FETAL MONITORING. REASONS TO MONITOR THE FETUS ANTENATAL: 1. MATERNAL INDICATIONS e.g. obstetric cholestasis 2. FETAL INDICATIONS e.g. reduced fetal movements, 3. PLACENTAL INDICATIONS e.g. placental insufficiency / growth restriction IN LABOUR: 1. LOW RISK PATIENT
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REASONS TO MONITOR THE FETUS
1. MATERNAL INDICATIONS e.g. obstetric cholestasis
2. FETAL INDICATIONS e.g. reduced fetal movements,
3. PLACENTAL INDICATIONS e.g. placental insufficiency /
1. LOW RISK PATIENT
2. HIGH RISK PATIENT
1. Breathing - Does the baby have breathing movements at least once in 30 minutes?
2. Body Movement - Does the baby move at least three times in 30 minutes?
3. Muscle Tone - Does the baby have at least one flexion-extension (open-close) movement of arms, legs or hands in 30 minutes?
4. Amount of amniotic fluid - Is there enough fluid around the baby?
5. CTG: Is it reactive?
The Amniotic Fluid Index (AFI) can be used to determine fetal well-being.
Most of the fluid in amniotic fluid is contributed to by fetal urine.
This is then resorbed by the membranes and umbilical cord
Rapid turnover - possible to measure amniotic fluid from one day to the next
8-10 = maximal score
0-4 = severe fetal compromise; delivery indicated
Non-invasive velocity measurements of blood flow
Fetus is completely dependent on the supply of oxygen and nutrients from the placenta
Examination of the blood flow through the umbilical circulation can assess fetal health
Increased placental vascular resistance, reduces velocity of the end-diastolic flow in
the umbilical cord artery
Several Doppler indices have been used to quantify abnormalities in umbilical artery
Doppler flow waveforms: A/B ratio, the resistance index, the pulsatility index
Placental insufficiency can be quantified based on the reduction of end-diastolic
Doppler flow velocity into
(1) reduced enddiastolic flow velocity,
(2) absent end-diastolic flow velocity, and
(3) reversed end-diastolic flow velocity.
Middle cerebral artery peak-systolic flow velocity (MCA-PSV) use
Doppler to detect fetal anaemia
Intermittent auscultation recommended for low-risk women
in established labour
INDICATIONS FOR continuous EFM:
1. meconium-stained liquor,
2. abnormal FHR detected by intermittent auscultation
3. maternal pyrexia
4. fresh bleeding in labour
5. oxytocin use for augmentation
6. the woman’s request.
1. The fetal heart pumps deoxygented blood to the placenta via the two umbilical arteries
2. At the placenta there is a free exchange of blood gases
(there's no mixing of foetal/maternal blood)
3. The blood is pumped back to the fetus via a single umbilical vein
The fetal heart is regulated by:
1. Nerve supply
i.e. HR is reduced by vagus nerve (parasympathetic), increased by sympathetic supply
2. Circulating catecholamines
3. Central nervous system activity
These are influenced by changes in:
1. fetal BP
2. fetal blood gas levels
(O2, CO2, pH)
7. Cord compression
8. Cerebral activity
B: Indicator showing movements felt by mother (caused by pressing a button);
C: Fetal movement;
D: Uterine contractions
and pathological FHR traces
Classifications of CTG’S
1) Normal: Implies fetal well-being
2) Suspicious: Indicates continued observation /additional tests
3) Pathological: Mandatory Action.
FRESH EYES LABELS
Define Risk: Low or High
Contractions: Frequency, Length
Baseline Rate: Bradycardia, Normal, Tachycardia
Accelerations: Present or Absent
Decelerations: Present or Absent, Type
Outcome: Normal, Suspicious. Pathological. Management Plan
DESIGNED TO ASSESS WHICH BABIES NEED RESUSCITATION;
IT DOESN'T TELL US WHY A BABY NEEDS RESUSCITATION
1. how well the oxygen supply has been maintained to the fetus during labour
2. How well the fetus has eliminated the waste product CO2
Gives an indication of the efficiency of placental gas exchange during labour
Cord gases can suggest a baby has been deprived of oxygen during labour
but it cannot tell us if the baby has suffered harm as a result
A baby could have good Apgars despite abnormal cord gases
A baby that has been deprived of oxygen during labour may have
compensated well but is still at risk of of e.g. hypoglycaemia
Divide up into 4 groups
Read through the case history
Using DR C BRAVADO review the CTG at the times indicated in BOLD