High Risk Pregnancy HB Tranx

7/28/2019 High Risk Pregnancy HB Tranx

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SUBJECT:ObstetricsandGynecology Transcriber:MilesFernandezTOPIC:HighRiskPregnancy/Antepartum Editor:SarahSy-SantosandIntrapartumAssessment

Lecturer:JennyLynnY.Vidanes,MD,DPOGS,FPSMFM NumberofPages:11

Legend: @ Things she stressed na most likely lalabas

High Risk Pregnancy

Description:- Pregnancies where there is an increased risk of maternal of fetal

morbidity and mortality

- Perinatal events have significant role in infant mortality

- Fetal deaths may occur during antepartum and intrrapartum

Attributed by:

30% Asphyxia(IUGR, Prolonged Gestation)

30% Maternal Complications

15% Congenital Anomalies

20% UNKNOWN etiology

5% Infection

High Risk Factors A. Maternal Factors

- Maternal Age

o Age is less than 18 years old à Lack of physical or

emotional maturity for pregnancy

o Multipara > 35 years old à Greater exposure to

infections/diseases; increased risk for developmental

abnormalties

o Woman greater than or equal to 35 years of age had a 2

fold greater risk for fetal death (Fretts, et al.)

o Fetal deaths are highest in teenagers (< 18 years old) and

women (> 35 years old) (Denmark data)

- Maternal Height

o 60 inches (153 cm) or less à Increased risk for cephalo

pelvic disproportion

o Increased rate for birth trauma, caesarean section,

congenital anomalies, and prematurity

o 42% contracted pelvis

- Maternal Weight

o Obesity/Abnormal BMI causes:

§ Increased fetal growth

§ Medical Complications (hypertension and diabetes

mellitus)

§ Increased need for operative delivery§ Increased still birth and neonatal death

§ Obesity increases propensity for cardiovascular

disease

- Social Factors

o Smokingà Teratogenic

§ Intrauterine Growth Restrictions

§ It would induce vascular damage, leading to placental

insufficiency

o Drugs

§ Opium, Barbiturates, Amphetamines, and Methadone:

Low birth weight

§ Tetracyclinw: Brownish staining of deciduous teeth

§ Chloramphenicol: Gray's Syndromeà Ash gray

cyanosis of baby due to vascular collapse; RDS

§ Streptomycin: Congenital Deafness

o Alcohol à Fetal mental retardation

§ Delerium Tremens

§ Craniofacial defect

§ Limb defects

§ Cardiovascular defects

§ IUGR

B. Obstetric History

- Multiparity (>5)

- Abruptio Placenta

- Placenta Previaà displacement of placenta anterior to fetal head; the placenta "blocks" the birth canal

- Postpartum Haemorrhage

- Uterine Rupture

- Twinning

- Dysfunctional Labor

- Congenital anomalies

C. PROM and Preterm Birth

- Cord prolapsed

- Intrauterine amniotic infection

- Respiratory distress syndrome

- Intraventricular haemorrhageà preterm

- Necrotizing enterocolitisà preterm

D. Fetal Growth Disorders

- IUGR

o Prematurity, Death

- Fetal Macrosomia

o Asphyxia

o Fetal distress

o Trauma

o Vaginal lacerations

o Uterine atony

à decreased contractions due to over

stretched uterus

E. Amniotic fluid abnormalities

- Polyhydramnios (> 24 cm)

- Oligohydramnios (< 5 cm)

F. Post-term pregnancy

- Sharp rise in both fetal and neonatal mortality

- Fetal injury from fetopelvic disproportion

- Asphyxial damage from fetal distress with increased chance of

mental subnormality and neurologic deficit

G. Maternal Medical Conditions

- Renal diseasesà increased risk for fetal pulmonary edema

- Diabetes Mellitusà macrosomic baby

- Thyroid disorders

o Hyperthyroidism à tachycardia, hepatosplenomegaly,

IUGR, craniosyntosis

o Hypothyroidismà Neurologic abnormalities, respiratory

difficulty, dysmorphic facies, hypotonia

- Cardiovascular disordersà predisposition to eclampsia

- Respiratory disorders

- Hematologic disorders

- Anemia

- Malnutritionà LBW infant



High Risk Clinic

- Pregnancies at extremes of reproductive age

o 17 years and below

o Primigravida 35 years and above

- Placenta Previaà increased chance of bleeding preterm

@Poor Obstetrical History

2 Consecutive Abortions 3 or more Repeated Abortions

Previous Preterm Delivery Previous Fetal and/or Neonatal

DeathPrevious birth with Congenitalanomaly

- Diagnosed medical conditionsà Hypertension, Diabetes

- Generative tract disorders

- Co-existing trophoblastic diseases or had a trophoblastic disease

within the last year

- Psychiatric conditions

- Problems in fetal, aging, structure, or size

- Malignancies (genital and extragenital)

- Polyhydramnios or Oligohydramnios

@ Intermittent Auscultation

Low Risk Pregnancy High Risk Pregnancy

1st stage of labor

Monitor every 30minutes


2nd stage of labor


Monitor every 5 minutes

Electronic Fetal Monitoring

- Done only for high risk patients

- Types:

a. External (Indirect)à Ultrasound Doppler Principle

b. Internal (Direct)à Electrode attached to fetal scalp

- Increased the overall CS rate (relative risk [RR], 1.66; 95%

confidence interval, 1.30-2.13) and the CS rate for abnormal Fetal

Heart Rate (FHR) or acidosis or both

- Increased the risk of both vacuum and forceps operative vaginal

delivery

- The use of Electronic Fetal Monitoring (EFM)

a. Reduces the risk of neonatal seizures (RR, 0.50; 95% CI,

0.31 - 0.80) à Only advantage

b. Does not reduce the perinatal mortality (RR, 0.85; 95% CI,

0.59 - 1.23)

c. Does not reduce the risk of cerebral palsy (RR 1.74; 95% CI,

0.97 - 3.11)

- Continuous EFM should be offered and is recommended for HighRisk Pregnancies

- Current evidence does not support the use of admission tocogram

in low risk pregnancy (Leve III, C)

From the book: Although maternal heart tones are 5x higher than the

baby’s, the machine selectively picks up the fetal heart tone. So one

way for the phycisan to know if the baby is dead is if the machine

already picks up the maternal heart tone.

Antepartum Surveillance à focuses on fetal physical activites (well being)

Intrapartum Surveillance à focuses on fetal heart rate analysis

Fetal Well Being

- Goal of Fetal Surveillance

- Prevent fetal death

- Assess the risk of fetal death in pregnancies complicated by pre-

existing maternal conditions as well as those in which

complications have developed

Fetal Response to Hypoxemia

a. Increase Oxygen Supply

§ Includes increase in baseline heart rate, haemoglobin

concentration, improved cardiac contractility or

efficiency, and increased oxygen extraction

§ This phase in unlikely to suffice in the case of placental

insufficiency

§ *Increase in placental resistance by increasing fetal

blood pressure (Fetal Hypertensive State)

b. Control Oxygen Distribution

§ Preservation of oxygenation in vital centers of the brain,

heart, adrenals, and placenta

§ Reduction of flow to the mesenteric, renal, and distal

aortic outflow tracts§ Causes assymetrical IUGR brought about by brain

sparing effect

c. Reduce Oxygen Consumption

§ Initiates minor increase in time between activity cycles

and may extend all the way to complete abolition of fetal

activity à Fetus may not move to conserve O2

consumption; therefore, less movement leads to more

conserved O2

§ Fetal oxygen consumption may fall more than 15%

during inactivity

@Fetal Asphyxia

a. Immediate adaptive response

§ Inhibition of

ü Heart rate acceleration

ü Fetal breathing movements

ü Gross body movements

§ Occurs within minutes of insult

§ CNS center regulating Non Stress Test (NST) most

sensitive

§ Fetal respiratory center almost as sensitive

§ Centers regulating fetal tone and movement least

sensitive

b. Chronic adaptive response

§ Reflexive in origin

§ Mediated by aortic arch and carotid chemoreceptors

§ Redistribution in cardiac output

ü Increased supply to brain, heart, adrenals, and

placenta

ü Decreased supply to other organs e.g. Decrease

in renal output due to oligohydramnios

§ Effects of redistribution of cardiac output develop slowly

§ Magnitude of responses mimic severity of insult

§ Response is progressive

§ Response is not reversible



Fetal Hypoxemia

(Asphyxia)

CNS Cellular Dysfunction Aortic body chemoreceptor stimulation

Hypotonia

Absent fetal breathing Reflex redistribution of Reflex Late

Absent fetal movement cardiac output deceleration

Non Reactive NST

Increased blood flow to: Decreased blood flow to:

Fetal Brain (? IVH) Fetal Kidneys (Oliguria)

Adrenals Lung (Respiratory Distress Syndrome - RDS)

Heart Gut (NEC)

Placenta Liver

Carcass

Regulation of Fetal Heart Rate- Sympathetic Regulation

a. Releases catecholamine from sympathetic nerve endings

and from chromaffin tissues of the adrenal glands

b. Causes cardiac acceleration

c. Induce fetal vasoconstriction and fetal hypertension

- Parasympathetic Regulation

a. @Most important controlling mechanism of the FHR

b. Travels from the cardioregulatory center in the ventral

surface of the brainstem to the heart via the cardiac fibers of

the vagus nerve

c. Releases acetylcholine in the region of SA and AV node

Antepartum Fetal Assessment

Indication for Antepartum Fetal Monitoring

1. For patients at high risk for uteroplacental insufficiency

a. Prolonged pregnancy

b. Diabetes Mellitus

c. Hypertension

d. Previous stillbirth

e. Suspected IUGR

f. Advanced Maternal Age

g. Multiple gestations with discordant growth

h. Antiphospholipid syndrome à Antibodies attack phospholipids

which leads to increased risk of spontaneous abortion

2. When other tests suggest fetal compromise

a. Suspected IUGR

b. Decreased fetal movement

c. Oligohydramnios

3. Routine antepartum surveillance

Obstetric Conditions and Management influenced by Anterpartum

Testing

- Preterm delivery

-

Route of delivery- Bed rest

- Observation

- Drug therapy

- Operative intervention in labor

- Neonatal intensive care

- Termination of pregnancy for a congenital anomaly

Aspects of Fetal Condition that Might be Influenced byAntepartum Testing

- Perinatal death

- IUGR

- Non reassuring fetal status

- Neonatal asphyxia

- Postnatal motor and intellectual impairment


- Need for specific therapy

When to do Antepartum Assessment? (ACOG)

- For most at risk patientsà 32 - 34 weeks

- For multiple or worrisome conditions à 26 - 28 weeks

Fetal Movement Counting

- Fetal activity that can be appreciated as early as 7 weeksà

different from quickening.

- Beyond 8 weeks, fetal body movements are never absent for

periods exceeding 13 minutes

- At 36 weeks the fetal behaviour status is already established

- Since 1973, case reports of decreased fetal activity preceded fetal

death

- Quantify fetal movement as a way to assess and prognosticate

fetal well-being- Several protocols:

Examples

§ Perception of 10 movements in 2 hours

§ Counting of fetal movements in 1 hour 3-4x a day

§ Time needed to feel 10 movements

§ 6 movements in 1 hour

- Decreased fetal movements

a. Decreased amniotic fluid: due to redistribution of blood in

response to asphyxia

b. Drugs

c. Sedatives: Maternal sedative or anesthesia can pass through

placenta

d. Sleep state in the fetus

e. Fetal compromise



Pros and Cons of Fetal Movement Counting

PROS CONS

Simple Intrude on the woman's time

Can be Done at Home Unnecessary anxiety to the mother

No human or material resourcesneeded

Staff overload as additionalinvestigations may have to be done

exclusive to fetal compromise

Might increase antenatal admissions,obstetric interventions, and

prematurity

- Related Studies:

a. Four studies, involving 71,370 women, were incuded in this

review; 68,654 in one cluster-randomised trial

b. Not enough evidence to influence practice

c. No trials compared fetal movement counting with no fetal

movement counting

d. Results neither confirm nor refute the effectiveness of fetal

movement counting as a method of fetal surveillance

e. Not enough evidence to recommend or not to recommend

formal fetal movement counting

f. Insufficient data to assess stillbirths accurately

g. Woman to count distinct fetal movements on a daily basis

after 28 weeks AOG

h. Perception of 10 distinct movements in up to 2 hours is

considered reassuring

i. The counting can be discontinued for that day after 10

movements

Fetal Behavioral States

1F: Quiescence (quiet sleep)

2F: Frequent gross body movements, Continuous eye movements, and

Oscillation of FHR (REM sleep)3F: Continuous eye movements, Without body movements, No

increase in FHR

4F: Vigorous body movements, Continuous eye movements (Awake

state)

- Fetuses spend most of their time in states 1F and 2F

- Sleep Awake Cycles

a. Independent of maternal sleep awake cycles

b. 20 - 75 minutes (mean: 40 minutes)

Biophysical Profile

- Non-invasive test that combines data from 2 sources:a. Ultrasound imaging

b. Fetal heart rate monitoring

- It predicts the presence or absence of fetal asphyxia and the risk

of death during the antenatal period

Parameters

a. Fetal breathing movements

b. Fetal movement

c. Fetal tone

d. Fetal heart rate activity

e. Amniotic fluid volume

Markers

f. Acute Markers

§ Fetal breathing movements

§ Fetal movement

§ Fetal tone

§ Fetal heart rate activity

b. Chronic Marker

§ Amniotic fluid volume

@Neural Control of Fetal Biophysical Activities

Biophysical

Parameter

CNS Center AOG

Fetal Tone Cortex Subcortical Area 7.5 - 8.5 weeks

Fetal Movement Cortex-Nuclei 9 weeks

Fetal Breathing Ventral surface of 4th

ventricle

20 - 21 weeks

Fetal Heart

Reactivity

Medulla and Posterior

Hypothalamus

24 - 26 weeks

Correlate with other significant fetal developments para masmadali

magmemorize ng AOGJ

8 weeks: About the time na pelvic organ pa ang uterus

9 weeks: Abdominal organ na ang uterus

20 weeks: Fundic height is around the umbilicus

24weeks: Same ang AOG with the fundic height in cm

@Hypoxia Cascade Theory

Cascade of hypoxia first affects the last neural center to be developed.

Kasi if it is last to be developed, meaning it is more immature and tookless time being developed than an area was formed first

Fetal Heart Rate Activity

(Medulla and Posterior Hypothalamus)

Fetal Breathing Movement

(Ventral Surface of 4th ventricle)

Fetal Movement

(Cortex Nuclei)

Fetal Tone(Cortex Subcortical Area)

**Hear Bach’s Movement and Tone. Haha. I tried. Sana gumana J

Parameters of Biophysical Profile

a. Fetal Breathing

§ Initial inward movement of the thorax with descent of

the diaphragm and abdominal contents, followed by a

return to the original position

§ Fetal "hiccups" (a variant of normal fetal breathing)

§ Paradoxical chest wall movement

§ Two types of Respiratory Movement:ü Gasps or Sighs

o Occurs at a frequency of 1 to 4 minutes

ü Irregular bursts of breathing

o Occurred at rates up to 240 cycles per

minute

§ Has diurnal variation, diminishes during night

(paradoxical breathing)

§ Variables that affect fetal respiratory movements

ü Hypoxia

ü Labor

ü Hypoglycemia

ü Sound stimuli

ü Cigarette smoking

ü Amniocentesis

ü Impending PTL

ü Gestational age

ü FHR (Fetal Heart Rate)



b. Fetal Tone

§ Limb or trunk extension with return to flexion

§ Opening of hand with finger and thumb extension with

return to closed-fist formation

§ Hand remains in flexed formation for the entire 30

minute period

c.

Amniotic Fluid Volume§ Largest single vertical pocket

§ Chronic Marker

§ Amniotic fluid index

ü Oligohydramnios: < 5 cm

ü Low normal: 5 - 7.9 cm

ü Normal: 8 - 18 cm

ü High Normal: 18.1 - 24 cm

ü Polyhydramnios: > 24 cm

@ Biophysical Profile Scoring

Component Score = 2 Score = 0

Fetal

Breathing

>1 episode of rhythmic

breathing lasting > 30

seconds within 30 minutes

< 30 seconds of

breathing in 30

minutes

Fetal

Movement

> 4 discrete body or limb

movements within 30

minutes

< 4 movements in

30 seconds

Fetal tone > 1 episode of extension of a

fetal extremity with return to

flexion, or opening or closing

hand

No movement or no

extension/flexion

Amniotic Fluid

Volume

Single vertical pocket > 2 cm Largest single

vertical pocket < 2

cmNon Stress

Test

> 2 acceleration of > 15

beats/minute for > 15

minutes in 20 - 40 minutes

0 or 1 acceleration in

20 to 40 minutes

Score Interpretation Management

10 Normal, non

asphyxiated fetus

Repeat testing weekly

For diabetics 2x a week

8/10(Normal AFV)

8/8(if NST is not

done)

Normal, non-

asphyxiated fetus

Repeat testing weekly

For diabetics 2x a week

8/10(Decreased

AFV)

Chronic AsphyxiaSuspected

Deliver

6 Possible fetal

asphyxia

If AFV abnormal à Deliver

If AFV normal at > 36 weeks

with favourable cervixà

Deliver

If repeat test is < 6 à Deliver

If repeat test is > 6à Observe

4 Probable fetal

asphyxia

Repeat test on same day, if < 6

à Deliver

0 - 2 Almost certain fetal

asphyxia

Deliver

BPP Score

0 Associated with fetal acidemia

2-4 Progressively moreaccurate predictor of abnormaloutcome

6 Equivocal test was a poor predictor of abnormaloutcome

8 or 10 Associated with normal pH

Factors Influencing BPP Performance

a. Drugs

§ Sedatives à Decrease activity

§ Cocaineà Bizarre fetal movement

§ Indomethacin à Oligohydramnios

b. Maternal cigarette smoking

§ Fetal breathing movement abolished or attenuated

§ Fetal movement reduced§ Causes decrease 02deliver by placenta

c. Maternal Hypoglycemia

§ Abnormal behaviour

Features of Electronic Fetal Monitoring

A. Baseline Fetal Heart Rate

*Please read the attached page on how to read fetal heart tones first J

pictures are also included at the back para kita J

Causes of Fetal Tachycardia

- Fetal Hypoxia

- Fetal Anemia

- Fetal Sepsis

- Fetal Heart Failure

- Fetal Tachyarrythmia

- Maternal Fever

- Maternal Hyperthyroidism

- Beta-Sympathomimetic drugs

- Parasympatholytic drugs: Atropine, Hydroxyzine HCl (Iterax),

Phenothiazines

- Fetal hypopituitarism with brainstem injury

- Maternal hypothermia

-

Prolonged hypoglycaemia- Beta blocker therapy

- Second stage of labor

- Maternal heart rate being recorded in a case of fetal demise

B. Baseline Variability

- Fluctuations in the baseline FHR that are irregular in amplitude

and frequency

- Visually quantified as the amplitude of peak to trough in beats per

minute

- Types:

o Absent: Amplitude range undetectable

o Minimal: Amplitude range detectable but 5 beats per minute

or fewer



o Moderate (Normal) Amplitude ranges 6 - 25 beats per

minute

o Marked: Amplitude range greater than 25 beats per minute

Causes of Decreased FHR variability

- Fetal sleep cycles

- Hypoxia/Acidosis

- Extreme prematurity


- Fetal tachycardia

- Pre-existing neurological abnormality

- Drugs: CNS depressants, parasympatholytics (atropine), Beta

Blockers

C. Periodic Changes

Acceleration

- Abrupt increase in FHR: Onset to peak in < 30 seconds

- Peak: > 15 bpm lasting 15 seconds from onset to return to

baseline

- Prolonged acceleration: > 2 minutes but less than 10 minutes

- Acceleration > 10 minutes = Baseline change

- A visually apparent abrupt increase (onset to peak in less than

30 seconds) in the FHR

- 32 weeks of gestation and beyond

§ Peak of 15 beats per minute or more above baseline, withduration of 15 seconds or more but less than 2 minutes

from onset to return

- Before 32 weeks of gestations

§ Acceleration has a peak of 10 beats per minute or more

above baseline, with duration of 10 seconds or more but

less than 2minutes from onset to return

- Prolonged acceleration

§ Lasts for 2 minutes or more but less than 10 minutes in

duration

- Baseline change

§ Acceleration lasts 10 minutes or longer

Deceleration

- Transient episode of slowing of the fetal heart rate beow the

baseline level of more than 15 bpm and lasting 15 seconds or

more

- If rate is below 110 bpm and duration is > 10 minutes à

bradycardia

Categories

a. Early deceleration (Head Compression)

• Visually apparent usually symmetrical gradual

decrease and return of the FHR associated with a

uterine contraction

• The nadir of the deceleration occurs at the same

time as the peak of the contraction

• The onset, nadir, and recovery of the deceleration

are coincident with the beginning peak, and endingof the contraction, respectively (mirror image)

• Generally seen in active labor between 4 and 7 cm

dilatation

• Not associated with fetal hypoxia, academia, or low

APGAR scores

• Symmetrical gradual decrease and return of the

FHR associated with a uterine contraction

• Onset to nadir: greater than or equal to 30 seconds

• Nadir occurs at the same time as the peak of the

contraction

b. Variable deceleration (Cord Compression)

• Visually abrupt decrease in FHR

• Onset, depth, and duration vary with successive

contraction

• Usually due to umbilical cord compression

• Abrupt decrease in FHR

• Onset to nadir: < 30 seconds

• Decrease in FHR is greater than or equal to 15

bpm, lasting greater than or equal to 15 seconds,

and less than 2 minutes in duration

(B) Variable Deceleration



Non Stress Test (NST)

- Done without uterine contractions

- Fetal heart rate of a fetus that is not acidotic or neurologically

depressed will temporarily accelerate with fetal movements

- Heart rate reactivity thought to be a good indicator of normal fetal

autonomic function

- Diurnal rhythm in mature fetuses:

• Acme (145 bpm): midday

• Nadir (120 bpm): early morning hours

Parameter @Normal

(Reactive)

Atypical

(Nonreactive)

Abnormal

(Nonreactive)

Baseline 100 - 160 100-110

>160, < 30

minutes

Rising Baseline

< 100

>160, >30

minutes

Erratic baseline

Variability 6 - 25

< 5 for < 40

minutes

< 5 for 40 - 80

minutes

< 5 for > 80

minutes

> 25 for > 10

minutes

Sinusoidal

Decelerations None or

occasional

but < 30

seconds

Variable

deceleration 30 -

60 seconds

Variable for > 60

seconds

Late

decelerations

Accelerations

Term

> 6 at > 15

bpm for 15

seconds

< 40 minute

testing

< 2 at > 15 bpm

for 15 seconds in

40 - 80 minutes

< 2 at > 15 bpm

for 15 seconds >

80 minutes

Accelerations

< 32 weeks

> 2 at > 10

bpm for 10

seconds

< 40 minute

testing

< 2 > 10 bpm for

10 seconds in 40

- 80 minutes

< 2 > 10 bpm for

10 seconds in >

80 minutes

Action Further

assessment

optional

Further

assessment

required

Urgent action

required

Reactive VS Non Reactive NST

REACTIVE NON-REACTIVE

BFHR 130-135 bpm 150 bpm

Variability Moderate Minimal to absent

Accelerations + -

Decelerations - -

- Loss of reactivity may be associated:

• Fetal Sleep Cycles

• Fetal Acidosis

• Central nervous system depression

- Indications

• It is initiated at 32 weeks AOG on a weekly basis or earlier or

more frequent in very high risk situations

• Twice weekly for women with post term pregnancy, multifetal

gestation, type 1 diabetes, IUGR, and PIH

Causes of FALSE NEGATIVE NST

- Prematurity

- Maternal smoking and stress

- Malnutrition

§ Glycemic levels§ Fetal sleep states

Causes of FALSE POSITIVE NST

§ Caffiene

§ Cocaine

§ Morphine

§ Sedatives

§ Alcohol

Contraction Stress Test (CST)

- Used to determine if there is Late deceleration à Uteroplacental

insufficiency

- Detection of presence or absence of FHR decelerations in

response to either spontaneous or induced uterine contraction

- Fetus with reduced placental reserve will develop transient fetal

hypoxemia in association with the interruption of uteroplacental

blood flow caused by contractions

- CST Method

- Mother in semi-recumbent position or in a left lateral tilt

- Initial trace of 15 minutes to determine baseline FHR and to

note for spontaneous contractions

- Induction of contraction:

- Intravenous oxytocin

• 10 'u'/1 L saline titrated (not to exceed 60 m'u'/min)

• Goal: 3 contractions in 10 minutes

- Manual Nipple Stimulation

• Not to exceed 2 minutes in duration, not less than 5

minutes apart

• Goal 3 contractions in 10 minutes

Contraindications for CST

- Absolute

§ Placenta previa

§ Chronic fetal abruption

§ Proven or suggested cord presentation

§ Upper uterine segment scar

- Relative

§ Pregnancy at risk for premature delivery

§ E.g. Multiple gestation, Incompetence

@ Interpretation

Category Interpretation

Normal or Negative No late or significant variable decelerationsPositive Late decelerations following 50% or more of

contractions

Equivocal-suspicious Intermittent late decelerations or significant

variable decelerations

Equivocal -

hyperstimulatory

Fetal heart rate decelerations with contractions >

every 2 minutes or lasting longer than 90

seconds

Unsatisfactory Fewer than three contractions in 10 minutes or

an uninterpretable tracing

*Take Note:

Negative CSTà Good indicator of fetal health

Positive CSTà Relatively poor predictor of fetal compromise

CSTà Best used in combination with other tests of fetal well-being

Intrapartum Fetal Assessment

- Done when the patient is already in labor

Fetal Heart Rate Analysis

- The primary means in which a fetus is evaluated for adequacy of

oxygenation



How to read fetal heart tones 101

Acme: Peak/ Highest point

Nadir: Trough/ Lowest point

Baseline Heart Rate Criteria:

§ Mean fetal heart rate rounded to increments of 5 beats per minute during a 10 minute segment excluding:

a. Periodic or episodic changes (e.g. acceleration,deceleration)

b. Periods of marked FHR variability (e.g. absent, minimal, marked)

c. Segments of baseline that defer by more than 25 beats per minute (only increments of 5)

§ The baseline must be for a minimum of 2 minutes in any 10 minute segment.

Here is a picture of normal FTH recording. Take note that 1 square=10 seconds. 6 squares = 1 min. The thickened line will mark 1 minute.The

vertical numbers correspond to the number of beats/minute. Each horizontal line= 10 beats. The baseline should follow the 2nd criteria. So dapat,

medyo steady/constant yung line at certain number of beats for at least 2 squares. The baseline you see in a 10 minute segment can be reported as

the range with increments of 5. So for this example, the FTR is 140-145 bpm.

Findings:Normal FHR baseline: 110 - 160 beats per minute

Tachycardia: FHR baseline values > 160 beats per minute

Bradycardia: FHR baseline values< 110 beats per minute

Acceleration

Deceleration

High Risk Pregnancy HB Tranx

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