Abnormal Labor

1. Abnormal Labor Supervised By: Prof. Faheem Zayed

2. Quick Revision Definition of labor. Criteria of normal labor. Stages of labor.

3. Defenition Labour can be defined as the process by which regular, painful uterine contractions bring about the effacement and dilatation of the cervix and the descent of the presenting part, leading to the expulsion of the foetus and the placenta from the mother.

4. Normal Labour Criteria Spontaneous onset Single cephalic presentation 37-42 weeks No artificial intervention Unassisted spontaneous vaginal delivery Duration less than 12hrs in nulliparous and 8 hrs in multiparous Without complications to mother or fetus. A retrospective diagnosis

5. Stages Of Labour Normal labour consists of 4 stages so any factor interfering with any of these stages will result in abnormal labour. Stage 1: Starts with the onset of true labour pain and ending with cervical dilatation. It lasts from 6-18 hours in primipara and 2-10 hours in multipara. Stage 2: Starts with the full dilatation of the cervix until the complete expulsion of the fetus. It lasts from 30min-3 hours in primipara and 5-30min in multipara.

6. Stages Of Labour Stage 3: It is the stage of placental expulsion. Lasts less than 30 minutes. Stage 4???: Early recovery of the patient starting after the placental expulsion. Normally lasts for one hour.

7. Abnormal labour Labour becomes abnormal when there is poor progress (by delay of cervical changes or descent of presenting part) and/ or if the fetus shows signs of compromise. i.e. when anything interferes with the normal course of labour and delivery. Causes of abnormal labor ; abnormalities of : - Power. - Passenger. - Passage.

8. Abnormal labour Risk factors for poor progress in labour: Small women ( less 1.52 m ) Large babies Malpresentation Malposition Early rupture of membranes Soft tissue/ pelvic malformations

9. Abnormal Labor Indicators

10. Abnormalities according to phases In Latent phase of first stage. In Active phase of first stage. In Second stage. In Third stage.

11. Prolonged latent phase: Prolonged latent phase: < 20 hr Nulliparus < 14 hr Multiparus A prolonged latent phase may result�from oversedation or from entering labor early with a thickened or uneffaced cervix. Causes: 1- Power (Inefficient uterine contraction) a) Hypertonic uterine contraction b) Hypotonic uterine contraction 2- Excessive use of sedative or analgesia. Diagnosis of abnormal labor during the latent phase is uncommon and likely an incorrect diagnosis

12. Power (Abnormal uterine action): Hypertonic uterine contraction Hypotonic uterine contraction Evaluation of the powers (uterine contractions): Manual palpation External tocodynomometer. Intrauterine pressure catheter (IUPC)

13. A) Hypertonic uterine contraction 1- Colicky uterus:- incoordination of different parts. 2-hyperactive lower uterine segment:- upper segment dominance is lost. Clinically: Painful contractions, irregular and more frequent, slow cervical dilatation.

14. Managment 1- Oxytocin with epidural analgesia makes uterine activity more coordinated and efficient. 2- It may respond to therapeutic rest with Pethedine.

15. B) Hypotonic uterine contraction: Montevideo units (MVUs) refer to the strength of contractions in millimeters of mercury multiplied by the frequency per 10 minutes as measured by intrauterine pressure transducer. Adequate contractions are perceived as >200 Montevideo units [MVU] per 10 minutes for 2 hours. SO .. Contractions are weak. infrequent and short. slow cervical dilatation. These might increase risk of PPH and retained placenta.

16. Management 1- ARM 2-Augmentation,with oxytocin should only ever be commenced if CTG is normal.

17. Abnormalities of the active phase Protracted dilatation of active phase: > 1.2 cm/hr Nulliparus > 1.5 cm/hr Multiparus Protracted descent of active phase: > 1 cm/hr Nulliparus > 2 cm/hr Multiparus Arrest of dilatation: arrest < 2 hr Arrest of descent: arrest < 1 hr

18. Protracted and arrest disorders: Causes: 1- Passenger ( Fetal malposition and malpresentation). 2- Passage (pelvic inadequacy i.e. CPD). 3- Power (Inefficient uterine contractions =< hypotonic) 4- Excessive sedation.

19. An arrest disorder of labor cannot be diagnosed until the patient is in the active phase and the contraction pattern exceeds 200 MVUs for 2 or more hours with no cervical change

20. Management For primary dysfunctional labour, ARM and oxytocin infusion are the chosen management in a primiparous lady; if it is the result of poor contractions or mal-position. If CPD, mal-position or mal-presentation are suspected in a multiparous lady, the use of oxytocin should be careful due to the higher risk of uterine rupture. So in these women, we better use the ARM and wait for spontaneous correction. Augmentation of contractions using oxytocin should only be done if the CTG is normal. A CS is necessary if progress fails to occur 4- 6 hours after augmentation. The active management of labour constitutes of early diagnosis and management with maternal re-hydration, ARM and Syntocinon to limit the possibility of C- sections. Syntocinon also can be used to coordinate the uterine contractions.

21. Precipitate labour: Strong and frequent contraction causing abnormally rapid progress of deliver within 1hr in multipara and 3 hr in primipara. Risk factor:- 1- strong uterine contraction. 2- small sized baby. 3- minimal soft tissue resistance. 4- previous hx of precipitate labour.

22. Precipitate labour SO WHAT IF SHE HAS PRECIPITATE LABOUR ?!!

23. Complications of precipitate labor: Maternal: 1- laceration of cervix, vagina and perineum. 2- inversion of uterus. 3- PPH. 4- amniotic fluid embolism. Fetal: 1- intracranial hemorrhage (sudden compression and decompression). 2- fetal distress. 3-Delivery in inappropriate place.

24. Management 1- Discontinue oxytocin. 2- Tocolytics may helpful. 3- Episotomy to avoid ICH and birth canal injuries. 4- After delivery observe mother for PPH and fetus for injuries.

25. CASE A 30 y/o G1P0 Presented at 40+6 GA admitted at 3 P.M with symptoms of early labour and PROM starting at 10 A.M. Contractions started at 12 P.M. Her pregnancy was uncomplicated. On Examination: V/S normal A single longitudinal Cephalic and vertex. Estimated fetal weight by U/S was 3.4 Kg CTG was reactive with BL 155 b.p.m. and multiple accelerations. On Vaginal Exam the cervix was 80% effaced and 3 cm. dilated ,the station was (-2). Pelvimetry assessed clinically to be within normal.

26. CASE Labour course: Over the next 2hr pt experienced Considerable pain and contractions. Over the next 5 1/2 hours she progresses to 6cm dilatation and station -2. By 9:30 P.M she is 7cm. Dilated and (-1) station. Strength of contractions was assessed to be inadequate. The pt. develops 38.5 fever and fetal tachycardia of 170 was recorded. Utrine contraction were measured to be hypotonic (less than 200 MVU) by vaginal catheter. She was gevin oxytocin. Her progress remains slow and the vertex was still at (0) station after 20 hours.

27. Questions 1. What type of abnormal labour did she have? Protracted active phase ( <1.2cm/hr in a prim ). 2. What are potential etiologies (causes) for this type of abnormal labour? 1.Abnormal powers ( for which she was given oxytocin). 2.Abnormal position (unlikely as she was assessed for that). 3.Abnormal maternal bony pelvis (also unlikely as clinical pelvimetry was normal ). 4. A combination of all the previous causes. 3. What is a possible cause for her fever and what is the proper treatment option? Clinical amnionitis and she needs AntiB (Ampicillin and Tobramycin ). This condition might have also attributed to this type of abnormal labour.

28. 1. What type of abnormal labour did she have? 2. What are potential etiologies (causes) for this type of abnormal labour? 1 2 3 4 3. What is a possible cause for her fever and what is the proper treatment option? ) .

29. THANKS

30. Active Management of Labor

31. 31 Active Management of Labor (Dublin protocol) Introduced in 1969 at the National Maternity Hospital in Dublin Ireland to shorten the length of labor in nulliparous women. The basic principle of active management is strict criteria for the diagnosis of labor and prompt intervention according to established guidelines if progress is unsatisfactory Safely reduces the incidence of Ceserean deliveries

32. 32 Dublin Protocol Criteria and Components Candidates: Nulliparous pregnant patient with spontaneous onset of labor and a singleton fetus in a cephalic presentation. Prenatal education classes and intrapartum reassurance to lower patient anxiety. Constant attendance during labor, usually by a labor nurse Review of all cesarean sections. No admittance to the labor unit without a clear diagnosis of labor based on: The quality of contractions: regular and painful . Complete cervical effacement Rupture of membranes Passage of Show

33. 33 Amniotomy and regular examination for progress in cervical dilatation Oxytocin augmentation of labor if cervical dilatation was: Lower than a rate of 1 cm/hour in the first stage of labor or If there is no descent of the fetal head for 1 hour in the second stage. An abnormal fetal heart rate pattern leads to further fetal evaluation before operative delivery is initiated. This includes determining the pH of blood from the fetal scalp. If progress fails to occur over the next 4-6 hours? cesarean delivery will be necessary.

34. Malpresentations

35. Malpresentations Definition: describes any presentation other than a vertex lying in close proximity to the internal os of the cervix and includes: Breech Brow Face Shoulder Arm Compound

36. Causes of Malpresentation Maternal Multiparity Pelvic tumors Congenital uterine anomalies Contracted pelvis Fetal Prematurity Multiple pregnancy Intrauterine death Macrosomia Fetal abnormality Hydrocephalus Anencephaly Cystic hygroma

37. Causes of Malpresentation Other causes Placenta previa Polyhydramnios Amniotic bands

38. Breech Presentation Occurs when fetal buttocks or lower extremities present into the maternal pelvis Incidence is 3-4% Prior to 28 weeks, approximately 25% of fetuses are in breech presentation position. By 34 weeks gestation, most fetuses have assumed the vertex presentation position.

39. Types of Breech Extended breeches (70%) Presenting part is the buttocks Complete (Flexed) breeches (15%) Both buttocks and feet are presenting Footling breeches (15%) One leg flexed and one extended

41. Etiology and Associations of Breech Presentation The major factor predisposing to breech presentation is prematurity Idiopathic Previous breech presentation Uterine abnormalities ( fibroids, bicornuate uterus) Placenta previa, obstructions to pelvis Fetal abnormalities (6%) Multiple gestations Polyhydramnios

42. Diagnosis of Breech Presentation Examination: Lie is longitudinal Head palpated at the fundus Presenting part is not hard Fetal heart is best heard high up on the uterus Vaginal examination may reveal one or both feet Investigations Ultrasound confirms dx and should also asses growth and anatomy due to associations with fetal abnormalities

43. Criteria for Vaginal Delivery of Breech Presentation Fetus must be in frank/complete breech presentation GA should be at least 36 weeks Estimated fetal weight should be between 2.3-3.8 kg. Fetal head must be flexed Adequate maternal pelvis (pelvimetry, prior delivery of reasonably large baby) No other maternal/fetal indication for C/S Anesthesiologist present/Obstetrician experienced

44. Assisted Breech Delivery

45. Cesarean Delivery Cesarean section delivery is currently preferred for both term and preterm breech infants In 2000 a large multicenter randomized trial (�Term Breech Trial�) compared elective c/s and planned vaginal delivery in term singeltons. No difference in mortality b/w the groups was seen, but an increase in short term morbidity was noted in those babies delivered vaginally.

46. Other Presentations

47. Face Presentation Fetal head is hyper extended such that the fetal face, between the chin and orbits is the presenting part Incidence 1:500 deliveries Diagnosis is made by VE during labor, when soft tissues of fetal mouth and nose are felt. Cofirmed with U/S. Factors associated with face presentation: extreme prematurity, high maternal parity, cong. anomalies such as fetal goiter, cystic hygroma, anencephaly

48. Face Presentation cont. Mentoanterior in 60% can be delivered vaginally and/or with forceps. Vacuum contraindicated. If mentum rotates posteriorly, cesarean section must be carried out. (Fetal head will be unable to extend farther to complete the birth process) Approximately 50% of mentoposterior and mentotransverse presentations spontaneously rotate to MA position. When delivered by spontaneous vag. delivery or with forceps, perinatal morbidity and mortality for face presentations are similar to those for vertex presentations.

50. Brow Presentation The head occupies a position midway between full flexion (vertex) and full extension (face). 1 in 1400

51. Brow presentation cont. Diagnosis Diagnosed in advanced labor Head does not descend below ischial spines VE is diagnostic as the frontal sutures, anterior fontanelle, orbital ridges and root of nose are palpable. 50-75% of brow presentations will convert to either face or vertex presentations. Persistent brow presentation will make vaginal delivery impossible due to the presenting diameter which is the occipitomental diameter (13.5cm) ? Cesarean section

52. Shoulder presentation Occurs in 1:250-300 deliveries More common in multiparous rather than primiparous women Causes: abdominal/uterine wall laxity Polyhydramnios Multiple gestations Placenta previa

53. Compound Presentation Fetal extremity (hand) prolapses alongside the presenting part (the head) and both parts enter the maternal pelvis at the same time. Premature gestations 1 in 700 Usually the prolapsed part does not interfere with labor.

54. Position The relation of an arbitrary chosen point of the fetal presenting part to the right or left side of the maternal birth canal Affected by the passage (pelvis)

56. Gynecoid: Classic type, 50% of women, it has a spacious cylindrical shape and is most favorable. Fetal head usually assumes an occipito-anterior position in this type.

57. Android: Typical male pelvis 30% of women, limited space at inlet and becomes narrower (funneling). Forces the head into occipito-posterior position causing deep transverse arrest of descent is common at midpelvis.

58. Anthropoid: Resembles that of the anthropoid ape, 20% of women. Allows fetal head to engage in AP diameter, and does so in the occipito-posterior position.

59. Platypelloid: A flattened gynecoid pelvis. 3% of women. Oval shaped inlet with wide transverse diameter. A gentle curve throughout. Fetal head must engage in the transverse diameter ? obstructed labour

60. Cephalopelvic Disproportion As we know any abnormality in labor is cuzed by abnormality in any of : Power Passage and passenger CPD is considered as passage abnormalityAs we know any abnormality in labor is cuzed by abnormality in any of : Power Passage and passenger CPD is considered as passage abnormality

61. -CPD exists if maternal bony pelvis is not of sufficient size and of appropriate shape to allow the passage of the fetal head . -The problem may occur as a result of contraction of one of the pelvic planes usually at the mid pelvis (why ??). -Relative (or feto-pelvic dis.) CPD occurs when a disproportion between the size of the fetus relative to the maternal pelvis exists .

62. Causes: Mother Small pelvis. Abnormal shape of the pelvis due to diseases like rickets, osteomalacia , DDH. Abnormal shape due to previous accidents. Tumors of the bones. Childhood poliomyelitis affecting the shape of the hips. Fetus Large fetus (Hereditary, Diabetes, Post maturity) Fetus position (OP position , brow , face) . Post maturity .

63. History : Rickets previous accidents Childhood poliomyelitis. Examination : -Gait: abnormal gait suggests abnormalities in the pelvis , spines or lower limbs -Stature: women with less than 150 cm height usually have contracted pelvis.

64. Abdominal / vaginal exam : 1- The finding of an unengaged head in nulliparous patient at the start of labor indicates increased likelihood of CPD at the pelvic inlet. Other causes of this finding include��.? 2-The arrest of the descent at station +2 +3 indicates mid-pelvis CPD

65. 3- sever moulding of fetal head .

66. Diagnosis of CPD Diagnosis of CPD is very difficult. This is because it is difficult to estimate exactly how much the mother's ligaments and joints will 'give' or relax before labor starts and the capacity of the fetal head to mould . Clinical or radiologic assessment of the maternal pelvis and fetal size is an inexact science with poor predictive value. The best test for an adequate pelvis is a trial of labor. Pelvimetry: It includes: Clinical pelvimetry Imaging pelvimetry

67. Clinical pelvimetry : The assessment of the size of the pelvis is made manually by examining the pelvis and palpating the pelvic bones by vaginal examination � this is usually done at 37weeks gestation , or at the time of labor . The entire bony arch of the mother's pelvis, including the sacrum , the sacro-coccygeal joint, the sacro-sciatic notch, the ischial spines, the ilio-pectineal lines and the pubic arch are palpated and an assessment of the size of the pelvis made. The diameter of the pelvis is measured with the index and middle fingers of the hand..

68. Clinical pelvimetry .. Cont Briefly, the examiner attempts to judge the anteroposterior diameter of the inlet (the diagonal conjugate), the interspinous diameter of the midpelvis, and the intertuberous distances of the pelvic outlet.

71. Imaging pelvimetry: Transvaginal ultrasound pelvimetry X-ray CT These studies are not error free because dystocia or abnormal labor can arise from soft tissue obstructions in the pelvic outlet, particularly in women who are obese

72. Cont MRI pelvimetry : The advantages of MRI pelvimetry include lack of ionizing radiation, accurate measurements, complete fetal imaging, and the potential for evaluating soft tissue dystocia� -Currently its use is limited because of expense, time involved for adequate imaging studies, and equipment availability

73. Cephalometry: fetal heads were measured within one week before delivery Ultrasonography: is the safe accurate and easy method and can detect: The biparietal diameter (BPD). The occipito-frontal diameter. The circumference of the head.

74. In the absence of any gross abnormality such as marked hydrocephalus, cephalopelvic disproportion may only be reliably diagnosed during labour. The first stage of labour will be prolonged. CPD at the level of the pelvic inlet causes a failure of descent and engagement of the head.

75. Trial of labor A woman with known complications, for example a previous Caesarean birth, may be given a trial of labor to see if she is able to give birth naturally. After a certain time, if labor fails to progress satisfactorily and it seems unlikely that the baby can be delivered safely through the vagina, she will be offered a Caesarean Ensure that conditions are favorable for trial of labor: The previous surgery was a low transverse caesarean incision The fetus is in a normal vertex presentation Emergency caesarean section can be carried out immediately if required. If these conditions are not met or if the woman has a history of two lower uterine segment caesarean sections or ruptured uterus, deliver by cesarean section.

76. Cont .. Monitor progress of labor using a partograph. If labor crosses the alert line of the partograph, diagnose the cause of slow progress and take appropriate action. If there is slow progress in labor due to inefficient uterine contractions , rupture the membranes and augment labor with oxytocin. If there are signs of cephalopelvic disproportion or obstruction deliver immediately by cesarean section. If there are signs of impending uterine rupture, deliver immediately by cesarean section. If uterine rupture is suspected, deliver immediately by cesarean section and repair the uterus� or perform hysterectomy

77. Obstructed Labor: As a pattern of abnormal progress in labor Is considered when the presenting part of the fetus cannot progress into the birth canal, because there is a barrier preventing its descent despite strong uterine contractions .

78. Causes : 1-cephalopelvic disproportion 2-Abnormal presentation :brow , shoulder , and chin posterior 3-fetal abnormalities : hydrocephalus . 4- Genital tract abnormalities : Pelvic tumours ,stenosis of the cervix or vagina .

79. When to suspect Obstructed labor ? -Maternal exhaustion, anxiousness, confusion -Patient develops hypertonic uterine contractions with poor relaxation in between. - Week , rapid pulse rate . - Low blood pressure . - Increase Respiratory rate . - Look for signs of uterine rupture

80. Other signs on abdominal examination - The widest diameter of the fetal head can be felt over the pelvic brim. -Bandl�s ring : an area between the lower and the upper uterine segment visible and /or palpable during uterine contractions . This ring (in normal cases called a retraction ring) cannot be normally palpated or seen , if you see it suspect obstructed labor .

81. Bandl�s ring is a late sign of obstructed labor , the depression can be seen or felt on the abdomen at the level of the umbilicus .. It signifies impending rupture of the lower uterine segment.

82. Signs on pelvic examination : -vulvar edema . - The cervix may or may not be fully dilated. - a large caput succedaneum can be felt . -presentation can be assessed .

83. Complications : Uterine rupture : during the 1st or 2nd stage of labor the fetus is forced into the lower segment by effective uterine contraction , if anything obscure the descent of the presenting part , the uterus will mould around the fetus causing over-stretching of the lower uterine segment and subsequent uterine rupture .

84. Cont .. Recto vaginal or vesico-vaginal fistula : -present a communication between the vaginal wall and the rectum and/or the urinary bladder. -appear after prolonged and neglected obstructed labor,,when the fetal head impacts against the soft tissue of the pelvic floor (bladder base urethra against the pelvic bone).

85. Cont .. -Because of impaired circulation, necrosis may result and become evident several days after delivery with the appearance of vesicovaginal, vesicocervical, or rectovaginal fistulas.

86. Complications .. Cont Pelvic floor injury : During childbirth the pelvic floor is exposed to direct compression from the fetal head as well as to downward pressure from maternal expulsive efforts. These forces stretch and distend the pelvic floor, resulting in functional and anatomical alterations in the muscles, nerves, and connective tissues. Leading eventually to pelvic organ prolaps .

87. -Intrapartum infection : Infection may complicate prolonged labor and pose a serious danger to mother and fetus - maternal and fetal bacteremia and sepsis. -Postpartum lower extremity nerve injury.

88. Fetal complications Caput Succedaneum: If the pelvis is contracted, during labor a large caput succedaneum frequently develops on the most dependent part of the fetal head. The caput may reach almost to the pelvic floor while the head is still not engaged. An inexperienced physician may make premature and unwise attempts at forceps delivery.

89. Fetal complications Fetal head molding : when the distortion is marked, molding may lead to tentorial tears, laceration of fetal blood vessels, and intracranial hemorrhage.

90. Management Caesarean section is the safest method of delivery even if the baby is dead as labor must be immediately terminated and any manipulations may lead to rupture uterus. In patients with hypovolemic shock, resuscitation must be rapid, because delivery is urgent. Correct dehydration, electrolyte deficit, and acidosis.

91. Cont .. Patient is likely to go into septic shock, so start prophylactic antibiotics. As soon as the patient is stabilized perform cesarean section

92. Partogram & Fetal Monitoring during labor

93. Partogram A graphic record of labor. Why? To allow rapid, visual assessment of the progress in labor and so the appropriate management can be carried out rapidly. Consists of 3 main parts: Maternal condition Fetal condition Progress of labor Different designs are present, no proof that one is better than the others.

95. Alert line: The line drawn at the end of the latent phase (after 8 hrs), demonstrating a progress of 1 cm/hr cervical dilatation (active phase). It predicts the ideal progress in the active phase. Action line: The line drawn 2-4 hrs to the right of the alert line. If the plot of the progress of labor fell on the right of the Action line, the progress is said to be SLOW.

98. CTG Measures FHR & Uterine contractions. Two methods: -External monitoring: - Electrodes are placed on the mother�s abdomen. - Done in early labor (still no ROM) - Measures contractions� frequency & duration but not intensity. -Internal monitoring: - One electrode is placed on the fetal scalp, ad the other is in the amniotic cavity to measure uterine contractions. - Membranes should be ruptured and Cx dilated > 2 cm . - Measures intensity in addition to frequency & duration.

100. Internal monitoring

101. When to do it? It is done on admission to the labor ward. If the results were normal and there are no risk factors or the pregnancy is not high risk pregnancy, no need to repeat the CTG unless indicated. For how long?? At least for 30 min.

102. Reading the CTG Cardiograph and Tocograph are printed on a strip. Changes of the cardio can be correlated to changes of toco. Physiologically, during contractions there is a decrease of baseline HR in front of each uterine contraction due to hypoxia.

103. Baseline variations Beat to beat variations in the baseline should be between 5 and 25 bpm (except during intervals of fetal sleep which should be no longer than 60 minutes). Prolonged reduced variability along with other abnormalities may be indicative of fetal distress. Normal baseline variability reflects a normal fetal autonomic nervous system.

105. Baseline fetal heart rate = the mean fetal heart rate. Measured over 5-10 min. Normally 110-160 bpm. <110 ?fetal bradycardia >160 ? fetal tachycardia

106. Fetal heart ACCELERATIONS Are increases in the baseline fetal heart rate of at least 15 bpm, for at least 15 seconds. 2 or more accelerations on a 20-30 min. CTG defines a reactive trace. Its importance is that it is usually absent in fetal hypoxia.

107. Fetal heart DECELERATIONS Are transient reductions in fetal heart rate of 15 bpm lasting more than 15 seconds. 3 types: 1)Early � normal 2)Late � abnormal 3) Variable - abnormal

108. Types of decelerations: Early Decelerations: Normal, due to head compression during contractions. (? vagal tone) Onset, peak, and end coincides with the timing of the contraction (mirror image).

110. Variable Decelerations Abnormal (mild, moderate or severe depending on duration), due to cord compression. Can occur at any time, and pattern change from one contraction to another. If they are repetitive, suspicion is high for the cord to be wrapped around the neck or under the arm of the fetus.

111. Classification of CTG: Normal CTG where all four features fall into the reassuring category. Suspicious CTG whose features fall into one of the non-reassuring categories and the remainder of the features are reassuring. Pathological CTG whose features fall into two or more non-reassuring categories or one or more abnormal categories.

112. FHR monitoring is a screening rather than diagnostic method, so once an abnormality is detected, a cause should be thought of. Intervention depends on the cause and the clinical circumstances. In general, a term fetus tolerates ominous heart patterns better than a preterm fetus . A fetus with additional risk factors, such as intrauterine infection from chorioamnionitis, may deteriorate sooner than a fetus in a normal parturient

113. Intervention: Change maternal position to the lateral recumbent position. Give oxygen by face mask. Stop oxytocin (Pitocin) infusion. Provide an IV fluid bolus. Give an IV tocolytic drug (MgSO4). Monitor maternal blood pressure. If persist longer than 30 minutes, fetal scalp blood pH should be obtained and C-section considered.

114. From: the Royal Women�s hospital clinical practice guidelines (Australia).

115. Fetal scalp pH When CTG is non-reassuring, it can be done to confirm hypoxia and acidosis (rem: Hypoxia ? anaerobic metabolim ? lactic acid ? acidosis). Done through a small incision in the scalp through which a small amount of blood is drawn. If pH > 7.25 : reassuring pH 7.20-7.25 pH <7.20 : non-reassuring Blood should not be contaminated with amniotic fluid which is basic. Not done in KAUH

116. Auscultation of fetal heart Done through hand-held doppler. Performed intermittently during labor.

117. Thank you Have a Nice Day