List of Abbreviations
ADCC – obstetric distant consultative center
WHO – World Health Organization
HIE – hypoxic-ischemic encephalopathy
DIC – disseminated intravascular coagulation
IVH – intraventricular hemorrhage
CP – cerebral palsy
FGR – fetal growth restriction
BMI – body mass index
ABG – acid-base balance
CS – cesarean section
CTG – cardiotocography
UPBF – uteroplacental blood flow
NICU – neonatal intensive care unit
ICU – intensive care unit
ultrasound – ultrasound examination
CNS – central nervous system
EA – epidural analgesia
ECG – electrocardiography
ACOG – American College of Obstetricians and Gynecologists
FIGO – International Federation of Gynecology and Obstetrics
RCOG – Royal College of Obstetricians and Gynaecologists
Terms and Definitions
Baseline rate – the mean FHR rounded to increments of 5 beats per minute during a 10-minute segment of CTG, excluding accelerations and decelerations, periods of marked FHR variability, and segments of baseline that differ by more than 25 beats per minute, expressed in bpm. The normal range is 110–160 bpm.
Tachycardia – a baseline rate above 160 bpm for a period of 10 minutes or more.
Bradycardia – a baseline rate below 110 bpm for a period of 10 minutes or more.
Variability – minor fluctuations in the FHR baseline defined as the average amplitude of the signal within a 1-minute interval.
Normal variability – within the range of 5–25 bpm.
Reduced variability – an amplitude range of less than 5 bpm for 50 minutes or more [1], or for 3 minutes or more during a deceleration [2].
Increased variability (saltatory rhythm) – an amplitude exceeding 25 bpm for a period of more than 30 minutes.
Accelerations – visually apparent abrupt increases (onset to peak in less than 30 seconds) in FHR above the baseline of 15 bpm or more, lasting for 15 seconds or more, but less than 10 minutes.
Decelerations – visually apparent decreases in FHR below the baseline of 15 bpm or more, lasting for 15 seconds or more, but less than 10 minutes.
Early decelerations – symmetrical, gradual decreases in FHR with a return to baseline associated with a uterine contraction, with normal variability.
Variable decelerations (V-shaped) – visually apparent abrupt decreases in FHR below baseline (onset to nadir in less than 30 seconds) with good variability within the deceleration, rapid return to baseline, and variable size, shape, and relationship to uterine contractions.
Late decelerations (U-shaped, with/without reduced variability) – visually apparent symmetrical gradual decreases in FHR (onset to nadir of 30 seconds or more) with a delayed onset in relation to the contraction and/or a delayed return to baseline and/or reduced variability within the deceleration. A gradual onset and return to baseline means that more than 30 seconds elapse between the onset/end of the deceleration and its nadir. A late deceleration starts more than 20 seconds after the onset of the contraction, reaches its nadir after the peak of the contraction, and returns to baseline after the contraction ends.
Prolonged decelerations – decelerations lasting for more than 3 minutes.
Sinusoidal pattern – a regular, smooth, wave-like baseline pattern resembling a sine wave, with an amplitude of 5 to 15 bpm and a frequency of 3 to 5 cycles per minute.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Hypoxia (oxygen deficiency) – a standard pathological process developing due to insufficient oxygen supply and/or utilization by cells, leading to impaired cellular function. Hypoxemia is a decrease in blood oxygen content, which can lead to tissue hypoxia. Impaired tissue respiration in hypoxia involves a shift from aerobic metabolism to the much less efficient anaerobic pathway with the release of large amounts of lactic acid. Acidosis is a shift in the body's acid-base balance toward increased acidity (decreased pH). Metabolic acidosis develops as a result of the accumulation of acidic products in tissues, their insufficient binding or clearance (ketoacidosis, lactic acidosis), and is combined with a decrease in the level (deficit) of bicarbonate and other buffer bases.
Fetal hypoxia – a condition that develops as a result of insufficient supply of oxygen and energy substrates (primarily glucose) to fetal tissues, initially accompanied by compensatory reactions. If oxygen delivery is not restored, decompensation, metabolic acidosis, functional, and subsequently irreversible cell damage occur. Severe and/or prolonged hypoxia may result in fetal death.
Fetal distress – clinical and/or laboratory/instrumental signs indicating a compromise of the normal fetal condition, most likely caused by temporary or permanent oxygen deficiency (other causes such as intoxication, hyper- or hypothermia, medication effects, etc. are also not excluded), which may lead to hypoxia. Such signs include growth restriction, alterations in fetal activity and heart rate, and meconium-stained amniotic fluid.
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Impaired fetal oxygen supply can be caused by various factors and localized in different parts of the mother-placenta-fetus system. Depending on the cause, oxygen deprivation can develop rapidly over a short period or gradually increase over weeks. The main causes of pre-placental hypoxia are conditions accompanied by a decrease in maternal blood oxygen saturation or its delivery to the placenta. These include environmental conditions (high altitude), pre-existing maternal cardiovascular diseases, or pulmonary hypertension. Anemia, infections, and chronic inflammation can also reduce oxygen consumption and its delivery to the fetus, thereby increasing the risk of adverse pregnancy outcomes [3], [4], [5], [6].
Uteroplacental hypoxia is associated with impaired placental formation in early pregnancy and angiogenesis in later stages. At the same time, local placental abnormalities are often combined with systemic ones: increased systemic vascular resistance, endothelial dysfunction, and activation of the blood coagulation system [7]. A reduced diameter of the uterine arteries decreases placental perfusion [8]. Chronic hypoxia associated with placental insufficiency plays a key role in the development of fetal growth restriction.
Post-placental hypoxia may be associated with impaired blood flow in the umbilical cord vessels (compression, rupture, thrombosis) or fetal diseases (infections, malformations, non-immune hydrops).
When oxygen deficiency develops during labor, the fetus first exhibits a decrease in blood oxygen levels (hypoxemia), to which it responds by restructuring the circulatory system (increased heart rate, redistribution of vascular tone) with preferential supply to vital organs (centralization of circulation) [9]. With continued oxygen deficit, biochemical processes in the fetus change, and metabolism shifts from the aerobic pathway to anaerobic glycolysis [10]. Centralization of circulation leads to enhanced blood supply to the brain and heart, but hypoxia and acidosis develop in other organs and tissues due to oxygen deficit, which is reflected by changes in acid-base balance parameters. Progression of the pathological process is accompanied by a drop in heart rate and blood flow velocity in the microvasculature, blood stasis, and deepening gas exchange disorders. This leads to tissue edema, hemorrhages, and brain oxygen deprivation [11]. Sphincter function is impaired, and meconium is released into the amniotic fluid. During spasmodic intrauterine breathing movements with an open glottis, meconium-stained amniotic fluid is aspirated, causing airway obstruction, inflammatory changes, and surfactant inactivation [12].
At the next stage, progressive brain hypoxia is joined by impaired cardiac rhythm regulation and hypoxic dysfunction of cardiomyocytes, culminating in a drop and arrest of cardiac activity.
1.3 Epidemiology of the Disease or Condition
Fetal hypoxia occurs in 10% of all pregnancies and is the cause of perinatal loss in 40% of cases [13], [14]. Fetal hypoxia is the most frequent cause of stillbirth, hypoxic-ischemic encephalopathy, cerebral palsy, and neonatal mortality [15].
1.4 Features of Coding the Disease or Condition
O36.3 – Signs of intrauterine hypoxia requiring care of mother
O36.8 – Other specified fetal problems requiring care of mother
O36.9 – Fetal problem, unspecified, requiring care of mother
O68.0 – Labor and delivery complicated by fetal heart rate anomaly
O68.1 – Labor and delivery complicated by meconium in amniotic fluid
O68.2 – Labor and delivery complicated by fetal heart rate anomaly with meconium in amniotic fluid
O68.3 – Labor and delivery complicated by biochemical evidence of fetal stress
O68.8 – Labor and delivery complicated by other evidence of fetal stress
O68.9 – Labor and delivery complicated by fetal stress, unspecified
O69.0 – Labor and delivery complicated by cord prolapse
O69.1 Labor and delivery complicated by umbilical cord entanglement around neck, with compression
O69.2 Labor and delivery complicated by umbilical cord entanglement
O69.3 Labor and delivery complicated by short umbilical cord
O69.4 Labor and delivery complicated by vasa praevia
O69.5 Labor and delivery complicated by vascular damage of umbilical cord
O69.8 Labor and delivery complicated by other umbilical cord complications
O69.9 Labor and delivery complicated by unspecified umbilical cord complication
P20.0 Intrauterine hypoxia first noted before onset of labor
P20.1 Intrauterine hypoxia first noted during labor and delivery
P20.9 Intrauterine hypoxia, unspecified
1.5 Classification of the disease or condition
Depending on the duration of exposure, fetal hypoxia is classified into acute, subacute, and chronic. According to the time of onset, it is divided into antenatal and intranatal. Depending on the underlying cause [16]:
- hemic (in congenital or hereditary defects of hemoglobin oxygen-binding or fetal anemia);
- hypoxic (in decreased fetal blood oxygenation);
- circulatory (occurring due to impaired oxygen transport to fetal tissues and organs);
- tissue (in impaired oxygen utilization by body tissues).
Depending on the level of origin, J. Kingdom and P. Kaufman (1997) classified hypoxia into:
1) postplacental hypoxia – develops due to impaired uteroplacental blood flow in uterine rupture, mechanical compression of umbilical cord vessels, or thrombosis of its arteries) [17], [18].
2) uteroplacental – occurs due to impaired placental implantation and changes in spiral arteries, resulting in decreased blood flow into the intervillous space [19].
3) preplacental (maternal) in the presence of maternal disorders that impair oxygen delivery [20],[21].
1.6 Clinical presentation of the disease or condition
There are no specific clinical symptoms characteristic of fetal compromise caused by hypoxia. Fetal compromise can be suspected if the pregnant woman notes a change in fetal movements (weakening, decreased number of movement episodes, or their absence); with a marked discrepancy between the abdominal (uterine) size and gestational age, which may indicate fetal growth restriction; upon the passage of meconium-stained amniotic fluid [22], [23],[24]. Diagnosis of hypoxic fetal conditions relies mainly on laboratory and instrumental methods.
2. Diagnostics, medical indications and contraindications for diagnostic methods
2.1 Complaints and Anamnesis
It is recommended to take medical history and complaints, and determine gestational age in accordance with the clinical guidelines "Normal pregnancy" [25] and "Normal labor and delivery" [26] to identify deviations from the normal course of pregnancy and childbirth.
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
It is recommended that all pregnant women after 26 weeks of gestation daily evaluate the nature of fetal movements based on subjective sensations to monitor fetal condition [27, 28].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: The pregnant woman should be informed that the nature of fetal movements and their maternal perception are individual. There is no evidence that any fetal movement counting test to identify fetuses at risk of adverse outcome is more effective than the woman's qualitative perception of movement patterns.
It is recommended that all pregnant women with a subjective change in fetal movements (absence, weakening, or reduction in motor activity) perform a fetal movement counting test [27, 28]. Recommendation strength C (evidence level - 5).
Comment: To perform the fetal movement counting test, the pregnant woman should assume a left lateral position and focus on counting movements for 2 hours.
It is recommended that pregnant women with risk factors for adverse perinatal outcomes perform a daily fetal movement counting test in the 3rd trimester of pregnancy [27, 28]. Recommendation strength C (evidence level - 5).
Comment: Risk factors for adverse perinatal outcomes are presented in Appendix G3. The movement test should be performed once daily, preferably at the same time.
It is recommended that all pregnant women, in the absence of 6 distinct individual fetal movements within a 2-hour movement counting test, immediately contact an obstetric inpatient facility to assess fetal condition [27, 28].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
It is recommended that when a pregnant woman contacts an obstetric inpatient facility with complaints of the absence of 6 distinct individual fetal movements within 2 hours in the 3rd trimester of pregnancy, a medical history review, clinical examination, fetal cardiotocography, fetal ultrasound, ultrasound Doppler of uteroplacental blood flow, and ultrasound Doppler of fetoplacental blood flow (as indicated: suspected fetal growth restriction, polyhydramnios, oligohydramnios, premature placental abruption, etc.) be performed to assess fetal condition [27, 28].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: Indications for hospitalization are determined based on examination results. If the pregnant woman's condition is satisfactory and fetal cardiotocography data are normal, the patient may continue outpatient monitoring with daily fetal movement counting tests and scheduled cardiotocography (interval determined based on risk group)
2.2 Physical Examination
It is recommended to determine abdominal circumference, measure uterine size, and perform fetal auscultation and palpation at every visit of a pregnant patient after 20 weeks of gestation and upon admission for delivery to detect complications caused by fetal hypoxia [29], [30], [31],[32],[33],[34],[35].
Leveled position 5Level of recommendation evidence C (level of data reliability - 5).
Comment: Assessment of fundal height, abdominal circumference, fetal heart rate, position, and presentation is necessary to determine management tactics as it allows estimating fetal weight, and suspecting intrauterine fetal demise or growth restriction.
It is recommended to perform a physical examination during labor in accordance with the "Normal labor and delivery" recommendations to diagnose complications that may lead to fetal hypoxia [26].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: decreased or elevated blood pressure, maternal hyperthermia, excessively high contraction frequency or uterine hypertonus, and profuse vaginal bleeding are signs indicating a high probability of fetal hypoxia due to complicated labor. In this situation, uncorrectable causes (premature placental abruption, uterine rupture, umbilical cord prolapse, etc.) must be ruled out first.
It is recommended to perform a physical examination during labor in accordance with the "Normal labor and delivery" recommendations upon the appearance of signs that may be caused by fetal hypoxia to clarify the diagnosis and determine management tactics [26].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comments: fetal heart rate abnormalities and meconium staining of amniotic fluid indicate a high probability of fetal hypoxia. Determining the position of the fetal presenting part and the degree of cervical dilation is necessary to clarify the obstetric situation and decide on the need for further examination, mode, and timing of delivery.
2.3 Laboratory Diagnostics
It is recommended, if necessary to clarify fetal condition during labor when cardiotocography data are insufficient for decision-making, to use fetal scalp blood lactate test results [36],[22],[37],[38]
GCR ALeE 1Grade of Recommendation A (Level of Evidence - 1).
Comment: Cardiotocography is not strictly specific; cardiotocogram recording results are influenced by confounding factors such as the thickness of the subcutaneous fat layer on the mother's abdomen, her physical activity, fetal position features, anesthesia, and others. Furthermore, the interpretation of cardiotocography results carries elements of subjectivity due to the limitations of visual assessment methods. Therefore, in the absence of obvious clinical factors determining indications for emergency delivery in a suspicious type or initial, non-progressive manifestations of a pathological CTG type, after implementing first-line measures and in the absence of improved parameters, a scalp blood lactate test [38] may be used to clarify fetal condition and select further management tactics (Appendix G4).
Assessment of fetal scalp blood status reduces the rate of operative delivery compared to the group where only CTG recording is used [1,2], [39], [37], [84].
It is recommended, if necessary to clarify fetal condition during labor when cardiotocography data are insufficient for decision-making and methods for assessing fetal metabolic status are unavailable, to use fetal scalp stimulation [40], [41]
Gar CLoE 1Grade of Recommendation C (Level of Evidence - 1).
Comment: Technique: The physician stimulates the fetal head during a vaginal examination. Stimulation should be performed when the fetal heart rate is at the baseline level (i.e., outside of a deceleration). An acceleration induced by fetal scalp stimulation (an increase in FHR by ≥ 10 bpm relative to the baseline rhythm lasting ≥ 10 seconds at < 32 weeks of gestation, or an increase in FHR by ≥ 15 bpm lasting ≥ 15 seconds at ≥ 32 weeks of gestation) indicates a low probability of fetal acidosis. When acceleration is obtained under these conditions, fetal pH is > 7.20 in 90% of observations, and when acceleration is not obtained, fetal pH is < 7.20 in 50% of observations [40], [41].
It is recommended in case of intrapartum fetal distress and/or an Apgar score of < 7 at 5 minutes after birth (Appendix G) to perform an assessment of acid-base status and blood gases from the umbilical artery and vein to diagnose hypoxia and objectively assess the newborn's condition [42, 43], [44], [45], [46].
LeveL of Recommendation AGrade of Evidence 2LeveL of Recommendation A (Grade of Evidence - 2).
Comment: Values of pH, base deficit, and lactate levels in umbilical artery blood in healthy newborns can vary within relatively wide ranges (Appendix A3). A normal umbilical cord blood pH indicates no correlation between the labor process and hypoxic brain injury. Detection of deviations from normal values of pH, base deficit, and lactate concentration in umbilical cord blood after birth has prognostic significance for metabolic disorders, transient tachypnea, and HIE [47–52]. The accuracy of determining acid-base balance parameters depends on staff preparedness, compliance with sampling conditions, and analysis performance (Appendix A3).
It is recommended, for the purpose of predicting the risk of neurological pathology due to hypoxia in the newborn based on umbilical artery acid-base status data, to use pH < 7.00 and base deficit (BE) ≥ 12 mmol/L values [45], [42].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: The Consensus of the International Cerebral Palsy Task Force in 1999 defined the criteria for metabolic acidosis based on umbilical artery blood gas analysis immediately after birth, which are significant for the subsequent development of neurological pathology. These criteria are currently adopted into practice by the majority of national medical communities: pH < 7.00 and base deficit (BE) ≥ 12 mmol/L [53–55].
2.4 Instrumental Diagnostics
It is recommended for uncomplicated pregnancies to refer the patient for fetal cardiotocography starting from 33 weeks of gestation with a frequency of once every two weeks [25]
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
It is recommended for pregnant women in the high-risk group to determine the necessity and frequency of fetal cardiotocography in accordance with the existing risk factors [27],[56],[57],[58].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: performing additional cardiotocographic examinations in pregnant women is indicated in the presence of both maternal and fetal risk factors. A list of the most common risk factors is presented in the appendix (Appendix A3). The frequency and rate of fetal cardiotocography in this case should be determined based on individual clinical data (anamnesis, gestational age, comorbid conditions, results of other diagnostic tests, such as Doppler ultrasonography), taking into account relevant clinical guidelines (multiple pregnancy, fetal hemolytic disease, fetal growth restriction, hypertensive disorders during pregnancy, and others) [1], [3], [4] [5] [6] [7], [8] ,[9],[10],[11] ,[12],[13], [14] ,[2], [59].
It is recommended, when fetal cardiac arrhythmia is suspected based on intermittent auscultation data, to switch to continuous fetal cardiotocography for at least 20 minutes to rule out fetal distress [59]
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: the laboring woman should be explained the purpose of switching to cardiotocography. If a normal trace type is recorded during 20 minutes of fetal cardiotocography, intermittent auscultation may be resumed, unless the laboring woman insists on continuing continuous cardiotocography [59].
Continuous fetal cardiotocography is recommended for laboring women in situations where there is a high risk of developing intrapartum hypoxia [59], [60], [61], [84].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
Comment: continuous fetal cardiotocographic monitoring during labor is indicated in the presence of both maternal and fetal risk factors [59], [60], [62], [63], [2], [61], [64], [65], [66], [67]. A list of the most frequent risk factors is presented in the appendix (Appendix A3).
It is recommended to follow the technical requirements for performing fetal cardiotocography to ensure correct cardiotocogram recording [67].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: to prevent inferior vena cava compression syndrome during cardiotocogram recording, the optimal positions for the patient are lateral (side-lying), semi-recumbent, and sitting. To ensure standardization and eliminate errors in visual assessment of cardiotocograms, the recommended recording speed is 1 cm/min. In addition, this speed provides a 2–3 fold saving in consumables. Before starting the cardiotocogram recording, it is necessary to check the date and time settings and enter the patient data; the last name, initials, and gestational age are mandatory. To correctly interpret the recording results, always use both transducers: for fetal heart rate (FHR) and uterine contractile activity. The fetal heart rate transducer must be placed at the point of clearest fixation while simultaneously checking the maternal pulse to rule out erroneous recording of the maternal heart rate. When performing CTG in a pregnant woman with a twin pregnancy, duplicate recording of the same fetus must be excluded. After starting the recording, its quality and character should be assessed within 5 minutes, and thereafter every 15 minutes. During the recording, events related to the mother's condition (pain relief, vaginal examination, position change, medication treatment, etc.) are marked on the paper strip. The strip with the recorded cardiotocogram is part of the medical history (chart) and must be stored under conditions that exclude exposure to light (degradation of thermal paper) [67].
It is recommended for all pregnant and laboring women to analyze CTG according to a standard algorithm to eliminate subjectivity in evaluating CTG results [60], [62].
LoR CGoE 4Level of Recommendation C (Grade of Evidence - 4).
Comment: CTG is used to identify signs of developing hypoxia in order to prevent acidemia and fetal cell damage. The CTG method has a relatively low specificity in predicting fetal labor outcomes. A limiting factor is the subjectivity of cardiotocogram assessment by the investigator, leading to discrepancies in conclusions between different specialists, varying levels of baseline compensatory reserves in fetuses, and the influence of a large number of difficult-to-account-for factors (uterine activity, duration of labor, degree of cord compression, effect of medications, etc.). To reduce subjectivity in evaluating CTG results, it should be performed according to an algorithm based on standard criteria: baseline rate, variability, accelerations, decelerations, and uterine activity (see terms and definitions). Given that visual assessment of the cardiotocogram is based on pattern recognition, a uniform amplitude and paper speed scale must be used to standardize the assessment by different specialists. In a typical situation, it is appropriate to use the scale adopted in European countries of 60–200 bpm at a speed of 1 cm/min. These parameters should be calibrated in the cardiotocograph settings.
It is recommended to always determine the type of cardiotocographic trace and its duration to predict the fetal condition and develop management tactics [68], [69], [70], [71].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: evaluation of the cardiotocographic trace should be carried out to determine its conformity to one of three types: normal, suspicious, pathological. Given the considerable heterogeneity and contradictions of existing CTG classifications, in 2013–2015 an international group of researchers under the auspices of FIGO developed the FIGO (2015) classification (Appendix A3), which relies on the analysis of fairly well-defined parameters; it reduces the number of evaluated parameters and tightens the criteria for a pathological CTG, which helps reduce the rate of false-positive diagnoses of fetal distress in labor. For the correct interpretation of signs such as reduced variability, tachycardia and bradycardia, repeated decelerations, and prolonged deceleration, it is necessary to take into account the relevant time intervals [68], [69], [70], [72], [73].
It is recommended in cases of maternal obesity or other factors preventing normal recording of the Doppler cardiotocographic signal during labor, to exclude artifacts and provided technical capability is available, to use the electrocardiographic method of CTG registration [74], [75], [76].
Strength of Recommendation = BEvidence Level = 1Strength of recommendation B (level of evidence - 1).
Comment: Cardiotocography using the electrocardiographic signal acquisition method can be performed using both external and internal sensors (scalp electrodes) [77], [78], [79]. Contraindications to the use of internal sensors include chorioamnionitis, human immunodeficiency virus infection, active genital herpes or hepatitis (B, C, D, E), as well as gestational age under 32 weeks, suspected fetal coagulopathy, and the inability to perform amniotomy.
Compared to fetal cardiotocography using Doppler fetal heart rate monitoring, direct fetal electrocardiography with automated ST-segment analysis (STAN) reduces the rate of operative vaginal delivery, helps decrease the need for fetal scalp blood pH and/or lactate determination, low Apgar scores, and neonatal metabolic acidosis, but does not affect the cesarean section rate [80], [81], [82]. It should be noted that the STAN analyzer software is not applicable in breech presentation, cardiac anomalies, and baseline fetal hypoxia.
2.5 Other Procedures
No
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
It is recommended that upon detecting a suspicious or pathological cardiotocogram type, diagnostic and therapeutic measures be initiated according to the algorithm [68], [83].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: The management algorithm for a suspicious or pathological type involves, at the first stage, assessing the clinical situation (calling for assistance in case of a pathological type) and taking measures to restore heart rate (Appendix B). The patient's complaints, general condition, body temperature, pulse, blood pressure, uterine tone, frequency, strength, and duration of uterine contractions, nature of vaginal discharge and amniotic fluid, cervical dilation, station and position of the fetal presenting part should be assessed, and umbilical cord prolapse should be ruled out. If an uncorrectable cause of fetal heart rate abnormalities is identified (uterine rupture, umbilical cord prolapse, placental abruption, etc.), or in the event of critical heart rate disturbance (bradyarrhythmia progressing for 5–10 min) or lack of response to resuscitative measures with an overtly pathological type (usually within 15–20 minutes), emergency delivery is indicated. In the case of a pathological type, heart rate restoration measures should be performed simultaneously with preparation for emergency delivery to prevent delay if resuscitation measures fail [84].
In the case of a suspicious type, the indication for delivery is the absence of a response to resuscitative measures and clear progression to a pathological CTG type in the absence of conditions for rapid spontaneous vaginal delivery. It should be noted that any deviation of the cardiotocogram from normal requires a consultative evaluation by the attending physician: immediately in the case of a pathological type, and upon failure of resuscitation measures in the case of a suspicious type. Furthermore, in the event of a suspicious or pathological cardiotocogram, the identified changes and management strategy should be discussed with the patient [66], [63], [65].
If necessary to objectify decision-making regarding management for a suspicious or pathological CTG, the results of the fetal scalp blood lactate test should be used (see the laboratory diagnostic studies section and Appendix A3).
To restore fetal heart rate, it is recommended to discontinue uterotonic agents (H01BB Oxytocin and its analogues, G02AD02 Dinoprostone vaginal delivery system), use positional therapy, and ensure rehydration via rapid infusion of an intravenous solution [64], [79].
GCP CLEL 5Level of Evidence C (Level of Likelihood of Evidence - 5).
Comment: Measures to restore heart rate include discontinuing oxytocin** infusion or removing the dinoprostone vaginal delivery system (in the presence of persistent tachysystole, short-term tocolysis should be performed: 2 ml (10 mcg) hexoprenaline** + 10 ml of 0.9% sodium chloride** solution intravenously slowly over 5 minutes); positional therapy (changing the parturient's position to eliminate umbilical cord compression or aortocaval compression); normalizing the patient's condition (depending on the clinical situation); rapid intravenous infusion of 500–1000 ml of solution for rehydration (dextrose**, complex sodium chloride solution [Potassium chloride + Calcium chloride + Sodium chloride]**, complex sodium lactate solution [Potassium chloride + Calcium chloride + Sodium chloride + Sodium lactate]**, sodium chloride**, infusion solution [Potassium chloride + Calcium chloride + Magnesium chloride + Sodium acetate + Sodium chloride + Malic acid]**, and other electrolytes [ATC code B05BB - Solutions affecting the electrolyte balance] with a similar effect may also be used); in the second stage of labor, temporarily suspending pushing efforts may be beneficial to restore fetal oxygenation [64], [83].
4. Medical Rehabilitation and Sanatorium-Resort Treatment
Not applicable
5. Prevention and Dispensary Observation
Not applicable
6. Organization of Medical Care
When a suspicious CTG type is detected antenatally, the diagnosis is clarified through re-analysis and consultation with the head of the department at the obstetric medical organization where the patient is observed. If necessary, the patient should be consulted at the regional perinatal center (Level III obstetric medical organization). When a pathological CTG type is detected antenatally, the patient is immediately referred for hospitalization to a Level II or III obstetric inpatient facility based on routing schemes approved by regional healthcare management authorities.
When fetal distress is detected during labor, medical care is provided in the inpatient facility where the patient is located at the time of diagnosis. If necessary, a teleconsultation with the regional perinatal center (Level III obstetric medical organization) is available.
7. Additional Information
No
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Yes | Absent |
|---|---|---|---|
1 | Anamnesis and physical examination were performed to assess risk factors for intrapartum fetal distress. | ||
2 | Cardiotocographic examination was performed starting at 33 weeks of gestation with a frequency of once every two weeks in uncomplicated pregnancies. | ||
3 | Continuous fetal cardiotocography was performed during labor in cases of high risk for intrapartum hypoxia. | ||
4 | In case of suspected fetal heart rate abnormalities based on intermittent auscultation, continuous fetal cardiotocography was performed for at least 20 minutes. | ||
5 | In the event of a suspicious or pathological cardiotocogram, diagnostic and therapeutic measures were performed according to the algorithm. |
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Appendix A1. Working Group Composition
Baev, Oleg Radomirovich – MD, Professor, Honored Doctor of the Russian Federation, Head of the Maternity Ward, Head of the Department of Innovative Technologies, Head of the Department of Obstetrics and Gynecology at the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Russian Ministry of Health (Moscow). No conflict of interest.
2. Natalia V. Dolgushina – MD, DSc, Professor, Deputy Director – Head of the Department of Scientific Activity Organization, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Chief freelance specialist in women's reproductive health of the Ministry of Health of the Russian Federation (Moscow). No conflict of interest.
3. Roman G. Shmakov - MD, DSc, Professor of the RAS, Director of the Institute of Obstetrics, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia, Chief freelance specialist in obstetrics of the Ministry of Health of the Russian Federation (Moscow). No conflict of interest.
4. Natalia V. Artymuk - MD, DSc, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakova, Kemerovo State Medical University of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Siberian Federal District (Kemerovo). No conflict of interest.
5. Nadezhda V. Bashmakova – MD, DSc, Professor, Chief Researcher, Ural Research Institute of Mother and Infant Care of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Ural Federal District (Ekaterinburg). No conflict of interest.
6. Vitaly F. Bezhenar - MD, DSc, Professor, Head of the Clinic of Obstetrics and Gynecology, Head of the Department of Obstetrics, Gynecology and Neonatology, Head of the Department of Obstetrics, Gynecology and Reproductology, Academician I.P. Pavlov First Saint Petersburg State Medical University of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the North-Western Federal District (Saint Petersburg). No conflict of interest.
7. Tatiana E. Belokrinitskaya – MD, DSc, Professor, Honored Doctor of the RF, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining, Chita State Medical Academy of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Far Eastern Federal District (Chita). No conflict of interest.
8. Kirill A. Desyatnik – Obstetrician-gynecologist, Organizational and Methodological Department, Sverdlovsk Regional Clinical Perinatal Center. No conflict of interest.
9. Vladislav I. Krasnopolsky - Academician of the RAS, MD, DSc, Professor, President, Moscow Regional Research Institute of Obstetrics and Gynecology (Moscow). No conflict of interest.
10. Victoria A. Krutova – MD, DSc, Professor, Chief Physician of the Clinic, Vice-Rector for Clinical Work, Kuban State Medical University of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Southern Federal District (Krasnodar). No conflict of interest.
11. Anna I. Malyshkina – MD, DSc, Professor, Director, V.N. Gorodkov Ivanovo Research Institute of Motherhood and Childhood of the Ministry of Health of Russia, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Central Federal District (Ivanovo). No conflict of interest.
12. Sergey V. Martirosyan – PhD, Chief Physician, Sverdlovsk Regional Clinical Perinatal Center, Associate Professor, Department of Obstetrics and Gynecology, Faculty of Medicine and Preventive Care, Ural State Medical University (Ekaterinburg). No conflict of interest.
13. Anton V. Mikhailov – MD, DSc, Professor, Honored Doctor of the RF, Chief freelance specialist in obstetrics and gynecology of the Healthcare Committee of Saint Petersburg, Chief Physician of Saint Petersburg State Budgetary Healthcare Institution "Maternity Hospital No. ***". No conflict of interest.
14. Anna A. Olina – MD, DSc, Professor, Deputy Director, D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology. No conflict of interest. of obstetrical care of the Ministry of Health of the Russian Federation.
15. Olga V. Perevozkina – PhD, Head of the Organizational and Methodological Department, Sverdlovsk Regional Clinical Perinatal Center. No conflict of interest.
16. Vasily A. Petruhin - MD, DSc, Professor, Honored Doctor of the RF, Director, Moscow Regional Research Institute of Obstetrics and Gynecology (Moscow). No conflict of interest.
17. Andrey M. Prikhodko – PhD,, Physician of the 1st Maternity Ward, Assistant Professor, Department of Obstetrics and Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia (Moscow). No conflict of interest.
18. Viktor E. Radzinsky - Corresponding Member of the RAS, MD, DSc, Professor, Head of the Department of Obstetrics and Gynecology with a Course in Perinatology, Peoples' Friendship University of Russia (Moscow). No conflict of interest.
19. Galina M. Savelieva – Academician of the RAS, MD, DSc, Professor, Honored Scientist, Head of the Department of Obstetrics and Gynecology, Pediatric Faculty, N.I. Pirogov Russian National Research Medical University (Moscow). No conflict of interest.
20. Vladimir N. Serov - Academician of the RAS, MD, DSc, Professor, Honored Scientist of the RF, President of the Russian Society of Obstetricians and Gynecologists, Chief Researcher, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia (Moscow). No conflict of interest.
21. Ildar F. Fatkullin – MD, DSc, Professor, Head of the Department of Obstetrics and Gynecology named after Prof. V.S. Gruzdev, Kazan State Medical University, Chief freelance specialist in obstetrics and gynecology of the Ministry of Health of Russia in the Privolzhsky Federal District (Kazan). No conflict of interest.
22. Oleg S. Filippov – MD, DSc, Professor, Honored Doctor of the RF, Professor of the Department of Obstetrics and Gynecology, Faculty of Advanced Training for Physicians, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia (Moscow). No conflict of interest.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. obstetrician-gynecologists
2. obstetrics and gynecology residents
3. midwives
Table 1. Level of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Level of Evidence (LoE) grading scale for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definitions |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Grade of Recommendation (GoR) scale for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Appendix A3. Reference Materials
· Compendium by the Central Research Institute for Health Organization and Informatics of the Ministry of Health of the RF "Key indicators of maternal and child health, activities of child healthcare and obstetrical services in the Russian Federation", Moscow 2019.
· Order of the Ministry of Health of the RF No. 1130n dated October 20, 2020 "On approval of the Procedure for providing medical care in the field of 'obstetrics and gynecology'".
· ACOG. Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles Replaces Practice Bulletin Number 70, December 2005. Reaffirmed 2017
· ACOG Committee Opinion No. 382: Fetal Monitoring Prior to Scheduled Cesarean Delivery. Committee on Obstetric Practice.
· Guidelines for Perinatal Care. 8th Edition. ACOG&AAP, 2017.
· WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018. Licence: CC BY-NC-SA 3.0 IGO.
· Antenatal Care. Routine care for the Healthy Pregnant Woman. NICE&NCCWCH, RCOG Press 2008
· FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography Diogo Ayres-de-Campos, Catherine Y. Spong, Edwin Chandraharan, for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 2015.
Classification of cardiotocography traces (FIGO, 2015)
· Normal type (fetus without hypoxia/acidosis): CTG is characterized by a baseline heart rate of 110–130 bpm, variability of 5–25 bpm, and the absence of repetitive decelerations.
· Suspicious type (low probability of hypoxia/acidosis): characterized by the absence of at least one characteristic of a normal curve type, but also the absence of pathological ones.
· Pathological type (high probability of hypoxia/acidosis): characterized by a baseline heart rate <100 bpm; decreased variability >50 min or increased variability >30 min or sinusoidal rhythm >30 min; repetitive late or prolonged decelerations >30 min or >20 min if variability is reduced; or the presence of one prolonged deceleration >5 min.
The presence of accelerations indicates the absence of hypoxia and acidosis in the fetus. The absence of accelerations in labor has no definitive diagnostic value.
Decelerations are considered repetitive when they are associated with more than 50% of uterine contractions.
Cardiotocographic curves should be interpreted in conjunction with the clinical assessment of factors such as gestational age, maternal position, maternal hemodynamic parameters, body temperature, features of pregnancy and labor course, administered medical therapy, etc.
A difficult-to-interpret CTG requires a consultative assessment by the attending physician in charge.
Determination of umbilical cord blood acid-base status.
Indications for umbilical cord blood sampling for acid-base status (ABS) determination [51], [85].
· Pathological CTG type in labor
· Meconium-stained amniotic fluid
· Chorioamnionitis or intrapartum pyrexia
· Emergency operative delivery
· Fetal growth restriction (FGR)
· Apgar score at 5 minutes of less than 7 points
· Other conditions presenting an increased risk of hypoxia in the fetus and newborn (multiple pregnancy, breech presentation, rupture of membranes exceeding 48 hours, etc.)
Umbilical cord blood sampling for ABS determination:
· After the birth of the child, apply two clamps closer to the child, isolating a 10–20 cm segment of the umbilical cord between them
· To avoid errors, draw blood into heparinized syringes (tubes) separately from the umbilical artery and vein
· Place the sample specimens on ice and deliver them to the laboratory
· Analyze the samples as soon as possible. If immediate analysis is impossible, the maximum allowable period for maintaining the suitability of the umbilical cord segment and blood for testing is 60 minutes.
Cord blood gas and acid-base balance parameters in healthy newborns [86]
pH | BE | lac | |
5th percentile | 7,12 | 2,2 | 2,5 |
25th percentile | 7,22 | 5,3 | 4 |
Median | 7,29 | 7,1 | 5,1 |
75th percentile | 7,32 | 9,2 | 6,6 |
95th percentile | 7,41 | 12,4 | 8,5 |
Mean value | 7,28 | 7,4 | 5,4 |
Risk factors determining the indications for additional antenatal cardiotocography (CTG) monitoring procedures* or continuous intrapartum CTG [59, 67, 87–93].
Risk factors | Pregnancy | Labor and delivery |
Maternal | ||
Uterine scar due to previous cesarean section or other surgery | + | |
Preeclampsia, hypertension | + | + |
Suspected chorioamnionitis or sepsis, or hyperthermia of 37.8 °C or higher | + | |
Maternal tachycardia above 110 bpm | + | |
PROM (premature rupture of membranes) > 12–24 hours | + | |
Labor induction | + | |
Labor dystocia (prolonged first and/or second stage of labor) | + | |
Oxytocin labor augmentation | + | |
Tachysystole (more than 5 contractions per 10 min) or uterine hypertonus (contraction duration of 2 min or more) | + | |
Before and during epidural/spinal analgesia | + | |
Antenatal and intrapartum hemorrhage | + | + |
Diabetes mellitus, gestational diabetes mellitus | + | + |
Intrahepatic cholestasis | + | + |
Other somatic diseases associated with the risk of reduced oxygenation during labor (e.g., congenital heart disease, chronic obstructive pulmonary disease, etc.) | + | |
Obesity (BMI > 30) | + | |
Unfavorable obstetric history (stillbirth, miscarriage, birth injury, etc.) | + | + |
Treatment with low molecular weight heparins due to complicated history or thrombophilia | + | + |
Ketonuria 3+ | + | |
Patient's request | + | |
Pregnancy resulting from ART | + | + |
Cord presentation/prolapse | + | |
Drug or alcohol intoxication | + | |
Operative vaginal delivery (vacuum-assisted fetal delivery) | + | |
Fetal | ||
Gestational age < 37 weeks and > 41 weeks | >40 weeks | + |
Fetal malpresentation (transverse, oblique, breech) | + | |
hCG > 2 MoM according to screening results | + | + |
Umbilical cord loop presentation | + | + |
Multiple pregnancy | + | + |
Fetal growth restriction or macrosomia | + | + |
Oligohydramnios or polyhydramnios | + | + |
Suspicious and pathological antenatal CTG findings | + | + |
Impaired blood flow according to Doppler studies, including decreased cerebroplacental ratio | + | + |
Fetal hemolytic disease | + | + |
Decreased fetal movements** | + | + |
Meconium-stained amniotic fluid | + | |
Blood-tinged amniotic fluid | + | |
Congenital fetal anomalies | + | + |
Fetal heart rate < 110 or > 160 bpm by auscultation | + | + |
Recurrent accelerations (immediately following a contraction) | + | |
Decelerations detected by auscultation | + | + |
Changes in baseline fetal heart rate by more than 10% on auscultation | + |
*- in the antenatal period, the need for and frequency of additional CTG monitoring procedures are determined according to individual clinical data (history, gestational age, concomitant pathology, results of other diagnostic tests, such as Doppler studies) taking into account relevant clinical guidelines (multiple pregnancy, hemolytic disease of the fetus, fetal growth restriction, hypertensive disorders during pregnancy, and others).
**- two or more episodes of decreased fetal movements during the third trimester of pregnancy and/or decreased fetal movements during the last 24 hours (reported by the pregnant woman)
Fetal scalp blood lactate test
The indication for fetal scalp blood lactate testing is the need to clarify the fetal condition, predict labor outcome, and determine management tactics when cardiotocography data are insufficient for objective decision-making:
· Pathological CTG tracing in the absence of an obvious need for immediate delivery and clinical data indicating a high probability of vaginal delivery
· Suspicious CTG tracing when it persists for a long time (more than 60–120 minutes) and/or is difficult to interpret (inability to confidently rule out a pathological tracing), as well as to decide on the possibility of labor induction or labor analgesia.
Fetal Scalp Blood Lactate Testing Technique
Preparation of the lactometer (Accutrend Plus portable biochemical analyzer), checking the calibration of the device and test strips.
Scalp lactate testing is performed under aseptic conditions. The procedure requires cervical dilation of at least 3–4 cm. After inserting the large amnioscope, the fetal head should be dried with a swab to prevent contamination with amniotic fluid or maternal blood. If necessary, fetal hair can be brushed aside using a swab with sterile liquid petrolatum. Make a small skin incision (up to 5 mm) and collect the resulting drop of blood into a heparinized capillary. Filling the capillary to 5 mm is sufficient. Apply the drop of blood to a non-absorbent surface.
Insert the test strip into the lactometer and turn on the device. Ensure contact between the absorbent part of the test strip and the drop of blood. Read and record the result.
The scalp lactate test result should be interpreted in accordance with the reference values for the specific lactometer used. It should be taken into account that when lactate concentration is determined by various portable devices, the obtained results differ in absolute values [94], [95], [96].
If acidosis is detected according to the scalp lactate test, immediate delivery is the preferred management. If blood lactate values in the fetal presenting part are normal, labor may be continued with monitoring. If indicated, the scalp lactate test may be repeated in 20–40 minutes or later. If intermediate lactate levels are identified, the management is determined individually taking into account the clinical situation.
Appendix B. Physician Action Algorithms
Diagnostic and management algorithm for intrapartum fetal distress
Appendix C. Patient Information
Assessing the condition of the fetus in utero is difficult because the fetus cannot report complaints, and routine diagnostic measures such as assessing skin color, counting the pulse, measuring blood pressure, and others cannot be used. Therefore, various instrumental methods are used.
What is antenatal fetal heart rate monitoring (CTG)?
Antenatal (before the onset of labor) fetal heart rate monitoring makes it possible to assess the condition of the fetus by documenting the nature of heart rate changes. This is done using a cardiotocograph (a device) that produces a cardiotocogram (a paper strip showing the fetal heart rate and uterine contractions). Antenatal fetal heart rate monitoring is currently considered one of the best ways to assess fetal well-being. Fetal heart rate monitoring has the advantage that it can be performed relatively quickly and yields immediate results.
The baseline fetal heart rate ranges from 110 to 160 beats per minute. In this case, minute-to-minute fluctuations normally range from 5 to 25 beats per minute. The fetal heart rate may change as the fetus responds to the condition of the uterus. An abnormal fetal heart rate may indicate that the fetus is not receiving enough oxygen or that other problems are present.
Is fetal heart rate monitoring harmful to the baby and the pregnant woman?
CTG monitoring is an absolutely safe procedure for both the fetus and the pregnant woman. CTG combines the measurement of the fetal heart rate obtained using an ultrasound Doppler transducer and uterine contractions recorded using a pressure transducer. The gel applied to the skin during the procedure is also harmless and leaves no stains on clothing. During the procedure, the pregnant woman generally experiences no discomfort from the placement of the transducer on the abdominal skin. Elastic belts used to hold the transducers in place can be adjusted if necessary.
When is fetal heart rate monitoring indicated?
Fetal heart rate monitoring is performed for all pregnant women to assess fetal well-being and detect any changes that may be associated with problems during pregnancy or labor. Fetal heart rate monitoring is especially useful in high-risk pregnancies (diabetes, high blood pressure, fetal growth restriction, or other complications). Fetal heart rate monitoring is initiated at 28–32 weeks of gestation (sometimes earlier), with a frequency of once every 14 days if parameters are normal.
What can fetal heart rate monitoring tell us about your baby?
The baby's heart rate during pregnancy and labor should be between 110 and 160 beats per minute, but it may fluctuate above or below this range for various reasons. Short bursts of acceleration in the baby's pulse are common and indicate that the baby is receiving an adequate supply of oxygen. Brief decelerations in the baby's heart rate can also be normal. If these rhythm changes go beyond acceptable limits, it may signify a number of undesirable and even dangerous conditions, such as excessive umbilical cord compression and reduced blood flow to the baby. Sometimes a simple intervention, such as a change in position, can improve the situation. If the fetal heart rate results indicate that your baby may be at risk, the physician will undertake additional diagnostic or therapeutic measures depending on the situation.
Why is it sometimes necessary to repeat cardiotocography in a patient with unsatisfactory data?
Sometimes situations arise when the fetus is sleeping during fetal CTG. In a sleeping fetus, the heart rate may be lower than during wakefulness. In such situations, the CTG may be unsatisfactory and require a repeat recording. A fetus usually does not sleep longer than 45–50 minutes. Thus, in a sleeping fetus, the fetal heart rate should return to normal values after 45–50 minutes. Conversely, a persistent decrease in the fetal heart rate with low variability is abnormal and indicates fetal distress (hypoxia), which may require additional diagnostic methods to clarify its condition (fetal ultrasound with dopplerometry), and sometimes hospitalization in a maternity hospital.
Why perform fetal CTG monitoring during labor?
During labor, uterine contractions can reduce blood flow to the placenta and through the umbilical cord to the fetus, thereby causing a decrease in oxygen delivery; therefore, it is very important to monitor the fetal heart rate during labor. In addition, clinical situations arise during labor when CTG monitoring is required according to specific indications: epidural anesthesia, use of oxytocin, meconium-stained amniotic fluid, high blood pressure, elevated pulse or temperature of the laboring woman, prolonged labor, and others.
What to do if changes in the fetal heart rate are detected by CTG during labor?
Changes in the fetal heart rate (tachycardia or bradycardia) during labor do not necessarily mean there is a problem. Some of them are natural, for example, the rate may increase when the baby moves or during contractions. These changes are considered signs of the baby's well-being. If the pulse is very fast or drops, the physician may suggest a few simple actions: changing the position of the laboring woman, intravenous fluid administration. If these actions are not sufficiently successful, the physician takes other steps to resolve these problems.
What is the scalp lactate test and is it dangerous to perform?
In clinical situations where it is difficult to objectively evaluate cardiotocography results or measures aimed at correcting fetal heart rate abnormalities are ineffective, the scalp lactate test is used to clarify the condition of the fetus and decide on the possibility of further management of labor. The technique of the test consists of obtaining a drop of blood from the scalp of the fetus through a microscopic incision and collecting it using a capillary tube. Then, a chemical analysis of the obtained drop of blood is performed to assess the acid-base balance and lactate concentration, which can provide insight into the fetal oxygen supply.
This test is harmless and has no negative impact on the condition of the baby in labor or its future development.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Appendix G1. Apgar score
Russian title: Apgar score
Original title: Apgar score
Source: Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr. Res. Anesth. Analg. 1953;32:260-267
Type: rating scale
Purpose: assessment of the newborn's condition
Content:
Parameter / Score | 0 | 1 | 2 |
|---|---|---|---|
Heart rate | Absent | <100 bpm | ≥100 bpm |
Respiration | Absent | Bradypnea, irregular | Active, regular, loud cry |
Muscle tone | Absent, limbs limp | Decreased, some flexion of extremities | Active movement |
Reflex irritability (response to stimulation during airway suctioning) | No response | Weak response (grimace, movement) | Response in the form of movement, cough, sneezing, loud cry |
Skin coloration | Generalized pallor or generalized cyanosis | Body pink and extremities blue (acrocyanosis) | Entire body and extremities pink |
Key (interpretation):
A score of 4–7 points at 1 minute after birth corresponds to mild or moderate birth asphyxia (P21.1, ICD-10), while 0–3 points at 1 minute after birth corresponds to severe asphyxia (P21.0, ICD-10). Although according to ICD-10 a total of 7 points at 1 minute after birth corresponds to moderate to mild asphyxia, it is inappropriate to assign this diagnosis because a 1-minute Apgar score of 7 is not clinically and/or prognostically significant. The prognostic value of the first Apgar score is inherently extremely low. Adverse short- and long-term outcomes correlate with low Apgar scores at 5 and 10 minutes after birth.
Note: The test is usually performed at 1 and 5 minutes after birth and may be repeated later if the score remains low.