1. Fetal assessment during labor involves monitoring amniotic fluid and the fetal heart rate. Amniotic fluid is assessed for color and clarity while the fetal heart rate is the primary assessment. 2. Fetal heart rate is monitored either intermittently by listening with a fetoscope every 15-30 minutes during the active phase of labor, or continuously through electronic fetal monitoring. Electronic monitoring can be external or internal. 3. Normal fetal heart rate is between 120-160 beats per minute with moderate variability. Abnormal patterns including tachycardia, bradycardia, minimal variability or late decelerations may indicate fetal distress requiring changes to the labor process or expedited delivery.

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2. Fetal Assessment During Labor
We asses:
1. Amniotic fluid
2. Fetal Heart Rate (FHR): the
primary assessment
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3. 1. Amniotic fluid analysis:
• Amniotic fluid should be clear, colorless
or pale yellow, when the membranes
rupture.
• Cloudy fluid with foul smell → Infection
• Green Fluid → Fetal Hypoxia due to
meconium (the first stool of the baby)
• Blood streak → Hemorrhage
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4. 2. Fetal Heart Rate (FHR) Monitoring
• Is the measuring of the fetus’s heart rate
during the labor by using a special
instruments.
• Types and methods of fetal heart
monitoring:
1. Intermittent auscultation
2. Electronic fetal monitoring (EFM)
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1. Intermittent Auscultation technique:
• Auscultation is a method of listening
to the fetal heartbeat for about 60
seconds by using a fetal stethoscope
(fetoscope or Pinard), or a hand-held
Doppler ultrasound device.

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• While listening to the heartbeat, the
doctor also palpates the mother’s uterus
by placing a hand on the abdomen to
measure the contractions.
• Intermittent auscultation should be done:
− Every 15-30 minutes during the active
phase of 1st stage,
− Every 5-15 minutes during the pushing
phase of 2nd stage.

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Fetoscope Pinard Hand-held
Doppler

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2. Electronic fetal monitoring (EFM)
• EFM is an electronic monitor used to
continuously measures the fetus’s heart
rate and using a pressure sensor to
monitor the mother’s contractions at the
same time.
• There are 2 types of EFM:
• External monitoring
• Internal monitoring

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Indications for EFM
• Pregnancy complications (Diabetes, preeclampsia…)
• Pre-term labor.
• Previous caesarean.
• The baby is smaller than expected.
• Multiple fetuses.
• Overweight mother.
• Prolonged 1st stage of labor.
• The amniotic fluid contains significant amounts of
meconium (The baby's first poo).
• Induction of labor.
• A high temperature mother.

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External monitoring:
• Measuring the heart rate through an
ultrasound device, and measuring the
contractions by using a pressure sensor;
both devises are held against the
mother's belly with a belt.
• The reading of external monitoring is
affecting by changing position.

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Internal monitoring:
• Measure the heart rate through a wire called
(electrode) contains a needle, inserted
through the vagina and cervix, and placed
under the baby's scalp. And measuring the
contractions with a thin tube inserted into the
uterus.
• Internal monitoring can be done only after the
cervix has dilated to at least 2cm and the
amniotic sac has ruptured.

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FHR patterns
• Normal Pattern:
Baseline FHR = 120 – 160 bpm (Beat/min.)
• Tachycardia:
Baseline FHR above 160 bpm
• Bradycardia:
Baseline FHR less than 120 bpm
*Baseline FHR = 10 minutes*

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Contraction Pattern
• Normal contractions:
5 or fewer contractions in 10 minutes
lasting about 60 seconds in the active
phase.
• Contraction intensity:
30 mmHg in early labor to 70 - 90 mmHg
in the second stage.

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Normal fetal heart rate with moderate variability
Normal Contraction

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Causes of Tachycardia
Tachycardia is a FHR above
160 bpm that lasts for at least
10 minutes
• Mother fever
• Mother and fetus infection
• Mother dehydration
• Mother and fetus anemia
• Fetus hypoxemia
• Fetal tachyarrhythmia
• Fetus cardiac abnormalities
Causes of Bradycardia
Fetal bradycardia is a
baseline FHR of less than 110
bpm that lasts for at least 10
minutes
• Mother Dehydration
• Mother Hypotension
• Rupture of uterus or vasa
previa
• Placental abruption
• Medications such as anesthetics
• Fetal hypoxia
• Late or profound hypoxemia
• Umbilical cord occlusion
• Fetal bradyarrythmias

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Baseline FHR Variability
• The normal fetal heart rate baseline is from
120 to 160 BPM and has variability usually
with a range of 3-5 bpm from the baseline.
• Characteristics:
1. Undetectable (less than 5 bpm)
2. Minimal (up to 5 bpm)
3. Moderate (6 to 25 bpm)
4. Marked (more than 25 bpm)
Abnormal if lasts
over 60 min.

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Periodic changes
Periodic changes are accelerations or
decelerations in the FHR that are in relation
to uterine contractions and persist over
time.

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Accelerations
• Accelerations are transient increases in the FHR
about (15 bpm) above baseline for about (15 sec. to
less than 2 min.) and then return normally to the
base line.
• Prolonged acceleration: Increase in heart rate lasts
for 2 to 10 minutes.
• The presence of accelerations is a sign of normal
fetus, because they are usually associated with
fetus stimulation, such as fetal movement, vaginal
examinations, and contractions.

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Fetal heart rate accelerations

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Decelerations
Transitory decrease in the FHR from the
baseline.
1. Early decelerations: the onset and return of a
deceleration is match to the contraction
2. Variable decelerations: variable in the time,
intensity, and duration of a deceleration
3. Late decelerations: the fetal heart rate return
to the baseline after the end of the
contraction

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Management
1. Early decelerations: No intervention is necessary,
just keep watching. It happen due to uterine
contractions.
2. Variable decelerations: Reposition of the mother,
oxygen mask, and stop oxytocin. It happen due to
Umbilical cord occlusion and problems.
3. Late decelerations: Reposition of the mother,
oxygen mask, stop oxytocin, give IV. It happen
due to reduction in O2

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Early decelerations

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Variable decelerations

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Late decelerations

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What happens if the fetal heart rate pattern
is abnormal?
• An abnormal fetal heart rate may mean that the fetus is
not getting enough oxygen or that there are other
problems.
• We should first try to find the cause.
• Steps can be taken to help the baby get more oxygen,
such as change the position of the mother, and giving her
an oxygen mask.
• If the procedures do not work, and the fetus still has a
problem, we should deliver the baby immediately.
• In this case, the delivery of the baby is more likely to be
by cesarean birth or with forceps or vacuum delivery.

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Forceps delivery
Vacuum delivery