Acceleration: A visually apparent abrupt increase (onset to peak in <30 seconds) in the FHR.

These are mediated by the

sympathetic nervous system in response to fetal movements or scalp stimulation.
• At ≥32 weeks gestation, an acceleration has a peak of >15 beats/min above baseline, with a duration of >15 seconds but < 2
min from onset to return.
• At <32 weeks gestation, an acceleration has a peak of >10 beats/min above baseline, with a duration of >10 sec but <2 min
from onset to return.
Early deceleration: A visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine
contraction. These are mediated by parasympathetic stimu- lation and occur in response to head compression.
• A gradual FHR decrease is defined as from the onset to the FHR nadir of >30 seconds.
• The decrease in FHR is calculated from the onset to the nadir of the deceleration.
• The nadir of the deceleration occurs at the same time as the peak of the contraction.
Late deceleration: A visually apparent usually symmetrical gradual decrease and return of the FHR associated with a uterine
contraction. These are mediated by either vagal stimulation or myocardial depression and occur in response to placental
insufficiency.
• A gradual FHR decrease is defined as from the onset to the FHR nadir of >30 seconds.
• The decrease in FHR is calculated from the onset to the nadir of the deceleration.
• The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction.
Variable deceleration: A visually apparent abrupt decrease in FHR. These are mediated by umbilical cord compression.
• An abrupt FHR decrease is defined as from the onset of the deceleration to the begin- ning of the FHR nadir of <30
seconds.
• The decrease in FHR is calculated from the onset to the nadir of the deceleration.
• The decrease in FHR is >15 beats per minute, lasting >15 seconds, and<2 minutes in duration.
Sinusoidal pattern: • A visually apparent, smooth, sine wave-like undulating pattern in FHR baseline with a cycle
frequency of 3–5/min which persists for ≥20 min.
Category I: FHR tracings are normal
Criteria include all of the following:
• Baseline rate: 110-160 beats/min
• Baseline FHR variability: moderate
• Late or variable decelerations: absent
• Early decelerations: present or absent
• Accelerations: present or absent
Interpretation: strongly predictive of normal fetal acid-base status at time of observation
Action: monitoring in a routine manner, with no specific action required
Category II: FHR tracings are indeterminate
These include all FHR tracings not categorized as category I or III, and may represent an appreciable fraction of those
encountered in clinical care.
Interpretation: not predictive of abnormal fetal acid-base status
Action: evaluation and continued surveillance and reevaluation, taking into account the entire associated clinical
circumstances
Category III: FHR tracings are abnormal
Criteria include absent baseline FHR variability and any of the following:
• Recurrent late decelerations
• Recurrent variable decelerations
• Bradycardia
• Sinusoidal pattern
Interpretation: associated with abnormal fetal acid-base status at time of observation; requires prompt evaluation
Action: expeditious intrauterine resuscitation to resolve the abnormal FHR pattern; if tracing does not resolve with these
measures, prompt delivery should take place.
AMNIOTIC FLUID INDEX
The 4-quadrant amniotic fluid index test assesses in centimeters the deepest single vertical amniotic fluid pocket in each of the
4 quadrants of the uterus. The sum of the pockets is known as the amniotic fluid index, or AFI. Interpretation is as follows:
<5 cm—oligohydramnios/ 5–8 cm—borderline/ 9–25 cm—normal/ >25 cm—polyhydramnios
BIOPHYSICAL PROFILE (BPP): A complete BPP measures 5 components of fetal well-being: NST, amniotic fluid volume,
fetal gross body movements, fetal extremity tone, and fetal breathing movements. The last 4 components are assessed using
obstetric ultrasound. Scores given for each component are 0 or 2, with maximum possible score of 10 and minimum score of 0.
• Score of 8 or 10—highly reassuring of fetal well-being. Management is to repeat the test weekly or as indicated. Fetal death
rate is only 1 per 1,000 in the next week. • Score of 4 or 6—worrisome. Management is delivery if the fetus is >36 weeks or
repeat the biophysical profile in 12–24 h if <36 weeks. An alternative is to perform a CST. • Score of 0 or 2—highly predictive
of fetal hypoxia with low probability of false posi- tive. Management is prompt delivery regardless of gestational age.
CONTRACTION STRESS TEST (CST):This test assesses the ability of the fetus to tolerate transitory decreases in intervillous
blood flow that occur with uterine contractions. It uses both external FHR and contraction moni- toring devices and is based on
the presence or absence of late decelerations. These are grad- ual decreases in FHR below the baseline with onset to nadir of ≥30
s. The deceleration onset and end is delayed in relation to contractions. If 3 contractions in 10 min are not spontane- ously
present, they may be induced with either IV oxytocin infusion or nipple stimulation. This test is rarely performed because of the
cost and personnel time required. The most com- mon indication is a BPP of 4 or 6.
• Negative CST requires absence of any late decelerations with contractions. This is reassuring and highly reassuring for fetal
well-being. Management is to repeat the CST weekly. Fetal death rate is only 1 per 1,000 in the next week.
• Positive CST is worrisome. This requires the presence of late decelerations associ- ated with at least 50% of contractions. Fifty
percent of positive CSTs are false positive (meaning the fetus is not hypoxemic). They are associated with good FHR variability.
The 50% of true positives are associated with poor or absent variability. Management is prompt delivery.
• Contraindications—CST should not be performed whenever contractions would be hazardous to the mother or fetus. Examples
include previous classical uterine incision, previous myomectomy, placenta previa, incompetent cervix, preterm membrane rup-
 1. Have a written breastfeeding policy that is regularly communicated to all health-care staff
2. Train all staff in skills necessary to implement this policy
3. Inform all pregnant women about the benefits and management of breastfeeding
4. Help mothers initiate breastfeeding within an hour of birth
5. Show mothers how to breastfeed and how to sustain lactation, even if they should be separated from their infants
6. Feed newborns nothing but breast milk, unless medically indicated, and prioritize donor breast milk when supplementation
is needed
7. Practice rooming-in, which allows mothers and newborns to remain together 24 hours a day
8. Encourage breastfeeding on demand
9. Give no artificial pacifiers to breastfeeding newborns
10. Help start breastfeeding support groups and refer mothers to them
Advantage BF: Nutritional/ Immunological /Developmental /Psychological /Social /Economic /Environmental /Optimal
growth and development Decrease risks for acute and chronic diseases
First trimester care: Care team/Postpartum visits/Lactation support/Infant feeding plan/Reproductive life plan /Contraception/
Pregnancy complications /Cardiovascular risk assessment/ Mental health/ Postpartum problems /Chronic conditions
CONDUCTION OF DELIVERY: Delivery of the head: The principles to be followed are to maintain flexion of the head,
to prevent its early extension and to regulate its slow escape out of the vulval outlet.
 The patient is encouraged for the bearing-down efforts during uterine contractions. This facilitates descent of the head.
Delivery of the shoulders: Not to be hasty in delivery of the shoulders. Wait for the uterine contractions to come and for the
movements of restitution and external rotation of the head to occur
Delivery of the trunk: After the delivery of the shoulders, the fore finger of each hand are inserted under the axillae and the
trunk is delivered gently by lateral flexion.