Prepared by Helen Cooke Warwick Giles February 2008

2. Goals Who should be monitored Tools for intrapartum monitoring Describe the parameters for intrapartum assessment

3. 2 FHR as a screening test Intrapartum FHR monitoring is a screening test that provides information to alert the clinician that a true test for fetal welfare assessment needs to be performed, eg: An atypical variable (pathological feature) fetal blood sampling should be performed Emphasize that FHR monitoring is a screening test. Emphasize that FHR monitoring is a screening test.

4. 3 Documentation At commencement of the CTG the documentation of the pattern should include woman�s name and MRN, estimated gestational age, clinical indications for performing the FHR pattern, time and date of commencement and maternal pulse rate. The outcome of the FHR pattern should be documented both on the CTG and in the woman�s medical records at least every � hourly throughout labour. This needs HUGE!!! emphasis as it is so important both legally and for communication between all clinicians. Emphasize ++++++++ This is BEST PRACTICE.This needs HUGE!!! emphasis as it is so important both legally and for communication between all clinicians. Emphasize ++++++++ This is BEST PRACTICE.

5. 4 FHR evaluation Dr C Bravado ? ALSO DR � determine the risk C � contractions Bra � baseline rate V � variability A � accelerations D � decelerations O � overall assessment (followed by a management plan) Dr C Bravado was developed as a tool for interpretation of intrapartum FHR patterns and thanks to ALSO for allowing us to use the mnemonic. Dr C Bravado was developed as a tool for interpretation of intrapartum FHR patterns and thanks to ALSO for allowing us to use the mnemonic.

6. 5 FHR Monitoring on admission in labour ??? Electronic FHR monitoring ??? Doppler auscultation ??? Pinards How do you decide? A search for antenatal or intrapartum risk factors will help you make the decision regarding the most appropriate form of monitoring for this pregnancy. If the woman has limited or no antenatal care then an evaluation of fetal welfare via electronic FHR monitoring is warranted on admission in labour.How do you decide? A search for antenatal or intrapartum risk factors will help you make the decision regarding the most appropriate form of monitoring for this pregnancy. If the woman has limited or no antenatal care then an evaluation of fetal welfare via electronic FHR monitoring is warranted on admission in labour.

7. 6 Considerations for which form of monitoring to use on admission Has the woman had good antenatal care? Are you aware of the fetal welfare and development? Are there any risk factors present? Is the woman in labour? If the woman is not established in labour is there a need to perform antenatal FHR monitoring? If she has presented to the birthing unit antenatally then it is important to assess fetal welfare at that time so start with assessment of fetal movement, palpation, auscultation and the electronic FHR monitoring.If the woman is not established in labour is there a need to perform antenatal FHR monitoring? If she has presented to the birthing unit antenatally then it is important to assess fetal welfare at that time so start with assessment of fetal movement, palpation, auscultation and the electronic FHR monitoring.

8. 7 Admission CTG�s Are a poor predictor of fetal compromise during labour in low risk women There is no current evidence that supports routine CTG testing on admission in low risk women & is therefore not recommended Rationale was that this would identify a sub group of fetus� who would benefit from intensive surveillance RCOG Make an assessment of the risks to determine whether electronic FHR monitoring is required The most important finding from a recent RCT of admission CTG�s by Mires et al (2001) demonstrates an increased rate of operative delivery in women who had admission CTG and had no identified antenatal or intrapartum risk factors at he time of admission in labour. Admission CTG�s refer to women in established labour � contracting regularly and at least 4cm dilated. If not established in labour then antenatal CTG should be considered in the presence of risk factors and interpreted in the light of it being an antenatal trace.The most important finding from a recent RCT of admission CTG�s by Mires et al (2001) demonstrates an increased rate of operative delivery in women who had admission CTG and had no identified antenatal or intrapartum risk factors at he time of admission in labour. Admission CTG�s refer to women in established labour � contracting regularly and at least 4cm dilated. If not established in labour then antenatal CTG should be considered in the presence of risk factors and interpreted in the light of it being an antenatal trace.

9. 8 Who should have continuous electronic FHR monitoring? Antenatal risk factors Prematurity Pre-eclampsia/eclampsia Diabetes Growth restriction Non-reassuring antenatal fetal welfare assessment Multiple pregnancy Malpresentation Any complication that may be associated with some potential for fetal compromise. Therefore, we should be watchful of the ability of this fetus to cope with the pressures of the labour marathon.Any complication that may be associated with some potential for fetal compromise. Therefore, we should be watchful of the ability of this fetus to cope with the pressures of the labour marathon.

10. 9 Who should be have continuous electronic FHR monitoring? Intrapartum factors Syntocinon Meconium Epidural Suspicious FHR on auscultation Prolonged rupture of the membranes Prematurity Previous C/S Particularly point out the importance of Syntocinon as a significant intrapartum factor. This is one factor that we have ULTIMATE CONTROL OVER!Particularly point out the importance of Syntocinon as a significant intrapartum factor. This is one factor that we have ULTIMATE CONTROL OVER!

11. 10 Practice Recommendations for intermittent auscultation Healthy women with uncomplicated labour IA with Pinards/Doppler recommended Active labour- after contraction for at least 60 seconds & at least every 15mins 1st stage every 5mins 2nd stage Continuous EFM is recommended if: Baseline < 110 or >160bpm; Decelerations or intrapartum risk factors develop Many units will find Doppler more suitable (Doppler is recommended by both the RCOG and RANZCOG). In second stage a handy rule would be after each contraction during active pushing. Auscultation of the fetal heart with a Pinards at the first auscultation helps to clearly identify the position of the baby and the true presence of the fetal heart as distinguished from maternal heart rate.Many units will find Doppler more suitable (Doppler is recommended by both the RCOG and RANZCOG). In second stage a handy rule would be after each contraction during active pushing. Auscultation of the fetal heart with a Pinards at the first auscultation helps to clearly identify the position of the baby and the true presence of the fetal heart as distinguished from maternal heart rate.

12. 11 Is the woman established in labour? The interpretation of the FHR pattern should be considered in context. If the woman is not established in labour is reactivity present? Where FHR monitoring is performed and the woman is not established in labour then the pattern should be interpreted as antenatal and you should therefore be monitoring to assess the presence of reactivity not just one or no accelerationsWhere FHR monitoring is performed and the woman is not established in labour then the pattern should be interpreted as antenatal and you should therefore be monitoring to assess the presence of reactivity not just one or no accelerations

13. 12 Guidelines Education based on Royal College of Obstetrics and Gynaecology (RCOG) Guidelines �The Use of Electronic Fetal Monitoring� www.rcog.org.uk RCOG provide clear descriptions that will provide a consistent approach to interpretation

14. If electronic FHR is performed, these are the RCOG guidelines for application, interpretation and intervention. These guidelines will form the basis of further discussion.If electronic FHR is performed, these are the RCOG guidelines for application, interpretation and intervention. These guidelines will form the basis of further discussion.

15. Each unit should develop guidelines for lactate levels. Individual levels should be based around the available resources and the expected timeframes between assessment and delivery.Each unit should develop guidelines for lactate levels. Individual levels should be based around the available resources and the expected timeframes between assessment and delivery.

16. 15 Categorisation of FHR Features

17. 16 Categorisation of FHR Patterns

18. 17 Baseline rate Normal = 110 � 160bpm Bradycardia (moderate) = 100 � 109bpm Bradycardia (abnormal) = < 100 bpm Tachycardia (moderate) = 161 � 180 bpm Tachycardia (abnormal) = >180 bpm (RCOG) Moderate Bradycardia and tachycardia are non-reassuring features Abnormal Bradycardia and tachycardia are PATHOLOGICAL features Moderate Bradycardia and tachycardia are non-reassuring features Abnormal Bradycardia and tachycardia are PATHOLOGICAL features

19. 18 Where there are multiple decelerations such as in this trace the clue is to �GO HIGH� to see the baseline heart rate.Where there are multiple decelerations such as in this trace the clue is to �GO HIGH� to see the baseline heart rate.

20. 19 Baseline Bradycardia Bradycardia (moderate) = 100 � 109bpm Bradycardia (abnormal) = < 100 bpm Rare Consider the cause if this is a sudden event � ? prolonged deceleration A baseline bradycardia during labour is RARE. A fetus post term with a mature central nervous system may have a FHR that shows normal features apart from a bradycardia. In the presence of normal variability, perhaps an acceleration and early or variable decelerations this is just a normal variance. However, if the rate is < 100 bpm consider the possibility of a prolonged deceleration from what was a normal rate. This should be considered in the presence of an event that may cause a very sudden hypoxia for the fetus. Severe bradycardia � The fetal hypertension following a hypoxic insult leads to a baroreceptor reflex, which leads to a vagal response and a fall in the fetal heart rate. The duration and severity of the bradycardia are correlated to the length and severity of the hypoxic event � cord prolapse, sudden maternal hypotension, ruptured uterus, antepartum or intrapartum haemorrhage, abruption, maternal apnoea secondary to a seizure (Blackburn, 289). End-stage bradycardia associated with second stage is probably a result of a vagal response to head compression as the fetus traverses the birth canal. A baseline bradycardia during labour is RARE. A fetus post term with a mature central nervous system may have a FHR that shows normal features apart from a bradycardia. In the presence of normal variability, perhaps an acceleration and early or variable decelerations this is just a normal variance. However, if the rate is < 100 bpm consider the possibility of a prolonged deceleration from what was a normal rate. This should be considered in the presence of an event that may cause a very sudden hypoxia for the fetus. Severe bradycardia � The fetal hypertension following a hypoxic insult leads to a baroreceptor reflex, which leads to a vagal response and a fall in the fetal heart rate. The duration and severity of the bradycardia are correlated to the length and severity of the hypoxic event � cord prolapse, sudden maternal hypotension, ruptured uterus, antepartum or intrapartum haemorrhage, abruption, maternal apnoea secondary to a seizure (Blackburn, 289). End-stage bradycardia associated with second stage is probably a result of a vagal response to head compression as the fetus traverses the birth canal.

21. 20 Causes of Baseline Tachycardia Excessive fetal movement Maternal dehydration Prematurity Maternal fever Maternal or fetal stress causing adrenaline release Chorioamnionitis

22. 21 An example of baseline tachycardia of 200-210 bpm with good variability.An example of baseline tachycardia of 200-210 bpm with good variability.

23. 22 Tachycardia Also seen with fetal asphyxia (low levels of O2) particularly in the early stages In the presence of true asphyxia, tachycardia is most commonly associated with other features such as decreased variability Fetus will increase their heart rate as a way of increasing the amount of O2 circulating around their body. This is a compensatory mechanism in response to falling O2 levels. The decreased variability is a sign of reduced oxygenation of the brain and the reduction of variability. The fetal heart rate pathway starts in the cerebral cortex and travels through the midbrain to the vagus nerve and then to the cardiac conductive system. (Blackburn, 289) A moderate tachycardia (160 �180bpm) with normal variability is not usually of serious concern, especially when there is an identifiable cause such as maternal pyrexia However, a tachycardia associated with reduced variability and/or decelerations is a suspicious sign of fetal hypoxia Fetus will increase their heart rate as a way of increasing the amount of O2 circulating around their body. This is a compensatory mechanism in response to falling O2 levels. The decreased variability is a sign of reduced oxygenation of the brain and the reduction of variability. The fetal heart rate pathway starts in the cerebral cortex and travels through the midbrain to the vagus nerve and then to the cardiac conductive system. (Blackburn, 289) A moderate tachycardia (160 �180bpm) with normal variability is not usually of serious concern, especially when there is an identifiable cause such as maternal pyrexia However, a tachycardia associated with reduced variability and/or decelerations is a suspicious sign of fetal hypoxia

24. 23 Variability Greater than 5bpm and less than 25bpm Increased variability is often seen following an acute hypoxic event. Should settle after about 10 mins when the fetus returns to normal O2 levels

25. 24 Saltatory As discussed in the antenatal workshop, variability > 25 bpm. Most commonly associated with a period of hypoxia. The increased variability demonstrates the very rapid sympathetic and parasympathetic interplay that happens to regulate the FHR after being deprived of O2. This is a NORMAL physiological response to hypoxia and should settle after about 10 � 15 mins . Think about trying to improve fetal oxygenation by changing the maternal position, reducing Syntocinon or increasing IV fluids if available.As discussed in the antenatal workshop, variability > 25 bpm. Most commonly associated with a period of hypoxia. The increased variability demonstrates the very rapid sympathetic and parasympathetic interplay that happens to regulate the FHR after being deprived of O2. This is a NORMAL physiological response to hypoxia and should settle after about 10 � 15 mins . Think about trying to improve fetal oxygenation by changing the maternal position, reducing Syntocinon or increasing IV fluids if available.

26. 25 Causes of Reduced Variability = 5bpm fetal sleep or quiet state Maternal medications � Morphine, Pethidine etc Fetal hypoxia � depressing the CNS Fetal anomalies Fetal Cardiac Arrhythmias

27. 26 Sinusoidal Wave like pattern of 3 � 5 oscillation / min ranging between 5 � 15 beats Very RARE. Sign of a dying baby. The improvements in U/S over the past 15 years mean that we very rarely see these babies any more. A sinusoidal FHR pattern is the next step in the FHR pattern that reflects no significantly reduced baseline variability and shallow decelerations. If the FHR pattern has been reassuring and suddenly becomes sinusoidal then consider this is possibly psuedosinusoidal and reflects a fetus in a deep sleep and perhaps the rhythmical motions of thumb sucking Very RARE. Sign of a dying baby. The improvements in U/S over the past 15 years mean that we very rarely see these babies any more. A sinusoidal FHR pattern is the next step in the FHR pattern that reflects no significantly reduced baseline variability and shallow decelerations. If the FHR pattern has been reassuring and suddenly becomes sinusoidal then consider this is possibly psuedosinusoidal and reflects a fetus in a deep sleep and perhaps the rhythmical motions of thumb sucking

28. 27 Accelerations Not always present in the intrapartum pattern as the most common feature is a deceleration A reassuring feature of an intrapartum pattern Spontaneous acceleration = pH >7.25 One isolated acceleration or an acceleration in response to some scalp stimulation during a VE is a REASSURING sign. Repetitive accelerations with each contractions is of uncertain significance (and very uncommon). Potentially this is a fetus that is releasing adrenaline as a stress response to the contraction. This fetus� reserves are not known so ongoing careful observation is required to ensure the FHR does not become constantly tachycardic or that atypical variables or late decelerations become present as a result of fetal compromise.One isolated acceleration or an acceleration in response to some scalp stimulation during a VE is a REASSURING sign. Repetitive accelerations with each contractions is of uncertain significance (and very uncommon). Potentially this is a fetus that is releasing adrenaline as a stress response to the contraction. This fetus� reserves are not known so ongoing careful observation is required to ensure the FHR does not become constantly tachycardic or that atypical variables or late decelerations become present as a result of fetal compromise.

29. 28 Decelerations Early Late Variable � typical and atypical Prolonged

30. 29 Early Repetitive from one contraction to another Recovery to baseline is always at the end on the contraction Caused by vagal nerve stimulation Vagal nerve is stimulated from about 7-8cm dilated as the fetal head is compressed leading to vagal nerve stimulation and causes the heart rate to decelerateVagal nerve is stimulated from about 7-8cm dilated as the fetal head is compressed leading to vagal nerve stimulation and causes the heart rate to decelerate

31. 30 If you draw a line at the peak of the contraction the deceleration will be occurring at the same time In this case you may point out that there is a decrease in variability which is short lived (~20 mins) and this is common with fetal sleep (when early decelerations also occur) If you draw a line at the peak of the contraction the deceleration will be occurring at the same time In this case you may point out that there is a decrease in variability which is short lived (~20 mins) and this is common with fetal sleep (when early decelerations also occur)

32. 31 The Fetal Heart Rate � Early decelerations Begin with head compression during the contraction This reduction of cerebral blood flow leads to hypoxia and hypercapnia Hypercapnia leads to hypertension with triggering of baroreceptors Results in bradycardia mediated by parasympathetic nervous system (via the vagal nerve) Fall in FHR is matched to rise in contraction strength Not indicative of fetal compromise Parasympathetic nervous system slows the fetal heart rateParasympathetic nervous system slows the fetal heart rate

33. 32 Late Decelerations Repetitive from one contraction to the next (3 or more) Recovery to baseline is late, well after the end of the contraction More ominous when associated with minimal variability & ? baseline Reflects a change in placental ability to adequately meet fetal needs May indicate the presence of fetal hypoxia and acidosis Often signifies fetal decompensation These late decelerations �party� in a group together. It could be likened to the fetus �running on empty�. The % of fetuses that are acidotic is about 1 in 3 where there are late decelerations.These late decelerations �party� in a group together. It could be likened to the fetus �running on empty�. The % of fetuses that are acidotic is about 1 in 3 where there are late decelerations.

34. 33 Again, if you draw a line at the peak of the contraction you can see the late decelerations occurring well after the contraction cycle has completedAgain, if you draw a line at the peak of the contraction you can see the late decelerations occurring well after the contraction cycle has completed

35. 34

36. 35 The Fetal Heart Rate � Late decelerations Lates represent fetal hypoxia and are related to an interruption in O2 supply at cardiac level Reduced O2 leads to stimulation of chemoreceptors Results in activation of the cardiac centres in the brainstem SA node is effected and the FHR slows. With the prolonged hypoxia, myocardium is effected causing further decrease in the FHR and hypotension Recovery is slower as the myocardium gradually reoxygenates Chemoreceptors can be found in both the peripheral and central nervous systems and may alter the FHR in response to hypoxaemia and acidosis. These decelerations are the result of fetal myocardial hypoxia and represent myocardial depression.Chemoreceptors can be found in both the peripheral and central nervous systems and may alter the FHR in response to hypoxaemia and acidosis. These decelerations are the result of fetal myocardial hypoxia and represent myocardial depression.

37. 36 Variable Decelerations Repetitive or intermittent Often mimic letters of the alphabet U V W M Rapid sudden fall in FHR Often rapid recovery Reflect some degree of umbilical cord impingement Often seen when liquor volume is ? RCOG describe two types of variables, typical and atypical and both will be covered These are the most common decelerations seen in labour. The W and M types often means that there is a �late� component.RCOG describe two types of variables, typical and atypical and both will be covered These are the most common decelerations seen in labour. The W and M types often means that there is a �late� component.

38. 37 Typical Variable - causes Compression of blood in umbilical vein results in loss of circulating blood volume causing a well fetus to have a primary acceleration � demonstrated by ? autonomic NS activity (1stshoulder) Followed by partial compression or stretching of the umbilical arteries causing blood flow interruption and the deceleration. This decreases blood flow to the Rt heart causes hypotension This stimulates the sympathetic nervous system and catecholamine release Causing a compensatory fetal tachycardia following the deceleration (the 2nd shoulder). Typical variables are classified as non-reassuring features. However in the presence of normal baseline rate and normal variability typical variables require no further action and reflect a normal fetal response to the pressure of contractions on the umbilical cord. Note the typical variables have 2 shoulders just like we do.Typical variables are classified as non-reassuring features. However in the presence of normal baseline rate and normal variability typical variables require no further action and reflect a normal fetal response to the pressure of contractions on the umbilical cord. Note the typical variables have 2 shoulders just like we do.

39. 38 Typical Variable - features? A sharp V shaped deceleration � caused by compression of blood in umbilical arteries preceded and followed by an acceleration (shoulder) The classic typical variable due to a transient occlusion of the umbilical cord for such a short duration that the period of hypoxia is not enough to effect the previously well fetus As typical variables are caused by cord compression, the ongoing management of the women should include such measures as Ch = Change Position I = Improve hydration C = Cease Syntocinon Ke = Keep monitoring N = notify The aim is to maximise the fetal environment by improving fetal blood flow either through the umbilical cord or maternally to the placenta. The typical variables are a normal response to cord compression.As typical variables are caused by cord compression, the ongoing management of the women should include such measures as Ch = Change Position I = Improve hydration C = Cease Syntocinon Ke = Keep monitoring N = notify The aim is to maximise the fetal environment by improving fetal blood flow either through the umbilical cord or maternally to the placenta. The typical variables are a normal response to cord compression.

40. 39 Baseline Rate Point out the recurrent typical variable with shoulders , a normal baseline rate (140-150) and variability and rapid return to the normal baseline.Point out the recurrent typical variable with shoulders , a normal baseline rate (140-150) and variability and rapid return to the normal baseline.

41. 40 Atypical Variable Decelerations Loss of primary or secondary rise in baseline rate (No Shoulders) Slow return to baseline FHR after the end of the contraction Prolonged increase or secondary rise in baseline rate (Overshoot) Biphasic deceleration (Variable followed by late component) Loss of variability during a deceleration Continuation of the baseline rate at a lower level Atypical variables are abnormal features and therefore make the fetal heart rate pattern PATHOLOGICAL. Any deceleration that are not earlies or typical variables make the pattern pathological and consideration should be given to the further assessment of fetal welfare such as ChICKeN pH or ChICKeN lactateAtypical variables are abnormal features and therefore make the fetal heart rate pattern PATHOLOGICAL. Any deceleration that are not earlies or typical variables make the pattern pathological and consideration should be given to the further assessment of fetal welfare such as ChICKeN pH or ChICKeN lactate

42. 41 Slow return to baseline Concerning feature Associated with low Apgar scores and fetal hypoxia 47% of fetuses will have a one min Apgar score < 7 however, only 10% have a five min Apgar < 7 Can be improved by inutero resuscitation Need to look for other non-reassuring features

43. 42 A series of atypical variables. Point out the lack of shoulders, the slow return to baseline at the start of the trace and the overshoots that can seen. The last part of the trace shows a failure to return to baseline.A series of atypical variables. Point out the lack of shoulders, the slow return to baseline at the start of the trace and the overshoots that can seen. The last part of the trace shows a failure to return to baseline.

44. 43 Point out. The the trace shows a failure to return to baseline following most decelerations. Point out. The the trace shows a failure to return to baseline following most decelerations.

45. 44 Point out the prolonged increase or secondary rise in baseline rate (Overshoot) seen in these atypical variables. Point out the prolonged increase or secondary rise in baseline rate (Overshoot) seen in these atypical variables.

46. 45 Prolonged Decelerations FHR falls for > 3 minutes Usually associated with an acute insult - Top up, VE, ? Syntocinon FHR pattern before and in recovery indicates fetal tolerance - not the deceleration itself Should be managed vigorously Vigorous management = Call for help, Change maternal position, Stop Syntocinon if running, increase IV fluids if available (ChICKeN) Many people may suggest the administration of O2. This is fine if there has been maternal collapse and the mother requires resuscitation. However, the important part of restoring placental � fetal circulation is to remove the cord occlusion or pressure so all the above measures will reduce pressure on the cord and hopefully return placental � fetal blood flow to normalVigorous management = Call for help, Change maternal position, Stop Syntocinon if running, increase IV fluids if available (ChICKeN) Many people may suggest the administration of O2. This is fine if there has been maternal collapse and the mother requires resuscitation. However, the important part of restoring placental � fetal circulation is to remove the cord occlusion or pressure so all the above measures will reduce pressure on the cord and hopefully return placental � fetal blood flow to normal

47. 46 Suspicious FHR Pattern: What should you do? Maternal Position Dehydration Infection Hypotension ?V.E/bedpan Vomiting/vasovagal Analgesia/Drugs Mechanical Poor quality CTG Maternal pulse Transducer site FSE Oxytocics Prostaglandins Change position L lateral preferably Check BP 500mls crystalloid if appropriate O2 administration � the prolonged use of O2 may be harmful to the fetus and should be avoided. There is no research evidence evaluating the benefits or risks associated with the short term use of maternal facial oxygen therapy in cases of suspected fetal compromise. (NICE 2001) Remember ChICKeN !!!!!! Change position L lateral preferably Check BP 500mls crystalloid if appropriate O2 administration � the prolonged use of O2 may be harmful to the fetus and should be avoided. There is no research evidence evaluating the benefits or risks associated with the short term use of maternal facial oxygen therapy in cases of suspected fetal compromise. (NICE 2001) Remember ChICKeN !!!!!!

48. 47 Pathological: What should I do? Roll woman into L) lateral Perform Fetal Blood Sampling If pH ?7.25 repeat within one hour if the FHR abnormality persists If pH 7.21-7.24 repeat within 30mins or deliver if rapid fall since last FBS If pH < 7.20 DELIVER immediately Lactate 4.2 - 4.8 DELIVER. All FBS should take into account previous pH, rate of progress & clinical information Lactate increases at approximately 1mmol every 25 minutes. Fetal brain injury begins to occur at a lactate level of 6mmol and greater. The decisions regarding which is the most appropriate lactate level for the decision to deliver to occur needs to remain at the local level as each hospital will have different on call arrangements and the the level will be dependent on the availability of staff and other resources. Lactate increases at approximately 1mmol every 25 minutes. Fetal brain injury begins to occur at a lactate level of 6mmol and greater. The decisions regarding which is the most appropriate lactate level for the decision to deliver to occur needs to remain at the local level as each hospital will have different on call arrangements and the the level will be dependent on the availability of staff and other resources.

49. 48 Abnormal FBS results Expedite delivery Mother consent Urgency should be dictated by severity of FHR abnormality & maternal factors Reasons FBS not appropriate maternal or fetal infection Fetal bleeding disorders Prematurity < 34 weeks There may be some discussion regarding the use of facial oxygen in the presence of a pathological FHR pattern or abnormal pH result. The evidence suggests that the prolonged use of facial oxygen may be harmful to fetus & should be avoided. There is no evidence evaluating risks of benefits associated with short-term use in cases of suspected fetal compromise. You can use the analogy of the kinked water hose where turning the tap off full blast does not mean any more water is going to come out the other end. The kink, or supply block needs to be removed. For the fetus this means that a well health woman will provide through uterine blood flow the required levels of fetal oxygen and the aim of improving fetal oxygenation is to improve blood supply through the placental bed. Some ways to achieve this are to roll the woman into L) lateral, reduce the contraction frequency and strength by turning off or down Syntocinon if running or by improving the maternal levels of hydration As mentioned in the previous discussion acute tocolysis as part of fetal resuscitation (eg ventolin, terbutaline)There may be some discussion regarding the use of facial oxygen in the presence of a pathological FHR pattern or abnormal pH result. The evidence suggests that the prolonged use of facial oxygen may be harmful to fetus & should be avoided. There is no evidence evaluating risks of benefits associated with short-term use in cases of suspected fetal compromise. You can use the analogy of the kinked water hose where turning the tap off full blast does not mean any more water is going to come out the other end. The kink, or supply block needs to be removed. For the fetus this means that a well health woman will provide through uterine blood flow the required levels of fetal oxygen and the aim of improving fetal oxygenation is to improve blood supply through the placental bed. Some ways to achieve this are to roll the woman into L) lateral, reduce the contraction frequency and strength by turning off or down Syntocinon if running or by improving the maternal levels of hydration As mentioned in the previous discussion acute tocolysis as part of fetal resuscitation (eg ventolin, terbutaline)

50. 49 Conclusion Earlies are caused by vagal nerve stimulation Variables are caused by cord compression Lates are caused by placental blood flow Increasing heart rate and decreased variability are non-reassuring and worthy of concern

51. 50 References RCOG 2001 The Use of Electronic Fetal Monitoring www.rcog.org.uk