Electronic Fetal Monitoring Prof Diana du Plessis Independent Midwifery Consultant 2017 diana.duplessis@mweb.co.za www.dianaduplessis.co.za

Why fetal heart monitoring? Introduction Steady increase in the number of malpractice claims in especially midwifery care Eruption of court cases over the last 4 years Most court cases are the result of Cerebral Palsy children

News headlines: Hospital horrors costing SA plenty

Why do we lose court cases? Lack of assessment Partograph Foetal surveillance Lack of interpretation Inability to resuscitate

Foetal surveillance The FHR is under constant and minute adjustment in response to the constant changes in the fetal environment and external stimuli

The principle aim of foetal surveillance: To prevent adverse perinatal outcomes as a result of foetal metabolic acidosis Used as an indication of whether or not the foetus is well oxygenated FHR monitoring does not provide evidence of the neurological status

CTG Features in labour FHR pattern, level of activity and muscular tone of foetus are all sensitive to hypoxemia and acidemia FHR is controlled by CNS and mediated by sympathetic and parasympathetic nerve impulses originating in the brain stem The presence of accelerations and foetal movement is believed to be an indicator of adequate oxygenation Factors [prematurity, sleep cycle, medication, foetal CNS abnormalities] impact biophysical parameters

Foetal surveillance includes: CFM which measures both FHR and contractions Intermittent auscultation of foetal heart Foetal blood sampling for indications of metabolic acidosis [pH and or lactate]

Consensus statement 1 CFM In the absence of risk factors – CFM has no proven benefits May increase the intervention rate in a normal spontaneous labour Increase the rate of C/S

Before, during and after a contraction Consensus statement 2: The fetal heart rate should be evaluated in relation to the uterine contractions during the intra partum period Before, during and after a contraction

Why? Uterine contractions Reduces placental blood flow Reduction in fetal oxygenation

Deviation 1: Contractions Basal tone: 10-15 mmHg (Resting tone) Intensity: 40-60 mmHg (How strong?) Duration: 30 - 90 seconds (How long?) Frequency: 2 - 5 in 10 minutes (How often?)

Consensus statement 3: intermittent auscultation Use in healthy women at low risk for complications Doppler more reliable than a Pinard Confirm foetal movement Document findings including when accelerations and decelerations are heard Palpate maternal pulse

Deviation 1b: Maternal pulse Baseline maternal HR is significantly lower than baseline FHR Maternal “accelerations” More rounded and uniform Increases at beginning of contraction or pushing effort Foetal accelerations: Differ in duration Have irregular shape Are asymmetric Occur at variable intervals

Example of maternal pulse

explanation Although this appears to be a bradycardia, this is registration of the maternal pulse through a dead baby. A typical contraction pattern of placenta abruption is present (high frequency, low amplitude

Deviation 2: Risk factors Abnormal NST, Doppler, ultrasound IUGR Oligo/polyhydramnios Malpresentations PROM C/S Increased BMI Maternal age Maternal illness IOL Abnormal CTG Regional anaesthesia Bleeding Maternal pyrexia MSL Absent liquor Prolonged labour Preterm Antenatal Intrapartum

Consensus statements 4: duration and frequency of auscultation Evidence for frequency and duration of auscultation from clinical trials are not available Before during and after contractions – at least 1 minute Every 15-30 minutes in active phase Second stage: every 5 minutes

When to transition to cfm: IOL or augmentation Transfer from MOU to hospital Development of intrapartum complications MSL Bleeding Maternal pyrexia Baseline lower than 110 bpm or > 160 bpm Any deceleration after a contraction

Consensus statement 5: nursing management principles Review CTG-tracing every 15-30 minutes Interpret systematically: Contractions Baseline [variability, accelerations, decelerations] Other findings and information [sleep pattern] Category of tracing Plan of action Differentiate maternal pulse

Machine setting Principle 2 Paper speed of 1 cm per minute Validate date and time settings

CTG-labelling and documentation Principle 3 Name Hospital number Date and time Maternal observations Intrapartum events Interpretation of tracing Date; time and signatures

Communication of information Principle 4 Keep mother and doctor informed Obtain assistance if needed Include CTG interpretation during handover Write short notes in progress reports Do not write “reactive”

Reactive heart pattern [a] Baseline of between 120-160 bpm [b] Normal variability of more than 5 bpm [i] Absence of decelerations [ii] At least 2 accelerations with an amplitude of 15 bpm and a duration of 15 seconds Does not have the characteristics of either the reactive or the pathological patterns Reactive heart pattern Non-reactive pattern

Deviation 3 The baseline A resting FHR not a sleeping rate The normal FHR: 120 - 160 bpm taken over 5- 10 minutes The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes Prematurity, maternal anxiety and maternal fever may increase the baseline rate Foetal maturity decreases the baseline rate

Why? Progressive vagal dominance occurs As the foetus approaches term Results in a gradual decrease in the baseline FHR

Vagus nerve Influence the FHR in response to Almost any stressful situation in the foetus Hypoxia Uterine contractions Foetal head compression Perhaps foetal grunting or Defecation

Deviation 4: Variability Minor fluctuations in FHR of more than 5 beats per minute This indicates a well- perfused CNS

Interpretation?

Conclusion: Normal Foetal Heart Tracing Good beat to beat variability (alterations in baseline over 1 min) Reassuring : Accelerations more than 15 beats above baseline during fetal movement and some contractions

Example of poor variability If associated with foetal distress: Turn mother on her side Give oxygen by face mask If associated with drugs: Administer Narcan to mother before birth

Storing of information Principle 6 Keep original Make photocopies or scan when there are adverse outcomes Death Apgar score at 5 min < 5 Active resuscitation needed ICU admissions

finally Confirmatory CTG Abnormal Problem resolved Normal Baseline Variability; Accelerations Decelerations Abnormal Reversible causes Cord compression Uterine hyperstimulation Maternal pyrexia Inadequate CTG quality Problem resolved No medical assistance expedite birth CFM Yes CFM and reassess in 30 minutes

DO NOT PUSH FOR A VAGINAL BIRTH AT ALL COST THE END