1. Prof William Stones Aga Khan University NON REASSURING FETAL STATUS

2. Aims Risk based approach When are we ‘not reassured’? Monitoring strategies Interventions for NRFS

3. Risk in obstetrics Presence of risk factors eg maternal hypertension Fetal biometry But: Most complications occur in ‘low risk’ patients Most ‘high risk’ patients do not develop complications Therefore: Awareness of risk status All require monitoring in labour Readiness to respond immediately when a problem emerges

4. Risk in the local setting Patient factors Hypertensive disease, IUGR, Gestational diabetes Obesity: difficult monitoring ‘Concordance’ regarding monitoring and intervention Service factors Staffing ratios Labour management: adherence to best practice Institutional culture ‘Serious about care in labour’ Blame game

5. Unhelpful ideas Placental maturation (Grannum) or calcification means reduced placental reserve and risk of ‘fetal distress’ Biophysical Profile ‘Cord round the neck’ on antenatal scan means high risk of ‘fetal distress’ in labour Meconium stained liquor = ‘fetal distress’ Giving glucose infusion will correct intrapartum hypoxia and acidaemia Oxygen administration will benefit the fetus

7. ‘Non reassuring fetal status’ Intermittent auscultation Fetal bradycardia <110 bpm in between contractions Thick (grade 3) meconium stained liquor Electronic fetal monitoring Persistent fetal bradycardia <110 Late decelerations Reduced baseline variability <5 beats

8. Interpretation challenges Partogram: how soon is delivery anticipated? Second stage Effect of drugs Oxytocin Prostaglandins Opioids (overstated) Patient factors Obesity Co-operation Noise!

9. Underpinning evidence Systematic review shows ‘evidence of no benefit’ for routine electronic monitoring versus intermittent auscultation in low risk pregnancy EFM without confirmatory tests results in excessive intervention eg CS for ‘fetal distress’ that isn’t Guidelines advocate selective use of EFM plus fetal scalp sampling for confirmation of fetal status where feasible Fetal scalp electrode with fetal ECG reduces intervention

11. Pitfalls Wrong risk assessment Inadequate ‘intermittent auscultation’ Poor quality external trace/ loss of contact Confidence and competence in FSE and FBS Wrong interpretation of CTG trace- over or under response Correct interpretation but failure to act

12. Key response interventions Turn off syntocinon Operative vaginal delivery CS in second stage should be exceptional Triage for likely success in delivery room versus trial in theatre A ‘sentinel function’ for BEONC Rapid access to CS when needed for NRFS Urgency categories clearly understood and adhered to

13. Role of cord blood gas analysis Feedback to the obstetrician Refutes/ confirms suspicion of ‘fetal distress’ Guide to early neonatal care and prognosis Apgar has very limited predictive value Low UA pH is a better predictor of complications Consideration of base excess adds value by distinguishing acute versus chronic hypoxaemia Can help in triaging newborns who may be at risk and require more surveillance, eg apparently good Apgar but acidaemia/ high base excess

14. FIGO Second Stage Guidelines Two attendants in the room Eg one gloved, one to continue auscultation Auscultation throughout second stage Hand held Doppler not fetoscope Instrumental delivery where needed!

15. Conclusions When ‘not reassured’…. Steps to improve the status Positioning eg avoid lying flat Turn off syntocinon Deliver the baby Vacuum CS Judge the degree of urgency and act accordingly