ELECTRONIC FETAL MONITORING

1. ELECTRONIC FETAL MONITORING By: Dr. Sahar Al-Suwailem Consultant GYN endoscopy KFMC, WSH

2. Introduction Stillbirth rate (fetal death rate). The number of stillborn infants per 1000 infants born, including live births and stillborns Neonatal mortality rate. The number of neonatal deaths per 1000 live births Perinatal mortality rate. The number of stillbirths plus neonatal deaths per 1000 total births Infant mortality rate. The number of infant deaths per 1000 live births

3. Introduction - cont. Introduced in 1960 at Yale university with the aim of reduction in cerebral palsy No reduction and rate is still 2-3/10000 live births (Parkes et al 2001) FHR by NST is most common test of fetal well being NST should not be relied upon as the sole means of establishing fetal well being (I A)

4. Cerebral Palsy Definition - a chronic neuromuscular disability characterized by aberrant control of movement or posture appearing early in life and not the result of recognized progressive disease. It may be accompanied by a seizure disorder or mental retardation or both Causes Unknown

5. Cerebral Palsy - cont. The largest study of risk factors associated with cerebral palsy did not confirm a strong relationship between perinatal asphyxia and cerebral palsy 10% of cerebral palsy in term infants is associated with perinatal asphyxia

6. Introduction -cont. Despite widespread use There is controversy about the efficacy of EFM Interpretation of fetal heart rate patterns Reproducibility of its interpretation Management algorithms for abnormal or non reassuring patterns

7. What are the criteria's of ideal test of fetal well being? Quick Easy to perform Yield readily interpreted results that are reproducible Clearly identify the compromised fetus at a stage at which intervention will improve the outcome It should not give an abnormal result for a healthy fetus UNFORTUNATELY this ideal test does not yet exist

8. Appropriate emergency nursing interventions Change maternal position Give oxygen per mask @ 8-10 liters Initiate or increase intravenous fluids (plasma expander such as ringer lactate) Discontinue oxytocin, remove prostaglandin if possible Vaginal examination

9. Monitoring Variables FHR- EXTERNAL MONITORING MODES-USS (movement of fetal heart) PHONOCARDIOGRAPHY( heart sounds) ABDOMINAL WALL FECG (Best indirect signal source) INTERNAL MONITORING SIGNAL SOURCE (electrical activity of FHR)

10. Factors Affecting Test Results SLEEP CYCLES (20-40 MIN) MEDICATIONS EPIDURAL ANALGESIA PARENTRAL NARCOTICS EFFECT OF STEROIDS (BETAMETHASONE) transiently decrease the FHR variability returned by 4-7 days and decrease in acceleration NO EFFECT OF DEXAMETHASONE MGSO4

11. MATERNAL SMOKING MATERNAL HYPOGLYCEMIA PREMATURITY - non reassuring FHR patterns may occur with up to 60 % of preterm parturient with most common abnormality being deceleration and bradycardia followed by tachycardia and flat tracing Variable decelerations more common among preterm (55-70%) than term (20-30%) Factors Affecting Test Results - cont.

12. Uterine Activity

13. Interpretation of EFH monitoring Baseline Baseline variability Accelerations Deceleration Early Late Variable Prolonged Tachycardia / Bradycardia

38. Classification of variable deceleration Reassuring

39. Atypical Features Deceleration < 70 bpm lasting > 60 seconds Loss of variability in baseline FHR and in the trough of deceleration Biphasic deceleration Prolonged secondary acceleration (post deceleration smooth overshoot of > 20 bpm increase or lasting > 20 seconds Slow return to baseline Continuation of the baseline at a lower level than prior to the deceleration The presence of fetal tachycardia

57. Part II - Fetal Blood Sampling Hypoxemi: Decreased oxygen content in blood Hypoxia: Decreased level of oxygen in tissue Acidemia: Increased concentration of hydrogen ions in the blood Asphyxia: Hypoxia with matabolic acidosis

58. Additional tests and therapies used in combination with EFM Units employing EFM should have ready access to fetal blood sampling facilities. Where delivery is contemplated because of an abnormal fetal heart-rate pattern, in cases of suspected fetal acidosis, fetal blood sampling should be undertaken in the absence of technical difficulties or any contraindications

60. Additional tests and therapies used in combination with EFM - cont. Contraindications to fetal blood sampling includes: Maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus) Fetal bleeding disorders (e.g. haemophilia) Permaturity (<34 weeks) Where there is clear evidence of acute fetal compromise (e.g. prolonged deceleration greater than three minutes), fetal blood sampling should not be undertaken and the baby should be delivered urgently

61. Additional tests and therapies used in combination with EFM - cont. Fetal blood sampling should be undertaken with the mother in the left-lateral position In the presence of abnormal FHR patterns and uterine hypercintractility (not secondary to oxytocin infusion) tecolysis should be considered. A suggested regimen is subcutaneous terbutaline 0.25 mg

62. Classification of fetal blood sample results