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The classification system for IA findings (normal, abnormal) and EFM tracings (normal, atypical, abnormal) is solely descriptive. The classification of fetal surveillance findings must then be used, in conjunction with the entire clinical situation, to determine subsequent management of the pregnancy.

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• Although fetal injury is rare in labour we must detect developing fetal hypoxia early and prevent adverse consequences

• The sensitivity of fetal cardiac changes as a bioassay of decreased oxygen will often allow timely intervention if the intrapartum assessment is done and interpreted correctly

• Inadequate fetal monitoring is frequently cited as a component of substandard care when compensation is awarded after litigation for birth asphyxia (main factor in 49% and contributing in 21%-2013 Norwegian study of 161 successful claims)

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Physiologic decline in pH is generally well tolerated

Limited reserves are situations limited fetal oxygenation such as • maternal oxygentation (smoking, anemia), • uterine blood flow (hypotension, maternal position), • uteroplacental factors (tachysystole, abruption, chorio, uterine rupture)• fetal factors (cord compression, fetal anemia)• metabolic acidosis and cardiovascular decompensation may pose a risk of long-

term CNS sequelae

Need to think about your pretest likelihood that an atypical or abnormal FHR pattern requires close observation, intervention or rapid intervention

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Aim of FHS is to detect signs of decompensation prior to damage

HIE hypoxic ischemia encephalopathy

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Many of the medical legal concerns with CP attribute it to intrapartum events so need to clarify it’s status relative to intrapartum events.

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Emphasize that the majority of cases have a cause other than intrapartum events

Many of these associated factors reduce utero placental function & thus increase the potential for metabolic acidosis when additional stressors ie labour are added

** Long list – don’t need to read them all – see content

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Early indicators of possible problem related to intrapartum timing

In addition to the four essential criteria identified by the International Cerebral Palsy Task Force (see above), the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics listed five additional criteria that collectively suggest an intrapartum timing (within close proximity to labour and delivery, e.g., 0 to 48 hours) but are non-specific to asphyxial insults. It is not necessary for all five of these to be present and, with the exception of the first criterion, they are only weakly associated with acute intrapartum hypoxia.

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• Examples of decreased maternal arterial 02 tension; respiratory disease, hypoventilation, seizure, trauma, smoking, obesity

• Examples of decreased maternal 02 carrying capability: significant anemia, carboxyhemoglobin (smokers)

• Examples of decreased uterine blood flow; hypotension, regional anaesthesia, maternal position

• Examples chronic maternal conditions; vasculopathies (e.g. Lupus), Type 1 diabetes, chronic hypertension, chronic heart disease, chronic obstructive pulmonary disease

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• Examples of excessive uterine activity; tachysystole, abruption

• Examples of uteroplacental dysfunction; placental infarction marked by IUGR, oligo or abnormal dopplers, chorio, uterine rupture, abruption

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• Cord compression due to oligohydramnios, prolapse, entanglement, single umbilical artery (due to less wharton’s jelly cushioning)

• Decreased fetal 02 carrying capability; significant anemia (e.g., isoimmunization, fetal-maternal bleed, ruptured vasa previa, carboxyhemoglobin (maternal smoking)

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Fetal surveillance is only one part of the picture

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The woman and her partner must be informed of the various methods of FHS and be involved in the decisions about their use in labour

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Must know IA palpation of contractions and auditory recognition of pertinent FHR changes

EFM: interpretation of EFM

Regardless of type of surveillance – care by a skilled and knowledgeable practitioner is required

• Recognize the necessity for change in institutional policy and staffing. This won’t happen unless there are people pushing to make it happen. Urge the audience to go home and make changes

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Regardless of using IA or EFM some definitions are the same- applies to baseline and post contraction

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With palpation the strength of contractions are mild, moderate , strong – remember still must palpate as external EFM does not provide information on strength of contractions

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Now going to address IA components

Increases or decreases in FHR referred to by SOGC as accelerations or deceleration – technically cannot quantify definition as 15 bpm up or down

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When you have done a full assessment of the characteristics of IA you categorize it as normal or abnormal

PCP = primary care provider

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EFM not required if you have an epidural – may still maintain IA

Maternal hypotension and FHR changes are often seen in the first 60 minutes after initiation of regional anesthesia

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-the 2 minutes for the baseline can be 2 separate one minute segments-if can’t obtain 2 minutes then baseline is indeterminant

Can view the baseline rate through a contraction

Periodic changes are those occurring regularly with contractions

Definition for brady and tachy are the same as with IA

- FHR < 110 - bradycardia- FHR > 160 - tachycardia

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Need 10 minutes to assess variability – to make sure the one minute you have selected is representative

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• Occurrence of fetal heart rate variability requires intact, functional and well oxygenated activity of everything shown in the diagram

• Fetal heart rate is principally regulated by the vagus nerve• Because fetal heart rate variability, or accelerations, depends on innervation of

the heart which is established with advancing gestation the mechanism for occurrence of these is less at younger gestational ages. Variability should be normal by 32 wks.

• Absent variability is due to the causes as listed. The one of concern is fetal hypoxia/acidosis. The one that is common is the normal fetus that is asleep. Principal risk here is that of false positive with a normal fetus sleeping. Reduced variability due to fetal quiescence usually recovers within 30 to 40 minutes.

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Use 15 seconds as that will not be an artifact

Can determine this with visual EFM – with IA you hear an increase but cannot quantify the amount of the increase

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Periodic because occur with contractions

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Remember that variable decelerations can occur unassociated with a contraction.

Periodic decelerations occur with a contraction.

Episodic decelerations are not associated with a contraction

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Late decelerations always periodic as associated with contractions

(gradual means onset to nadir � 30 seconds)

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Possible actions based on clinical situation

• The lateral positioning and fluid loading will increase placental blood flow, this directly addresses the usual underlying pathophysiology

• 2012 Cochrane review found that cord blood pH values <7.2 were more frequent when mothers received prophylactic oxygen. In the absence of maternal hypoxia or hypovolemia, prolonged use of maternal oxygen should be avoided.

• 2012 Cochrane review of amniofusiono for suspected umbilical cord compression found a reduction in:

• CS rate• FHR decelerations• Apgar < 7 at 5 minutes• Meconium below the vocal cords• Pp endometritis and maternal LOS

• Maternal 02 supplementation should be reserved for maternal hypoxia or hypovolemia and not used for management of atypical or abnormal fetal heart rate

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The pH level of 7.20 for intervention

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Lactate levels correlate well with both fetal scalp and cord blood pH and base deficit

No differences in mode of birth or neonatal outcomes

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• The recommendation of the SOGC guideline• Provision of intermittent auscultation will require the provision of close support

in labour, with implications for nursing staffing – midwifery staffing often makes this easier for midwives

• It is recognized that practice guidelines alone don’t change practice; it was the existence of the original SOGC Task force on CP together with the management of labour guideline that led to the establishment of the ALARM Course for the purpose of the dissemination of the recommendations and their rationale and, it is hoped, change of behavior.

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These are examples of women with risk factors that would benefit from EFM

PLEASE DO NOT READ THE LIST. Acknowledge that this is a lengthy list which is also in your text that addresses conditions associated with an increased risk.

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• Note what we have already said about the latent phase that patients in the latent phase shouldn’t be in hospital at all, and therefore shouldn’t be having auscultation

• This is a statement about what to do if for some other reason they are there in the latent phase but it does not refute the suggestion that women in the latent phase of labour are better off at home

• There is no “placebo controlled trial” of auscultation. The auscultation frequency recommended is that from the auscultation limbs of the randomized controlled trials and represents arbitrary choices

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• 5 RCTs from Aust, USA, Germany – no difference in NB outcome = for pulse oximetry

• ST – needed extensive education in the European studies which did result in fewer acidotic babies, fewer scalp samples, fewer AVD – no diff in CS NICU admits

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• Three randomized controlled trials including 11,259 women and 11 observational studies including 5,831 women were reviewed. BJOG 2005• women randomized to the labour admission test compared with women

randomized to auscultation on admission were more likely to have minor obstetric interventions like- epidural analgesia [relative risk (RR) 1.2, (95% CI 1.1–1.4)- continuous electronic fetal monitoring (RR 1.3, 95% CI 1.2–1.5)- fetal blood sampling (RR 1.3, 95% CI 1.1–1.5)

Acknowledge this may be hard to change due to nursing staffing but is also habit for many

Important to let caregivers know that this should be shared with women and families so they understand

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