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Definition
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Definition
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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
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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.
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Clinical manifestation
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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
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Baseline variability
1. The minor fluctuations on baseline FHR at 3-5
cycles/min produces Baseline variability.
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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
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Variable Decelerations
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Prolonged Deceleration
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Sinusoidal pattern
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Category Definition
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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))
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
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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
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Management based on BPP score
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Apgar testing
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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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