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A - MSRA Obstetrics [16] > [37] Intrapartum Assessment of Fetal Wellbeing > Flashcards

[37] Intrapartum Assessment of Fetal Wellbeing Flashcards

1
Q

What is intra-partum fetal monitoring?

A

The monitoring used immediately preceding or during childbirth

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2
Q

What suggests the possibility of fetal hypoxia?

A
  • Changes in fetal HR

- Meconium-stained liquor

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3
Q

Can changes in fetal HR and meconium-stained liquor occur in normal labour?

A

Yes

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4
Q

What might a reduction in fetal movements indicate?

A

Fetal jeopardy

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5
Q

What might cessation in fetal movements indicate?

A

Fetal death

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6
Q

What things can be used to assess fetal wellbeing?

A
  • Meconium
  • Intermittent auscultation
  • Fetal cardiotocography
  • Fetal scalp blood sampling
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7
Q

What is meconium?

A

A dark green liquid normally passed by a newborn baby

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8
Q

What does meconium contain?

A
  • Mucus
  • Bile
  • Epithelial cells
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9
Q

What can sometimes happen with meconium?

A

It can be passed when the baby is still in the womb, staining the amniotic fluid

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10
Q

What variation is there in meconium in the liquor?

A

Can very from very light to heavy staining

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11
Q

When is meconium staining in the liquor considered significant?

A

If dark green or black, with thick, tenacious appearance

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12
Q

What is meconium stained liquor considered to be a sign of?

A

Fetal distress

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13
Q

What is the problem with passing meconium whilst still in utero?

A

Components of the meconium, especially bile salts and enzymes, can cause serious complications if they are inhaled by the fetus at any stage of labour

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14
Q

What can be caused by inhalation of meconium by the baby?

A

Meconium aspiration syndrome

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15
Q

What pathological mechanisms participate in meconium aspiration syndrome?

A
  • Airway obstruction
  • Surfactant dysfunction
  • Inflammation
  • Lung oedema
  • Pulmonary vasoconstriction
  • Bronchoconstriction
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16
Q

What % of infants in the developed world are born with meconium-stained liquor?

A

8-25%

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17
Q

What % of live births does meconium aspiration syndrome occur in?

A

1-3%

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18
Q

What are the risk factors for passing meconium in utero?

A
  • Placental insufficiency
  • Maternal hypertension and pre-eclampsia
  • Oligohydraminos
  • Smoking
  • Cocaine abuse
  • Increased maternal age
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19
Q

What should be done if significant meconium staining is noted in labour?

A

Should be continuous electrical fetal monitoring

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20
Q

What should be done if there is significant meconium staining noted in labour, and signs of fetal distress?

A

A fetal blood sample should be obtained

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21
Q

What should be done at delivery if there is meconium stained liquor, and the neonate is in good condition?

A

There should be no suction, and the baby should be observed for signs of respiratory distress in the first hour of life, the second hour of life, and then 2 hourly until 12 hours old

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22
Q

How is it defined that the fetus is in good condition at delivery?

A

Apgar score >5

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23
Q

What should be done at delivery if there is blood or any lumps of meconium in the oropharynx?

A

Suction should be used in the upper airways

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24
Q

What should be done at delivery if there is meconium stained liquor, and the neonate is unwell?

A

Follow guidelines for meconium aspiration

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25
Q

What is intermittent auscultation used for?

A

Monitoring of FHR

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26
Q

How often should FHR be monitored in the first stage of labour?

A

Every 15 minutes for a period of 1 minute

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27
Q

When should the FHR be checked in the first stage of labour?

A

Soon after a contraction

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28
Q

How is intermittent auscultation of FHR performed?

A

Using a handheld Doppler ultrasound transducer or Pinard fetal stethoscope

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29
Q

How often is the FHR monitored during the second stage of labour?

A

Every 5 minutes, or every other contractions

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30
Q

How are contractions monitored in labour?

A

By manual palpation over a period of 10 minutes

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31
Q

What can manual palpation of contractions over a period of 10 minutes determine?

A

Frequency and duration

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32
Q

What can the indications for the use of continuous electrical fetal monitoring be divided into?

A
  • Maternal

- Fetal

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33
Q

What are the maternal indications for the use of continuous electrical fetal monitoring?

A
  • Previous C-section
  • Pre-eclampsia
  • Post-term pregnancy
  • Prolonged rupture of membranes
  • Induced labour
  • Diabetes
  • Antepartum haemorrhage
  • Other maternal medical disease
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34
Q

What are the fetal indications for the use of continuous electrical fetal monitoring?

A
  • Fetal growth restriction
  • Prematurity
  • Oligohydraminos
  • Abnormal Doppler artery velocimetry
  • Multiple pregnancy
  • Meconium-stained liquor
  • Breech presentation
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35
Q

What does cardiotocography enable?

A

Continuous monitoring of the fetal HR, and the frequency and duration of uterine contractions

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36
Q

How is the FHR determined in CTG?

A

Usually using a Doppler ultrasound transducer

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37
Q

Where is the Doppler ultrasound transducer placed for CTG monitoring?

A

Applied externally to maternal abdomen

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38
Q

How is uterine activity usually recorded for CTG monitoring?

A

Using a pressure transducer

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39
Q

Where is the pressure transducer applied for CTG monitoring?

A

Over the anterior abdominal wall, between the fundus and the umbilicus

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40
Q

Other than using a pressure transducer, how can uterine activity be measured?

A

By inserting a fluid-filled catheter or pressure sensor into the uterine cavity through the cervical canal

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41
Q

What is the advantage of external tocography?

A

It gives an accurate measurement of the frequency and duration

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42
Q

What is the limitation of external tocography?

A

It only gives relative information of intrauterine pressure

43
Q

What does accurate measurements of intrauterine pressure require?

A

Intrauterine catheter or transducer

44
Q

Why are intrauterine catheters and transducers not routinely used to measure uterine pressure in most centres?

A

Lack of evidence about clinical benefit

45
Q

What is the normal FHR?

A

100-160 BPM

46
Q

What is meant by baseline variability?

A

The FHR exhibits variation from the baseline lol

47
Q

What does baseline variability record?

A

Oscillations of the heart rate around the baseline heart rate

48
Q

How much is baseline variability?

A

5-25bpm

49
Q

When is baseline variability reduced physiologically?

A

During the fetal sleep phase

50
Q

When can baseline variability be reduced pathologically?

A
  • Hypoxia
  • Infection
  • Medication
51
Q

What is classified as an abnormal baseline variability?

A

Variability >5bpm for >90 minutes

52
Q

What might an abnormal baseline variability indicate?

A

Fetal jeopardy

53
Q

What are accelerations defined as?

A

Transient, abrupt increases in heart rate of more than 15 bpm for more than 15 seconds

54
Q

What are accelerations associated with?

A

Fetal movements

55
Q

What are accelerations a reflection of?

A

Activity of the somatic nervous system

56
Q

What are accelerations a sign of?

A

Reassuring sign of good fetal health

57
Q

What are decelerations defined as?

A

A decrease in heart rate of more than 15bpm for more than 15 seconds

58
Q

What defines the different patterns of decelerations?

A

Their relationship to uterine contractions and their intensity

59
Q

What are early decelerations synchronous with?

A

Uterine contraction

60
Q

When does the nadir (lowest point) occur with early decelerations?

A

At the peak of the contraction

61
Q

How much does the HR decrease in early decelerations?

A

Generally less than 40 bpm

62
Q

What are early decelerations due to?

A

Generally due to head compression

63
Q

Are early decelerations considered to be physiological?

A

Yes

64
Q

When are early decelerations seen?

A

In the late first and second stage of labour

65
Q

Describe late decelerations

A

The onset of slowing of HR occurs well after the contraction is established, and does not return to normal baseline rate until at least 20 seconds after the contraction is completed

66
Q

What are late decelerations due to?

A

Placental insufficiency

67
Q

What might late decelerations be indicative of?

A

Fetal hypoxia

68
Q

When might late decelerations be indicative of fetal hypoxia?

A

When accompanied by a rise in the baseline rate and reduction in baseline variability

69
Q

In what respects do variable decelerations variable?

A

Timing and amplitude

70
Q

Describe variable decelerations

A

They have a initial slight transitory rise in the baseline rate, followed by a precipitous fall followed by quick recovery to the baseline and slightly beyond

71
Q

How much does the heart rate fall by with variable decelerations?

A

Usually at least 40BPM

72
Q

What causes variable decelerations?

A

Cord compression

73
Q

What is the result of variable decelerations being caused by cord compression?

A

It varies with each contraction, giving rise to variable shapes, sizes, and timings of decelerations

74
Q

What are variable decelerations considered to be?

A

Non-reassuring features in a CTG trace

75
Q

What features of variable decelerations suggest worsening hypoxia?

A
  • Increase in depth and duration of decelerations
  • Rise in baseline rate
  • Reduction in baseline variability
76
Q

What are atypical variable decelerations?

A

Additional changes to simple variable decelerations in the form of slow recovery to baseline rate or a combined variable followed immediately by late decelerations

77
Q

What are atypical variable decelerations considered to be?

A

Abnormal features

78
Q

What can FHR trace features be classified into?

A
  • Reassuring
  • Non-reassuring
  • Abnormal
79
Q

What is the classification of FHR traces based on?

A

The classification of the features found on it

80
Q

What can FHR traces be classified as overall?

A
  • Normal
  • Suspicious
  • Pathological
81
Q

What are reassuring features on FHR trace?

A
  • Baseline 110-160bpm
  • Variability 5 or more bpm
  • No decelerations
  • Accelerations present
82
Q

What are non-reassuring features on FHR trace?

A
  • 100-109 or 161-180 bpm
  • Variability <5 for 40-90 minutes
  • Typical variable decelerations with over 50% of contractions, occuring for over 90 minutes, or simple prolonged deceleration for up to 3 minutes
83
Q

What are abnormal features on FHR trace?

A
  • <100 or >180 bpm, or sinusoidal pattern
  • Variability of <5 for 90 minutes
  • Atypical variable decelerations with over 50% of contractions or late decelerations, both for over 30 minutes, or single prolonged deceleration for more than 3 minutes
84
Q

What is classified as a normal FHR trace?

A

All features are classified as reassuring

85
Q

What should be done when a normal FHR is determined?

A

Continue intermittent or continuous monitoring, as indicated by risk factors

86
Q

What is classified as a suspicious FHR trace?

A

FHR trace with one feature classified as non-reassuring, and the remaining as reassuring

87
Q

What should you do when a suspicious FHR trace is determined?

A
  • Exclude factors indicating the need for immediate delivery
  • Treat dehydration, hyperstimulation, hypotension, and change position
  • Continue CTG
88
Q

What things that would require immediate delivery should be excluded when there is a suspicious FHR trace?

A
  • Cord prolapse
  • Uterine rupture
  • Abruption
89
Q

What is classified as a pathological FHR trace?

A

FHR trace with two or more features classified as non-reassuring, or one or more classified as abnormal

90
Q

What should you do when a pathological FHR trace is found?

A
  • Exclude factors indicating need for immediate delivery
  • Treat dehydration or hyperstimulation
  • Change position
  • Deliver if prolonged bradycardia
  • Either obtain further information on fetal status by fetal blood scalp sampling, or deliver
91
Q

What is fetal scalp blood sampling?

A

When fetal blood is obtained directly from the scalp through an amnioscope

92
Q

When is fetal scalp blood sampling used?

A

When abnormalities of fetal heart rate occur in labour

93
Q

What is the purpose of fetal scalp blood sampling?

A

To determine fetal acid-base balance

94
Q

How should a sample be obtained for fetal scalp blood sampling?

A

The amnioscope is inserted through the cervix, which must be dilated to at least 2cm. The mother lies in the left lateral position. A small stab incision is made in the fetal scalp, and blood is collected into a heparinised capillary tube

95
Q

Why should the mother lie in left lateral position when obtaining a sample for fetal scalp bloood sampling?

A

To avoid the risk of inducing supine hypotension

96
Q

How is the sample collected for fetal scalp blood sampling analysed?

A

In a blood gas analyser

97
Q

What is the normal pH of fetal blood?

A

7.25-7.35

98
Q

What does the management of abnormal fetal blood pH depend on?

A

The degree of abnormality

99
Q

What does a fetal blood pH of 7.2-7.25 in the first stage of labour indicate?

A

Mild acidosis

100
Q

How should a fetus with mild acidosis be managed?

A

Sampling should be repeated within the next 30 minutes

101
Q

How should a fetal blood pH of <7.2 be managed?

A

Delivery is recommended, unless spontaneous delivery is imminent

102
Q

What should be done if there is a sufficient sample of fetal blood?

A

A full blood gas analysis

103
Q

Why should a full blood gas analysis be performed if there is sufficient sample of fetal blood?

A

Because a raised pCO2 with normal base excess may indicate respiratory acidosis

104
Q

Why is it important to know if the fetus has respiratory acidosis?

A

It may correct itself if the posture of the mother is changed

A - MSRA Obstetrics [16] (61 decks)

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