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Fetal surveillance :crossed_swords: (:white_flower: Intrapartum…
Fetal surveillance :crossed_swords:
:white_flower:
Intra
partum
Intermittent auscultation
(IA)
by Stethoscope or Doppler device
Low risk preg
1st stage of labor: Auscultate q 30 min
2nd stage of labor: Auscultate q 15 min
High risk preg
1st stage of labor: Auscultate q 15 min
2nd stage of labor: Auscultate q 5 min
Continuous electric fetal monitoring
(EFM)
I/C
:check:
High risk
preg
Maternal medical illness
Gestational DM
HT
Asthma
Ob
stetric
com
plications
Multiple gestation
Post-date gestation
Previous C/S
Intrauterine growth restriction (IUGR)
Pre-eclampsia
Premature rupture of membranes (PROM)
Congenital malformations
3rd trimester bleeding
Oxytocin induction/augmentation of labor
Psychosocial risk factors
No prenatal care
Tobacco use & Drug abuse
Abnormal results in
IA
2 ways of recording
:cd:
Internal
fetal monitoring: Scalp electrode
External
fetal monitoring: Ultrasound Doppler *วอร์ดชอบใช้อันนี้
:chocolate_bar:
Interpretation
:dango:Baseline Fetal Heart Rate (FHR)
select 10-min segment (with increments of 5 bpm)
excluding
Periodic or episodic changes/Segments of baseline that differ > 25 bpm
2 mins in those 10 mins must ไม่ห่างกันมาก
Normal FHR baseline: 110 - 160 bpm
Tachycardia: FHR baselines > 160 bpm
Bradycardia: FHR baseline < 110 bpm
:dango:Variability
def: fluctuations in baseline FHR that are irregular in Amplitude and Freq
visually quantified as
amplitude
of peak-to-trough in bpm
Levels
Absent : Amplitude range
undetectable
Minimal : Amp. range detectable but
≤ 5 bpm
Moderate (normal): Amp. range
6 - 25 bpm
Marked: Amp. range
≥ 25 bpm
:dango:Acceleration
visually apparent abrupt increase (
onset to peak in < 30 s
)
Prolonged
acceleration
lasts
≥ 2 min, but < 10 min
if last
≥ 10 min
meaning that
baseline change
GA
≥ 32 wk
: peak of
≥ 15 bpm above baseline
with
duration ≥ 15 sec
BUT :!:
< 2 min fr onset to return
< 32 wk
: peak of
≥ 10 bpm above baseline
with
duration ≥ 10 sec
BUT :!:
< 2 min fr onset to return
:Dango:Deceleration
Types of DC
:red_flag:
Early
DC
#
:candy: Gradual + Symmetrical + Asso. with
UC
แปล: PSO change in Active labor คือช่วงที่
head compression กด pubic floor
-> vagal reflex -> bradycardia
Nadir of FHR ตรงกะ Peak of UC
:red_flag:
Late
DC
:Candy: Gradual + Asso. with
UC
แปล: Uteroplacental insufficiency (
UPI
)
Onset of DC = peak of UC AND Nadir of DC =
after
peak of UC
:red_flag:
Variable
DC
V
shaped
± shoulder หน้า/หลัง
:Fire: Abrupt + FHR :arrow_down: ≥ 15 bpm for ≥ 5 secs but < 2 min + Not really associated with UC
แปล:
Cord compression
m/c :star: found in...
Oligohydramnios:
UPI + Variable DC + Late DC
Prolapsed cord
: No UPI + :star: M/C cause of Variable DC
:red_flag:
Prolonged
DC
:arrow_down: FHR fr baseline ≥ 15 bpm for ≥ 2 mins but < 10 mins
Type
แยกตาม basis of its waveform
:candy: Gradual = :arrow_down: FHR baseline from onset to nadir
≥ 30 secs
:fire: Abrupt = :arrow_down: FHR baseline > 15 bpm from onset to nadir
< 30 secs
:dango:
Sinusoidal
pattern
Smooth, sine wave-line undulation pattern in FHR baseline
Cycle frequency 3 - 5 bpm with persist ≥ 20 mins
:statue_of_liberty:
Categories
(3)
Indirect
Dx by FHR monitoring
:stars:Category
I
: Normal FHR
:cookie: แปล: No abnormal fetal acid-base status,
No hypoxia or Acidosis
:green_apple:
Mx
: no intervention needed to improve fetal oxygenation
:book: Readings
Baseline FHR
110 - 160 bpm
Baseline FHR
moderate
variability
Accelerations: present or absent
Early DC: present or absent
Late or Variable DC:
absent
Category
II
: Indeterminate FHR
Not categorized as Cat I or Cat III
:book: Readings
Baseline FHR
Not accompanied by Absent baseline variability
Tachycardia
Baseline FHR
variability
Minimal baseline variability
Absent baseline variability not accompanied by recurrent DCs
Marked baseline variability
Acceleration: Absence of induced ACs after fetal stimulation
Deceleration:
Periodic DCs
(assoc. with UCs) or :eyes:
Episodic DCs
(
not
asso. with UCs)
Recurrent variable
dcs accompanied by
Minimal or Moderate
baseline variability
Prolonged dc
> 2 mins but < 10 mins
Recurrent Late
dcs with
Moderate
baseline variability
Variable
dcs with other characteristics, such as
slow return to baseline, 'overshoots', or 'sholuders'
:cookie: แปล: Not predictive of abnormal fetal acid-base status,
Low probability of hypoxia or acidosis
:green_apple:
Mx
:
*requires re-evaluation to correct reversible causes
close monitoring
adjunctive methods
:stars:Category
III
: Abnormal FHR
:book: Readings
Absent baseline FHR variability
with
one
of
Recurrent Late dcs (late dc ≥ 50% compared to UC)
Recurrent Variable dcs
Bradycardia
Sinusoidal pattern
:cookie: แปล: Predictive of abnormal fetal-acid base status at time of observation;
High probability of hypoxia or acidosis
:green_apple:
Mx
:
immediate action to correct reversible causes
immediate IUGR + immediate delivery
adjunctive methods
:white_flower:
Ante
partum
I/C
:check:
Pregnancy induced HT (PIH)
Oligohydramnios
Slow fetal growth
Decreased fetal movement
Hx of death fetus in utero (DFIU) - unknown cause
Post term
Maternal risk: HD, Autoimmune ds, CKD, HT, DM
Test ไรบ้าง?
Fetal movement
:arrow_down: fetal movement related to uteroplacental insufficiency (
UPI
) &
antepartum death
:night_with_stars:Counting method (FMC)
(Lerdsin uses
combo of 2
methods)
Count to ten system (modified Cardiff count)
rec time: 8.00 - 12.00
count till reach 4 hrs
if
alrdy reach ≥ 10 times before 4 hrs can stop counting
Decrease fetal movement
< 10 times in 4 hrs
Sadovsky system
rec time: 8.00 - 20.00
count for 3 times (เช้ากลางวันเย็น) each time = 1 hr
sum all counts
Movement alarm signal (MAS)
< 10 times in 4 hrs
1.+2.: 'Count to 10 in 12 hr since 8am to 8pm not caring about working or not working ➭ then count 1 when baby kick
if
≥ 10 times ➭ normal
< 10 times ➭ do
NST
:stars:
Early sign of Fetal asphyxia
➭
can't
neglect FMC monitoring
Fetal breathing
uses sonography to determine
chest wall movements
might reflect fetal health
Fetal chest wall movements has
paradoxical movement
and
diurnal variation
Contraction stress test (CST)
:star:
Relation of
FHR & UC
(recorded simultaneously with an external monitor)
if Uteroplacental pathology (
UPI
) ➭
Late
FHR decelerations (following ≥ 50% of contraction)
C/I
Pt w/ risk of Uterine rupture
Pt. w/ risk of premature labor pain
Hx of previous C/S
Twins
Hydramnios
Preterm premature rupture of membrane (PPROM)
Contraction stimulation methods
Oxytocin challenge test
:stars:
ACOG 2012
rec ➭ Nipple stimulation
Criteria
for interpretation of CST :grapes:
Uteroplacental function
:star2:
Non-stress test (NST)
describe
FHR acceleration
in response to
Fetal movement
➭ Sign of Fetal health
Fetal condition
:star2:
ไรก็ไม่รู้
FHR acceleration (ACs)
Normal AC based on GA
GA ≥ 32 wks:
≥ 15 bpm
, last
15 sec
to 2 mins
GA < 32 wks: ≥ 10 bpm, last 10 sec to 2 mins
Normal nonstress tests
≥ 2 AC
, peak
≥ 15 bpm above baseline, lasting ≥ 15 secs
Abnormal nonstress test
terminal cardiotocogram included
baseline oscillation of < 5 bpm (absent beat-to-beat variability)
absent ac
late dc with spontaneous ucs
Decelerations during nonstress testing
:check:Brief non-repetitive variable dc < 30 secs
don’t indicate fetal compromise
No need for obstetrical intervention
:no_entry:Repetitive variable dc ≥ 3 in 20 mins
:arrow_up: risk of C/S for fetal distress
Dc lasts ≥ 1 min - even worse prognosis
Acoustic stimulation test
(Fetal vibroacoustic stimulation test; FAST)
(Acoustic stimulation nonstress test)
How
? Acoustic stimulator or Artificial larynx is position on Maternal abdomen & Stimulus of 1-2 secs is applied
text
Response
Positive
response :heavy_plus_sign: : rapid appearance of a qualifying AC following stimulation
FHR acceleration: reactive
Non-response
: if stimulate 30-60sec/each time x 3 times ➭ Mom can’t feel the kick ➭ baby can have risk ➭ should investigation more
May repeat up to 3 times for up to 3 secs
Pro & Cons
Pros: :arrow_down: average time of NST from 24 ➭ 15 mins
Cons: Fetal tachyarrhythmia was provoked with vibroacoustic stimulation
:bird:6.
Biophysical profile (BPP)
uses U/S + NST
Assess
5
fetal biophysical components
(each normal variables = 2 scores)
(each abnormal variables = 0 score)
Fetal heart rate acceleration (FHR)
Fetal breathing movement (FBM)
Fetal movements (FM; gross body movements)
Fetal tone (FT)
Amniotic fluid volume (AFV) or Amniotic fluid index (AFI)
Alternatives
Modified Biophysical profile :star:
NST + AFI
Rapid Biophysical profile (rapid BPP)
SPFM (Fast acoustic) + AFI
Positive test
: abnormal both AFI and NST/SPFM
Amniotic fluid volume
Methods
:yellow_heart:
Single deepest pocket or Maximum vertical pocket :yellow_heart:
Normal range: 2-8 cm
In Sagittal plane, the
Largest vertical pocket fluid
is identified
Amniotic fluid index (AFI) :yellow_heart:
Normal range:
5-24 cm
Def: Sum of the single deepest pocket fr each quadrant
Color Doppler
is used to verify that
the pocket isn’t umbilical cord
Criteria for Dx
Oligohydramnios
(ACOG2011)
AFI < 5 cm
Note that AFI was significantly inc in Hydrated women
Maximum deepest vertical pocket < 2 cm
assess
Fetal health
by volume estimation
Timing for evaluation:
2nd or 3rd trimester
:arrow_down:
uteroplacental perfusion
➭ may led to :arrow_down: Fetal RBF, :arrow_down: urine output ➭ ultimately,
oligohydramnios
Doppler velocimetry
Three fetal vascular circuits
Umbilical artery
Middle cerebral artery
Ductus venosus
Determine
Fetal health
& Aid in decision to intervene for
Growth-restricted fetuses
Def: blood flow velocity measured by
Doppler ultrasound
reflects downstream impedance
Maternal uterine artery
Doppler velocimetry ➭
use to evaluation prediction of Placental dysfunction
:fireworks:
Umbilical Artery Velocimetry
looking for
Umbilical artery systolic-diastolic (S/D) ratio
Abnormal
S/D ratio found in
Above 95th percentile for GA (inc S/D ratio)
Absent end-diastolic flow (AEDV)
Reversed end-diastolic flow (REDV)
Only benefit in pregnancies with
suspected fetal-growth restriction