40516550 fetal distress

8/8/2019 40516550 Fetal Distress

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Fetal Distress


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FETAL DISTRESS

Compromise of the fetus during theantepartum period (before labor) or

intrapartum period (birth process).

commonly used to describe fetalhypoxia (low oxygen levels in the

fetus).


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FETAL DISTRESS

Hypoxia that may result in fetaldamage or death if not reversed or

the fetus delivered immediately.acute distress

chronic distress.


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Etiology of fetal distress

Maternal:

poor placental perfusion

hypovolaemia

hypotension

myometrial hypertonus

prolonged labor

excess oxytocin


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fetal:

cord compression

oligohydramnios

entanglement

prolapse

pre-existing hypoxia or growth retardation

infectioncardiac


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NUCHAL

CORD


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MECONIUM ASPIRATION SYNDROME


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Tachycardia & Bradycardia

oespecially during contractionso

Decreased variability in FHRMeconium in the amniotic fluid

o Fetal acidosis fetal scalp pH


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Signs and symptoms

Acute fetal distress


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Cardiotocography signs :

increased or decreased fetal heart (tachycardia and

bradycardia), especially during and after acontraction decreased variability in the fetal heart

rate

Abnormal fetal heart rate (less than 120 or morethan 180 beats per minute). A normal fetal heart rate

may slow during a contraction but usually recovers

to normal as soon as the uterus relaxes.

A very slow fetal heart rate in the absence of

contractions or persisting after contractions is

suggestive of fetal distress.


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A rapid fetal heart rate may be a response to

maternal fever, drugs causing rapid maternal heartrate, hypertension or amnionitis. In the absence of

a rapid maternal heart rate, a rapid fetal heart rate

should be considered a sign of fetal distress

For a diagnosis of fetal distress to be made, one ormore of the following must be present:

1) Persistent severe variable deceleration.

2) Persistent and non-remediable latedecelarations.

3) Persistent severe bradycardia.


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Variable deceleration: no consistent

relationship with uterine contraction. It is

sometimes caused by compression of theumbilical cord between the uterus and the

fetal body, or because it is looped round

some part of the fetus. Provided that it doesnot persist for more than a few minutes it

may have little significance, but persistence

for more than 15minutes would call for

treatment


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The most serious pattern of heart rate

changes is fetal bradycardia with lossof baseline variability and late

decelerations.

decrease (defined as onset of deceleration to nadir =30seconds) and return to baseline FHR associated with a

uterine contraction. The deceleration is delayed in

timing, with the nadir of the deceleration occurring

after the peak on the contraction.


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Biophysical Profile

Amniotic Fluid Volume Normal = 2 Points;

Non-Stress Test Result Positive = 2 Points;

Fetal Breathing Movements Active = 2 Points;

Fetal Extremity/Trunk Movements Active = 2 Point;Fetal Movements Active= 2 Point.

IfBiophysical Profile scores less than 4 suggest fetal

distressPlacental Insufficiency: Low estriol levels , E3 inurine less than 10mg/24h


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FETAL DISTRESS INDEX

ONE POINT ADDED FHR = 10-19

LOV= > 20 MIN.LATE DECELARATIONS

TACHYCARDIA ( > 100) 10-30 MIN

TWO POINTS FHR > 20BRADYCARDIA ( 100-120) > 30 min. *

THREE POINTS BRADYCARDIA

THE POINTSARE TRANSFERRED TO NEXT 5 MIN

AND ACCUMULATED EXCEPT FOR *

3 OR MORE POINTS SUGGEST FETAL DISTRESS


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Definitions must grasped

Baseline FHR: approximate mean FHR rounded to

increments of 5 bpm during a 10-minute segment,

excluding periodic or episodic changes, periods of marked

FHR variability, and segments of the baseline that differby >25 bpm. In any 10-minute window, the minimum

baseline duration must be at least 2 minutes or the baseline

for that period is indeterminate.


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B

aseline FHR variability-fluctuations in thebaseline FHR =2 cycles per minute. These

fluctuations are irregular in amplitude and

frequency, and are visually quantitated as the

amplitude of the peak to the trough in beats perminute as follows: amplitude range undetectable,

absent FHR variability; amplitude range greater

than undetectable but = 5 bpm, minimal FHR

variability; amplitude range 6 bpm to 25 bpm,moderate FHR variability; amplitude range >25

bpm, marked FHR variability.


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Bradycardia-a baseline FHR 160 bpm.


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Early deceleration-a visually-apparent, gradual

decrease (defined as onset of deceleration to nadir

=30 seconds) and return to baseline FHR

associated with a uterine contraction. The decrease

is calculated from the most recently determined

portion of the baseline. It is coincident in timing

with the nadir of the deceleration occurring at the

same time as the peak of the contraction. In most

cases the onset, nadir, and recovery of the

deceleration are coincident with the beginning,

peak, and ending of the contraction, respectively.


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Variable deceleration-a visually-apparent, abruptdecrease in FHR below the baseline. The decrease

is calculated from the most recently determined

portion of the baseline. The decrease in FHR

below the baseline is =15 bpm, lasting =15

seconds and =2 minutes from onset to return to

baseline.


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Late deceleration-a visually-apparent, gradualdecrease (defined as onset of deceleration to nadir

=30 seconds) and return to baseline FHR

associated with a uterine contraction. The decrease

is calculated from the most recently determinedportion of the baseline. The deceleration is

delayed in timing, with the nadir of the

deceleration occurring after the peak on the

contraction.


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Non-stress Test

Ultrasound Cardiotocography

Fetal blood sampling scalp

prick

Diagnosis


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Mechanism of fetal distress

Contractions reduce temporarily placental blood flow and cancompress the umbilical cord.

If a women is in labor longer then this can cause fetal distress

via the above mechanism

Acute distress can be a result of placental abruption, prolapseof the umbilical cord (especially with breech presentations),

hypertonic uterine states and the use of oxytocin.

Hypotension can be caused by either epidural anesthesia or the

supine position, which reduces inferior vena cava return of

blood to the heart.

The decreased blood flow in hypotension can be a cause of

fetal distress.


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Breathing problems

Abnormal position and presentation of the fetus

Multiple births

Shoulder dystocia

Umbilical cord prolapse

Nuchal cordPlacental abruption

Premature closure of the fetal ductus arteriosus

Altered blood supply to the fetus

Impaired supply of O2 to the fetus

Agitation of fetus due to lack of O2

Meconium StainingTachycardia

Constriction of fetal peripheral vessels

Initiation of hypoxemia

Fetal fatigue

Elevated BP

Bradycardia

Compromised respiration

Anaerobic glucose metabolism

Fetus aspirates meconium

Elevated lactate concentration

High-energy phosphates decrease in cerebrumFetal brain damage or Death


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Nursing Diagnoses:

Decreased Cardiac Output (fetal)

Impaired Gas Exchange (fetal)

IneffectiveTissue Perfusion (fetal)

Anxiety (maternal)

Deficient Knowledge (maternal)


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FETALDISTRESS

MANAGEMENT


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If the mother is receiving

oxytocin, discontinue Oxytocin

If conservative measures areunsuccessful, immediate

delivery of the baby (often by

cesarean section) is required


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If necessary, resuscitate the baby in the uterus

before performing the cesarean delivery: use of

medication

Continue monitoring fetus closely for signs that

the treatment is not working, which would

require the immediate commencement of thecesarean delivery.

The negligence to implement an appropriatetreatment plan can result in permanent injury, or

even death, to baby and mother.


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Treatment for Fetal Distress

Reposition patient: left-side-lying position.Administer oxygen by mask.

Perform vaginal examination to check for

prolapsed cord.

Ensure that qualified personnel are in

attendance for resuscitation and care of the

newborn.


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Each of the following actions should be

performed and documented prior to starting a

Cesarean section for fetal distress:

Perform vaginal exam to rule out imminent

vaginal delivery;

Initiate preoperative routines;

Monitor fetal heart tones (by continuous

fetal monitoring or by auscultation)

immediately prior to preparation of theabdomen;


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Ensure that qualified personnel are in

attendance for resuscitation and care of

the newborn (each institution shall

define in writing the term qualified

personnel for resuscitation and care of

the newborn).

Stop using oxytocin, because oxytocin

can strengthen the contraction ofuterine which affects the baby's heart

rate.


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Umbilical cord

prolapse


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Umbilical Cord Prolapse


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Umbilical Cord Prolapse (UCP)

A rare, obstetrical emergency thatoccurs when the umbilical corddescends alongside or beyond the fetal

presenting part.It is life threatening to the fetus sinceblood flow through the umbilical vessels

is usually compromised fromcompression of the cord between thefetus and the uterus, cervix, or pelvic

inlet.


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Types of Umbilical Cord Prolapse

Overt Prolapse

The most common;

Refers to protrusion of the cord in advanceof the fetal presenting part, often through

the cervical os and into or beyond the vagina.The fetal membranes are invariablyruptured in these cases and the cord is visibleor palpable on examination.


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Occult ProlapseO

ccurs when the cord descends alongside,but not past, the presenting part. It canoccur with intact or ruptured membranes.

The diagnosis should be considered in the

setting of a sudden, prolonged fetal heartrate deceleration. An occult prolapse often cannot be

diagnosed with certainty, but is suggestedby clinical features (eg, fetal bradycardia)and findings at cesarean delivery.


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Signs

Ill-fitting or non-engaged presentingpart

Prolapsed umbilical cord

umbilical cord visualized invagina or at vulva

umbilical cord palpated onpelvic exam

Fetal distress on Fetal Heart TracingMay follow rupture of membranes


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Prognosis

High perinatal mortalityfor delayed delivery >40min


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Risk Factors

Premature rupture of the amniotic sacPolyhydramnios

Having a large volume of amniotic

fluid. The cord may be forced out withthe more forceful gush of waters.

Long umbilical cord

Fetal malpresentation

Multiparity


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Multiple gestation

Placenta previaIntrauterine tumors

Prevents the presenting part fromengaging.

A small fetus

CPDPrevents firm engagement.


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Diagnostic Test

During delivery, a fetal heart monitor is used

to measure the babys heart rate. If theumbilical cord has prolapsed, the baby mayhave bradycardia (a heart rate of less than 120beats per minute)

Electric Fetal Monitoring (EFM), alsocalled a cardiotocograph, allows the fetusheartbeat to be viewed in relationship tothe mothers contractions. EFM is themost commonly used instrument for thediagnosis of fetal distress.


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A pelvic examination can also be conductedby a physician and may see the prolapsed

cord, or palpate (feel) the cord with thefingers.

Note: Routine ultrasound examination isNOT sufficiently sensitive or specific foridentification of cord presentationantenatally and should not be performed to

predict increased probability of cordprolapse, unless in the context of a researchsetting.


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Pathophysiology

Fetomaternal Factors

Fetal malpresentationPrematurity

Multiple gestationMultiparity

Rupture of membranesPolyhydramnios

Obstetrical Interventions

Artificial rupture of membranesVaginal manipulation of the fetus with

ruptured membranesExternal cephalic versionInternal podalic version

Stabilising induction of laborInsertion of uterine pressure transducer

Frank cord presentation cord prolapsed through cervix

Occult cord presentation Cord trapped alongside presenting part

Rupture of membrane and amniotic sac occurs when presenting part is ill fittingFootling Breech Presentation

CPDFetal Abnormaliy

Umbilical cord prolapses

Fetal blood supply obstructed when cord out of the uterus as the fetusMoves downward into the pelvis

VasospasmsOf

Umbilicalvessels

CompressionBet. Pelvic brim

And presentingpart

Oxygen and blood

Supply diminishesOr cut-off

Drop in tem-

parature of

prolapsed

cord


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Nursing Diagnoses:

Impaired Gas Exchange (fetal)

Risk for Injury (fetal)

Fear (maternal)

Anxiety (maternal)

Deficient Knowledge (maternal)


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Umbilical Cord

ProlapseManagement

Initial management hospital setting:


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Initial management -hospital setting:

When diagnosed before full dilatation,

assistance should be immediately calledand preparations made for immediate

delivery

To prevent vasospasm, there should be

minimal handling of loops of cord lying

outside the vagina.

To prevent cord compression, it is

recommended that the presenting part beelevated either manually or

by filling the urinary bladder.

educe cord compression by placing mother on


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educe cord compression by placing mother on

kneechest position or head-down tilt (preferably

in left-lateral position).

Tocolysis can be considered while preparing forcaesarean section if there are persistent fetal heart

rate

abnormalities after attempts to prevent

compression mechanically and when the delivery

is likely to be delayed.

Although the measures described above are

potentially useful during preparation for delivery,they must not result in unnecessary delay.

Optimal mode of delivery with cord


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Optimal mode of delivery with cord

prolapse:

A caesarean section is the recommended mode of

delivery in cases of cord prolapse when vaginal

delivery is not imminent, to prevent hypoxia

acidosis.

A category 1 caesarean section should beperformed with the aim of delivering within 30

minutes or less if there is cord prolapse

associated with a suspicious or pathological fetal

heart rate pattern but without unduly riskingmaternal safety.

Verbal consent is satisfactory.

Category 2 caesarean section is appropriate


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Category 2 caesarean section is appropriate

for women in whom the fetal heart rate pattern

is normal.

Regional anaesthesia may be considered in

consultation with an experienced anaesthetist.

Vaginal birth, in most cases operative, can be

attempted at full dilatation if it is anticipatedthat delivery would be accomplished quickly

and safely.


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Breech extraction can be performed under some

circumstances, such as after internal podalic

version for the second twin.

A practitioner competent in the resuscitation of

the newborn should attend all deliveries with cord

prolapse.


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Management in community setting:

Women should be advised to assumethe kneechest face-down position while

waiting for hospital transfer.

During emergency ambulance transfer,the kneechest is potentially unsafe and

the left- lateral position should be used

Advise mother transfer to the nearest hospital for


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Advise mother transfer to the nearest hospital for

delivery, unless an immediate vaginal examination

by a competent professional reveals that a

spontaneous vaginal delivery is imminent.Preparations for transfer should still be made.

The presenting part should be elevated during

transfer by either manual or bladder filling

methods.

Health care provided should carry a Foley catheter

for this purpose and equipment for fluid infusion.

To prevent vasospasm there should be minimal


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To prevent vasospasm, there should be minimal

handling of loops of cord lying outside the vagina.

Expectant management should be discussed for

cord prolapse complicating pregnancies with

gestational age at the limits of viability.

the threshold of viability.

40516550 fetal distress

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