Maternal Distress 5f2w5g

Fetal Distress  Fetal distress is a condition in which the fetus (unborn baby) develops a problem during the mother’s labor.  Compromise of the fetus during the antepartum period (before labor) or intrapartum period (birth process).  The term "fetal distress" is commonly used to describe fetal hypoxia in utero (low oxygen levels in the fetus).This occurs when conditions which interfere with the supply of oxygen to the foetus are present.  It is ill defined term , used to express intrauterine fetal jeopardy, a result of intrauterine fetal hypoxia.(Dutta)  The concern with fetal hypoxia is it may result in fetal damage or death if not reversed or if the fetus is not promptly delivered.  Fetal distress can be detected due to abnormal slowing of labor, the presence of meconium (dark green fecal material from the fetus) or other abnormal substances in the amniotic fluid, or via fetal monitoring with an electronic device showing a fetal scalp pH of less than 7.2. Signs and symptoms of fetal distress include: 

Decreased movement felt by the mother

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Meconium in the amniotic fluid

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Cardiotocography signs

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increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction.

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decreased variability in the fetal heart rate

Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp prick through the open cervix in labour o

fetal acidosis

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elevated fetal blood lactate levels indicating the baby has a lactic acidosis (Lactic acidosis is a condition caused by the buildup of lactic acid in the body. It leads to acidification of the blood (acidosis), and is considered a distinct form of metabolic acidosis. Fetal Hypoxia Metabolic acidosis

H-ions first stimulate and then depress the sino-auricular node

Leading trachycardia and bradycardia

Also causes parasympathtic stimulation

Hyperparistalsis and relaxation of the anal sphincter.

age of muconium. o

Note: A normal fetal heart rate may slow or fast during a contraction but usually recovers to normal as soon as uterus relaxes.

Causes of fetal distress Fetal distress can occur during pregnancy, or more commonly during labour. Fetal Distress can be due to a wide range of reasons. The main cause of antepartum fetal distress is uteroplacental insufficiency. Factors within labour are complex but processes such as uteroplacental vascular disease, reduced uterine perfusion, fetal sepsis, reduced fetal reserves, and cord compression can be involved alone or in combination, and gestational and antepartum factors can modify the fetal response. Reduced liquor volume, maternal hypovolaemia and fetal growth restriction are known associations. Some of the more common causes include: 1. Not enough oxygen: The most common reason for fetal distress is the baby is not receiving enough oxygen when inside the uterus. This is usually because there is not an adequate blood flow through the placenta and cord. When the uterus contracts in labour, it momentarily reduces blood flow to the baby, as the uterus relaxes, the blood flow increases. This is a normal, natural process that healthy babies, with a healthy placenta, are not concerned with. In fact, it actually stimulates the baby (usually shown as an increase in their heart rate). There are some situations when the blood flow (and hence the oxygen supply), are lessened, causing the baby to become either slowly distressed over time, or suddenly distressed if the incident is severe. Some causes of fetal distress can include

Placental insufficiency. This is when the placenta is not functioning at its best and can be due to high blood pressure, heart conditions, bleeding in late pregnancy, small baby or post dates, Pre-eclampsia, eclampsia, chronic nephritis and DM.

Over stimulation of the uterus, due to being induced or augmented. A sharp drop in the mother's blood pressure due to her having an epidural, or experiencing a haemorrhage, or lying for a prolonged period flat on her back in labour. Cord compression due to an early artificial rupture of the membranes (ARM) or a cord prolapse. The blood supply may also be reduced if the umbilical cord is wrapped several times around the baby's neck or body. True knot in the umbilical cord, short umbilical cord. Twins sharing a single placenta. Known as Twin to twin transfusion. Placental abruption (or separation of the placenta from the wall of the uterus), Placenta previa. Prolonged labour, especially if the membranes have been long ruptured. Degenaration of placenta associated with post maturity. 2. Blood chemical imbalances : Sometimes chemical imbalances in the woman's blood stream can stress the baby. In most cases the women is unwell when this happens. Health conditions that can cause this are cholestasis, diabetes or kidney disease. 3. The baby is unwell : The baby may be unwell due to: An inherited disorder. An abnormality in the baby. An infection, such as group B strep. The baby being overheated due to the mother having a fever. The baby reacting unfavorably to drugs (or anesthetics) given to the woman.

Causes of fetal stress during labour 

Compression of the fetal head during contractions.

During uterine contractions compression of the fetal skull causes vagal stimulation, which slows the fetal heart rate. Head compression usually does not harm the fetus. However, with a long labour due to cephalopelvic disproportion, the fetal head may be severely compressed. This may result in fetal distress. 

Decrease in the supply of oxygen to the fetus.

UTERINE CONTRACTIONS: Uterine contractions are the commonest cause of a decrease in the oxygen supply to the fetus during labour. REDUCED BLOOD FLOW THROUGH THE PLACENTA: The placenta may fail to provide the fetus with enough oxygen and nutrition due to a decrease in the blood flow through the placenta, i.e. placental insufficiency. Patients with pre-eclampsia have poor formed spiral arteries that provide maternal blood to the placenta. This can also be caused by narrowing of the uterine blood vessels due to maternal smoking. ABRUPTIO PLACENTAE: Part or all of the placenta stops functioning because it is separated from the uterine wall by a retroplacental haemorrhage. As a result the fetus does not receive enough oxygen. CORD PROLAPSE OR COMPRESSION: This stops the transport of oxygen from the placenta to the fetus. “UTERINE CONTRACTIONS ARE THE COMMONEST CAUSE OF A DECREASED OXYGEN SUPPLY TOTHE FETUS DURING LABOUR”

HOW DOES THE FETUS RESPOND TO A LACK OF OXYGEN?

A reduction in the normal supply of oxygen to the fetus causes FETAL HYPOXIA. This is a lack of oxygen in the cells of the fetus. If the hypoxia is mild the fetus will be able to compensate and, therefore, show no response. However, severe fetal hypoxia will result in FETAL DISTRESS. Severe, prolonged hypoxia will eventually result in fetal death.

Decreased fetal oxygenation in labour Hypoxia Metabolic acidosis Asphyxia Tissue damage Fetal death

Management In many situations fetal distress will lead the obstrecion to recommend steps to urgently deliver the baby. This can be done by induction, or in more urgent cases, a caesarean section may be performed.

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Prop up the woman or place her on her left side, which helps to improve placental circulation. Lateral positioning avoids compression of venacava and aorta by the gravid uterus. This increase cardiac output and uteroplacental perfusion.

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Stop oxytocin if it is being istered.

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Correction of dehydration by IV fluids improves intravascular volume and uterine perfusion.

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Correction of maternal hypotension, following epidural analgesia, with immediate infusion of 1 litre of crystalloid (RL) Tocholytic (inj turbutaline 0.25 mg sc) is given when uterus is hyppertonus and there is non reassuring FHR. Aminio-infusion has been shown to be beneficial in this situation, with a reduced risk of Caesarean section This an initial infusion of a 250-500ml bolus of warmed normal saline, through a double lumen intrauterine pressure catheter. (Uterine pressure and fetal heart rate (via scalp electrode) are monitored constantly.) It is thought to dilute meconium and reduce the risk of meconium aspiration and reduces cord compression. The potential adverse effects include umbilical cord prolapse, uterine scar rupture and amniotic fluid embolism. Check uterine contraction for strength, duration of fregnancy.

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If a maternal cause is identified (e.g. maternal fever, drugs), initiate appropriate management.

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If a maternal cause is not identified and the fetal heart rate remains abnormal throughout at least three contractions, perform a vaginal examination to check for explanatory signs of distress: - If there is bleeding with intermittent or constant pain, suspect abruptio placentae; - If there are signs of infection (fever, foul-smelling vaginal discharge) give antibiotics as for amnionitis; - If the cord is below the presenting part or in the vagina, manage as prolapsed cord. 

If fetal heart rate abnormalities persist or there are additional signs of distress (thick meconium-stained fluid), plan delivery: In second stage of labour, if the head is in the perineum fiven episiotomy to hasten delivery or farcep delivery can be done. -

In second stage of labour, if the head is in the perineum given episiotomy to hasten delivery.

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If the cervix is fully dilated and the fetal head is not more than 1/5 above the symphysis pubis or the leading bony edge of the head is at 0 station, deliver by vacuum extraction or forceps;

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If the cervix is not fully dilated or the fetal head is more than 1/5 above the symphysis pubis or the leading bony edge of the head is above 0 station, deliver by caesarean section.

Note: Pediatrician and resuscitations set should be made available

MECONIUM 

Meconium staining of amniotic fluid is seen frequently as the fetus matures and by itself is not an indicator of fetal distress. A slight degree of meconium without fetal heart rate abnormalities is a warning of the need for vigilance.

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Thick meconium suggests age of meconium in reduced amniotic fluid and may indicate the need for expedited delivery and meconium management of the neonatal upper airway at birth to prevent meconium aspiration.

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In breech presentation, meconium is ed in labour because of compression of the fetal abdomen during delivery. This is not a sign of distress unless it occurs in early labour.

Abnormal fetal heart rate 

A normal fetal heart rate may slow during a contraction but usually recovers to normal as soon as the uterus relaxes.

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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 heart rate (e.g. tocolytic drugs), 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.

Maternal distress Maternal distress means maternal exhaustion i.e. the strain and stress of labour have proved too much for the mother. It is a condition of mental and physical exhaustion of the mother during labour usually caused by prolonged labour. Causes. 1. Prplonged labour due to a Contracted pelvis b D c Malpresentation and malposition d Rigid cervix e Rigid pelvic floor f Ineficient and incoordinated uterine action 2. Obstructed labour due to a Malpresentation, malpostion, congenital abnormalities. b Compound presentation c D, locked twins etc. 3 Insufficient uterine contraction eg hypotonic, hypertonic, incoordinate uterine action 4 Maternal bearing down from first stage Sign and symptoms 1 Increase in the pulse rate is one of the earliest sign of distress. 2 Raise in temperature 3 Increase respiration 4 Mother looks ill restless and weakness and sweating 5 Anxious look with sunken eyes 6 Sign of dehydration: dry lip, dry and coated tongue, presence of acetone in the breath and utrine 7 Abdominal distension 8 Vomiting occurring at times. 9 The above signs are indications that things have gone wrong and the mother's life is threatened. Management a Adequate rest, sedation, hydration and avoidance of prolonged labour are preventive measures aganist mental distress. b Keep confineous monitoring of feal hart rate and uterine activity. c Observe materal vital sign. d Encourage to void periodically e Provide and encourage to take planty of fluids regularly. f Provide reassurance and emotional to the mother.

g Inform to obstreforccian immediately when the sign of maternal distress are seen. h Give QV ifusion of 5-10% dentrose and R/L to correct dehydration and keto-acidosis. i Labour is terminated if the patient is exhausted and the method employed depends on the degree of cervical diltation. In the first stage of labour this will necessitate LS. - In second stage of labour, if the head is in the perineum fiven episiotomy to hasten delivery or farcep delivery can be done. If head is high, delivery by vccum extraation. j Inform and make available pediatrician during delivery. k Provide complete rest to mother offer delivery. “Pediatrician and resuscitations set should be made available”.