COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF MIDWIFERY
MATERNITY AND RH NURSING POSTGRADUATE
CLASS
LECTURE ON INTRAPARTUM FETAL MONITORING

08/09/2021 By Yibelu Bazezew 1

Presentation outline
Objectives
 Introduction
Methods of IPFHR assessment
Interpretation of IPFHR patterns
Management of abnormal IPFHR patterns
Reference

08/09/2021 By Yibelu Bazezew 2

Objectives
At the end of this session the learners will be able to:
Define oxygen pathway
Recognize intrapartum fetal assessment methods
Discus intrapartum fetal heaart rate patterns
Recognize reassuring and non reassuring FHRPs
Identify possible management options for NRFHRPs abnormal test results

08/09/2021 By Yibelu B. (BSc, MSc) 3

08/09/2021 By Yibelu Bazezew 4
 INTRODUCTION
Definition of intrapartum fetal monitoring (IFM)
Observe the fetal behavior during labor
Goal of IFM
To detect hypoxia (to assess the adequacy of fetal oxygenation) during labor
and
 to initiate management depending upon the severity of hypoxia
• to prevent the potential consequences of fetal hypoxia
 Severe hypoxia in labor lead to metabolic acidosis which can cause fetal organ
damage or fetal death
In between contractions:
 the intraluminal pressure within the spiral artery (85 mmHg) is higher than
the intramyometrial pressure (10 mm of Hg) and
this maintain the uteroplacental blood flow
08/09/2021 By Yibelu Bazezew 5
Intro. cont.…
During peak uterine contractions:
Myometrial pressure (120 mm Hg) exceeds the arterial pressure (90 mmHg)
causing temporary halting of O2 delivery to the fetus through the
placenta
Depending upon the intensity and duration of contraction, fetal
hypoxia may develop.
In a normal labor, the baby is subjected to stress due to:
 Uterine contractions temporarily limit the uteroplacental circulation
 Head compression affecting the function of the vital centers of the brain
A healthy fetus can withstand the stress of labor within physiological limits
A compromised fetus and/or in a pathological state of labor, Nonreassuring fetal
status may appear abruptly

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 Transfer of O2 From the Environment to the Fetus

Oxygen path way

Environment Lung Heart Vasculature Uterus Placenta Cord

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O2 transfer conti….
Maternal Lungs
• Alveolar PO2 is approximately 100 to 105 mm Hg
Maternal Blood
• Oxygen requirement increased during pregnancy
• The tendency for hemoglobin to release oxygen is increased
Maternal Heart
• Reduced cardiac output resulting from
• Hypovolemia
• Compression of the inferior vena cava by the gravid uterus
• Due to other causes

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O2 transfer conti….
Maternal Vasculature
• Interruption of oxygen transfer from the environment to the fetus at the
level of the maternal vasculature commonly results from
Hypotension
hypovolemia
impaired venous return
 impaired cardiac output, or medication
Uterus
• Interruption of oxygen transfer from the environment to the fetus at the
level of the uterus commonly results from
 uterine contractions that compress intramural blood vessels and impede the
flow of blood
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O2 transfer conti….

Placenta

• Oxygen is transferred from the intervillous space to the fetal blood

and it depends upon:
the PaO2 of maternal blood perfusing the intervillous space

the flow of oxygenated maternal blood into and out of the intervillous space

the chorionic villous surface area, and

the rate of oxygen diffusion across the placental blood-blood barrier

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O2 transfer conti….
Intervillous Space PaO2
• The average intervillous space PaO2 is about 45 mmHg
Intervillous Space Blood Flow
• At term uterine perfusion accounts for 10% to 15% of maternal cardiac output
or 700 to 800 mL/min.
Chorionic Villous Surface Area
• This area may be limited by conditions that affect placenta architecture such
as infarction, thrombosis, inflammation, infection or insufficient placental
growth.
Diffusion Across the Blood-Blood Barrier
• At term, the placental blood-blood barrier is very thin, and the diffusion
distance is short.
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O2 transfer conti….

Interruption of Placental Blood Vessels

• Damaged chorionic vessels can allow leakage of fetal blood into the
intervillous space, leading to fetal maternal hemorrhage.
Fetal Blood
• Adequate delivery of oxygen to the fetal tissues is maintained by
greater hemoglobin concentration in the fetus
 greater affinity for oxygen
Umbilical Cord
• Interruption of the transfer of oxygen from the environment to the
fetus at the level of the umbilical cord can result from simple
mechanical compression.
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Methods of Intrapartum fetal monitoring

Intermittent Auscultation

Continuous fetal heart monitoring

 Electronic fetal heart monitoring (Cardiotocography)
2 types:
External: Indirect method
 Internal: Direct method
Meconium in the liquor amnii: clinical method

08/09/2021 By Yibelu Bazezew 13

 Methods of FHR monitoring ……

Intermittent auscultation of FHR: to indicate its rate, rhythm and

intensity using
Stethoscope
Fetoscope
A handheld Doppler (fetal Doppler)

08/09/2021 By Yibelu Bazezew 14

Methods conti ….

Evidences of distress in intermittent Auscultation

FHR >160/min or < 110/min

FHR takes a long time to come back to its normal rate after the
contraction passes off

Irregularity

08/09/2021 By Yibelu Bazezew 15

Methods conti ….

Advantages intermittent auscultation

Widely available

Easy to use

Inexpensive

Effective if done in consistent manner at appropriate interval for the

stage of labor
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Methods conti ….
Disadvantages intermittent auscultation

Not continuous

No hard copy or permanent record

Requires skill to use fetoscope

Unable to determine patterns of FHR

Unable to determine variability

Sometimes difficult (obesity)

Intensive /exhaustive
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 Methods conti…..
Meconium in the liquor amnii
 is a potential sign of fetal hypoxia
gives a crude idea of intrauterine fetal jeopardy
It acts as a toxin, if the fetus aspirates it
Pathogenesis:
Hypoxia →(↑) vagal response →(↑) peristaltic activity and relaxation of the anal
sphincter → passage of meconium.
Placental insufficiency → oligohydramnios → cord compression → hypoxia →
thick meconium → gasping breath → meconium aspiration
MSAF and NRHR pattern necessitates urgent intervention
RFHR pattern and thin MSAF can be managed expectantly

08/09/2021 By Yibelu Bazezew 18

FHR monitoring…….

Continuous electronic fetal monitoring (EFM)

Some indications of continuous EFM

Maternal conditions: Hypertension, previous cesarean delivery, induced
labor, APH, PROM, Systemic infection, Hypotension, etc.
Fetal conditions: IUGR, oligohydramnios, multiple pregnancy, abnormal FHR
on auscultation, etc.
Can be applied without indication

08/09/2021 By Yibelu Bazezew 19

 Electronic fetal monitoring (CTG)
Continuous recording & graphical representation of FHR & ux contractions
EFM-can either be performed externally(indirect) or internally(direct)
 External EFM

FHR is detected through maternal

abdominal wall using the ultrasound
Doppler principle

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External EFM……
Advantages

Noninvasive, less risk of trauma and infection to the mother and fetus

Can be used when membranes are intact (should not be ruptured)

No fear of vertical transmission of HIV and other viruses
Permanent record of FHR
Can be used in the outpatient areas and in the hospitals

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 External EFM……..

Disadvantage
Limited accuracy Not as accurate as IEFM

Sensitivity of the monitor is negatively affected by variables such as maternal

obesity and premature gestational age

It is more uncomfortable for the mother and limits her mobility

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Internal EFM
FHR bipolar spiral
electrode are applied directly
to the fetal scalp & second
reference electrode is placed
up on maternal thigh to
eliminate electrical
interference

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25
 IEFM……

Advantages of Internal EFM

Accurate FHR & measurement of uterine pressure

Direct FHR
More accurate FHR-clear base line, variability

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 IEFM CONT…..

Disadvantages IEFM
 Invasive procedure
Must have ROM
Increase risk of infections
Can only be placed if presentation is known
No face presentations, no eyes, not over fontanelles, or on genitals.
Can not be placed with maternal hx of STI’s or infections
Can not be used if placenta location is not known or with placenta Previa
Personnel needs to be trained to place internal scalp electrode
Sterile procedure
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 Fetal Heart Rate Patterns(FHRPs)

The clinical application of EFHR monitoring consists of 3 independent elements

1. Definition
2. Interpretation, and
3. Management
FHRPs
Baseline FHR
Baseline variability
Acceleration of FHR
Deceleration of FHR
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration
Sinusoidal pattern of FHR
08/09/2021 By Yibelu Bazezew 28
 FHRPs……..

 Baseline FHR
 is the mean FHR rounded to increment of 5bpm during a 10 minute
segment, excluding
 Periodic changes( acceleration and decelerations)
 Periods of marked FHR variability
 Segments of the baseline that differ by > 25 beats/min

 The minimum baseline duration must be at least 2min in a 10 min window

 Normal baseline FHB: 110-160 bpm
 Tachycardia baseline FHB: >160 bpm
 Tachycardia baseline FHB: <110 bpm
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 FHRPs……..
 Baseline Variability
 Differences in FHR from beat to beat
 Reflected as a line that fluctuates above and below the baseline
 Irregular in amplitude and frequency
 Visually quantitated as the amplitude of the peak-to-trough in bpm.
Results from constant interplay b/n the SN and PN arms of the fetal ANS
Is a reflection of an intact and active CNS and normal cardiac responsiveness.
The most useful single parameter in determining severity of hypoxia

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 Baseline Variability……
Good variability reliably excludes hypoxia
Absence of variability – non-reassuring but nonspecific
Baseline variability classifications
Absent: amplitude range undetectable (0-2bpm)

Minimal: amplitude range detectable but < 5 bpm

Moderate: amplitude range 6 to 25bpm: Reassuring(normal)

Marked: amplitude range >25bpm

 Can be associated with fetal hypoxia

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Baseline Variability……

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 Baseline Variability……

Causes of decreased variability

Hypoxia and acidosis

Fetal anomalies, especially of the CNS (anencephaly, severe hydrocephalus)

Extreme prematurity

Fetal behaviour states(Fetal sleep cycles):inactive/ sleep

Drugs: narcotics, analgesics, parasympatholytics

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FHRPs……..

Deceleration
Four principal type based on timing, relationships to uterine
contractions , duration and shape
Early
 Late
 Variable
 Prolonged

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Early decelerations
Visually apparent gradual decrease (defined as onset of
deceleration to nadir > 30 seconds) and return to baseline FHR
associated with a uterine contraction.

The nadir of the deceleration occurring at the same time as the

peak of the contraction.

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 Early decelerations conti…….

In most cases the onset, nadir, and recovery of the deceleration
are coincident with the beginning, peak, and ending of the
contraction, respectively.
Caused by compression of fetal head by the uterine cervix (4-
7cm cervical dilation)
Not associated with fetal hypoxia, acidemia or low APGAR
scores

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Early deceleration

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 Late deceleration
 Visually apparent gradual (defined as onset of deceleration to nadir > 30
seconds) decrease and return to baseline FHR associated with a uterine
contraction.

 The nadir of the deceleration occurring after the peak of the

contraction.

 In most cases the onset, nadir, and recovery of the deceleration occur after
the beginning, peak, and ending of the contraction, respectively.
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Late deceleration

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Late deceleration cont’d
Causes can be
Excessive Ux contraction (oxytocin)

Maternal hypotension

Vascular diseases of the placenta (post matures, HDP, DM, abruption)

Severe maternal anemia or hypoxemia

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Variable decelerations

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Variable deceleration

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 Variable decelerations cont’d

Causes
Oligohydramnios: compression
Nuchal cord/cord stretching
Cord prolapse

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 Prolonged deceleration

 Visually apparent decrease in FHR below the baseline

 The decrease from the baseline is > 15 beats/min, lasting > 2 minutes, but <
10 minutes from onset to return to baseline.

 If a deceleration lasts ≥ 10 min, it is a baseline change

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Prolonged deceleration

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Accelerations

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 Accelerations cont’d

Except those associated with variable decceleration, accelerations are

physiologic response to fetal movement.

Presence of acceleration (Spontaneous /stimulation) – reassuring

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 Sinusoidal pattern
 Visually apparent, smooth, sine wave-line pattern in FHR baseline with
a cycle frequency of 3–5/min which persists for 20 min or more
 Acceleration in response to movement absent

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Sinusoidal pattern cont’d
True sinusoidal pattern:

is due to hypoxia secondary to fetal anemia

Isoimmunization

Ruptured vasa previa

Feto-maternal hemorrhage

TTT

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 RFHRPs vs NRFHRPs

FHRPs recorded by an EFM is typically categorized as reassuring or non-reassuring.

Reassuring FHRP

a normal FHRP

associated with an infant vigorous at birth

indicates that there is minimal likelihood of acidemia at that point in time

it is not predictive of future states as tracing pattern can change.

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Components of RFHRPs
A baseline FHR of 110-160 bpm.

Absence of FHR deceleration(late or variable)

Age appropriate FHR acceleration.

Moderate FHR variability(5-25 bpm).

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Normal tracing

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NRFHRPs

NRFHRPs replaces the term fetal distress

associated with abnormal fetal acid base status at the time of observation

Prompt evaluation & intervention is nessasary.

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 Patterns that qualify as NRFHRP include

1. Absence of baseline variability plus one of the following

 Recurrent late decelerations
 Recurrent variable decelerations
 Bradycardia
 Prolonged deceleration

2. Sinusoidal pattern

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 Management of NRFHRP

1. Identify the cause of abnormality if possible like AP, cord

compression ,rapid descent

2. Correct the problem or start general measures that increase oxygen

delivery
Maternal position

Oxygen to increase fetal oxygen

Hydration

D/C Oxytocine
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 NRFHP Mgt cont’d

Tocolysis (terbutaline)
iaterogenic tachysystole is the leading cause of abnormality but with out
tachysystole not indicated.

Amnioinfusion- for cord compression but needs further surveillance

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 Summary

FHR accelerations & variability are reassuring findings that suggest the
fetus is neither hypoxemic nor acidotic

Repetitive, deep & prolonged decelerations reflect a more severe

abnormality and may become associated with development of metabolic
acidosis & hypotension

A higher baseline rate & loss of variability are additional signs of fetal
decompensation
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References

Obstetrics ,Normal and problem pregnancies,7th

edition. Steven G Gabe,2017

Williams obstetrics,25th edition .

Up-To- Date- 21.2

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 THANK YOU!!!

08/09/2021 By Yibelu Bazezew 59