Obstetrics 1
Intrapartum Assessment
Submitted by: Mamauag, Angela Beatriz C.
Trician Villarosa, MD
_________________________________________________________________________________________________________
I. ELECTRONIC FETAL MONITORING
A. Internal (Direct) Electronic
Monitoring
o Direct FHR measurement is accomplished by
attaching a bipolar spiral electrode directly to the
fetus
o The wire electrode penetrates the fetal scalp, and
the send pole is a metal wing in the electrode.
o The P wave, QRS complex, and T wave the
electrical fetal cardiac signal are amplified and fed
into a cardiotachometer for heart rate calculation.
o The peak R-wave voltage is the most reliably
detected portion of the fetal electrocardiogram
(ECG)
o Time (t) in milliseconds between fetal R waves is
fed into a cardiotachometer, and a new FHR is set
with the arrival of each new R wave
o Baseline variability
 It is the phenomenon of continuous R-to-R
wave FHR computation formerly known as
beat-to-beat variability (old)
o If present, fetal premature atrial contractions
(PACs) cause the cardiotachometer to rapidly and
erratically seek new heart rates and create the
“spiking”
o Electrical cardiac complexes detected by the fetal
electrode include those generated by the mother.
o However, the amplitude of the maternal ECG
signal is diminished when recorded through the
fetal scalp electrode. Thus, maternal cardiac
signals don’t appear in the FHR tracing
o However, if the fetus is dead, maternal R waves
can be still detected by the scalp electrode as the
next best signal and are counted by the
cardiotachometer
B. External (Indirect) Electronic
Monitoring
o Although it avoids membrane rupture, external
monitoring does not provide the precision of
internal FHR monitoring
o Moreover, in some women, external monitoring
may be difficult
o The FHR is detected through the maternal
abdominal wall using the ultrasound Doppler
principle
o The instrument contains a transducer that emits
ultrasound and a sensor to detect a shift in
frequency of the reflected sound
o The transducer is placed in the maternal abdomen
at a site where fetal heart action is best detected
o Coupling gel must be applied because air conducts
ultrasound waves poorly
o The device is held in position by an elastic belt
o Autocorrelation
 It is based on the premise that the FHR has
regularity, whereas “noise” is random and
lacks regularity
o Other features of current external monitors
include:
 Ability to monitor twin fetuses
 Concurrently assess maternal heart rate
 Display fetal ECG
 Record maternal pulse oximetry values
o Wireless, abdominal, dermal-path, external array
systems
 May improve the interpretability of
intrapartum FHR tracings in obese women
 Use electrocardiography to accurately
measure maternal and fetal heart rates yet
allow patient mobility during labor
C. Fetal heart rate patterns
o The interpretation of FHR patterns can be
problematic without definitions and nomenclature
o Pattern interpretation derives from the FHR that is
portrayed on the monitor or graph paper
o Thus, the choice of vertical and horizontal scaling
greatly affects patterns
o National Institute Child Health and Human
Development Workshop scaling parameters
recommend that each centimeter on the vertical
axis represents 30 beats per minute (bpm).
 Measurement markers on this axis range from
30 to 240 bpm.
o Along the horizontal axis, the heart render moves
at a speed 3 m/min
o The time between each bold vertical line on this
axis is 1 minute
o FHR patterns during labor are dynamic and
interchange rapidly
o Thus, a full description should include an
evaluation of changes or trends over time
D. Baseline fetal heart activity
o This refers to FHR baseline characteristics apart
from periodic accelerations or decelerations
o Elements include:
 Rate
 Variability
 Distinct FHR patterns such as sinusoidal or
saltatory.
Rate
o Beginning at 16 weeks’ gestation, the heart rate
drops approximately 1 bpm each week
o This continues postnatally such that the average
rate is 85 bpm by age 8 years
o This normal gradual slowing of the FHR is thought
to correspond to maturation of parasympathetic
(vagal) heart control
o Baseline fetal heart rate
 The approximate mean rate rounded to
increments of 5 bpm during a 10-minute
tracing segment
 In any 10-minute window, the minimum
interpretable baseline duration must be at
least 2 minutes- otherwise the baseline is
considered indeterminate.
o Bradycardia
 Third Trimester - the normal mean baseline
FHR ranges between 110 and 160 bpm
 Rate between 100 and 119 bpm, in the
absence of their FHR changes, usually is not
representative of fetal compromise
 Low baseline heart rates have also been
attributed to head compression from input
posterior or transverse positions, particularly
during secondstage labor
 Fetal Bradycardia may stem from congenital
heart block or from fetal hypoxia due to
maternal or fetal causes
o Tachycardia
 Maternal fever from chorioamnionitis and
other infections
 Fetal compromise – associated with
concomitant HR decelerations
 Cardiac arrhythmia
 Maternal administration of atropine
(parasympathetic drug) or terbutaline
(sympathomimetic drug)
Baseline variability
o It is an important index of cardiovascular function
o It reflects a sympathetic and parasympathetic
“push and pull” mediated by the fetal sinoatrial
node. This produces beat-to-beat fluctuations of
the baseline FHR
o Variability describes these changes during 1
minute, which modify the baseline’s waviness
o The NICHD workshop defined baseline variability
as irregular fluctuations in the baseline excluding
accelerations and decelerations
o Normal variability shows oscillations that change 6
to 25 bpm
o FHR variability increases with advancing
gestational age
o Increased Variability
 Greater variability accompanies fetal
breathing and body movements
 In one study of 390 fetuses, greater
intrapartum variability was associated with
abnormal fetal arterial cord blood gas
measurements but without increased
neonatal morbidity rates.
o Decreased variability
 Absent variability and minimal variability are
defined as no baseline fluctuation or changes
≤5 bpm
 Diminished variability can be an ominous sign
that indicates a seriously compromised fetus.
○ Diminished variability, when it reflects fetal
compromise, likely reflects acidemia rather
than hypoxia
 Severe maternal acidemia also can lower fetal
variability
 Reduced baseline FHR variability is the single
most reliable sign of fetal compromise.
 Another common cause of diminished
variability is administration of some analgesic
drugs during labor which include narcotics,
barbiturates, phenothiazines, tranquilizers and
general anesthetics
 Magnesium sulfate can diminish variability
and is widely used in the United States for
fetal neuroprotection, tocolysis, and seizure
prophylaxis in preeclampsia
  In summary, variability is affected by fetal
physiology, and its meaning differs depending
on clinical setting
 A decrease in variability but without
decelerations is unlikely to reflect fetal
hypoxia
 A persistently flat FHR baseline—absent
variability—within the normal baseline rate
range and without decelerations may reflect a
prior fetal insult that has resulted in
neurological damage
Cardiac arrhythmia
o When fetal cardiac arrhythmias are first suspected
using electronic monitoring, findings include
 Baseline bradycardia
 Tachycardia
 Abrupt baseline spiking
o Intermittent baseline bradycardia is frequently
due to congenital heart block
o Conduction defects, most commonly complete
atrioventricular (AV) block, usually are found in
association with maternal connective-tissue
diseases
o Scalp electrodes – fetal monitors can be adapted
to output the scalp electrode signals into an
electrocardiographic recorder
Sinusoidal heart rate
o True sinusoidal pattern may be observed with
 Fetal intracranial hemorrhage
 With severe fetal asphyxia
 With severe fetal anemia from rh
alloimmunization
 Fetomaternal hemorrhage
 Twin-twin transfusion syndrome
 Vasa previa with bleeding
o Insignificant sinusoidal patterns have been
reported following administration
 Meperidine
 Morphine
 Alphaprodine
 Butorphanol
o Sinusoidal pattern also has been described with
 Chorioamnionitis
 Fetal distress
 Umbilical cord occlusion
o Other investigators have proposed a classification
of sinusoidal HR patterns
 Mild—amplitude 5 to 15 bpm
 Intermediate—16 to 24 bpm
 Major—25 or more bpm to quantify fetal risk
o Pseudosinusoidal – intrapartum sine wavelike
baseline variation with periods of acceleration.
o Antepartum sine wave baseline undulation
portends severe fetal anemia
A. Periodic fetal heart rate changes
o Periodic FHR – refers to deviations from baseline
that are temporally related to uterine contractions
o Acceleration – refers to an increase in FHR above
baseline
o Deceleration - refers to drop below the baseline
rat
Accelerations
o Onset of acceleration to a peak in less than 30
seconds— in the FHR baseline.
o At 32 weeks’ gestation and beyond, the
acceleration has a peak of 15 bpm with a duration
of 15 seconds or more but less than 2 minutes
o Before 32 weeks, a peak of 10 bpm for 15 seconds
to 2 minutes is considered normal
o Prolonged acceleration was defined as 2 minutes
or more but less than 10 minutes
o Fetal heart accelerations during the first or last 30
minutes during labor, or both, was a favorable sign
for fetal wellbeing
o There is an approximately 50-percent chance of
acidemia in the fetus who fails to respond to
stimulation in the presence of an otherwise
nonreassuring pattern
o Most often occur antepartum, in early labor, and
in association with variable decelerations.
o Proposed mechanisms for intrapartum
accelerations include:
 Fetal movement
 Stimulation by uterine contractions
 Umbilical cord occlusion
 Fetal stimulation during pelvic examination
 Fetal scalp blood sampling
 Acoustic stimulation
Deceleration
o Decrease below the baseline rate.
o The nomenclature most commonly used in the
United States is based on the timing of the
deceleration in relation to contractions—thus,
early, late, or variable in onset related to the
corresponding uterine contraction
o The waveform of these decelerations is also
significant for pattern recognition.
o Early and late decelerations: the slope of FHR
change is gradual, resulting in a curvilinear and
uniform or symmetrical waveform
o With variable decelerations: the slope of FHR
change is abrupt and erratic, giving the waveform
a jagged appearance
o Description of decelerations is based on the
pathophysiological events:
 Early decelerations are termed head
compression
 Late decelerations are termed uteroplacental
insufficiency
 Variable decelerations become cord
compression patterns
Early deceleration
o Consists of a gradual decrease and return to
baseline associated with a contraction
o Physiologically, there is a HR drop with
contractions and that this was related to cervical
dilatation.
o Generally seen in active labor between 4 and 7 cm
dilatation
o The degree of deceleration is generally
proportional to the contraction strength and
rarely falls below 100 to 110 bpm or 20 to 30 bpm
below baseline
o Head compression probably causes vagal nerve
activation as a result of dural stimulation, and this
mediates the HR deceleration
Late deceleration
o This deceleration is a smooth, gradual,
symmetrical decline in the FHR that begins at or
after the contraction peak and returns to baseline
only after the contraction has ended.
o It reaches its nadir within 30 seconds of its onset
o Late deceleration’s depth is <10 to 20 bpm below
baseline
o These usually are not accompanied by
acceleration
o Often reflect poor uterine perfusion or placental
dysfunction.
o Late decelerations are the 1st FHR consequence of
uteroplacental-induced hypoxia.
o Fetal acidemia develops after frequent or
prolonged periods of hypoxia.
o Late decelerations alone do not predict fetal
acidemia
o Late decelerations plus decreased variability,
which itself is an indicator of less activity in the
cardioregulatory center of the medulla, are more
predictive of fetal acidemia and neonatal
morbidity
o The following can induce late deceleration
 hypotension from epidural analgesia (most
common)
 uterine hyperactivity from oxytocin
stimulation (most common)
 maternal hypotension
 excessive uterine activity
 placental dysfunction
Variable deceleration
o Defined as a drop in the FHR that begins with the
contraction’s onset and reaches a nadir in <30
seconds.
o The deceleration lasts between 15 secs and 2
minutes, its depth is ≥15 bpm in amplitude
o The onset of deceleration typically varies with
successive contractions.
o Most frequent deceleration pattern encountered
during labor
o Attributed to umbilical cord occlusion
o The slope of FHR change is abrupt and erratic,
giving the waveform its jagged shape.
o Often reflects some degree of umbilical cord
occlusion
o Represents reflexes that reflect either blood
pressure changes due to interruption of umbilical
flow or changes
o Recurrent variable decelerations with minimal to
moderate variability are indeterminate
o Recurrent variable decelerations with absent
variability are abnormal
o A saltatory FHR baseline is another pattern linked
to umbilical cord complications during labor
o The pattern is rapidly recurring couplets of
acceleration and deceleration causing relatively
large oscillations of the FHR baseline
o In the absence of other FHR findings, this pattern
does not signal fetal compromise
Prolonged deceleration
o This pattern is defined as an isolated deceleration o The only benefits reported for scalp pH testing are
with a depth >15 bpm and length ≥2 minutes but fewer cesarean deliveries for fetal distress
<10 minutes from onset to return to baseline o The scalp pH sampling does not increase delivery
o Difficult to interpret because they are seen in rate for fetal distress. They concluded that scalp
many different clinical situation pH sampling was unnecessary
o Epidural, spinal, or paracervical analgesia may o Fetal scalp blood lactate concentration was used
induce a prolonged deceleration as an adjunct to pH
o Scalp blood pH analysis and scalp blood lactate
analysis are equivalent in predicting fetal acidemia
B. Fetal heart rate patterns during
second stage labor
o Decelerations are virtually ubiquitous during the
second stage labor
B. Scalp stimulation
o Alternative to scalp blood sampling
o Both cord and fetal head compressions are
o HR acceleration in response to pinching of the
implicated as causes decelerations and baseline
scalp with an Allis clamp just before obtaining
bradycardia in this stage
blood was invariably associated with a normal pH
o Failure to provoke acceleration was not uniformly
predictive of fetal acidemia
C. Computerized interpretation
o FHR pattern interpretations are subjective. Thus,
the potential for computer assistance to enhance
the precision identifying abnormal patterns
appeared promising C. Vibroacoustic stimulation
o FHR acceleration in response to vibroacoustic
stimulation has been recommended as a
substitute for scalp sampling
o Response to vibroacoustic stimulation is
II. OTHER INTRAARTUM ASSESSMENT considered normal if FHR acceleration of at least
TECHNIQUES 15 bpm for at least 15 seconds occurs within 15
A. Fetal scalp blood sampling seconds after the stimulation and with prolonged
o Measurements of the pH in capillary scalp blood
fetal movements
may help to identify the fetus in serious distress o Vibroacoustic stimulation is an effective predictor
o It also emphasized that neither normal nor
of fetal acidosis in the setting of variable
abnormal scalp pH results have been shown to be
decelerations
predictive of infant outcome
o Although vibroacoustic stimulation in second-
o The procedure is now used uncommonly and is
stage labor is associated with FHR reactivity, the
not even available at some hospitals quality of the response did not predict neonatal
o The pH of fetal capillary scalp blood is usually outcome or enhance labor management
lower than that of umbilical venous blood and
approaches that of umbilical arterial blood.
o Confirmation of fetal distress
D. Fetal pulse oximetry
 If the pH is > 7.25, labor is observed
o Technology similar to that of adult pulse oximetry.
 If between 7.20 and 7.25, the pH
o Tool measures fetal oxyhemoglobin saturation
measurement is repeated within 30 minutes.
once membranes are ruptured
 If the pH is <7.20, another scalp blood sample
o Unique padlike sensor is inserted through the
is collected immediately, and the mother is
cervix and positioned against the fetal face
taken to an operating room and prepared for
o 30% → lower limit for normal fetal oxygen
surgery
saturation
 Delivery is performed promptly if the low pH
o U.S. Food and Drug Administration (FDA)
is confirmed. Otherwise, labor is allowed to
approved → Nell-cor N-400 Fetal Oxygen
continue, and scalp blood samples are
Monitoring System.
repeated periodically
 E. Fetal electrocardiography
o As fetal hypoxia worsens, the fetal ECG changes.
o Mature fetus with hypoxemia develops an
elevated ST segment and a progressive rise in the
T-wave height that can be expressed as a T:QRS
ratio
o Increasing T:QRS ratios
 To reflect fetal cardiac ability to adapt to
hypoxia
 Appear before neurological damage
o Further worsening of hypoxia then leads to
progressively negative ST-segment deflection that
creates a biphasic form
III. NONREASSURING FETAL STATUS
o Nonreassuring designation suggests inability to
remove doubt
o Heart rate control stems from interconnected
mechanisms that depend on blood flow and
oxygenation
o Normal labor is a process of repeated fetal hypoxic
events and an infrequently lead to significant
acidemia
A. Diagnosis
o Category I or II training with a 5-minute Apgar
score >7 or with normal arterial blood acid–base
values is not consistent with an acute hypoxic-
ischemic event
o Five-tier system had better sensitivity than the
three-tier one
IV. MECONIUM IN THE AMNIOTIC FLUID
o Fetuses may pass meconium in response to
hypoxia, and meconium therefore signals fetal
compromise
o However, in utero passage meconium may
represent normal gastrointestinal tract maturation
under neural control
o Common but transient umbilical cord entrapment
leads to vagal stimulation, increased bowel
peristalsis, and meconium passage
A. Management options
o Initial management variant FHR patterns aim to
correct any fetal insult, if possible
o The woman is moved to lateral position, and
supplemental oxygen is provided by mask.
o Correct maternal hypotension caused by regional
analgesia and discontinuing oxytocin both serve to
improve uteroplacental perfusion. Vaginal
examination excludes a prolapsed cord or
impending delivery
o Three maneuvers that significantly raise fetal
oxygen saturation levels
 IV hydration with 500 to 1000 mL lactated
Ringer solution given over 20 minutes
 Lateral versus supine positioning;
 Administration supplemental oxygen at 10
L/min using a nonrebreathing mask
Tocolysis
o Terbutaline sulfate given to relax the uterus can be
a temporizing maneuver in the management of
nonreassuring FHR patterns during labor
o A single 250-μg IV or subcutaneous injection is
used to inhibit uterine contractions and thereby
improve fetal oxygenation
o The American College of Obstetricians and
Gynecologists (2019b) cites that evidence is
insufficient to recommend tocolysis for
nonreassuring FHR patterns. We consider
terbutaline during labor stimulation to resolve
tachysystoleassociated prolonged decelerations.
However, the chance of success is balanced
against terbutaline’s side effects should cesarean
delivery be needed for unresolved bradycardia.
o Contraindications
 Maternal cardiopulmonary disease
 Poorly controlled hyperthyroidism
 Maternal or fetal tachycardia with loss of
variability
Amnoinfusion
o For variable decelerations, other studies also
support amnioinfusion to reduce variable
deceleration frequency, improve neonatal
outcome, and lower cesarean delivery rates.
o Amnioinfusion is a reasonable approach to treat
repetitive variable decelerations but not late
decelerations
o Attempts to flush out or dilute thick meconium
are not recommended
o Despite differing amnioinfusion protocols, most
provide a 500- to 800-mL bolus of warmed normal
saline, which is followed by a continuous infusion
of 3 mL/min
B. FHR patterns and brain injury
o Complete asphyxia was produced by total
occlusion umbilical blood flow that led to
prolonged deceleration
o Fetal arterial pH did not drop to 7.0 until
approximately 8 minutes after complete cessation
of oxygenation and umbilical with at least 10
minutes prolonged deceleration were required
before surviving fetuses demonstrated brain
damage
o Persistent nonreactive FHR tracing was already
present at the time of admission in 70% of
neurologically impaired fetuses.
C. Benefits of EFHR monitoring
o Fetal monitor – implies that inanimate technology
in some fashion “monitors.”
o The assumption is made that if a dead or damaged
infant is delivered, the tracing strip must provide
some clue, because the fetal monitor was
monitoring fetal condition → Led to great
expectations and the belief that all neonatal
deaths or injuries were preventable
o Electronic fetal monitoring increased the rate of
cesarean and operative vaginal deliveries but
produced no declines in rates of perinatal
mortality, neonatal seizures, or cerebral palsy
o Despite being widely used; electronic fetal
monitoring has failed as a public health screening
program.
o Fetal monitoring increased operative delivery
rates but decreased early neonatal mortality rates
on singleton live births
o Temporal increase in fetal monitoring was
associated with a decline in neonatal mortality
rates, especially in preterm gestations
V. INTRAPARTUM SURVEILLANCE
UTERINE CAVITY
o Analysis of electronically measured uterine
activity
o Permits some generalities concerning the
relationship of certain contraction patterns to
labor outcome
o Uterine muscle efficiency to effect delivery varies
greatly
A. Patterns of uterine activity
o Contraction intensity- defined as the rise in this
pressure above a resting pressure baseline
o Uterine performance
 Product of contraction intensity in mm Hg
multiplied by the number of contractions in a
10- minute span
 For example, three contractions in 10 minutes,
each with 50-mm Hg intensity, would equal
150 Montevideo units
o Clinical labor
 Reaches values between 80 and 120
Montevideo units
 Three contractions of 40 mm Hg every 10
minutes
 No clear-cut division marks labor onset
o First-stage labor
 25 mm Hg at labor commencement to 50 mm
Hg at its end
 Advances from three to five contractions per
10 minutes
 Uterine baseline tone rises from 8 to 12 mm
Hg
o Second stage labor
 Aided by maternal pushing
 Contraction intensity of 80 to 100 mm Hg is
typical
 Five to six times each 10 minutes
o Uterine contractions are clinically palpable only
 Exceeds 10 mm Hg
 Until the intensity of contractions reaches 40
mm Hg, the uterine wall can readily be
depressed by the finger
 At greater intensities, the uterine wall then
becomes so hard that it resists easy
depression
 Not associated with pain until their strength
exceeds 15mm Hg.
o The uterus that performs poorly before delivery is
also prone to atony and puerperal hemorrhage
OF
B. Uterine contraction terminology
o Normal uterine activity
 Defined as five or fewer contractions in 10
minutes, averaged during a 30-minute span
o Tachysystole
 More than five contractions in 10 minutes,
averaged over 30 minutes
 Applied to spontaneous or induced labor
C. Electronic fetal monitoring complications
o Rarely, an intrauterine pressure catheter may
lacerate a fetal vessel in the placenta during
placement
o Also with insertion, placental and possibly uterine
perforation can cause hemorrhage, abruption, and
spurious recordings that have resulted in
inappropriate management
o Severe cord compression has been described from
entanglement with the pressure catheter
o Injury to the fetal scalp or breech by a FHR
electrode is rarely severe. However, face
presentations pose risk for eye or mouth trauma.
o Both the fetus and the mother may be at greater
risk of infection from internal monitoring
o Scalp wounds from the electrode may become
infected, but subsequent cranial osteomyelitis is
rare