Prof William Stones Aga Khan University

1. NON REASSURING FETAL STATUS Prof William Stones Aga Khan University

2. Aims • Risk based approach • When are we ‘not reassured’? • Monitoring strategies • Interventions for NRFS

3. Risk in obstetrics • Presence of risk factors eg maternal hypertension • Fetal biometry But: • Most complications occur in ‘low risk’ patients • Most ‘high risk’ patients do not develop complications Therefore: • Awareness of risk status • All require monitoring in labour • Readiness to respond immediately when a problem emerges

4. Risk in the local setting Patient factors • Hypertensive disease, IUGR, Gestational diabetes • Obesity: difficult monitoring • ‘Concordance’ regarding monitoring and intervention Service factors • Staffing ratios • Labour management: adherence to best practice • Institutional culture • ‘Serious about care in labour’ • Blame game

5. Unhelpful ideas • Placental maturation (Grannum) or calcification means reduced placental reserve and risk of ‘fetal distress’ • Biophysical Profile • ‘Cord round the neck’ on antenatal scan means high risk of ‘fetal distress’ in labour • Meconium stained liquor = ‘fetal distress’ • Giving glucose infusion will correct intrapartum hypoxia and acidaemia • Oxygen administration will benefit the fetus

7. ‘Non reassuring fetal status’ Intermittent auscultation • Fetalbradycardia <110 bpm in between contractions • Thick (grade 3) meconium stained liquor Electronic fetal monitoring • Persistent fetalbradycardia <110 • Late decelerations • Reduced baseline variability <5 beats

8. Interpretation challenges • Partogram:how soon is delivery anticipated? • Second stage • Effect of drugs • Oxytocin • Prostaglandins • Opioids (overstated) • Patient factors • Obesity • Co-operation • Noise!

9. Underpinning evidence • Systematic review shows ‘evidence of no benefit’ for routine electronic monitoring versus intermittent auscultation in low risk pregnancy • EFM without confirmatory tests results in excessive intervention eg CS for ‘fetal distress’ that isn’t • Guidelines advocate selective use of EFM plus fetal scalp sampling for confirmation of fetal status where feasible • Fetal scalp electrode with fetal ECG reduces intervention

11. Pitfalls • Wrong risk assessment • Inadequate ‘intermittent auscultation’ • Poor quality external trace/ loss of contact • Confidence and competence in FSE and FBS • Wrong interpretation of CTG trace- over or under response • Correct interpretation but failure to act

12. Key response interventions • Turn off syntocinon • Operative vaginal delivery • CS in second stage should be exceptional • Triage for likely success in delivery room versus trial in theatre • A ‘sentinel function’ for BEONC • Rapid access to CS when needed for NRFS • Urgency categories clearly understood and adhered to

13. Role of cord blood gas analysis • Feedback to the obstetrician • Refutes/ confirms suspicion of ‘fetal distress’ • Guide to early neonatal care and prognosis • Apgar has very limited predictive value • Low UA pH is a better predictor of complications • Consideration of base excess adds value by distinguishing acute versus chronic hypoxaemia • Can help in triaging newborns who may be at risk and require more surveillance, eg apparently good Apgar but acidaemia/ high base excess

14. FIGO Second Stage Guidelines • Two attendants in the room • Eg one gloved, one to continue auscultation • Auscultation throughout second stage • Hand held Doppler not fetoscope • Instrumental delivery where needed!

15. Conclusions • When ‘not reassured’…. • Steps to improve the status • Positioning eg avoid lying flat • Turn off syntocinon • Deliver the baby • Vacuum • CS • Judge the degree of urgency and act accordingly