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Fetal distress

Prepared by:

Dr. Gehanath Baral


MBBS,DGO,MD
Senior Consultant Gynecologist & Obstetrician: Government of Nepal
Visiting Professor: CTGU
30th Mar,2007

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Definition

Fetal distress is defined as


depletion of oxygen and
accumulation of carbon
dioxide, leading to a state
of “hypoxia and acidosis ”
during intra-uterine life.

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Definition

1) “Meconium", from simple meconium passage


immediately prior to birth or during the act of delivery to
meconium staining of amniotic fluid during labor, at
spontaneous membrane rupture, or on amniocentesis,

2) Abnormal antepartum testing including reduced


biophysical profile score, fetal heart rate abnormalities
including severe variable decelerations, late
decelerations and extended bradycardia, reduced beat-
to-beat variability, and sustained tachycardia, and/or

3) Fetal acidosis on scalp sample.

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MECONIUM STAINING:

Definition:
The presence of fetal stool in the amniotic fluid, indicative of fetal
distress.
Increased incidence with post-term delivery, & small-for-
gestational-age infants.
Risks:
• Increases risk of “meconium aspiration syndrome”& severely
depressed infant
• Increased perinatal mortality, hypoxemia, aspiration pneumonia, &
pneumothorax.

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Meconium:

The significance of meconium passage is very different at different gestational ages. The
fetal gut matures progressively, moving meconium ever closer to the terminal colon.
Meconium passage at term, therefore, may reflect a trivial and unsustained stressful event
without fetal or neonatal repercussions. In the term infant, meconium passage in the
absence of the stress during labor, or prior to membrane rupture (e.g. at diagnostic
amniocentesis) may be more significant. On the other hand, passage of meconium in a
preterm fetus may imply a significant, possibly protracted stress sufficient to move
meconium over a greater colonic distance. Midtrimester passage of meconium may be
associated with acute ascending infection causing a fetal gastroenteritis and diarrhea. Acute
meconium soilage, occurring immediately preceding or during delivery, can be easily
washed off the surface of the amnion. Meconium that sits on the amnion surface will begin
to cause amnion damage. The initial change is individual cell necrosis, followed by amnion
hyperplasia, pseudostratification and vacuolation. Meconium is phagocytosed by
macrophages in the membranes and eventually cleared from the amnion fluid. What time is
required to clear meconium from the amniotic fluid, and whether meconium is ever cleared
from cells of the extraplacental membranes are unknown. It is worth recalling that all
prenatal health care measures including routine antepartum fetal heart monitoring
performed regularly for the last decade have not reduced the incidence of cerebral palsy or
mental retardation when appropriately adjusted for gestational age of observed populations.
In our experience, more "ominous" heart rate patterns generally occur in a fetus with a
chronically damaged placenta (e.g., chronic villitis or defective placentation

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Etiology
Maternal factors:
1. Microvascular ischaemia(PIH)
2. Low oxygen carried by RBC(severe
anemia)
3. Acute bleeding(placenta previa, placental
abruption)
4. Shock and acute infection
5. Obstructed of Utero-placental blood flow

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Placenta、umbilical factors:
1. Obstruction of umbilical blood flow
2. Dysfunction of placenta

Fetal factors:
4. Malformations of cardiovascular system
5. Intrauterine infection

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Pathogenesis
Hypoxia、accumulation of carbon
dioxide

Respiratory Acidosis
Acute fetal distress  ↓
FHR↑ → FHR ↓→ FHR ↑

Intestinal peristalsis

Relaxation of the anal sphincter

Meconium aspiration

Fetal or neonatal pneumonia
Chronic fetal distress  IUGR

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KEY TERMS
1. Amnioinfusion —A procedure whereby a physiologic solution such as
normal saline or lactated ringer's solution is infused through a lumen in an
intrauterine pressure catheter into the uterus to alleviate cord compression
and to help dilute meconium staining.
2. Amniotic fluid —The liquid in the amniotic sac that cushions the fetus and
regulates temperature in the placental environment. Amniotic fluid also
contains fetal cells.
3. Amniotomy—Rupturing or breaking the amniotic sac (bag of waters) to
permit the release of fluid.
4. Asphyxia—Lack of oxygen.
5. Deceleration—A decrease in the fetal heart rate that can indicate
inadequate blood flow through the placenta.
6. Hypoxia—A condition characterized by insufficient oxygen in the cells of the
body
7. Meconium—A greenish fecal material that forms the first bowel movement
of an infant.
8. Perinatal—Referring to the period of time surrounding an infant's birth, from
the last two months of pregnancy through the first 7 days of life.

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Clinical manifestation

Acute fetal distress Acute fetal distress

(1)FHR (2) Meconium staining of the


FHR>180 beats/min amniotic fluid grade I、II、III
(tachycardia) (3) Fetal movement
<100 beats/min Frequently → decrease and
(bradycardia) weaken
(LD) Repeated Late (4) Acidosis
deceleration FBS (fetal blood sample)
Placenta dysfunction pH<7.20
(VD) Variable deceleration pO2<10mmHg (15~30mmHg)
CO2>60mmHg (35~55mmHg)

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FHR pattern
1. Reactive or Normal variability:- FHR elevates at least 15 bpm above the
baseline heart rate for at least 15 seconds twice in a 20-minute period. FHR
rises briefly on movement.

2. Loss of variability:- A tracing that shows no variability at all. It is a flat


tracing and indicates that the baby has sustained a severe assault on its
central nervous system.

3. Extreme bradycardia/tachycardia:- If the baby's heart rate drops very low


or rises very high, for longer than a ten-minute period. During a contraction,
the flow of oxygen (from the mother) through the placenta (to the baby) is
temporarily blocked.

4. Early deceleration:- A drop in FHR during a contraction and recovers to a


normal level when contraction is over.

5. Late deceleration:- A drop in the baby's heart rate after a contraction

6. Variable deceleration:- Irregularly occurring bradycardia irrespective of


uterine contraction.

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Clinical manifestation

Chronic fetal distress

(1) Placental function


(24h E3<10mg or
E/C<10)
(2) FHR
(3) BPS
(4) Fetal movement
(5) Amnioscopy

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Management
 Remove the induced factors  Terminate the pregnancy
actively (4) Repeated LD and
severe VD
 Correct the acidosis: (5) Baseline variability
5%NaHCO3 250ML disappear with LD
(6) FBS pH<7.20
 Terminate the pregnancy
(1) FHR>160 or <120 bpm Forceps delivery
meconium staining or
(II~III)
(2) Meconium staining Caesarean section
grade III
amniotic fluid
volume<2cm
(3) FHR<100 bpm
continually
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Fetal monitor belt around a pregnant woman's
torso to record the heart rate of her baby

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Basic Features of FHR tracing

1. Baseline FHR - Mean level of FHR when this is stable, excluding


Accelerations and Decelerations (110-160 bpm)
• Tachycardia
• Bradycardia

2. Baseline Variability-5 bpm or greater than or equal to 5bpm,


between contractions
• Normal
• Non-reassuring-Less than 5 bpm or less but less than 30
min
• Abnormal-less than 5 bpm for 90 min or more.

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Baseline variability
1. The minor fluctuations on baseline FHR at 3-5
cycles/min produces Baseline variability.

2. Examine 1 min segment and estimate highest peak


and lowest trough.

3. Normal is 5-25 bpm– this indicates N-CNS.

4. NRCTGs- reduced or less than 5 bpm for 40 min or


more but less than 90 mins.

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Deceleration

Transient slowing
of
FHR below the
baseline level of
more than 15 bpm
and lasting for 15
sec.
Or more.

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Early Decelerations

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Late Decelerations

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Fetal rhythm

Fetal bradycardia/tachycardia Causes of Prolonged Decelerations


 Moderate Bradycardia 100-  Cord prolapse.
109 bpm
 Maternal hypertension
 Abnormal bradycardia less
than 100bpm.  Uterine Hypertonia

 Tachycardia 161-180 bpm  Followed by a VE or ARM or


SROM with High PP
 Abnormal Tachycardia more
than 180 bpm

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Variable Decelerations

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Prolonged Deceleration

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Sinusoidal pattern

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Category Definition

1. Normal A CTG where all four features fall


into the reassuring category.

2. Suspicious A CTG whose features fall into


one of the non-reassuring categories and the
remainder of the features are reassuring.

3. Pathological A CTG whose features fall into


two or more non-reassuring categories or one
or more abnormal categories.

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Non reactive CTG
Any of the following for more than 15min:
1. Persistent Late decelerations
2. Sinusoidal pattern
3. Variable decels
– Less than 70 bpm for more than 60 sec
– Persistent slow return to the baseline
– Long term variability less than 5 bpm
4. Tachycardia more than 160 bpm.
5. Recurrent prolonged deceleration 2 or more in15 min
and less than 70bpm for 90 sec .
6. Any on of the following for more than 60 min
– Tachycardia with variability less than 5bpm
– Persistent reduced baseline variability less than 5 bpm for more
than 60min.

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Feature Baseline Variability (bpm Decelerations Accelerations
(bpm))

Reassuring 110-160 = >5 None Present

Non-reassuring 100-109 < 5 for >40 to <90  Early deceleration The absence of
minutes  161-180 Variab le accelerations with an
deceleration otherwise normal
 Single p rolonged CTG are of uncertain
deceleration up to 3 significance
minutes

abnormal < 100 ,> 180 < 5 for = > 90 Atypical variable decelerations
sinusoidal min.
pattern > = Late decelerations
10 min.
Single p rolonged deceleration
>3 min.

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Fetal Blood Sampling: pH
• Normal-7.25-7.35

• Low –normal PH should be repeated in 30 min

• Values between 7.2 and 7.24 need further


evaluation

• Less than 7.20


– Significant asphyxia
– Eminent delivery

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FBS: Contraindications
1. Fetal
• Premature –less than 34 ks
• Active Herpes
• Known HIV,Hep B,C positive status.
• Thrombocytopenia.

2. Maternal
• Unfavourable Cx
• Mobile PP
• Malpresentation(face etc) uncertain??
• Pl Praevia or APH
• Sepsis

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Biophysical profile scoring
Observation for 30min: Normal=2; Abnormal=0;
Parameters Minimal normal criteria Score

1. NST Reactive 2

2. Fetal breathing 1 episode lasting >30sec. 2


movements
3. Gross body 3 discrete body or limb 2
movements movements
4. Fetal muscle tone 1Episode of extension of limb 2
or trunk with return of flexion
5. Amniotic fluid 1 pocket >2cm in 2 2
perpendicular planes

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Management based on BPP score

BPP score Interpretation Management

8-10 No fetal asphyxia Repeat test weekly

6 Chronic asphyxia If >36wks  deliver

4 Chronic asphyxia If >36wks  deliver;


If <32wksrepeat test in 4-6hrs

0-2 Certain asphyxia Test for 2hrs  persistent


score <4  deliver

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Apgar testing

• Five factors are considered in the evaluation


of a newborn and the word Apgar can be
used as a mnemonic to remember them, i.e.,
1. A = Appearance (or skin color)
2. P = Pulse
3. G = Grimace (or reflexes to stimuli)
4. A = Activity (or muscle tone)
5. R = Respiration

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Partograph and
Criteria for Active
Labor
• Label with patient
identifying information
• Note fetal heart rate, color
of amniotic fluid, presence
of moulding, contraction
pattern, medications given
• Plot cervical dilation
• Alert line starts at 4 cm--
from here, expect to dilate
at rate of 1 cm/hour
• Action line: if patient does
not progress as above,
action is required

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