Downloaded 53 times
More Related Content
Similar to Intrapartum fetal surveillance
More from Kavinda Hewawitharana
Intrapartum fetal surveillance
- 1.
- 2. What does itmean? • It is the “ assessment of fetal wellbeing from passage of intrauterine life to extra uterine life” (www.glowm.com)
- 3. Why it isimportant??? • The greatest challenge of obstetrician is to ensure wellness of mother and growing fetus (during parturition fetus is at very stressful condition that it should bear) • Greatest enemy is ACUTE HYPOXIA of fetus that can happen in delivery. This brings serious neurological problems or even stillbirths.
- 4. What brings AcuteHypoxia? • Uterine hyper stimulation • Placental Abruptions • Umbilical cord accidents • We clinicians should be able to recognize these events to intervene.
- 5. Current methods available •Intermittent Intelligent Auscultation • Electronic Fetal Monitoring • Fetal Scalp Blood Sampling • Fetal Scalp Lactate Test • Fetal Stimulation Test • Fetal Pulse Oxymetry • Fetal ECG • Clinical Assessments
- 6. Intermittent Auscultation ( Pinardor hand held Doppler) • Alone enough for low risk pregnancies @ First stage Auscultate for 1 min soon after contractions in each 15 min gap @ Second stage Monitor FHS in each 5 min interval
- 7. What indicates by“intelligent” • Feel for fetal movements and listen FHS > 15bpm increment during this(acceleration) • After contraction, look for any reduction of FHS(deceleration) • If movement associated FHS rise noted , CTG also likely to be reactive.
- 8. ELECTRONIC FETAL MONITERING •AKA Cardiotocography (CTG) • 2 types as External and Internal CTG • Advised to do as continuous monitoring if pregnancy is a high risk Maternal causes GDM,PIH,VBAC,APH,PROM>24hrs or INDUSED Fetal Causes FGR,LOW AFI,TWINS,BREECH,MECONIUM
- 9. Fetal Scalp BloodSampling • This should not be the choice if preterminal CTG patterns or clinical situations happening Eg ; Prolonged Bradycardia , markedly reduced variability ,Late/Atypical Deceleration , cord accidents. THIS IS CONTRAINDICATED when known BLEEDING DIASTHESIS or TRANSMISSIBLE INFECTIONS present
- 10. FBS Cont. • Thismight not reflect hypoxia or acidosis in some situations. • If pH value < 7.2 ; immediate delivery 7.2-7.25 ; repeat again in ½ hr >7.25 ; observe for CTG improvement and repeat if necessary GOOD Clinical assessment & CTG reduces need of SCALP SAMPLING
- 11. Fetal stimulation tests •FHR acceleration in response to external stimulation is likely that fetus is not Acidotic • Scalp simulation with ALLIS TISSUE FORCEP or VIBROACOUSTIC STIMULATION across maternal abdomen is used. • If no response there is nearly 50% chance of fetal acidosis
- 12. Fetal Pulse Oxymetry •spO2 fluctuate in fetus at 30%- 80% • If it is less than 30% for 10min or more, imminent delivery plan is required. • This is also an application of scalp electrode and interpretation as electronic machine reading
- 13. Fetal Scalp LactateSampling • Metabolic acidosis is reflected by pH , BE and lactate level • If hypoxia for more than 10 min , lactate begins to buildup in fetal blood. Longer the duration , accumulation also more. But it’s disappearance is more time consuming. • Scalp lactate levels correlate with umbilical cord blood lactate Levels.
- 14. LACTATE CONT. • Whylactate is more effective detection method when compare with FBS BECAUSE IT NEEDS ONLY 1/7 VOLUME OF SAMPLE NEED FOR FBS(5microL Vs 35 micro)
- 15. HOW TO INTERPRINT •< 4.2 ; Normal. If CTG changes still present consider to repeat in 1 hr • 4.2-4.8 ; Pre acidemia. Repeat in 30 min or deliver if significant rise from last value • >4.8 ; Acidemia. Immediate delivery is need.
- 16. Fetal ECG Analysis •We all know about ECG . It is……. • ST segment/ T wave elevation favors hypoxic event in the myocardium , adrenalin surges • Such myocardial ischemic changes is related to cardiac glycogen content • Scalp electrode is used together with maternal skin electrode and analyze using ST wave analyzer
- 17. ECG CONT. • Thisproduce sample ECG from 30 received complexes & analyze T/QRS ratio and changes of ST segment called BIPHASIC ST wave form Rise of T/QRS ratio Increasing ST Waveform grading Suggestive of cardiac ischemia of fetus
- 18. How To GetT/QRS Ratio • Computer calculate lowest ratio for 20 min • Then this last ratio is validated for next 3 hrs ahead to see any rise of ratio • Even if we stop the STAN analyzer, and reconnect within next 3 hrs ,still first base line ratio is valid
- 19. What is thisBiphasic ST waveform • If the ST wave is above the isoelectric line, then it is called BST 1 • If it cuts the line, then its called BST 11 • If changes are below isoelectric line,BST111
- 20. • This changeis due to ventricular repolarization and current flow from endocardium to epicardium. • Preterm fetuses show these changes . Hence fetal ECG is not applicable to preterm fetuses(<36 weeks)
- 21. STAN EVENT • ProlongBiphasic events are known as STAN event . They are noted as >2 or >5 min events • > 2 STAN events + suspicious CTG OR >1 STAN event + pathological CTG indicate to intervene • But its not the LSCS always . Even we may resuscitate with CTG monitoring • If CTG is difficult to describe , try FBS too.
- 23. • Fetal ECG+ CTG co use have reduced the need of FBS , Fetal acidosis and operative delivery rates.(Acta Obstet gynecol Scand 2014;571-586)
- 24. CLINICAL ASSESMENT Palpate forprolong contractions Uterine tenderness/Scar tenderness Fresh PV bleeding MECONIUM can be used to recognize ongoing fetal adverse events and should correlate with other detection methods
- 25. MECONIUM • Appears usuallyat term . but rare in preterm unless Listeriosis like infection or hypoxic event. • At term this indicates functional maturity and as with dates reach post term , incident is 5% vs 15%. • But PG induction is another reason as PG increases gut motility. • Alternative explanation is anal sphincter relaxation at hypoxia cause meconium passage
- 26. • Its notcommon to find meconium in acute hypoxia like cord prolapse or abruptions. • Meconium does not always sense that fetus in trouble . And clear liquor is not promising for well oxygenated fetus . so use this finding wisely without getting ourselves into trouble. • Thick meconium with lack of free flow is indicative of poor renal perfusion . Now fetal brain is so stressed to get more blood . so chance of fetal acidemia is higher than thin meconium stain with free flow of liquor. • But remember if CTG is pathological even with thin meconium , chance to get acidosis rises sharply than pathological CTG alone
- 27. • Because ofthis reason , if meconium present better to do CTG monitering And consider early scalp blood sampling. • Meconium aspiration has no correlation to fetal acidosis.
- 28. Intrapartum maternal pyrexia •> 38 *c is known to be associated with increased incidents of fetal encephalopathy. (Odds ratio is 9.5 ) AND acidosis risk is markedly rise . Hence fluid therapy and paracetamol is useful interventions.(best practice in labour,2nd edition)
- 29. BEFOR I STOPTHIS • EXPECTED RESULTS OF IP SURVEILLANCE METHODS ARE LESS THAN OPTIMAL. • Reasons include poor communication , poor CTG Interpritation , Inabilty to put clinicals together with high tech findings to make decisions,delay in taking actions,poor team work(4th annual report of CESDI-1997)
- 30. LETS TOGETRHER TRY •Intermittent Intelligent Auscultation • Electronic Fetal Monitoring • Fetal Scalp Blood Sampling • Fetal Scalp Lactate Test • Fetal Stimulation Test • Fetal Pulse Oxymetry • Fetal ECG • Clinical Assessments
- 31. REFERENCES • 12th EditionMunroe Kerr’s • 02nd Edition Best Practice In Labour &Delivery • 2014 Nice Guideline Of Intrapartum Fetal Surveillance • Internet based literatures
- 32.