6/8/2018

Disclosures

• I have nothing to disclose

Category II Tracings:
Does Fetal Resuscitation Work?
Brian L. Shaffer, MD
Associate Professor
Maternal Fetal Medicine
Doernbecher Fetal Therapy
June 8, 2018

Objectives: In Utero Resuscitation in Cat II FHR Intrauterine Resuscitation (IUR): Pathophysiology

Oxygen Delivery to the Fetus
• Pathophysiology – O2 transfer to fetus Maternal status
– Maternal status Maternal Oxygenation (Environment)
– Uterine activity  Cardio-Pulmonary status (Cardiac Output)
– Umbilical cord  Vasculature
• Resuscitative options: Can be interrupted  Uterus (Activity)
– “Amelioration of the fetal heart rate tracing” - JTP diminished along  Placenta
– Help or Harm – What’s the evidence? this pathway  Cord (Compression)
– “Routinely used, poorly studied” Fetal status
Goal: Prevent, Identify, and ameliorate fetal acidemia
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IUR - Pathophysiology (cont.) IUR - Pathophysiology (cont.)

• Hypoxemia  Anaerobic metabolism  Lactate  ↓pH
• FHR monitoring: indicate risk of acidemia
– Cat I – very low risk
– Cat III – very high risk
• Immediate IUR and if not successful….
• Expeditious delivery
• Very uncommon <1% of all FHR
• Category II – not predictive of fetal-acid base status
– Requires evaluation, continued surveillance and re-evaluation
– Common - 2h prior to delivery: ~40% of FHR is cat II
– Moderate variability & accelerations – Absence of acidemia
– More “abnormal” findings  higher the probability of acidemia
• Minimal variability, Decelerations, Tachycardia, etc…
• ~30% of fetuses demonstrate a “nonreassuring” pattern in labor
– Nonreassuring ≠ acid base values
– With the limitations of FHR –
• What can we do about it? – IUR!

IUR – Goals and Actions IUR – Goals and Actions

Goals “Resuscitation” Goals “Resuscitation”
Deliver O2 Lateral decubitus, IV fluid bolus Alleviate cord Lateral decubitus, Amnioinfusion (stage I)
To Fetus Reduce/Stop uterotonics, Alter pushing Compression Alter pushing (every 2nd/3rd)
Administer O2 (Maternal)
Treat maternal Lateral decubitus, IV fluids
↓ Uterine Lateral decubitus, IV fluid bolus, Hypotension Meds: ephedrine, phenylephrine
Activity Reduce/Stop Uterotonics, Tocolytic
• Must consider clinical context – parity, stage, chorio, etc.
• Characteristics of FHR, pattern evolution (~60 min)*
• Cascade of actions – position, IV fluids...
*Parer JT 2006 J Mat Fetal Neo Med

IUR: Lateral decubitus position
• Lateral decubitus (Left or Right)
– Supine position  Aortocaval compression
• Decreases venous return & increases afterload
• Reduction of CO – up to 30%
– May use wedge
• Lateral position & Fetal O2 status
– Lateral position compared with supine
• Normal FHR, small number of subjects
• Increased fetal O2 by fetal pulse ox (fetal SpO2)
• Left and right similar increased in SpO2
• Fetal SpO2 was lowest - supine hypotensive episode
Carbonne 1996 Obstet Gynecol; Simpson KR Am J Obstet Gynecol 2005
IUR: IV Fluid Bolus
Hypovolemia/Hypotension ↓ Uterine blood flow ↓Fetal O2
• IV fluid bolus – 500-1000cc NS/LR
• Do not utilize glucose containing IVF
– Increased fetal lactate, decreased pH
– Increased risk for fetal hyperglycemia  neo hypoglycemia
hyperinsulinsim, jaundice, TTN
Simpson KR Obstet Gynecol 2005
6/8/2018
IUR: Lateral decubitus position
• Most common intervention
• May alleviate compression with uterine wall/fetal parts
• Prevents supine hypotension episode
– May maximize maternal CO
• Left more commonly utilized
– Both R&L may modify uterine blood flow and assist in
resolution of late decelerations
• First response to a “nonreassuring” pattern
Carbonne 1996 Obstet Gynecol; Simpson KR Am J Obstet Gynecol 2005
IUR: IV fluid bolus – Fetal oxygenation Sp02
• IVF and fetal oxygen saturation (Sp02)
– IOL, oxytocin, epidural, n=56, normal FHR
– 500 vs. 1000cc LR
– Increase fetal oxygen saturation (Sp02)
• 1000cc increase in fetal SpO2 - 5.2%
• 500cc increase in fetal SpO2 - 3.7%
– Improved fetal SpO2 in normotensive, well hydrated patients
• Fetal pulse oxygenation?
• Caution: Pre-eclampsia, Magnesium Pulmonary edema
Simpson KR Obstet Gynecol 2005
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IUR: IV Fluid Bolus Audience Poll

Neuraxial anesthesia/Supine position (both!)  Hypo- 35 yo G2P1001 at 40 5/7 wks IOL for rapid labor
volemia/Hypotension  ↓ Uterine blood flow ↓Fetal O2 and SVE of 6/80/0, oxytocin at 3mu/min FHR 150s 85%

Action: Lateral position, IVF bolus min-mod variability, intermittent late and severe
• If not corrected – Ephedrine, phenylephrine variable decelerations. Toco:q1-2
– Ephedrine – mixed α and β agonist A. None, with some moderate variability the fetus is 4% 2%
9%
0%

• Epinephrine (α only) can constrict uterine blood flow
– Associated with marked FHR variability
• Data - Few studies
• May reduce hypotension, but most benefit illustrated with high dose
– No longer utilized in contemporary anesthesia
• No clear benefit to FHR, hypotension – epidural, spinal
Hofmeyr Cochrane Review 2010
unlikely to be acidemic, AROM and glove up
B. Position change, Fluid bolus, O2  CD if not resolved
C. If B doesn’t work, AROM and Amnioinfusion
D. Oxytocin off, position change, IVF, Tocolytic if
E. No resolution 10 min

IUR: Uterine activity IUR: Uterine activity

• Contraction - Intermittent interruption of O2/CO2 transfer • Contraction - Intermittent interruption of O2/CO2 transfer
– Tetany/Tachysystole ↓ Intervillous flow  ↓Fetal O2 – Tetany/Tachysystole ↓ Intervillous flow  ↓Fetal O2
Anaerobic metabolism Anaerobic metabolism
Acidemia Acidemia

• Reduction in UCs  • Reduction in UCs 

improved perfusion improved perfusion
• Action:  Uterotonics • Action:  Uterotonics
• Limitation – pulse Ox
Simpson KR Am J Obstet Gynecol 2008 Simpson KR Am J Obstet Gynecol 2008
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IUR: Excessive Uterine activity Audience Poll

Tachysystole - >5 UCs in 10 min (30 minutes)
• Spontaneous
• Induction/Augmentation: (misoprostol, Oxytocin, etc.)
35 yo G2P1001 at 40 5/7 wks IOL for rapid labor and
SVE of 6/80/0, oxytocin at 3mu/min FHR 150s min-mod
variability, int late and severe variable decelerations.
Toco:q1-2 Which Tocolytic? 76%

• Anesthesia – Intrathecal opioids/Response

ACTION A. A IV terbutaline
• Reduce/Stop Uterotonics B. B IV nitroglycerine
• Tocolytic C. C IV Magnesium 21%

– Terbutaline SQ or IV D. D SQ terbutaline 1% 1% 0%

– Nitroglycerine E. E Atosiban
– Magnesium

IUR: Excessive Uterine activity IUR: Excessive Uterine activity

Terbutaline/Beta agonists vs. No medication
• Abnormal FHR, fetal scalp pH, randomized
• Neonate – decrease rate of acidemia
• Maternal – transient maternal tachycardia
Terbutaline (0.25mg SQ) vs. Magnesium (4gm bolus IV)
• Awaiting CD for FHR abnormalities
• Terbutaline  reduced uterine activity (MVU)
• Magnesium  no significantly reduced uterine activity
– More neonates with CUA pH <7.2
Kulier R Cochrane review 2009
Terbutaline v Nitroglycerine (IV)
• Amelioration of nonreassuring FHR tracing, n=110
– NRFHT
• Decels: Prolonged, late or severe variables;
• Tachycardia + min variability
– Success = complete resolution (10 min)
Terbutaline:
– Fewer median UCs (2.9 vs. 4 UCs/10 min)
– Resolution of tachysystole (1.8 vs. 18.9%)
• Similar rates of successful resuscitation (72 vs. 64%, NS)
• Maternal MAP decreased with Nitroglycerine
• No differences in Ob Outcomes
Pullen KM AJOG 2007

Audience Poll
29 yo G1 at 39 5/7 weeks with SOOC and SVE of 5/80/-1 FHR
150s mod variability and recurrent severe variables.
Toco: q2-3
A. A: None, with mod variability - fetus is unlikely
acidemic
B. B: Position change, Fluid bolus – “Fix” those
variables
16%
C. C: Position change, Fluid bolus and O2
0%
D. D: If B doesn’t work, AROM and Amnioinfusion
E. E: Cesarean: too remote from delivery
IUR: Suspected umbilical cord compression
• 19 trials, n=>1000
• Reductions in:
– FHR decelerations (RR 0.53)
– CD for NRFHT (RR 0.62) & Endometritis (RR 0.45)
– Apgar <7 at 5 min (RR 0.47)
– Meconium below cords (RR 0.53)
• Maternal risks
– Appears to be generally safe, No increased risk in VBAC
Hofmeyr GJ, Cochrane Review 2012
6/8/2018
IUR: Suspected umbilical cord compression
• Umbilical cord compression – recurrent severe
variable decelerations despite position change
• Concept: alleviate cord compression via infusion of
NS/LR into the uterus with IUPC
53%
• Beware of iatrogenic poly – ensure fluid egress
26%
4%
Hofmeyr GJ, Cochrane Review 2012
IUR: Stage II Alternate Pushing
• Consider interruption of pushing  fetus to recover
• Decrease frequency and length of each effort
– 3-4 efforts for 6-8 seconds
• Effort with every other UC or every third
• Some advocate laboring down – cat II?
• Few adequate well designed trials to provide clear
recommendations
– “Street Smarts”
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Audience Poll IUR: Hyperoxygenation

29 yo G1 at 41 5/7 weeks IOL now pushing for 1h. +1 OP • Recurrent late or prolonged decelerations
FHR: tachycardia, min variability, intermittent lates.
36% – May represent fetal hypoxia
Position, IVF bolus, push every other - done. 34%
O2 at 10L/min, non- rebreather. How long? – Action: Increase delivery of O2 to fetus & prevent acidemia
• No studies: Maternal oxygen for fetal distress
A. A: 30 min
14% 13%
B. B: Until FHR improves significantly • 6 studies, <100 women in labor without NRFHT
C. C: 60 min 3% – 10L/min, nonrebreather  FiO2 of 80-100%, route/amount varied
D. D: As long as it takes to move for CD – Increases fetal oxygenation (fetal SpO2, scalp/cord sample etc.)
– Improves FHR pattern
E. E: No limit, O2 is beneficial
Fawole B, Cochrane Review 2012

Hyperoxygenation – Potential benefits Hyperoxygenation – Potential benefits

• Maternal O2 (40-100 FiO2), Term, Labor n=24 • O2 with IVF and position change
• 30 minutes on/off for each treatment – Elective IOL, oxytocin, epidural, n=56, normal FHR
• Abnormal FHR – Increase fetal Sp02 ~8.7%
– Intermittent or recurrent variable or late decelerations – Effect lasted about 30 min after discontinued
– Decreased variability or tachycardia – Effect was greater in fetuses with lower (<40%) saturations

• Increased mean fetal SpO2

– 4.9 (FiO2 40%) to 6.5% (FiO2 100%) • Fetal oxygen saturation is not utilized
• No outcomes/morbidity reported – Limited utility

Haydon ML 2006 Am J ObGyn Simpson KR Obstet Gynecol 2005


Hyperoxygenation – Potential benefits
• Can O2 improved NRFHT? Treat/Limit/Reduce acidemia
• 100% O2, n=21, tachycardia, “type II dips”1
– Tachycardia, late decelerations resolved/improved
– NRFHT returned after O2 discontinued
• Other studies illustrated improved FHR characteristics
– Resolution of late decelerations2
– Improved variability, non reactive  reactive3
1) Althabe O Am J Obstet Gynecol 1967 2)Khazin Am J Obstet Gynecol 1971
3) Bartnicki In J Ob 1994
Hyperoxygenation - Potential harms
• Prospective cohort – composite morbidity, n=>7000
– Death, MAS, intubation, ventilation, HIE, hypothermia
– Hyperoxemia –UV partial pressure O2 - >90thcentile
• 80-90% of cohort had O2 (200 min)
– No difference in morbidity with and without hyperoxemia
• 1.5% vs 1.3%
– Hyperoxemia plus acidemia (pH<7.1)
• Increased composite morbidity (RR 2.3)
– O2 reoxygenation injury?
Raghuraman N Obstet Gynecol 2017
6/8/2018
Hyperoxygenation - Potential harms
• Term RCT, stage 2, 10L O2 (FiO2 of 0.81)
– n=86, O2 on for stage 2
– Mean 36 min O2, Stratified by >10 (prolonged) or <10min
– No CD for fetal indications, normal FHR
– Lower pH (<7.2) in those who had O2 (RR 3.51)
– CUA worse with O2 (pH, PO2, PCO2, base excess)
– Cord pH lower in prolonged O2 group (7.24 v 7.29 v. 7.31)
• Statistical but not clinically different
• Methodological concerns
Thorp JA Am J Obstet Gynecol 1995
O2 administration – Harmful?
• Hypoxia leading to acidemia followed by Hyperoxia
may lead to injury
– Oxygen free radicals  oxidative stress  injury
– Is oxidative stress causal or a consequence of the
sequelae of hypoxia? Unknown in a fetus
• Neonatal resuscitation – recommend FiO2 of .21
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O2 administration – Controversy O2 administration – Controversy

O2 administration – Controversy O2 administration – Controversy

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O2 administration – Harmful? Conclusions – Intrauterine Resuscitation

• Common, like FHR – IUR will be utilized
• Abstract
• Safe and potentially efficacious
– Noninferiority
– IVF, position change, alternate push pattern – Individualized
• Safe and likely efficacious
• O2 therapy – Second tier therapy – Amnioinfusion – Severe variables, stage I
– After position change, IVF fluid, stop/decrease uterotonics • Iatrogenic Polyhydramnios
• Unlikely needed if FHR has moderate variability
– Stop uterotonics / Tocolytics – terbutaline
- If using, Discontinue when FHR is improved • Maternal tachycardia
- Develop timing protocols
• Safety uncertain / Efficacy – short term
– Hyperxoygenation – timing is everything
• Second tier approach – Shortest time feasible, be aware of
pattern evolution, remove if improvement

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