1. FETAL MONITORING ANTE AND INTRAPARTUM
DR. OSHINOWO
M.B;B.S, FRCOG
OBSTETRICIAN/GYNAECOLOGIST

2. INTRODUCTION The aim of ANC Identifying risks factors
Ensure maternal well being
Ensure Fetal well being
Identifying risks factors
Monitoring of certain parameters ie Weight, BP, Urinalysis, Blood sugar (if necessary)

3. ANTEPARTUM
PHYSICAL
BIOCHEMICAL
ELECTRONIC

4. PHYSICAL FUNDAL HEIGHT SMALL FOR DATE LARGE FOR DATE OLIGOHYDRAMNIOS
IUGR
IUD
LARGE FOR DATE
MULTIPLE GESTATION
POLYHYDRAMNIOS
FIBROIDS

5. ULTRASONOGRAPHY Comes in 2D, 3D and recently 4D modes
Demonstrates features like Fetal anatomy, fetal weight, fetal movement, placental location, amniotic fluid volume
Helpful in specialized procedures like amniocentesis, Chorionic villus sampling, Biophysical profile, Fetal doppler, Fetal echocardiogram etc

6. GROWTH ULTRASOUND Performed every 3 to 4 weeks
Fetus at risk of fetal growth restrictions secondary to medical conditions of pregnancy or fetal abnormalities

7. FETAL MOVEMENT ASSESSMENT
Normal: 10 movements/fetal kicks in 12 hours (Cardiff count to ten)
Decreased fetal movement may precede fetal death by days
Mothers should be encouraged to keep a FKC especially in high risks patients
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8. NON STRESS TEST (NST) Assesses fetal movements with FHR acceleration
Reactive/Reassuring NST: 2 or more FHR accelerations at least 15 bpm above the baseline lasting at least 15 secs in a 20 mins period
Non reassuring NST may suggest fetal acidosis
What to do depends on gestational age

9. BIOPHYSICAL PROFILE (BPP)
Composes of 5 components
Non stress test (NST)
Amniotic Fluid Volume (vertical pocket of 2cm or more)
Fetal breathing movements (30 secs or more in 30 mins)
Fetal movements (3 or more in 30 mins)
Fetal tone (Extension/Flexion of an extremity)
Each carry a score of 2 points, a total of 8 or 10 is Normal, 6 is Equivocal, and 4 or less is abnormal

10. MODIFIED BIOPHYSICAL PROFILE
Combines Non stress Test + Amniotic Fluid Index (AFI)
AFI is measured by dividing the uterus into 4 quadrants and measuring the largest vertical pocket in each quadrant; the result summed up in millimeters
A nonreactive NST + AFI less than 50mm requires further intervention

11. CONTRACTION STRESS TEST (CST)
Rarely used today
Measures the response of Fetal HR to contractions
The test requires 3 contractions in 10 mins
A positive or Abnormal test results in decelerations in more than half of the contractions
Negative result: no deceleration with the contractions
Contraindication : Any case where labour not allowed

12. DOPPLER STUDIES Assesses multi-vessel evaluation of fetal status
Can be used to assess a compromised fetus i.e growth restriction
Functions as a diagnostic tool that alerts the clinician

13. INTRAPARTUM FETAL MONITORING

14. Baseline Fetal Heart Rate (FHR)
Is the mean level of the FHR when this is stable, excluding accelerations and decelerations
It is determined over a time period of 5-10 minutes, expressed as beats per minute (bpm)
NOTE: Preterm fetuses tend to have values towards the upper end of the normal range

15. Basic Features of FH Trace

16. Baseline Variability Is the minor fluctuation in baseline FHR
It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace
Uterine activity Normal variability is reassuring Sign that fetus nervous system is intact

17. Baseline variability CTG Baseline variability

18. 2 types of Variability
Short- Term variability or Beat to Beat variability
Is the difference between successive heartbeats or the moment
Long Term Variability
Is wider fluctuations
Over one (1) minute that causes wavy appearance in the monitor
Absent - No fluctuation Minimal - 5 bpm or less Moderate/Normal – 5bpm to 25

19. Accelerations
Are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds.
Accelerations in preterm fetuses may be of lesser amplitude and shorter duration.

20. Decelerations
Are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds, which are:
Early, Variable and Delayed
Time relationships with contraction cycle may be variable but most commonly occur simultaneously with contractions.

21. EFM Decelerations Decelerations- transient slowing of FHR below the
baseline level of
more than 15 bpm
and lasting for 15 sec.
Or more.

22. Early Deceleration
Uniform,
repetitive decrease of FHR with
slow onset early in the contraction and
slow return to baseline by the end of the contraction

23. Fig 3 Early Decelerations

24. Late decelerations
Uniform, repetitive decreasing of FHR with, usually,
slow onset mid to end of the contraction and
nadir more than 20 seconds after the
peak of the contraction and ending after
the contraction

25. Fig 4 Late Decelerations

26. Variable Deceleration
Repetitive or intermittent decreasing of FHR with rapid onset and recovery
Variable onset

27. Fig 5 Variable Decelerations

28. Prolonged Decelerations
Decrease of FHR below the baseline of more than 15 bpm for longer than 90 seconds but less than 5 minutes
Is pathological when crosses 2 contractions i.e 3 mins
Reduction in Oxygen transfer to placenta
Associated with poor neonatal outcome

29. Fig 6 Prolonged Deceleration

30. Prolonged Decelerations CAUSES
Cord prolapse.
Maternal hypertension
Uterine Hypertonia
Followed by a VE or ARM or SROM with High presenting part

31. Normal antenatal CTG trace
The normal antenatal CTG is associated with a low probability of fetal compromise and has the following features:
Baseline fetal heart rate (FHR) is between bpm
Variability of FHR is between 5-25 bpm
Decelerations are absent or early
Accelerations x2 within 20 minutes

32. Non-reassuring CTG trace
Is where any of the following is present:
The presence of two or more features is considered abnormal as these may be associated with fetal compromise and require further action
Baseline FHR is between bpm or between bpm
Variability of FHR is reduced (3-5 bpm for >40 minutes)

33. Abnormal CTG trace
The following features are very likely to be associated with significant fetal compromise and require further action-
Two of the features described in non-reassuring CTG trace are present, OR
Baseline FHR is <100 bpm or >170 bpm
Variability is absent or <3 bpm
Variability is sinusoidal
Decelerations are prolonged for >3 minutes / late / have complicated variables

34. Process Preparation Determine indication for fetal monitoring
Discuss fetal monitoring with the woman and obtain permission to commence
Perform abdominal examination to determine lie and presentation
Give the woman the opportunity to empty her bladder
The woman should be in an upright or lateral position (not supine)

35. Process Preparation
Check the accurate date and time has been set on the CTG machine, and paper speed is set at 1cm per minute
CTGs must be labelled with the mother’s name, her number and date / time of commencement
Maternal heart rate must be recorded on the CTG at commencement of the CTG in order to differentiate between maternal and fetal heart rates

36. ASSESSING THE CTG USING DR C M BRAVADO
Determine risk if the woman is a high or low obstetric risk. This sets the background for the interpretation
C Assess the frequency and quality of Contractions per 10 minutes.
M Assess fetal Movements, presence of Meconium and Maternal observations
Bra Determine Baseline Rate and compare with earlier rate if possible.
V Assess baseline Variability, is it normal, increased or reduced.
A Are Accelerations present in response to fetal movements or contractions
D If Decelerations are present, what are their characteristics.
O Give an overall classification for the CTG
Normal
Suspicious
Pathological

37. FETAL SCALP BLOOD SAMPLING
Useful in the presence of a non reassuring CTG
A scalp blood sample for pH or lactate determination
Specificity is high ( A normal value rules out asphyxia)
The sensitivity and positive predictive value of a low scalp pH in identifying a newborn with Hypoxic-ischaemic encephalopathy is low

38. FETAL PULSE OXIMETRY Measures fetal oxygenation during labour
It is performed using a sensor placed transcervically against the fetal cheek
Normal values btw 35% and 65%
Metabolic acidosis develops when the value falls below 30% for at least mins

39. CONCLUSION
The well being of any pregnancy begins pre-conception with adequate counselling of mothers with medical conditions
Pregnancy monitoring begins early in the gestation
Early and frequent prenatal care allows the care provider to screen the population to identify pregnancies at risk, afterall

40. “A NORMAL DELIVERY IS ONE IN WHICH THE MOTHER AND THE BABY ARE IN GOOD CONDITION REGARDLESS OF THE MODE OF DELIVERY”

41. THANK YOU FOR LISTENING