A MATERIAL ON

INTRAPARTUM FETAL MONITORING

SUBMITTED TO SUMBITTED BY
MADAM MRS SMITHA MS. ANURADHA
ASSISTANT PROFESSOR MSc. NURSING 1ST YEAR
HFCON HFCON
 INTRAPARTUM FETAL MONITORING
INTRODUCTION
Early in the gestation the fetal heart rate is predominantly under control of the sympathetic
nervous system and arterial chemoreceptors. As the foetus develops its heart rate decreases in
response to parasympathetic (vagal stimulation) nervous system maturation and variability
becomes more pronounced. Intrapartum monitoring serves as a important measures to prevent
any complication to mother and the baby.
DEFINITION
Intrapartum fetal monitoring(IFM) means careful observation of the fetal behaviour during
labour.
AIM
Birth of the healthy baby with minimum intervention and to identify fetal hypoxia.
METHOD OF FETAL MONITORING
I. CLINICAL METHODS
i. Intermittent fetal heart auscultation
ii. Meconium stained liquor amnii
II. BIOPHYSICAL METHODS
i. Electric fetal monitoring: cardiotocographic (CTG) recording
ii. Fetal acoustic stimulation test
iii. Fetal scalp stimulation test
iv. Umbilical artery Doppler velocimetry
v. Intrapartum monitoring with fetal ECG wave form analysis.
III. BIOCHEMICAL METHOD
i. Fetal blood sampling
ii. Fetal pulse oximetry
iii. Lactate level measurement
iv. Near infrared spectroscopy
CLINICAL METHOD
 INTERMITTENT FETAL HEART AUSCULTATION

 Traditional method and most commonly used

 Economical and easily available in all hospital
 Fetal heart sound is heard through a stethoscope, fetoscope or a Doppler heart
detector periodically.
  Should be performed following uterine contraction to note any post deceleration
of fetal heart rate.
 Should be done before and after amniotomy, administration of medication or
analgesia and abnormal uterine activity.
 Can used in low risk pregnancy without complication
Reassuring findings
 Baseline fetal heart rate 110-160 beats per minute(bpm)
 Acceleration
Non-reassuring finding
 Inability to clearly auscultate fetal heart.
 Baseline bradycardia (<110bpm or tachycardia that is >160bpm)
 No acceleration heard, especially with fetal monitoring
 Deceleration of fetal heart rate.
LIMITATION
 Baseline variability
 Acceleration and deceleration are difficult to quantify.
Causes of fetal bradycardia:
 Fetal hypoxia and acidosis
 Administration of certain depressant drugs to mother (e.g. pethidine and anti-
hypertensive drugs, local anaesthetic drugs and epidural analgesia)
 Fetal heart defects (heart block)
Causes of fetal tachycardia
 Maternal and fetal infection
 Maternal and fetal anaemia
 Fetal compromise
 Administration of certain drugs to mother (e.g. beta drenergic drugs like ritodrine,
terbutaline or isoxsuprine) for preterm labour

 MECONIUM STAINED LIQUOR AMNII

Meconium in amniotic fluid has been considered a sign of fetal hypoxia due to subclinical
uteroplacental insufficiency and oligohydramnios.
Hypoxia causes vagus nerves stimulation which increases the peristaltic activity of intestine
and causes relaxation of the anal sphincter causing passage of meconium.
The meconium staining of amniotic fluid is classified as thin or thick according to subjective
assessment of concentration of meconium in amniotic fluid:
a) Thin meconium: with normal fetal heart rate is not significant.
b) Thick meconium: continuous cardiotocography should be started.
c) Meconium staining associated with other complication e.g. fetal growth restriction,
fetal heart rate abnormality should be managed according to the clinical assessment.
BIOPHYSICAL METHOD
1. ELECTRONIC FETAL MONITORING

Indication of maternal and fetal indications of electronic fetal monitoring(EFM) during

pregnancy and labour are: -
Antenatal indication:
a) Maternal indication
 Hypertensive disorder of pregnancy
 Pre-existing diabetes mellitus/gestational diabetes
 Antepartum haemorrhage
 Maternal medical disease: cardiac diseases, anaemia, hyperthyroidism, vascular disease
and renal disease.
 Maternal trauma
 Morbid obesity
b) Fetal indication
 Intrauterine (fetal) growth restriction
 Prematurity
 Oligohydramnios
 Abnormal umbilical artery Doppler velocitymetry
 Isoimmunisation
 Multiple pregnancy
 Breech presentation
Intrapartum indication
 a) Maternal indication
 Vaginal bleeding in labour
 Intrauterine infection/Chorioanmnionitis
 Previous caesarean section
 Prolonged rupture of membranes (24hors at term)
 Induced labour
 Augmented labour
 Hypertonic uterus
 Post-term pregnancy (42 weeks)
b) Fetal indication
 Meconium staining of the amniotic fluid
 Abnormal fetal heart rate on auscultation

Admission test: the recording of short cardiotocography for 20 min om admission in labour in
low risk pregnancy and deciding modality for labour monitoring depending on the result is one
of the strategies in limited resource settings.
If the admission test is normal and if oxytocin and epidural analgesia is not used, the risk of
fetal hypoxia occurring in next three hours is low provided no acute event like abruption occurs.
FROM THE NATURE OF TRACE DETERMINE
 Intensity of monitoring
 Duration and frequency of monitoring
Description of fetal heart traces and interpretation of electronic fetal monitoring
there are four main features that should be systematically examined to assist with the
interpretation of the CTG
 Baseline rate
 Baseline variablility
 Deceleration
 Acceleration
CTG can be classified as normal, suspicious or pathological .
CATEGORY DEFINITION
Normal A FHR trace in which all the four features are classified as reassuring
Suspicious A FHR trace with one features classified as non reassuring and the
remaining features classified as reassuring
Pathological A FHR trace with two or more features classified as non-reassuring or
one more classified as abnormal

Continuous EFM in the presence of oxytocin

 Intravenous oxytocin may be used either induce or argument. Oxytocin to induce labour
is often used in circumstances where the fetal risk is thought to be increased.
 Oxytocin augment labour is usually used to treat inefficient uterine action, particularly
in first time mothers.
 If fetal rate is normal, an oxytocin infusion may be increased until the women is
experiencing four to five contractions every minute. The oxytocin infusion rate should
be reduced by 10 drops per minute (10 IU in 1L normal saline), initially contractions
occur more frequently than five contractions in 10 min
 If fetal rate is found to be suspicious when an oxytocin infusion is in progress a review
by an experienced obstetrician should be requested. Once reviewed, the obstetrician
may be recommended that the oxytocin continues to be increased but only to a dose
which archives four to five contractions in 10 minute.
 If fetal rate trace is classified as pathological, oxytocin infusion should be stopped and
clinical reassessment undertaken before the oxytocin is recommended.
S.no. Normal or Suspicious or Pathological or
reassuring FHR nonreassuring FHR abnormal FHR
1. Baseline fetal (110-160bpm) Moderate bradycardia Bradycardia<100bpm
heart rate 100-110bpm Tachycardia>160
Tachycardia >161-180 for>60min
bpm Erratic baseline
2. Baseline (>5 bpm between <5bpm for 40-90 < 5 bpm for 90minutes
variability contraction) minutes >25bpm for >10 min
Sinusoidal pattern
3. Deceleration none Early detection Atypical variable
Variable decelerations decelerations
Occasional late
decelerations Late deceleration
Single prolonged Single prolonged
deceleration upto 3 deceleration > 3min
minutes
4. Accelerationfetal heart rate Absence of No acceleration
increases> 15bpm acceleration with the
or more and scalp stimulation
lasting> 15sec
acceleration
present with fetal
scalp stimulation
5. Management: No action required vigilant assessment Action required
required, especially
 when combined Review overall clinical
features are present situation, perform scalp ph
if appropriate or prepare for
delivery

Baseline variability
Normal baseline rate ranges from 110 to 160 bpm for a 10-minute segment and duration ≥ 2
minutes. he baseline FHR is the heart rate during a 10 minute segment rounded to the
nearest 5 beat per minute increment excluding periods of marked FHR variability, periodic or
episodic changes, and segments of baseline that differ by more than 25 beats per minute.

The minimum baseline duration must be at least 2 minutes. If minimum baseline duration is
< 2 minutes then the baseline is indeterminate.

 Bradycardia :Mean FHR < 110 BPM

 Tachycardia: Mean FHR>160 BPM

Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles
per minute. No distinction is made between short-term variability (or beat-to-beat
variability or R-R wave period differences in the electrocardiogram) and long-term
variability.

Grades of fluctuation are based on amplitude range (peak to trough):

 Absent variability = Amplitude range undetectable

 Minimal = < 5 BPM
 Moderate = 6 to 25 BPM
 Marked = > 25 BPM

The tracing shows an amplitude range of ~ 10 BPM (moderate variability ).

Factors affecting variability

 Normal variability: 98% foetuses are not acidotic

 Decreased variability: fetal metabolic acidosis, CNSNS depressants, fetal sleep
cycle, congenital anomalies, prematurity, fetal tachycardia, pre existing neurologic
abnormality, betamethasone.
 Increased variability: acute hypoxia or cord compression.

Acceleration
An acceleration is an abrupt increase in FHR above baseline with onset to peak of the
acceleration less than < 30 seconds and less than 2 minutes in duration. The duration of the
acceleration is defined as the time from the initial change in heart rate from the baseline to
the time of return to the FHR to baseline.

Adequate accelerations are defined as:

 <32 weeks' : >10 BPMabove baseline for >10 seconds

 >32 weeks' : >15 BPM above baseline for > 15 seconds.

Prolonged acceleration: Increase in heart rate lasts for 2 to 10 minutes.

The absence of accelerations for more than 80 minutes correlates with increased neonatal
morbidity [38,39].

Fetal scalp stimulation can be used to induce accelerations. There is about a 50% chance of
acidosis in the fetus who fails to respond to stimulation in the presence of a nonreassuring
pattern [17]. This technique should not be used to verify the absence of acidemia during a
deceleration of the FHR since there is insufficient literature to support its use during a
deceleration.

Deceleration

Gradual decreases in fetal heart rate of>15bpm and lasting >15 seconds with return to normal.
Prolonged deceleration lasts for more then 2 minutes but less than 10 minutes. The
decelerations are classified as follows:
1. Early deceleration (Type 1 dips): the decrease in fetal heart rate concides with the
uterine contraction and it recovers with the ned of uterine contraction. They are usually
due to compression of fetal head.
 Caused: by fetal head compression, usually seen in 4 to 6 cm of dilation.
Management: check fetal pH, if pattern persists, look for hyperstimulation, stop
oxytocics.
2. Late decelerations (Type 2 dips): the decreases in fetal heart rate is in later part of
uterine contraction and continues well after the end of uterine contraction.

Causes: uteroplacental insufficiency, maternal hyotension, post maturity, DM,HTN,

Management: fetal pH
The most ominous picture is shallow late decelerations, loss of baseline variability and
tachycardia.
3. Variable deceleration: the decreases in fetal heart rate beginning is at no fixed time in
relation to uterine contractions. They are usually due to cord compression. If they are
persistent, fetal hypoxia is likely.

Management: turn the patient, maintain hydration, stop oxytocics, oxygen by face
mask. If pattern persists, check fetal pH and deliver.
4. Beat-to-beat variability: normally there is beat to beat variation in the fetal heart rate
due to interaction of sympathetic and parasympathetic nerve action on the heart.
Reduction or loss of baseline irregularly (<5 beats per minute) is the single most reliable
sign of fetal compromise(hypoxia).
Management: check fetal pH and deliver.
5. Sinusoidal fetal heart rate: visually appresnt, smooth, sine wave-like undulating
pattern in FHR baseline with A cycle frequency of 3-5 per minute whoch perisists for
20min or more
 Indicates: severe fetal anaemia as occurs in Rh isoimmunisation, feto maternal
haemorrhage, twin pregnancy, twin twin transfusion syndrome.
Severe hypoxia

Management: immediate delivery is desirable.

Classification of intrapartum CTG trace

 Normal tracing- reassuring in older classification
 Atypical or indeterminate tracing- non-reassuring in older classification
 Abnormal tracing- non-reassuring in older classification
Management of abnormal CTG and fetal distress
1. Turn the woman on her side.
2. Administration oxygen (6-8 L/min) to improve fetal oxygen. Stop the oxytocin
infusion, if it is being given.
3. Check pulse, BP and temperature of the mother.
4. Correct hypotension, if present by infusion of crystalloids dextrose saline or Ringer
lactate solution.
5. If the uterus is hypertonic, consider giving tocolytics with ritodrine.
6. Perform an ARM (amniotomy) to look for the presence of meconium.
7. If abdominal probe is not recording CTG continuously properly, fetal scalp electrode is
applied for better recording of CTG tracing (less commonly used in India)
8. Fetal blood sampling can be performed if facilities are available(most hospital in India
do not do it).
9. All patients with fetal distress must have an experienced obstetrician and a paediatrician
present during delivery.
10. If trace is repeatedly abnormal early in labour and cervix is not dilated, caesarean
delivery should be performed.
11. If patient is in second stage and delivery is feasible, instrumental delivery should be
performed.
Effects of Medication on FHR patterns
 Narcotics- decreased variability and acceleration
 Corticosteroids-decreased variability (with beta-methasone but not dexamethasone)
 Magnesium sulphate- a significant decreased in short term variability, clinically
insignificant decreased in FHR inhibits the increased in accelerations with advancing
gestational age.
 Epidural analgesia- decreased variability and acceleration
 Terbutaline-Increase in Baseline FHR.
2. VIPRO OR FETAL ACOUSTIC STIMULATION TEST (VAST OR FAST)

Acoustic stimulation test is used to produce sound. The fetal response is noted on CTG, it
can improve the sensitivity of admission test if combined with it. A foetus which is not
hypoxic, would exhibit two acceleration > 15 beats for 15 seconds or a sustained lasting
more than 3 minutes.
3. FETAL SCALP STIMULATION TEST

A painful stimulus is given to the scalp. Presence of fetal heart rate acceleration in response
is taken as normal.
4. UMBILICAL ARTERY DOPPLER VELOCITY
 Abnormal Doppler velocity can be associated with increased perinatal mortality and
morbidity necessitating continuous electronic fetal heart rate monitoring.
5. FETAL ECG WAVE FROM ANALYSIS (ST SEGMENT ANALYSIS)
Fetal ECG and be obtained from fetal scalp electrode during internal monitoring with CTG
machine for any abnormality. It is not used in clinical practice.

BIOCHEMICAL METHOD
1. FETAL BLOOD SAMPLING

 Should be done for EFM abnormalities to avoid unnecessary caesarean deliveries.

 False positive diagnosis of abnormal trace can be relieved by FBS.
Indication:
a) Atypical and abnormal tracing on EFM
b) Thick meconium stained liquor
Delivery should be expedited where:
  Significant fetal acidosis is suspected.
 There is clear evidence of serious fetal compromise (FBS not appropriate)
 CTG abnormality require further assessment but FBS is considered clinically
inappropriate or not feasible and should be accomplished within 30 min
Contraindication:
 If spontaneous vaginal delivery is imminent or easy or instrumental delivery is feasible,
it better to deliver rather than performing FBS.
 During or soon after an episode of prolonged bradycardia.
 When an ominous FHR trace necessitates immediate delivery.
 When there is associated failure of progress of labor.
 Clear evidence of serious fetal compromise
 Fetal bleeding disorders.
 Maternal infection(herpes,HIV,hepatistis etc)
 <34 weeks gestation
 Face presentation
Procedure
 Left lateral position should be given to the mother.
 Check blood pressure and give 500ml crystalloid(IV) if appropriate.
 The urgency and mode of delivery should be taken into account the severilty of the fetal
heartv rate and the clinical circumstances. Ideally delivery should occur within 30
minutes.
 Using appropriate amnioscope, ethylchloride is sprayed on the fetal scalp and it is
coated with silicin grease.
 Incise scalp with guided blade.
 Collect blood sample (100microL) in a capillary tube without oral suction.
 Analyse the blood sample immediately on an appropriate machine.
 INTERUPTION OF FETAL ph RESULTS
 More than 7.5 – no evidence of fetal acidosis in the sample. And if CTG
continues to be abnormal, FBS is repeated in 1Hr.
 7.20 – 7.25 - if not delivered repeat FBS in 1 hour
 Less than 7.20- indicated acidosis and need immediately delivery
Note: vacuum extractor to be avoided within 1 hour of FBS to avoid cephalohematoma
formation
 2. FETAL PULSE OXIMETRY
Measures fetal oxyhemoglobin saturation by placing a sensor on the fetal cheek through
cervix after rupture of membrane. It should be between 40-70%. Less than 30% is abnormal.

3. LACTATE LEVEL MEASUREMENTS IN FETAL BLOOD SAMPLING

Systematic lactate level is a known indicator of anaerobic respiration.
 Normal fetal scalp lactate level is <2.8 mmol/L
 Suspicious 2.9-3.08
 Abnormal >3.08
4. NEAR INFRARED SPECTROSCOPY
Light is passed through the detectors placed on the fetal head it will be reflected back
depending on the oxygenation and the amount of blood flow through the fetal head.

RESEARCH STUDY
Intrapartum fetal monitoring to assess fetal well-being during the labor and delivery process
has been a central component of intrapartum care for decades. Today, electronic fetal
monitoring (EFM) is the most common method used to assess the foetus during labor without
substantial evidence to suggest a benefit. A study was done by CAHILL, ALISON G., MD,
MSCI; SPAIN, JANINE, MD Department of Obstetrics and Gynaecology, Washington
University School of Medicine, St. Louis, Missouriof 13 trials, which included over 37,000
women, found that continuous EFM provided no significant improvement in perinatal death
rate [risk ratio (RR) 0.86; 95% confidence interval (CI), 0.59-1.23] or cerebral palsy rate (RR
1.75; 95% CI, 0.84-3.63) as compared with intermittent auscultation; however, there was a
significant decrease in neonatal seizures (RR 0.50; 95% CI, 0.31-0.80). In addition, there was
a significant increase in caesarean delivery (RR 1.63; 95% CI, 1.29-2.07) and operative vaginal
delivery (RR 1.15; 95% CI, 1.01-1.33). Despite the lack of scientific support to suggest that
EFM reduces adverse neonatal outcomes, its use is almost universal in the hospital setting and
very likely has contributed to the rise in caesarean rate.
SUMMARY AND CONCLUSION
Intrapartum help to detect changes in the normal heart rate pattern during labour. If certain
changes are detected, steps can be taken to help treat the underlying situation problem. A full
knowledge regarding the intrapartum fetal monitoring must to every midwife to detect and
change from normal to abnormal as to prevent any complication to the mother and foetus so
that healthy baby can deliver.
BIBLIOGRAPHY
 Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition, page no. 222-
229
 Cunningham F. Gary, Williams Obstetrics, Medical mc graw hill education
publication, 24th edition, page no. 473-500
 Daftary S.N., Chakravarti Sudip, Holland and Brews manual Of Obstetrics, Elesevier
India Pvt Limited 2011, 3rd edition, page no. 231-247
 https://journals.lww.com/clinicalobgyn/Abstract/2015/06000/Intrapartum_Fetal_Moni
toring.9.aspx
 http://perinatology.com/Fetal%20Monitoring/Intrapartum%20Monitoring.htm