2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Name: 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Uploaded: 2017-07-11T01:51:38+00:00
Duration: PTM25S56
Channel: Shavonne Spencer
Description: 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
FIGO INTRAPARTUM FETAL MONITORING COURSE Safe Motherhood and Newborn Health Committee - FIGO Coordination + texts: Diogo Ayres-de-Campos Illustrations: Dimitri Santos

INTRODUCTION 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

1985 IJOG 1987;25:159-67 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO guidelines Wide consensus Common terminology, accessible language Simple, objective, easy to remember Including management options Basis for research and progress Widespread clinical use 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO societies contacted to appoint one subject matter expert RCOG and ACOG contacted to appoint one co-author each for CTG chapter ICM invited to write the chapter on intermittent auscultation 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

34 experts appointed by national societies Daniel Surbek (Switzerland), Gabriela Caracostea (Romania), Yves Jacquemyn (Belgium), Susana Santo (Portugal), Lennart Nordström (Sweden), Vladas Gintautas (Lithuania), Tullia Todros (Italy), Branka Yli (Norway), George Farmakidis (Greece), Sandor Valent (Hungary), Bruno Carbonne (France), Kati Ojala (Finland), José Luis Bartha (Spain), Joscha Reinhard (Germany), Anneke Kwee (Netherlands), Romano Byaruhanga (Uganda), Ehigha Enabudoso (Nigeria), John Anthony (South Africa), Fadi Mirza (Lebanon), Tak Yeung Leung (Hong Kong), Ramon Reyles (Philipines), Park in Yang (South Korea), Henry Murray (Australia and New Zealand), Yuen Tannirandorn (Thailand), Krishna Kumar (Malaysia), Taghreed Alhaidari (Iraq), Tomoaki Ikeda (Japan), Ferdousi Begum (Bangladesh), Jorge Carvajal (Chile), José Teppa (Venezuela), Renato Sá (Brasil). 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

16 experts invited based on literature search Lawrence Devoe (USA), Gerard Visser (Netherlands), Richard Paul (USA), Barry Schifrin (USA), Julian Parer (USA), Philip Steer (UK), Vincenzo Berghella (USA), Isis Amer-Wahlin (Sweden), Susanna Timonen (Finland), Austin Ugwumadu (UK), João Bernardes (Portugal), Justo Alonso (Uruguay), Ingemar Ingemarson (Sweden), Sabaratnam Arulkumaran (UK), Catherine Spong (USA), Edwin Chandraharan (UK). 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

3-round consensus Agreement to be included in panel No internal or external funding 10 months to prepare 18 months for the consensus 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Launched at the XXI FIGO World Congress of Gynecology and Obstetrics in Vancouver (Oct 2015) Published open access in the IJGO (Oct 2015) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Endorsed/supported by: 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

PHYSIOLOGY OF FETAL OXYGENATION AND THE MAIN GOALS OF INTRAPARTUM FETAL MONITORING 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Energy – aerobic metabolism glucose and O2 CO2 Maternal respiration Maternal circulation Placental perfusion Placental gas exchange Umbilical and fetal circulation 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Hypoxemia Reduced O2 concentration in arterial blood Reduced O2 concentration in tissues Hypoxia 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Anaerobic metabolism limited time 19× less energy lactic acid 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

H+ of lactic acid is transferred slowly across the placenta Metabolic acidosis (or acidemia)  arterial pH due to intracellular acids 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Circulating bases buffer intracellular acids (H+) Bicarbonate Hemoglobin Plasma proteins Metabolic acidosis can be quantified by pH and base deficit (depletion of buffers) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Metabolic acidosis Arterial pH < 7.00 and BD >12 mmol/l Arterial lactate > 10 mmol/l is an alternative (reference values may vary according to device) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

BDecf believed by some experts to be the best representative of H+ concentration of metabolic origin in the different fetal compartments BDblood slightly higher, can also be used 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Carbonic acid Bicarbonate CO2 + H2O H2CO HCO H+ Respiratory acidemia Reduction in arterial pH due to diminished placental CO2 elimination and H+ accumulation quickly reversible with re-establishment of placental gas exchange → no injury 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Metabolic acidosis (hypoxia) Respiratory acidemia (↓ gas exchange) Mixed acidosis Metabolic component has the greatest potential for harm, as it indicates  cell oxygen and energy 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Umbilical cord blood gas analysis
Only objective way of quantifying hypoxia/acidosis occurring just prior to birth (or newborn circulation in first min of life) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Umbilical blood sampling
innocuous to the newborn relatively inexpensive enhances experience with monitoring important medical-legal value Local guidelines and resources Recommended in suspected fetal hypoxia/acidosis and/or Apgars 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

SAMPLING TECHNIQUE Unnecessary to clamp the cord Sampling as soon as possible after birth (< 15 min) 1-2 ml from artery and vein, heparinised syringes Remove air bubbles, cap syringes, roll with fingers Analysis within 30 min 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Arterial blood reflects fetal acid-base status better than venous
vein arteries important to obtain blood from both artery and vein 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

arteries Sampling of wrong vessel Mixed sampling vein 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Arterial pH < vein pH Difference in pH < 0.02 Difference in pCO2 < 5 mm Hg (0.7 kPa) Same vessel or mixed sampling pCO2 < 22 mm Hg (2.9 kPa) Contamination from vein or from air 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

TERM BIRTHS Median art. pH = 7.25 (p5=7.06, p95=7.37) Median art. BDecf = 2.8 (p5=-1.8, p95=10.0) Median art. BDblood = 5.6 (p5=-0.28, p95=11.48) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

When placental gas exchange is preserved there is slow H+ transfer Hyperventilation  fetal pH Acidemia  fetal pH 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

↓ pH + ↓ energy production
Compromised cell function Cell death Organ damage Death 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Apgar scores Pulmonary, cardiovascular, neurological functions depressed when hypoxia/acidosis is sufficiently intense and prolonged to affect these systems 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Apgar scores Unaffected by minor hypoxia/acidosis Non-hypoxic causes:: prematurity birth trauma infection meconium aspiration congenital anomalies pre-existing neurological lesions medication administered to the mother early endotracheal aspiration 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

1-minute Apgar important to decide newborn resuscitation low association with intrapartum hypoxia 5-minute Apgar stronger association with short- and long-term neurological outcome and neonatal death 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Metabolic acidosis and low Apgars Vast majority recover quickly Few are of sufficient intensity and duration to cause death or long-term morbidity 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Hypoxic-ischemic encephalopathy (HIE) Neurological changes in first 48 h Metabolic acidosis Other system dysfunctions may occur Hypotonia: majority recover Seizures: 20-30% have sequelae Coma: majority with sequelae 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Cerebral palsy (spastic quadriplegic, dyskinetic ) 1-4 years Neurological complication more commonly associated with term intrapartum hypoxia 80-90% NOT caused by intrapartum hypoxia Infection Congenital diseases Metabolic, coagulation disorders Antepartum and post-natal hypoxia Birth trauma 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Normal oxygenation Transitory Hypoxemia Progressive Reversible Hypoxia Progressive HIE Grade 1 Grade 2 Grade 3 CP Fetal death 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

INTRAPARTUM EVENTS LEADING TO FETAL HYPOXIA/ACIDOSIS
2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Reversible causes 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Contractions compress myometrial vessels,
 placental perfusion and may compress the cord The interval between contractions is crucial to re-establish fetal oxygenation 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Excessive uterine activity Maternal pushing aggravates the effect  oxytocin, removing PGs Acute tocolysis (salbutamol, terbutaline, ritodrine, atosiban, nitroglycerine) Push on alternate contractions Turn mother on her side 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Cord compression Oxygenation may still recover between contractions
Low-lying cord, cord knot, nuchal cord Oxygenation may still recover between contractions 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Maternal supine position Aorto-caval compression by uterus Turn mother on her side 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Sudden maternal hypotension Following epidural or spinal analgesia Rapid fluid administration Efedrine IV bolus 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Irreversible causes 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Umbilical cord prolapse Cord compression Major placental abruption Blood loss,  gas exchange Uterine rupture Blood loss,  gas exchange 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Fetal hemorrhage Ruptured vasa praevia, fetal-maternal hemorrhage Expedite delivery 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Maternal causes 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Maternal cardio-respiratory disfunction Severe asthma, cardiorespiratory arrest, thromboembolism, etc Reversible nature? Speed of recovery? 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Mechanical complications
2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Shoulder dystocia, retention of the head Specific management 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Aims of intrapartum fetal monitoring Avoid adverse fetal outcome related to intrapartum hypoxia/acidosis Avoid unnecessary intervention, associated with increased maternal and fetal risks 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Fetal monitoring should indicate intervention at an early stage of hypoxia/acidosis in order to prevent adverse newborn outcomes 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

In order to avoid adverse outcome, fetal surveillance requires timely clinical response, and the ready availability of adequate equipment and trained staff 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

1st BREAK 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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