Intrapartum fetal assessment

Ahmad Zeiree bin Abdullah

Nur Insyirah bt Abdullah
CTG
Indication
Mother
Medical
iatrogenic
others
Fetus
IUGR
Meconium
Multiple
pregnancy
Breech
presentation
labour
augmentation
Epidural
Vaginal
bleeding
Fever
Classification
Baseline heart
rate
Heart rate
variability
Deceleration acceleration
Reassuring 110-160 >5 Absent present
Non reassuring 100-109/161
180
<5 for 40-90
mins
Early/variable/s
ingle prolonged
<3mins
Absence in
presence of
other findings
abnormal <100/>180/sin
usoid (S-
shaped) >10
minutes
<5 for >90mins
Late/atypical
variable/single
prolonged
>3mins
As above
-a normal CTG means that all four categories
are normal.
-Suspicious CTGs have 1 non-
reassuring feature.
-pathological is anything else i.e. >1 non-
reassuring/1 or >1 abnormal.
1 non reassuring feature
Inadequate quality Uterine hypercontractility
Maternal
Tachycardia/Pyrexia
Other relevant maternal
adverse factor
Suspicious
CTG
If the CTG trace is of inadequate
quality:
Check contact and connections of external
transducer.
Check contact and connections of fetal scalp
electrode (FSE), if being used.
Check maternal pulse and ensure not
recording this in error.
Consider use of FSE if not currently being used

If there is evidence of uterine
hypercontractility
Consider discontinuation of oxytocin, if being
used.
Check whether vaginal prostaglandins have
been utilised.
Consider use of terbutaline or other tocolytic
agents.

If there is maternal
tachycardia/pyrexia
Consider screening investigations and
empirical treatment for infection.
Consider treatment for maternal dehydration.
Consider the effect of tocolytics and
discontinuing them if this may be causing the
tachycardia.
Check maternal blood pressure (BP) and
consider 500 ml infusion of crystalloid if
indicated.

If there are other relevant maternal
adverse factors:
Check maternal position and, if supine, then move into
left lateral position.
Consider effect of recent vaginal examination.
Consider effect of recent bedpan use.
Consider effect of recent vomiting or vasovagal
episode.
Consider effect of recent siting or topping-up of
epidural analgesia infusion.
Check BP and, if low, give 500 ml infusion of crystalloid
if there are no contra-indications to this.

Pathological CTG
If fetal blood sampling is indicated/feasible:
Encourage the mother to use the left lateral
position and check BP, giving 500 ml
crystalloid if appropriate.
Proceed to fetal blood sampling with maternal
consent.
Decide further course on the basis of fetal
blood sampling results

If fetal blood sampling is not indicated or not feasible:
Use left lateral position and BP check with crystalloid
infusion as above.
Expedite delivery according to anaesthetic, paediatric and
experienced obstetric opinion.
Speed of delivery should take into account the severity of
FHR abnormalities and relevant maternal factors.
The current accepted standard is that expedited delivery
should occur within 30 minutes. The evidence base for this
recommendation, and its real-world practicality, have been
questioned. Most practitioners advocate that quick, safe
delivery is more important than rapid delivery.

Fetal Blood Sampling
Diagnostic test for fetal acidosis
Used to measure Blood pH and base excess

indication
Prolonged and
persistent early
decelerations
Persistent late/
variable decelerations
on CTG
Significant meconium
stained liquor (Grade
2/3) along with CTG
abnormality
Persistent fetal
tachycardia
Prolonged loss of
baseline variability
contraindication
Fetal bleeding
disorder
Vertical
transmission of
maternal infection
Severe fetal or
maternal distress

Ph results following fetal FBS
pH Interpretation Management
>7.25 Normal No treatment
7.20-7.25 Borderline Repeat in 30-60 minutes if
not delivery
<7.25 Abnormal Deliver by
forceps,ventouse or
ceasarian section as
appropriate
Base Excess Interpretation
<-6mEq/L Normal
-6.1 to -7.9 mEq/L Borderline
>-7.9 mEq/L Metabolic acidosis
Interpretation of results
CTG (4 features) pH Risk percentage
Normal <7.2 2%
1-2 abnormal <7.2 20%
2-4 abnormal <7.2 50%
complication
Fetal scalp hemorrhage
infection