Definition

Fetal distress is an ill-defined term, used to express

intrauterine fetal jeopardy, a result of intrauterine fetal hypoxia.
Nonreassuring fetal status is characterized by tachycardia or
bradycardia, reduced FHR variability, decelerations and absence of
accelerations (spontaneous or elicited). It must be emphasised that
hypoxia and acidosis is the ultimate result of the many causes of
intrauterine fetal compromise.
FHR patterns in labor are dynamic and can change rapidly
from normal to abnormal and vice versa. Because of this uncertainty
about the diagnosis of fetal distress terminologies used are
Reassuring and Non-reassuring patterns instead of fetal distress.
Pathophysiology
Under normal conditions when oxygen supply is adequate,
aerobic glycolysis occurs in the fetus and glycogen is converted into
pyruvic acid which is ultimately oxidized via the Krebs cycle. During
hypoxia when O2 saturation falls below 40%, anaerobic glycolysis
occurs, resulting in the accumulation of lactic acid and pyruvic acid
leading to metabolic acidosis. H-ions first stimulate and then
depress the sinoauricular node leading to tachycardia and
bradycardia respectively. It also causes parasympathetic stimulation
leading to hyperperistalsis and relaxation of the anal sphincter with
passage of meconium. Decreased fetal oxygenation in labor
hypoxia metabolic acidosis asphyxia tissue damage/fetal
death.
Etiology
A. Acute
a. During pregnancy less common
- Placental separation in placenta previa or
abruptio placentae
- Following external cephalic version due to
cord entanglement
- During oxytocin induction
b. During labor common
- Uterine hyperstimulation following oxytocin
for augmentation of labor
- Uterine rupture or scar dehiscence
- Cord prolapse
- Injudicious administration of analgesics and
anesthetic agents
- Maternal hypotension as in epidural
analgesia
- Placental abruption
B. Chronic

The various clinical conditions which are responsible for

chronic placental insufficiency and IUGR, are also linked with
chronic fetal distress
Fetal condition at birth is assessed by blood gas values of the
umbilical artery. Normal (mean) values are : pH 7.27, PCO2 50;
HCO3- 23, base excess -3.6. The correlation between the FHR and
long term neurological sequelae is poor. In many cases asphyxia
occur prior to labor.
Management
Nonsurgical
- Lateral positioning avoids compression of vena cava and aorta
by the gravid uterus. This increases cardiac output and
uteroplacental perfusion.
- Oxygens administered (6-8 L/min) to the mother with mask to
improve fetal SaO2.
- Correction of dehydration by IV fluids (crystalloids) improves
intravascular volume and uterine perfusion.
- Correction of maternal hypotension (following epidural
analgesia) with immediate infusion of 1L of crystalloid
(Ringers solution)
- Stoppage of oxytocin to improve fetal oxygenation. Fetal
hypoxia may be due to strong and sustained uterine
contractions. With reassuring FHR and in absence of fetal
acidemia, oxytocin may be restarted.
- Tocolytic (Inj terbutaline 0.25 mg SC) is given when uterus is
hypertonus and there is nonreassuring FHR.
- Amnioinfusion is the process to increase the intrauterine fluid
volume with warm normal saline (500 mL). Indications are : (a)
oligohydramnions and cord compression (b) To dilute or to
wash out meconium (c) To improve variable or prolonged
decelerations. Advantages : Reduces cord compression,
meconium aspiration, and improves Apgar score. It also
reduces cesarean section rate.
If the fetal heart rate pattern remains nonreassuring, further tests
are performed to rule out metabolic acidosis.
Tests are: (i) To detect FHR accelerations (CTG) spontaneous or
induced, (ii) Scalp blood pH, (iii) Fetal pulse oximetry, (iv) Fetal
ECG/ST segment analysis (STAN).
If acidosis is excluded labor is monitored with repeat testing
(every 30 minutes) to exclude acidosis. If the fetus is acidaemic
urgent delivery by safest method (vaginal or abdominal) depending
on the individual case
Surgical

Cesarean delivery should be done with a 15 lateral tilt till the baby is
delivered. Thirty minutes has been accepted as the gold standard
for decision to delivery interval in cases of confirmed fetal
compromise.