ANTENATAL FETAL ANTENATAL FETAL MONITORINGMONITORING

SALWA NEYAZISALWA NEYAZI

CONSULTANT OBESTETRICIAN GYNECOLOGISTCONSULTANT OBESTETRICIAN GYNECOLOGIST

PEDIATRIC & ADOLESCENT GYNECOLOGISTPEDIATRIC & ADOLESCENT GYNECOLOGIST

ANTENATAL FETAL MONITORINGANTENATAL FETAL MONITORING

WHAT IS THE AIM OF MONITERING?WHAT IS THE AIM OF MONITERING?To To perinatal morbidity & mortality (outcome of asphyxia) perinatal morbidity & mortality (outcome of asphyxia)It should guide future care It should guide future care

ReassuranceReassuranceMore frequent testingMore frequent testingAdmission to hospitalAdmission to hospitalDelivery Delivery

WHICH PATIENTS ARE EXPECTED TO BENEFIT FROM WHICH PATIENTS ARE EXPECTED TO BENEFIT FROM THIS TESTING?THIS TESTING?

Patients at riskPatients at riskIUGRIUGR fetal movementfetal movementPost-term pregnancy > 42 wkPost-term pregnancy > 42 wkPreeclampsia / Ch HPTPreeclampsia / Ch HPT

DMDMInsulin requiring GD Insulin requiring GD PPROMPPROMCh (stable) abruptionCh (stable) abruption

ANTENATAL FETAL MONITORINGANTENATAL FETAL MONITORING

WHEN TO INITIATE TESTING?WHEN TO INITIATE TESTING?Insulin requiring GD/DM Insulin requiring GD/DM 32- 36 wk 32- 36 wkPost dated pregnancy Post dated pregnancy 41-42 41-42 fetal movement fetal movement instantly instantly Other conditions Other conditions variable according to severity & GA variable according to severity & GA

WHAT IS THE FREQUENCY OF TESTING?WHAT IS THE FREQUENCY OF TESTING?Depends on the perceived risk of fetal asphyxiaDepends on the perceived risk of fetal asphyxiaIf risk persists If risk persists 1-2 /wk 1-2 /wkSome times daily in the premature fetus Some times daily in the premature fetus to aid timing of to aid timing of delivery “max GA” / avoid significant morbiditydelivery “max GA” / avoid significant morbidity

ANTENATAL FETAL MONITORINGANTENATAL FETAL MONITORING

WHAT ARE THE AVAILABLE TESTING TECHNIQUES?WHAT ARE THE AVAILABLE TESTING TECHNIQUES?

Fetal movementFetal movement

Nonstress CTGNonstress CTG

Contraction stress testContraction stress test

BPPBPP

Fetal umbilical artery Doppler Fetal umbilical artery Doppler

METHODS OF ANTENATALTESTING

Sadovsky

Fetal movement

Cardiff

Routine countingStandard inquiry FMSelective counting ↑ risk +

No difference in mortality

METHODS OF ANTENATALTESTING

Non stress test Stress test

CTG

Non reactive Reactive

ContinueAnother

20 Min

Non reactive

BPP

50% ofN fetus

<28

+ve -veSuspecious

Perinatal MortalityWithin 1wk

1.2/1000 birth

METHODS OF ANTENATALTESTING

BPP

Amnioticfluid

Tone FBM30 SEC

3FM

NST

N AF AF

6/10 8/10

+ +

Equivocal

Deliver

Repeat

6/10

Term

PreT Intensive Survilence

Cerebral pulsy risk4.7/10001.3/1000

METHODS OF ANTENATALTESTING

UmbilicalDoppler

Only for ↑ risk

IUGRPET

CH HPT

End diastolicFlow

Absent

Reversed N

PNM75%

PNM41%

PNM4%

PNM38%

In ↑ risk

INTRAPARTUM FETAL INTRAPARTUM FETAL MONITORINGMONITORING

INTRAPARTUM FETAL MONITORINGINTRAPARTUM FETAL MONITORING

WHAT ARE THE METHODS AVAILABLE FOR FETAL WHAT ARE THE METHODS AVAILABLE FOR FETAL MONITERING IN LABOR? MONITERING IN LABOR?

Electronic fetal heart monitoring Electronic fetal heart monitoring External or internalExternal or internal

Intermittent auscultation Intermittent auscultation

Fetal scalp sampling Fetal scalp sampling PH determination PH determination

Color of the amniotic fluidColor of the amniotic fluid

WHAT IS THE AIM OF MONITERING ?WHAT IS THE AIM OF MONITERING ?

To To the risk of intrapartum fetal asphyxia the risk of intrapartum fetal asphyxia

Improve perinatal morbidity & mortalityImprove perinatal morbidity & mortality

INTRAPARTUM FETAL MONITORINGINTRAPARTUM FETAL MONITORING

All Pt inActive labor

Intermittentascultation

ContiuousCTG

No difference inNeonatal outcome

+ PV 40%False + 50%

False – 1.4%

Dublinseizures

CONTINUOUS FHR MONITORINGCONTINUOUS FHR MONITORING

External Internal

ADVANTAGESDISAVANTAGES

Rupture of membranesScalp infection

Transmission of Hepatitis

Chance of pickingMaternal pulse

True representation ofVariability

Technically easier

CONTINUOUS FHR MONITORINGCONTINUOUS FHR MONITORING

WHAT ARE THE FEATURES OF A NORMAL TRACING?WHAT ARE THE FEATURES OF A NORMAL TRACING?

Baseline 110-160 BPMBaseline 110-160 BPM

2 Accelerations > 15 BPM > 15 sec / 20 min trace2 Accelerations > 15 BPM > 15 sec / 20 min trace

Variability > 5 BPM (10-25)Variability > 5 BPM (10-25)

No decelrations No decelrations

ABNORMALITIES OF FHR TRACING

Decelrations

Variability

TachycardiaBradycardia

<5BPM

>160 BPM

For 20 MinN

For 40 MinSuspicious

For 90 MinAbnormal

Sleepcycle

<100 BPM>3 Min

Absence of accelerations

HypoxiaNarcotics / Mg Sulfate

CNS abn

Cord prolapse ↑↑ Uterine cont

Maternal BPRapid descent in laborAbruptionCongenital heart block

InfectionMaternal fever

RitodrinFetal anemiaFetal hypoxia

1st feature to indicate Fetal hypoxia

DECELRATIONS

PhysiologicFetal head compression

Mirror image of the contractionFH<60 BPM< 60 sec

Early Late

Variable

Cord compressionNot related to the cont

Variable duration & degree ofFHR depresiion

After the contractionUteroplacental insufficiency

Fetal asphyxia/acidosisWorst prognosis

MANAGEMENT OF FHR ABNORNMALITIESMANAGEMENT OF FHR ABNORNMALITIES

WHAT ARE THE FACTRS THAT INFLUENCE OUR WHAT ARE THE FACTRS THAT INFLUENCE OUR MANAGEMENT?MANAGEMENT?

ParityParity

Cx dilatationCx dilatation

Rate of progress of labourRate of progress of labour

Associated high risk factorsAssociated high risk factors

-Thick meconium-Thick meconium

-Scanty amniotic fluid-Scanty amniotic fluid

-IUGR-IUGR

-IU infection -IU infection

-Preterm-Preterm

-Postdates-Postdates

MANAGEMENT OF FHR ABNORNMALITIESMANAGEMENT OF FHR ABNORNMALITIES

WHAT ARE THE 1WHAT ARE THE 1STST STEPS OF MANAGEMENT? STEPS OF MANAGEMENT?P/V P/V To asses progress of labor To asses progress of laborChange of position of the mother Change of position of the mother Lt lateral position Lt lateral position Oxygen by face maskOxygen by face maskRehydration / IV fluidsRehydration / IV fluidsStop SyntocinonStop SyntocinonRitodrin in case of hyperstimulationRitodrin in case of hyperstimulation

WHAT IS SUPINE HYPOTENSION SYNDROME?WHAT IS SUPINE HYPOTENSION SYNDROME?

MANAGEMENT OF FHR ABNORNMALITIESMANAGEMENT OF FHR ABNORNMALITIES

Variability>40 Min

ABNORMALFHR

Variable Decelerations

Abnormalbaseline

AbsenceOf Accelerations

+1

SuspeciousFHR

FBS

Late Decelrations

V DWith mnious

signs

AbsenceOf Accelerations

+Variability> 90 Min

Bradicardia

Sinusoidal

Shallow dec+ Var + Absence of accelerations

Deliver

FBS

≥7.2 <7.2

Persistant FHR

Abnormality

Repeat20-30 Min

Deliver

CSInstrumental

delivery