Fetal Distress

Objectives
To discuss fetal distress, its etiologies,
mechanism, clinical manifestations and
overview of its management
To discuss intrapartum fetal assessment
esp. the cardiotocography
 Fetal Distress
Defined as depletion of oxygen and
accumulation of carbon dioxide, leading to
a state of hypoxia and acidosis during
intra-uterine life.
Normal labor is a process of repeated fetal
hypoxic events resulting inevitably in
acidemia.
 Mechanism
There are potentially limitless causes for fetal
distress, but several key mechanisms are
usually involved

Contractions reduce temporarily placental blood

flow and can compress the umbilical cord

If a women is in labor longer then this can cause

fetal distress via the above mechanism
Pathogenesis
Pathogenesis
 Clinical manifestations:
Acute Fetal Distress
(1)FHR
FHR>180 beats/min (tachycardia)
<100 beats/min (bradycardia)
Repeated Late deceleration
Placenta dysfunction
(VD) Variable deceleration
Umbilical factors
 Acute Fetal Distress
(2) Meconium staining of the amniotic fluid
grade I II III
(3) Fetal movement
Frequentlydecrease and weaken
(4) Acidosis
FBS (fetal blood sample)
pH<7.20
pO2<10mmHg (15~30mmHg)
CO2>60mmHg (35~55mmHg)
Meconium Stained Amnionic Fluid
There are 3 degrees about contaminated
I - slight contamination
The color of the amniotic fluid = slight green

II - mild contamination
Color of the amniotic fluid = dark green

III - severe contamination

Color of the amniotic fluid is dark yellow.
If the amniotic fluid is severely contamination, it
suggests the, fetal distress - it must be managed as
soon as possible
 Chronic Fetal distress
(1) Placental function
(24h E3<10mg or E/C<10)
(2) FHR
(3) BPS
(4) Fetal movement
(5) Amnioscopy
 Management
Remove the induced factors actively
Correct the acidosis: 5%NaHCO3 250ML
Terminate the pregnancy
(1) FHR>160 or <120 bpm, meconium
staining (II~III)
(2) Meconium staining grade III amniotic fluid
volume<2cm
(3) FHR<100 bpm continually
 Terminate the pregnancy
(4) Repeated LD and severe VD
(5) Baseline variability disappear with LD
(6) FBS pH<7.20

Forceps delivery or Caesarean section

Intrapartum Fetal Assessment
Intrapartum Fetal Assessment

Fetal surveillance in labor, whether by

intermittent auscultation (IA) or by electronic
fetal monitoring (EFM), should be recommended
to all women.
 Intrapartum Fetal Assessment

Frequency of intermittent auscultation is as

follows:
For low risk patients - every 30 mins for 1st stage,
then every 15 mins for the 2nd stage
For high risk patients - every 15 mins for 1st stage,
then every 5 mins for the 2nd stage
 Intrapartum Fetal Assessment
Based on available data, there is no clear
benefit for the use of EFM over IA in a patient
without complications.
In ideal settings, continuous EFM should be
offered and is recommended for high risk
pregnancies where there is increased risk of
perinatal death, cerebral palsy or neonatal
encephalopathy
 Intrapartum Fetal Assessment
Continuous EFM is reserved for abnormal
auscultation, prolonged labor, and labor which is
induced or augmented, meconium present,
multiple gestation/fetal complication

R
outine use of continuous EFM shown to lead to
higher intervention rates and no improvement in
outcome for the neonate
 The use of EFM is associated with an increased
rate of both vacuum and forceps operative
vaginal delivery, and caesarean delivery for
abnormal FHR patterns or acidosis or both.

There is high interobserver and intraobserver

variability in interpretation of FHR tracing.
 The use of EFM does not result in a reduction of
cerebral palsy.

A three-tiered system for the categorization of

FHR patterns is recommended.

The labor of women with high-risk conditions

should be monitored with continuous FHR
monitoring.
 Continuous EFM
External (Doppler)
Internal (Fetal Scalp Monitoring)
Fetal Scalp Monitoring
 Cardiotocography
More commonly known as electronic fetal
monitor
The FHR is detected through the maternal
abdominal wall using the ultrasound
Doppler principle
Described in terms of baseline FHR,
variability (short-term, long-term), and
periodicity (accelerations, decelerations)
External (Doppler)
 Baseline FHR
normal range is 110-160 bpm
parameter of fetal well-being vs. distress
 Baseline variability
physiologic variability is a normal characteristic of FHR
variability is measured over a 15 min period and is
described as: absent, minimal (<6 bpm), moderate (6-25
bpm), marked (>25 bpm)
normal variability indicates fetal acid-base status is
acceptable
can only be assessed by electronic fetal monitoring
(CTG)
variability decreases intermittently even in healthy fetus
 Periodicity
accelerations: increase of 15 bpm lasting
15 s, in response to fetal movement or
uterine
contraction (or 10 bpm lasting 10 s if
<32 wk GA)
decelerations: 3 types, described in terms
of shape, onset, depth, duration recovery,
occurrence, and impact on baseline FHR
and variability
Early deceleration
Variable Deceleration
Late Deceleration
ACOG recommended use of the
three tiered system
Category I (normal FHR) patterns
Category II (indeterminate FHR) patterns
Category III (abnormal FHR) patterns
Three-Tier FHR Interpretation System
Category I (POGS)
Three-Tier FHR Interpretation System

Category IIIndeterminate
Include all FHR tracings not categorized as
Category I or III.
Category II
Category II
Category II (POGS)
Category III
Category III (POGS)
Some Resuscitative Measures for Category
II and III Tracings
A Category II or Category III FHR tracing
requires initial evaluation and treatment may
include the following
Discontinuation of any labor stimulating agent

Cervical examination to determine umbilical cord

prolapse, rapid cervical dilatation, or descent of the fetal
head.

Changing maternal position to left or right lateral

recumbent position, reducing compression of the vena
cava and improving uteroplacental blood flow
A Category II or Category III FHR tracing
requires initial evaluation and treatment may
include the following
Monitoring maternal blood pressure level for evidence of
hypotension, especially in those with regional anesthesia
(if present, treatment with volume expansion or with
ephedrine or both or phenylephrine may be warranted)

Assessment of patient for uterine tachysystole by

evaluating uterine contraction frequency and duration
Fetal scalp
sampling
 Fetal scalp sampling
Fetal scalp sampling should be used in
conjunction with electronic FHR monitoring
and contraction monitoring (CTG) to
resolve the interpretation of abnormal or
atypical patterns
 Fetal Scalp Sampling
indicated when atypical or abnormal fetal
heart rate is suggested by clinical
parameters including
heavy meconium or moderately to severely
abnormal FHR patterns, including
unexplained low variability, repetitive late
decelerations, complex variable
decelerations, fetal cardiac arrhythmias
 pH 7.25: normal, repeat if abnormal FHR
persists
pH 7.21-7.24: repeat assessment in 30
min or consider delivery if rapid fall since
last sample
pH 7.20: indicates fetal acidosis, delivery
is indicated
 Fetal Scalp Sampling
Contraindications:
known or suspected fetal blood dyscrasia
(hemophilia, von Willebrand disease)
active maternal infection (HIV, genital
herpes)
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