1. ANTENATAL FETAL MONITORING SALWA NEYAZI CONSULTANT OBESTETRICIAN GYNECOLOGIST PEDIATRIC & ADOLESCENT GYNECOLOGIST

2. ANTENATAL FETAL MONITORING WHAT IS THE AIM OF MONITERING? To  perinatal morbidity & mortality (outcome of asphyxia) It should guide future care Reassurance More frequent testing Admission to hospital Delivery WHICH PATIENTS ARE EXPECTED TO BENEFIT FROM THIS TESTING? Patients at risk IUGR  fetal movement Post-term pregnancy > 42 wk Preeclampsia / Ch HPT DM Insulin requiring GD PPROM Ch (stable) abruption

3. ANTENATAL FETAL MONITORING WHEN TO INITIATE TESTING? Insulin requiring GD/DM  32- 36 wk Post dated pregnancy  41-42  fetal movement  instantly Other conditions  variable according to severity & GA WHAT IS THE FREQUENCY OF TESTING? Depends on the perceived risk of fetal asphyxia If risk persists  1-2 /wk Some times daily in the premature fetus  to aid timing of delivery “max GA” / avoid significant morbidity

4. ANTENATAL FETAL MONITORING WHAT ARE THE AVAILABLE TESTING TECHNIQUES? Fetal movement Nonstress CTG Contraction stress test BPP Fetal umbilical artery Doppler

5. METHODS OF ANTENATALTESTING Sadovsky Fetal movement Cardiff Routine counting Standard inquiry FM Selective counting  ↑ risk + No difference in  mortality

6. METHODS OF ANTENATALTESTING Non stress testStress test CTG Non reactiveReactive Continue Another 20 Min Non reactive BPP 50% of N fetus <28 +ve-ve Suspecious Perinatal Mortality Within 1wk 1.2/1000 birth

7. METHODS OF ANTENATALTESTING BPP Amniotic fluid Tone FBM 30 SEC 3FM NST N AF  AF 6/108/10 ++ Equivocal Deliver Repeat 6/10 Term PreT Intensive Survilence  Cerebral pulsy risk 4.7/1000  1.3/1000

8. METHODS OF ANTENATALTESTING Umbilical Doppler Only for ↑ risk IUGR PET CH HPT End diastolic Flow Absent Reversed N PNM 75% PNM 41% PNM 4%  PNM 38% In ↑ risk

9. INTRAPARTUM FETAL MONITORING

10. WHAT ARE THE METHODS AVAILABLE FOR FETAL MONITERING IN LABOR? Electronic fetal heart monitoring  External or internal Intermittent auscultation Fetal scalp sampling  PH determination Color of the amniotic fluid WHAT IS THE AIM OF MONITERING ? To  the risk of intrapartum fetal asphyxia Improve perinatal morbidity & mortality

11. INTRAPARTUM FETAL MONITORING All Pt in Active labor Intermittent ascultation Contiuous CTG No difference in Neonatal outcome + PV 40% False + 50% False – 1.4% Dublin  seizures

12. CONTINUOUS FHR MONITORING External Internal ADVANTAGESDISAVANTAGES Rupture of membranes Scalp infection Transmission of Hepatitis  Chance of picking Maternal pulse True representation of Variability Technically easier

13. CONTINUOUS FHR MONITORING WHAT ARE THE FEATURES OF A NORMAL TRACING? Baseline 110-160 BPM 2 Accelerations > 15 BPM > 15 sec / 20 min trace Variability > 5 BPM (10-25) No decelrations

14. ABNORMALITIES OF FHR TRACING Decelrations  Variability Tachycardia Bradycardia <5BPM >160 BPM For 20 Min N For 40 Min Suspicious For 90 Min Abnormal Sleep cycle <100 BPM >3 Min Absence of accelerations Hypoxia Narcotics / Mg Sulfate CNS abn Cord prolapse ↑↑ Uterine cont Maternal  BP Rapid descent in labor Abruption Congenital heart block Infection Maternal fever Ritodrin Fetal anemia Fetal hypoxia 1 st feature to indicate Fetal hypoxia

15. DECELRATIONS Physiologic Fetal head compression Mirror image of the contraction  FH<60 BPM< 60 sec EarlyLate Variable Cord compression Not related to the cont Variable duration & degree of FHR depresiion After the contraction Uteroplacental insufficiency Fetal asphyxia/acidosis Worst prognosis

16. MANAGEMENT OF FHR ABNORNMALITIES WHAT ARE THE FACTRS THAT INFLUENCE OUR MANAGEMENT? Parity Cx dilatation Rate of progress of labour Associated high risk factors -Thick meconium -Thick meconium -Scanty amniotic fluid -Scanty amniotic fluid -IUGR -IUGR -IU infection -IU infection -Preterm -Preterm -Postdates -Postdates

17. MANAGEMENT OF FHR ABNORNMALITIES WHAT ARE THE 1 ST STEPS OF MANAGEMENT? P/V  To asses progress of labor Change of position of the mother  Lt lateral position Oxygen by face mask Rehydration / IV fluids Stop Syntocinon Ritodrin in case of hyperstimulation WHAT IS SUPINE HYPOTENSION SYNDROME?

18. MANAGEMENT OF FHR ABNORNMALITIES  Variability >40 Min ABNORMAL FHR Variable Decelerations Abnormal baseline Absence Of Accelerations + 1 Suspecious FHR FBS Late Decelrations V D With mnious signs Absence Of Accelerations +  Variability > 90 Min Bradicardia Sinusoidal Shallow dec +  Var + Absence of accelerations Deliver

19. FBS ≥7.2 <7.2 Persistant FHR Abnormality Repeat 20-30 Min Deliver CS Instrumental delivery