ASSESSMENT OF FETAL ASSESSMENT OF FETAL WELL BEINGWELL BEING

Assessment of fetal wellbeing is Assessment of fetal wellbeing is either:either:

Antepartum:Antepartum: assessment late in assessment late in pregnancy, before onset of labor.pregnancy, before onset of labor.

Intrapartum:Intrapartum: assessment during assessment during labor.labor.

ANTEPARTUM ANTEPARTUM ASSESSMENT OF FETAL ASSESSMENT OF FETAL

WELL- BEINGWELL- BEINGAIM: AIM:

To detect fetuses at risk of To detect fetuses at risk of hypoxia hypoxia during 3rd trimester of during 3rd trimester of pregnancypregnancy, so that it can be , so that it can be delivered before IUFD, or hypoxic delivered before IUFD, or hypoxic injury. Fetal hypoxia is mostly caused injury. Fetal hypoxia is mostly caused by by uteroplacental insufficiency.uteroplacental insufficiency.

PLACENTAL PLACENTAL INSUFFICIENCYINSUFFICIENCY

DEFINTIONDEFINTION Failure of the placental functions to Failure of the placental functions to

deliver adequate oxygenation and deliver adequate oxygenation and nutrition to the fetus.nutrition to the fetus.

TYPESTYPES Acute: Acute: Suddenly occurring associated with Suddenly occurring associated with

otherwise normal fetusotherwise normal fetus. . (E.g. Placental separation).(E.g. Placental separation). Chronic:Chronic: Associated usually with intrauterine Associated usually with intrauterine

growth restriction (IUGR - small for date growth restriction (IUGR - small for date fetus).fetus).

AETIOLOGYAETIOLOGY:: Impairment of the placental circulation Impairment of the placental circulation

due to thrombosis of the vessels or due to thrombosis of the vessels or placental infarcts. placental infarcts.

Hypertensive states of pregnancy (PE, Hypertensive states of pregnancy (PE, eclampsia, and chronic hypertension).eclampsia, and chronic hypertension).

Accidental hemorrhage or placenta praevia.Accidental hemorrhage or placenta praevia. Postmaturity syndrome.Postmaturity syndrome. Diabetic pregnancy when associated with Diabetic pregnancy when associated with

vasculopathy.vasculopathy. Placental infarctions. Placental infarctions. Idiopathic.Idiopathic.

PATHOLOGYPATHOLOGYFetal response to placental insufficiency:Fetal response to placental insufficiency: Redistribution of blood flow preferentially to Redistribution of blood flow preferentially to

the brain and fetal heart.the brain and fetal heart. Asymmetric IUGR.Asymmetric IUGR. Oligohydramnios due to reduced renal Oligohydramnios due to reduced renal

perfusion.perfusion. Decreased fetal movement to conserve energy.Decreased fetal movement to conserve energy. Disturbance of fetal heart rate due to defective Disturbance of fetal heart rate due to defective

autonomic regulation.autonomic regulation.

DIAGNOSIS OF PLACENTAL DIAGNOSIS OF PLACENTAL INSUFFICIENCYINSUFFICIENCY::

HISTORY: HISTORY: Careful history taking may reveal the cause of Careful history taking may reveal the cause of

placental insufficiency, e.g. PE, post maturity, etc.placental insufficiency, e.g. PE, post maturity, etc. CLINICAL SIGNS suggestive ofCLINICAL SIGNS suggestive of SGA fetus SGA fetus or or

Oligohydramnios:Oligohydramnios: Poor maternal weight gain during regular ANC follow Poor maternal weight gain during regular ANC follow

up (normal = 0.5 kg/wk > 20 wks).up (normal = 0.5 kg/wk > 20 wks). fundal level < Gestational age "GA". fundal level < Gestational age "GA".

ANTEPARTUM FETAL SURVEILLANCE AFS ANTEPARTUM FETAL SURVEILLANCE AFS (Placental Function Tests)(Placental Function Tests)

Placental Function TestsPlacental Function Tests

Daily fetal movement count (DFMC).Daily fetal movement count (DFMC).

Non-Stress Test (NST).Non-Stress Test (NST).

Fetal Biophysical Profile (BPP).Fetal Biophysical Profile (BPP). Doppler color flow studies.Doppler color flow studies.

Oxytocin challenge test (OCT).Oxytocin challenge test (OCT).

The Non Stress Test The Non Stress Test ((NSTNST))

Idea:Idea: To test FHR changes in response To test FHR changes in response to fetal movements. to fetal movements.

Procedure: Procedure: external cardiotocographyexternal cardiotocography (CTG)(CTG)

Basal FHR is recorded and its changes in Basal FHR is recorded and its changes in response to fetal movements are detected.response to fetal movements are detected.

Duration of the test: FHR recordings over 20 Duration of the test: FHR recordings over 20 min observation period. The test may be min observation period. The test may be extended for another 20 minutes if fetal extended for another 20 minutes if fetal movements are insufficientmovements are insufficient..

Response to NSTResponse to NST::

Reactive:Reactive:

Normally a rise in FHR of at least Normally a rise in FHR of at least 15 bpm, for at least 15 sec. will 15 bpm, for at least 15 sec. will occur at least twice within a occur at least twice within a period of 15-20 min. testing.period of 15-20 min. testing.

Non reactive:Non reactive:

No FHR changes or changes less No FHR changes or changes less than normalthan normal

Management according to Management according to NSTNST : :

Reactive NST:Reactive NST: repeat every week. repeat every week. Non reactive NST:Non reactive NST: Further fetal Further fetal

evaluation: evaluation: Ultrasound Biophysical Profile Score Ultrasound Biophysical Profile Score

(BPPS) (BPPS) Colour Doppler velocimetry studies Colour Doppler velocimetry studies

(fetal umbilical and cerebral arteries) (fetal umbilical and cerebral arteries) Oxytocin Challenge Test (OCT).Oxytocin Challenge Test (OCT).

Ultrasound Biophysical Ultrasound Biophysical Profile Score (BPPS)Profile Score (BPPS)::

The BPPThe BPP is one of the most popular and is one of the most popular and informative tests for antepartum fetal informative tests for antepartum fetal surveillance (AFS). It is a simple test based surveillance (AFS). It is a simple test based on clear ultrasound parameters that can pick on clear ultrasound parameters that can pick up those fetuses at risk of hypoxia. Each up those fetuses at risk of hypoxia. Each tested parameter is given a score (either 0 or tested parameter is given a score (either 0 or 2).2).

Timing of BPP: Timing of BPP: The test is done any time The test is done any time during the third trimester and can be during the third trimester and can be repeated freely whenever AFS is indicated. repeated freely whenever AFS is indicated.

Parameters studiedParameters studied:: observation of the following parameters over a period observation of the following parameters over a period

of 30 minutes: of 30 minutes:

Fetal tone (flexion attitude of fetal limbs, head Fetal tone (flexion attitude of fetal limbs, head and body).and body).

Fetal body movements (flexion / extensionFetal body movements (flexion / extension limb limb and body movements).and body movements).

Fetal breathing movements (expansion Fetal breathing movements (expansion movements of the fetal abdomen).movements of the fetal abdomen).

Amniotic fluid volume (or amniotic fluid index - Amniotic fluid volume (or amniotic fluid index - AFI).AFI).

NST ( normal when FHR accelerations show rise NST ( normal when FHR accelerations show rise of 15 bpm, for 15 secs, twice in 15-20 min. of 15 bpm, for 15 secs, twice in 15-20 min. duration.duration.

Interpretation of the testInterpretation of the test Each item is scored either 0 or 2, with a maximum 10/10.Each item is scored either 0 or 2, with a maximum 10/10.

Scores of 10 to 10 denote a normal fetal well Scores of 10 to 10 denote a normal fetal well being, with normal fetal PH.being, with normal fetal PH.

Scores of 8/10 may need repeating the test Scores of 8/10 may need repeating the test and /or adding Doppler US evaluation.and /or adding Doppler US evaluation.

Scores < 8 suggest severe hypoxia.Scores < 8 suggest severe hypoxia.

Termination of pregnancy should be considered.Termination of pregnancy should be considered. Scores < 6 denote severe fetal acidaemia, with Scores < 6 denote severe fetal acidaemia, with

severely compromised fetal outcomeseverely compromised fetal outcome..

Modified BPPModified BPP It combines non - stress test (NST) and It combines non - stress test (NST) and

Amniotic fluid index (AFI).Amniotic fluid index (AFI).

It is less complicated and less time It is less complicated and less time consuming.consuming.

If the non – stress test is non-reactive, a If the non – stress test is non-reactive, a complete BPP should be done.complete BPP should be done.

COLOR DOPPLER STUDIES COLOR DOPPLER STUDIES OF FETAL BLOOD FLOWOF FETAL BLOOD FLOW

Measurement of the resistance to fetal blood flow Measurement of the resistance to fetal blood flow within thewithin the umbilical arteryumbilical artery and theand the middle middle cerebral arterycerebral artery yields excellent information about yields excellent information about the state of fetal organ perfusion.the state of fetal organ perfusion.

HIGHHIGH resistance in the umbilical artery is concomitant resistance in the umbilical artery is concomitant with placental insufficiency, while with placental insufficiency, while LOWLOW resistance in resistance in the fetal middle cerebral artery points to vascular the fetal middle cerebral artery points to vascular shift and brain sparing, suggestive of hypoxia.shift and brain sparing, suggestive of hypoxia.

Absent or reversed end-diastolic flow in the umbilical Absent or reversed end-diastolic flow in the umbilical arteries Doppler velocimetry flow studies denotes a arteries Doppler velocimetry flow studies denotes a severely compromised fetus that needs urgent severely compromised fetus that needs urgent delivery. delivery.

OXYTOCIN CHALLENGE OXYTOCIN CHALLENGE TEST (OCT)TEST (OCT)::..

Monitoring FHR changes on CTG, in Monitoring FHR changes on CTG, in response to I.V. oxytocin induced mild response to I.V. oxytocin induced mild uterine contractions.uterine contractions.

Positive OCT:Positive OCT: FHR decelerations obtained after each FHR decelerations obtained after each uterine contraction (fetal distress).uterine contraction (fetal distress).

Negative OCT:Negative OCT: No FHR changes occur in response to No FHR changes occur in response to contractions (good fetal well being). contractions (good fetal well being).

The test has formerly been indicated if the The test has formerly been indicated if the NST was non reactive, however OCT is rarely NST was non reactive, however OCT is rarely used nowadays being outdated by the safer used nowadays being outdated by the safer and easier Doppler US velocimetry studies.and easier Doppler US velocimetry studies.

MANAGEMENT OF PLACENTAL MANAGEMENT OF PLACENTAL

INSUFFICIENCYINSUFFICIENCY

Cases suffering Cases suffering chronic placental chronic placental insufficiencyinsufficiency with IUGR are with IUGR are carefully carefully monitoredmonitored and delivered nearest to 37 weeks and delivered nearest to 37 weeks gestation. If Doppler studies revealed very high gestation. If Doppler studies revealed very high umbilical artery resistance index with poor BPP umbilical artery resistance index with poor BPP score, score, immediate termination of pregnancyimmediate termination of pregnancy is is indicated.indicated.

Cases with Cases with acute placental insufficiencyacute placental insufficiency from the start, or those who developed acute from the start, or those who developed acute on top of chronic insufficiency, with on top of chronic insufficiency, with Oligohydramnios, poor BPP scores, abnormal Oligohydramnios, poor BPP scores, abnormal Doppler studies, are for Doppler studies, are for immediate termination immediate termination of pregnancyof pregnancy irrespective of fetal lung maturity. irrespective of fetal lung maturity.

Delivery by CSDelivery by CS offers the best chance for fetal survival in offers the best chance for fetal survival in

cases with placental insufficiency when cases with placental insufficiency when pregnancy termination is indicated. In pregnancy termination is indicated. In some selected cases induction of labour some selected cases induction of labour may be chosen with continuous electronic may be chosen with continuous electronic FHR monitoring by the CTG. If fetal FHR monitoring by the CTG. If fetal bradycardia occurs, or if ROM revealed bradycardia occurs, or if ROM revealed presence of meconium, vaginal delivery is presence of meconium, vaginal delivery is abandoned and CS is rapidly performed.abandoned and CS is rapidly performed.

KEY POINTS IN KEY POINTS IN ANTEPARTUM FETAL ANTEPARTUM FETAL SURVEILLANCE (AFS)SURVEILLANCE (AFS)::

AFS detects fetuses at risk secondary to utero-placental AFS detects fetuses at risk secondary to utero-placental insufficiency, but cannot predict sudden events.insufficiency, but cannot predict sudden events.

All pregnant women at high risk for placental insufficiency All pregnant women at high risk for placental insufficiency should do a DFMC.should do a DFMC.

The NST should be offered to cases with decreased DFMC or to The NST should be offered to cases with decreased DFMC or to high risk cases in general.high risk cases in general.

The BPP includes a NST with evaluation of specific US The BPP includes a NST with evaluation of specific US parameters. It should be performed and repeated whenever parameters. It should be performed and repeated whenever fetal compromise is suspected.fetal compromise is suspected.

Doppler umbilical artery studies are indicated whenever an Doppler umbilical artery studies are indicated whenever an abnormal BPP is encountered. Abnormal findings reflect serious abnormal BPP is encountered. Abnormal findings reflect serious fetal condition.fetal condition.

Normal AFS tests may be repeated on weekly or biweekly Normal AFS tests may be repeated on weekly or biweekly intervals.intervals.

Abnormal AFS tests necessitate termination of pregnancy.Abnormal AFS tests necessitate termination of pregnancy. In most cases CS delivery will offer best chances for fetal In most cases CS delivery will offer best chances for fetal

neonatal survival.neonatal survival.

INTRAPARTUM INTRAPARTUM ASSESSMENT OF ASSESSMENT OF

FETAL WELL BEINGFETAL WELL BEING Aim:Aim: To detect fetuses at risk for To detect fetuses at risk for hypoxia hypoxia

during labourduring labour (fetal distress)(fetal distress), thus , thus minimizing the risks of intrapartum and minimizing the risks of intrapartum and neonatal fetal death, or severe fetal hypoxic neonatal fetal death, or severe fetal hypoxic injury (e.g.; cerebral palsy).injury (e.g.; cerebral palsy).

Pathophysiology of hypoxia: Pathophysiology of hypoxia: Decreased Oxygen supply to the fetus during Decreased Oxygen supply to the fetus during

labour is associated with decreased elimination labour is associated with decreased elimination of CO2, with resultant fetal respiratory acidosis of CO2, with resultant fetal respiratory acidosis and decreased fetal blood PH.and decreased fetal blood PH.

CAUSES OF INTRAUTERINE CAUSES OF INTRAUTERINE FETAL HYPOXIA (FETAL FETAL HYPOXIA (FETAL

DISTRESS)DISTRESS)1. 1. Acute fetal hypoxia:Acute fetal hypoxia: Cord accidents (cord prolapse, cord compression, true Cord accidents (cord prolapse, cord compression, true

knots, coils around fetal neck, and rupture vasa praevia).knots, coils around fetal neck, and rupture vasa praevia). Placental separation (accidental Haemorrhage, placenta Placental separation (accidental Haemorrhage, placenta

praevia).praevia). Placental compression (prolonged ROM, uterine Placental compression (prolonged ROM, uterine

hypertonicity, obstructed labour).hypertonicity, obstructed labour). Some congenital and or chromosomal fetal anomalies.Some congenital and or chromosomal fetal anomalies.

2. 2. Chronic fetal hypoxia:Chronic fetal hypoxia: Placental insufficiency.Placental insufficiency. Maternal hypoxia: (Severe anemia or excessive Maternal hypoxia: (Severe anemia or excessive

haemorrhage, congestive heart failure, severe pulmonary haemorrhage, congestive heart failure, severe pulmonary disease, during eclamptic fits, during anaesthesia with disease, during eclamptic fits, during anaesthesia with improper oxygenation).improper oxygenation).

Diagnosis of Fetal Distress Diagnosis of Fetal Distress during Laborduring Labor::

A- CLINICAL DIAGNOSIS:A- CLINICAL DIAGNOSIS: Abnormal FHR recordings by the sonicaid (severe Abnormal FHR recordings by the sonicaid (severe

bradycardia, severe tachycardia).bradycardia, severe tachycardia). Passage of meconium after ROM in (cephalic presentation Passage of meconium after ROM in (cephalic presentation

not breech).not breech).N.B.:N.B.: Intrauterine asphyxia results in relaxation of the fetal anal Intrauterine asphyxia results in relaxation of the fetal anal

sphincter & increased intestinal peristalsis. Meconium, (the sphincter & increased intestinal peristalsis. Meconium, (the thick intestinal particulate secretion in the neonate), will thick intestinal particulate secretion in the neonate), will then escape into the amniotic fluid giving it yellowish or then escape into the amniotic fluid giving it yellowish or greenish colour that appears after rupture of membranes.greenish colour that appears after rupture of membranes.

B- INTRAPARTUM FETAL SURVEILLANCE tests: - IFSB- INTRAPARTUM FETAL SURVEILLANCE tests: - IFS The aim of IFS tests is to detect fetal distress occurring The aim of IFS tests is to detect fetal distress occurring

during labour.during labour. The best available method for such IFS is The best available method for such IFS is the use of continuousthe use of continuous externalexternal electronic FHR electronic FHR monitoring.monitoring.

ELECTRONIC FHR ELECTRONIC FHR MONITORING:MONITORING:

( Cardiotocography – ( Cardiotocography – CTG)CTG)

The CTG entails Continuous electronic FHR The CTG entails Continuous electronic FHR monitoring during labour in relation to uterine monitoring during labour in relation to uterine activity. An externalactivity. An external US transducer is placed US transducer is placed on the maternal abdomen at a site selected to on the maternal abdomen at a site selected to give the best FHR recordings. Another give the best FHR recordings. Another transducer is placed to record the onset, transducer is placed to record the onset, duration and intensity of uterine contractions duration and intensity of uterine contractions and associated increased intrauterine and associated increased intrauterine pressure pressure

Interpretation of FHR Monitoring Interpretation of FHR Monitoring by CTGby CTG::

Normal FHR tracings: Normal FHR tracings: Normal FHR values: 120-140 Normal FHR values: 120-140

beat per minute (b/m). beat per minute (b/m). Normal FHR Pattern: beat to Normal FHR Pattern: beat to

beat variability (fluctuations beat variability (fluctuations by ± 5 to 10 b/m. by ± 5 to 10 b/m. periodically).periodically).

Interpretation of FHR Interpretation of FHR Monitoring by CTG (cont.)Monitoring by CTG (cont.)::

Abnormal FHR tracings:Abnormal FHR tracings: Baseline bradycardiaBaseline bradycardia: < 100 b/m.: < 100 b/m. Baseline tachycardiaBaseline tachycardia: > 160 b/m.: > 160 b/m. Absence of beat to beat variabilityAbsence of beat to beat variability: FHR variation : FHR variation

within 1 min is < 5 b/m.within 1 min is < 5 b/m. Late DecelerationsLate Decelerations: Slowing of FHR at the : Slowing of FHR at the peakpeak of of

the uterine contraction that returns to normal a the uterine contraction that returns to normal a short period after the contraction ends. Late short period after the contraction ends. Late deceleration is the deceleration is the most dangerousmost dangerous pattern, as it pattern, as it indicates severe utero-placental insufficiency.indicates severe utero-placental insufficiency.

Variable DecelerationsVariable Decelerations: Slowing of FHR which is not : Slowing of FHR which is not related to uterine contractions. It mostly indicates related to uterine contractions. It mostly indicates cord compression especially in cases with ROM or cord compression especially in cases with ROM or Oligohydramnios.Oligohydramnios.

N.B.:N.B.: Early Decelerations refer to slowing of Early Decelerations refer to slowing of

FHR that starts at the FHR that starts at the onset onset of the of the uterine contraction and returns to normal uterine contraction and returns to normal with its end. It is mostly associated with with its end. It is mostly associated with head compression within the bony pelvis head compression within the bony pelvis with reflex stimulation of vagus nerve. with reflex stimulation of vagus nerve. Early decelerations are usually harmless.Early decelerations are usually harmless.

N.B.: N.B.: Sinusoidal FHR pattern is a smooth Sinusoidal FHR pattern is a smooth wave like pattern of regular frequency (3-wave like pattern of regular frequency (3-5 cycles/min), and amplitude (5-20 bpm). 5 cycles/min), and amplitude (5-20 bpm). Short episodes of sinusoidal FHR patterns Short episodes of sinusoidal FHR patterns are considered a variant of normal. are considered a variant of normal. Longer episodes may reflect fetal Longer episodes may reflect fetal anaemia and severe hypoxia (e.g. anaemia and severe hypoxia (e.g. accidental haemorrhage). accidental haemorrhage).

Fetal Blood sampling During Fetal Blood sampling During labourlabour

Abnormal FHR patterns on CTG during labour are Abnormal FHR patterns on CTG during labour are sometimes misleading, with a resultant increase in sometimes misleading, with a resultant increase in the rate of unnecessary CS deliveries. In cases where the rate of unnecessary CS deliveries. In cases where FHR tracings on the CTG are abnormal, fetal blood FHR tracings on the CTG are abnormal, fetal blood sampling (FBS) will be the most accurate .sampling (FBS) will be the most accurate .

The blood sample is taken via a small needle probe The blood sample is taken via a small needle probe applied to fetal scalp after ROM , which is known as applied to fetal scalp after ROM , which is known as fetal scalp PH. Normal fetal pH ranges from 7.25 - fetal scalp PH. Normal fetal pH ranges from 7.25 - 7.35.7.35.

In cases of fetal hypoxia: In cases of fetal hypoxia: Accumulation of Co2. Accumulation of Co2. (Anaerobic pathway for energy & lactic acid).(Anaerobic pathway for energy & lactic acid).

This leads to fetal acidosis. If < 7.25 =Mild acidosis.This leads to fetal acidosis. If < 7.25 =Mild acidosis. If < 7.2 = severe acidosis.If < 7.2 = severe acidosis.

Management of fetal distress Management of fetal distress during labourduring labour::

High risk cases should be offered a continuous High risk cases should be offered a continuous CTG monitoring throughout labour.CTG monitoring throughout labour.

Whenever abnormal CTG findings are recorded Whenever abnormal CTG findings are recorded Stop oxytocin, if it has been infusedStop oxytocin, if it has been infused Change position of the mother to Left Change position of the mother to Left

lateral position .lateral position . O2 mask to the mother (to avoid maternal O2 mask to the mother (to avoid maternal

hypoxia).hypoxia). I.V. Fluids (to avoid maternal dehydration).I.V. Fluids (to avoid maternal dehydration).

If the above measures are successful):If the above measures are successful):

Labour is allowed to proceed under Labour is allowed to proceed under strict observation.strict observation.

Management of fetal Management of fetal distress during labour distress during labour

(cont.)(cont.)::If The above measures were If The above measures were

unsuccessful i.e.; unsuccessful i.e.; FHR patterns showed persistent FHR patterns showed persistent

abnormality.abnormality. Abnormal FHR patterns recurred after a Abnormal FHR patterns recurred after a

period of normality.period of normality. A difficult and prolonged vaginal delivery A difficult and prolonged vaginal delivery

is anticipated.is anticipated. An immediate delivery by CS will be An immediate delivery by CS will be

the best and safest option available.the best and safest option available.

N.B.: If fetal distress occurs when the N.B.: If fetal distress occurs when the cervix is fully dilated, the membranes cervix is fully dilated, the membranes ruptured, the presenting part engaged, ruptured, the presenting part engaged, and the maternal pelvis is adequate, and the maternal pelvis is adequate, immediate vaginal delivery may be immediate vaginal delivery may be encouragedencouraged byby: :

Instrumental delivery by the low Instrumental delivery by the low forceps procedure.forceps procedure.

Breech extraction in cases of complete Breech extraction in cases of complete or frank breech presentations.or frank breech presentations.

Key points in intrapartum Key points in intrapartum fetal surveillance (IFS)fetal surveillance (IFS)::

Cases at high risk for fetal hypoxia should be Cases at high risk for fetal hypoxia should be selected and carefully monitored throughout selected and carefully monitored throughout labour.labour.

Intrapartum fetal monitoring will detect early Intrapartum fetal monitoring will detect early fetal hypoxia.fetal hypoxia.

IFS, has decreased the number of intrapartum IFS, has decreased the number of intrapartum fetal deaths, but it has increased the number of fetal deaths, but it has increased the number of CS deliveries.CS deliveries.

FHR accelerations signify normal fetal PH and FHR accelerations signify normal fetal PH and intact CNS.intact CNS.

Key points in intrapartum Key points in intrapartum fetal surveillance (cont.)fetal surveillance (cont.)::

Decelerations are characterized based on Decelerations are characterized based on the timing with contractions:the timing with contractions:

1.1. Early decelerations: head compression Early decelerations: head compression vagal response (no hazards).vagal response (no hazards).

2.2. Late decelerations: uteroplacental Late decelerations: uteroplacental insufficiency (serious hypoxia anticipated).insufficiency (serious hypoxia anticipated).

3.3. Variable decelerations: cord compression Variable decelerations: cord compression (especially with ROM or oligohydramnios).(especially with ROM or oligohydramnios).

Whenever IFS points to fetal distress,Whenever IFS points to fetal distress,

measures should be taken for measures should be taken for

immediate deliveryimmediate delivery::

Most cases will benefit from immediate CS.Most cases will benefit from immediate CS.

Some selected cases may continue a Some selected cases may continue a carefully carefully

monitored trial for a rapid vaginal monitored trial for a rapid vaginal delivery.delivery.