Maternal “Oxygen and Fluids Therapy” to Correct Abnormalities in the Cardiotocograph (CTG): Scientific Principles vs Historical (Mal) Practices

Some Guidelines on Cardiotocograph (CTG) trace continue to recommend the administration of oxygen and fluids to the mother to correct the abnormalities observed on the cardiotocograph.However, the fetushas a separate autonomic nervous system, blood volume, haemoglobin concentration, oxygen saturation and cardiovascular responses as compared to the mother. Therefore, administration of oxygen and fluids to the mother to correct observed “suspicious” CTG traces should be questioned in contemporary obstetric practice. This commentary examines the scientific principles and current scientific evidence on these historical practices, and all practising midwives and obstetricians should urgently review their individual clinical practice, based on the knowledge of anatomy, physiology and biochemistry as well as a critical review of current scientific evidence to prevent avoidable patient harm. Current evidence suggests that administration of oxygen to the mother, who has a normal oxygen saturation does not correct the observed abnormalities on the CTG trace, and it may in fact lead to harm. Similarly, administration of fluids (oral or intravenous) to a woman during labour who is not dehydrated or hypotensive may notonly cause maternal dilutional hyponatremia and resultant complications, but also, it may cause neonatal convulsions. Women and babies expect every healthcare provider to practice evidence-based medicine during the intrapartum period, which is based on logic, common sense and robust scientific principles, irrespective of what is erroneously stated by some CTG guidelines

The Value of Cardiotocography for Evaluation of Fetal Condition and Outcome in Women Presenting with Less Fetal Movement

Objective: In this study our main goal is to determine the valueof cardiotocography for evaluation of fetal condition andoutcome in women presenting with less fetal movement.Method: This cross-sectional study was done at Department ofObstetrics and Gynaecology, Bangabandhu Sheikh MujibMedical University (BSMMU), Dhaka between June 2015 -December 2016. Where women >34 weeks’ gestation withsingleton pregnancies presenting during the study period withmaternal perception of less fetal movement (LFM) in the outpatient Department of Obstetrics and Gynecology in BSMMU.Results: During the study, the mean age was found25.61±5.65 years varied from 19 to 38 years in normal CTGand 24.82±3.81 years varied from 19 to 38 years in abnormalCTG. Majority patients were primiparous in both groups (56.0%vs. 52.0%). More than half (52.0%) of the patients in normalCTG and a half (50.0%) in abnormal CTG patients were camefrom lower middle-income group family. Emergency caesareansection was 12.0% and 42.0% in normal and abnormal CTGrespectively. Emergency caesarean section was significantlyhigher in abnormal CTG. At 1-minute APGAR score £7 wasfound 94.0% babies in normal CTG and 78.0% in abnormalCTG. Needed resuscitation was 4.0% in normal CTG and22.0% in abnormal CTG. Admission to NICU 10.0% babies innormal CTG and 36.0% in abnormal CTG.Conclusions: Decelerations, tachycardia and non-reactive(absent of accelerations) were the more common types ofabnormal CTG. Emergency caesarean section, low APGARscore, needed resuscitation, admission to NICU and prolongedhospital stay were higher in abnormal CTG. CTG can becontinued as a good screening test of fetal surveillance but it isnot the sole criteria to influence the management of high-riskpregnancies.

The Significance of ‘Non-Significant’ Meconium Stained Amniotic Fluid (MSAF): Colour versus Contents

The presence of ‘thin’ or ‘non-significant’ meconium stained amniotic fluid (MSAF) is currently being considered by some intrapartum guidelines as ‘low risk’, requiring only an intermittent auscultation and not continuous electronic fetal heart rate monitoring using the cardiotocograph (CTG). Clinicians not only must exclude ‘non-physiological’ causes of MSAF but consider the potential effect of MSAF on fetal wellbeing, irrespective of whether the passage was secondary to a normal physiological process or due to an underlying pathology. Management decisions should be made based on the parity, rate of progress of labour, cervical dilatation at diagnosis, and observed CTG changes and the risk factors such as multiple pregnancy and intra-uterine growth restriction. Presence of any meconium within the amniotic fluid should be considered as an important intrapartum risk factor. The thin meconium may be ‘non-significant’ on visual inspection, but it is very significantfrom the point of view of a fetus, who is covered with toxic materials within the surrounding amniotic fluid

Fetal Heart Rate Interpretation in the Second Stage of Labour: Pearls and Pitfalls.

It is vital to determine whether a fetus is showing a normal physiological response to the stress of labour or if the fetus is exposed to intrapartum hypoxia to ensure timely and appropriate management. Failure to interpret fetal heart rate correctly during second stage of labour may lead to increased maternal and neonatal morbidity due to an unnecessary caesarean section or an instrumental vaginal delivery. Conversely, delay in timely and appropriate intervention can also result in increased perinatal morbidity and mortality. This review addresses the pathophysiology behind features observed on the CTG trace as well as the types of intrapartum hypoxia during second stage of labour and aims to identify common pitfalls including inadvertent monitoring of maternal heart rate as well as monitoring and interpretation of cardiotocograph of twin pregnancies in the second stage of labour.