1. Fetal Assessment

2. Litigation Cost of CTG Misinterpretation
In the ten years ( ) covered by the study, 300 claims involving alleged CTG misinterpretation were reported to the NHSLA. The total value of these claims is estimated to be in the region of £466million.
2,330,000,000,000 Toman, 2.3 trillion T or 2300 Billion T ( assuming 1£=5000 T)
Source: NHSLA

6. Screening for high risk pregnancy
History
* Age
*Social burden
*Smoking
*Past medical conditions e.g D.M, HTN
*Past Obstetric history

7. Fetal assessment
Aim: Ensure fetal wellbeing ( Identify patients at risk of fetal asphyxia)
To prevent prenatal mortality & morbidity

8. When to start fetal Assessment
** Risk assessed individually
**For D.M. fetal assessment should start from 32 weeks onward if uncomplicated
***If complicated D.M. start at 24 weeks onward
**For Post date pregnancy start at 40 weeks
**For any patient with decrease fetal movement start immediately
** Fetal assessment is done once or twice weekly

9. FETAL AND NEONATAL COMPLICATIONS OF ANTEPARTUM ASPHYXIA
Fetal Outcomes Neonatal Outcomes
Stillbirth Mortality
Metabolic acidosis at birth Metabolic acidosis
Hypoxic renal damage
Necrotizing enterocolitis
Intracranial haemorrhage
Seizures
Cerebral palsy

10. Small for gestational age fetus Decreased fetal movement
CONDITIONS ASSOCIATED WITH INCREASED
PERINATAL MORBIDITY/MORTALITY WHERE
ANTENATAL FETAL TESTING
MAY HAVE AN IMPACT
Small for gestational age fetus
Decreased fetal movement
Postdates pregnancy (>294 days)
Pre-eclampsia/chronic hypertension
Pre-pregnancy diabetes
Insulin requiring gestational diabetes
Preterm premature rupture of membranes
Chronic (stable) abruption

11. Cerebral Palsy
Cerebral palsy is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain.
Source: cerebralpalsy.org

12. Fetal Assessment Fetal movement counting Non stress test
Contraction stress test
Ultrasound fetal assessment
Umbilical Doppler Velocimetry

13. Fetal movement counting
Cardiff technique: *Done in the morning, patient should *calculate how long it takes to have 10 fetal movement **10 movements should be appreciated in 12 hours

14. Fetal movement counting
Sadovsky technique: -For one hour after meal the woman should lie down and concentrate on fetal movement -4 movement should be felt in one hour -If not , she should count for another hour -If after 2 hours four movements are not felt, she should have fetal monitoring

15. Non stress test
*Done using the cardiotocometry with the patient in left lateral position **Record for 20 minutes

16. Non stress test *The base line 120-160 beats/minute *Reactive:
At least two accelerations from base line of 15 bpm for at least 15 sec within 20 minutes
Non reactive:
No acceleration after 20 minutes- proceed for another 20 minutes

17. Non stress test
If non reactive in 40 minutes---proceed for contraction stress test or biophysical profile The positive predictive value of NST to predict fetal acidosis at birth is 44%

18. NST

19. A typical CTG output for a woman not in labour
A typical CTG output for a woman not in labour. A: Fetal heartbeat; B: Indicator showing movements felt by mother (caused by pressing a button); C: Fetal movement; D: Uterine contractions

20. NST

21. Contraction stress test
Fetal response to induced stress of uterine contraction and relative placental insufficiency Should not be used in patients at risk of preterm labor or placenta previa Should be proceeded by NST

22. Contraction stress test
Contraction is initiated by nipple stimulation or by oxytocin I.V.
The objective is 3 contractions in 10 minutes
If late deceleration occur-----positive CST

23. Interpretation of CTG
Normal Baseline FHR 110–160 bpm – Moderate bradycardia 100–109 bpm – Moderate tachycardia 161–180 bpm – Abnormal bradycardia < 100 bpm – Abnormal tachycardia > 180 bpm

25. Acceleration

26. Deceleration EARLY : Head compression LATE : U-P Insufficiency
VARIABLE : Cord compression
Primary CNS dysfunction

27. Early deceleration

28. Late deceleration

29. Variable Deceleration

30. Reduced Variability

31. Tachycardia Hypoxia Chorioamnionitis Maternal fever B-Mimetic drugs Fetal anaemia,sepsis,ht failure,arrhythmias

32. # Intrapartum Fetal Assessment

33. INDEX 1. Internal Electronic Fetal Hearth Rate Monitoring
2. External (Indirect) Electronic Fetal Heart Rate
3. Fetal Heart Rate Pattern
- Baseline Fetal Heart Activity

34. FETAL HEART RATE MONITORING
INTERNAL ELECTRONIC
FETAL HEART RATE MONITORING
Standard fetal monitor tracing of heart rate using fetal scalp electrode shown at top. Bottom two tracings represent cardiac electrical complexes detected from fetal scalp and maternal chest wall electrodes. Spiking of the fetal rate in the monitor tracing is due to the premature atrial contractions. (F=fetus; M=mother; PAC=fetal premature atrial contraction.)

35. FETAL HEART RATE MONITORING
INTERNAL ELECTRONIC
FETAL HEART RATE MONITORING
Placental abruption: The fetal scalp electrode detected heart rate first of the dying fetus. After fetal death, the maternal ECG complex is detected and recorded.

36. EXTERNAL (INDIRECT) ELECTRONIC FETAL HEART RATE MONITORING
◎ External detectors to monitor
fetal heart and uterine action
⇒ the necessity for membrane
rupture and uterine invasion
may be avoided
◎ FHR (fetal heart rate)
⇒ detected through the
maternal abdominal wall
using the ultrasound Doppler
principle

37. FETAL HEART RATE PATTERNS
• other cause
: congenital heart block and serious fetal
compromise
Fetal bradycardia measured with a scalp electrode in a pregnancy complicated by placental abruption and subsequent fetal death.

38. FETAL HEART RATE PATTERNS
B. Tachycardia
• mild : 161 ~ 180 bpm
severe : 181 bpm or more
• cause
maternal fever from amnionitis (m/c)
fetal compromise
cardiac arrhythmias
parasympathetic (atropine) or sympathomimetic
(terbutaline) drugs
• fetal compromise with tachycardia
⇒ concomitant heart rate deceleration (key point)

39. FETAL HEART RATE PATTERNS
2) Beat-to-beat variability
• an important index of cardiovascular function
• regulated largely by the autonomic nervous system
A. Short-term variability
• instantaneous change in FHR from one beat to the next
• time interval between cardiac systoles

40. FETAL HEART RATE PATTERNS
B. Long-term variability
• the oscillatory changes that occur during the course
of 1 minute
- result in waviness of the baseline
- normal frequency : 3 ~ 5 cycle/min

41. FETAL HEART RATE PATTERNS
• physiological and pathological processes
(affect or interfere with beat-to-beat variability)
① fetal breathing
② fetal body movements
③ advancing gestation
- after 30 wks,
fetal inactivity
→ diminished variability
activity
→ variability increased

42. FETAL HEART RATE PATTERNS
④ maternal acidemia
- cause decreased fetal beat-to-beat variability
⑤ analgesic drugs given during labor
- diminished variability
(narcotics, barbiturates, phenothiazines,
tranquilizer)
- MgSO4
: decrease variability only in the third hour of
the infusion
: be deemed clinically insignificant
: blunted the frequency of acceleration

43. FETAL HEART RATE PATTERNS
Grades of baseline fetal heart rate variability. (1) Undetectable, absent variability; (2) minimal≤5 bpm variability; (3) moderate (normal), 6 to 25 bpm variability; (4) marked,＞25 bpm variability; (5) sinusoidal pattern.

44. FETAL HEART RATE PATTERNS
3) Cardiac arrhythmia
◎ first suspected signs
- baseline bradycardia
- tachycardia
- abrupt baseline spiking (m/c)

45. FETAL HEART RATE PATTERNS
4) Sinusoidal heart rates
◎ true sinusoidal pattern
- observed with serious fetal anemia
• from D-isoimmunization
• ruptured vasa previa
• fetomaternal hemorrhage
• twin to twin transfusion
◎ insignificant sinusoidal pattern
• administration of meperidine, morphine, alphaprodine,
and butorphanol
• amnionitis, fetal distress, and umbilical cord
occlusion

46. FETAL HEART RATE PATTERNS
◎ pathophysiology of sinusoidal patterns is unclear
Sinusoidal fetal heart rate pattern associated with maternal intravenous meperidine administration. Sine waves are occurring at a rate of 6 cycles/min.

47. Assessment of fetal growth by ultrasound
Biometry:
Biparietal diameter (BPD)
Abdominal Circumference (AC)
Femur Length (FL)
Head Circumference (HC)
Amniotic fluid
Placental localization

48. BPD

49. BPD & HC

50. Abdominal circumference

51. FL

52. Growth chart

53. Placental localization

54. Placenta previa

55. Amniotic fluid

56. Fetal Biophysical profile
Abnormal (score= 0)
Normal (score=2)
Biophysical Variable
Absent FBM or no episode >30 s in 30 min
1 episode FBM of at least 30 s duration in 30 min
Fetal breathing movements
2 or fewer body/limb movements in 30 min
3 discrete body/limb movements in 30 min
Fetal movements
Either slow extension with return to partial flexion or movement of limb in full extension Absent fetal movement
1 episode of active extension with return to flexion of fetal limb(s) or trunk. Opening and closing of the hand considered normal tone
Fetal tone
Either no AF pockets or a pocket<2 cm in 2 perpendicular planes
1 pocket of AF that measures at least 2 cm in 2 perpendicular planes
Amniotic fluid volume

57. Management Interpretation Test Score Result
Intervention for obstetric and maternal factors
Risk of fetal asphyxia extremely rare
10 of 10
8 of 10 (normal fluid)
8 of 8 (NST not done)
Determine that there is functioning renal tissue and intact membranes. If so, delivery of the term fetus is indicated. In the preterm fetus less than 34 weeks, intensive surveillance may be
preferred to maximize fetal maturity.
Probable chronic fetal compromise
8 of 10 (abnormal fluid)
Repeat test within 24 hr
Equivocal test, possible
fetal asphyxia
6 of 10 (normal fluid)
Delivery of the term fetus. In the preterm fetus less than 34 weeks, intensive surveillance may be preferred to maximize fetal maturity
Probable fetal asphyxia
6 of 10 (abnormal fluid)
Deliver for fetal indications
High probability of fetal asphyxia
4 of 10
Fetal asphyxia almost certain
2 of 10
Fetal asphyxia certain
0 of 10

58. Umbilical Doppler Velocimetry
Indication:
IUGR
PET
D.M.
Any high risk pregnancy
Use a free loop of umbilical cord to measure blood flow in it

59. Umbilical cord

61. Umbilical Artery Doppler

62. Umbilical cord doppler

63. Reverse flow in umbilical artery

65. Umbilical Doppler

67. Management of abnormal Doppler
Depends on:
fetal maturity
gestational age
Obstetric history

68. Management of Doppler results
Reverse flow or absent end diastolic flow--- Immediate delivery
High resistance index---- repeat in few days or delivery
Normal flow---- repeat in 2 week if indicated

69. Any question

70. Thank you