Fetal Monitoring
Objectives
Intra-partum
Fetal Monitoring
History of CEFM
• 1818 - Fetal heart beat first heard
• 1838 - Use of fetal stethoscope
• Late 1960s - EFM debuted
• 1980 - Nearly half of all labouring
women monitored with CEFM!
• 2000 - Evidence-based CEFM
Fetal Indications for CEFM
• Multiple gestation
• Intra-uterine growth restriction
• Preterm labour
• Breech presentation
• Rh iso-immunisation
• Review evidence regarding continuous
electronic fetal monitoring (CEFM)
• Identify key factors in use of structured
intermittent auscultation (SIA) versus CEFM
• Utilize the mnemonic DR C BRAVADO
• Develop plan based on overall assessment of
the mother and fetus
Maternal Indications for CEFM
• Hypertensive disease
• Diabetes
• Cardiac disease
• Severe anaemia or haemoglobinopathy
• Hyperthyroidism
• Collagen vascular disease
• Renal disease
Labour Indications for CEFM
• Induced or augmented labour
• Prolonged labour
• Regional analgesia
• Labour after caesarean section
• Abnormal uterine activity
• Meconium
• Suspicious fetal heart rate with SIA
• Vaginal bleeding in labour
• Abnormal CTG on admission tracing
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Effects of Fetal Monitoring Outcomes With CEFM

• Continuous Monitoring • 12 RCTs of >58,000 patients:
Ð mobility
) No difference in 1 min. APGAR score <7
Ð contact with staff, partner
) Slight decrease in neonatal seizures
Ð direct midwife-patient contact
) No difference in NICU admission rates
Ï operative delivery rate
) Increased rate of caesarean and operative
• Intermittent Auscultation vaginal delivery, especially in low-risk
) Adequate number of trained personnel pregnancies
necessary

Choice of Monitoring Method Intermittent Auscultation -

Frequency
• Determine staff availability and
comfort level Low-Risk High-Risk

• Determine risk of mother and fetus First Stage, q15-30 min q15 min
Active phase
• Discuss with woman
Second Stage q5 min q5 min
(or after each contraction)

Auscultation Procedure CEFM as a Screening Test

• Doppler over point of maximum fetal heart • Limitations:

sounds ) Low specificity
• Differentiate maternal from fetal pulse ) Non-reassuring tracing not predictive of poor
outcome
• Palpate uterus for contractions
• Strengths:
• Count FHR for 1 minute between
contractions (= baseline rate) ) High sensitivity
) Reassuring tracing predictive of good outcome
• Count FHR for 1 minute after contraction

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DR C BRAVADO DR = Determine Risk

• Determine Risk
• Antenatal risk factors
• Contractions
• Intra-partum risk factors
• Baseline RAte
• Variability • Fetal reserve
• Accelerations • Labour progress
• Decelerations
• Overall assessment & plan

C = Contractions BRA = Baseline RAte

• Method of monitoring • Requires >10 minutes to establish

) Palpation • Normal =110-160
) External transducer • SIA - determine between contractions
• Pattern and intensity • Baseline rate influenced by:
) Adequate ) Prematurity
) Hyper-stimulation (>7 in 15 min) ) Change in fetal status
) Maternal fever, position, medication

Bradycardia
160 Mild: 100 - 110 bpm Tachycardia
Severe: < 100 bpm Mild: 160 - 180 bpm
140
Possible causes: congenital heart Moderate: 180 - 200 bpm
120 disease, heart block, severe hypoxia 240 Severe: > 200 bpm

100 210
80 180
60 150

80 120

60 90

40 60

20 30

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V = Variability Causes of Decreased Variability

• Normal = 5-25 bpm around baseline • Hypoxia / acidosis

• Decreased = 3-5 bpm • Fetal sleep cycle

• Prematurity
• Absent = <3 bpm
• Congenital anomalies (CNS)
• Reflects normal CNS function
• Drugs
• Best predictor of good fetal outcome „ nervous system depressants
„ anticholinergics / parasympatholytics
„ corticosteroids
„ magnesium sulphate
„ -caine agents (N.B. Bupivicaine)

Variability A = Accelerations
Normal variability is the most important • Definition
characteristic of a reassuring tracing
) Increase of > 15 bpm above baseline
240 240
210 210 ) Lasts > 15 seconds
• Presence indicates fetal well-being
180 180
150 150
120 120 • Absence
90 90
60 60 ) Frequently false positive in low risk patients
30 30 ) Further evaluation required
Normal Decreased

Accelerations D = Decelerations
240
210
180 • Requires correlation to contraction
150 pattern
120 • Classification impossible with SIA
90
) appropriate to consider CEFM
60 Increase of 15 bpm associated
with movement or stimulation is
80
measure of fetal well-being
60
40
20
0

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Early Decelerations Variable Decelerations

200
180 Variable in shape and timing in relationship
160 Early decelerations mirror contraction: they are 180
to contraction - may have “shoulders”
140 usually benign, related to head compression 160
140
120
120
100
100
80
80
60
60
80
80
60
60
40 40
20 20
0 0

Complicated Variable Decelerations Late Decelerations

180
160
Hypoxia is more likely with: 140

• a rising baseline or baseline tachycardia 120

100
• reduced baseline variability 80 Begin after onset of contraction, nadir after
• smooth overshoot post-deceleration 60 peak of contraction, return to baseline after
• persistent large amplitude/duration decelerations 80 end of contraction
60
• slow return to baseline after the contraction
40
• loss of pre- and post-deceleration shouldering 20
0

O = Overall Assessment & Plan Causes of Sudden

Decrease in FHR
• Assessment of fetal status
• Amniotomy
) Reassuring
• Cord prolapse
) Non-reassuring
• Vaginal examination
• Management plan • Fetal scalp blood sampling
) Based on clinical context • Uterine hypertonus
) Must include plan for further monitoring • Placental abruption
• Maternal hypotension or position change

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Management of Scalp pH Interpretation

Non-reassuring CTG
• Re-assess maternal vital signs
• Maternal position change, O2, IV fluids Fetal Above 7.20 to Below 7.20
Scalp pH
• Assess cervix for dilatation or cord prolapse 7.25 7.25
• Stop syntocinon (if in use) Repeat pH in Repeat pH in Deliver
• Acoustic or scalp stimulation Action one hour if 30 minutes if immediately
• Fetal scalp blood sampling tracing non- tracing not
reassuring improved
• Tocolysis
• Amnio-infusion
• Plan immediate delivery

Scalp pH Substitutes Local Guidelines

• Two non-invasive methods:

„ Fetal acoustic stimulation RANZCOG guidelines:
„ Scalp stimulation http://www.ranzcog.edu.au/publications/pdfs/
) If acceleration, pH > 7.25 ClinicalGuidelines-IFSSecEd.pdf
) Less data regarding interpretation if no
acceleration

• Scalp lactate measurement

Summary

• Assessment of fetal and maternal risk is

important first step in fetal monitoring
• DR C BRAVADO provides a systematic way
to interpret tracings
• Multiple methods exist to respond to CTG
tracing changes
• Consider periodic updates for staff on use of
CTG monitoring