2                                                   Assessment of                                                   fetal ...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y               61FETAL GROWTH                                   ...
62    MATERNAL CARE3. From 36 weeks onwards, the presenting                          Between 18 and 36 weeks of pregnancy,...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y                                         63GESTATION 12 13 14 15...
64    MATERNAL CARE              GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 3...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y             65Doppler measurement of blood flow in the         ...
66    MATERNAL CARE                                                      adequate number of fetal movements has been Askin...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y            672. The patient should be allowed to rest and      ...
68    MATERNAL CARE Reactive pattern           Non-reactive pattern             dependent diabetes, preterm rupture of the...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y            692-31 What are reactive and non-                   ...
70    MATERNAL CARE                                                                         0                             ...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y             712-39 What is the emergency management            ...
72   MATERNAL CAREfetus has moved a lot, as usual, that day. The      CASE STUDY 3s-f height has not increased over the pa...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y           735. What is the correct management                  ...
74    MATERNAL CARE                                                   Gestation 28                                        ...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y             75                                              Con...
76    MATERNAL CARE                                                 Decreased fetal mo ements                             ...
ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y               77                                            Fet...
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Maternal Care: Assessment of fetal growth and condition during pregnancy

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Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care

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Transcript of "Maternal Care: Assessment of fetal growth and condition during pregnancy"

  1. 1. 2 Assessment of fetal growth and condition during pregnancyBefore you begin this unit, please take the INTRODUCTIONcorresponding test at the end of the book toassess your knowledge of the subject matter. You During the antenatal period, both maternal andshould redo the test after you’ve worked through fetal growth must be continually monitored.the unit, to evaluate what you have learned. Individualised care will improve the accuracy of antenatal observations. Objectives At every antenatal visit from 28 weeks gestation onwards, the wellbeing of the fetus When you have completed this unit you must be assessed. should be able to: • Assess normal fetal growth. 2-1 How can you assess the condition of the fetus during pregnancy? • List the causes of intra-uterine growth restriction. The condition of the fetus before delivery is • Understand the importance of assessed by: measuring the symphysis-fundus height. 1. Documenting fetal growth. • Understand the clinical significance of 2. Recording fetal movements. fetal movements. • Use a fetal-movement chart. When managing a pregnant woman, remember • Manage a patient with decreased fetal that you are caring for two individuals. movements. • Understand the value of antenatal fetal heart rate monitoring.
  2. 2. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 61FETAL GROWTH Poor maternal weight gain is of very little value in diagnosing intra-uterine growth restriction.2-2 What is normal fetal growth? 2. Fetal factors • Multiple pregnancy.If the assessed fetal weight is within the • Chromosomal abnormalities,expected range for the duration of pregnancy, e.g. trisomy 21.then the fetal growth is regarded as normal. • Severe congenital malformations. • Chronic intra-uterine infection, To determine fetal growth you must have an e.g. congenital syphilis. assessment of both the duration of pregnancy 3. Placental factors and the weight of the fetus. • Poor placental function (placental insufficiency) is usually due to a maternal problem such as pre-2-3 When may fetal growth eclampsia.appear to be abnormal? • Smoking. Poor placental function isFetal growth will appear to be abnormal when uncommon in a healthy woman whothe assessed fetal weight is greater or less than does not smoke.that expected for the duration of pregnancy. If severe intra-uterine growth restriction isRemember that incorrect menstrual dates present, it is essential to look for a maternal orare the commonest cause of an incorrect fetal cause. Usually a cause can be found.assessment of fetal growth. NOTE True primary placental inadequacy is2-4 When is intra-uterine growth an uncommon cause of intra-uterine growthrestriction suspected? restriction as placental causes are almost always secondary to an abnormality of the spiral arteries.Intra-uterine growth restriction is suspectedwhen the weight of the fetus is assessed as 2-6 How can you estimate fetal weight?being less than the normal range for theduration of pregnancy. The following methods can be used: 1. Measure the size of the uterus on2-5 What maternal and fetal abdominal examination.factors are associated with intra- 2. Palpate the fetal head and body onuterine growth restriction? abdominal examination. 3. Measure the size of the fetus usingIntra-uterine growth restriction may be antenatal ultrasonography (ultrasound).associated with either maternal, fetal orplacental factors: 2-7 How should you measure1. Maternal factors the size of the uterus? • Low maternal weight, especially a low body-mass index resulting from 1. This is done by determining the undernutrition. symphysis-fundus height (s-f height), • Tobacco smoking. which is measured in centimetres from the • Alcohol intake. upper edge of the symphysis pubis to the • Strenuous physical work. top of the fundus of the uterus. • Poor socio-economic conditions. 2. The s-d height in centimetres should be • Pre-eclampsia and chronic plotted against the gestational age on the hypertension. s-f growth curve.
  3. 3. 62 MATERNAL CARE3. From 36 weeks onwards, the presenting Between 18 and 36 weeks of pregnancy, the s-f part may descend into the pelvis and height normally increases by about 1 cm a week. measurement of the s-f height will not accurately reflect the size of the fetus. A 2-9 When will the symphysis-fundus height reduction in the s-f height may even be suggest intra-uterine growth restriction? observed. If any of the following are found:2-8 What is the symphysis- 1. Slow increase in uterine size until onefundus growth curve? measurement falls under the 10th centile. 2. Three successive measurements ‘plateau’The symphysis-fundus growth curve compares (i.e. remain the same) without necessarilythe s-f height to the duration of pregnancy. crossing below the 10th centile.The growth curve should preferably form 3. A measurement which is less than thatpart of the antenatal card. The solid line of recorded two visits previously withoutthe growth curve represents the 50th centile, necessarily crossing below the 10th centile.and the upper and lower dotted lines, the 90thand 10th centiles, respectively. If intra-uterine Note that a measurement that was originallygrowth is normal, the s-f height will fall normal, but on subsequent examinationsbetween the 10th and 90th centiles. The ability has fallen to below the 10th centile, indicatesto detect abnormalities from the growth curve intra-uterine growth restriction and notis much increased if the same person sees the incorrect dates.patient at every antenatal visit. SIGNATURE: DATE: GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both SF-measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths) GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43Figure 2-1: The symphysis-fundus growth chart
  4. 4. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 63GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both SF-measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical landmarks HEAD ABOVE PELVIS (fifths)GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43Figure 2-2: One measurement below the 10th centileGESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both SF-measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical Vx landmarks HEAD ABOVE PELVIS (fifths) 5 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43Figure 2-3: Three successive measurements that remain the same
  5. 5. 64 MATERNAL CARE GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 45 GESTATION EST. BY: 45 Dates Sonar 40 40 Both SF-measurement 35 LW. 0. = Weight 35 x = measurement 30 30 25 25 20 20 15 15 10 10 Start SF measurement Repeat examination of breasts at 34 weeks 5 Uterine size using PRESENTING PART 5 anatomical VxVxVx landmarks HEAD ABOVE PELVIS (fifths) 5 5 5 GESTATION 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 BLOOD- S st. PRESSURE Diast. P P Urine S S OEDE A RRT 2 01 Fetal mo ements Antenatal Haemoglobim (g dl) card B ENGFigure 2-4: A measurement less than that recorded two visits before2-10 How can you identify severe diet. It may be necessary to arrange sickintra-uterine growth restriction? leave and social support for the patient. 2. A poor diet which is low in energyWith severe intra-uterine growth restriction, (kilojoules) may cause intra-uterine growththe difference between the actual duration of restriction, especially in a patient with apregnancy and that suggested by plotting s-f low body-mass index. Therefore, ensureheight is four weeks or more. that patients with suspected intra-uterine growth restriction receive a high-energy2-11 Does descent of the presenting diet. If possible, patients must be givenpart of the fetus affect your food supplements (food parcels).interpretation of the growth curve? 3. Exclude pre-eclampsia as a cause.Yes. Descent of the presenting part may occur 4. If the gestational age is 28 weeks or more,in the last 4 weeks of pregnancy. Therefore, careful attention must be paid to countingafter 36 weeks the above criteria are no the fetal movements.longer valid, if at subsequent antenatal visits 5. The patient should be followed up weeklyprogressively less of the fetal head is palpable at a level 1 hospital.above the pelvic inlet. 2-13 Which special investigation2-12 What action would you take if the is of great value in the furthersymphysis-fundus height measurement management of this patient?suggests intra-uterine growth restriction? The patient must be referred to a fetal1. The patient should stop smoking and rest evaluation clinic or a level 2 hospital for a more, while attention must be given to her
  6. 6. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 65Doppler measurement of blood flow in the 2. An ultrasound examination should beumbilical arteries: done, if available, to exclude serious congenital abnormalities.1. Good flow (low resistance) indicates good 3. If the fetus has reached viability (28 weeks placental function. As a result the woman or more, or 1000 g or above), antenatal can receive further routine management fetal heart rate monitoring should be done as a low-risk patient. Spontaneous onset of regularly. If this suggests fetal distress, labour can be allowed. Induction of labour the fetus must be delivered by Caesarean at 38 weeks is not needed. section.2. Poor flow (high resistance) indicates poor 4. In severe intra-uterine growth restriction, placental function. Antenatal electronic the immediate danger is of intra-uterine fetal heart rate monitoring must be done. death, so the delivery of the fetus should be The further management will depend on considered at 36 weeks. the result of the monitoring.If a Doppler measurement is not available, thepatient must be managed as given in 2-14. FETAL MOVEMENTS2-14 What possibilities must beconsidered if, after taking the above 2-16 When are fetal movements first felt?steps, there is still no improvement 1. At about 20 weeks in a primigravida.in the symphysis-fundus growth? 2. At about 16 weeks in a multigravida.1. Intra-uterine death must be excluded by the presence of a fetal heartbeat on 2-17 Can fetal movements be auscultation. used to determine the duration2. With moderate intra-uterine growth of pregnancy accurately? restriction and good fetal movements, the No, because the gestational age when fetal patient must be followed up weekly and movements are first felt differs a lot from delivery at 38 weeks should be considered. patient to patient. Therefore, it is only useful3. If the above patient also has poor social as an approximate guide to the duration of circumstances, an admission to hospital pregnancy. will need to be considered. This should ensure that the patient gets adequate rest, a good diet, and stops smoking. 2-18 What is the value of4. If there are decreased or few fetal move- assessing fetal movements? ments, the patient should be managed as Fetal movements indicate that the fetus is well. described in sections 2-25 and 2-26. By counting the movements, a patient can5. When there is severe intra-uterine growth monitor the condition of her fetus. restriction, the patient must be referred to a level 2 or 3 hospital for further 2-19 From what stage of pregnancy management. will you advise a patient to become aware of fetal movements in order2-15 What is the management of severe to monitor the fetal condition?intra-uterine growth restriction? From 28 weeks, because the fetus can now1. All patients with severe intra-uterine be regarded as potentially viable (i.e. there is growth restriction must be managed in a a good chance that the infant will survive if level 2 or 3 hospital. delivered). All patients should be encouraged to become aware of the importance of an adequate number of fetal movements.
  7. 7. 66 MATERNAL CARE adequate number of fetal movements has been Asking the patient if the fetus is moving normally recorded for the day. on the day of the visit is an important way of monitoring the fetal wellbeing. A uterus which increases in size normally, and2-20 What is a fetal-movement chart? an actively moving fetus, indicate that the fetus is well.A fetal-movement chart records the frequencyof fetal movements and thereby assesses thecondition of the fetus. The name ‘kick chart’ 2-24 What is the least numberis not correct, as all movements must be of movements per hour whichcounted, i.e. rolling and turning movements, indicates a good fetal condition?as well as kicking. 1. The number of movements during an observation period is less important than2-21 Which patients should use a decrease in movements when compareda fetal-movement chart? to previous observation periods. If the number of movements is reduced by half,A fetal-movement chart need not be used it suggests that the fetus may be at anroutinely by all antenatal patients, but only increased risk of fetal distress.when: 2. If a fetus normally does not move much,1. There is concern about the fetal condition. and the count falls to three or fewer per2. A patient reports decreased fetal hour, the fetus may be in danger. movements. 2-25 What would you advise if the2-22 How should you advise a patient fetal movements suggest that the fetalto use the fetal-movement chart? condition is not good?Fetal movements should be counted and 1. The mother should lie down on her side forrecorded on the chart over a period of an hour another hour and repeat the count.per day after breakfast. The patient should 2. If the number of fetal movementspreferably rest on her side for this period. improves, there is no cause for concern. 3. If the number of fetal movements does2-23 How accurate is a fetal not improve, she should report this to hermovement count? clinic or hospital as soon as possible.A good fetal movement count always indicates NOTE A patient who lives far away from hera fetus in good condition. A distressed fetus nearest hospital or clinic should continuewill never have a good fetal movement count. with bed rest, but if the movements areHowever, a low count or a decrease in fetal three or fewer over a six-hour period, thenmovements may also be the result of periods arrangements must be made for her toof rest or sleep in a healthy fetus. The rest and be moved to the nearest hospital.sleep periods can last several hours. 2-26 What should you do if a patientTests with electronic equipment have shown with reduced fetal movements arrivesthat mothers can detect fetal movements at the clinic or hospital without aaccurately. With sufficient motivation, the cardiotocograph (CTG machine)?fetal-movement chart can be an accuraterecord of fetal movements. It is, therefore, 1. Listen to the fetal heart with a fetalnot necessary to listen to the fetal heart at stethoscope or a doptone to exclude intra-antenatal clinics if the patient reports an uterine death.adequate number of fetal movements, or an
  8. 8. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 672. The patient should be allowed to rest and • If the cervix is favourable and the count fetal movements over a six-hour pregnancy is of more than 36 weeks period. With four or more movements duration, the membranes should be during the next six hours, repeat the ruptured. The fetal heart rate must be fetal movement count the next day, after carefully monitored with a stethoscope breakfast. If there are three or fewer during labour. movements over the next six hours, the • If the cervix is unfavourable, and the patient should see the responsible doctor. patient is more than 42 weeks pregnant, a Caesarean section must be done.The patient should be given a drink containing • If the patient does not fall into eithersugar (e.g. tea) to exclude hypoglycaemia as of the above-mentioned categories, shethe cause of the decreased fetal movements. must be observed for a further six hoursThe management of a patient with confirmed in hospital. If there is no improvementdecreased fetal movements in a hospital is in the number of fetal movements, thedemonstrated in Flow diagram 2-2. patient must be referred to a hospital which has facilities for electronic fetal2-27 What should the doctor do, in heart rate monitoring.a hospital without fetal heart rate Sections 2-28 to 2-38 need only be studiedmonitoring equipment, if there are by nurses and doctors who work in a level 2decreased fetal movements? or 3 hospital where electronic fetal heart rateFirst make sure that the fetus is potentially monitoring is available. All students must studyviable (at least 28 weeks or 1000 g). Further sections 2-39 and 2-40.management will then depend on whetheror not there are signs of intra-uterine growthrestriction: ANTENATAL FETAL HEART1. If there are clinical signs of intra-uterine RATE MONITORING growth restriction: • If the cervix is favourable, the mem- branes must be ruptured. The fetal 2-28 What is antenatal fetal heart rate must be very carefully moni- heart rate monitoring? tored with a stethoscope during labour. Antenatal (electronic) fetal heart rate • If the cervix is unfavourable, a monitoring assesses the condition of the fetus Caesarean section must be done. by documenting the pattern of heart rate • If the estimated weight of the fetus changes. It is done with a cardiotocograph (the is 1500 g or more, the delivery may machine) which produces a cardiotocogram be managed in a level 1 or 2 hospital. (the paper strip showing the uterine However, if the estimated weight of contractions and the fetal heart rate pattern). the fetus is less than 1500 g, then the delivery must take place in a level 2 Antenatal fetal heart rate monitoring is hospital with a neonatal intensive care currently regarded as one of the best ways unit, or a level 3 hospital. to assess the fetal condition. Fetal heart rate monitoring has the advantage that it can be done reasonably quickly, and that the results Intra-uterine growth restriction plus decreased are immediately available. fetal movements is an indication for delivery. Hospitals which deal with mainly low-risk2. If there are no clinical signs of intra-uterine patients can manage perfectly well without growth restriction: a cardiotocograph. There is also no evidence that antenatal fetal heart monitoring of low-
  9. 9. 68 MATERNAL CARE Reactive pattern Non-reactive pattern dependent diabetes, preterm rupture of the membranes or severe pre-eclampsia which 200 is being managed conservatively. 180 2-30 How do you interpret an 160 antenatal fetal heart rate pattern? 140 1. The fetal condition is good when: • There is a reactive (normal) fetal heart 120 rate pattern. 100 Beats/minute • There is a normal stress test. 2. No comment can be made about the fetal 80 condition when there is a non-reactive fetal Rate: 1 cm/minute 60 heart rate pattern. In this case there are no contractions and, therefore, one cannotFigure 2-5: Reactive and non-reactive fetal heart determine whether there is a normal orrate patterns abnormal stress test. The variability of the heart rate will indicate whether there isrisk patients does anything to improve the fetal wellbeing or possible fetal distress.outcome of the pregnancy. The interpretation 3. Fetal distress is present when:of fetal heart rate patterns needs considerable • There is an abnormal stress test.experience, and should only be done where • There are repeated U-shapedthe necessary expertise is available. decelerations at regular intervals, even though no contractions are observed.2-29 When is antenatal fetal heart • There is fetal bradycardia, with a fetalrate monitoring indicated? heart rate constantly below 100 beats per minute.1. If a patient with a viable fetus reports a • There is a non-reactive fetal heart rate decrease in fetal movements or a poor fetal pattern with poor variability (i.e. less movement count which does not improve than five beats). when the count is repeated.2. If a high-risk patient has a condition for which the value of fetal movement counts has not yet been proven, e.g. insulin- Good variability Poor variability 200 200 180 180 160 160 140 140 120 120 100 100 80 80 60 60Figure 2-6: Non-reactive fetal heart rate pattern with good and poor variability.
  10. 10. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 692-31 What are reactive and non- • The variability in the heart rate will bereactive heart rate patterns? less than five beats, in other words, will remain within one block (Figure 2-6).1. The fetal heart rate pattern is said to • The fetal heart monitoring must be be reactive when it has at least two repeated after 45 minutes. accelerations per ten minutes, each with • If the poor variability persists, there is an amplitude (increase in the number of fetal distress. beats) of 15 or more beats per minute and a duration of at least 15 seconds (Figure 2-5).2. In a non-reactive fetal heart rate pattern 2-33 Why must you repeat the there are no accelerations. cardiotocogram after 45 minutes in a patient with a non-reactive fetal heart rate pattern and poor variability?2-32 How is the variability in the fetalheart rate used to determine whether a 1. Because a sleeping fetus may have a non-fetal heart rate pattern is non-reactive? reactive fetal heart rate pattern with poor variability.1. With good variability: 2. A fetus does not sleep for longer than 45 • The variability in the heart rate will minutes. In a sleeping fetus the fetal heart be five beats or more, in other words, rate pattern should, therefore, after 45 will involve one or more blocks in the minutes have returned to a reactive pattern cardiogram. Each block indicates five or a non-reactive pattern with good beats (Figure 2-6). variability. • Good variability indicates fetal 3. A persistent non-reactive fetal heart rate wellbeing. pattern with poor variability is abnormal2. With poor variability: and indicates fetal distress. Normal Abnormal 200 200 180 180 160 160 140 140 120 120 100 100 80 80 60 60 2 0 0484 69 100 100 80 80 60 60 40 40 2 2 20 20 0 0Figure 2-7: Normal and abnormal stress tests
  11. 11. 70 MATERNAL CARE 0 0Figure 2-8: A late deceleration2-34 What is a stress test? 2. However, false-positive abnormal stress tests can be caused by posturalIf contractions are present during fetal heart hypotension or spontaneousrate monitoring in the antenatal period, then overstimulation of the uterus. Therefore, athe monitoring is called a stress test. The fetal stress test must always be performed withheart rate pattern can now be assessed during the patient on her side in the 15 degreesthe stress of a uterine contraction. lateral position. 3. Whenever a fetal heart rate pattern2-35 How is a stress test interpreted? indicates fetal distress, the cardiogram1. A normal stress test has no fetal heart rate must be repeated immediately. If it is again decelerations during or following at least abnormal, action should be taken as shown two contractions which last at least 30 in Flow diagram 2-4. seconds (Figure 2-7). 4. A persistent fetal bradycardia is usually2. An abnormal stress test has late a preterminal event and, therefore, an decelerations associated with uterine indication for an immediate Caesarean contractions (Figure 2-7). This indicates section if the fetus is viable. that the fetus is distressed. The use of antenatal fetal heart rate monitoring is demonstrated in Flow diagram 2-3.2-36 What are the characteristicsof a late deceleration? 2-38 Why should you not immediatelyOn the cardiotocogram the trough of the do a Caesarean section if the fetaldeceleration occurs 30 seconds or later after heart rate pattern indicates fetalthe peak of the contraction (Figure 2-8). distress and the fetus is viable? Studies have shown that a false-positive2-37 What should you do in the case abnormal stress test can occur in up to 80% ofof an abnormal stress test, fetal cases (i.e. an abnormal stress test in a healthybradycardia, repeated decelerations, or fetus). Therefore, whenever a fetal hearta non-reactive fetal heart rate pattern pattern indicates fetal distress, the cardiogramwith persistent poor variability? must always be repeated immediately.1. The patient is managed as an acute emergency as these fetal heart rate patterns indicate fetal distress.
  12. 12. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 712-39 What is the emergency management CASE STUDY 1of proven fetal distress with a viable fetus?Immediately proceed with fetal resuscitation, A patient is seen at the antenatal clinic at 37as follows: weeks gestation. She is clinically well and reports normal fetal movements. The s-f1. Turn the patient onto her side. height was 35 cm the previous week and is2. Give 40% oxygen through a face mask. now 34 cm. The previous week the fetal head3. Start an intravenous infusion of Ringer’s was ballotable above the brim of the pelvis and lactate and give 250 μg (0.5 ml) salbutamol it is now 3/5 above the brim. The fetal heart slowly intravenously if there are no rate is 144 beats per minute. The patient is contraindications. The 0.5 ml salbutamol reassured that she and her fetus are healthy, must first be diluted in 9.5 ml sterile and she is asked to attend the antenatal clinic water. Monitor the maternal heart rate for again in a week’s time. tachycardia.4. Deliver the infant by the quickest possible route. If the patient’s cervix is 9 cm or 1. Are you worried about the decrease in more dilated and the head is on the pelvic the s-f height since the last antenatal visit? floor, proceed with an assisted delivery. No, as the fetal head is descending into the Otherwise, perform a Caesarean section. pelvis. The head was 5/5 above the brim of the5. If the patient cannot be delivered pelvis and is now 3/5 above the brim. immediately (e.g. she must be transferred to hospital) then a side-infusion of 200 ml 2. What is your assessment saline with 30 mg salbutamol (ventolin) of the fetal condition? can be run at a speed needed to keep the maternal pulse rate at about 120 beats per The fetus is healthy as the s-f height is normal minute. for 37 weeks and the fetus is moving normally.It is important that you know how to give fetal 3. What is the value of a normal fetalresuscitation, as it is a life-saving procedure heart rate during the antenatal period?when fetal distress is present, both during theantepartum period and in labour. The fetal heart rate is not a useful measure of the fetal condition before the onset of labour. NOTE Uterine contractions can also be suppressed If the fetus moves well during the antenatal if 30 mg nifedipine (Adalat) is given my mouth period, there is no need to listen to the fetal (one capsule = 10 mg). The three capsules must heart. be swallowed and not used sublingually. 4. What is the value of fetal movements2-40 What are the aims of during the antenatal period?fetal resuscitation? Active fetal movements, noted that day,1. Suppressing uterine contractions and indicate that the fetus is healthy. The patient reducing uterine tone, which increases can therefore monitor the condition of her maternal blood flow to the placenta and, fetus by taking note of fetal movements. thereby, the oxygen supply to the fetus.2. Giving the mother extra oxygen which will also help the fetus. CASE STUDY 2It is, therefore, possible to improve the fetalcondition temporarily while preparations are You examine a 28-year-old gravida 4 para 3being made for the patient to be delivered, or patient who is 34 weeks pregnant. She has noto be transferred to the hospital. particular problems and mentions that her
  13. 13. 72 MATERNAL CAREfetus has moved a lot, as usual, that day. The CASE STUDY 3s-f height has not increased over the past threeantenatal visits but only the last s-f height A patient, who is 36 weeks pregnant withmeasurement has fallen to the 10th centile. The suspected intra-uterine growth restriction, ispatient is a farm labourer and she smokes. asked to record her fetal movements on a fetal- movement chart. She reports to the clinic that1. What do the s-f height her fetus, which usually moves 20 times permeasurements indicate? hour, only moved five times during an hourThey indicate that the fetus may have intra- that morning.uterine growth restriction, as the last threemeasurements have remained the same even 1. What should the patient have done?though the s-f height measurement has not Rather than come to the clinic, she shouldfallen below the 10th centile. have counted the number of fetal movements for a further hour.2. What are the probable causesof the poor fundal growth? 2. What is the correct managementHard physical labour and smoking. Both of this patient?these factors can cause intra-uterine growth She must not go home unless you are sure thatrestriction. her fetus is healthy. She should lie on her side and count the number of fetal movements3. What is the possibility of fetal distress during one hour. If she has not had breakfast,or death in the next few days? give her a cold drink or a cup of sweetened teaBoth these possibilities are most unlikely as the to make sure that she is not hypoglycaemic.patient has reported normal fetal movements. 3. What should you do if the fetus moves4. What can be done to more than ten times during the hour?improve fetal growth? If the number of fetal movements returns toArrangements should be made, if possible, for more than half the previous count (i.e. morethe patient to stop working. She must also stop than ten times per hour), she can go home andsmoking, get enough rest and have a good diet. return to the clinic in a week. In addition, she must count the fetal movements daily.5. How should this patient be managed? 4. What should you do if the fetus movesShe must be given a fetal-movement chart and fewer than ten times during the hour?you must explain clearly to her how to usethe chart. She must be placed in the high-risk If the fetal movement count remains less thancategory and therefore seen at the clinic every half the previous count, the patient shouldweek. If the fundal growth does not improve, be transferred to a hospital where antenatalthe patient must be hospitalised and labour electronic fetal heart monitoring can be done.should be induced at 38 weeks. Further management will depend on the result of the monitoring.If a Doppler blood flow measurement of theumbilical arteries indicates normal placentalfunction, routine management of a low-riskpatient can be given. Induction at 38 weeks istherefore not needed.
  14. 14. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 735. What is the correct management 2. Does the fetal heart rate patternif electronic fetal heart indicate fetal distress?monitoring is not available? The condition of the fetus cannot beFetal movements should be counted for a full determined if there is a non-reactive antenatalsix hours. If the fetus moves fewer than four fetal heart rate pattern. The variability musttimes, there is a high chance that the fetus is now be examined. If there is good variabilitydistressed. A doctor must now examine the (five beats or more), this indicates fetalpatient and decide whether the fetus should wellbeing.be delivered and what would be the safestmethod of delivery. 3. What must you do if there is poor variability (fewer than five beats)?Case study 4 need only be attempted by thosewho have studied the section on antenatal fetal The test should be repeated after 45 minutes.heart rate monitoring. 4. Why must you repeat the test after 45 minutes if there is a non-reactiveCASE STUDY 4 pattern with poor variability? A sleeping fetus may have a fetal heart rateAntenatal fetal heart rate monitoring is done pattern with poor variability. However, a fetuson a patient who is 36 weeks pregnant and does not sleep for longer than 45 minutes.who reports a decrease in the number of fetal The fetal heart rate pattern in that case willmovements. She lies flat on her back during therefore have reverted to normal when thethe test. A non-reactive fetal heart rate pattern test is repeated 45 minutes later.is found. 5. What must you do if the test,1. What is wrong with the method performed 45 minutes later, continuesused to monitor the fetal heart rate? to show poor variability?The patient should not have been on her back The test now indicates fetal distress. If theduring the test as this can cause postural fetus is viable, arrangements must be made tohypotension resulting in a falsely abnormal deliver it (see Flow diagram 2-4).fetal heart rate pattern. The patient should lieon her side with a 15 degree lateral tilt whilethe fetal heart rate is monitored.
  15. 15. 74 MATERNAL CARE Gestation 28 Gestation 28 weeks or more weeks or more with normal with normal fetal growth oncern about oncern about fetal wellbeing fetal wellbeing 1. Inform patient about Good fetal Use fetal mo ements importance of fetal mo ements or 4 or chart for 1 hour each mo ements more mo ements morning 2. Routine low-risk care per hour Decrease of 50 or more or 3 or fewer mo ements per hour Repeat mo ements count Good fetal Repeat count for a the next da mo ements further hour Send patient to nearest clinic or Fetal mo ements hospital still poorFlow diagram 2-1: The management of a patient with decreased fetal movements
  16. 16. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 75 Confirmed Gestation 28 decreased fetal movements Intra-uterine Fetal oncern about heart present? death fetal wellbeing See flow diagram 2-3 Fetal heart rate monitoring available? Repeat fetal Repeat fetal movement count Four or more fetal movement count the next day movements over next six hours Fewer than four See section 2-26 fetal movements?Flow diagram 2-2: The management of a patient with confirmed decreased fetal movements in a hospital
  17. 17. 76 MATERNAL CARE Decreased fetal mo ements or three or fewer mo ements per hour No impro ement in mo ements after another hour Reacti e Non-reacti e ontinue counting Antenatal fetal heart Spontaneous fetal mo ements rate monitoring contractions Negati e Yes No Stress test Variablit Negati e Positi e Repeat stress test aesarean section See Flow diagram immediatel Positi e 2-4Flow diagram 2-3: The use of antenatal fetal heart rate monitoring
  18. 18. ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANC Y 77 Fetal heart rate ariation Good Poor Fi e beats or more Fewer than fi e beats ontinue with fetal Repeat after mo ement count 45 minutes Good ariabilit fi e or more beats Poor ariabilit Fewer than fi e beats aesarean sectionFlow diagram 2-4: The interpretation of variability when the fetal heart rate pattern is non-reactive with NOspontaneous uterine contractions.

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