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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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Presentation Transcript
slide1

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

2. HIGH RISK PATIENT

slide2

ANTENATAL FETAL MONITORING

BIOPHYSICAL PROFILE

USS:

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?

AMNIOTIC FLUID

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

slide3

BIOPHYSICAL PROFILE SCORE

8-10 = maximal score

0-4 = severe fetal compromise; delivery indicated

slide4

Doppler blood flow velocity waveforms

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.

slide6

Doppler blood flow velocity waveforms

Middle cerebral artery peak-systolic flow velocity (MCA-PSV) use

Doppler to detect fetal anaemia

ductus venosus dopplers
Ductus Venosus Dopplers
  • May be used as a trigger for delivery of IUGR fetus.
  • Late sign of CV decompensation
  • Reflects decreased ability to handle venous return.
  • Precedes FHR decels
  • Present in 79/211 (37%) of preterm IUGR, useful > 29wks
  • Predictive of pH<7.2
  • Baschat, O&G, 2007
slide8

MONITORING IN LABOUR

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.

slide9

FETAL PHYSIOLOGY

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

slide10

FETAL HEART RATE

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)

3. Hypoxia

4. Pyrexia

5. Drugs

6. Gestation

7. Cord compression

8. Cerebral activity

slide11

A: Fetal heartbeat;

B: Indicator showing movements felt by mother (caused by pressing a button);

C: Fetal movement;

D: Uterine contractions

slide13

Definition of normal, suspicious

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.

slide14

SMALL GROUP / PAIR WORKSHOP

using

FRESH EYES LABELS

slide15

DR. C BRAVADO

Define Risk: Low or High

Contractions: Frequency, Length

Baseline Rate: Bradycardia, Normal, Tachycardia

Variability: 5-10bpm/min

Accelerations: Present or Absent

Decelerations: Present or Absent, Type

Outcome: Normal, Suspicious. Pathological. Management Plan

slide17

APGAR SCORES

DESIGNED TO ASSESS WHICH BABIES NEED RESUSCITATION;

IT DOESN'T TELL US WHY A BABY NEEDS RESUSCITATION

slide18

CORD GASES

Indication of:

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

slide19

SMALL GROUP WORKSHOP

Divide up into 4 groups

Read through the case history

Using DR C BRAVADO review the CTG at the times indicated in BOLD