Litigation in obstetrics is common, and evidence suggests that a disturbingly high number of poor outcomes are preventable. The aim of intrapartum continuous electronic fetal monitoring using a cardiotocograph ctg is to identify a fetus exposed to intrapartum hypoxic insults so that timely and appropriate action could be instituted to improve perinatal outcome. Identify the advantages and limitations of each method of fetal surveillance. Labour also represents the obstetricians last opportunity to influence perinatal outcome and ensure that those fetuses who have suffered chronic hypoxia antenatally are recognized promptly, so that. Member, fetal surveillance education program steering committee royal australian and new zealand college of obstetricians and gynaecologists foreword. Fetal monitoring during labour nice pathways bring together everything nice says on a topic in an interactive flowchart. The initial description of the fetal heart rate fhr apparently dates to marsacs report in 1650 1.
Intrapartum fhr monitoring management decision model. Antepartum fetal monitoring two thirds of fetal deaths occur before the onset of labor, many of which are due to uteroplacental insufficiency. Intrapartum fetal surveillance in the presence of, or with the emergence of, fetal andor maternal risk factors management of fetal heart rate patterns considered suggestive of fetal compromise exessive uterine activity and uterine hyperstimulation fetal blood sampling other techniques for intrapartum fetal surveillance. Midwives intrapartum monitoring process and management. Intrapartum fetal monitoring a disappointing story nejm. Internal fhr monitoring is accomplished with a fetal electrode, which is a spiral wire placed directly on the fetal scalp or other presenting part. Improved fetal maternal monitoring monica healthcare. Lvhile epideiniologists and scientists continue the debate, there is a drainatic rise in claims for inedical negligence. Fetal physiology in relation to electronic fetal monitoring efm. This technique records changes in the fetal heart rate fhr via doppler. It has been developed by the editorial board based on the experience gained from maternity units where a reduction in the. A retrospective analysis of data for 400 labouring women with singleton pregnancies at. The concept of intrapartum monitoring of the fetal heart rate by auscultation has been extant for almost 200 years and by electronic means for more than 30 years. Examples include, antepartum fetal heart rate monitoring and fetal movement counting.
This guideline will focus on the clinical application of currently available methods for intrapartum fetal monitoring. Fetal heart rate monitoring may be performed externally or internally. Risk management related to fetal monitoring must include both the creation of systems to provide safer care and the mitigation of liability exposure through the use of protocols and documentation strategies that are designed to provide evidence of clinicians attentive. It is an effective solution for monitoring high bmi patients ref 1, 2 and minimizes the risk of maternal fetal heart rate confusion ref 3, 4. Eugene bailey, md, suny upstate medical university, syracuse, new york i ntrapartum fetal monitoring was developed in the 1960s to identify events that might result. Jan 20, 20 antepartum fetal monitoring two thirds of fetal deaths occur before the onset of labor, many of which are due to uteroplacental insufficiency. Freeman, one of the pioneers of fetal assessment with heart rate monitoring both antepartum and intrapartum, lamented, clearly, the hopedfor benefit from intrapartum continuous electronic fetal monitoring has not been realized. Identify the purposes of fetal surveillance before birth. Ia can be done using either the fetoscope or doppler ultrasound figure 171.
Electronic fetal heart rate monitoring american academy of. Intrapartum external fetal monitoring in obese women adc. Baseline variability is defined as fluctuations in the fetal heart rate of more than 2 cycles per minute. The purpose of fhr monitoring is to follow the status of the fetus during labor so that clinicians can intervene if there is evidence of fetal distress, as reflected in fhr above or below the.
Although ctg, also known as electronic fetal monitoring, is widespread in developed nations, its ability to identify the fetus that may be becoming asphyxiated. Chapter 17 intrapartum fetal surveillance learning objectives after studying this chapter, you should be able to. This is called an internal fetal electrode or fetal scalp electrode or clip. Pdf intrapartum fetal surveillance case based learning. In 1985, the figo subcommittee on standards in perinatal medicine. Most external monitors use a doppler device with computerized logic to interpret and count the doppler signals. Implications of perinatal safety nurse fetal monitoring.
Current techniques rely predominantly on the use of electronic fetal monitoring through the use of cardiotocography ctg. Alerting philips ob tracevue system generates awareness of. Despite the extensive uptake of intrapartum fetal surveillance in the last 2030 years, particularly in the form of ctg monitoring, the hope for impact on intrapartum asphyxia has not occurred. Sometimes it is necessary to attach the monitor directly on your baby via a special lead. No single test can detect abn with 100% accuracy ideal detection. Intrapartum fetal surveillance ifs refer to online version, destroy printed copies after use page 3 of 29 flow chart. The fetal heart rate may be monitored using continuous electronic fhr monitoring efm components external cardiotocography ctg or internal.
From the maternal point of view, intensive fetal monitoring has profound implications by virtue of its usual effect on incidence of caesarean birth, although the dublin trial results, with regard to incidence of caesarean section, emphasize the importance of considering intrapartum fetal monitoring as just one part of the overall supervision of. The terms fetal distress and fetal asphyxia are often erroneously used interchangeably. Pdf intrapartum fetal monitoring towards improved perinatal. The aim of fetal surveillance in labour is to identify hypoxia and allow intervention to prevent the sequelae of asphyxia. This guideline describes fetal monitoring using physiologybased ctg interpretation. Combines pdf files, views them in a browser and downloads. No distinction is made between shortterm variability or beattobeat variability or rr wave period differences in the electrocardiogram and longterm variability grades of fluctuation are based on amplitude range peak to trough. Fetal monitoring is listening to your babys heart beat to see how they are coping during labour. Pdf figo consensus guidelines on intrapartum fetal. However, there have been delays in providing timely and necessary obstetric interventions, most likely. Intrapartum fetal heart rate monitoring is commonly used to evaluate fetal status in labor, despite a lack of convincing randomized studies to support its use. The report provides separate comprehensive analytics for the us, canada, japan, europe, asiapacific, latin america, and rest of world. Intrapartum electronic fetalheartrate monitoring was introduced in the united states in the early 1970s after studies supported the existence of a correlation between patterns of fetal heart. The clip is placed on your babys scalp during an internal vaginal examination.
Low ja, victory r, derrick ejpredictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis. The primary objective of electronic fetal monitoring is to provide information with relation to fetal oxygenation and to prevent fetal injury that could result in impaired fetal oxygenation during labor fedorka, 2010. Feb 04, 2015 this article deals with those monitoring techniques that are used immediately preceding or during childbirth known as intrapartum fetal monitoring. These techniques are poorly defined and as a result the interobserver variation in interpretation is high nielsen et al. The intrapartum management of fetal distress is a challenge to obstetricians, compounded by difficulties in interpreting the fetal heart rate fhr pattern and confusion regarding the definition of asphyxia. Annual estimates and forecasts are provided for the period. It is well documented that many complications of pregnancy are avoidable by providing skilled midwifery care during and immediately after childbirth.
Fetal monitoring tutorial a tutorial about fetal monitoring during labour including example ctgs and test mcqs. Figo consensus guidelines on intrapartum fetal monitoring. Cervix needs to be 45cm dilated and vx at 1 st or below ph 7. Intrapartum electronic fetal monitoring agency for healthcare research and quality stan case library. Fetal heart rate changes environment lungs heart vasculature uterus placenta cord fetus hypoxemia hypoxia metabolic acidosis metabolic acidemia potential injury 1. A system whicli can archive 4000 case records and ctgs on one optical disk with a life of 25 years would appear to be a wortliwhile in\. In fetal monitoring many aspects of analysis rely on visual interpretation of results, for example recognition of heart rate patterns on a fetal heart rate plot. Ppt intrapartum fetal monitoring powerpoint presentation. We identified rcts that compared stwaveform analysis and conventional cardiotocography for intrapartum fetal monitoring of singleton pregnancies in cephalic presentation beyond 34 weeks of. This article explores historical aspects of fetal monitoring, the advent of electronic fetal monitoring and its controversies, and present and future research opportunities to. Use of continuous electronic fetal monitoring in a preterm.
Fetal fever infection medications anemia arrhythmia heart block congenital anomaly extreme prematurity preexisting neurologic injury sleep cycle other causes of fetal heart rate changes environment lungs heart vasculature uterus placenta cord fetus hypoxemia hypoxia metabolic acidosis metabolic acidemia potential injury 1. Intrapartum care and fetal heart rate monitoring in labour uhl obstetric guideline page 1 of 65 author. Intrapartum fetal surveillance by intermittent auscultation of the fhr continued to evolve early in the 20th century and, in fact, had become. In spite of these limitations, most experts believe that continuous ctg monitoring should be considered in all situations where there is a high risk of fetal hypoxia. Nice pathways are interactive and designed to be used online. Guideline working party, updated by working party written. The avoidance of adverse fetal outcomes is the objective of intrapartum fetal monitoring. Feb 08, 2014 fetal scalp ph in women with abnormal fetal heart rate tracings. In addition, the cablefree system requires no repositioning ref 4, 8 and keeps the work environment clear. Take the following into account when assessing baseline fetal heart rate. It is generally accepted that intermittent auscultation ia is.
From the fetal viewpoint, labour is a prolonged contraction stress test which most pass without incident. Intrapartum fetal monitoring medicolegal implications. Decelerations late, variable or prolonged signal interruption of the. Essentials of fetal monitoring, fourth edition murray phd rnc, michelle, huelsmann bsn rnc, gayle, koperski rnc mba mhsa lncc, nanci on. The purpose of fetal heart rate monitoring is to identify evidence of fetal well being and oxygenation during labor and then appropriately intervene to reduce the incidence of poor neonatal outcomes. Since the advent of electronic fetal monitoring, there has been much debate over the relationship between the use of. Intrapartum fetal monitoring guideline published february 2018 disclaimer this guideline describes fetal monitoring using physiologybased ctg interpretation. Features observed on a ctg trace reflect the functioning of somatic and autonomic nervous systems and the fetal response to hypoxic or mechanical insults. This objective is the same for all hospitals providing maternity services. Intrapartum fetal monitoring professor declan devane is professor of midwifery and holds a joint post between nui galway and the west, northwest hospitals group. Objectives to evaluate the success of intrapartum external fetal monitoring in obese women. Intrapartum fetal monitoring medicolegal implic at ions sabaratnam anilkumaran md phd frcs frcog introduction he contribution of birth asphyxia to cerebral palsy has t tieen debated since 18621 and.
Standardisation of fetal heart rate monitoring fetal heart rate monitoring, whether by intermittent auscultation ia or electronic fetal monitoring efm, should be recommended to all women in labour. The nurse may use ia of fhr and palpation of uterine activity for intrapartum fetal surveillance procedure. Explain the normal and pathologic mechanisms that influence fetal heart rate fhr. International federation of obstetrics and gynaecology. Ultrasonography, although in the strictest sense an invasive technique energy is imparted to the fetu s, is widely considered as being noninvasive. Guidelines on the use of electronic fetal monitoring 6 which included a comprehensive bibliography and. Interpretation of the electronic fetal heart rate during labor american academy of family physicians screening.
Intrapartum electronic fetal heartrate monitoring was introduced in the united states in the early 1970s after studies supported the existence of a correlation between patterns of fetal heart. Risk factors should be identified and recorded see table 1. It is indisputable that monitoring of the fetal heart is an essential part of the care of the fetus in labour. With the philips avalon fm20 and fm30 fetal monitors, this includes triplet monitoring. Declan is an associate editor with the cochrane pregnancy and childbirth group, an associate senior lecturer with the uk cochrane centre and an author of numerous cochrane systematic.
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