. It happen due to uterine contractions.

2. Variable decelerations: Reposition of the mother, oxygen mask, and stop oxytocin. It happen due to Umbilical cord occlusion and problems.

3. Late decelerations: Reposition of the mother, oxygen mask, stop oxytocin, give IV. It happen due to reduction in O2

26Early decelerations

27Variable decelerations

28Late decelerations

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What happens if the fetal heart rate pattern is abnormal?• An abnormal fetal heart rate may mean that the fetus is

not getting enough oxygen or that there are other problems.

• We should first try to find the cause. • Steps can be taken to help the baby get more oxygen,

such as change the position of the mother, and giving her an oxygen mask.

• If the procedures do not work, and the fetus still has a problem, we should deliver the baby immediately.

• In this case, the delivery of the baby is more likely to be by cesarean birth or with forceps or vacuum delivery.

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Forceps delivery

Vacuum delivery