Principle of fetal monitoring
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Transcript of Principle of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
PRINCIPLES OF FETAL MONITORINGMohd Hanafi Ramlee
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
I’M SORRY, I CAN’T INTERPRET SOME OF THE PICTURE HERE!!!
BUT I’LL TRY MY BEST!!!
Obstetric And Gynaecology
Principles of fetal monitoring
AIMS OF FETAL MONITORING
• Assessment of fetal well-being especially in high-risk mother
• Assessments of fetal growth• Identification of fetal abnormalities and
condition in all stages of pregnancy• Determination of gestational period• To ensure a safe delivery
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan
4. Amniotic Fluid Index
5. Doppler Investigation
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
1. Clinical
Sign
Weight Gain
Symphysio –
fundal Height
WEIGHT GAIN
• Cheap and simple method using weighing machine
• Mother should gain 0.5 kg/week during 2nd and early 3rd trimester then, the rate of weight gain is plateaus off
• ↓: possibilities of IUGR, persistent nausea and vomiting or forced dieting
• ↑: PIH, renal disease and polyhydramnios.
Obstetric And Gynaecology
Principles of fetal monitoring
1. Clinical
Sign
Weight Gain
Symphysio –
fundal Height
SYMPHYSIOFUNDAL HEIGHT
• At least 2 times weekly• The centimeters should roughly
correspond to the period of gestation
• ↑: polyhydramnios• ↓: oligohydramnios
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
FETAL KICK CHART• Commonest methods – Cardiff ‘count to ten’• Start count at 9am every morning• Record the time taken for baby to move 10 times • Normal fetal activity-little variation in time taken• ↓ fetal activity [fetal compromise] - delay in time taken• Benefit: detection of fetal compromise, more easier and
cheap• Limitation: Maternal anxiety is common, unsure of
movement, is a crude guide and sometimes inconsistent
Obstetric And Gynaecology
Principles of fetal monitoring
A FAVOURABLE FETAL MOVEMENT CHART
Day
Time (am/pm))
Patient’s Name
Obstetric And Gynaecology
Principles of fetal monitoring
AN UNFAVOURABLE FETAL MOVEMENT CHART
Day
Time (am/pm))
Patient’s Name
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
Ultrasound
Diagnostic
Doppler
Routine
MRIUltraso
und
Diagnostic
Doppler
Routine
MRI
Obstetric And Gynaecology
Principles of fetal monitoring
DIAGNOSTIC ULTRASOUND SCAN- 2 dimensional map of content of uterus.- Image constantly updated in real time
and fetal cardiac and other movement can be studied.
- < 12 weeks usage of transvaginal transducer.
- > 12 weeks usage of abdominal transducer.
- Good image depend on operator skill.- Disadvantages : Bio effects on cells,
inducing heating.
Obstetric And Gynaecology
Principles of fetal monitoring
transvaginal -TRANDUCER - abdominal
Obstetric And Gynaecology
Principles of fetal monitoring
Diagnostic Ultrasound
Pregnancy
FetalPlacenta
Others
Early Problems
Age Assessment
Symmetry
Measurement
Weight
Growth
Anatomy
Morphology
Location
Umbilical Cord Abnormalities
Amniotic Fluid Volume
Invasive Procedure
Obstetric And Gynaecology
Principles of fetal monitoring
EARLY PREGNANCY PROBLEMS
- transvaginal ultrasound role in diagnosis of disorder in early pregnancy.
• E.g. miscarriage - fetus present, absent fetal heart• E.g. ectopic pregnancy- absent of gestational sac within uterus
Obstetric And Gynaecology
Principles of fetal monitoring
FETAL MEASUREMENTS
SERIAL ULTRASOUND MEASUREMENT OF THE FETUS (>24/52 POG)
Common [2wk interval]
Biparietal Diameter & Head Circumference Femur Length
Sensitive
Abdominal Circumference
SERIAL ULTRASOUND MEASUREMENT OF THE FETUS (<24/52 POG)
Crown-rump Length
Obstetric And Gynaecology
Principles of fetal monitoring
FETAL MEASUREMENT
• Common = relatively ‘spared’ in growth restriction
• Sensitive = organ that are sensitive to changes to any factor that cause IUGR [liver/spleen]
Obstetric And Gynaecology
Principles of fetal monitoring
CROWN-RUMP LENGTH
Obstetric And Gynaecology
Principles of fetal monitoring
CROWN-RUMP LENGTH
Geatational sac
Yolk sac
Fetal pole
Obstetric And Gynaecology
Principles of fetal monitoring
BPD, HC LENGTH
Biparietal diameter
Head circumference
Obstetric And Gynaecology
Principles of fetal monitoring
BPD, HC LENGTH
Obstetric And Gynaecology
Principles of fetal monitoring
FEMUR LENGTH
Femur length
Obstetric And Gynaecology
Principles of fetal monitoring
FEMUR LENGTH
Obstetric And Gynaecology
Principles of fetal monitoring
ABDOMINAL CIRCUMFERENCE
Abdominal Circumference
Obstetric And Gynaecology
Principles of fetal monitoring
GESTATIONAL AGE ASSESSMENT
• CRL/BPD these measurements are plotted on the normogram
• Predictions of gestational age by ultrasound scan before 20 weeks is more accurate than predictions from last menstrual period.
• Measurements are done at least 2 week apart• Measurements are plotted in centile-charts
against a normogram
Obstetric And Gynaecology
Principles of fetal monitoring
MEASUREMENT ON FETAL GROWTH CHART
Obstetric And Gynaecology
Principles of fetal monitoring
Consistent growth of Small fetus
Obstetric And Gynaecology
Principles of fetal monitoring
Slowed growth—fetal compromise
Obstetric And Gynaecology
Principles of fetal monitoring
FETAL SYMMETRY
• ↑HC: Hydrocephalus• ↓HC: Microcephaly• ↓FL: constitutional short stature,
achondroplasia• ↑AC: Diabetic pregnancy,• ↓AC: triploidy / trisomy 18• Asymmetry: IUGR
Obstetric And Gynaecology
Principles of fetal monitoring
PLACENTA
• Transvaginal scan: if the placenta covers the internal os major placenta praevia
• Mid pregnancy scan low-lying placenta• 3rd pregnancy scan minor placenta praevia
Obstetric And Gynaecology
Principles of fetal monitoring
OTHERS CONDITION
• Amniotic Fluid scan: commonly base on AFI [if <2cm: Oligohydramnious, >7cm: Polyhdramnious]
• Umbilical Cord: scan with colour doppler [Nuchal displacement: common event associated with fetal distress]
• Invasive procedure: amniocentesis, chorion villus sampling, cordocentesis, fetal bladder shunt therapy, fetoscopy and endoscope.
Obstetric And Gynaecology
Principles of fetal monitoring
Ultrasound
Diagnostic
Doppler
Routine
MRIUltraso
und
Diagnostic
Doppler
Routine
MRI
Obstetric And Gynaecology
Principles of fetal monitoring
AIMS OF ROUTINE ULTRASOUND SCAN
Early scan(11-14 weeks)•To confirm fetal viability•EDD•Diagnose multiple gestation•Identify gross abnormalities
Mid-pregnancy scan(18-22 weeks)
•EDD, if not done.•Detailed fetal anatomical survey•Placenta location•AFI
Third-pregnancy scan(>22 weeks)
•Fetal growth•Fetal well being
Obstetric And Gynaecology
Principles of fetal monitoring
Ultrasound
Diagnostic
Doppler
Routine
MRI
• Magnetic Resonance Imaging: useful when i) US images are not diagnostic or ii) suboptimal because of maternal obesity
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
MRI
Obstetric And Gynaecology
Principles of fetal monitoring
39
AMNIOTIC FLUID Produce : Kidneys & Lungs Remove : Fetal swallowing and blood
Functions : Prevent mechanical injury, permit movement and lung development
4 quadrant method (R/L hypocondrium R/L illiac fossa)
Obstetric And Gynaecology
Principles of fetal monitoring
AMNIOTIC FLUID INDEX• Liquor volume reflects the placental size, placental
function and fetal metabolism• Sum of all the maximum vertical pool of liquor from
the 4 quadrant of the uterus• In 3rd tri, normal AFI should be between 10 and 25cm • AFI -below 5cm -oligohydramnios
above 25cm -polyhydramnios
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
DOPPLER ULTRASOUND
Measuring blood velocity in umbilical artery of fetus.
Recorded in waveform pattern :Systolic - blood velocity speeds up.Diastolic - blood velocity slows down (depending
amount resistant in arterial bed in placenta).
Obstetric And Gynaecology
Principles of fetal monitoring
Doppler Umbilical Artery Waveforms• Measure blood velocity in umbilical artery of fetus• Recorded in waveform pattern showing a systolic &
diastolic component• During normal fetal life, diastolic flow in the umbilical
artery↑ gradually (placental resistance falls) with gestation
• In placental damage/insufficiency- absent/reversed end diastolic flow which leads to fetal distress and intrauterine death.
Obstetric And Gynaecology
Principles of fetal monitoring
Doppler Uterine Artery Waveforms
• Assessment of uterine artery waveforms at 24th weeks’ gestation.
• Benefits: Even at absence of risk factors, severely abnormal waveforms identify 75% of pregnancies at risk of adverse neonatal outcome in early 3rd trimester.
• Limitations: Less effective at prediction of later problems.
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
49
Cardiotocograph (CTG)
Computerized tracing of fetal heart rate pattern
Sensitive Reflects physiological
and pathological changes
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
50
CTG Parameters:
Baseline heart rate :Normally 110 – 160bpm<110 bpm = bradycardia >160 bpm = tachycardia
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
51
Baseline variability : Reflects normal fetal autonomic nervous system. Modified by :
Fetal sleep states and activity.Hypoxia.Fetal infection.Drugs e.g. opioids and hypnotics (reduce
baseline variability). Baseline variability – 8 bpm and 2-6 times in a minute.
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
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Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
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Fetal heart rate (FHR) acceleration.
Increased baseline FHR at least 15 bpm lasting at least 15 seconds.
Within 20 – 30 minutes CTG, 2 or more accelerations present define as reactive trace.
Importance – fetal hypoxia
Obstetric And Gynaecology
Principles of fetal monitoring
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FHR deceleration Transient reduction fetal heart rate of 15 bpm or > lasting more than
15 seconds.
Type 1 decelerationnadir (lowest point) of deceleration coincides with the peak of uterine contraction
Type 2 decelerationnadir of deceleration lags behind and persist even after the peak of uterine contraction
Variable deceleration patternnadir variable in depth and timing peak of contraction
Obstetric And Gynaecology
Principles of fetal monitoring
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Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring
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Obstetric And Gynaecology
Principles of fetal monitoring
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Obstetric And Gynaecology
Principles of fetal monitoring
Methods
1. Clinical Sign
2. Fetal Kick Chart
3. Ultrasound
Scan4. Amniotic
Fluid Index
5. Doppler Investigati
on
6. Cardio –toco -graph
7. Meconium Stained Liqour
Obstetric And Gynaecology
Principles of fetal monitoring
Meconium Stained Liquor
• Sign of fetal compromise• Can only be diagnose during labour, or only after
the membrane have been ruptured• May be due to– Intestinal hurry– Spontaneous dilatation of anal sphincters
• Manifestations of foetal hypoxia.
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
OTHERS MONITORINGMohd Hanafi Ramlee
Obstetric And Gynaecology
Principles of fetal monitoring
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Biochemical ScreeningPrenatal screening test: Fetal nuchal - measurement of fluid filled
translucency space on post. surface of fetal neck.- increase measurement
associated with fetuses with major chromosomal abnormalities and sex chromosomal abnormalities (e.g. Down syndrome).
Maternal serum screening - neural tube defect and Down syndrome.
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring 62
Fetal Nuchal Translucency
Obstetric And Gynaecology
Principles of fetal monitoring
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Maternal full blood indices/electrophoresis – detect thalasemia.
Sickledex test – sickle cell disease.Maternal blood group/rhesus
antibodies.Maternal serum virology –
CMV/toxoplasmosis/Rubella/parvovirus
Serology for syphilis.
Obstetric And Gynaecology
Principles of fetal monitoring
Principles of Fetal Monitoring 64
Maternal Serum Screening15 – 20 weeks of gestation.maternal serum alpha-fetoprotein (AFP)
screening for neural tube defects (NTDs) and Down syndrome.
Increase level - fetal open NTDs.Decrease level - Down syndrome.
Screening test on Down syndrome:maternal serum AFP.human beta-chorionic gonadotropinunconjugated oestriol.advanced age – risk.
Obstetric And Gynaecology
Principles of fetal monitoring
Biophysical ProfileBiophysical variable Normal (score 2) Abnormal (score 0)
Fetal breathing movements
> 1 episode for 30s in 30 min
Absent < 30s in 30 min
Gross body movements > 3 body/ limb movements in 30min
< 3 body/ limb movements in 30min
Fetal tone > 1 episode body/ limb extension followed by return to flexion, open-close cycle of fetal hand
Slow, or absent extension-flexion of or body or limbs
Reactive fetal heart rate >2 accelerations with fetal movements in 30min
<2 accelerations, or 1+deceleration in 30min
Qualities amniotic fluid >1 pool of fluid, at least 1cm x 1cm
Either no measurable pool, or pool <1cm x 1cm
Obstetric And Gynaecology
Principles of fetal monitoring
Obstetric And Gynaecology
Principles of fetal monitoring
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