2. Intrapartum Assessment

3. Electronic fetal monitoring
Internal (Direct) Electronic Monitoring:
attaching a bipolar spiral e lectrode directly to the fetus
The wire electrode penetrates the fetal scalp, and the second pole is a metal wing on the electrode.

5. External (Indirect) Electronic Monitoring
The fetal heart rate is detected through the maternal abdominal wall using the ultrasound Doppler principle

7. Baseline Fetal Heart Activity
Rate:
With increasing fetal maturation, the heart rate decreases.
In any 10-minute window, the minimum interpretable baseline duration must be at least 2 minutes
Heart rate also is under the control of arterial chemoreceptors such that both hypoxia and hypercapnia

8. Bradycardia:
Pragmatically, a rate between 100 and 119 bpm, in the absence of other changes, usually is not considered to represent fetal compromise_ have been attributed to head compression from occiput posterior or transverse positions
congenital heart block and serious fetal compromise
placental abruption
Maternal hypothermia

9. Tachycardia. greater than 160 bpi
e most common explanation for fetal tachycardia is maternal fever from chorioamnionitis
Fetal tachycardia caused by maternal infection typically is not associated with fetal compromise unless there are associated periodic heart rate changes or fetal sepsis.
fetal compromise
cardiac arrhythmias
maternal administration of parasympathetic (atropine) or sympathomimetic (terbutaline) drug

10. Wandering Baseline between 120 and 160 bpi
suggestive of a neurologically abnormal fetus and may occur as a preterminal event.

12. Beat-to-Beat Variability
regulated largely by the autonomic nervous system
Increased Variability:fetal breathing_Fetal body movements _advancing gestation_
Decreased Variability: fetal academia_ Severe maternal acidemia _analgesic drugs_Magnesium sulfate
It is generally believed that reduced baseline heart rate variabill l ity is the single most reliable sign of fetal compromise.
maintained for 1 hour was diagnostic of developing acidemia and imminent fetal death

14. Cardiac Arrhythmia
Intermittent baseline bradycardia is frequently due to congenital heart block.
AV) block, usually are found in association with maternal connective-tissue diseases.
Sonographic evaluation of fetal anatomy and echocardiography may be useful

15. Sinusoidal Heart Rate
fetal intracranial hemorrhage_severe fetal asphyxia _severe fetal anemia from Rh a lloimmunization_ fetomaternal hemorrhage, twin-twin transfusion syndrome, or vasa previa with bleeding_maternal meperidine administration_chorioamnionitis, fetal distress, and umbilical cord occlusion
The pathophysiology of sinusoidal patterns is unclear,

16. 1. Stable baseline heart rate of 120 to 160 bpm with regular oscillations,
2. Amplitude of 5 to 15 bpm (rarely greater),
3. Long-term variability frequency of 2 to 5 cycles per minute,
4. Fixed or flat short-term variability,
5. Oscillation of the sinusoidal waveform above or below a baseline
6. Absent accelerations.

17. Early Deceleration
This consists of a gradual decrease and return to baseline associated with a contraction
the degree of deceleration is generally proportional to the contraction strength and rarely falls below 100 to 110 bpm or 20 to 30 bpm below baseline
Head compression probably causes vagal nerve activation

19. Late Deceleration
index of either uterine perfusion or placental function
a smooth, gradual, symmetrical decrease in fetal heart rate beginning at or after the contraction peak and returning to baseline only after the contraction has ended
any process that causes maternal hypotension, excessive uterine activity, or placental dysfunction can induce late decelerations
Placental abruption can cause acute late decelerations

21. Variable Deceleration
defined as an abrupt decrease in the fetal heart rate beginning with the onset of the contraction and reaching a nadir in less than 30 seconds. The decrease must last between ≥ 15 seconds and 2 minutes and must be ≥ 15 bpm in amplitude
due to obstruction of umbilical artery
According to the American College of Obstetricians and Gynecologists (2013a), recurrent variable decelerations with minimal to moderate variability are indeterminate, whereas those with absent variability are abnormal.

23. Prolonged Deceleration
isolated deceleration greater than 15 bpm lasting 2 minutes or longer but < 10 minutes from onset to return to baseline.
cervical examination, uterine hyperactivity, cord entanglement, and maternal supine hypotension Epidural, spinal, or paracervical analgesia
maternal hypoperfusion or hypoxia from any cause, placental abruption, umbilical cord knots or prolapse, maternal seizures including eclampsia and epilepsy, application of a fetal scalp electrode, impending birth, or even maternal Valsalva maneuver

24. Fetal Heart Rate Patterns During Second-Stage Labor
Both cord compression and fetal head compression have been implicated as causes of decelerations and baseline bradycardia during secondstage labor.
the longer a fetus was exposed to variable decelerations, the lower the Apgar score was at 5 minutes.
abrupt fetal heart rate deceleration to < 100 bpm associated with loss of beat- to-beat variability for 4 minutes or longer was predictive of fetal academia

25. OTHER INTRAPARTUM ASSESSMENT TECHNIQUES

26. Fetal Scalp Blood Sampling
normal nor abnormal scalp pH results have been shown to be predictive of infant outcome
the pH is > 7.25: labor is observed
between 7.20 and 7.25, the pH measurement is repeated within 30 minutes
pH is < 7.20, another scalp blood sample is collected immediately, and the mother is taken to an operating room and prepared for surgery
Benefit : fewer cesarean deliveries for fetal distress

27. Fetal Pulse Oximetry
A unique padlike sensor is inserted through the cervix and positioned against the fetal face, where it is held in place by the uterine wall
transient fetal oxygen saturations below 30 percent were common during labor
Saturation values below 30 percent, however, when persistent for 2 minutes or longer, were associated with an increased risk of potential fetal compromise.
There were no neonatal benefits or adverse effects associated with fetal pulse oximetry

29. Fetal Heart Rate Patterns and Brain Damage
fetal neurological injury occurred predominately before arrival to the hospital
It is clear that for brain damage to occur, the fetus must be exposed to much more than a brief period of hypoxia.
umbilical cord blood gases be obtained whenever there is cesarean delivery for fetal compromise, a low 5-minute Apgar score, severe fetal-growth restriction, an abnormal fetal heart rate tracing, maternal thyroid disease, or multifetal gestatio

30. umbilical cord blood gases be obtained :
there is cesarean delivery for fetal compromise,
a low 5-minute Apgar score,
severe fetal-growth restriction,
an abnormal fetal heart rate tracing,
maternal thyroid disease,
multifetal gestatio

31. GA : 39+3
Full dilatation duration : 1:35
Delivery rout : NVD
Chief complain of mother : labor pain
Vaginal examination at admission : 2FF
PMH of mother : none
Drug history in pregnancy: none
CST : OK

32. ABG : PH :6.8
PO2 : 68
HCO3: 10.7
BE:23
Apgar :4/10 and 5/10
O2 saturation : 98%
CXR : Pneumothorax - pneumomediastin