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Fetal Distress

Fetal distress is a condition in which the fetus (unborn baby) develops a problem during the
mothers labor.
Compromise of the fetus during the antepartum period (before labor) or intrapartum period
(birth process).
The term "fetal distress" is commonly used to describe fetal hypoxia in utero (low oxygen
levels in the fetus).This occurs when conditions which interfere with the supply of oxygen to
the foetus are present.
It is ill defined term , used to express intrauterine fetal jeopardy, a result of intrauterine fetal
hypoxia.(Dutta)
The concern with fetal hypoxia is it may result in fetal damage or death if not reversed or if
the fetus is not promptly delivered.
Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium
(dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid,
or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2.
Signs and symptoms of fetal distress include:

Decreased movement felt by the mother

Meconium in the amniotic fluid

Cardiotocography signs

increased or decreased fetal heart rate (tachycardia and bradycardia), especially


during and after a contraction.

decreased variability in the fetal heart rate

Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp
prick through the open cervix in labour
o

fetal acidosis

elevated fetal blood lactate levels indicating the baby has a lactic acidosis (Lactic
acidosis is a condition caused by the buildup of lactic acid in the body. It leads to
acidification of the blood (acidosis), and is considered a distinct form of
metabolic acidosis.
Fetal Hypoxia
Metabolic acidosis

H-ions first stimulate and then depress


the sino-auricular node

Leading trachycardia and bradycardia

Also causes parasympathtic


stimulation

Hyperparistalsis and relaxation of the


anal sphincter.

Passage of muconium.
o

Note: A normal fetal heart rate may slow or fast during a contraction but usually recovers to
normal as soon as uterus relaxes.

Causes of fetal distress


Fetal distress can occur during pregnancy, or more commonly during labour. Fetal Distress can
be due to a wide range of reasons. The main cause of antepartum fetal distress is
uteroplacental insufficiency.
Factors within labour are complex but processes such as uteroplacental vascular disease,
reduced uterine perfusion, fetal sepsis, reduced fetal reserves, and cord compression can be
involved alone or in combination, and gestational and antepartum factors can modify the fetal
response. Reduced liquor volume, maternal hypovolaemia and fetal growth restriction are
known associations.
Some of the more common causes include:
1. Not enough oxygen: The most common reason for fetal distress is the baby is not receiving
enough oxygen when inside the uterus. This is usually because there is not an adequate blood
flow through the placenta and cord. When the uterus contracts in labour, it momentarily reduces
blood flow to the baby, as the uterus relaxes, the blood flow increases. This is a normal, natural
process that healthy babies, with a healthy placenta, are not concerned with. In fact, it actually
stimulates the baby (usually shown as an increase in their heart rate).
There are some situations when the blood flow (and hence the oxygen supply), are lessened,
causing the baby to become either slowly distressed over time, or suddenly distressed if the
incident is severe.
Some causes of fetal distress can include

Placental insufficiency. This is when the placenta is not functioning at its best and can
be due to high blood pressure, heart conditions, bleeding in late pregnancy, small baby
or post dates, Pre-eclampsia, eclampsia, chronic nephritis and DM.

Over stimulation of the uterus, due to being induced or augmented.


A sharp drop in the mother's blood pressure due to her having an epidural, or
experiencing a haemorrhage, or lying for a prolonged period flat on her back in labour.
Cord compression due to an early artificial rupture of the membranes (ARM) or a cord
prolapse. The blood supply may also be reduced if the umbilical cord is wrapped
several times around the baby's neck or body.
True knot in the umbilical cord, short umbilical cord.
Twins sharing a single placenta. Known as Twin to twin transfusion.
Placental abruption (or separation of the placenta from the wall of the uterus), Placenta
previa.
Prolonged labour, especially if the membranes have been long ruptured.
Degenaration of placenta associated with post maturity.
2. Blood chemical imbalances : Sometimes chemical imbalances in the woman's blood stream
can stress the baby. In most cases the women is unwell when this happens. Health conditions that
can cause this are cholestasis, diabetes or kidney disease.
3. The baby is unwell : The baby may be unwell due to:
An inherited disorder.
An abnormality in the baby.
An infection, such as group B strep.
The baby being overheated due to the mother having a fever.
The baby reacting unfavorably to drugs (or anesthetics) given to the
woman.

Causes of fetal stress during labour

Compression of the fetal head during contractions.

During uterine contractions compression of the fetal skull causes vagal stimulation, which slows
the fetal heart rate. Head compression usually does not harm the fetus. However, with a long
labour due to cephalopelvic disproportion, the fetal head may be severely compressed. This may
result in fetal distress.

Decrease in the supply of oxygen to the fetus.

UTERINE CONTRACTIONS: Uterine contractions are the commonest cause of a decrease in


the oxygen supply to the fetus during labour.
REDUCED BLOOD FLOW THROUGH THE PLACENTA: The placenta may fail to provide
the fetus with enough oxygen and nutrition due to a decrease in the blood flow through the
placenta, i.e. placental insufficiency. Patients with pre-eclampsia have poor formed spiral arteries
that provide maternal blood to the placenta. This can also be caused by narrowing of the uterine
blood vessels due to maternal smoking.
ABRUPTIO PLACENTAE: Part or all of the placenta stops functioning because it is separated
from the uterine wall by a retroplacental haemorrhage. As a result the fetus does not receive
enough
oxygen.
CORD PROLAPSE OR COMPRESSION: This stops the transport of oxygen from the placenta
to the fetus.
UTERINE CONTRACTIONS ARE THE COMMONEST CAUSE OF A DECREASED OXYGEN SUPPLY TOTHE FETUS DURING
LABOUR

HOW DOES THE FETUS RESPOND TO A LACK OF OXYGEN?

A reduction in the normal supply of oxygen to the fetus causes FETAL HYPOXIA. This is a lack
of oxygen in the cells of the fetus. If the hypoxia is mild the fetus will be able to compensate and,
therefore, show no response. However, severe fetal hypoxia will result in FETAL DISTRESS.
Severe, prolonged hypoxia will eventually result in fetal death.

Decreased fetal oxygenation in labour


Hypoxia
Metabolic acidosis
Asphyxia
Tissue damage
Fetal death

Management
In many situations fetal distress will lead the obstrecion to recommend steps to urgently deliver
the baby. This can be done by induction, or in more urgent cases, a caesarean section may be
performed.

Prop up the woman or place her on her left side, which helps to improve placental
circulation. Lateral positioning avoids compression of venacava and aorta by the gravid
uterus. This increase cardiac output and uteroplacental perfusion.

Stop oxytocin if it is being administered.

Correction of dehydration by IV fluids improves intravascular volume and uterine


perfusion.

Correction of maternal hypotension, following epidural analgesia, with immediate


infusion of 1 litre of crystalloid (RL)
Tocholytic (inj turbutaline 0.25 mg sc) is given when uterus is hyppertonus and there is
non reassuring FHR.
Aminio-infusion has been shown to be beneficial in this situation, with a reduced risk of
Caesarean section This an initial infusion of a 250-500ml bolus of warmed normal saline,
through a double lumen intrauterine pressure catheter. (Uterine pressure and fetal heart
rate (via scalp electrode) are monitored constantly.) It is thought to dilute meconium and
reduce the risk of meconium aspiration and reduces cord compression. The potential
adverse effects include umbilical cord prolapse, uterine scar rupture and amniotic fluid
embolism.
Check uterine contraction for strength, duration of fregnancy.

If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate


management.

If a maternal cause is not identified and the fetal heart rate remains abnormal
throughout at least three contractions, perform a vaginal examination to check for
explanatory signs of distress:
- If there is bleeding with intermittent or constant pain, suspect
abruptio placentae;
- If there are signs of infection (fever, foul-smelling vaginal
discharge) give antibiotics as for amnionitis;
- If the cord is below the presenting part or in the vagina,
manage as prolapsed cord.

If fetal heart rate abnormalities persist or there are additional signs of distress
(thick meconium-stained fluid), plan delivery: In second stage of labour, if the head
is in the perineum fiven episiotomy to hasten delivery or farcep delivery can be done.
-

In second stage of labour, if the head is in the perineum


given episiotomy to hasten delivery.

If the cervix is fully dilated and the fetal head is not


more than 1/5 above the symphysis pubis or the
leading bony edge of the head is at 0 station, deliver
by vacuum extraction or forceps;

If the cervix is not fully dilated or the fetal head is


more than 1/5 above the symphysis pubis or the
leading bony edge of the head is above 0 station,
deliver by caesarean section.

Note: Pediatrician and resuscitations set should be made available

MECONIUM

Meconium staining of amniotic fluid is seen frequently as the fetus matures and by itself is
not an indicator of fetal distress. A slight degree of meconium without fetal heart rate
abnormalities is a warning of the need for vigilance.

Thick meconium suggests passage of meconium in reduced amniotic fluid and may indicate
the need for expedited delivery and meconium management of the neonatal upper airway at
birth to prevent meconium aspiration.

In breech presentation, meconium is passed in labour because of compression of the fetal


abdomen during delivery. This is not a sign of distress unless it occurs in early labour.

Abnormal fetal heart rate

A normal fetal heart rate may slow during a contraction but usually recovers
to normal as soon as the uterus relaxes.

A very slow fetal heart rate in the absence of contractions or persisting after
contractions is suggestive of fetal distress.

A rapid fetal heart rate may be a response to maternal fever, drugs causing
rapid maternal heart rate (e.g. tocolytic drugs), hypertension or amnionitis. In

the absence of a rapid maternal heart rate, a rapid fetal heart rate should be
considered a sign of fetal distress.

Maternal distress
Maternal distress means maternal exhaustion i.e. the strain and stress of labour have proved too
much for the mother.
It is a condition of mental and physical exhaustion of the mother during labour usually caused by
prolonged labour.
Causes.
1.
Prplonged labour due to
a
Contracted pelvis
b
CPD
c
Malpresentation and malposition
d
Rigid cervix
e
Rigid pelvic floor
f
Ineficient and incoordinated uterine action
2.
Obstructed labour due to
a Malpresentation, malpostion, congenital abnormalities.
b Compound presentation
c CPD, locked twins etc.
3
Insufficient uterine contraction eg hypotonic, hypertonic, incoordinate uterine action
4
Maternal bearing down from first stage
Sign and symptoms
1
Increase in the pulse rate is one of the earliest sign of distress.
2
Raise in temperature
3
Increase respiration
4
Mother looks ill restless and weakness and sweating
5
Anxious look with sunken eyes
6
Sign of dehydration: dry lip, dry and coated tongue, presence of acetone in the breath
and utrine
7
Abdominal distension
8
Vomiting occurring at times.
9
The above signs are indications that things have gone wrong and the mother's life is
threatened.
Management
a Adequate rest, sedation, hydration and avoidance of prolonged labour are preventive
measures aganist mental distress.
b Keep confineous monitoring of feal hart rate and uterine activity.
c Observe materal vital sign.
d Encourage to void periodically
e Provide and encourage to take planty of fluids regularly.
f Provide reassurance and emotional support to the mother.

g Inform to obstreforccian immediately when the sign of maternal distress are seen.
h Give QV ifusion of 5-10% dentrose and R/L to correct dehydration and keto-acidosis.
i Labour is terminated if the patient is exhausted and the method employed depends on the
degree of cervical diltation.
In the first stage of labour this will necessitate LS.
- In second stage of labour, if the head is in the perineum fiven episiotomy to
hasten delivery or farcep delivery can be done.
If head is high, delivery by vccum extraation.
j Inform and make available pediatrician during delivery.
k Provide complete rest to mother offer delivery.
Pediatrician and resuscitations set should be made available.