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It is essential to monitor the fetus during labour in order to assess the response to the stresses of labour. The stress of a normal labour usually has no effect on a healthy fetus.
Uterine contractions may compress the fetal head and cause slowing of the fetal heart rate. Head compression usually does not harm the fetus.
Uterine contractions are the commonest cause of a decreased oxygen supply to the fetus during labour.
Uterine contractions may:
Usually uterine contractions do not reduce the supply of oxygen to the fetus, as there is an adequate store of oxygen in the placental blood to meet the fetal needs during the contraction. Normal contractions in labour do not affect the healthy fetus with a normally functioning placenta, and, therefore, are not dangerous.
However, contractions may reduce the oxygen supply to the fetus when:
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.
Fetal distress caused by a lack of oxygen results in a decrease in the fetal heart rate. The fetus responds to hypoxia with a bradycardia to conserve oxygen.
Two observations are used:
Any one of the following three pieces of equipment:
In most low risk labours the fetal heart rate is determined using a fetal stethoscope. However, a doptone is helpful if there is difficulty hearing the fetal heart, especially if distress or intra-uterine death is suspected. If available, a doptone is the preferred method in primary care clinics and hospitals. Cardiotocograph is not needed in most labours but is an important and accurate method of monitoring the fetal heart in high risk pregnancies.
A doptone is the preferred method of assessing the fetal heart rate in primary care clinics and hospitals.
Because uterine contractions may decrease the maternal blood flow to the placenta, and thereby cause a reduced supply of oxygen to the fetus, it is essential that the fetal heart rate should be monitored during a contraction. In practice, this means that the fetal heart pattern must be checked before, during and after the contraction. A comment on the fetal heart rate, without knowing what happens during and after a contraction, is almost valueless.
The fetal heart rate must be assessed before, during, and after a contraction.
Low risk patients who have had normal observations on admission:
Women with a high risk of fetal distress should have their observations done more frequently. The following women would be regarded as at higher risk:
These women need more frequent recording of the fetal heart rate:
There are two features that should always be assessed:
These fetal heart rate patterns (with the exception of variable decelerations) can be easily recognised with a stethoscope or doptone. However, cardiotocograph recordings (figures 2-1, 2-2 and 2-3) are useful in learning to recognise the differences between the three types of deceleration.
It is common to get a combination of patterns, e.g. a baseline bradycardia with late decelerations. It is also common to get one pattern changing to another pattern with time, e.g. early decelerations becoming late decelerations.
Early decelerations are characterised by a slowing of the fetal heart rate starting at the beginning of the contraction, and returning to normal by the end of the contraction. Early decelerations are usually due to compression of the fetal head which causes the heart rate to slow during the contraction.
Figure 2-1: An early deceleration
Early decelerations do not indicate the presence of fetal distress. However, these fetuses must be carefully monitored as they are at an increased risk of fetal distress.
A late deceleration is a slowing of the fetal heart rate during a contraction, with the rate only returning to the baseline 30 seconds or more after the contraction has ended.
With a late deceleration the fetal heart rate only returns to the baseline 30 seconds or more after the contraction has ended.
Figure 2-2: A late deceleration
Late decelerations are a sign of fetal distress and are caused by fetal hypoxia. The degree to which the heart rate slows is not important. It is the timing of the deceleration that is important.
Late decelerations indicate fetal distress.
Variable decelerations have no fixed relationship to uterine contractions. Therefore, the pattern of decelerations changes from one contraction to another. Variable decelerations are usually caused by compression of the umbilical cord and do not indicate the presence of fetal distress. However, these fetuses must be carefully monitored as they are at an increased risk of fetal distress.
Variable decelerations are not easy to recognise with a fetal stethoscope or doptone. They are best detected with a cardiotocograph.
Figure 2-3: Variable decelerations
A baseline fetal heart rate of more than 160 beats per minute.
There is an increased risk of fetal distress if a fetal tachycardia is present.
A baseline fetal heart rate of less than 100 beats per minute.
A baseline bradycardia of less than 100 beats per minute usually indicates fetal distress which is caused by severe fetal hypoxia. If decelerations are also present, a baseline bradycardia indicates that the fetus is at great risk of dying.
A normal baseline fetal heart rate without any decelerations.
These fetal heart rate patterns do not indicate fetal distress but warn that the fetal heart rate must be closely observed as fetal distress may develop.
If electronic monitoring (a cardiotocograph) is available, the fetal heart rate pattern must be monitored.
The fetal heart rate must be observed before, during and after a contraction. The following questions must be answered and recorded on the partogram:
First the relation of the decelerations to the uterine contractions must be observed to determine the type of deceleration. Then manage the patient as follows:
The observations of the fetal heart rate must be recorded on the partogram as shown in figure 2-4. A note of what management is decided upon must also be made under the heading ‘Management’ at the bottom of the partogram.
Fetal distress due to severe hypoxia is present!
Therefore, you should immediately do the following:
It is important that you know how to give fetal resuscitation, as it is a life-saving procedure when fetal distress is present, both during the antepartum period and in labour.
Always prepare to resuscitate the infant after birth if fetal distress is diagnosed during labour.
Yes, in 10–20% of patients the liquor is yellow or green due to meconium staining. The incidence of meconium-stained liquor is increased in the group of women that go into labour after 42 weeks gestation.
Although fetal and neonatal complications are more common which thick meconium, all cases of meconium-stained liquor should be managed the same during the first stage of labour. The presence of meconium is important and the management does not depend on the consistency of the meconium.
Meconium-stained liquor warns that either fetal distress is present or that there is a high risk of fetal distress.
Three symbols are used to record the liquor findings on the partogram:
I = Intact membranes (i.e. no liquor draining).
C = Clear liquor draining.
M = Meconium-stained liquor draining.
The findings are recorded in the appropriate space on the partogram as shown in figure 2-4.
The liquor findings should be recorded when:
Figure 2-4: Recording fetal observations on the partogram
A primigravida with inadequate uterine contractions during labour is being treated with an oxytocin infusion. She now has frequent contractions, each lasting more than 40 seconds. With the woman in the lateral position, listening to the fetal heart rate reveals late decelerations.
The late decelerations indicate that fetal distress is present.
No. Correctable causes of poor oxygenation of the fetus must first be ruled out, e.g. postural hypotension and overstimulation of the uterus with oxytocin. The oxytocin infusion must be stopped and oxygen administered to the woman. Then the fetal heart rate should be checked again.
As overstimulation of the uterus with oxytocin was the most likely cause of the late decelerations, labour may be allowed to continue. However, very careful observation of the fetal heart rate pattern is essential, especially if oxytocin is to be restarted. The fetal heart should be listened to every 15 minutes or fetal heart rate monitoring with a cardiotocograph should be started.
A woman who is 38 weeks pregnant presents with an antepartum haemorrhage in labour. On examination, her temperature is 36.8 °C, her pulse rate 116 beats per minute, her blood pressure 120/80 mm Hg, and there is tenderness over the uterus. The baseline fetal heart rate is 166 beats per minute. The fetal heart rate drops to 130 beats per minute during contractions and then only returns to the baseline 35 seconds after the contraction has ended.
A maternal tachycardia is present and there is uterine tenderness. These findings suggest an abruptio placentae.
Both the baseline tachycardia and the late decelerations.
Because the deceleration continues for more than 30 seconds after the end of the contraction. This observation indicates fetal distress. The number of beats by which the fetal heart slows during a deceleration is not important.
Part of the placenta has been separated from the wall of the uterus by a retroplacental clot. As a result, the fetus has become hypoxic.
During the first stage of labour a woman’s liquor is noticed to have become stained with thin green meconium. The fetal heart rate pattern is normal and labour is progressing well.
Meconium in the liquor indicates an episode of fetal hypoxia and suggests that there may be fetal distress or that the fetus is at high risk of fetal distress.
Yes. All meconium in the liquor indicates either fetal distress or that the fetus is at high risk of fetal distress. The management does not depend on whether the meconium is thick or thin.
By listening to the fetal heart rate. Late decelerations or a baseline bradycardia will indicate fetal distress.
The fetal heart rate pattern must be determined carefully every 15 minutes in order to diagnose fetal distress should this occur.
The infant’s mouth and pharynx must be well suctioned immediately after the head has been delivered. No further suctioning is needed if the infant cries or breathes well. However, if the infant does not breathe well directly after delivery, suctioning should be repeated before mask ventilation is started. If the infant is intubated, further suctioning of the larger airways via the endotracheal tube should be done before ventilation is started.