Monitoring in Labour

Objectives
• Discuss fetal heart rate patterns using Continuous
Electronic Fetal Monitoring (CEFM) tracings.

• Compare the evidence between EFM and

structured intermittent auscultation (SIA)

• Discuss relevant physiology in fetal monitoring

• Describe systematic approaches in fetal
monitoring using Dr C Bravado
• Outline guidelines for fetal heart rate monitoring
using SIA
CEFM vs. SIA
Perinatal outcomes
50% reduction in neonatal seizures (RR0.50, 95%CI 0.31-0.80)

… but no significant difference in incidence of:

- long-term neurological handicap (RR1.74, 95%CI 0.97-3.11)
- or perinatal mortality (RR0.85, 95%CI 0.59-1.23)

Obstetric outcomes
- 66% increase in C. Section rate (RR1.66, 95%CI 1.30-2.13)

- 16% increase in instrumental delivery (RR1.16, 95%CI 1.01-1.32)

Alfiveric Z et al, Cochrane Database Syst Rev

2006
 Pathophysiology of FH rate changes

• Changes in FH rate patterns occur in response to changes

in O2, CO2, hydrogen ions and arterial pressure

• These changes are mediated via the vagus nerve,

chemoreceptors & carotid body baroreceptors
• It is difficult to measure fetal oxygenation and pH
continuously

• FH rate patterns only allow indirect assessment of fetal

acid-base balance. Fetal scalp sampling is required to
confirm whether the fetus is hypoxic…
Hinshaw K & Ullal A. Anaes Int Care Med (Aug 2007)
A systematic approach to CTG interpretation using EFM

DR. C. BRAVADO
Determine Risk
Contractions (< 5 in 10)
Baseline Rate (110-150bpm)
Variability (>5)
Accelerations-reassuring
Decelerations
Overall Assessment & Plan
Few centres in Tanzania have this facility - refer to ALSO
manual for further information
 “ DR C BRAVADO”
A systematic approach to CTG interpretation

Determine Risk
Assess degree of “clinical risk” in relation to
clinical outcome

• High
Comparable to TRAFFIC LIGHTS

• Low
Risk Factors
Maternal:
• Previous Caesarean section
• Pre-eclampsia
• Pregnancy >42 weeks
• Prolonged ROM >24 hours
• Diabetes
• Antepartum haemorrhage
• Significant medical condition – eg cardiac
Risk Factors
Fetal:
• Intrauterine growth restriction
• Oligohydramnios
• Preterm labour
• Multiple pregnancy
• Breech presentation
Risk Factors
Intrapartum
• Significant meconium-stained liquor
• Abnormal FHR on auscultation
 baseline <110 or >160 bpm
 any decelerations after a contraction
• Maternal pyrexia
• Fresh bleeding in labour
• Oxytocin augmentation
 “ DR C BRAVADO”
A systematic approach to CTG interpretation

Assess contraction pattern

• Rate
• Duration of contractions
• Coordinate or In-coordinate?
• Baseline Tone
 “ DR C BRAVADO”
A systematic approach to CTG interpretation

Baseline Rate

• Normal range 110-160bpm

• Baseline Bradycardia <110
• Baseline Tachycardia >160 bpm
 BASELINE RATE

BRADYCARDIA<110 TACHYCARDIA>160
• Gestation > 40 weeks • Excessive fetal
• Cord compression movement
• Congenital heart • Maternal anxiety
malformations • Gestation <32 weeks
• Drugs • Maternal pyrexia
eg.benzodiazepines • Fetal infection
• Chronic hypoxia
 “ DR C BRAVADO”
A systematic approach to CTG interpretation

Variability
The presence of normal fetal heart rate
variability is one of the best indicators of
intact integration between the central nervous
system and the heart of the fetus
• Normal ≥5 bpm
 VARIABILITY

Persistent absence of or reduced variability

is potentially ominous

Reduced Normal
 “ DR C BRAVADO”
A systematic approach to CTG interpretation
Accelerations

• Increase of at least 15 bpm above the baseline

for at least 15 seconds
• Associated with movement or stimulation
• Presence is the single best indicator of fetal
well-being
• An antenatal CTG should always contain
accelerations to be considered normal.
ACCELERATIONS
3 examples are highlighted
“ DR C BRAVADO”
A systematic approach to CTG
interpretation

• Early Decelerations mirror

contractions
• Fall of <60 beats from baseline
associated (almost exclusively)
with excellent fetal outcome
• True early uniform decelerations
are rare and benign and therefore
not significant
 “ DR C BRAVADO”
A systematic approach to CTG interpretation
Variable Decelerations
• Most decelerations in labour are variable
• Can reflect cord compression
• ‘Variable’ in shape, depth and/or onset
• Usually benign but …. if late or deep may imply
cord prolapse or hypoxia
• ‘Need to assess the frequency and duration
VARIABLE DECELERATIONS
COMPLICATED VARIABLES
 “ DR C BRAVADO”
A systematic approach to CTG interpretation
Late Decelerations
• Associated with fetal compromise (hypoxia)
but only in 50-60% of cases
• Ominous if associated with:
- fresh particulate meconium
- ‘high-risk’ clinical situation
• Ominous if:
-  ‘lag-time’ (peak to trough)
- deceleration is slow to recover
LATE DECELERATIONS

• Begin after onset of contraction

• Nadir (or trough) after peak of
contraction
• Return to baseline after end of
contraction
Structured Intermittent Auscultation
In Active phase of labour
MINIMUM OF 60 SECONDS after a
contraction
Differentiate maternal pulse
Each 30 minutes in first stage of labour
Each 15 minutes if any risk factor
After each contraction while actively
pushing
If fetal heart rate persist
above 180 bpm or below 100 bpm
plan delivery:

• If the cervix is fully dilated and the fetal head is

not more than 1/5 above the symphysis pubis (or
at station 0 or below) deliver by vacuum
• If the cervix is not fully dilated or the fetal head is
more than 1/5 above the symphysis pubis (or
above station 0) deliver by cesarean section

”Managing obstetric complications, WHO”