Introduction

FETAL DISTRESS

Compromise of the fetus during the antepartum period (before labor) or intrapartum period
(birth process). The term "fetal distress" is commonly used to describe fetal hypoxia (low
oxygen levels in the fetus). The concern with fetal hypoxia is it may result in fetal damage or
death if not reversed or if the fetus is not promptly delivered.

Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium
(dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid,
or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2.

Fetal distress, also more commonly known as “nonreassuring fetal heart tracing”, is basically
a particular complication when during labor your baby’s heart beat becomes flat, or drops to a
lower level repeatedly causing stress for your baby. When you are in labor your baby’s heart
rate will constantly be monitored for any sign of complications or stress.

There are three types of heart decelerations:

Early - These are usually indicative of a head compression and are the most common of all
three.
Variable - These are usually indicative of a cord compression and are usually seen in the
pushing stage of labor.
Late - These are the ones which usually cause the most concern. A single deceleration may
not be so bad, but persistent late decelerations are usually followed by concern for the baby’s
well being.

I. Risk Factors

II. Breathing problems

III. Abnormal position and presentation of the fetus

IV. Multiple births

V. Shoulder dystocia

VI. Umbilical cord prolapse

VII. Nuchal cord

VIII. Placental abruption

IX. Premature closure of the fetal ductus arteriosus

X. Uterine rupture
While some change in fetal heart pattern during labor is fairly normal, there are also a variety
of different factors which may cause fetal distress. Some of the common causes include:

A loop of umbilical cord around the baby's neck. Almost 30% of babies have a cord around
their neck
Uterine infection
Placental abruption
Uterine rupture

-Compromise of the fetus during the antepartum period (before labor) or intrapartum period
(birth process)

-commonly used to describe fetal hypoxia (low oxygen levels in the fetus)

-Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium
(dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid,
or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2.

Etiology/Risk factors:

 Maternal
-poor placental perfusion
-hypovolemia
-hypotension
-myometrial hypotonus: prolonged labor, excess oxytocin
-with cardiac problems
-<35 y/o and 16 below
 Fetal
-cord compression: oligohydramnios, enlargement, prolapsed
-infection
-nuchal cord
-pre-existing hypoxia

Signs & symptoms:

 ↑ FHT above 160/min or ↓100/min

 ↓ O2 sat
 Maternal fever, abnormal HR, Difficulty of breathing, irritable
 Persistent severe variable deceleration
 Fetal bradycardia
Nursing Management:

 Alteration of maternal position (left-side lying)

 hydration, O2 admin by mask, discontinue oxytocin, bed rest
 Teach how to properly bear down
 Immediate delivery of the baby is required; if unsuccessful emergency CS
 Frequent FHT monitoring & fetal movement

REAL CASE
A) Patient History
Real case I studied is Fetal Bradycardia in general known as fetal distress. Patient name, Fatin
Nur Syafiqah Binti Saiful Nizam (RN 5015), Malay and 26 years old women came to Labor
room from Ward 3 on 7 August 2019 at 8.00 am for the delivery. She accompanied by her
husband. The chief complaint made by this patient is leaking of liquor. Next, the history of
presenting complaint made by this patient is, 26 year-old Malay, gravida 2 para 1 at 35 weeks
+ 6 days period of gestation was admitted to Hospital Slim River for elective lower segment
caesarean section due to fetal bradycardia.The patient came to Hospital Slim River after being
scheduled for elective lower segment caesarean section today, 8 of August 2019, in the
afternoon.At 21 weeks period of gestation during her booking, she was diagnosed to have
gestational diabetes mellitus after being tested for modified glucose tolerance test. She was
only advised to control her diet and was not prescribed on any medications. After had a
conversation with this patient, we get to know that she does not have any past medical and
surgical history.

52 years old husband 50 years old mother (diabetic)

1st son 28 years old 26 years old (patient)

Based on patient’s family history, we can know that this patient have parents and 1 sibling.
Both her parents are healthy. Her mother is now 50 years old, having diabetes mellitus type 2
whereas her father has no known chronic illnesses. She is the second child out of 2, all her
siblings are healthy. No family history of hypertension, heart disease, breast tumor,
endometrial, cervical, or any other tumors related to female reproductive tract.No family
history of congenital abnormalities like Down Syndrome.From the drug history, we can know
that this patient do not have any drug allergic. While the social history of this patient shows
that this patient is a housewife and not a smoker or alcoholic consumer.

Physical Exam

Linea Nigra

Striae
gravidarum

During general examinations, this patient is look alert, pink, conscious and good hydration.
The vital sign of this patient is,

Initial Current

Blood pressure (BP) 122/76 mmHg 127/71 mmHg

Pulse rate (PR) 78/min 91/min

Respiration rate (RR) 20/min 18/min

Body temperature (BT) 37 degree Celsius 37.3 degree Celsius

Pain score 5/10 7/10

Cardiovascular system is shown dual rhythm no murmur (DRNM) and S1S2 heard clearly.
When auscultate the lungs, air entry show equal and clear. During palpitation, stomach shows
in soft, non-tender, no mass condition and bowel sound active also found in stomach. Other
physical examination found in her body is back pain and abdominal pain caused by contraction.
No edema and varicose vein seen on both feet.

B) Differential diagnosis

The differential diagnosis that can made is caesarean and assisted vaginal delivery (AVD).

Investigation

After undergo the patient’s history, physical examination and finding differential diagnosis,
next doctor carry out some laboratory and radiology investigation. For laboratory test, full
blood count (FBC) were taken. The result is as shown below:

Blood Group: AB+

Event Results Ref. range Status

RBC 4.61 4.5 – 6.5 x 109/L Normal

WBC 9.09 4.0 – 11.0 x 109/L Normal

Hemoglobin 11.4 13.5 – 18.0 g/dL Low

 Hematocrit 34.6 40.0 – 54.0 % Low

Mean Cell Volume 75.2 76.0 – 96.0 fl Low

Mean Cell Hemoglobin 32.8 31.0 – 40.0 (pg/cell) Normal

Concentration

Red cell distribution width 15.1 11.5-14.5 Abnormal

Platelet count 300 150 – 450 x 109/L Normal

Automated differentials:

a) % of Neutrophil: 65.4% (40.0-80.0)

b) % of Lymphocyte: 26.4% (20.0-40.0)

c) % of Monocyte: 3.5% (2.0-10.0)

d) % of Eosinophil: 2.6% (1.0-6.0)

e) % of Basophil: 0.6% (0.0-2.0)

Results: Hemoglobin, hematocrit, mean cell volume were low.

Interpretation: Physiological hemodilution effect occurring in pregnancy.

Result of Urine FEME is as shown below

UFEME Result

Leucocyte Negative

Nitrite Negative

Urobilinogen Normal

pH 6.5

Protein Negative
 Blood Negative

Ketones Negative

Bilirubin Negative

Glucose Negative

C) Diagnosis

Fetal Distress(Bradycardia)

D) Treatment and management

The intention is to achieve vaginal delivery. Labour can be induced by doses of

oxytocin. An artificial rupture of membrane (ARM) should be performed. Blood glucose level
needs to be monitored at frequent intervals; mostly done at 2 hourly. The fetus should be
monitored throughout labour and during vaginal delivery shoulder dystocia should be
anticipated. On the other hand, a caesarean section may be performed if there is significant
petal macrosomia or poor fetal status (CTG), or if labour fails to progress satisfactorily.
Uncomplicated diabetes is not an indication for operative delivery.

Ward Management

The routine ward management done to this patient is taking cardio tocography (CTG), and plot
patograph, doing bed making in the morning, checking patient’s vital sign 4 hourly, give
medication to the patient in correct dosage based on doctor’s order. Other routine ward
management is observing the branula intact of this patient to avoid from occurring bleeding
and strict input and output I/O charting. Not only that, other routine ward management is giving
nursing care and always observe this patient rest on bed.

While the specific ward management send this patient to labour room for artificial rupture of
membrane and for delivery. Other specific management is inserting Foley catheter to mother
before delivery to empty the bladder, monitoring blood sugar level 4 hourly, encourage mother
to breast feed her baby, give an oxytocin vaccines to mother and give BCG and Hepatitis B
vaccines to baby after delivered.
Post-Operative Management

 Uterus contracted and refracted well. No active per vaginal bleeding seen.

 Catheter in out done with 100ml of clear urine.

 Placenta delivered. Membrane and cortiledon complete

 Perineum inspected intact

 Episiotomy sutured and repaired with safil 2/ox2

 Health care education is given

 Baby at birth vigorous, active and good crying

 Cord clamped and cut

 Regime placenta is checked and vulva swabbing done

Pharmacological treatment

Drugs Generic name Trade name Dose Indication

IM Pethidine Pethidine HCL - Adult: 0.5- Moderate to

75mg PRN 50 mg/ml 2mg/kg SC or IM severe acute
injection every 3-4 hours if pain
necessary

IM Phenergen Promethazine PHENERGEN By deep IM Pre and

25mg PRN Adult: 25-50mg, postoperative,
maximum 100mg. or obstetric
Maximum 100mg sedation

-Prevention and
control of
nausea and
vomiting

T. Paracetamol Paracetamol PANADOL Adult: 500-1000 Mild to

1g TDS 500mg tab Tablet mg every 4-6 moderate pain
hours, maximum and pyrexia
of 4g daily

Tramal 50mg Tramadol HCL TRAMAL Adult: IV/ IM/ SC Moderate to

TDS 50mg/mℓ 50-100mg (IV severe acute or
Injection injection over 2-3 chronic pain
minute or IV (eg. post-
infusion). Initially operative pain,
100mg then 50- chronic cancer
100mg every 4-6 pain and
hours. Maximum: analgesia
400 mg daily.
E) Advice

 Eat medications followed by the dosage that has been prescribed by doctor

 Drink plenty of water

 Do simple exercise

 Take plenty of rest

 Take care personal hygiene to prevent infection

 Eat healthy and vitamin rich diet

 Give breastfeeding to the baby. Exclusive breastfeeding for 1st 6 months

 Take an immunization of the baby like BCG and Hepatitis B properly as early as
possible

 If there have any symptoms of jaundice appear, contact with a doctor.

 Avoid heavy work

 Walk

 Sleep when the baby sleeps

 Separate from husband for six weeks

 Contraceptive for two years – injectible, oral POP, IUCD (cannot give COCP;
breastfeeding(
 REFERENCE A

DEFINITION

In medicine (obstetrics), fetal distress is the presence of signs in a pregnant woman—before

or during childbirth—that the fetus is not well or is becoming excessively

SIGN AND SYMPTOM

• Decreased movement felt by the mother

• Meconium in the amniotic fluid

• Cardiotocography signs

– increased or decreased fetal heart rate (tachycardia and bradycardia), especially

during and after a contraction

– decreased variability in the fetal heart rate

• Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp
prick through the open cervix in labour

– fetal acidosis

– elevated fetal blood lactate levels indicating the baby has a lactic acidosis

– Some of these signs are more reliable predictors of actual distress than others.
For example, cardiocartography can give high false positive rates, even when
interpreted by highly experienced medical personnel. Acidosis is a highly
reliable predictor, but is not always available. A highly effective method of
assessment of distress would be to use fetal heart rate as a first indicator of
distress, to be confirmed with a more reliable method of diagnosis before radical
treatment is performed

CAUSE

• Breathing problems

• Abnormal position and presentation of the fetus

• Multiple births
 • Shoulder dystocia

• Prolapsed umbilical cord

• Nuchal cord

• Placental abruption

• Premature closure of the fetal ductus arteriosus

RISK FACTOR

• Women with a history of:

– Stillbirth

– Intrauterine growth retardation

– Oligohydramnios or polyhydramnios

– Multiple pregnancies

– Rhesus sensitisation

– Hypertension

– Diabetes and other chronic diseases

– Decreased fetal movements

– Post-term pregnancy.

• There is some evidence that maternal age over 35 years is an independent risk factor
for uteroplacental insufficiency and fetal distress

TREATMENT

In many situations fetal distress will lead the obstetrician to recommend steps to urgently
deliver the baby. This can be done by induction, or in more urgent cases, a caesarean
section may
 • Normal range at term is 120-160 bpm.

• Fetal bradychardia (<120bpm) or tachycardia (> 160bpm) may be associated with

hypoxia but several other factors can cause tachycardia, e.g. maternal pyrexia or
dehydration.

Late decelerations, defined as uniform,repeated, periodic slowing of the fetal heart rate, whose
onset is from mid to end of the contraction, with its nadir more than 20 seconds after the peak
intensity of the contraction, suggest fetal hypoxia
REFERENCE B

Fetal Distress

 Fetal distress is a condition in which the fetus (unborn baby) develops a problem during
the mother’s labor.
 Compromise of the fetus during the antepartum period (before labor) or intrapartum
period (birth process).
 The term "fetal distress" is commonly used to describe fetal hypoxia in utero (low oxygen
levels in the fetus).This occurs when conditions which interfere with the supply of oxygen
to the foetus are present.
 It is ill defined term , used to express intrauterine fetal jeopardy, a result of intrauterine
fetal hypoxia.(Dutta)
 The concern with fetal hypoxia is it may result in fetal damage or death if not reversed or
if the fetus is not promptly delivered.
 Fetal distress can be detected due to abnormal slowing of labor, the presence of
meconium (dark green fecal material from the fetus) or other abnormal substances in the
amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH
of less than 7.2.

Signs and symptoms of fetal distress include:

 Decreased movement felt by the mother

 Meconium in the amniotic fluid
 Cardiotocography signs
o increased or decreased fetal heart rate (tachycardia and bradycardia),
especially during and after a contraction.
o decreased variability in the fetal heart rate
 Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp
prick through the open cervix in labour
o fetal acidosis
o elevated fetal blood lactate levels indicating the baby has a lactic acidosis
(Lactic acidosis is a condition caused by the buildup of lactic acid in the
body. It leads to acidification of the blood (acidosis), and is considered a
distinct form of metabolic acidosis.

Fetal Hypoxia

Metabolic acidosis

H-ions first stimulate and then depress the Also causes parasympathtic
sino-auricular node stimulation

Leading trachycardia and bradycardia Hyperparistalsis and relaxation of the anal

sphincter.
 o

Note: A normal fetal heart rate may slow or fast during a contraction but usually recovers to
normal as soon as uterus relaxes.

Causes of fetal distress

Fetal distress can occur during pregnancy, or more commonly during labour. Fetal Distress
can be due to a wide range of reasons. The main cause of antepartum fetal distress is
uteroplacental insufficiency.
Factors within labour are complex but processes such as uteroplacental vascular disease,
reduced uterine perfusion, fetal sepsis, reduced fetal reserves, and cord compression can be
involved alone or in combination, and gestational and antepartum factors can modify the
fetal response. Reduced liquor volume, maternal hypovolaemia and fetal growth restriction
are known associations.

Some of the more common causes include:

1. Not enough oxygen: The most common reason for fetal distress is the baby is not
receiving enough oxygen when inside the uterus. This is usually because there is not an
adequate blood flow through the placenta and cord. When the uterus contracts in labour, it
momentarily reduces blood flow to the baby, as the uterus relaxes, the blood flow increases.
This is a normal, natural process that healthy babies, with a healthy placenta, are not
concerned with. In fact, it actually stimulates the baby (usually shown as an increase in their
heart rate).
There are some situations when the blood flow (and hence the oxygen supply), are lessened,
causing the baby to become either slowly distressed over time, or suddenly distressed if the
incident is severe.
Some causes of fetal distress can include

Placental insufficiency. This is when the placenta is not functioning at its best and
can be due to high blood pressure, heart conditions, bleeding in late pregnancy,
small baby or post dates, Pre-eclampsia, eclampsia, chronic nephritis and DM.

Over stimulation of the uterus, due to being induced or augmented.

A sharp drop in the mother's blood pressure due to her having an epidural, or
experiencing a haemorrhage, or lying for a prolonged period flat on her back in
labour.
 Cord compression due to an early artificial rupture of the membranes (ARM) or a
cord prolapse. The blood supply may also be reduced if the umbilical cord is
wrapped several times around the baby's neck or body.

True knot in the umbilical cord, short umbilical cord.

Twins sharing a single placenta. Known as Twin to twin transfusion.

Placental abruption (or separation of the placenta from the wall of the uterus),
Placenta previa.

Prolonged labour, especially if the membranes have been long ruptured.

Degenaration of placenta associated with post maturity.

2. Blood chemical imbalances : Sometimes chemical imbalances in the woman's blood

stream can stress the baby. In most cases the women is unwell when this happens. Health
conditions that can cause this are cholestasis, diabetes or kidney disease.

3. The baby is unwell : The baby may be unwell due to:

An inherited disorder.

An abnormality in the baby.

An infection, such as group B strep.

The baby being overheated due to the mother having a fever.

Causes of fetal stress during labour

 Compression of the fetal head during contractions.

During uterine contractions compression of the fetal skull causes vagal stimulation, which
slows the fetal heart rate. Head compression usually does not harm the fetus. However, with a
long labour due to cephalopelvic disproportion, the fetal head may be severely compressed.
This may result in fetal distress.

 Decrease in the supply of oxygen to the fetus.

UTERINE CONTRACTIONS: Uterine contractions are the commonest cause of a decrease
in the oxygen supply to the fetus during labour.

REDUCED BLOOD FLOW THROUGH THE PLACENTA: The placenta may fail to
provide the fetus with enough oxygen and nutrition due to a decrease in the blood flow
through the placenta, i.e. placental insufficiency. Patients with pre-eclampsia have poor
formed spiral arteries that provide maternal blood to the placenta. This can also be caused by
narrowing of the uterine blood vessels due to maternal smoking.
ABRUPTIO PLACENTAE: Part or all of the placenta stops functioning because it is
separated from the uterine wall by a retroplacental haemorrhage. As a result the fetus does
not receive enough

oxygen.

CORD PROLAPSE OR COMPRESSION: This stops the transport of oxygen from the
placenta to the fetus.

“UTERINE CONTRACTIONS ARE THE COMMONEST CAUSE OF A DECREASED

OXYGEN SUPPLY TOTHE FETUS DURING LABOUR”

HOW DOES THE FETUS RESPOND TO A LACK OF OXYGEN?

A reduction in the normal supply of oxygen to the fetus causes FETAL HYPOXIA. This is a
lack of oxygen in the cells of the fetus. If the hypoxia is mild the fetus will be able to
compensate and, therefore, show no response. However, severe fetal hypoxia will result in
FETAL DISTRESS. Severe, prolonged hypoxia will eventually result in fetal death.

Decreased fetal oxygenation in labour

Hypoxia

Metabolic acidosis
 Asphyxia

Tissue damage

Fetal death

Management

In many situations fetal distress will lead the obstrecion to recommend steps to urgently
deliver the baby. This can be done by induction, or in more urgent cases, a caesarean section
may be performed.

 Prop up the woman or place her on her left side, which helps to improve placental
circulation. Lateral positioning avoids compression of venacava and aorta by the
gravid uterus. This increase cardiac output and uteroplacental perfusion.
 Stop oxytocin if it is being administered.
 Correction of dehydration by IV fluids improves intravascular volume and uterine
perfusion.
 Correction of maternal hypotension, following epidural analgesia, with immediate
infusion of 1 litre of crystalloid (RL)
 Tocholytic (inj turbutaline 0.25 mg sc) is given when uterus is hyppertonus and there
is non reassuring FHR.
 Aminio-infusion has been shown to be beneficial in this situation, with a reduced risk
of Caesarean section This an initial infusion of a 250-500ml bolus of warmed normal
saline, through a double lumen intrauterine pressure catheter. (Uterine pressure and
fetal heart rate (via scalp electrode) are monitored constantly.) It is thought to dilute
meconium and reduce the risk of meconium aspiration and reduces cord compression.
The potential adverse effects include umbilical cord prolapse, uterine scar rupture and
amniotic fluid embolism.
 Check uterine contraction for strength, duration of fregnancy.

 If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate

management.
 If a maternal cause is not identified and the fetal heart rate remains abnormal
throughout at least three contractions, perform a vaginal examination to check for
explanatory signs of distress:

- If there is bleeding with intermittent or constant pain,

suspect abruptio placentae;
 - If there are signs of infection (fever, foul-smelling vaginal
discharge) give antibiotics as for amnionitis;
- If the cord is below the presenting part or in the vagina,
manage as prolapsed cord.
 If fetal heart rate abnormalities persist or there are additional signs of distress
(thick meconium-stained fluid), plan delivery: In second stage of labour, if the
head is in the perineum fiven episiotomy to hasten delivery or farcep delivery can
be done.

- In second stage of labour, if the head is in the

perineum given episiotomy to hasten delivery.

- If the cervix is fully dilated and the fetal head is

not more than 1/5 above the symphysis pubis or
the leading bony edge of the head is at 0 station,
deliver by vacuum extraction or forceps;

- If the cervix is not fully dilated or the fetal head is

more than 1/5 above the symphysis pubis or the
leading bony edge of the head is above 0 station,
deliver by caesarean section.

MECONIUM

 Meconium staining of amniotic fluid is seen frequently as the fetus matures and by
itself is not an indicator of fetal distress. A slight degree of meconium without fetal
heart rate abnormalities is a warning of the need for vigilance.

 Thick meconium suggests passage of meconium in reduced amniotic fluid and

may indicate the need for expedited delivery and meconium management of the
neonatal upper airway at birth to prevent meconium aspiration.

 In breech presentation, meconium is passed in labour because of compression of

the fetal abdomen during delivery. This is not a sign of distress unless it occurs in
early labour.
 Abnormal fetal heart rate

 A normal fetal heart rate may slow during a contraction but usually
recovers to normal as soon as the uterus relaxes.
 A very slow fetal heart rate in the absence of contractions or persisting
after contractions is suggestive of fetal distress.
 A rapid fetal heart rate may be a response to maternal fever, drugs causing
rapid maternal heart rate (e.g. tocolytic drugs), hypertension or amnionitis.
In the absence of a rapid maternal heart rate, a rapid fetal heart rate should
be considered a sign of fetal distress.

DISCUSSION

SIMILARITY

Real case, Reference A and Reference B

Based on my case study, there have a few similarity I found in real case, Reference A
and Reference B. First similarity I found in this three cases is its definition. These three cases
stated fetal distress is describe fetal hypoxia (low oxygen levels in the fetus). The concern with
fetal hypoxia is it may result in fetal damage or death if not reversed or if the fetus is not
promptly delivered. It can be detected due to abnormal slowing of labor, the presence of
meconium (dark green fecal material from the fetus) or other abnormal substances in the
amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH of
less than 7.2.

Next similarity I found from the real case and the references is the sign and symptom.
the reference A, B and real case said that there decreased movement felt by the mother
Meconium in the amniotic fluid Cardiotocography signs increased or decreased fetal heart rate
(tachycardia and bradycardia), especially during and after a contraction. decreased variability
in the fetal heart rate.

Other similarity found from Reference A, B and real case is the causes of fetal distress.
Medical staff in real case and Reference A and B mentioned the indication of fetal distress is
lack of oxygen. The most common reason for fetal distress is the baby is not receiving enough
oxygen when inside the uterus. This is usually because there is not an adequate blood flow
through the placenta and cord. When the uterus contracts during labour, it momentarily reduces
blood flow to the baby, as the uterus relaxes, the blood flow increases. This is a normal, natural
process that healthy babies, with a healthy placenta, are not concerned with. In fact, it actually
stimulates the baby (usually shown as an increase in their heart rate).
There are some situations when the blood flow (and hence the oxygen supply), are lessened,
causing the baby to become either slowly distressed over time, or suddenly distressed.

Next similarity from these three cases is the complication of the fetal distress. Real case
and these two references mentioned the complication maybe faced by the mother after
delivered is labour and shoulder dystocia, breech presentation, post-partum hemorrhage which
defined as an excess blood loss from the uterus (more than 500 mL) during and after delivery.
Other complication is cord prolapse, meconium, vacuum assisted delivery and non-progression
of expulsion for example the head or presenting parts are not delivered despite adequate
contractions.

As a conclusion, we can understand that the real case, Reference A and B are used same
definition of fetal distress, sign and symptom,causes.