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Fetal Monitoring or Antepartum Fetal Surveillance

Fetal Monitoring or Antepartum Fetal Surveillance. Definition. To identify the fetuses at risk of intrauterine hypoxia or even death in utero. Physiology of Utero placental circulation. Normal Utero placental insufficiency. Aims.

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Fetal Monitoring or Antepartum Fetal Surveillance

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  1. Fetal Monitoring orAntepartum Fetal Surveillance

  2. Definition • To identify the fetuses at risk of intrauterine hypoxia or even death in utero.

  3. Physiology of Utero placental circulation • Normal • Utero placental insufficiency

  4. Aims • To identify fetuses at risk of intrauterine hypoxia so that a permanent injury like death should be prevented by timely intervention. • To identify healthy fetuses among those suspected to be in problem on clinical evaluation so that an unnecessary intervention may be avoided.

  5. Timing of prenatal Assessment • 1st trimester – diagnosis of pregnancy and gestational age. • 2nd trimester – diagnosis of congenial malformations • 3rd trimester – assessment of fetal wellbeing

  6. Methods • Classification • During pregnancy – Antepartum • During labour – Intrapartum

  7. INDICATATIONS Antepartum • Primigravida aged 35 or more. • Multipara aged 40 or more. • Small for date fetus. • Bad obstetrics history. • Pre-existing medical conditions. > Diabetes mellitus. > Renal disease. > Hypertension.

  8. Contd • Pregnancy related Diseases: > PIH. > rhesus incompatibility. • Post date pregnancy. • APH. • Decreased fetal movements.

  9. HISTORY • Electronic Intrapartum foetal heart monitoring was processed by Edward Hon in the late 50’s. • Caldeyro-Barcia 1968 correlation of intrapartum changes in foetal heart rate with foetal blood oxygen and acid base state. • Hammacher K-1968 FH frequency and condition of foetus and new born.

  10. …… Contd • Hon. E.H-1967 5th owrld congress of Gynae & Obs, Sydney Obstetricians can now identify FHR characteristics that support the diagnosis of loss of foetel well being. • Hon. E.H 1963 & 67 • Introduced scalp electrodes for internal cardiotocography.

  11. HOW OFTEN • Once a week • Twice a week in cases of post dates, diabetes mellitus and I.U.G.R.

  12. When to start and how often Clinical conditions 34 weeks Twice a wk (diabetes Mellitus, Ch hypertension ,thyroid disease, sickle cell disease, cardiac disease.) Cholestasis of pregnancy 36 weeks Once a wk PIH on diagnosis Twice a wk IUGR 287-293 Days Twice a wk Post dates 294 Days Once a wk

  13. ….. Contd Previous stillbirths a wk before Twice a wk previous loss/ 34 wks. Spron On diagnosis Daily Discordat twins On diagnosis Twice a wk RH disease Individualize Once a wk

  14. Fetal Monitoring predicts more accurately a healthy baby than a depressed baby.

  15. Methods of Fetal Surveillance • Biophysical scoring . • Doppler studies. • Cordocentesis. • C.T.G.

  16. Biophysical Scoring System.

  17. Foetal Biophysical Scoring SystemManning et Al 1981 Parametersscore 2score 0 Breathing movements FBM for at least 30 i.absent FBM secs in 30 mins ii.FBM>30 secs. Gross body movements 3 movements of 2 or less fetal baby /limbs in movements in 30 mins 30 mins. Fetal Tone active Ext with i.no movement return to flex ii.slow Ext with spinal/Limb return to partial flex.

  18. Foetal Biophysical Scoring System. Parametersscore 2score 0 Amniotic at least one i.no pool Fluid volume pool of AF ii.pool<2cm of atleast 2cm. Foetal Heart 2 episode of accel i. less than Reactivity of 15 bpm of sets 2 episode of in 30 minutes acceler of 15 sec. Score of 8 to10 is normal Score of 4 or less is abnormal Score of 6 is equivcal

  19. Modified Biophysical Profilemanning and associates- 1987 Accesses fetus ultrasonically, if four parameters are normal, they do not perform NST. • Normal score is 8/8. • False negative tests < 1 per 1000. • False positive very high.

  20. Amniotic Fluid Index(AFI) Average 16.2 + 5.3 cms. Oligohydramnios < 5.0 cms. Polyhydramnios > 24.0 cms.

  21. Contraction Stress Test

  22. CLINICAL FH measurement. US. • BPD, FL, HC, AC, FL/AC, ratio. • AFI. Doppler. Amnio. Cardocentesis.

  23. Fetal Heart Rate Variability • Short term variability • Long term variability • Decreased variability • Acceleration • Decelerations

  24. Early Deceleration • Benign. • Uniform shape • Onset with onset of contraction • Return to the base line as the contraction ends. • Nadir of deceleration corresponds to the peek of contraction • Fail in rate is >20 – 30 BPM.

  25. A Reactive or Normal FHR Trace • Normal baseline rate 120-160 bpm • Variability • Two accelerations of 15 beats above baseline rate for 15 seconds and no deceleration.

  26. Indications Intra Partum • Breach presentation • Trail of labour • Clinical signs of fetal distress • Prolonged labour • Twins • Oxytocin in use • Epidural anaesthesia

  27. …… Contd • Supine hypertension • Drugs given to mother. > Benzodiazepines. > Tocolytic agents. > Analgensics

  28. Fetal Acid Base Assessment Indications • Repetitive late deceleration • Diminished FHR variability • Repetitive severe variable decelerations • Atypical variable decelerations. • Sinusoidal pattern • Persistent non-reactive FHR pattern • A clinically confusing FHR pattern.

  29. Contraindications to FBS • Early delivery indicated • FHR trace is reassessing • Changes are due to oxytocin stimulations • Failure to progress in labour • During or soon after a prolonged episode of bradycardia • Spontaneous vaginal delivery is imminent.

  30. Terminology • Baseline fetal heart rate FHR 120-160 bpm in between uterine contractions. • Bradycardia baseline FHR <120 bpm. • Trachycardia baseline FHR of >160 bpm

  31. Bradycardia(FHR <120 bpm) • Local anaesthetic drugs • Epidural anaesthesia • Post term fetus • Head and umbillical cord compression • Fetal heart block • Severe acidosis.

  32. Trachycardia • Prematurity • Maternal fever • Maternal hyperthyroidism • Anxiety • Chorioamnionities • Fetal anemia • Chronic hypoxaemia and acidemia • Cardiac arrythmias

  33. Methods of Fetal Surveillance in Labour Clinical • Assessment of fetus size • Volume and color of AF • Intermittent auscultation of FHR Biophysical • Electronic fetal heart monitoring Biochemical • Estimation of PH and blood gas composition from scalp sampling

  34. Intrapartum fetal surveillance Purpose is to detect hypoxia and so prevent asphyxia which may cause either death or permanent neurological damage, expressed as cerebral palsy, mental deficiency or a combination of both.

  35. The ability of fetus to withstand the stress of labor depends therefore on • The condition of fetus at the onset of labour. • The characteristics of labour : a. Duration and intensity of contractions. b. Total duration of labour.

  36. Interpretation of results PH 7.25 or more = Normal PH 7.2 to 7.25 = Intermediate Range PH below 7.2 = Foetal acidosis

  37. Thank You

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