1. FETAL MONITORING REASONS TO MONITOR THE FETUS ANTENATAL: 1. MATERNAL INDICATIONS e.g. obstetric cholestasis 2. FETAL INDICATIONS e.g. reduced fetal movements, 3. PLACENTAL INDICATIONS e.g. placental insufficiency / growth restriction IN LABOUR: 1. LOW RISK PATIENT 2. HIGH RISK PATIENT

2. ANTENATAL FETAL MONITORING BIOPHYSICAL PROFILE USS: 1. Breathing - Does the baby have breathing movements at least once in 30 minutes? 2. Body Movement - Does the baby move at least three times in 30 minutes? 3. Muscle Tone - Does the baby have at least one flexion-extension (open-close) movement of arms, legs or hands in 30 minutes? 4. Amount of amniotic fluid - Is there enough fluid around the baby? 5.CTG: Is it reactive? AMNIOTIC FLUID The Amniotic Fluid Index (AFI) can be used to determine fetal well-being. Most of the fluid in amniotic fluid is contributed to by fetal urine. This is then resorbed by the membranes and umbilical cord Rapid turnover - possible to measure amniotic fluid from one day to the next

3. OBSERVATIONNORMAL (2 POINTS)ABNORMAL (0 POINTS) CTG (NON-STRESS TEST)REACTIVENON-REACTIVE FETAL BREATHING ONE BREATHING PERIOD LASTING AT LEAST 60 SEC NO BREATHING OBSERVED FETAL MOVEMENTS 3 DISCRETE AND DEFINTE MOVEMENTS OF ARMS LEGS OR BODY LESS THAN 3 DISCRETE MOVEMENTS FETAL TONE ARMS & LEGS FLEXED. ONE DEFINITE EXTENSION / RETURN TO FLEXION NO FLEXION AMNIOTIC FLUID LARGEST POCKET OF FLUID MORE THAN 1cm WITHOUT LOOPS OF CORD LARGEST POCKET OF FLUID LESS THAN 1cm WITHOUT LOOPS OF CORD BIOPHYSICAL PROFILE SCORE 8-10 = maximal score 0-4 = severe fetal compromise; delivery indicated

4. Doppler blood flow velocity waveforms Non-invasive velocity measurements of blood flow Fetus is completely dependent on the supply of oxygen and nutrients from the placenta Examination of the blood flow through the umbilical circulation can assess fetal health Increased placental vascular resistance, reduces velocity of the end-diastolic flow in the umbilical cord artery Several Doppler indices have been used to quantify abnormalities in umbilical artery Doppler flow waveforms: A/B ratio, the resistance index, the pulsatility index Placental insufficiency can be quantified based on the reduction of end-diastolic Doppler flow velocity into (1) reduced enddiastolic flow velocity, (2) absent end-diastolic flow velocity, and (3) reversed end-diastolic flow velocity.

5. DOPPLER WAVEFORMS

6. Middle cerebral artery peak-systolic flow velocity (MCA-PSV) use Doppler to detect fetal anaemia Doppler blood flow velocity waveforms

7. Ductus Venosus Dopplers May be used as a trigger for delivery of IUGR fetus. May be used as a trigger for delivery of IUGR fetus. Late sign of CV decompensation Late sign of CV decompensation Reflects decreased ability to handle venous return. Reflects decreased ability to handle venous return. Precedes FHR decels Precedes FHR decels Present in 79/211 (37%) of preterm IUGR, useful > 29wks Present in 79/211 (37%) of preterm IUGR, useful > 29wks Predictive of pH<7.2 Predictive of pH<7.2 Baschat, O&G, 2007

8. MONITORING IN LABOUR Intermittent auscultation recommended for low-risk women in established labour INDICATIONS FOR continuous EFM: 1. meconium-stained liquor, 2. abnormal FHR detected by intermittent auscultation 3. maternal pyrexia 4. fresh bleeding in labour 5. oxytocin use for augmentation 6. the woman’s request.

9. FETAL PHYSIOLOGY 1. The fetal heart pumps deoxygented blood to the placenta via the two umbilical arteries 2. At the placenta there is a free exchange of blood gases (there's no mixing of foetal/maternal blood) 3. The blood is pumped back to the fetus via a single umbilical vein

10. The fetal heart is regulated by: 1. Nerve supply i.e. HR is reduced by vagus nerve (parasympathetic), increased by sympathetic supply 2. Circulating catecholamines 3. Central nervous system activity These are influenced by changes in: 1. fetal BP 2. fetal blood gas levels (O2, CO2, pH) 3. Hypoxia 4. Pyrexia 5. Drugs 6. Gestation 7. Cord compression 8. Cerebral activity FETAL HEART RATE

11. A: Fetal heartbeat; B: Indicator showing movements felt by mother (caused by pressing a button); C: Fetal movement; D: Uterine contractions

12. Feature Baseline (bpm) Variability (bpm) DecelerationsAccelerations Reassuring110–160≥ 5None Present Non- reassuring 100–109 161–180 < 5 for 40–90 minutes Typical variable decelerations with over 50% of contractions, occurring for over 90 minutes Single prolonged deceleration for up to 3 minutes The absence of accelerations with otherwise normal trace is of uncertain significance Abnormal < 100 > 180 Sinusoidal pattern ≥ 10 minutes < 5 for 90 minutes Either atypical variable decelerations with over 50% of contractions or late decelerations, both for over 30 minutes Single prolonged deceleration for more than 3 minutes Classification of FHR trace features

13. CategoryDefinition Normal An FHR trace in which all four features are classified as reassuring Suspicious An FHR trace with one feature classified as non-reassuring and the remaining features classified as reassuring Pathological An FHR trace with two or more features classified as non-reassuring or one or more classified as abnormal Definition of normal, suspicious and pathological FHR traces Classifications of CTG’S 1) Normal: Implies fetal well-being 2) Suspicious: Indicates continued observation /additional tests 3) Pathological: Mandatory Action.

14. SMALL GROUP / PAIR WORKSHOP using FRESH EYES LABELS

15. DR. C BRAVADO Define Risk:Low or High Contractions: Frequency, Length Baseline Rate:Bradycardia, Normal, Tachycardia Variability:5-10bpm/min Accelerations:Present or Absent Decelerations: Present or Absent, Type Outcome:Normal, Suspicious. Pathological. Management Plan

16. FBS result (pH) Interpretation Action ≥ 7.25 Normal FBS FBS should be repeated if the FHR abnormality persists within 60 minutes or within 30 minutes if FHR pattern deteriorates 7.21–7.24 Borderline FBS Repeat FBS within 30 minutes or consider delivery if rapid fall since last sample ≤ 7.20 Abnormal FBS Delivery indicated The classification of fetal blood sample (FBS) results

17. APGAR SCORES DESIGNED TO ASSESS WHICH BABIES NEED RESUSCITATION; IT DOESN'T TELL US WHY A BABY NEEDS RESUSCITATION 012 colourblue/pale all over Blue extremities, body pink No cyanosis, Body/extremities pink HR0<100>100 Reflex irritabilityNo response grimace/feeble cry cry/pull away when stimulated TonenoneSome flexion Flexed arms & legs, resist extension BreathingabsentIrregular, gaspingStrong, lusty cry

18. CORD GASES Indication of: 1. how well the oxygen supply has been maintained to the fetus during labour 2. How well the fetus has eliminated the waste product CO2 Gives an indication of the efficiency of placental gas exchange during labour Cord gases can suggest a baby has been deprived of oxygen during labour but it cannot tell us if the baby has suffered harm as a result A baby could have good Apgars despite abnormal cord gases A baby that has been deprived of oxygen during labour may have compensated well but is still at risk of of e.g. hypoglycaemia

19. SMALL GROUP WORKSHOP Divide up into 4 groups Read through the case history Using DR C BRAVADO review the CTG at the times indicated in BOLD

20. THANK YOU