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Intrapartum Fetal Monitoring

Intrapartum Fetal Monitoring. Partograph and Fetal Cardiotocography Prof. Azza Alyamani Department of Obstetrics &Gynecology. Aims of the presentation : 1. Be able to interpret routine data collected in labor. 2. Be confident to interpret a partogram and

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Intrapartum Fetal Monitoring

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  1. Intrapartum Fetal Monitoring Partograph and Fetal Cardiotocography Prof. Azza Alyamani Department of Obstetrics &Gynecology

  2. Aims of the presentation : 1. Be able to interpret routine data collected in labor. 2. Be confident to interpret a partogram and formulate a management plan based on the patterns observed. 3. Understand fetal response in labor. 4. Be able to interpret fetal monitoring . 5. Be familial of normal and abnormal fetal CTG traces.

  3. Partogram Definition: it is graphical record of key data of labor progress with both maternal and fetal data entered against time . it is the process by which normal and abnormal progress of labor and also fetal response in labor can be defined.

  4. Importance : It allows an instant visual assessment of the rate Cervical dilatation and comparison with an expected Norm , so that slow progress can be recognized Earl and appropriate actions taken to correct it Where possible.

  5. Components Part 1 : Fetal condition a. Fetal heart rate. b. The condition of the membranes and liquor amnonii. c. Moulding and caput formation.

  6. Part 2 : Progress of labor ( Cervicogram ): * it is a graphic representation of cervical dilatation and descent of the presenting part . * it is an essential part of the partogram . * it offer the chance of early detection of slow progress of labor. * first ,we set an alert line at 1cm/h. for the active phase dilatation to represent the ideal progress. then ,we set an action line 2-4h.later to the right of the alert line.

  7. if the marks (plots) of progress falls beyond the action line , the progress of labor is slow and the cause of this should be sought and corrected if possible or the decision of cesarean section is considered.

  8. the cervicogram

  9. Friedman′s Division of Labor : he divided the first stage of labor into: latent phase and active phases. then , he divided the active phase further into 3 parts : * acceleration phase. * phase of maximum slope and * deceleration phase.

  10. Friedman’ s Division of labor

  11. Uterine contractions : Efficient powers ( good uterine contractions) are at the center of Efficient labor bec: * it cause cervical dilatation in the 1st stage , and * rotation & descent in the 2nd stage. efficient uterine contractions should be : 3-4 contractions in the 10 minutes ,each lasts 45-60 sec with amplitute of at least 50 mmHg.

  12. Part 3 : Maternal condition Assessment of maternal condition regularly by monitoring : * vital signs; temperature , pulse and bl.P * drugs ; oxytocin ,analgesics ,IV fluids ect.. * investigations as urine analysis for protein and acetone and volume.

  13. Management of labor using the partogram

  14. Normal Progress of Labor *latent phase : 8 hours or less . *active phase : progress of the cervical dilatation remains on the alert line or between the alert and the action lines ( 1cm/hour ). small doses of oxytocin or/and ARM may be needed for active management of labor. *second stage : reseanable rotation and descent of the presenting part within 1 h. or less .

  15. Abnormal (poor) Progress of Labor a. Prolonged Latent Phase: if extends 12 h (20h), in PG or 8h (14), in MG. b. Primary dysfunctional ( prolonged ) labor : slow cervical dilatation or poor descent . c. secondary arrest ( obstructed ) labor: of cervical dilatation in the 1st stage usually in the deceleration phase or arrest of the descent of the presenting part in the 2nd stage.

  16. 1= Prolonged latent phase. 2= primary dysfunctional labor ( protracted cervical dilatation). 3= primary dysfunctional labor ( protracted descent ). 5= secondary arrest of cervical dilatation. 6= secondary arrest of descent.

  17. ElectronicFetal Heart Rate Monitoring (EFM)

  18. Electronic fetal heart monitoring {EFM}: developed in the 1960s. is achieved by either : * internal or direct monitoring , by applying a bipolar electrode to the skin of the fetal scalp ,the cervix has to be dilated and membranes ruptured. * external or indirect monitoring. by using ultrasound ,usually by ; External toco dynamo metry with a pressure transducer placed on the uterus.

  19. Indications for EFM *low risk women with; normal RHR on auscultation , no meconium staining liquor and normal progress of labor are extremely unlikely to deliver an asphyxiated infants. Admission test : initial 20 minutes EFM screen in early labor is enough to predict the likelihood of subsequent fetal hypoxia.

  20. * high risk women; Maternal disorders: • hypertensive diseases. • diabetes mellitus. • renal diseases. • cardiac diseases. • APH. • RH isoimmunization.

  21. Labor complications : • dysfunctional labor ( slow progress). • oxytocin augmentation or induction . • preterm labor. • VBAC. Fetal complications : • IUGR. • previous SB. • meconium staining. • Post term pregnancy. • abnormal FHR on auscultation. • twins.

  22. Fetal Heart Rate Patterns A. Baseline FHR : * tachycardia. * bradycardia. * variability. B. Periodic FHR : * Accelerations. * decelerations. • early • prolonged • variable • mixed • late • sinusoidal

  23. Baseline FHR: * It is the rate recorded in between uterine contractions. * Normally 110 – 150 bpm. * usually assessed over 15 minute interval during labor.

  24. Baseline tachycardia * It is a FHR above 150 - 160 bpm. * causes : • Fetal hypoxia. • Maternal or Fetal infection. • Drugs as ritodrine and atropine. • Maternal hyperthyrodism. • maternal dehydration. • Fetal anemia . • Fetal cardiac arhythmias.

  25. Baseline tachycardia

  26. Baseline bradycardia * It is a FHR less than 90 -110 bpm. * It may be mild ( 90 -110 bpm. ) or severe ( < 90 bpm. ). * persistent mild fetal bradycardia is usually benign. While severe bradycardia caused by fetal congenital heart block.

  27. Baseline bradycardia

  28. Variability * baseline or beat - to -beat variability is controlled by the balance between the sympathetic and parasympathetic nervous control of the heart. * normal variability is 5 – 25 bpm. * it is reduced < 5 bpm. in : • fetal hypoxia. • physiological during fetal sleep cycles. • drugs as ;dethadine ,barbiturates and atropine.

  29. normal beat to beat variability

  30. Reduced beat to beat variability

  31. Poor or absent variability

  32. Periodic FHR periodic changes in the FHR may be either : A. Accelerations : * is associated with ; • fetal movements. • uterine contractions. * are considered benign and its presence indicates a well oxygenated fetus.

  33. normal FHR accelerations associated with fetal movements ( reactive NST )

  34. normal FHR accelerations with uterine contractions

  35. B. decelerations : classically 3 well defined decelerations are described ; early ,variable and late. 1. Early deceleration : • this deceleration have a uniform shape ( bell), starts early in the contraction and mirrors it. • the magnitude of the deceleration is <40bpm. • cause : head compression mediated by vagal reflex. • it occurs during the active phase , they are benign .

  36. early deceleration

  37. 2.Variable deceleration : • it is the most common deceleration pattern. • it appears as abrupt fall and return in FHR, preceded and followed by small accelerations ( shoulders). • they are variable in shape V ,U or W shape , duration and timing. • the magnitude is usually 50-80 bpm. • cause : cord compression. if it persists fetal hypoxia occurs. • mild variable deceleration ( last < 30 sec.) is benign. moderate (last 30 -60 sec.) and severe (last > 60 sec.) indicates fetal hypoxia.

  38. Variable deceleration.

  39. 3. Late deceleration: • it have a similar shape and magnitude as early deceleration but their timing is different. • it start as the contraction peaks and does not return to the baseline FHR until after the end of the contraction. • cause : fetal hypoxia.

  40. Late decelerations

  41. Prolonged deceleration

  42. (up) Sinusoidal pattern, (down) Pseudo-sinusoidal

  43. Interpretation of FHR Patterns First identify : 1. baseline FHR. 2. presence , reduced or loss of variability. 3. presence of accelerations or decelerations. 4. if there is decelerations ,its frequency ,type and severity .

  44. Types of FHR patterns: a. reassuring or normalpattern. * Baseline fetal heart rate between 110 and 150 bpm. * Good variability. * Presence of accelerations . * Absence of significant decelerations.

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