Intra-partum assessment of fetal well-being for neonatologist

1. Intrapartum assessment
of fetal wellbeing
Dr. Mahmoud El Naggar
Egyptian Board of Neonatology
Hera General Hospital
Makkah
11/28/20161Mahmoud El naggar

2. Intrapartum assessment
A) Continuous electronic
fetal monitoring
B) Fetal scalp blood
sample
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3. A) Continuous electronic
fetal monitoring (CTG)
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4. What is cardiotocography (CTG)?
CTG is used during pregnancy to monitor both the fetal heart and the
uterine contractions.
It is usually only used in the 3rd trimester.
It’s purpose is to monitor fetal well-being and allow early detection of
fetal distress.
An abnormal CTG indicates the need for more invasive investigations
and may lead to the need for emergency caesarian section
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5. How it works
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6. How to read a CTG?
2- Interpretation of
fetal heart rate
1- Interpretation of
uterine contractions
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8. 1- Uterine contractions
O Record the number of contractions present in a 10 minute
period – e.g. 3 in 10
O Individual contractions are seen as peaks on the part of
the CTG monitoring uterine activity.
O You should assess contractions for duration and intensity
O Normal: ≤ 5 contractions in 10 minutes
O Tachy-systole: >5 contractions in 10 minutes
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10. 2- Fetal heart rate interpretation
5- Trends &
patterns
4- Decelerations
3- Acceleration
2- Variability
1- Baseline
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11. 1- Base line fetal heart rate
Base line= 110- 160 beats/ min
Bradycardia, HR< 110 beats/ min
Tachycardia, HR > 160 beats/ min
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12. 1- Normal base line HR 110-160
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13. 1- Normal base line HR 110-160
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14. Fetal bradycardia HR< 110
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15. Causes of prolonged severe
bradycardia are:
Severe prolonged bradycardia (< 80 bpm for > 3 minutes)
indicates severe hypoxia.
• Prolonged cord compression
• Cord prolapse
• Epidural & spinal anesthesia
• Maternal seizures
• Rapid fetal descent
If the cause cannot be identified and corrected,
immediate delivery is recommended.
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16. Fetal tachycardia HR> 160
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17. Fetal tachycardia HR> 160
Fetal hypoxia
Chorioamnionitis – if maternal fever also present
Hyperthyroidism
Fetal or maternal anemia
Fetal tachyarrhythmia
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18. 2- Beat to beat variability
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19. 2- Beat to beat variability
To calculate variability
you look at how much the
peaks and troughs of the
heart rate deviate from
the baseline rate (in bpm)
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20. 2- Beat to beat variability
Baseline variability refers to the variation of fetal heart rate from one
beat to the next.
Variability occurs as a result of the interaction between the nervous
system, chemoreceptors, baroreceptors and cardiac responsiveness.
Therefore it is a good indicator of how healthy the fetus is at that
particular moment in time.
This is because a healthy fetus will constantly be adapting its heart
rate to respond to changes in its environment.
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21. Normal
reassuring
< 5
6- 25
> 26
Zero
2- Beat to beat variability
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22. 2- Beat to beat variability
Absent = no variation in the fetal heart rate
Minimal= < 5
Moderate= 6- 25
Marked= > 26
Moderate variability is reassuring sign of adequate fetal
oxygenation and normal brain function
Normal reassuring
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23. Decrease beat to beat variability
1- hypoxia
2- acidemia
3- tachycardia
4- drugs that depress the fetal CNS
5- prolonged uterine contraction
6- CNS and cardiac anomalies
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25. 3- Accelerations
Elevation of the heart rate above the base line ≥ 15 beats for ≥ 15 seconds but
less than 2 minutes ( 15 x 15 )
Normal in case of fetal movement due to sympathetic stimulation
Reassuring if there is to 2 acceleration or more within 20 minutes
Before 32 weeks’ gestation, accelerations are defined by an increment ≥ 10 beats/min above the most recently determined baseline for ≥ 10 seconds
Prolonged acceleration lasts > 2 minutes but <10 minutes
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26. 3- Acceleration( 15x 15)
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27. 3- Acceleration( 15x 15)
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28. 4- Decelerations( 15x 15)
O Decrease of fetal heart rate by ≥ 15 beats for ≥ 15 seconds
( 15 x 15)
O 3 types of decelerations in relation to uterine contraction
a) Early b) Late c) Variable
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29. Types of deceleration
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30. a) EARLY
DECELERATION
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31. a) Early deceleration
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32. a) Early deceleration
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33. a) Early deceleration
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34. a) Early deceleration
Deceleration will start slowly at the beginning of uterine contraction (onset to nadir
>30 seconds)
Nadir of deceleration opposite to the peak of contraction
Recovery of deceleration slowly with the end of contraction
Caused by head compression during uterine contraction will increase the vagal
tone
Considered a periodic pattern because it occurs with uterine contractions
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35. b) LATE
DECELERATION
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36. b) Late deceleration
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37. b) late deceleration
Deceleration will start slowly at the peak of uterine contraction
Nadir will be opposite to the end of uterine contraction
Recovery of deceleration will be slowly later after the end of uterine contraction and in severe
cases may be it will not return back to the previous base line heart rate
Also considered a periodic pattern
Caused by utero-placental insufficiency or decreased uterine blood flow
Indicate fetal metabolic acidosis 11/28/2016 37Mahmoud El naggar

38. c) VARIABLE
DECELERATION
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39. c) Variable deceleration
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41. c) Variable deceleration
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43. c) Variable deceleration
variable in the time as regarding uterine contraction
Variable in intensity
Variable in duration
Variable in shape v or w
May be episodic (occurs without a contraction) or periodic
Rapid decrease and rapid increase
Due to umbilical cord compression 11/28/2016 43Mahmoud El naggar

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45. Prolonged deceleration
Decrease in the FHR ≥ 15 beats/min below the most recently
determined baseline lasting > 2 minutes but <10 minutes from
onset to return to baseline
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as
abnormal.
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46. Recurrent or intermittent
Recurrent decelerations if they occur with
≥ 50% of uterine contractions in a 20-
minute period.
Intermittent decelerations occurring with
<50% of uterine contractions in a 20-
minute segment.
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48. Late deceleration placental insufficiency
Acceleration ok
Early deceleration Head compression
Variable deceleration cord compression
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49. 5- Sinusoidal pattern
A smooth, regular,
wave-like pattern
Frequency of around
2-5 cycles a minute
Stable baseline rate
around 120-160 bpm
No beat to beat
variability
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50. A sinusoidal pattern indicates:
Severe fetal
hypoxia
Severe fetal
anemia
Fetal/maternal
hemorrhage
Immediate C-
section is
indicated for this
kind of pattern.
Outcome is
usually poor
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51. Fetal heart rate tracing categories
I. Reassuring (Normal)
II. Suspicious( Non reassuring)
III. Pathological (Abnormal)
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52. Fetal heart rate tracing categories
DefinitionType
All 4 features are classified as reassuringI. Reassuring
( normal)
One feature classified as non-reassuring +
AND
the remaining 3 features classified as reassuring
II. Non-reassuring
( suspicion)
Two or more features classified as non-reassuring /
OR
One or more classified as abnormal
III. Abnormal
( pathological)
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53. -
-
6- 25
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54. I.Reassuring
• Baseline: 110-
160
• Moderate
variability
• Late or variable
deceleration: -
• Early
deceleration : +/-
• Acceleration : +/-
II.Non-reassuring
• inbetween
I and III
III.Abnormal
• Loss of beat
to beat
variability +
one of:
• 1- Recurrent late
decelerations
• 2- Recurrent
variable
decelerations
• 3-Bradycardia
• Or
sinusoidal
wave pattern
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55. Pathophysiological interpretation
IReassuring
• Fetus
with no
hypoxia
or
acidosis
IINon-reassuring
• Fetus with
a low
probability
of having
hypoxia
or
acidosis
IIIAbnormal
• Fetus with
a high
probability
of having
hypoxia
or
acidosis
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56. Clinical management
IReassuring
• No
intervention
necessary
to improve
fetal
oxygenatio
n state
• Follow up
IINon-reassuring
• Action to
correct the
reversible
causes if
identified
• Close
monitoring
• Additional
methods to
evaluate fetal
oxygenation
IIIAbnormal
• Immediate action to
correct reversible
causes
• Additional methods
to evaluate fetal
oxygenation
• If it is not possible
expedite delivery
• In acute cases
immediate delivery
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57. Examples of type II tracings
O Bradycardia not accompanied by absent variability
O Tachycardia
O Minimal or marked baseline variability
O Absent variability without recurrent decelerations
O Absence of induced accelerations after fetal stimulation
O Recurrent variable decelerations with minimal or moderate
variability
O Prolonged decelerations
O Recurrent late decelerations with moderate Variability
O Variable decelerations with other characteristics, such as slow
return to baseline
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60. B) Fetal scalp blood sample
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61. B) Fetal scalp blood sample
O Fetal scalp blood sampling is used during labor to determine
the fetal acid-base status when the FHR tracing is non-
reassuring or abnormal.
O It can be performed only after rupture of membranes.
O It is contraindicated in cases of possible blood dyscrasias in
the fetus and with maternal infections caused by herpes virus
or HIV.
O An intrapartum scalp pH >7.20 with a base deficit <9 mmol/L is
normal.
O Many obstetric units have replaced fetal scalp blood sampling
with noninvasive techniques to assess fetal status.
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63. INTRAUTERINE FETAL
RESUSCITATION
If CTG monitoring indicates serious fetal compromise, or FBS result is abnormal, a decision
to deliver, often by emergency caesarean section, should be made.
A number of maneuvers can be performed to improve fetal oxygenation before delivery.
These may be performed with continuous CTG monitoring
If successful may reduce the urgency to deliver allowing time to provide neuraxial anesthesia.
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64. INTRAUTERINE FETAL
RESUSCITATION (SPOILT)
Syntocinon
off
Position full
left lateral
Oxygen
I.V. infusion
of crystalloid
fluid
Low blood
pressure – if
present give
i.v.
vasopressor
Tocolysis -
terbutaline
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65. Case 1(NR may 2015) O Variability: Moderate
O Baseline rate: 140 beats per
minute
O Acceleration: None
O Deceleration: None
O Uterine contractions: Irregular,
mild per palpation
O Interpretation: Category I,
normal tracing, predictive of
normal acid-base status
O Differential diagnosis: Transient
compression of the umbilical
cord during ultrasonography
O Action: It was decided that she
would return for twice weekly
nonstress tests for the next 2
weeks, and further follow-up
would be determined at that
time 11/28/2016 65Mahmoud El naggar

66. After 2 w O Variability: Moderate in the beginning
of the tracing to minimal in the last
few minutes
O Baseline rate: 140 beats per minute
O Acceleration: None
O Deceleration: Prolonged deceleration
with a nadir to 50 beats per minute
O Uterine contractions: Unable to
determine, palpation is required to
assess contraction frequency and
intensity, although not perceived by
patient
O Interpretation: Category II
O Differential diagnosis: Tachysystole,
umbilical cord compression, abnormal
placental umbilical cord insertion
O Action: The patient was repositioned,
given oxygen by face mask, and
received a bolus of fluid with fetal
tracing returning to category I
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67. After 2 hours O Variability: Moderate
O Baseline rate: 140 beats per
minute
O Acceleration: None
O Deceleration: None
O Uterine contractions: Every 2
to 8 minutes, mild by
palpation
O Interpretation: Category I
O Differential diagnosis:
Normally oxygenated infant
O Action: Continued fetal
monitoring
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68. After an other 2 hours O Variability: Moderate in the beginning
of the tracing to minimal in the last
few minutes
O Baseline rate: 150 beats per minute
O Acceleration: None
O Deceleration: Prolonged deceleration
with nadir to 50 beats per minute
O Uterine contractions: Unable to
determine, palpation is required to
assess contraction frequency and
intensity, although not perceived by
the patient
O Interpretation: Category II
O Differential diagnosis: Tachysystole,
umbilical cord compression, abnormal
umbilical cord insertion
O Action: The patient was repositioned
and fetal status returned to overall
reassuring with moderate variability
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69. Case 2(NR march 2015) O Variability: Moderate
O Baseline rate: 135 beats per
minute
O Episodic patterns:
Accelerations
O Periodic patterns: None
O Uterine contractions: None
O Interpretation: Category I
O Differential diagnoses:
Normal FHR and variability,
gestational hypertension, rule
out preeclampsia
O Action: No intervention was
required for the fetus at this
point. 11/28/2016 69Mahmoud El naggar

70. After 2 hours O Variability: Moderate
O Baseline rate: 130 beats per
minute
O Episodic patterns: None
O Periodic patterns: Variable
decelerations
O Uterine contractions: Every 2 to
3 minutes, requires palpation for
intensity and tone
O Interpretation: Category II
O Differential diagnosis: Cord
compression due to
anhydramnios or nuchal cord
O Action: Appropriate
interventions to relieve the cord
compression are lateral
repositioning, hydration, and an
amnioinfusion.
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71. After some hours O Variability: Moderate
O Baseline rate: 130 to 140 beats
per minute toward the end of the
tracing
O Episodic patterns: None
O Periodic patterns: Recurrent
variable decelerations
O Uterine contractions: Unable to
determine; palpation is required
to assess contraction frequency
and intensity
O Interpretation: Category II
O Differential diagnosis: Cord
compression most likely due to
anhydramnios or nuchal cord
O Action:requires close
surveillance for loss of variability
and lack of accelerations,
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72. After 4 hours O Variability: Minimal to moderate
O Baseline rate: 120 beats per
minute
O Episodic patterns: None
O Periodic patterns: Recurrent
variable decelerations
O Uterine contractions: Not
recording well but appears to be
every 2 to 3 minutes; palpate
contractions for frequency and
intensity
O Interpretation: Category II
O Differential diagnosis: No
change
O Action: Recurrent variable
decelerations continue and have
not improved with repositioning
and hydration.
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73. After 30 min O Variability: Minimal
O Baseline rate: 135 beats per
minute
O Episodic patterns: None
O Periodic patterns: Appears to be
recurrent variable decelerations
but difficult to determine
because of gaps in the tracing
O Uterine contractions: Monitor
needs to be adjusted; palpate
contractions for frequency and
intensity
O Interpretation: Category II
O Differential diagnosis: No
change
O Action: Physician at bedside,
NICU staff present, patient is
prepared for delivery
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74. Case 3 (NR sept 2014)
O Variability: Moderate
O Baseline rate: 140 initially, and
then appears to have
characteristics of a sinusoidal-
type pattern, but not definitive.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions: Irregular,
mild per palpation
O Interpretation: Category I,
normal tracing, predictive of
normal acid-base status.
O Differential diagnosis: R/o fetal
anemia due to isoimmunization.
O Action: at this point, the
increasing MCA Dopplers and
possible sinusoidal-like pattern
is concerning.
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75. One hour later O Variability: Absent
O Baseline rate: Indeterminate
due to sinusoidal pattern.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions:
Irregular, palpate for intensity
and tone.
O Interpretation: Category III
tracing.
O Differential diagnosis:
Abnormal tracing associated
with an increased risk of
abnormal acid-base status,
most likely secondary to fetal
anemia.
O Action: planned for CS
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76. After 1 hour O Variability: Absent
O Baseline rate: Indeterminate
due to sinusoidal pattern.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions: Unable
to determine, palpate for
intensity and tone.
O Interpretation: Category III
tracing.
O Differential diagnosis:
Abnormal tracing associated
with an increased risk of
abnormal acid-base status.
O Action: A persistent sinusoidal
pattern should prompt an
immediate C/S;11/28/2016 76Mahmoud El naggar

77. References
- Most of volumes of neoreviews since 2008 till the
moment includes strip of the months, mention regularly
the previous summary of the terminology, definitions and
assumptions found in the 2008 NICHD work shop report.
-In 2008, ACOG, NICHD, and the Society for Maternal-Fetal
Medicine reviewed and updated the definitions for fetal
heart rate patterns, interpretation, and research
recommendations
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