2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
INTERMITTENT AUSCULTATION 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

The technique of listening to the fetal heart rate for short periods of time without a display of the resulting pattern 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Pinard stethoscope DeLee stethoscope 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Handheld Doppler Power independent with self-winding power source
Handheld Doppler Power independent with self-winding power source 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Recommended in all labours where there is no access to CTG Where CTG is available, it may be used in low-risk cases 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Required conditions Antepartum Intrapartum No serious health conditions No diabetes or pre-eclampsia No vaginal hemorrhage Normal fetal growth, amniotic fluid and Doppler Normal antenatal CTGs No previous uterine scar Normal fetal movements No ROM> 24 hours Singleton, term, cephalic Normal UC frequency No induction/augmentation No epidural No abnormal hemorrhage No fresh or thick meconium No temp > 38ºC Active 1st stage < 12 h 2nd stage < 1 hour Clearly audible normal FHR 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Advantages Promotes increased contact and support Facilitates assessment of other parameters Can be acquired in different positions/locations Favours maternal mobility Easier availability and sustainability Disadvantages Variability is not adequately evaluated No independent confirmation/record More labour intensive 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Stethoscope Doppler Inexpensive Readily available No consumables needed Slow learning curve Difficult to identify accelerations/decelerations Variability not evaluated May be difficult to use in certain maternal positions More confortable for woman FHR audible to all present More confortable in certain maternal positions Calculates and displays FHR Low variability suspected Costly to buy and maintain Sensor prone to damage May pick up the MHR 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Technique Identify fetal position by palpation Simultaneous evaluation of FHR (fetal back, “galloping sound”) MHR (maternal pulse) UC + fetal movements (hand in fundus) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

UC + fetal movements FHR MHR 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Features to evaluate What to register FHR Duration: ≥ 60 secs (for 3 UC if abormal) FHR in bpm Accelerations/decelerations (presence or absence) Timing: during and ≥ 30 secs after UC Interval: Every 15 min in active phase. Every 5 min in 2nd stage Uterine contractions Before and during IA (in order to detect ≥ 2 UCs) Frequency (in 10 min) Fetal movements At the same time as UCs Presence or absence MHR At the time as IA MHR in bpm 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Abnormal findings Baseline < 110 bpm or > 160 bpm Decelerations Presence of repetitive or prolonged (>3 min) decelerations Contractions More than 5 contractions in 10 mins Extend evaluation over 3 UC to confirm If CTG available  continuous CTG 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

When CTG is 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 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

ADJUCTIVE TECHNOLOGIES 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Adjunctive technologies are aimed at reducing false-positives with CTG and the resulting unnecessary intervention 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Adjunctive technologies Fetal blood sampling (FBS) Fetal stimulation (FS) Fetal electrocardiography (CTG+ST) Computer analysis of CTGs (cCTG) Continuous pH and lactate (discontinued) Pulse oximetry (discontinued) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FBS for pH and lactate Introduced in 1962 Good correlation with carotid and umbilical blood Capillary blood may be affected by redistribution of circulation 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Technique (disposable or re-usable set) Vaginal exam - presenting part, ROM, ≥ 3 cm. Amnioscope with light held tightly in place. Presenting part dried with small swabs. Thin layer of paraffin to form blood drop. 1-2 mm incision in fetal skin. Collection in heparin-coated capillary. Inspection of incision, and pressure if bleeding. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Indications Suspicious or pathological CTGs NOT advised in severe and acute events (causes further delay) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Same contra-indications as internal FHR monitoring
Failed FBS with pH – 10% Blood clotting, insufficient blood, air bubbles, blood gas measurer. Failed FBS with lactate – 1.5% 5 mcl vs. 50 mcl Point-of-care measurement 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Interpretation pH Lactate Attitude Normal > 7.25 < 4.2 Intermediate Abnormal < 7.20 > 4.8 No further action usually required, but if CTG remains grossly abnormal, repeat FBS 60 min. Measures to improve fetal oxygenation, and if CTG pattern persists or worsens, repeat FBS min Actions towards normalization of the CTG pattern or rapid delivery Lactate values need to consider the apparatus used for measurement After 3 normal results, consideration of further testing is rarely needed 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Benefits and limitations May  operative deliveries (moderate level of evidence) No evidence that fetal outcomes are improved Mainly used in central and northern Europe Not patient- or user-friendly. Time-consuming (~18 minutes pH, ~2 min lactate) Information quickly becomes outdated Difficult to perform in early labour Small risk of infection and bleeding 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Fetal stimulation (FS) Rubbing with fingers most widely used easiest to perform less invasive similar results to others Forceps to clasp skin Vibro-acoustic stimulation (maternal abdomen) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Indications Reduced variability - deep sleep vs. hypoxia/acidosis Accelerations and normal CTG  very predictive of absent hypoxia/acidosis No accelerations, no change in pattern  limited predictive value 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FS may reduce FBS use by  50% Not evaluated in RCTs 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Fetal electrocardiography (CTG+ST) Commercialised in 2000 Fetal electrode Average ECG (30 cycles) T-wave amplitude, ST shape ST events (relevant ST changes) R T P Q S 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Myocardial glycogenolysis and anaerobic metabolism
Increased T-wave amplitude P Q R S T Myocardial glycogenolysis and anaerobic metabolism Depressor effect of hypoxia on myocardium (infection, malformations, prematurity) Type 2 and 3 biphasic STs P Q R S T 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

CTG T-wave amplitude ST Biphasic STs 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Episodic T-wave elevation Basal T-wave elevation ST events Relevant biphasic STs 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Indications Suspicious or pathological CTGs If ↓variability and no accelerations at start, ST information may be unreliable. FBS Measures to improve CTG 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Same contra-indications to internal FHR monitoring
Not extensively studied < 36 weeks Continuous information 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Unique CTG classification system Normal Intermediate Abnormal Preterminal Intervention according to ST event 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

ST events in normal CTGs No measure necessary
2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Rare cases of CTG evolving from normal to abnormal CTGs without ST events Abnormal CTG > 60 min or quickly deteriorating  reassessment by senior When CTG indicates a severe and/or acute event  immediate action 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

ST signal loss may hide ST events
2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

RCTs comparing CTG with CTG+ST Plymouth (2434 women) AJOG 1993;169: Swedish (4966 women) Lancet 2001;358:534-8 Finnish (1483 women) BJOG 2006;113:419-23 French (799 women) AJOG 2007;197:299 Dutch (5681 women) AJOG 2010;115: American (11108 women) NEJM 2015;373:632-41 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Q R S T Differences in RCT methodology Several systematic reviews: Lower need for FBS Modest reduction in operative deliveries Conflicting results for metabolic acidosis 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Q R S T  metabolic acidosis over time published by a few centres Importance of training ST events in ≈ 50% well-oxigenated fetuses 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Computer analysis of CTGs (cCTG) Reproducible Objective evaluation of parameters that are difficult to assess visually (variability) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

All incorporated in central monitoring stations Real-time visual and sound alerts Raise attention, prompt evaluation and action 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

CTG or CTG+ST analysis Similar colour-coding of alerts No management recommendations Different mathematical algorithms 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Evaluation Satisfactory comparison with experts Good prediction of newborn acidemia Two RCTs concluded (not published) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Conclusions Reproducible and quantifiable approach Promising technology Continued optimisation Further studies to compare systems and evaluate effect on outcomes and interventions 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Adjunctive technologies Further research and development is needed, to remove the uncertainty that surrounds them, and to provide more robust evidence on how they affect adverse outcome and intervention rates 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

CASE DISCUSSION 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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