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Fetal Distress

What is fetal distress?


Fetal distress is the term commonly used to
describe fetal hypoxia. It is a clinical diagnosis
made by indirect methods and should be defined
as:Hypoxia that may result in fetal damage or
death if not reversed or the fetus delivered
immediately.
More commonly a fetal scalp pH of less than 7.2 is
used to indicate distress

Etiology
Fetal oxygen supplied from:
maternal circulation-----placenta------umbilical
cord------fetus

maternal factors
cardiovescular diseases
acute bleeding
uterus

Etiology
Fetal factors
cardiovescular dysfunction
deformity

umbilical cord and placental factors


abnormal cord:entanglement,
nuchal umbilical cord
prolapse of cord
abnormal placenta

Causes of Hypoxia*
risk factors
Maternal risk factors
Diabetes
Pregnancy-induced or chronic hypertension
Maternal infection
Sickle cell anemia
Chronic substance abuse
Asthma
Seizure disorders
Post-term or multiple-gestation pregnancy

Intrapartum causes of fetal


hypoxia**
Abnormal presentation of the fetus (i.e.
breech)
Premature onset of labor
Rupture of membrane more than 24 hours
prior to delivery
Prolonged labor
Administration of narcotics and anesthetics

Maternal hypoventilation
Maternal hypoxia
Hypotension can be caused by either
epidural anaesthesia 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 (supine hypotension syndrome**).

Pathophysiology
Hypoxia!
Acidosis----sympathetic nerve excited--- hypertension,
tachycardia (initial signs)

profound acidosis-----vagus nerve--- hypotension,


bradycardia,
hyperperistalsis----meconium discharge

chronic condition:
nutritional deficiency----FGR

Clinical manifestation
Chronic fetal distress

FGR
dysfunction of maternal-placental-fetal unit
fetal heart monitoring
fetal movement calculation
amnioscopy

Clinical manifestation
Acute fetal distress

fetal heart rate


characteristics of fluid
fetal movement
acidosis

How to define the newborn


asphyxia
Usually with fetal distress.
Apgar score: 8-10 normal

4-7 mild asphyxia

0-3 severe asphyxia

Effects of Asphyxia
Fetal hypoxia is associated with severe
complications in all systems. The infant may
suffer:
Hypoxic ischemic encephalopathy
Meconium aspiration syndrome
Acidosis with decompensation
Cerebral palsy
Neonatal seizures

Mecunium
Normal condition: mature of colon
Fetal hypoxia can stimulate fetal colonic
contraction that leads to evacuation of meconium
(fetal stool) into the amniotic fluid
How meconium is dealt with will depend on what
it looks like and what your provider's approach is.
Old meconium is yellow and less likely to be a
problem .

Meconium
Thick, green, particulate meconium which may have
already caused baby to "gasp" in utero.
If the meconium is accompanied by decreased heart rates
that do not recover well, a c-section will be the safest
approach.
Fetal gasping due to the lack of oxygen which then causes
aspiration of the meconium into the lungs.
The presence of this material can produce bronchial
obstruction and a chemical pneumonitis and treatment must
be initiated during delivery. If not adequately removed, the
meconium blocking the airways can lead to further
hypoxia.

Meconium aspiration most often


occurs in

Term infants
Growth-retarded infants
Post-term infants
Breech presentation delivery
The degree of meconium aspiration and the length of
exposure to meconium determines the severity of the
hypoxia suffered by the fetus. Staining of the umbilical
cord, skin, or nails of the infant indicates exposure to
meconium 3 to 6 hours in utero prior to delivery.

Assessment
**
Antepartum Testing:
Tests for antepartum fetal evaluation include:
Fetal movement count
Non stress test
Contraction stress test
Biophysical profile

Fetal movement
Fetal movement counts are performed by the
mother and are an inexpensive, noninvasive
method of assessing fetal well-being. The patient
records the number of times she feels fetal
movement within a designated time period. The
exact number of normal perceived movements has
not been determined, however approximately 10
movements should be felt within a 12 hour period.

Non Stress Test (NST)


The is an indirect measurement of
uteroplacental function and
requires specialized equipment and
trained personnel.
This test measures the detection of
heart rate accelerations associated
with perceived fetal movements.
A reactive or normal stress test
will exhibit at least two
accelerations in the fetal heart rate
in a 20-minute period.

Contraction Stress Test (CST)


CST or oxytocin challenge test, is more
costly and presents more of a risk to the
fetus. but identifies fetal reserve during
contractions. The test measures late
decelerations during contractions induced
by either nipple stimulation or oxytocin
infusion. The test is negative if no late
decelerations are observed.

Biophysical profile

fetal movement
amniotic fluid volume
respiratory movement
movement of extremity
NST

Intrapartum Testing
Tests utilized to assess fetal well being during
labor include:
Intermittent auscultation of the fetal heart
rate
Continuous electronic fetal monitoring
Scalp pH measurement

Measurement of the fetal heart rate: abnormal


decelerations and decreased variability during
contractions are suggestive of fetal distress.
Intermittent auscultation of the fetal heart rate is a
reliable indicator of fetal well being and can be
used in low risk deliveries. Routine electronic
fetal monitoring is not recommended for low-risk
women in labor when adequate clinical monitoring
including intermittent auscultation by trained staff
is available .

Continuous intrapartum fetal monitoring is


the mainstay in most modern obstetric units.
The heart rate of the fetus is monitored to
detect increases or decreases during
contractions. The variability and trends are
interpreted to determine fetal distress or
well being.

Scalp pH measurement helps to determine


the presence of acidosis and fetal hypoxia
and may influence the decision of
whether to continue observation or to
perform a cesarean delivery. Neurologic
deficits usually occur when there is a
severe acidosis, due to hypoxia, present at
birth. Severe hypoxia will often cause
hypoxic-ischemic encephalopathy in the
infant.

Whats the typical signs of fetal


distress?**
Typical signs of fetal distress include :
late heart rate decelerations
variable decelerations
prolonged bradycardia
indications of meconium staining.

Intrapartum hypoxia is thought to be the


leading cause of cerebral palsy and now
accounts for 3 to 15% of cerebral palsy
cases. Chronic fetal hypoxia, caused by
maternal smoking or anemia, may also
contribute to a predisposition for Sudden
Infant Death Syndrome (SIDS).

Treatment of Hypoxia
Mothers condition must be treated to prevent
hypoxia to the fetus including:
Blood pressure stabilization
Maternal positioning on the left side
Monitoring maternal oxygenation
Pelvic exam to identify cord presentation

Treatment of Hypoxia
Oxygen administration to the mother may provide
additional availability of oxygen to the fetus.
Trained neonatal resuscitation staff should be
available at all times and should be present in the
delivery suite for those patients with known risk
for fetal distress or hypoxia.
Cesarean sections are performed if all else fails,
and are the last alternative when faced with the
possibility of fetal distress.

The decision to delivery interval


Medical litigation is on the rise in our
country particularly with relation to
obstetrics. The day is not far when
premiums for malpractice nsurance rise
parallel to the rise in the compensation
offered for these cases. Majority of the
cases seem to be due to the delay in the
decision to delivery interval rather than the
problems with diagnosis.

The decision to delivery interval


Although there is poor correlation between FHR
patterns and long term outcome a significant
association has been noted between the decision to
delivery interval and admission to the neonatal
intensive care unit for neonatal asphyxia
An effort must be made to reduce the decision to
delivery interval and restrict it to not more than 30
minutes. It should be the norm to keep the women
and her relatives apprised of the situation of the
labor at all times and involve them in the decision
making.

The decision to delivery interval


In some cases of fetal distress immediate operative
delivery may be the only option to ensure a
healthy neonate. Even in these situations
intrauterine resuscitation can play a role in
enhancing the perinatal outcome. Ultimately,
efficient management and a good outcome in cases
of fetal distress reflects a strong infrastructure and
good coordination between the obstetrician, the
nursing staff, the staff in the operation room and
the neonatologist.

Premature rupture of membrane


(PROM)

What is premature rupture of


membranes?**
The diagnosis of PROM is made whenever the bag
of water ruptures before the onset of true labor.
PPROM: Preterm premature rupture of
membranes is the rupture of membranes during
pregnancy before 37 weeks' gestation.
It occurs in 3 percent of pregnancies and is the
cause of approximately one third of preterm
deliveries.

Incidence
Varied greatly 2.7%--17%
PROM is causally related to about 10%
perinatal deaths regardless of gestation age.
Its occurrence before term adds the risk of
neonatal respiratory distress syndrome
(NRDS) from hyaline membrane disease to
the risk of chorioamnionitis , neonatal
sepsis associated with ascending infection.

What causes premature rupture of


membranes?**
The exact etiology of PROM remains
unknown, there have been many postulated
causes, but a single common denominator
has not yet been found.

What causes premature rupture of


membranes?**
Infection: subclinical infection, chorioamnionitis
coitus : patients who had coitus within 7 days before delivery.
low socioeconomic conditions : less likely to receive proper
prenatal care)
sexually transmitted infections such as chlamydia and
gonorrhea

What causes premature rupture of


membranes?**

Previous preterm birth


Vaginal bleeding
Cigarette smoking during pregnancy
Trauma
Cervical incompetence/cervical lacerations
/cervical operations
Polyhydramnios/multiple gestations
Black patients are at increased risk of preterm
PROM compared with white patients.

What causes premature rupture of


membranes?**
unknown causes
There appears to be no single etiology of
preterm PROM. It is likely that multiple
factors predispose certain patients to
preterm PROM.

Complications of Preterm PROM


Complications

Incidence (%)

Delivery within one week

50 to 75

Respiratory distress syndrome 35


Cord compression

32 to 76

Chorioamnionitis

13 to 60

Abruptio placentae

4 to 12

Antepartum fetal death

1 to 2

What are the symptoms of PROM?


The following are the most common
symptoms of PROM. However, each
woman may experience symptoms
differently. Symptoms may include:
leaking or a gush of watery fluid from the
vagina
constant wetness in panties

How is premature rupture of


membranes diagnosed?*
In addition to a complete medical history and physical examination,
PROM may be diagnosed in several ways, including the following:
an examination of the cervix (may show fluid leaking from the cervical
opening)
testing of the pH (acid or alkaline) of the fluid
accuracy rate:93-96%
False-positive:
cervicitis/vaginitis/presence of semen ,alkaline urine/blood in
vagina
looking at the dried fluid under a microscope (may show a characteristic
fern-like pattern)

Management
Hospitalization
expectant management (in some cases of
PPROM, the membranes may seal over and
the fluid may stop leaking without treatment)
monitoring for signs of infection such as fever,
pain, increased fetal heart rate, and/or
laboratory tests

Management
corticosteroids that may help mature the lungs of the
fetus (lung immaturity is a major problem of premature
babies). However, corticosteroids may mask an infection
in the uterus.
antibiotics (to prevent or treat infections)
tocolytics - medications used to stop preterm labor.
delivery (if PROM endangers the well-being of the
mother or fetus, then an early delivery may be necessary
to prevent further complications)