Transcript of Intrapartum fetal survellence
- DR. Mohit Satodia DR.BHARTI GOEL
- GOAL The timely identification and rescue of the fetus at risk
of neonatal and long term morbidity from intrapartum hypoxic
insult
- Intrapartum monitoring FHR monitoring Intermittent
auscultation(IA) Electronic fetal monitoring(EFM) Fetal Scalp pH
Fetal Pulse oximetry Fetal scalp lactate testing ST waveform
analysis
- FETAL HEART RATE MONITORING External FHR monitoring- Hand-held
Doppler ultrasound probe External transducer
- External FHR monitoring-
- TECHNICAL CONSIDERATIONS Basis for FHR monitoring is beat to
beat recording For practical purposes ,this is possible only when
direct fetal electrocardiograms are recorded with a scalp
electrode. Paper speed is important. Commonly used are 1,2 or 3
cm/min. 1 cm/min a) good records for clinical purposes and limiting
the cost and amount of paper b)crowding together of the record
making baseline variability difficult to interpret.
- Contd 3 cm/min- a) useful when record is difficult to interpret
at slow speed i.e. during second stage of labor b) waste of paper
more
- Internal FHR monitoring Spiral electrode attatched to the fetal
scalp with a connection to FHR monitor. The fetal membranes must be
ruptured, and the cervix must be at least partially dilated before
the electrode may be placed on the fetal scalp.
- Intermittent auscultation In uncomplicated pregnancies .
Doppler better than stethoscope. Every 15 - 30 minutes in active
phase of first stage and every 5 minutes in second stage Listen in
the absence of active pushing and toward the end of the contraction
and at least for 30seconds after each contraction ACOG JUlY 2009
CONTINUOUS EFM No benefit in low risk Continuous EFM -when risk
factors for present Every 15 minutes in first stage and every 5
minutes during the second stage.
- Fetal Assessment : IA & EFM Surveillence Low-Risk High-Risk
Pregnancies Pregnancies Acceptable methods Intermittent
Auscultation* Yes Yes (a) Continuous Electronic Fetal Monitoring
(EFM) Yes Yes (b) First-stage Labour 30 min 15 min (a,b) Second
stage labour 15 min 5 min (a,c) Evaluation Intervals a- before,
during and especially after a contraction for 60 sec b- includes
evaluation of tracing every 15 min c- evaluation of tracing every 5
min (ACOG & AAP 2007)
- INDICATIONS FOR CONTINUOUS EFM Antepartum risk factors Abnormal
Doppler umbilical artery velocimetry Suspected IUGR APH HTN /
preeclampsia (current pregnancy) DM Multiple pregnancy Uterine scar
/ previous CS Iso-immunisation Oligohydramnios / polyhydramnios
Maternal medical conditions(including severe anaemia, cardiac
disease, hyperthyroidism, vascular disease, renal disease)
- Risk factors during labour Prolonged rupture of membranes (>
24 hours) Meconium-stained or blood-stained liquor Fetal
bradycardia Fetal tachycardia Maternal pyrexia > 38 C
Chorioamnionitis Vaginal bleeding in labour Prolonged active first
stage of labour (> 12 hours regular uterine contractions with
cervical dilatation>3cm) Prolonged second stage of labour .
- Other indications Any use of oxytocin whether for induction or
for augmentation of labour Before and for at least 20 minutes after
administration of prostaglandin Epidural analgesia (immediately
after inserting an epidural block)
- Benefits of EFM over IA Reduced risk of neonatal seizures(RR
0.50) No benefit over IA did not reduce perinatal mortality(RR,
0.85) did not reduce the risk of cerebral palsy (RR, 1.74) Risks of
EFM High false-positive results. Increased rates of surgical
intervention High interobserver and intraobserver variability
COCHRANE 2006
- Electronic fetal monitoring Various components include
-Baseline -Variability -Accelerations -Decelerations
- External fetal monitoring BASELINE The mean FHR rounded to
increments of 5 bpm during a 10minute segment, excluding: Periodic
or episodic changes Periods of marked FHR variability Segments of
baseline that differ by more than 25 bpm The baseline must be for a
minimum of 2 minutes in any 10-minute segment Normal : 110160 bpm
Tachycardia: > 160 bpm Bradycardia: 25 bpm
- Short term variability small changes in fetal beat to beat
intervals under physiological conditions Long term variability-
certain periodicity in the direction and size of these changes
causes oscillations of fetal heart rate around mean level In FHR
tracings short term variability is superimposed over long term
variability as minimal deflexions, not interpreted by naked eye,
therefore in clinical practice variability means long term
variability
- Long term variability characterized by frequency and amplitude
Frequency is difficult to assess correctly Therefore , variability
is usually quantitated by amplitude of the oscillations around
baseline heart rate.
- The tracing shows an amplitude range of ~ 10 BPM (moderate
variability ).
- Factors affecting variability Normal variability : 98% fetuses
not acidotic Decreased variability: Fetal metabolic acidosis , CNS
depressants, fetal sleep cycles, congenital anomalies, prematurity,
fetal tachycardia, preexisting neurologic abnormality,
betamethasone. Increased variability (saltatory pattern):Acute
hypoxia or cord compression, eg 2nd Stage
- ACCELERATION A visually apparent abrupt increase in the FHR 10
BPM above baseline for >10 sec >32 weeks: >15 BPM above
baseline for > 15 sec Prolonged acceleration lasts >2 min
but