Intrapartum Fetal Monitoring

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Session Outlines
 Objectives
 Overview Of Intrapartum Fetal Well Being Assessment
 Introduction
 Pathophysiology of Fetal Oxygenation
 Components And Effects of Intrapartum Fetal Monitoring (IFM)
 Electronic Fetal Monitoring (EFM)
 Intermittent Auscultation (IA)
 Adjunctive Technologies
 Efficacy Of Fetal Surveillance and The Controversial Theories
 Recommendations And Consensus Statements Of Selected Organizations
 References

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Objectives Of The Session
 Associate the oxygen pathway, compensatory fetal mechanisms to oxygen
deprivation and fetal response to interruption of oxygenation with Hypoxia/Acidosis
 Standardization on nomenclature/definitions/interpretation for FHR features
 Delineate the strengths and shortcomings of components of IFM
 Discuss future trends in fetal monitoring
 To evaluate the impact of intrapartum fetal monitoring on neonatal and maternal
outcome by reviewing data on the efficacy it's components
 Describe recommendations and consensus statements to develop an overall
assessment and general management plan.
 Discuss pros and cons in implementing CEFM in our hospital
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THE OVERVIEW

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 Introduction
 Intrapartum monitoring is intended to assess the adequacy of fetal
oxygenation and uterine activity during labor so that appropriate measures can
be taken to:
 Avoid hypoxic fetal injury
 Ensure appropriate labor progress
 Optimize the likelihood of safe vaginal delivery
 The main goals/aim of intrapartum fetal monitoring:
 Avoid adverse fetal outcome related to intrapartum hypoxia/acidosis.
 Avoid unnecessary intervention, associated with increased maternal and fetal risks.
* Unfortunately there is no available tool to determine this accurately

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 Pathophysiology Of Fetal Oxygenation
 Fetal brain modulates the FHR through ANS  FHR monitoring can be an
indicator of whether or not a fetus is well oxygenated.
 The Normal Fetal Oxygenation:
≈ The Oxygen Pathway
 Interruption of Oxygenation:
≈ Compensatory mechanisms
≈ Hypoxemia (Transitory)  Hypoxia
[(progressive, Anaerobic metabolism
(limited time, 19× less energy, LA)]  
Metabolic acidosis ( intracellular acids) 
  Metabolic Acidemia ( arterial pH)
≈  pH +  energy  Compromised cell
function   Cell death    Organ
damage     Death
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 Components And Effects Of IPFM
 In order to avoid adverse outcome, fetal surveillance requires:
 Assessment of risk factors
 The adequate equipment , Trained staff availability and level of comfort
 Informed consent of the patient
 Timely clinical response
 The methods of intrapartum fetal surveillance include:
1. Intermittent Auscultation
2. Electronic monitoring or cardiotocography
3. Adjunctive technologies

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 Intermittent Auscultation (IA)
 Listening to the FHR for short periods of time without a display of the resulting
pattern.
 The fetal stethoscope
 Prerequisites:
 Singleton, term
 No serious medical/obstetric conditions
 Normal fetal growth
 Normal amniotic fluid and Doppler
 Normal antenatal BPP/NST
 No previous uterine scar
 Normal fetal movements
 No ROM > 24 hours
 When to Auscultate

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 Evaluation:
 Identify fetal position
 FHB + MHR + UC + fetal movements
 Measure And Register:
≈ FHR
≈ The rhythm
≈ Accelerations/decelerations
 Frequency And Duration Of Evaluation:
≈ Evidence from clinical trials not available.
≈ Consensus suggests:
* For low risk  Q30 min in 1st stage and Q15 min in 2nd stage
* For high risk  Q15 min in 1st stage and Q5 min in 2nd stage

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 Management
 The principle is
~ Assess FHR after implementing recommendations
~ Abnormal Findings:
≈ Tachy/Bradycardia
≈ Presence of repetitive or prolonged (>3 min) decelerations
≈ More than 5 contractions in 10 mins
* Extend evaluation over 3 UC to confirm
* If CTG available  transition to continuous CTG but When it’s not
available:
╞ FHR < 110 bpm for > 5 min  delivery
╞ FHR > 160 bpm for 3 UCs  assess for possible causes of tachycardia
╞ Repetitive decelerations  assess reversible causes of hypoxia, if no
effect  delivery

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 Effects Of Intermitant Auscultation
 Benefits:
≈ Inexpensive, simple, readily available and easily sustainable
≈ Promotes increased contact and support
≈ Facilitates assessment of other parameters
≈ Favours maternal mobility
 Limitations:
≈ Variability not evaluated
≈ Difficult to identify accelerations/decelerations
≈ Results slow learning curve with no independent confirmation/record
≈ More labour intensive
≈ May be difficult to use in certain maternal positions/body composition

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 Electronic Fetal Monitoring (EFM)/CTG
 CTG is A graphic recording of the FHR features, uterine activity and maternally
perceived fetal activity.
 Paper Stripes
~ The two Cartesian graphs
~ Horizontal VS vertical scale
 Tracing Acquisition
~ Lateral recumbent
~ Half-sitting, upright
~ Telemetry

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 Modes Of Electronic Fetal Monitoring
1. External Electronic Monitoring
 Non invasive and indirect application
* External FHR Monitoring
~ Doppler US  approximation to true FHR
~ Performed prior to labor  NST.
~ Problem:
≈ Artifacts  autocorrelation
≈ Do not record arrhythmias
* External Uterine Activity Monitoring
~ Tocodynamometer  relative frequency of UC
~ Problem:
≈ Failed/incorrect registration
≈ Duration, intensity and baseline uterine tone not assessed.
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2. Internal Electronic Monitoring
 Direct transcervical application and is invasive
 Indicated when acceptable record not possible with external
* Internal FHR Monitoring
~ ECG Electrodes
~ Accurate assessment of:
≈ FHR
≈ Fetal cardiac arrhythmia
* Internal Uterine Activity Monitoring
~ IUPC
~ Quantitative information on:
≈ Intensity And Duration Of Contractions
≈ Basal Uterine Tone

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 Prerequisits:
~ ROM, Cx dilated
~ Access to fetal presenting part
~ No contraindications like:
┌ For fetal ECG electrodes
≈ Active HSV, HIV, hepatitis
≈ Fetal blood disorders
≈ If artificial ROM is inappropriate
≈ Uncertainty about presenting part
┌ For IUPC
≈ Haemorrhage
≈ low lying placenta
 Problem:
~ Risk of fetal injury, placental haemorrhage, infection
~ Not recommended for routine clinical use
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 Analysis of EFM/CTG Features
Basic CTG Features
 FHR Patterns are categorized as baseline, periodic, or episodic which include:
~ Baseline Rate: Normal, tachycardia, bradycardia and Wandering Baseline
~ Variability: Absent, minimal, moderate (normal), marked (saltatory)
~ Accelerations
~ Deceleration: early, variable, late, prolonged and the atypicals
~ Sinusoidal and Pseudo-sinusoida Patterns
~ Changes over time
 The uterine activity is the contraction
~ Normal
~ Coordinated Vs Uncoordinated: Hypertonus, Hyperstimulation and tachysystole

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FHRP Recognition And Interpretation
 Analysis of CTG to make a clinical decision involves:
~ The Clinical Setting:
≈ G/A
≈ Risk assessment:- Antenatal conditions, Medications…
≈ Prior results of fetal assessment  to assess whether they can be used as
a baseline for the current monitoring
≈ Current clinical situation, and indication for CTG
~ Qualitative and quantitative assessment of traces
≈ Set the limits acceptable as normal for THIS trace BEFORE starting the assessment
≈ Individual FHR features vs overall assessment (DR C BRAVADO)
~ The Stage of labor

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5. NICHD The Three Tier Categorization System:

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 Interpretation of FHRP tracings for assessing mechanisms of fetal
oxygenation interruption is helpful only at the time they are observed
~ Moderate variability and/or accelerations reliably exclude ongoing hypoxic
injury.
~ Short, shallow decelerations  mild reduction in fetal O2 tension.
~ Repetitive, deep, prolonged decelerations  may be associated with
development of Hyoxia & metabolic acidosis
~ A higher baseline rate & loss of variability are may have additional signs of fetal
decompensation.

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* Pitfall in attributing abnormal FHRP to fetal hypoxia/acidosis is presence of Non-
hypoxic causes:
► Prematurity:- Increased baseline rate, decreased variability, reduced
frequency and amplitude of accelerations
► Fetal sleep cycle:- Decreased variability, reduced frequency and amplitude
of accelerations
► Maternal fever, infections:- Increased baseline rate, decreased variability
► Congenital anomalies:- Decreased variability, decelerations
► Tachyarrhythmias:- tachycardia, decreased variability
► Heart block:- Bradycardia, decreased variability
► Pre-existing neurologic injury:- Decreased variability, absent accelerations
► Fetal anemia:- Sinusoidal pattern, tachycardia
► Medications:- drugs, epidurals
► Meconium aspiration
► Others:- Maternal heart rate artifact, Technical factors,
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 Management Of CTG Tracings
 Management must be based on clinical context, fetal tracing category and include a plan for further fetal surveillance if
labor is allowed to continue

 Management Of Intrapartum FHRP Based On NICHD Category .

Category I FHR tracings Management:
~ Normal tracings
~ May be monitored in a routine manner
~ No specific action is required.

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Category II/III FHR tracings Management:
~ A Standardized “ABCD” Approach to Management of Category II/III FHRP tracings:

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~ Further management depends on response to resuscitative/ corrective measures
and possible underlying causes
* Intrapartum Events Leading To Fetal Hypoxia/Acidosis:
1.Reversible Causes
≈ Uterine Contractions
≈ Cord Compression
≈ Maternal supine position
≈ Post epidural or spinal analgesia
2.Irreversible Causes
≈ Umbilical cord prolapse
≈ Major placental abruption
≈ Uterine rupture
≈ Fetal exsanguination

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 Intrapartum fetal heart rate (FHR) management algorithm

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 The Effects of EFM/CTG
 Benefits:
~ Labor saving device
~ Ability to understand mechanism of developing hypoxia management could
be directed to the cause
~ Detect contraction  able to see problems of power together
 Limitation:
~ Maternal discomfort  Telemetry
~ Medico legal litigation
~ The subjectivity of observer analysis
~ Unnecessary obstetric intervention that confers additional risks for the
mother and newborn
~ Increased risk of vertical perinatal transmission

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 Adjunctive Technologies
 Adjunctive technologies are aimed at reducing false-positives with CTG and the
resulting unnecessary intervention
 Indicated:
 Persistent NRFHR despite non surgical interventions
 Attempts to find out whether the hypoxia has progressed to metabolic acidosis
 Include:
 Fetal stimulation (FS)
 Fetal blood sampling (FBS)
 Pulse oximetry (discontinued)
 Fetal electrocardiography (CTG+ST)
 Computer analysis of CTGs (cCTG)
 Continuous pH and lactate (discontinued)
 Umblical cord blood gas analysis

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1) Fetal Stimulation (FS)
 Methods:
≈ Digital Scalp stimulation
≈ Vibroacoustic stimuli (VAS)
≈ fetal scalp puncture
≈ Allis clamp scalp stimulation
 Indications:
≈ Reduced variability  deep sleep vs. hypoxia/acidosis
≈ This should be performed when the FHR is at its baseline rate
 Evaluation And Management:
Accelerations and normal CTG  the fetal pH is >7.20 in >90 % of cases 
≈
very predictive of absent hypoxia/acidosis
≈ No accelerations, no change in pattern  pH is <7.20 in 50 % of cases 
limited predictive value  repeat test or do FBS
 FS may reduce FBS use by 50%  Not evaluated in RCTs
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2) Fetal Blood Sampling (FBS)
 Assess the presence and degree of acidemia by analyzing fetal capillary blood’s
PH and alternatively lactate.
 Indications:
≈ Late deceleration persists >30min
≈ NOT advised in severe and acute events
 Contrandications: as in internal EFM, G/A < 34wks
 Techniques:
≈ ROM, ≥ 3 cm.
≈ Amnioscope
≈ Dry presenting part
≈ 1-2 mm incision.
≈ Collection
≈ Inspection

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 Benefits and limitations:
≈ May reduce operative deliveries
≈ Difficult to perform in early labour  Cx at 4-5cm, Station -1 /below, ROM
≈ No evidence that fetal outcomes are improved
≈ Information quickly becomes outdated
≈ Not patient/user-friendly  cumbersome, repeat sample and time-consuming
(~18 minutes pH, ~2 min lactate)
≈ Risk of infection and bleeding

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3) Fetal Pulse Oxymetry
 It accurately determine the oxygen saturation  direct assessment of fetal
oxygenation
 It gives adequate signal in 30 - 70 % of the cases
 Prerequisites
~ ROM and Cx 2-3 cm
~ Fetal accessibility
 Interpretation
~ If the fetal oxygen saturation remains above 30% during labor, there
appears to be no risk of acidosis.
~ A saturation below 30% and sustained one ( >10 minute ) for required
acidosis to develop

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 Problems:
~ Only quantifies the saturation, not the mechanism of hypoxia
~ Problem of the vertex in light transmission (vernix, hair,meconium)
~ Development capute creates stasis
~ Low pulse pressure of the fetus
~ Fetal Hg alters absorption curves of the normally used red and infrared
wavelengths
~ Critical threshold for fetal acidosis below which occur
* Currently special sensor that lie to the cheek of the fetus overcome this
problems
~ No large clinical trial  Pulse oximetry has not been demonstrated to be a
clinically useful test in evaluating fetal status.

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4) Fetal ECG analysis (STAN)
 Using electrodes to asses T-wave amplitude, ST Changes (shape, events) in
addition to CTG FHRP .
 Prerequisites:
~ Presence of acceleration and moderate variability
 Interpretations and interventions:

~ Elevated T-wave  Myocardial

glycogenolysis and anaerobic
metabolism
~ Biphasic STs  Depressor effect
of hypoxia on myocardium due to
infection, malformations,
prematurity…

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 Benefits and Limitations:
~ Continuous information
~ Several systematic reviews show:
o Lower need for FBS
o Modest reduction in operative deliveries
o Conflicting results for metabolic acidosis:
*  metabolic acidosis over time published by a few centres
* ST events in ≈ 50% well-oxigenated fetuses
~ Not extensively studied < 36 weeks

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5) Umbilical Cord Blood Gas Analysis
 Only objective way of quantifying hypoxia/acidosis occurring just prior to birth
or newborn circulation in 5th min of life
 Technique:
~ Sampling as soon as possible after birth (< 15 min)
~ 1-2 ml from artery and vein, heparinised syringes, remove air bubbles, cap
syringes, roll with fingers
~ Analysis within 30 min
 Interpretation:
~ Cord blood gas values may vary according to Gestation, Type and time of
birth

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 Benefits and limitations:
~ There is no contraindications
* The ACOG Committee recommends to obtain umbilical blood in the following situation:
≈ Cesarean delivery for fetal compromise
≈ Low 5-minute Apgar score
≈ Severe growth restriction
≈ Abnormal fetal heart rate tracing
≈ Maternal thyroid disease
≈ Intrapartum fever
≈ Multifetal gestations
~ Innocuous to the newborn
~ Relatively inexpensive
~ Important medical-legal value
~ Sampling of wrong vessel or Mixed sampling may occur

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6) Computer analysis of CTGs (cCTG)
 Objective evaluation of parameters that are difficult to assess visually
(variability)
≈ All incorporated in central monitoring stations
≈ Real-time visual and sound alerts
≈ Raise attention, prompt evaluation and action
 No management recommendations
 Two RCTs concluded (not published)
~ Satisfactory comparison with experts
~ Good prediction of newborn acidemia
~ Conclusion:
≈ Reproducible and quantifiable approach
≈ Promising technology
≈ Continued optimisation
≈ Further studies to compare systems and evaluate effect on outcomes and
interventions 36
Efficacy Of Fetal Surveillance And
Controversial Theories

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 Efficacy Of Fetal Surveillance
 Does intrapartum FHR monitoring improve outcome?
 Studies have shown, IA as compared to EFM, to be similar in detecting hypoxia
when:
≈ One to one nurse to patient ratio
≈ Monitored Q15 min in 1st stage and Q5 min in 2nd stage for full 60sec through
& following contraction
* Limitations of these studies were:
◊ May be patients was electronically monitored prior to randomization
◊ When the auscultation was abnormal they were monitored electronically
◊ Some NRHFR are not detectable by auscultation
◊ Difficulty to have one to one nurse ratio

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Recommendations And Consensus
Statements

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WHO Recommendations
 On routine assessment of fetal well-being in labour admission:
 Routine cardiotocography is not recommended for the assessment of fetal
well-being on labour admission in healthy pregnant women presenting in
spontaneous labour.
 Auscultation using a Doppler ultrasound device or Pinard fetal stethoscope is
recommended for the assessment of fetal wellbeing on labour admission.
 Intermittent auscultation of the fetal heart rate with either a Doppler or a
Pinard stethoscope is recommended for healthy pregnant women in labour.
 Continuous cardiotocography is not recommended for assessment of fetal well-
being in healthy pregnant women undergoing spontaneous labour.

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FIGO Consensus Statement
 Intermittent auscultation is recommended in all labours where there is no
access to CTG, but in area where CTG is available, it may be used in low-risk
cases.
 The interval is at least Q15min in active phase and Every 5 min in 2nd stage,
during and ≥ 30 secs after UC but ≥ 60 secs for 3 UC if abormal

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ACOG Recommendations
 Either EFM or IA is acceptable in uncomplicated patients who are at low risk of
developing intrapartum fetal acidosis
 IA:
≈ The intervals are at least Q30 min in the 1st stage of labor and every 15
minutes in the second stage.
≈ Auscultation performed - after contraction for 60 seconds with 1 : 1
nurse-patient ratio
 The EFM should be reviewed at least Q15 minutes in the 1 st stage of labor
and Q5 minutes during the 2nd stage
 High-risk pregnancies (eg, preeclampsia, suspected growth restriction, type 1
diabetes mellitus) should be monitored continuously during labor.

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NICE Consenses Statements
 In all birth settings, offer IA to low-risk women in the 1 st stage of labor. Do not
perform/offer CTG in low-risk women.
 Advise CEFM (CTG) if any of the following risk factors occur during labor:
 Maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
 Pain that differs from the pain normally associated with contractions
 Suspected chorioamnionitis, sepsis, or temperature ≥38°C
 Severe hypertension (≥160/110 mmHg), Diagnosed preeclampsia
 The presence of Significant meconium
 Fresh vaginal bleeding that develops in labour
 Hypertonus/tachysystole, Oxytocin use
 Confirmed delay in the first or second stage of labour
 If CEFM (CTG) was used because of concerns arising from intermittent
auscultation but the tracing is normal after 20 minutes of observation, remove
the CTG and return to intermittent auscultation.
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RCOG Consensus Statement
 For a woman who is healthy and has had an otherwise uncomplicated pregnancy,
intermittent auscultation (IA) should be offered and recommended in labour to
monitor fetal wellbeing.
~ In the AFSOL, IA should occur after a contraction, for a minimum of 60
seconds, and at least:
 every 15 minutes in the first stage
 every 5 minutes in the second stage
~ CEFM should be offered and recommended in pregnancies previously
monitored with intermittent auscultation:
 if there is evidence on IA of a baseline <110 />160 bpm
 if there is evidence on auscultation of any decelerations
 if any intrapartum risk factors develop
 CEFM should be offered and recommended for high-risk pregnancies where
there is an increased risk of perinatal death, CP or neonatal encephalopathy.
 It is not recommended to use of admission CTG in low-risk pregnancy. 44
Ethiopian FMOH Recommendation
 FHR - use Pinnard stethoscope for a women with no known problem Immediately
after a contraction for 1 min and every 30 min for a parturient without any risk
and every 15 min for with a risk condition
 Continuous electronic FHR monitoring for Known problem ( external/internal)

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Implementation of EFM In Our
Hospital

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Summary of Fetal monitoring during labour

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References
 Williams obstetrics, chapter 24 - Intrapartum Assessment. 25 th edition, 2018.
 Gabbe obstetrics: normal & problem pregnancy, chapter 15 - Intrapartum Fetal Evaluation. 7 th
edition, 2017.
 Hacker & Moore's Essentials Of Obstetrics & Gynecology, chapter 9 - fetal surveillance during
labor. 6th edition, 2016
 WHO recommendation on intermittent fetal heart rate auscultation and continuous
cardiotocography during labor. February, 2018.
 FIGO consensus guidelines on intrapartum fetal monitoring, Volume 131 (3-29). October, 2015.
 ACOG Practice bulletin, Intrapartum Fetal heart rate monitoring, Pb 106/Pb 116. November,
2017.
 ACOG committee opinion, fetal heart rate tracing in labor. February, 2019.
 NICE Pathway, Fetal monitoring during labor. December, 2018.
 RCM and RCOG joint statement on electronic fetal monitoring. July, 2018.
 IJOG, Delphi consensus statement on intrapartum fetal monitoring in low resource settings.
January, 2019.
 Management protocol on selected obstetrics topics (FMOH). January, 2010.
 Up To Date 2018, literature review on Intrapartum fetal heart rate assessment and management. 48
THANK YOU

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