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Manual of Foetal Monitoring
Richa Saxena
SECTION 1: OVERVIEW OF FOETAL MONITORING
CHAPTER 1:
Concept of Foetal Monitoring
INTRODUCTION
FOETAL HEART RATE
Heart Rate at Term
Measurement of Foetal Heart Rate
Changes in Foetal Heart Rate with Increasing Gestation
Significance of Low Embryonic Heart Rate
Heart Rate and Sex of the Embryo
History of Foetal Heart Monitoring
Foetoscope28 (Figs 1.1A and B)
Hand Held Doppler Device28 (Figs 1.3A and B)
Role of Amniotic Fluid Measurement in Foetal Well-being29
CLINICAL ABDOMINAL EXAMINATION30,31
Fundal Height (Height of the Uterus)
Measurement of Symphysio Fundal Height (Fig. 1.5)
Obstetric Grips or Lepold's Manoeuvres (Fig. 1.6)
Fundal Grip (Lepold's First Manoeuvre)
Lateral Grip (Lepold's Second Manoeuvre)
Pelvic Grips
Uterine Contractions
Foetal Descent
Abdominal Assessment of Foetal Descent (Figs1.7A and B)
Auscultation of Foetal Heart
Usual Management of a Booked Patient at the Time of Labour (Flow chart 1.1)
Intermittent Auscultation
Location of Foetal Heart Rate (Figs 1.8A and B)30
Continuous Electronic Foetal Monitoring
VAGINAL EXAMINATION30,31
Cervical Dilatation (Fig. 1.10)
Cervical Effacement (Fig. 1.11)
Descent of Foetal Head (Station) (Fig. 1.12)
Position of the Foetal Presenting Part
Moulding of Foetal Head (Fig. 1.15)
Pelvic Assessment
PARTOGRAM (Figs 1.16A and B)
SUMMARY
CHAPTER 2:
Physiological Basis of Foetal Monitoring
INTRODUCTION
Implantation of Blastocyst1
Amniotic Cavity
Abnormal Sites of Implantation2
DEVELOPMENT OF HUMAN PLACENTA
Decidua3-12
Chorionic Villi Formation
Stages of Chorionic Villi
Primary Villi (Fig.2.8)
Secondary Villi (Fig.2.9)
Tertiary Villi (Fig. 2.10)
Cytotrophoblastic Shell (Fig. 2.11)
Structure of Human Placenta
Placental Barriers or Placental Membrane19
Function of the Placenta (Fig. 2.15)
Transport Function (Fig.2.15)
Endocrine Function
Immunological Function20-22
Characteristics of the Human Placenta
Trophoblastic Invasion of Uterine Blood Vessels23-31 (Fig 2.19)
Prevention of Excessive Trophoblastic Invasion
CIRCULATION
Utero-placental Circulation
Adult Circulation (Fig. 2.20)
Foetal Circulation (Figs 2.21 A to C)33-41
Foetal Circulation Outside the Uterine Cavity
SUMMARY
SECTION 2: ANTEPARTUM FOETAL MONITORING
CHAPTER 3:
Ultrasound Examination for Foetal Monitoring
INTRODUCTION
PRINCIPLE OF ULTRASOUND (FIG. 3.1)1
USES OF ULTRASOUND EXAMINATION IN PREGNANCY
Role of Ultrasound Examination in the First Trimester (Table 3.1)
Role of Ultrasound Examination in the Second Trimester (Table 3.2)
Role of Ultrasound Monitoring in the Third Trimester (Table 3.3)
Foetal Surveillance Using Ultrasonography5-7
Radiation Exposure during Pregnancy
Safety of Ultrasound
Types of Ultrasound
Transvaginal Ultrasound37-38 (Fig. 3.2A)
Transabdominal Sonography (Fig. 3.3A)
Doppler Ultrasound39-40
3-D Ultrasound41 (Fig. 3.4)
ULTRASONIC PARAMETERS FOR FOETAL MONITORING
The Crown-rump Length (CRL)
Biparietal Diameter
Occipitofronal Diameter
Abdominal Circumference
Transverse Cerebellar Diameter
Grading of Cerebellar Appearance on Ultrasound47,48
Grade I Criteria
Grade II Criteria
Femur Length
Prediction of Gestational Age
Summary of Foetal Ultrasound Parameters
The Schedule for Ultrasound Scanning
Level II Ultrasound
SUMMARY
CHAPTER 4:
Doppler Ultrasound for Foetal Monitoring
INTRODUCTION
Principle (Fig. 4.1)
Uses of Colour Flow Doppler
History
Anatomy of Uterine Blood Supply (Fig. 4.2)
Uterine Arteries3
USE OF DOPPLER SONOGRAPHY IN OBSTETRICS
Evaluation of Foetal Blood Vessels
Evaluation of Maternal Side of the Placental Circulation
Doppler Indices
Type of Doppler Waveforms (Fig. 4.4)
UMBILICAL ARTERY DOPPLER
OTHER DOPPLER STUDIES
UTERINE ARTERY DOPPLER
Introduction
Normal Uterine Artery Waveforms
Resistance in Uteroplacental Circulation
Available Evidence Regarding Benefits of Uterine Artery Evaluation
Indications for Uterine Artery Doppler Velocimetry
Treatment
Use of Low Dose Aspirin for Pre-eclampsia
MIDDLE CEREBRAL ARTERIES
Changes in MCA with IUGR (Flow chart 4.1)
Available Evidence
Middle Cerebral Artery Peak Systolic Velocity as a Predictor of Foetal Anaemia
FOETAL DESCENDING AROTA (FDA)
DOPPLER ULTRASOUND IN IUGR FOETUS
Introduction
Antenatal Foetal Surveillance using Doppler Ultrasound in Cases of IUGR (Flow chart 4.2)
VENOUS SYSTEM DOPPLER
Ductus Venosus
Inferior Vena Cava (IVC)
Umbilical Vein Doppler
SUMMARY
CHAPTER 5:
Foetal Assessment in Early Pregnancy
INTRODUCTION
Down's Syndrome
Effect of Maternal Age
Serum Markers for Down's Syndrome
Triple Test14,15
Quadruple Test20,21
Screening in the First or Second Trimester of Pregnancy?
Ultrasound Assessment of Down's Syndrome
Major Markers of Aneuploidy
“Soft Markers” of Aneuploidy
Nuchal Fold Thickening
Pathophysiology of a Thickened Nuchal Translucency
Measurement Technique
Other Ultrasound Soft Markers
Absence or Presence of Nasal Bone
Foetal Echogenic Bowel
Short Long Bones
Echogenic Intracardiac Foci (EIF)
Choroid Plexus Cysts (CPC)
Mild Pyelectasis
Significance of Presence of the Ultrasonic Markers
Index Scoring System (ISS)
Age-adjusted Ultrasound Risk Assessment (AAURA)
CYTOGENIC TESTS
Introduction
AMNIOCENTESIS
Introduction
Principle
Procedure 91 (Fig. 5.2)
Third Trimester Amniocentesis
Complications of Amniocentesis
Miscarriage
Infection
Rare Injuries
Amniotic Fluid Leakage
CHORION VILLUS BIOPSY
Principle
Procedure
Procedure For Transcervical CVS (Fig.5.3)
Procedure For Transabdominal CVS (Fig.5.4)
Complications of CVS
Signs of Complications
Comparison between Amniocentesis and CVS
SUMMARY
CHAPTER 6:
External Electronic Foetal Monitoring
INTRODUCTION
External Foetal Monitoring3-7
Internal Cardiotocography
Criteria for Recording CTG
Reading the Foetal Monitor Strip
Principle of Foetal Monitoring
Procedure
Uses of EFM
Advantages of EFM
Disadvantages of EFM
Available Evidence Regarding the Efficacy of EFM
FOETAL HYPOXIA
Introduction
Sequence of Events Following Foetal Hypoxia
Consequences of Foetal Hypoxia
Foetal Heart-rate Traces
FEATURES OF THE HEART-RATE OBSERVED ON THE CTG
1. Baseline Heart-rate
Foetal Bradycardia
Causes of Baseline Bradycardia
Tachycardia
2. Baseline Variability
Causes of Reduced Variability (Table 6.15)
3. Decelerations
Different Types of Decelerations
Early Deceleration
Late Deceleration
The Underlying Mechanism
Late Decelerations Associated with Preserved Beat-to-beat Variability (Fig. 6.10)
Late Decelerations Associated with No Variability
Management of Late Decelerations
Variable Decelerations
Management of Variable Decelerations
Acceleration
Reactivity or acceleration
Causes of Acceleration
Foetal Movements
Uterine Contraction
Foetal Stimulation
Other Significant Heart-rate Patterns
Sinusoidal Pattern (Fig.6.13)
Saltatory Pattern (Fig. 6.15)
Prediction of Sex-based on Foetal Heart-rate
MANAGEMENT ABNORMAL RATE45-50
Deciding Management Based on the Foetal Heart Trace (Flow chart 6.3)
Management of an Abnormal Trace in Antepartum Period (Flow chart 6.4)
Management of an Abnormal Trace in Intrapartum Period (Flow chart 6.5)
Intermittent Foetal Monitoring
Indications for Continuous EFM
LATEST MODIFICATIONS OF CTG MONITORING
Automatic Computer Analysis of the Tracing
Advantages
The Principle
Current Use
Telemetry Monitoring (Figs. 6.16 A and B)
FUTURE OF EFM
Problems with Standard Practices of Foetal Monitoring
Future Recommendations
Near-infrared Spectroscopy
SUMMARY
CHAPTER 7:
Antepartum Foetal Assessment in Late Pregnancy
INTRODUCTION
Principle of Foetal Assessment Tests
FOETAL MOVEMENT COUNT
Cardiff Count of 10
Technique
Modified Protocols
NONSTRESS TEST
Indications for Doing a NST
Principle
Procedure (Fig. 7.2)
Interpretation of the Tests
Implications of a Nonstress Result
Implications of a reactive (normal) nonstress test
Implications of a nonreactive (abnormal) nonstress test
Maternal Glucose Administration
CONTRACTION STRESS TEST (CST)
Introduction
Principle
Interpretation of the Test
Procedure (Fig. 7.4)
Interpretation (Table 7.6)
Reasons for Doing CST
Risks
Relative Contraindications
BIOPHYSICAL PROFILE
Components of BPP (Fig. 7.5)
Modified Biophysical Profile
VIBROACOUSTIC STIMULATION (VAST)
Procedure
Response to VAST
Nonreactive VAST
Factors that may Influence the Result of VAST
Place of VAST in Intrapartum Foetal Monitoring
As an admission test
VAST as an alternative to FBS
Safety of VAST
SUMMARY
CHAPTER 8:
Analysis of Amniotic Fluid for Assessment of Foetal Well-being
INTRODUCTION
Formation of the Amniotic Fluid (Fig. 8.1)
Drainage of the Amniotic Fluid
Physical Properties of the Amniotic Fluid
Volume
Colour of Amniotic Fluid
Functions of Amniotic Fluid
Myths about Amniotic Fluid
Ultrasound Measurement of Amniotic Fluid
Maximal Vertical Pocket Depth of Amniotic Fluid (Table 8.3)
Amniotic Fluid Index
DISORDERS OF AMNIOTIC FLUID VOLUMES
Oligohydramnios
Aetiology of Oligohydramnios
Diagnosis
History
Abdominal Examination
Complications due to Presence of Oligohydramnios
Early pregnancy
Late pregnancy
Management
Treatment strategies
Prognosis
POLYHYDRAMNIOS
Aetiology of Polyhydramnios
Foetal
Maternal
Symptoms
Abdominal Examination
Degrees of Polyhydramnios
Complications Due to Polyhydramnios17–19
Treatment of Polyhydramnios
Treatment of the underlying cause
Decompression by amniocentesis
Procedure
Treatment with indomethacin
Antepartum Foetal Surveillance
CLINICAL APPLICATIONS OF AMNIOTIC FLUID
Amniotic Fluid Foetal Fibrinonectin Levels
Tests for Lung Maturity
Amniotic Stem Cell Lines
SUMMARY
CHAPTER 9:
Assessment of Foetal Lung Maturity
INTRODUCTION
FOETAL PULMONARY CIRCULATION1
Changes in Foetal Circulation Following Birth
LUNG SURFACTANT AND ITS ROLE
Introduction
Production of Pulmonary Surfactant
Surfactant Physiology
Functions of the Pulmonary Surfactant
MEASUREMENT OF PHOSPHOLIPIDS IN THE AMNIOTIC FLUID
Lecithin/Spingomyelin Ratio
Shake Test and Foam Stability Test
Foam Stability Index
Phosphatidylglycerol
Fluorescence Polarisation
New Probes for Fluorescence Polarisation
Advantages of NBD-PC Fluorescence Polarisation Assay
The Phospholipid Content of the Lamellar Body Fraction
RESPIRATORY DISTRESS SYNDROME
Aetiology (Table 9.3)
Pathophysiology of RDS (Fig. 9.8)
Clinical Presentation
Diagnosis
X-ray
Clinical Presentation
Other Investigations
Blood Gas Specimen
Pulse Oximetry
Blood Cultures
Appearance of Lungs
Gross Features
Histologic Appearance (Fig. 9.10)
Complications of RDS (Table 9.5)
Treatment of RDS
Supplemental Oxygen Therapy
Artificial Surfactants1,36
Prevention
Antenatal Corticosteroid Therapy
SUMMARY
SECTION 3: INTRAPARTUM FOETAL MONITORING TECHNIQUES
CHAPTER 10:
Foetal Well-being During Labour
INTRODUCTION
INTERNAL CARDIOTOCOGRAPHY
Introduction
Principle
Advantages
Disadvantages
Procedure (see Fig. 10.1)
Pre-requisites
Steps
Precautions
Criticism Towards the Use of Internal Cardiotocography
Indirect signal of the foetal condition
Substantial Intra and Inter observer Variation Regarding the Interpretation
Low Validity, High Incidence of False-positive Findings
Cardiotocography Increases Medicolegal Vulnerability
Increase in the rate of obstetric interventions
Confusion due to the Many Influences on the Foetal Heart Rhythm
Differences in Recording Techniques
External CTG Monitoring vs Internal Monitoring
FOETAL SCALP BLOOD SAMPLING
Introduction
Principle
Prerequisites for Foetal Scalp pH Sampling
Procedure (Fig. 10.2)
Drawbacks
Contraindications for Foetal Scalp Blood Sampling
FOETAL SCALP BLOOD LACTATE ANALYSIS
Micro FBS and Instant Lactate Assay Using Lactate ProTM
Principle
Advantages
Normal Lactate Values in Foetal Scalp Blood
Comparison Between the Lactate Analysis and Foetal Scalp pH Analysis
Future Perspective
Foetal Scalp Stimulation
PULSE OXYMETRY
Normal Values of Pulse Oxymetry (Table 10.5)
Available Evidence
Principle
Advantages of Foetal Pulse Oxymetry
ST ANALYSIS ON FOETAL ELECTROCARDIOGRAPHY
Introduction
Principle
Pre-requisites
Procedure
CTG cum Foetal ECG vs CTG Alone
SUMMARY
CHAPTER 11:
Management of Foetal Distress
INTRODUCTION
Definition
Aetiology of Foetal Distress
Risk Factors
Mechanism of Development of Foetal Distress
Pathophysiology of Foetal Distress4 (Flow chart 11.1)
Biochemical Abnormalities in Foetal Distress (Fig. 11.5)
DIAGNOSIS OF FOETAL DISTRESS
Signs and Symptoms
Investigations
Investigations for Foetal Distress during Antenatal Period (Table 11.4)
Investigations for Foetal Distress during Labour (Table 11.5)
MANAGEMENT
General Management (Table 11.6)
Prop up the Woman or Place her on her Left Side
Administration of Oxygen via a Nasal Mask
Oxytocin Administration to be Stopped
Administration of Tocolytic Agents for Foetal Distress
Maintenance of Maternal Hydration
Definite Management
Planning Delivery8–15
CONSEQUENCES OF FOETAL DISTRESS
Foetal Hypoxia
Consequences of Foetal Hypoxia (Flow chart 11.2)
MECONIUM ASPIRATION SYNDROME
CEREBRAL PALSY
Definition
Description
Classification of Cerebral Palsies
1. Motor Abnormalities
2. Associated Impairments
3. Anatomic and Radiological Findings
Anatomic Distribution
Radiological Findings
4. Causation and Timing
Types of Cerebral Palsies (Table 11.9)
Spastic Type of Cerebral Palsy
Ataxic Cerebral Palsy
Athetoid Cerebral Palsy
Mixed Cerebral Palsy
Mechanism of Brain Injury (Fig. 11.7)
Risk Factors for Cerebral Palsy (Fig. 11.8)
Relationship Between Intrapartum Foetal Asphyxia and Cerebral Palsy
HYPOXIC-ISCHAEMIC ENCEPHALOPATHY
Introduction
Definition
Diagnosis
Risk Factors for HIE (Fig. 11.9)
Pathophysiology36–45 (Flow chart 11.3)
Cellular Mechanism
Stage of Reperfusion
Clinical Presentation
Classification of the Degree of Encephalopathy
Diagnosis
Cranial ultrasound
CT scan
Magnetic resonance imaging
Treatment48
Medical treatment
Surgical Care
Prognosis
SUMMARY
CHAPTER 12:
Management of Meconium-stained Amniotic Fluid
INTRODUCTION
Types of Meconium (Table 12.1)
Significance of Presence of Meconium (Table 12.2)
MANAGEMENT OF MECONIUM-STAINED AMNIOTIC FLUID
At the Time of Labour
Management of Infant at Delivery
MECONIUM ASPIRATION SYNDROME
Introduction
Physiological Changes at Birth
Risk Factors for Development of MAS (Table 12.3)
Pathophysiology of MAS
Mechanical Obstruction
Chemical Inflammation
Inactivation of Surfactant
Umbilical Vessel Spasm
MANAGEMENT OF MECONIUM ASPIRATION SYNDROME
ANTENATAL THERAPIES
Introduction
Principle
Equipment
Actual Procedure
Adverse Effects
Available Evidence Regarding the use of Amnioinfusion
Contraindications (Table 12.8)
Delivery by Caesarean Section
Maternal Sedation
INTRAPARTUM / POSTPARTUM MANAGEMENT
Oropharyngeal Suctioning (Figure 12.5)
Physical Manoeuvres
POSTNATAL INTERVENTION
Endotracheal Suctioning (Fig. 12.6)
Delivery Room Management of Infants Born with Meconium-stained Liquor
Management during First Stage2
Second Stage
Postnatal Management
Evidence Regarding Intratracheal Suctioning in all Babies
ASSESSMENT OF THE NEONATE AFTER DELIVERY
Indicators of Hypoxia at the time of Delivery
Cord Blood Gas Analysis
Umbilical Cord Blood Gases
APGAR Score
SUMMARY
INDEX
TOC
Index
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