OBSTETRICS I – Intrapartum Assessment o Parasympathetic

(Lecture by Dra Coloma) • Chemo- and baro-receptors

USTMED ’07 Sec C - AsM
ADVANCING GESTATION,
CONDUCT OF LABOR AND DELIVERY • Parasympathetic dominance (vagus nerve)
• Decreasing rate
Monitoring
• Increasing variability
• Maternal
o Vital signs, uterine contractions, general BASELINE RATE
condition • Approximate mean rate rounded to increments of 5 bpm
• Fetal during a 10-minute segment, minimum interpretable
o FHR duration of 2 min
• Progress of labor • Normal: 110-150 bpm
o dilatation and descent
• Bradycardia : < 110 bpm, for at least 3 min.
Monitoring the fetus o moderate 80-100
• Clinical o severe less than 80
o
o
Auscultation of fetal heart tones
Character of the amniotic fluid
• Tachycardia: > 160 bpm
o mild 161-180 bpm
• Electronic FHR monitoring = cardiotocograph ( CTG)
o severe > 180 bpm

!!!LOOK OUT FOR FETAL DISTRESS!!!

AMNIOTIC FLUID

Fetal hypoxia

Pituitary release of
arginine vasopressin

Increased intestinal
peristalsis

Passage of meconium
BASELINE VARIABILITY
• Oscillations at the baseline (jiggliness)
Auscultation • Figure 14-10. Edwards text
• Stethoscope or Doppler devices
• The maternal pulse must be counted as the FHR is Grades of baseline variability
counted. • Absent variability
• Minimal (poor) +/< 5 bpm
• The fetal heart must be auscultated IMMEDIATELY • Moderate = NORMAL 6-25 bpm
AFTER A CONTRACTION. • Marked > 25 bpm
** Changes in the fetal heart rate that are most likely to be Periodic patterns
ominous almost always are detectable immediately after a • ACCELERATION
uterine contraction.
o Visually abrupt increase above baseline
o Intact neurohormonal cardiovascular control
Suspect compromise if:
mechanisms
• FHT repeatedly below 110 bpm, even though there is
o Favorable sign of fetal well-being
recovery to 110-160 bpm
• Further labor if allowed should be should be monitored
• DECELERATION
electronically
o Early – head compression
Recommendations o Late – placental insufficiency
In the absence of any abnormalities
• First stage – every 30 min o Variable – cord compression
• Second stage – every 15 minutes
INTERPRETATION
High-risk pregnancies FIGO classification
• First stage – every 15 minutes • Normal
• Second stage – every 5 minutes • Suspicious
• Abnormal
NICHD
Electronic FHR monitoring • Reassuring = FIGO normal
ADMISSION TEST (baseline trace) • Non-reassuring = FIGO suspicious
• Normal: • Ominous = FIGO abnormal
o intermittent auscultation,
o trace every 2 hrs NORMAL TRACE or REASSURING PATTERN
• Abnormal trace or high-risk case: • Baseline rate 110-160 bpm
o continuous trace • Baseline variability 6-25 bpm
Reading EFM trace • Accelerations present
• Baseline heart rate • Decelerations absent
• Baseline variability
• Accelerations SUSPICIOUS
• Decelerations • Absence of accelerations and any one of the following:
FHR regulation 1. abnormal baseline rate < 110bpm or > 150 bpm
• Central nervous system 2. reduced baseline variability < 10bpm for >40mins
• Autonomic nervous system 3. variable decelerations without ominous features
o Sympathetic
Abnormal
 • Baseline < 100bpm or >170bpm
• Baseline variability <5 bpm for >40 mins
• Severe variable decelerations
• Severe repetitive early decelerations
• Prolonged decelerations
• Late decelerations
• Sinusoid pattern
SEVERELY ABNORMAL CTG PATTERNS
• Poor to absent variability
• Persistent late or variable decelerations
• Prolonged bradycardia

Management approach to non-reassuring FHR pattern

Intrauterine Resuscitation
• Administer oxygen to mother
• Reposition patient
• Discontinue uterine stimulamnts
• Hydrate patient
• Vaginal examination
• Alert anesthesia, nursing and neonatal care staff
• Possible abdominal delivery

Intrapartum Assessment
• Electronic monitor trace
• Clinical context

-fin-

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