Definition of Terms:
A.
B.
C.
D.
E.
F.
G.
H.
Baseline
Baseline variability
Acceleration
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration
Sinusoidal pattern
BASELINE
The mean fetal heart rate (FHR) rounded
to increments of 5 beats per minute
during a 10-minute segment, excluding:
Periodic or episodic changes
Periodic of marked FHR variability
Segments of baseline that defer by more than
25 beats per minute
BASELINE
The baseline must be for a minimum of 2
minutes in any 10-minute segment, or the
baseline for that time period is
indeterminate.
In this case, one may refer to the prior 10minute window for determination of
baseline.
BASELINE
Normal FHR baseline: 110-160 beats per
minute
Tachycardia: FHR baseline is greater than
160 beats per minute
Bradycardia: FHR baseline is less than
110 beats per minute
BASELINE VARIABILITY
Fluctuations in the baseline FHR that are
irregular in amplitude and frequency.
Variability is visually quantified as the
amplitude of peak-to-trough in beats per
minute.
BASELINE VARIABILITY
Absent amplitude range undetectable
Minimal amplitude range detectable but
5 beats per minute or fewer
Moderate (Normal) amplitude range 625 beats per minute
Marked amplitude range greater than 25
beats per minute
ACCELERATION
A visually apparent abrupt increase (onset
to peak in less than 30 seconds) in the
FHR.
At more than or equal to 32 weeks of
gestation, acceleration has a peak of 15
beats per minute or more above baseline,
with duration of 15 seconds or more but
less than 2 minutes from onset to return.
ACCELERATION
Before 32 weeks of gestation, an
acceleration has a peak of 10 beats per
minute or more above baseline, with a
duration of 10 seconds or more but less
than 2 minutes from onset to return.
Prolonged acceleration lasts 2 minutes or
more but less than 10 minutes in duration.
If an acceleration lasts 10 minutes or
longer, it is a baseline change.
EARLY DECELERATION
Visually apparent usually symmetrical
gradual decrease and return of the FHR
associated with a uterine contraction.
Gradual FHR decrease is defined as from
the onset to the FHR nadir of 30 seconds
or more.
The decrease in FHR is calculated from
the onset to the nadir of the deceleration.
EARLY DECELERATION
The nadir of the deceleration occurs 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.
LATE DECELERATION
Visually apparent usually symmetrical
gradual decrease and return of the FHR
associated with a uterine contraction.
A gradual FHR decrease is defined as
from the onset to the FHR nadir of 30
seconds or more.
The decrease in FHR is calculated from
the onset to the nadir of the deceleration.
LATE DECELERATION
The deceleration is delayed in timing, with
the nadir of the deceleration occurring
after the peak of the contraction.
In most cases the onset, nadir, and
recovery of the deceleration occur after the
beginning, peak, and ending of the
contraction, respectively
VARIABLE DECELERATION
Visually apparent abrupt decrease in FHR.
An abrupt FHR decrease is defined as
from the onset of the deceleration to the
beginning of the FHR nadir less than 30
seconds.
The decrease in FHR is calculated from
the onset to the nadir of the deceleration.
VARIABLE DECELERATION
PROLONGED DECELERATION
Visually apparent decrease in FHR below
the baseline.
Decrease in FHR from the baseline that is
15 beats per minute or more, lasting 2
minutes or more but less than 10 minutes
in duration.
If a deceleration lasts 10 minutes or
longer, it is a baseline change.
SINUSOIDAL PATTERN
Visually apparent, smooth, sine wave-like
undulating pattern in FHR baseline with a
cycle frequency of 3-5 per minute which
persists for 20 minutes or more.
Classification of FHR
Tracings Three
Tiered System for the
Categorization of FHR
Patterns
Categ FHR
ory
Tracin
gs
Definition
Catego
FHR
ry
Tracings
II
Definition
continued
surveilance
and
reevaluation, taking into account
the entire associated clinical
circumstances.
In some circumstances, either
ancillary tests to ensure fetal well
being
or
intrauterine
Catego
FHR
Definition
ry
Tracings
III
Abnorm associated with abnormal fetal
al
acid-base status at the time of
observation.
require clinical evaluation
on
the
clinical
Depending
situation, efforts to expeditiously
resolve the abnormal FHR pattern
may include but are not limited
to provision of:
1.maternal oxygen
2.change in maternal position
3.
discontinuation
of
labor
stimulation
4.treatment
of
maternal
Categ
ory
III
FHR
Tracings
Definition
Abnor If
category
III
mal tracing does not
resolve with these
measures, delivery
should
be
undertaken.
Frequency of IA is as follows:
Category
II
III
Bradycar
dia
Category
Decelerati Absent
ons
early, late
or
variable
II
Recurrent
variable
decelerations
accompanied by
minimal or
moderate
baseline
variability
Prolonged
deceleration
more than 2
minutes but less
than 10 minutes
Recurrent late
III
Recurrent
late
deceleratio
ns
Recurrent
variable
deceleratio
ns
Category
Decelerat Absent
ions
early,
late
or
variable
II
III
Variable
decelerations with
other
characteristics such
as slow return to
baseline,
overshoots, or
shoulders
Recurrent
late
decelerati
ons
Recurrent
variable
decelerati
ons
Accelerati Present
Absence of
ons
or Absent induced
accelerations
after fetal
Sinusoidal
pattern
(Level I, Grade A)
DYSTOCIA
Diagnostic Criteria
Nulliparas Multiparas
Prolongaton Disorder
1. Prolonged Latent
> 20 hrs
Phase
Protraction Disorder
1. Protracted Active
< 1.2 cm/hr
Phase Dilation (Phase
of maximum slope of
dilatation)
2. Protracted Descent
< 1 cm/hr
(maximum slope of
descent during the pelvic
> 14 hrs
< 2cm/hr
LABOR PATTERN
Arrest Disorder
1.
Prolonged
Deceleration
Phase
(cervical dilatation arrested
at 8 to 9 cm)
2. Secondary Arrest of
Dilatation
(progressive
cervical dilatation stops at
the phase of maximum
slope)
3. Arrest of Descent
(progressive descent stops
during pelvic division of
labor, station + 1)
Diagnostic Criteria
Nulliparas Multiparas
> 3 hrs
> 1 hr
> 2 hrs
> 1 hr
LABOR PATTERN
Diagnostic Criteria
Nulliparas Multiparas
> 1 hr
without
regional
anesthesia
Recommendations
1. Prolonged Latent Phase
2. Protracted Active Phase Dilatation
3. Arrest Disorders
Recommendations
1. Prolonged Latent Phase
2. Protracted Active Phase Dilatation
3. Arrest Disorders
(Level I, Grade A)
Recommendations
1. Prolonged Latent Phase
2. Protracted Active Phase Dilatation
3. Arrest Disorders
Arrest Disorders
Continuous support during labor from
caregivers should be encouraged because it
is beneficial for women and their newborns.
(Level I, Grade A)
Arrest Disorders
If with CPD, do CS.
(Level III, Grade B)
Arrest Disorders
The 2-hour rule for the diagnosis of arrest in
active labor has been challenged.
In a clinical trial, 542 women were managed
by a protocol in which, after active phase
arrest was diagnosed, oxytocin was initiated
with the intent to achieve a sustained uterine
contraction pattern of greater than 200
Montevideo units.
Arrest Disorders
Cesarean delivery is not performed for
labor arrest until there were at least 4
hours of sustained uterine contraction
pattern of greater than 200 Montevideo
units, or a minimum of 6 hours of oxytocin
augmentation if the contraction pattern
could not be achieved.
Arrest Disorders
The protocol resulted in a high rate of
vaginal delivery (92%) with no severe
adverse maternal or fetal outcomes.
Extending the minimum period of oxytocin
augmentation for active phase arrest from 2
hours appears effective.
(Level III, Grade C)
DYSTOCIA SECONDARY TO
PROBLEMS IN PASSENGER
BREECH PRESENTATION
EXTERNAL CEPHALIC VERSION
PERSISTENT OCCIPUT POSTERIOR,
OCCIPUT TRANSVERSE
BROW PRESENTATION
FACE PRESENTATION
FETAL MACROSOMIA
SHOULDER DYSTOCIA
TRANSVERSE LIE/OBLIQUE LIE
COMPOUND PRESENTATION
BREECH PRESENTATION
BREECH PRESENTATION
Recommendations:
Planned cesarean section (CS) for babies in
breech presentation has a reduced risk for
perinatal death and neonatal morbidity
compared to planned vaginal birth.
(Level I, Grade A)
(Level I, Grade A)
Recommendations:
Information is limited about the potential for
problems with future pregnancies.
(Level I, Grade C)
(Level I, Grade A)
Recommendations:
There is no data to quantify risks of CS to
the mother (scar dehiscence in a
subsequent pregnancy, increased risk to
repeat CS, placenta accreta).
(Level III, Grade C)
Recommendations:
Planned vaginal breech delivery remains a
viable option, provided the criteria are met,
a skilled obstetrician and facilities for CS
are immediately available, and the women
is informed of all possible risks.
(Level I, Grade B)
Recommendations:
For a woman with suspected breech
presentation, pre- or early labor ultrasound
should be performed to assess type of
breech presentation, fetal growth and
estimated weight, and attitude of fetal
head. If ultrasound is not available, CS is
recommended.
Recommendations:
Contraindications to labor
include:
a) Cord presentation. (Level II, Grade A)
b) Fetal growth restriction or macrosomia
(Level I, Grade A)
Recommendations:
Contraindications to labor
include:
d)Clinically inadequate maternal pelvis
(Level
III, Grade B)
Recommendations:
Vaginal breech delivery can be offered when the
estimated fetal weight is between 2500 g and
4000 g.
(Level II, Grade B)
Recommendations:
Continuous electronic fetal heart monitoring (EFM)
is preferable in the first stage and mandatory in
the second stage of labor.
(Level I, Grade A)
Recommendations:
Recommendations:
A health care professional skilled in neonatal
resuscitation should be in attendance at the time of
delivery.
(Level III, Grade A)
Recommendations:
An experienced obstetrician-gynecologist comfortable
in the performance of vaginal breech delivery should be
present at the delivery to supervise other health care
providers, including a trainee.
(Level I, Grade A)
Recommendations:
Total breech extraction is inappropriate for term
singleton breech delivery
(Level II, Grade A)
Recommendations:
Recommendations:
The fetal head may deliver spontaneously, with the
assistance of suprapubic pressure, by MauriceauSmellie-Veit maneuver, or with the assistance of
Piper forceps.
Recommendations:
Recommendations:
The consent discussion and chosen plan
should be well documented and
communicated to labor room staff.
(Level III, Grade B)
Recommendations:
Recommendations:
A physician is free to choose whom he will serve.
He may refuse calls, or other medical services for
reasons satisfactory to his professional
conscience.
Recommendations:
Recommendations:
Not enough evidence to support the
intervention of helping a breech baby to be
born in one pushing contraction following
the birth of the babys umbilicus.
(Level III, Grade B)
Recommendations
Women should be counseled that ECV
reduces the chance of breech presentation at
delivery.
(Level I, Grade A)
Recommendations
The use of tocolysis with beta
sympathomimetic drugs may be offered to
women undergoing ECV as it has been
shown to increase the success rate.
(Level I, Grade A)
Recommendations
There is insufficient evidence to support
the use of postural management as a
method of promoting spontaneous version
over ECV.
(Level I, Grade A)
Recommendations
Absolute contraindications for ECV
that are likely to be associated with
increased mortality or morbidity:
Recommendations
Relative contraindications where ECV
might be more complicated:
Small for gestational age fetus with abnormal
Doppler parameters
Proteinuric pre-eclapmsia
Oligohydramnios
Major fetal anomalies
Scarred uterus
Unstable lie
Recommendations
Digital rotation should be considered when
managing the labor of a fetus in the
occipito-posterior position. This maneuver
successfully rotates the fetus reducing the
need for CS, instrumental delivery, and
other complications associated with
persistent occiput posterior
Recommendations
Use of hands and knees position for ten minutes
twice daily in late pregnancy or during labor to
correct occipito-posterior position cannot be
recommended as an intervention. This is not to
suggest that women should not adopt this position
if they found it confortable. The use of this position
was associated with reduced backache.
(Level I, Grade A)
BROW PRESENTATION
BROW PRESENTATION
Recommendations:
Expectant management is reasonable as
long as the fetal heart tracing remains
reassuring and dilation and descent are
progressing normally because
spontaneous conversion to vertex or face
may occur.
Recommendations
The use of forceps or manual conversion
to convert a brow presentation to a more
favorable position is contraindicated.
FACE PRESENTATION
FACE PRESENTATION
Recommendations
Continuous EFM is considered mandatory
by many authors because of the increased
incidence of abnormal FHR patterns
and/or fetal compromise. Careful
application of the electrode must be
ensured; the mentum is recommended site
of application.
Recommendations
Oxytocin can be used to augment labor
using the same precaution as in a vertex
presentation and using the same criteria of
assessment of uterine activity, adequacy of
the pelvis, and reassuring fetal hear
tracing.
Recommendations
Attempts to manually convert the face to
vertex (Thom maneuver) or to rotate a
posterior position to a more favorable anterior
mentum position are rarely successful and are
associated with high perinatal mortality and
maternal morbidity.
Internal podalic version and breech extraction
are no longer recommended in the modern
management of the face presentation.
Recommendations
Forceps may be used if the mentum is anterior.
Any typical forceps including Keilland forceps,
can be used.
(Level III, Grade B)
FETAL MACROSOMIA
FETAL MACROSOMIA
The term fetal macrosomia implies fetal
growth beyond a specific weight, usually
4000 gm (8 lb 13 oz) or 4500 gm (9 lb 4
oz) regardless of the fetal gestational age.
Recommendations
The diagnosis of fetal macrosomia is
imprecise. For suspected fetal
macrosomia, the accuracy is estimated
fetal weight using ultrasound biometry is
no better than that obtained with clinical
palpation (Leopolds maneuvers).
(Level I, Grade A)
Recommendations
Labor and vaginal delivery is not
contraindicated for women with estimated
fetal weights up to 5,000 g in the absence
of maternal diabetes.
(Level II, Grade B)
Recommendations
Although the diagnosis of fetal
macrosomia is imprecise, prophylactic
cesarean delivery may be considered for
suspected fetal macrosomia with
estimated fetal weights more than 5,000 g
in pregnant women without diabetes and
more than 4,500 g in pregnant women with
diabetes.
SHOULDER DYSTOCIA
SHOULDER DYSTOCIA
Recommendations
Risk assessments for the prediction of
shoulder dystocia are insufficiently
predictive to allow prevention of the large
majority of cases.
(Level II, Grade B)
Recommendations
Late pregnancy ultrasound likewise displays
low sensitivity, decreasing accuracy with
increasing birth weight, and an overall
tendency to overestimate the birth weight.
(Level II, Grade B)
Recommendations
Episiotomy is not necessary for all cases,
is reserved to facilitate maneuvers such as
delivery of posterior arm or internal
rotation of shoulders.
(Level III, Grade C)
Recommendations
Suprapubic pressure is useful
(Level III, Grade C)
Recommendations
Other maneuvers such as Rubins, Woods
screw maneuver, Zavanelli, cleidotomy
and symphysiotomy have been employed
but no controlled trials have been made.
Rubin Maneuver
Zavanelli maneuver
Symphysiotomy
COMPOUND PRESENTATION
COMPOUND PRESENTATION
Recommendations
If the hand has not prolapsed beyond the
presenting part, causing the hand to
retract often is accomplished, if necessary.
It can be ignored as long as labor is
progressing normally.
COMPOUND PRESENTATION
Recommendations
In contrast, if the hand or arm has
prolapsed past the presenting part,
abdominal vaginal delivery and proceeding
to cesarean delivery is wise.
Thank you