INTRAPARTUM FETAL MONITORING
Dr Manal Behery
Professor OB&GYNE
2014
Methods available for fetal monitering
in labor
 Intermittent auscultation
CTG Fetal electrocardiography
Scalp stimulat...
Types of Intermittent
Monitors
Intermittent Auscultation
The three unique risk factors for fetus
during labor
Factor of uterine contraction
Factor of cord accident
Factor of he...
Factor of uterine contraction
Oxy –Hb 0.19 micromol/100Gm of brain
Cerebral O2 saturation 9%
•
 In spite of this slight...
Factor of head compression
Some degree of compression is inevitable during normal labor
But
Excessive compression over l...
Factor of cord accident
Only during labor cord prolapse ,presentation and
entanglements become apparent either by compres...
Aim of intrapertum fetal monitering
 1- to detect the earliest stages of hypoxia so therapy
can be directed to prevent as...
What is Cardiotocography(CTG)?
It is a paper record of the continuous FHR blotted
simultaneously with a record of uterine...
CTG reCords
Non stress test
without uterine contraction
Stress test
in correlation to uterine contraction
External monitoring
Internal monitoring
Intrapartum Fetal monitoring CTG
FHR trace(4 components)
 Base line FHR
 Baseline variability
 Accelerations
 Decelerations
Baseline FHR
The dominant reading taken ≥10 min
Normal baseline FHR 110-160(pbm)
Controlled by atrial pacemaker
Baseline FHR
Tachycardia FHR>160 bpm
Baseline bradycardia FHR<110bpm
Baseline varibility
 The Oscaltatory pattern of FHR when recorded on a graph.
 Short term(beat t0 beat)
 is the fluctua...
Baseline varibility
Short term variability
(scalp electrode)
Long term variability
defined as 3-5 cycle/min
Baseline varibility
No variability (0-2 ครั้ง/นาที)
Mark variability (>25 ครั้ง/นาที)
Moderate variability (11-25
ครั้ง/นาที)
No variability (...
Accelaration
Increase in FHR with contraction or with other activities
Increase15pbm
lasting 15 sec
Return to base lin...
Accelaration
Decelerations
Decelerations
 Transient slowing of FHR below
The baseline level> 15 bpm
 and lasting for 15 sec.
or more.
Early Decelerations
 Uniform
 Synchronous with contraction (mirror image)
 Rarely fall below 110 (pbm)
 Due to head co...
Early Decelerations
Late Deceleration
Uniform
Start after peak of contraction
Associated with decreased
Variability
Reflect a baroreceptor...
Late Deceleration
Repetitive late decelration
increases risk of
Umbilical artery acidosis
Apgar score < 7 at 5 ms
Cerebral palsy
If asso...
Variable Deceleration (the most
common type)
Varible in appearance and Timing.
May be assoicated with increased variabil...
Variable Deceleration
Tyes of decleration
Prolonged Deceleration
deceleration
 A deceleration that lasts more than 90
 seconds (but less than 10 minutes)
 Drop i...
Prolonged Deceleration
What are the features of a normal
tracing?
Baseline FHR 110-160 BPM
Baseline Variability > 5 pbm (10-25)
2 Acceleration...
Normal -Reassuring CTG
Interpertation of CTG
Normal -Reassuring(R)- CTG with all 4
Features
Suspicious (equivocal)- one non reassuring
category...
Interpertation of CTG
Consider
Intrapartum / antepartum trace.
Stage of labour
Gestation
Fetal presentation.
Any augmentation
Medications
Is Normal CTGs always Reassuring?
 With normal CTC the chance of fetus to develop hypoxia is
1.5% due to unpredictable ac...
Is NR CTGs always worrisome ?
 60% CTG in Labour have 1 abnormal feature
 Only 15-20% of NR CTGs are pathological.
 Hig...
?? To reduce CS….
Consider these factors with abnormal
CTG
 Maturity of the fetus
Reduced variability and baseline tachycardia is conmen in...
Consider these factors with abnormal
CTG
 Posture of patient during CTG
o Supine position give abnormal tracing
o Some co...
Correct reversible causes
Change mother position from supine to left lateral
position-----increase uterine blood flow
Im...
Secondary tests of fetal well-being
Vibro-acoustic stimulation
Used as a substitute for scalp sampling when CTG –is NR
...
Fetal blood sampling
If the pH >7.25 --- observe.
If the pH 7.2 and 7.25---repeated
within 30 minutes.
If the pH <7.2--...
Scalp stimulation.
Firm digital pressure
Gentile pinch by atramatic Allis forceps
Fetal pulse oximetry.
THANK YOU
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Fetal monitoring for undergraduate

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Undergraduate course lectures in PB&GYNE prepared by Dr Manal Behery ,Professor of OB&GYNE .Faculty of medicine ,Zagazig University

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Fetal monitoring for undergraduate

  1. 1. INTRAPARTUM FETAL MONITORING Dr Manal Behery Professor OB&GYNE 2014
  2. 2. Methods available for fetal monitering in labor  Intermittent auscultation CTG Fetal electrocardiography Scalp stimulation  Vibroacoustic stimulation Fetal scalp sampling  PH determination Fetal pulse oximetry
  3. 3. Types of Intermittent Monitors
  4. 4. Intermittent Auscultation
  5. 5. The three unique risk factors for fetus during labor Factor of uterine contraction Factor of cord accident Factor of head compression
  6. 6. Factor of uterine contraction Oxy –Hb 0.19 micromol/100Gm of brain Cerebral O2 saturation 9% •  In spite of this slightly worrying picture, Nothing harmful effect happen if fetus is healthy labor contraction are normal Placenta has adequate reserve
  7. 7. Factor of head compression Some degree of compression is inevitable during normal labor But Excessive compression over long period causing supermoulding as in obstructed labor may cause fetal hypoxia
  8. 8. Factor of cord accident Only during labor cord prolapse ,presentation and entanglements become apparent either by compression or stretch secondary to uterine contraction
  9. 9. Aim of intrapertum fetal monitering  1- to detect the earliest stages of hypoxia so therapy can be directed to prevent asphyxia and asphyxial damage( e.g Cerebral palsy)  2-To Improve perinatal morbidity & mortality
  10. 10. What is Cardiotocography(CTG)? It is a paper record of the continuous FHR blotted simultaneously with a record of uterine activity Ultrasound (cardio) transducer Tocotransducer
  11. 11. CTG reCords Non stress test without uterine contraction Stress test in correlation to uterine contraction
  12. 12. External monitoring
  13. 13. Internal monitoring
  14. 14. Intrapartum Fetal monitoring CTG
  15. 15. FHR trace(4 components)  Base line FHR  Baseline variability  Accelerations  Decelerations
  16. 16. Baseline FHR The dominant reading taken ≥10 min Normal baseline FHR 110-160(pbm) Controlled by atrial pacemaker
  17. 17. Baseline FHR
  18. 18. Tachycardia FHR>160 bpm
  19. 19. Baseline bradycardia FHR<110bpm
  20. 20. Baseline varibility  The Oscaltatory pattern of FHR when recorded on a graph.  Short term(beat t0 beat)  is the fluctuation of HR over short interval  Long term is the fluctuation over long interval(≥2 min)  Indicates mature fetal neurologic system
  21. 21. Baseline varibility Short term variability (scalp electrode) Long term variability defined as 3-5 cycle/min
  22. 22. Baseline varibility
  23. 23. No variability (0-2 ครั้ง/นาที) Mark variability (>25 ครั้ง/นาที) Moderate variability (11-25 ครั้ง/นาที) No variability (0-2 ครั้ง/นาที) Moderate variability (11-25 ครั้ง/นาที) Minimal variability (3-4 ครั้ง/นาที)
  24. 24. Accelaration Increase in FHR with contraction or with other activities Increase15pbm lasting 15 sec Return to base line <2 min
  25. 25. Accelaration
  26. 26. Decelerations Decelerations  Transient slowing of FHR below The baseline level> 15 bpm  and lasting for 15 sec. or more.
  27. 27. Early Decelerations  Uniform  Synchronous with contraction (mirror image)  Rarely fall below 110 (pbm)  Due to head compression  Should not be disregarded if they appear early in labor or Antenatal.
  28. 28. Early Decelerations
  29. 29. Late Deceleration Uniform Start after peak of contraction Associated with decreased Variability Reflect a baroreceptor response Indicate fetal hypoxia
  30. 30. Late Deceleration
  31. 31. Repetitive late decelration increases risk of Umbilical artery acidosis Apgar score < 7 at 5 ms Cerebral palsy If associated with decrease or loss of variability
  32. 32. Variable Deceleration (the most common type) Varible in appearance and Timing. May be assoicated with increased variability . Reflect umbilical cord compression • Of no clinical significance if non recurrent .
  33. 33. Variable Deceleration
  34. 34. Tyes of decleration
  35. 35. Prolonged Deceleration deceleration  A deceleration that lasts more than 90  seconds (but less than 10 minutes)  Drop in FHR of 30 bpm or More  Reduction in O2 transfer to placenta.  Associated with poor neonatal outcome
  36. 36. Prolonged Deceleration
  37. 37. What are the features of a normal tracing? Baseline FHR 110-160 BPM Baseline Variability > 5 pbm (10-25) 2 Accelerations > 15 BPM > 15 sec / 20 min trace No decelrations
  38. 38. Normal -Reassuring CTG
  39. 39. Interpertation of CTG Normal -Reassuring(R)- CTG with all 4 Features Suspicious (equivocal)- one non reassuring category and reminder are reassuring Abnormsal -Non reasurring (NR) - 2 or more non-reassuring categories or one or more abnormal categories.
  40. 40. Interpertation of CTG
  41. 41. Consider Intrapartum / antepartum trace. Stage of labour Gestation Fetal presentation. Any augmentation Medications
  42. 42. Is Normal CTGs always Reassuring?  With normal CTC the chance of fetus to develop hypoxia is 1.5% due to unpredictable acute events  So a normal CTG is always Reassuring
  43. 43. Is NR CTGs always worrisome ?  60% CTG in Labour have 1 abnormal feature  Only 15-20% of NR CTGs are pathological.  High false positive rate with unnecessary operative intervention for fetal distress.  Thus NR CTG is not always worrisome.
  44. 44. ?? To reduce CS….
  45. 45. Consider these factors with abnormal CTG  Maturity of the fetus Reduced variability and baseline tachycardia is conmen in preterm  State of maternal pulse Drugs may cause maternal and fetal tachycaedia  Check blood pressure for hypotension in patients on epidural.
  46. 46. Consider these factors with abnormal CTG  Posture of patient during CTG o Supine position give abnormal tracing o Some cord compression can get released by change posture and must be tried with variable deceleration  Congenital fetal malformation Color Doppler of fetal heart to exclude congenital heart block
  47. 47. Correct reversible causes Change mother position from supine to left lateral position-----increase uterine blood flow Improve maternal oxygenation—100% O2 by masK Correct maternal hypotension –IV fluid Decrease or stop any oxytocin infusion Remove vaginal prostaglandins
  48. 48. Secondary tests of fetal well-being Vibro-acoustic stimulation Used as a substitute for scalp sampling when CTG –is NR Normal ----------if FHR acceleration > 15 bpm for 15 seconds within 15 seconds after the stimulation with prolonged fetal movements. Abnormal ----Only 50% have acidotic PH
  49. 49. Fetal blood sampling If the pH >7.25 --- observe. If the pH 7.2 and 7.25---repeated within 30 minutes. If the pH <7.2----repeat immediately If pH still low -- Prompt delivery
  50. 50. Scalp stimulation. Firm digital pressure Gentile pinch by atramatic Allis forceps Fetal pulse oximetry.
  51. 51. THANK YOU
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