Monitoring in Labour

1. Monitoring in Labour

2. Discuss fetal heart rate patterns using Continuous Electronic Fetal Monitoring (CEFM) tracings. Compare the evidence between EFM and structured intermittent auscultation (SIA) Discuss relevant physiology in fetal monitoring Describe systematic approaches in fetal monitoring using Dr C Bravado Outline guidelines for fetal heart rate monitoring using SIA Objectives

3. Perinatal outcomes 50% reduction in neonatal seizures (RR0.50, 95%CI 0.31-0.80) … but no significant differencein incidence of: - long-term neurological handicap(RR1.74, 95%CI 0.97-3.11) - or perinatal mortality (RR0.85, 95%CI 0.59-1.23) Obstetric outcomes - 66% increase in C. Section rate (RR1.66, 95%CI 1.30-2.13) - 16% increase in instrumental delivery (RR1.16, 95%CI 1.01-1.32) Alfiveric Z et al, Cochrane Database Syst Rev 2006 CEFM vs. SIA

4. Changes in FH rate patterns occur in response to changes in O2, CO2, hydrogen ions and arterial pressure These changes are mediated via the vagus nerve, chemoreceptors & carotid body baroreceptors It is difficult to measure fetal oxygenation and pH continuously FH rate patterns only allow indirect assessment of fetal acid-base balance. Fetal scalp sampling is required to confirm whether the fetus is hypoxic… Hinshaw K & Ullal A. Anaes Int Care Med (Aug 2007) Pathophysiology of FH rate changes

5. A systematic approach to CTG interpretation using EFM DR. C. BRAVADO Determine Risk Contractions (< 5 in 10) Baseline Rate (110-150bpm) Variability (>5) Accelerations-reassuring Decelerations Overall Assessment & Plan Few centres in Tanzania have this facility - refer to ALSO manual for further information

6. “DRCBRAVADO” DetermineRisk Assess degree of “clinical risk” in relation to clinical outcome High Low A systematic approach to CTG interpretation Comparable to TRAFFIC LIGHTS

7. Maternal: Previous Caesarean section Pre-eclampsia Pregnancy >42 weeks Prolonged ROM >24 hours Diabetes Antepartum haemorrhage Significant medical condition – eg cardiac Risk Factors

8. Fetal: Intrauterine growth restriction Oligohydramnios Preterm labour Multiple pregnancy Breech presentation Risk Factors

9. Intrapartum Significant meconium-stained liquor Abnormal FHR on auscultation baseline <110 or >160 bpm any decelerations after a contraction Maternal pyrexia Fresh bleeding in labour Oxytocin augmentation Risk Factors

10. “ DR C BRAVADO” A systematic approach to CTG interpretation Assesscontraction pattern Rate Duration of contractions Coordinate or In-coordinate? Baseline Tone

11. “DRCBRAVADO” A systematic approach to CTG interpretation Baseline Rate Normal range 110-160bpm Baseline Bradycardia <110 Baseline Tachycardia >160 bpm

12. BASELINE RATE BRADYCARDIA<110 Gestation > 40 weeks Cord compression Congenital heart malformations Drugs eg.benzodiazepines TACHYCARDIA>160 Excessive fetal movement Maternal anxiety Gestation <32 weeks Maternal pyrexia Fetal infection Chronic hypoxia

13. “ DR C BRAVADO” A systematic approach to CTG interpretation Variability The presence of normal fetal heart rate variability is one of the best indicators of intact integration between the central nervous system and the heart of the fetus Normal ≥5 bpm

14. VARIABILITY Persistent absence of or reduced variability is potentially ominous ReducedNormal

15. “DRCBRAVADO” A systematic approach to CTG interpretation Accelerations • Increase of at least 15 bpm above the baseline • for at least 15 seconds • Associated with movement or stimulation • Presence is the single best indicator of fetal • well-being • An antenatal CTG should always contain accelerations to be considered normal.

16. ACCELERATIONS 3 examples are highlighted

17. “DRCBRAVADO” • A systematic approach to CTG interpretation • Early Decelerations mirror contractions • Fall of <60 beats from baseline associated (almost exclusively) with excellent fetal outcome • True early uniform decelerations are rare and benign and therefore not significant

18. A systematic approach to CTG interpretation Variable Decelerations Most decelerations in labour are variable Can reflect cord compression ‘Variable’ in shape, depth and/or onset Usually benign but …. if late or deep may imply cord prolapse or hypoxia ‘Need to assess the frequency and duration “DR C BRAVADO”

19. VARIABLE DECELERATIONS

20. COMPLICATED VARIABLES

21. A systematic approach to CTG interpretation Late Decelerations Associated with fetal compromise (hypoxia) but only in 50-60% of cases Ominous if associated with: - fresh particulate meconium - ‘high-risk’ clinical situation Ominous if: -  ‘lag-time’ (peak to trough) - deceleration is slow to recover “DR C BRAVADO”

22. LATE DECELERATIONS • Begin after onset of contraction • Nadir (or trough) after peak of contraction • Return to baseline after end of contraction

23. Structured Intermittent Auscultation In Active phase of labour • MINIMUM OF 60 SECONDS after a contraction • Differentiate maternal pulse • Each 30 minutes in first stage of labour • Each 15 minutes if any risk factor • After each contraction while actively pushing

24. If fetal heart rate persist above 180 bpm or below 100 bpm plan delivery: • If the cervix is fully dilated and the fetal head is not more than 1/5 above the symphysis pubis (or at station 0 or below) deliver by vacuum • If the cervix is not fully dilated or the fetal head is more than 1/5 above the symphysis pubis (or above station 0) deliver by cesarean section ”Managing obstetric complications, WHO”