Introduction to fetal monitoring 2


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  • Antenatal indicators for Electronic FHR Monitoring.Antenatal EFM must be commenced if risk factors develop throughout pregnancy, if there is a change in the maternal condition or any suspicion of inutero fetal compromise, and after 25 +6 (26 completed weeks) weeks gestation (Lui, 2005).
  • For pregnancies assessed as having normal risk and where labour is uncomplicated, the fetal heart must be monitored by intermittent auscultation (IA). In the first instance a Pinards or binaural stethoscope must be used to identify the fetal heart and rate. This is written into the policy for fetal heart rate assessment document for NSW government. Auscultation of the fetal heart with a Pinards at the first auscultation helps to clearly identify the position of the baby and the true presence of the fetal heart as distinguished from maternal heart rate.
  • All further auscultation can be performed using a hand help DopplerActivity:Role play an informercial selling this product highlighting the advantages
  • Loads of books and Courses
  • Introduction to fetal monitoring 2

    1. 1. Introduction to fetal monitoring<br />
    2. 2. Discuss the basics of fetal heart rate monitoring<br />Course objective<br />
    3. 3. Specific objectives-<br />By the end of the tutorial the student should be able to:<br /><ul><li>Discuss the principles of fetal monitoring
    4. 4. Describe the difference between intermittent auscultation and continuous electronic fetal monitoring
    5. 5. Describe the elements necessary to determine a “normal” CTG
    6. 6. Discuss issues that can affect the accuracy of the CTG</li></li></ul><li>Central Nervous system (involuntary)<br />Cortical<br />Subcortical<br />Autonomic nervous system<br />Sympathetic System (increase heart rate)<br />Parasympathetic system (decrease heart rate)<br />Control of fetal heart(revision)<br />
    7. 7. Cardioregulatory Centre in brainstem<br />Circulatory catecholamines<br />Chemoreceptors<br />Baroreceptors<br />Central Nervous System<br />
    8. 8. Fright or flight<br />Sympathetic stimulation<br />
    9. 9. Parasympathetic stimulation<br />
    10. 10. Methods of fetal heart rate monitoring<br />Pinards<br />Binaural stethoscope <br />Handheld doppler<br />Cardiotogograph (CTG)<br />
    11. 11. “The process of birth is the most dangerous journey any individual undertakes” – Gibb & Arulkumaran (2007)<br />There is no evidence to support the use of routine EFM in women with uncomplicated pregnancies (NICE, 2008)<br />*?DISCUSS<br />Clinical Assessment & Recording<br />
    12. 12. After > 41 completed weeks<br />Amniotic Fluid Index <5cm<br />A sudden elevation of BP after 25 weeks<br />Antepartum haemorrhage<br />Unstable or insulin dependent diabetes<br />Pre term rupture of membranes <37wks prior to commencement of uterine activity<br />Summarize History & Document - Antenatal Risk <br />
    13. 13. Preterm labour (PTL) or preterm uterine activity<br />Intrauterine growth restriction (IUGR)<br />Oligohydramnious<br />Polyhydramnious<br />Decreased fetal movements<br />Or other obstetric conditions that increase fetal risk e.g. Vasa Praevia<br />Indicators for EFM cont.<br />
    14. 14. Use of electronic FHR monitoring instead of intermittent auscultation has not led to a reduction in the overall risk of perinatal death (RR 0.85, 95% CI 0.59-1.23) <br />(Alfirevic Z, Devane D, Gyte GM. 2006)<br />*BRAINSTORM*<br />Why do we listen to fetal heart?<br />
    15. 15. The primary goal is to recognize fetuses in whom timely intervention will prevent death. <br />A secondary goal is to avoid fetal neurologic injury.<br />
    16. 16. The use of admission cardiotocography (CTG) in low-risk pregnancy is not recommended in any birth setting (NICE, 2008).<br />Where there are identified antenatal or intrapartum risk factors continuous EFM should be commenced. <br />Intrapartum EFM<br />
    17. 17. Induction or augmentation with Syntocinon<br />Meconium stained liquor (any degree)<br />Any non-reassuring FHR feature heard on auscultation <br />Breech presentation<br />Multiple Pregnancy<br />Prolonged labour<br />Vaginal Birth after Caesarean Section operation <br />Prolonged ROM, Regional analgesia <br />Intrapartum Risk Factors for EFM<br />
    18. 18. Maternal temperature<br />Maternal pulse<br />Respiratory Disease<br />Hypoventilation, seizure, trauma<br />Smoking – carboxyhaemoglobin<br />Anemia (iron deficiency, haemoglobinopathies)<br />Hypotension<br />Epidural<br />Maternal positioning<br />Vasculopathies(e.g., systemic lupus erythematosus, type I diabetes, chronic hyper- tension) <br />Antiphospholipidsyndrome <br />Maternal factors that may affect fetal oxygenation in labour<br />
    19. 19. Excessive uterine activity<br />Hyperstimulation secondary to oxytocin, prostiglandins or spontaneous labour<br />Placental abruption<br />Placental infarction<br />Intra Uterine Growth Retardation<br />Oligohydramnious<br />Abnormal doppler studies<br />Chorioamnionitis<br />Uteroplacental factors<br />
    20. 20. Cord compression<br />Cord prolapse or entanglement<br />Anaemia (e.g. isoimmunization, maternal-fetal bleed, ruptured vasa previa)<br />Fetal factors<br />
    21. 21. Pinards or binaural stethoscope<br />In the absence of risk factors: Intermittent Auscultation<br />
    22. 22. If you do not become accustomed to using a Pinard in the antenatal period you will not be able to use it in the early labour assessment.<br />Use it or lose the skill!<br />PRACTICE POINT<br />
    23. 23. Auscultation of the fetal heart with a Pinards at the first auscultation helps to clearly identify the position of the baby and the true presence of the fetal heart as distinguished from maternal heart rate. <br />Aim<br />
    24. 24. Hand Held Doppler<br />Further auscultation<br />Activity: Role play infomercial for doppler<br />
    25. 25. During active labour- towards the end and after a contraction for at least 60 seconds at least <br />every 15mins 1st stage <br />every 5mins 2nd stage <br />During active second stage towards the end and after every contraction <br />Frequency of Intermittent Auscultation<br />
    26. 26. CTG Interpretation<br />
    27. 27. Attach pressure toco-transducer using supplied belt on the fundus of the uterus<br />Attach the ultrasound transducer with the supplied belt over the area expected to detect the fetal heart most readily.<br />Label the CTG with the woman’s name, date, time of the assessment and pulse rate<br />Application of the Electronic Fetal Monitor (CTG)<br />
    28. 28. Calibrate the toco transducer to the baseline reading (usually 20 units)<br />Check that the fetal heart rate is recording<br />Check that the paper speed is set at 1cm/min<br />Instruct the woman to note when the baby moves (give her the marking tool)<br />Stay with the woman until satisfied no immediate evidence of fetal compromise<br />Application of the Electronic Fetal Monitor (CTG)<br />
    29. 29. Any events should be noted on the CTG such as change of position, blood pressure, vaginal examinations, rupture of membranes<br />If the necessary elements for a reassuring assessment are met within 10mins in an antenatal woman having routine monitoring, it can be discontinued<br />Assessment and Documentation<br />
    30. 30. In labour, the CTG should be reviewed every 30mins, signed on the tracing and documented every hour in the woman’s chart<br />Documentation<br />
    31. 31. DR – Define Risk<br />C – Contractions<br />BRa – Baseline Rate<br />V – Variability<br />A – Accelarations<br />D – Decelarations<br />O – Overall impression<br />Assessment: DR C BRAVADO<br />
    32. 32. Baseline fetal heart rate:<br />Mean level of fetal heart rate when it is stable without accelerations or decelerations – normal range 110-150bpm<br />Terminology<br />
    33. 33. Bradycardia<br />Baseline heart rate of less than 110bpm<br />
    34. 34. A tachycardia<br />A baseline heart rate of more than 150bpm<br />
    35. 35. An acceleration<br />A transient increase in heart rate of 15bpm or more lasting 15 seconds or more<br />
    36. 36. A decelaration<br />A transient episode of slowing of the fetal heart rate below the baseline level of more than 15bpm and lasting 15secs or more<br />
    37. 37. Baseline Variability<br />The degree to which the baseline varies within a particular band width excluding accelerations and decelerations<br />
    38. 38. Early Decelerations<br />Begin with the contraction and return to baseline after the contraction<br />Cause:<br />Head compression causing stimulation of vagal nerve & bradycardia<br />end of 1st stage & 2nd stage or following rupture of membranes<br />Usually benign.<br />Practice Point:<br />Beware early decelerations without descent of the head<br />Deceleration Types<br />
    39. 39. Late Decelerations:<br />The onset, duration and recovery of the deceleration is out of phase with the contractions<br />Cause:<br />Restricted supply of oxygen fetus is using up the oxygen in the retroplacental space<br />Pathological in nature<br />
    40. 40. Variable Deceleration<br />Vary in shape and sometimes<br />Timing<br />Cause:<br />Possibly due to cord compression, common with reduced amniotic fluid and associated with ‘shouldering’<br />Over stimulated uterus<br />May or may not indicate fetal hypoxia<br />180<br />180<br />150<br />150<br />120<br />120<br />90<br />90<br />100<br />100<br />75<br />75<br />50<br />50<br />25<br />25<br />0<br />0<br />
    41. 41. Caused by:<br />Entanglement around fetal body<br />Knotted<br />Cord prolapse<br />Oligohydramnious<br />Cord Compression<br />
    42. 42. The umbilical vein has a thinner wall than the umbilical ateries. As the contraction begins the vein is compressed causing the fetal circulation to increase. This leads to an acceleration. As the contraction intensifies the cord becomes completely occluded and the fetal heart rate falls. As the contraction ends the pressure is released first in the umbilical vein causing acceleration before returning to the baseline. Hence ‘shouldering’<br />Cord Compression and ‘shouldering’<br />
    43. 43. Variable deceleration & shouldering<br />
    44. 44. CTG Interpretation<br />
    45. 45. Example of added documentation to notes<br />
    46. 46. It is 11am at a busy antenatal clinic<br />Jane, is a primip and now 36 weeks gestation. She presents to the antenatal clinic with a history of decreased fetal movement.<br />Having had a discussion regarding how often her baby is moving and is this a change from normal movement? Jane explains that she hasn’t felt the baby move all morning. The FHR is present on auscultation<br />Jane also explains that she slept in this morning and hasn’t had breakfast<br />CTG Cases<br />
    47. 47. Determine Risk<br />
    48. 48. Assessment<br />
    49. 49. Andrea is a primigravida, now 40wks + 10 days gestation<br />Admitted for Prostin Induction of Labour<br />Pre-prostin trace<br />Case 2<br />
    50. 50. Determine risk<br />
    51. 51. Assessment<br />
    52. 52. Andrea, pt.2<br />
    53. 53. Assessment<br />
    54. 54. Shelley is in her second pregnancy G2 P1, 39wks<br />Ist pregnancy normal birth following induction of labour at 38wks + 5 days<br />Shelley has history of IDDM since 12yrs old<br />Reason for induction: IDDM<br />Case 3<br />
    55. 55. Pre – Prostin Trace Determine Risk<br />
    56. 56. Assessment<br />
    57. 57. Jennifer is expecting her 1st baby she is 37wks gestation<br />Admitted with a history of persistent headaches & feeling unwell<br />B/P on admission 150/95, Fetal heart rate reactive & normal<br />Today her B/P is 130/90 you perform daily CTG<br />Case 4<br />
    58. 58. Determine Risk<br />
    59. 59. Assessment<br />
    60. 60. Sarah is expecting her 4th baby she is 40wks + 3days<br />Presents to birthing unit with history of ?ruptured membranes<br />She states that baby hasn’t moved since her waters broke<br />Case 5<br />
    61. 61. Determine Risk<br />
    62. 62. Assessment<br />
    63. 63. Alkira is expecting her first child she is 33wks she presents to the rural birthing unit feeling very unwell. She has had no antenatal care.<br />She has been busy preparing food for a large family gathering but baby has been quiet<br />She has headache, B/P 165/110 ++protein in her urine<br />Case 6<br />
    64. 64. Determine Risk<br />
    65. 65. Assessment<br />
    66. 66. Pippa is 39 years old having her third baby<br />Two previous baby’s normal vaginal births at 37+2 & 36+6 wks<br />Presents with a history of reduced fetal movements – 6 movements in the last 24hrs<br />You listen in with a pinards and the fetal heart rate is 180bpm<br />Case 7<br />
    67. 67. Determine Risk<br />
    68. 68. Assessment<br />
    69. 69. Pippa cont.<br />
    70. 70. Assessment<br />
    71. 71. Amira is 19yr old woman expecting her first baby, she is 28wks gestation<br />She is Arabic<br />She has presented been referred with a history of fetal growth restriction and decreased liquor volume<br />Case 8<br />
    72. 72. Determine Risk<br />
    73. 73. Assessment<br />
    74. 74. Kathryne is 28yrs old G2 P1 37wks gestation<br />Previous C/S breech<br />No significant medical history<br />Presents for assessment with flu like symptoms for 3 days<br />B/P 120/70, P. 102, T. 37.2<br />Case 8<br />
    75. 75. Determine Risk<br />
    76. 76. Assessment<br />
    77. 77. Change maternal position<br />Assess potential causes of FHR characteristics<br />Continue EFM as necessary<br />Complete ongoing maternal & fetal assessment as indicated (vital signs)<br />Interpret non-reassuring findings in conjunction with total clinical picture. (Contractions, presentation, stop oxytocin infusion)<br />Notify medical staff<br />Document assessment, findings and interventions<br />Managing a Non-Reassuring FHR<br />
    78. 78. It will take 20mins for intravenously administered oxytocin to unbind from the body’s receptors once it is stopped<br />Therefore only possible to see if syntocinon is responsible for the decelerations after period of 20mins<br />When recommencing syntocinon only start back at half the rate at which it was discontinued<br />Practice Point<br />
    79. 79. Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2006; 3:CD006066.<br />BCRCP (2006) Fetal Health Surveillance in Labour. Retrieved August 11th2011 from<br />Freeman, R. K. (2003) Fetal Heart Rate Monitoring. Philadelphia, Lippincott Williams & Wilkins<br />Gibb, D., Arulkumaran, S. (2008) Fetal Monitoring in Practice. Sydney, Churchill Livingstone<br />Gleeson, D (2010) CTG Interpretation<br />Mater Health Services (2009). Fetal heart rate Monitoring for assessment of fetal wellbeing. Policy no: MHS-WCH-W-OG-317<br />NICE (2008) Intrapartum Care: full guideline. Retrieved August 10th2011 from<br />RANZCOG Intrapartum Fetal Surveillance. Clinical Guidelines. Retrieved August 11th 2008 from<br />SOGC (2007). SOGC Clinical Guidelines: Antepartum and Intrapartum Consensus Guideline. No.197, September<br />Tucker, S. (2004) Fetal Monitoring and Assessment. Missouri, Mosby.<br />References & Acknowledgements<br />