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Fetal Distress in Labour

ZULFADLI
You are the obstetrician on call for labour
ward when this CTG arrives by fax.
A CTG arrives from labour ward
Analyse and classify this CTG
What is the degree of urgency that
requires your further evaluation of this
patient
What further information do you require
About this patient?
About the resources available to you
A CTG arrives from labour ward
Baseline FHR
Possibly 140 bpm at the beginning and probably 150 at the
end of this recording
Short term variability 5 bpm
Within normal limits but not totally reassuring

There are no accelerations present


Atypical variable decelerations
With most contractions, to a depth of 100 bpm with onset,
nadir and recovery >20sec beyond the contractions and
lasting up to 2 minutes
Tocographic evidence of excessive uterine
activity
This is a pathological CTG (RCOG 2007
classification)
Further information required
Are there any risk factors
for fetal hypoxaemia
Any other signs of fetal
distress
The stage of labour
The experience of the
person caring for this
patient
Access to scalp sampling
Access to theatre
Paediatric resources
Further information required
Are there any risk factors Nullipara at 41.5w
for fetal hypoxaemia undergoing induction of
Any other signs of fetal labour after a normal
distress pregnancy
The stage of labour
No liquor with attempted
amniotomy. Oxytocin 12
The experience of the mU/min
person caring for this
patient
3 cm dilated and 50%
effaced
Access to scalp sampling In the care of a midwife
Access to theatre No scalp sampling
Paediatric resources available
Theatre doing an
orthopaedic case
Specialist paediatrician on
call. Level 2 nursery
List and discuss the causes of fetal
heart rate decelerations
Maternal hypotension
Cord prolapse and
compression
Uterine
hypercontractility
Uteroplacental
insufficiency
Maternal drugs
Acute events
Second stage labour
List and discuss the causes of fetal
heart rate decelerations
Maternal hypotension Can be caused by supine
position, epidural
anaesthesia or drugs that
lower BP
Correct by rolling the
patient on her side and
provide IV fluids by rapid
infusion
Adrenergic agents are
sometimes used by
anaesthetists to correct
spinal hypotension
List and discuss the causes of fetal
heart rate decelerations
Cord prolapse and Cord prolapse occurs
compression with prematurity, high
presenting part or
malpresenation
Cord compression occurs
with oligohydramnios +/-
IUGR
May be recognised in its
early stages by an
acceleration deceleration-
type CTG or variable
decelerations
Immediate VE to exclude
obvious cord presentation
or prolapse is desirable
List and discuss the causes of fetal
heart rate decelerations
Uterine hypercontractility Occurs in up to 40% of labours
stimulated with oxytocin >12
mU/min
May be due to a high baseline
tone, frequent or prolonged
contractions
Is difficult to diagnose using
external tocography
Takes up to 45 minutes to
recover after cessation of
oxytocin
Can also occur after vaginal or
oral prostaglandins and
spontaneously in a few
multigravida
List and discuss the causes of fetal
heart rate decelerations
Uteroplacental insufficiency Usually associated with a
pregnancy at risk e.g.
hypertension, small for dates,
smoking, recurrent APH etc.
Classically causes late
decelerations
May be compounded by cord
compression with
oligohydramnios
So severe variable
decelerations or other CTG
signs of fetal acidosis such as
tachycardia or reduced short
term variability may occur
List and discuss the causes of fetal
heart rate decelerations
Maternal drugs Sedative drugs and
narcotics cause reduced
short term variability rather
than decelerations

But a bolus of local


anaesthetic reaching the
fetal myocardium can cause
bradycardia

And this can occur with


paracervical block and
sometimes epidural
anaesthesia
List and discuss the causes of fetal
heart rate decelerations
Acute events e.g. Usually associated with
Placental abruption profound and prolonged
Uterine rupture bradycardia
Fetal haemorrhage
Abruption usually
Maternal collapse from associated with PV bleeding
eclampsia, embolism, high Dark bleeding from vasa
spinal etc. previa can be tested for
fetal haemoglobin
Uterine rupture practically
never occurs in a
nulliparous patient
Maternal collapse usually
self evident when priority
should be given to maternal
resuscitation
List and discuss the causes of fetal
heart rate decelerations
Second stage labour Decelerations are
common in the second
stage of labour
Due to head compression
+/- any contribution from
cord entanglement &
compression
The depth and width of
decelerations, recovery
after dips and nature of
any interval CTG is
helpful in assessment
Plus the clinical
background more likely
to be significant in the
fetus at risk
You assess this patient 12 min later. Oxytocin infusion has
ceased. There is no improvement in the CTG. The midwife
reports fresh meconium. What do you do next? Why?
Reassure the patient
Quickly evaluate any
antenatal record that
is available
Perform abdominal
and vaginal
examination
Attach a scalp clip
Reassure the patient
You assess this patient 12 min later. Oxytocin infusion has
ceased. There is no improvement in the CTG. The midwife
reports fresh meconium. What do you do next? Why?
Reassure the patient Maternal anxiety reduces
uterine perfusion
It is desirable to quickly
establish rapport and
cooperation with the
patient
It is also desirable to
strengthen team
performance by taking
charge
You assess this patient 12 min later. Oxytocin infusion has
ceased. There is no improvement in the CTG. The midwife
reports fresh meconium. What do you do next? Why?
Quickly evaluate the AN If all the information is readily
record (if possible) available in a format familiar to
you then you can quickly look
for risk factors for fetal hypoxia
Assists is interpreting the CTG
and assessing fetal reserve
Provides cues that may assist
in patient communication or
cooperation e.g. first name,
age, status, history of sexual
abuse etc.
Any contraindication to scalp
clip such as HIV?
You assess this patient 12 min later. Oxytocin infusion has
ceased. There is no improvement in the CTG. The midwife
reports fresh meconium. What do you do next? Why?
Perform abdominal and Requires removal of
vaginal examination abdominal straps
Exclude abruption, assess
Attach a scalp clip fetal size, position and how
much head is palpable in the
hope that immediate assisted
delivery may be possible
Exclude cord prolapse and
presentation, assess stage of
labour and how fast the
process is going
A scalp clip is the best method
of FHR assessment
And an acceleratory response
to this trauma would be
reassuring
No antenatal records available. Mother anxious but cooperative.
Uterus NAD & relaxing. EFW average. Head 2/5 palpable, back
to the left. Cx 4 cm & effaced. Head at spines -1, LOT. No FH
response to scalp clip attachment. CTG deteriorating wider
deeper decelerations & variability <5 bpm
What is the positive
predictive value of this
CTG for fetal acidosis

What would be the


optimal management of
this patient
No antenatal records available. Mother anxious but cooperative.
Uterus NAD & relaxing. EFW average. Head 2/5 palpable, back
to the left. Cx 4 cm & effaced. Head at spines -1, LOT. No FH
response to scalp clip attachment. CTG deteriorating wider
deeper decelerations & variability <5 bpm
What is the positive o With the exception of a
predictive value of this pre terminal CTG this test
CTG for fetal hypoxia has no better than 50%
PPV for fetal hypoxia and
What would be the acidosis
optimal management of o Fetal scalp sampling for
this patient pH or lactate. Lactate
requires a smaller blood
sample, cheaper & more
robust equipment & is
less prone to interference
from exposure to air
There are no facilities for scalp sampling. You cannot access a
theatre for Caesarean for 45 60 minutes. List and discuss the
pros and cons of the various options for intrauterine
resuscitation that you may consider in the interim.

Maternal oxygen
administration
Uterine tocolysis
IV Fluids
Betamimetic drugs
Nitroglycerin or Nifedipine
Amnioinfusion
There are no facilities for scalp sampling. You cannot access a
theatre for Caesarean for 45 60 minutes. List and discuss the
pros and cons of the various options for intrauterine
resuscitation that you may consider in the interim.

Maternal oxygen Administration in short


administration bursts (up to 10 min) has
been shown by fetal
oximetry to improve fetal
oxygenation
But animal studies
suggest that it can be
detrimental in the longer
term because it causes
uterine vasoconstriction
There are no facilities for scalp sampling. You cannot access a
theatre for Caesarean for 45 60 minutes. List and discuss the
pros and cons of the various options for intrauterine
resuscitation that you may consider in the interim.

Uterine tocolysis The rapid IV infusion of 250


IV Fluids 500 ml of crystalloid causes
Betamimetic drugs 20 min of uterine diastole. This
can be useful esp. if maternal
Nitroglycerin or Nifedipine
hypotension is contributing to
reduced uterine perfusion
RCTs of intrauterine
resuscitation with
betamimetics demonstrate
improved neonatal outcomes
without significant maternal
risk
Anecdotal reports suggest
sublingual nitroglycerin and
nifedepine can be similar
There are no facilities for scalp sampling. You cannot access a
theatre for Caesarean for 45 60 minutes. List and discuss the
pros and cons of the various options for intrauterine
resuscitation that you may consider in the interim.

Amnioinfusion RCTs of amnioinfusion for


meconium or suspected
cord compression show
improved CTGs, reduced
rates of CS and improved
neonatal outcomes
But these are restricted to
settings without standard
peripartum surveillance
No effect on overall
perinatal mortality has been
demonstrated
And maternal risks remain
incompletely explored

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