Monitoring the heart of the fetus is one of the important topics in the midwifery profession

1. Fetal Heart Monitoring

2. Out lines
- History of using fetal monitoring.
-Types of fetal monitoring.
- Indications of using fetal monitor.
- Effects of using fetal monitor.
- Choice of using fetal monitoring.
- Auscultation procedure.
- How to read fetal monitor.
- Future options.
Fetal Heart Monitoring

3. History of Fetal Monitoring
1818-fetal heart beat first heard.
1838-use of fetal stethoscope.
Late 1960-Electrical fetal monitoring
’EFM’ debuted.
1980-Nearly half of all laboring
patients monitored with EFM

5. Types of Electronic Fetal Monitoring
Internal monitoring External monitoring

8. Cardiotocography -CTG
•
Is a technical means of recording (-graphy)
the fetal heartbeat(cardio-) and the uterine
contractions (-toco-) during pregnancy.
•
The machine used to perform the monitoring
is called a cardiotocograph, more commonly
known as an electronic fetal monitor(EFM).

10. Indications for using Fetal
Monitoring
Maternal
indications
Fetal
indications
Labor
indications

11. Maternal Indications for EFM
- Hypertensive disease.
- Diabetes.
disease.
- Cardiac
- Severe anemia or hemoglobinopathy.
- Hyperthyroidism.
- Auto immune disease.
- Renal disease.

12. Fetal indications for Fetal Monitoring
- Multiple gestation.
- Intrauterine growth restriction.
- Preterm labor.
- Breech presentation.
- Rh isoimmunization.

13. Labor Indications for CEFM
Abnormal FHR on admission tracing.
Vaginal bleeding in labor.
Induced or augmented labor.
Prolonged labor.
Regional analgesia.
Abnormal uterine activity.
Particulate meconium.

14. Effects of using fetal monitoring
♣ Continuous monitoring :
↓ Mobility.
↓ Contact with staff ,partner.
↓ Direct nursing –patient contact.
↑ Operative delivery rate.
: ♣ Intermittent Auscultation needs
Adequate number of trained personnel necessary.
.

15. * Determine staff availability and comfort level.
* Discuss with patient.
* Determine risk of mother and fetus.
Choice of monitoring method

16. Intermittent Auscultation frequency
low-risk pt high –risk pt
First stage , q15-30min q15min
Active phase
Second stage q5-15min q5min
(or after each contraction)

17. Auscultation Procedure
- Doppler over point of maximum FHT
intensity.
- Differentiate maternal from fetal pulse.
- Palpate uterus for contractions.
- Count FHR for 1 minute between
contractions (=baseline rate).
- Count FHR for 1minute after contraction.

18. How to read fetal
monitoring

19. D = Determine Risk.
C = Contractions.
B R A =Baseline Rate.
V = Variability.
A = Accelerations.
D = Decelerations.
O = Overall assessment.
DR C BRAVADO

20. DR = Determine Risk
- Prenatal risk factors.
- Intrapartum risk factors.
- Fetal reserve.
- Labor progress.

21. C= Contractions
:
Method of monitoring
Palpation
External transducer
Intrauterine pressure monitor
Pattern and intensity
Adequate.
Hyperstimulation (>7in15min).

22. Uterine Contractions
•
Number of contractions in 10 minutes
–
averaged over thirty minutes
•
Document
–
Frequency
–
Intensity
–
Duration
–
Relaxation
•
time between contractions

23. Monitoring of Contractions

25. Contractions
•
Record the number of contractions
present in a 10 minute period.

26. Tachysystole
•
>5 contractions in 10
mins
–
Averaged over 30
mins

27. BRA=Baseline RAte
Requires >10minutes to establish.
Normal =110-160 bpm.
–
Rounded to increments of 5
–
Excluding accelerations and decelerations
Baseline rate influenced by :
Prematurity.
Change in fetal status.
Maternal fever ,position, medication.

28. Baseline is RED LINE

30. Base line bradycardia
Mild :100-110 bpm.
Sever :<100 bpm.
Possible causes: congenital heart disease , heart block, severe
hypoxia.

32. Base line tachycardia
Mild :160-180bpm.
Moderate : 180-200bpm.
Sever : >200bpm.

33. V=Variability
Normal=10-15bpm around baseline.
Reflects normal CNS function and maturation.
Best predictor of good fetal outcome.

35. Decreased Variability Good variability

36. Variability
•
Fluctuations in FHR
–
Over 10 minutes
•
Descriptors are:
–
Absent: undetectable amplitude range
–
Minimal: undetectable up to 5 BPM
–
Moderate: amplitude range 6 to 25 BPM
–
Marked: amplitude range greater than 25 BPM

42. Causes of Decreased Variability
♣ Hypoxia/acidosis.
♣ Fetal sleep cycle- this should last no longer than 40
minutes – most common cause
♣ Prematurity.
♣ Congenital anomalies(CNS).
♣ Drugs – opiates, benzodiazipine’s, methyldopa, magnesium
sulphate
Nervous system depressants.
Anticholinergics / parasympatholytics.
Corticosteriods.

43. A=Accelerations
Definition
Accelerations are an abrupt increase in baseline heart rate
of >15 bpm for >15 seconds
there should be at least 2 accelerations every 15 minutes
Lasts>15seconds.
Presence indicates fetal well-being, because it`s
associated with movement or stimulation.
Absence:
Frequently false positive in low risk patients.
Further evaluation required.

46. Accelerations

48. Decelerations
•
Decelerations are an abrupt decrease in baseline heart
rate of >15 bpm for >15 seconds
•
There are a number of different types of decelerations,
each with varying significance
.1
Early deceleration
.2
Late deceleration
.3
Variable deceleration
.4
Prolonged deceleration
Prolonged deceleration

49. D=Decelerations
Requires correlation to contraction pattern.
Classification impossible with IA.

50. Decelerations

51. Early deceleration
•
Early decelerations start when uterine contraction
begins & recover when uterine contraction stops.
•
This is due to increased fetal intracranial pressure.
•
This type of deceleration is therefore considered to
be physiological & not pathological.

53. Early Decelaration

55. Early deceleration

56. Late deceleration
–
Late decelerations begin at the peak of uterine
contraction & recover after the contraction ends.
Onset to nadir > 30 second
•
This type of deceleration indicates there is
insufficient blood flow through the uterus &
placenta.
•
Reduced utero-placental blood flow can be caused by:
•
Maternal hypotension
•
Pre-eclampsia
•
Uterine hyper-stimulation

59. Late decelerations

60. •
The presence of late decelerations is taken seriously &
foetal blood sampling for pH is indicated
•
If foetal blood pH is acidotic it indicates significant foetal
hypoxia & the need for emergency C-section

65. Variable Declerations
Slow in FHR that
occur un
predictable time in
relation to
contraction due to
cord compression.
Pathophysiology
umbilical cord
compression

68. Variable Decelerations
•
Abrupt decrease in
fetal heart rate
–
Onset to nadir less
than 30 seconds
•
Decrease in FHR
–
15 BPM or more
–
Lasting 15 seconds
to 2 mins

69. Prolonged deceleration
•
A deceleration that last more than 2 minutes.
•
If it lasts between 2-3 minutes it is classed as
Non-Reasurring.
•
I
•
f it lasts longer than 3 minutes it is immediately
classed as Abnormal.
•
Action must be taken quickly .

71. Causes of sudden decrease in FHR
Amniotomy.
Cord prolapse.
Vaginal exam.
Scalp sampling.
Uterine hypertonus.
Maternal hypotension or position change.

72. O=Overall Assessment
Asessment of fetal status:
Reassuring.
Non-reassuring.
Management plan:
Based on clinical context.
Must include plan for further surveillance.

76. Categorization of FHR Patterns
•
An evaluation of the fetus at a
particular point in time
•
Categories I, II, and III

77. 3 Categories

78. Management of non reassuring
FHR

79. A. Reversible cause:
* stop oxytocin .
* treat hypotension.
* maternal repositioning
in left lateral position.
* relieve pain & fear.
* give oxygen to mother.
* treat maternal fever.
* pelvic exam:
• to exclude cord prolapse.
• cx. fully dilated carry out
assisted vaginal delivery.

80. B. Irreversible cause :
cx. is not fully dilated with
persistent non-
reassuring FHR patterns.
* immediate delivery and
extra- uterine
resuscitation.
* fetal scalp blood pH
determination :
• if pH >7.25 observe.
• if pH 7.2 – 7.25 repeat.
• if pH <7.2 CS.

81. The end…