Electronic Fetal Monitoring

Definition
Electronic fetal monitoring (EFM) is a method for examining the condition of a baby in the uterus by notin
g any unusualchanges in its heart rate. Electronic fetal monitoring is performed late in pregnancy or continu
ously during labor to ensurenormal delivery of a healthy baby. EFM can be utilized either externally or inte
rnally in the womb.
Purpose
The heart rate of a fetus undergoes constant adjustment as it responds to its environment and other s
timuli. The fetal monitorrecords an unborn baby's heart rate and graphs it on a piece of paper. Electr
onic fetal monitoring is usually advised for highrisk pregnancies, when the baby is in danger of distre
ss. Specific reasons for EFM include: babies in a breech position,premature
labor, and induced labor, among others.
When electronic fetal monitoring was originally introduced in the 1960s and 1970s, the hope was tha
t it would helpphysicians diagnose fetal hypoxia, or lack of oxygen, in time to prevent damage to the b
aby. This lack of oxygen, also knownas perinatal asphyxia or birth asphyxia, is an important cause of
stillbirth and newborn deaths. It occurs when there are lessthan normal amounts of oxygen delivered
to the body or an organ and there is buildup of carbon dioxide in the body ortissue. A lack of blood fl
ow to an organ can cause asphyxia. Perinatal asphyxia can occur a long time before birth, shortlybefo
re birth, during delivery, or after birth. If the interruption to the supply of oxygen is short, the baby m
ay recover withoutany damage. If the time is longer, there may be some injury that is reversible. If th
e time period without oxygen is very long,there may be permanent injury to one or more organs of th
e body. It is important to detect any signs of asphyxia as soon as
possible. One of the signs is an abnormal heart rate and rhythm in the unborn baby, which can b
detected by electronicfetal monitoring.The fetal monitor is a more intricate version of the machine th
at a health care provider uses to listen to a baby's heartbeat.The monitor that is used during prenatal
visits just picks up the sound of the baby's heart beating. The fetal monitor alsokeeps a continuous pa
per record of the heart rate. In addition, the fetal monitor can record uterine contractions on the low
erpart of the paper strip. This helps the doctor or midwife determine how a baby is handling the stres
s of contractions. Thenormal pattern is for the baby's heartbeat to drop slightly during a contraction
and then go back to normal after thecontraction is over. EFM looks for any changes from this normal
pattern, particularly if there is a drastic drop in the baby'sheart beat or if the heart rate does not reco
ver immediately after a contraction.Because it is an indirect test, it is not perfect. When an adult com
plains to a provider about not feeling well, checking the
heart rate is only one of many things that the doctor will do. With an unborn baby, however, checking
the heart rate isbasically the only thing that a doctor or midwife can do.
Fetal monitoring can be helpful in a variety of different situations. During pregnancy, fetal monitorin
g can be used as a part ofantepartum
testing. If the practitioner feels that a baby may be at increased risk of problems toward the end of pr
egnancy, ababy can be checked every week or every other week with a nonstress test. In this test, changes in the baby's heart rate aremeasured along with the fetus' own move
ments. The heart rate of a healthy baby should go up whenever she or he moves.
Fetal monitoring is used on and off during early labor. As labor progresses, more monitoring is often
needed. Usually, as thetime for delivery nears, the monitor is left on continuously since the end of lab
or tends to be the most stressful time for thebaby.
A baby who is having trouble in labor will show characteristic changes in heart rate after a contractio
n(late decelerations). If
a baby is not receiving enough oxygen to withstand the stress of labor anddelivery is many hours aw
ay, a cesarean section (C-section) may be necessary.
Fetal Heart Determination
The objective of this study was to examine the accuracy of fetal gender prediction at a routine first
trimester scan. Pregnant women, from an unselected population around the world were recruited for this

study. They agreed to the study, to examine the accuracy of fetal gender prediction, at a routine first
trimester scan for detailed assessment of fetal anatomy and nuchal thickness measurement.
The clinical value of early ultrasound determination of fetal sex includes, confirmation of zygosity and
analysis of chorionic villous sampling in twin pregnancies, early information for demanding parents and a
powerfull method to decide whether to carry out prenatal invasive testing in pregnancies at risk of sexlinked genetic disorders, because it would be unnecessary in pregnancies with female fetuses.
The examinations were made with the use of normal two-dimensional (2D), three-dimensional (3D),
transabdominal and transvaginal sonography data. Sex confirmation data was obtained postnatally from
hospital registries, parents information or by ultrasound performed after 25 weeks of gestation.
Some gender determination was performed as a part of the sonographic examination preceding genetic
amniocentesis or chorionic villus sampling. The results were compared with the gender at birth or with fetal
karyotype results obtained from amniotic fluid cells or chorionic villus sampling.

Triple test
The triple test, also called triple screen, the Kettering test or the Bart's test, is an investigation performed
during pregnancy in the second trimester to classify a patient as either high-risk or low-risk for
chromosomal abnormalities (and neural tube defects).
The term "multiple-marker screening test" is sometimes used instead. This term can encompass the "double
test" and "quadruple test" (described below).
The Triple test measures serum levels of AFP, estriol, and beta-hCG, with a 70% sensitivity and 5% falsepositive rate. It is complemented in some regions of the United States, as the Quad test (adding inhibin A to
the panel, resulting in an 81% sensitivity and 5% false-positive rate for detecting Down syndrome when
taken at 1518 weeks of gestational age)[3] and other prenatal diagnosis techniques, although it remains
widely used in Canada[4] and other countries. A positive test means having a high risk of chromosomal
abnormalities (and neural tube defects), and such patients are then referred for more sensitive and specific
procedures to receive a definitive diagnosis, mostly invasive procedures like amniocentesis. The Triple test
can be understood as an early predecessor to a long line of subsequent technological improvements. In
some American states, such as Missouri, Medicaid reimburses only for the Triple test and not other
potentially more accurate screening tests, whereas California offers Quad tests to all pregnant women.

Percutaneous umbilical cord blood sampling

Percutaneous umbilical cord blood sampling (PUBS), also called cordocentesis, fetal blood sampling,
or umbilical vein sampling is a diagnostic genetic test that examines blood from the fetal umbilical cord to
detect fetal abnormalities. Fetal and maternal blood supply are typically connected in utero with one vein
and two arteries to the fetus. The umbilical vein is responsible for delivering oxygen rich blood to the fetus
from the mother; the umbilical arteries are responsible for removing oxygen poor blood from the fetus. This
allows for the fetus tissues to properly perfuse. PUBS provides a means of rapid chromosome analysis and
is useful when information cannot be obtained through amniocentesis, chorionic villus sampling,
or ultrasound (or if the results of these tests were inconclusive); this test carries a significant risk of
complication and is typically reserved for pregnancies determined to be at high risk for genetic defect. It
has been used with mothers with immune thrombocytopenic purpura.

Phosphatidylglycerol
Phosphatidylglycerol is a glycerophospholipid found in pulmonary surfactant.[1]

The general structure of phosphatidylglycerol consists of a L-glycerol 3-phosphate backbone ester-bonded

to either saturated or unsaturated fatty acids on carbons 1 and 2. The head group substituent glycerol is
bonded through a phosphomonoester. It is the precursor of surfactant and its presence (>0.3) in the
amniotic fluid of the newborn indicates fetal lung maturity.
Approximately 98% of alveolar wall surface area is due to the presence of type I cells, with type II cells
producing pulmonary surfactant covering around 2% of the alveolar walls. Once surfactant is secreted by
the type II cells, it must be spread over the remaining type I cellular surface area. Phosphatidylglycerol is
thought to be important in spreading of surfactant over the Type I cellular surface area. The major
surfactant deficiency in premature infants relates to the lack of phosphatidylglycerol, even though it
comprises less than 5% of pulmonary surfactant phospholipids. It is synthesized by head group exchange of
a phosphatidylcholine enriched phospholipid using the enzyme phospholipase D.

Coombs test
A Coombs test (also known as Coombs' test, antiglobulin test or AGT) is either of two clinical blood
tests used inimmunohematology and immunology. The two Coombs tests are the direct Coombs test (DCT,
also known as direct antiglobulin test or DAT), and the indirect Coombs test (also known as indirect
antiglobulin test or IAT).
The Direct Coombs test is used to test for autoimmune hemolytic anemia; i.e., a condition of a low count
of red blood cells(aka RBCs) caused by immune system lysis or breaking of RBC membranes causing RBC
destruction.
In certain diseases or conditions an individual's blood may contain IgG antibodies that can specifically bind
to antigens on the RBC surface membrane, and their circulating RBCs can become coated with IgG
alloantibodies and/or IgG autoantibodies. Complement proteins may subsequently bind to the bound
antibodies and cause RBC destruction.[1] The direct Coombs test is used to detect these antibodies or
complement proteins that are bound to the surface of red blood cells; a blood sample is taken and the RBCs
are washed (removing the patient's own plasma) and then incubated with antihuman globulin (also known
as "Coombs reagent"). If this producesagglutination of RBCs, the direct Coombs test is positive, a visual
indication that antibodies (and/or complement proteins) are bound to the surface of red blood cells.
The indirect Coombs test is used in prenatal testing of pregnant women, and in testing blood prior to
a blood transfusion. It detects antibodies against RBCs that are present unbound in the patient's serum. In
this case, serum is extracted from the blood sample taken from the patient. Then, the serum is incubated
with RBCs of knownantigenicity; that is, RBCs with known reference values from other patient blood
samples. If agglutination occurs, the indirect Coombs test is positive.

Types of Deliveries
Delivering a baby is both a stressful and a beautiful moment in your life. Whatever your birth
plan, the staff Scripps maternity centers want to provide you with a safe place to deliver your baby.
Vaginal delivery
A vaginal delivery is where your baby is delivered through the birth canal. This is the natural form
of labor and is the most common form of delivery. While a vaginal delivery can take place outside of a
hospital, many healthy women chose to deliver their baby in a hospital as a precaution. Scripps hospital
staff will try to accommodate most birth plans, so you and your baby can have a safe and rewarding
delivery.

During a vaginal delivery, many women elect to have some form of anesthesia to help reduce the
pain. An epidural is a form of anesthesia placed directly into the spine. An epidural is an optional
procedure. Talk to your OB-GYN about any concerns you may have about anesthesia during childbirth.
Cesarean section
A cesarean section (C-section) is a surgical procedure where the baby is delivered through an incision
in the abdomen rather than through the birth canal. A cesarean is usually performed when there are
complications that would make a vaginal delivery dangerous for you or your baby. When these
complications are detected in advance, the surgery may be scheduled. Some of these complications include:
The baby is in breech presentation inside the wombmeaning the babys head is upright instead
of directed toward the birth canaland efforts to correct the positioning have not been effective
You are having a multiple birth (twins, triplets, etc.)
You have a previous health condition such as high blood pressure, a heart condition or you have
poorly controlled diabetes
You have an active case of genital herpes
In other cases, a C-section might be performed if complications arise after active labor has already
begun. These situations may include:
If the umbilical cord has become wrapped or tangled around the baby
Fetal distress including changes in heart rate is detected on the fetal monitors
The baby is too large to delivery vaginally
The umbilical cord has become trapped in the cervix
You become too physically exhausted to continue with a vaginal delivery
Your contractions are ineffective in moving the baby through the birth canal
Vaginal birth after cesarean (VBAC)
It was previously thought that once a baby was delivered by cesarean, future pregnancies needed
to also be delivered by C-section. However, many women are now delivering their babies vaginally even
after they have had a previous C-section, which is called a VBAC.

In order to pursue this option, your physician will want to know:

Why did you have your c-section?
Is this condition going to recur?
Where was your uterine incision placed?
Was there any reason to believe you did not heal well?
Which hospital will you deliver at?
Can emergency c-sections be performed promptly at the hospital youve chosen?

Your physician will discuss your delivery options with you and determine if you and your baby are
healthy and able to go through a VBAC delivery.

Partogram
Partogram is a composite graphical record of key data (maternal and fetal) during labour entered against
time on a single sheet of paper. Relevant measurements might include statistics such as cervical
dilation, fetal heart rate, duration of labour and vital signs.
It is intended to provide an accurate record of the progress in labour, so that any delay or deviation from
normal may be detected quickly and treated accordingly. However, a Cochrane review came to the
conclusion that there is insufficient evidence to recommend partograms in standard labour management and
care.
Many partograms showing cervical dilation versus time include an alert line. It starts at the position where
there is 3 or 4cm ofcervical dilation. It is then continued diagonally at a rate of 1 cm per hour in

primigravidae and 1.5 cm in multigravidae. Anaction line is parallel to the alert line, and is located 4 hours
to the right of the alert line.