Fetal Assessment During Labor

Fetal Heart Rate (FHR) Monitoring during labor

1. Fetal Assessment During Labor 1

2. Fetal Assessment During Labor We asses: Amniotic fluid Fetal Heart Rate (FHR): the primary assessment 2

3. 1. Amniotic fluid analysis: Amniotic fluid should be clear, colorless or pale yellow, when the membranes rupture. Cloudy fluid with foul smell → Infection Green Fluid → Fetal Hypoxia due to meconium (the first stool of the baby) Blood streak → Hemorrhage 3

4. 2. Fetal Heart Rate (FHR ) Monitoring Is the measuring of the fetus’s heart rate during the labor by using a special instruments. Types and methods of fetal heart monitoring: Intermittent auscultation Electronic fetal monitoring (EFM) 4

5. 5 Intermittent Auscultation technique: Auscultation is a method of listening to the fetal heartbeat for about 60 seconds by using a fetal stethoscope ( fetoscope or Pinard ), or a hand-held Doppler ultrasound device .

6. 6 While listening to the heartbeat, the doctor also palpates the mother’s uterus by placing a hand on the abdomen to measure the contractions. Intermittent auscultation should be done: Every 15-30 minutes during the active phase of 1 st stage, Every 5-15 minutes during the pushing phase of 2 nd stage.

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8. 8 Fetoscope Pinard Hand-held Doppler

9. 9 2. Electronic fetal monitoring (EFM ) EFM is an electronic monitor used to continuously measures the fetus’s heart rate and using a pressure sensor to monitor the mother’s contractions at the same time. There are 2 types of EFM: External monitoring Internal monitoring

10. 10 Indications for EFM Pregnancy complications (Diabetes, preeclampsia…) Pre-term labor. Previous caesarean. The baby is smaller than expected. Multiple fetuses. Overweight mother. Prolonged 1 st stage of labor. The amniotic fluid contains significant amounts of meconium (The baby's first poo). Induction of labor. A high temperature mother.

11. 11 External monitoring: Measuring the heart rate through an ultrasound device, and measuring the contractions by using a pressure sensor; both devises are held against the mother's belly with a belt. The reading of external monitoring is affecting by changing position.

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13. 13 Internal monitoring: Measure the heart rate through a wire called (electrode) contains a needle, inserted through the vagina and cervix, and placed under the baby's scalp. And measuring the contractions with a thin tube inserted into the uterus. Internal monitoring can be done only after the cervix has dilated to at least 2cm and the amniotic sac has ruptured.

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15. 15 FHR patterns Normal Pattern: Baseline FHR = 120 – 160 bpm (Beat/min.) Tachycardia: Baseline FHR above 160 bpm Bradycardia: Baseline FHR less than 120 bpm * Baseline FHR = 10 minutes*

16. 16 Contraction Pattern Normal contractions: 5 or fewer contractions in 10 minutes lasting about 60 seconds in the active phase. Contraction intensity: 30 mmHg in early labor to 70 - 90 mmHg in the second stage.

17. 17 Normal fetal heart rate with moderate variability Normal Contraction

18. 18 Causes of Tachycardia Tachycardia is a FHR above 160 bpm that lasts for at least 10 minutes Mother fever Mother and fetus infection Mother dehydration Mother and fetus anemia Fetus hypoxemia Fetal tachyarrhythmia Fetus cardiac abnormalities Causes of Bradycardia Fetal bradycardia is a baseline FHR of less than 110 bpm that lasts for at least 10 minutes Mother Dehydration Mother Hypotension Rupture of uterus or vasa previa Placental abruption Medications such as anesthetics Fetal hypoxia Late or profound hypoxemia Umbilical cord occlusion Fetal bradyarrythmias

19. 19 Baseline FHR Variability The normal fetal heart rate baseline is from 120 to 160 BPM and has variability usually with a range of 3-5 bpm from the baseline . Characteristics: Undetectable (less than 5 bpm) Minimal (up to 5 bpm) Moderate (6 to 25 bpm) Marked (more than 25 bpm) Abnormal if lasts over 60 min.

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21. 21 Periodic changes Periodic changes are accelerations or decelerations in the FHR that are in relation to uterine contractions and persist over time.

22. 22 Accelerations Accelerations are transient increases in the FHR about (15 bpm) above baseline for about (15 sec. to less than 2 min.) and then return normally to the base line. Prolonged acceleration: Increase in heart rate lasts for 2 to 10 minutes. The presence of accelerations is a sign of normal fetus, because they are usually associated with fetus stimulation, such as fetal movement, vaginal examinations, and contractions.

23. 23 Fetal heart rate accelerations

24. 24 Decelerations Transitory decrease in the FHR from the baseline . Early decelerations: the onset and return of a deceleration is match to the contraction Variable decelerations: variable in the time, intensity, and duration of a deceleration Late decelerations: the fetal heart rate return to the baseline after the end of the contraction

25. 25 Management Early decelerations: No intervention is necessary, just keep watching . It happen due to uterine contractions. Variable decelerations : Reposition of the mother, oxygen mask, and stop oxytocin. It happen due to Umbilical cord occlusion and problems. Late decelerations : Reposition of the mother, oxygen mask, stop oxytocin, give IV. It happen due to reduction in O 2

26. 26 Early decelerations

27. 27 Variable decelerations

28. 28 Late decelerations

29. 29 What happens if the fetal heart rate pattern is abnormal? An abnormal fetal heart rate may mean that the fetus is not getting enough oxygen or that there are other problems. We should first try to find the cause. Steps can be taken to help the baby get more oxygen, such as change the position of the mother, and giving her an oxygen mask. If the procedures do not work, and the fetus still has a problem, we should deliver the baby immediately. In this case, the delivery of the baby is more likely to be by cesarean birth or with forceps or vacuum delivery.

30. 30 Forceps delivery Vacuum delivery