40516550 fetal distress
TRANSCRIPT
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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
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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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Umbilical Cord Prolapse
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Umbilical Cord Prolapse
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Umbilical Cord Prolapse
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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.