A female patient 27+3 SSW with a high BMI was accepted on the intensive care unit because of ARDS syndrome requiring artificial ventilation.

Intermittent CTG monitoring of the fetus proved difficult under these conditions however, it succeeded by means of modern technology: continuous electrocardiogram monitoring.

For surveillance of the fetus intermittent CTG controls were carried out. However, due to high body mass index (BMI = 31), a very active child and best positioning of the Doppler-probe by the midwife evaluation was not always possible (see illustration 1 below).

Continuous fetal and maternal heart rate electrocardiogram (ECG) monitoring was evaluated using the Monica AN24™-System (see illustration 2 below), which showed a fetal heart rate trace with little signal loss (see illustration 3 below).

Illustration 3:

Further development of the fetal ECG surveillance system now shows a system for clinical usage especially for obese women. This system is approved for usage prenatally and for the first stage of labour. Evaluation can be continues real time using a Bluetooth connection. Current computerised analyses after Dawes and Redman as well as short time variation are implemented in the software and help the obstetrician for signs of fetal distress.

Dr. Joscha Reinhard, MBBS, BSc(Hon),

Frauenklinik, Universitдt Witten / Herdecke, Akademisches Lehrkrankenhaus der Ruhr-Universitдt Witten, Marien Hospital Witten, Germany

Case example taken from:

Fetale Ьberwachung unter Extrembedingungen
J. Reinhard, E. Frick, H. Hatzmann, S. Schiermeier

Frauenarzt, issue 50 (2009) p. 518-519

original in German

25 subjects were monitored simultaneously with the Monica AN24 and an IUPC during stage 2 labour. In the illustration below

• X axis: 1 square = 1 minute
• Y axis: 0 - 250 = full scale (100mmHg for IUPC and 3000 microvolt for Monica AN24 Uterine Activity.
• Black line = Uterine Activity using the Monica AN24
• Cyan Line = IUPC

Illustration:

We are aware that monitoring the fetal heart rate using Doppler ultrasound in obese pregnant women can be a challenging, Doppler ultrasound has a poor penetration in fat tissue, this is an important issue as obese women are more likely to require more monitoring in their pregnancies as they are at a higher risk of complications such as hypertension, diabetes.

Case example
A Woman admitted to hospital in her second pregnancy with pre-eclampsia, she is currently 37 weeks plus 2 days into her pregnancy gestation. Fetal presentation is breech and her weight on booking was 75 kg, height was 149.86cm, her calculated body mass index was 48, this puts her in the category of obese class lll (Classification by The World Health Organisation).

Twice daily CTG’s were requested by the doctors as part of her clinical management. Two methods were used to obtain data, the AN24 (for research purposes) and Doppler ultrasound.

Comparison of the two fetal heart rate traces
Both fetal heart rate traces were taken on the same day. The trace in figure 1(below) shows no loss of contact during the trace which will mean that the data is of a good quality to interpret. Figure 2 (below) is a photocopy of the original trace using Doppler ultrasound, it clearly shows loss of contact initially, the woman was also holding and moving the transducer to ensure the fetal heart rate was being detected which was not the case with the AN24. The quality of data obtained with Doppler ultrasound means that the woman could be on the monitor for long periods of time to obtain a quality FHR trace for interpretation.

Figure 1:

Figure 2:

During the first stage of labour or the induction of labour in obese women the AN24 can be a practical solution for recording the fetal heart rate with minimal disruption to the woman, minimizing staff time, as well as offering good clinical data and maternal satisfaction.

This case example demonstrates that a higher body mass index does not interfere with the ability of the monitor to successfully detect the fetal heart rate. Hence monitoring the fetus of an obese mother is no more difficult than a non obese mother.

Karnie Bhogal

Clinical Specialist RGN RM, Monica Healthcare Ltd.

Displayed below are sections of an overnight CTG recording (using the Monica AN24 as part of a research study) from a woman who was 31weeks and 5 days gestation.

Clinical and ultrasound assessments 2 days previously had indicated IUGR (Intrauterine Growth Restriction). Umbilical artery Doppler RI was 0.87-0.98 and a course of steroids (Betamethasone) was started 36 hours before the AN24 recording, (need to take into account when interpreting the CTG as steroids can affect fetal heart rate variability).  Daily CTG’s using Doppler ultrasound was part of the care package.

Following the overnight CTG with the AN24 recording the Team caring for this woman was alerted.

CTG done with Doppler ultrasound also showed a concerning trace. Doppler studies showed an Absent End Diastolic Flow.

Following completion of Betamethasone doses a baby girl was delivered in good condition by an urgent LSCS and weighed 1.3kg at birth with good 5 minute Apgar scores and cord blood pH/BE.

Figure 1:

Figure 2:

This case example demonstrates that a longer recording in high risk pregnancies may be beneficial as part of the clinical assessment.

Dr. Asanka Jayawardane

MBBS, MD (O&G), Nottingham City Hospital, UK.

Case example
A 23 year old pregnant woman is admitted to hospital at 8.50 am for the induction of labour for post maturity, her pregnancy gestation is 40 weeks and 1 day (indication of induction as per hospital protocol).

Previous Obstetric history: - Gravid 3, Para 2, two previous normal deliveries.
No History of any medical problems and no problems identified in this pregnancy.

At 8.50am admitted to the Labour ward, no signs of labour on admission and the findings from the vaginal examination were that the cervix was 2 cm dilated. Decision was made to do an ARM (artificial rupture of membranes) and to commence Syntocinon.

Continuous fetal monitoring commenced using a Doppler ultrasound; the toco was placed at the fundus of the uterus.  Monica was applied with the woman’s consent. Pain relief used in labour was Entonox.
Maternal Position during Labour was in the bed in a supine / semi recumbent position.

The woman progressed well in labour and had a normal delivery of a female infant at 1.19pm, Infants weight was 3.5kg, Apgar scores were 8 at 1 minute and 9 at 5 minutes.

Figure 1 below shows a copy of the trace produced by the Monica AN24.

Figure 2 shows copy of the Doppler CTG trace taken at the same time.

Discussion
Feedback from the Nurse regarding the AN24 was very positive, she felt confident with the continuity of data from the AN24 and was pleased with the time saved by not having to readjust the AN24 electrodes, which is an issue with the transducers on the Doppler CTG.

Staffing levels at this hospital meant that one Nurse would generally be responsible for providing care to four women on the delivery suite. Relatives and partners were not allowed in the delivery suite so women were on their own and relied totally on their Nurse to provide care and support. Due to the wearable wireless design of the AN24, the patient was empowered to support herself with basic needs such as using the toilet and accessing a glass of water (which was out of reach) without intervention from the Nurse. Previously the patient would need to wait for the Nurse to disconnect her from the CTG monitor. Now if the Nurse is reassured by the fetal heart rate, the mother can be encouraged to be mobile which may help to reduce the time of labour (Lawrence et al, 2009). Due to the staffing ratio these features could help both the Nurse and patient.

The added information of the Maternal Heart rate was of an interest to the Nurse as the pattern follows that similar to the uterine activity pattern, this is something the Nurse had not seen. During the Uterine contraction it is usual to see an increase in the maternal heart rate which are considered to reflect a transient contraction related to an increase in cardiac output and endogenous catecholamine secretion. (Catecholamines, epinephrine and norepinephrine, cause characteristic "fight or flight" responses of increased heart rate and blood pressure, vasoconstriction, and other autonomic responses).  This case example reflects this very clearly. Uterine contraction-associated decelerations of the maternal heart rate are rare and remain unexplained; an example of one is of a young multifarious patient with systemic lupus erythematosus who presented in early labour at 39 weeks gestation. Intrapartum continuous maternal heart rate monitoring demonstrated repetitive uterine contraction associated decelerations of the maternal heart rate of 60 beats per minute, each lasting 2 minutes, simulating non-reassuring fetal status. Simultaneously depicted fetal heart rate was reassuring. In addition, this case illustrates the potentially dangerous similarity of an intrapartum maternal heart rate to an abnormal fetal heart rate pattern, and emphasizes the importance of correct identification of the maternal and fetal heart rates, respectively (Sherer et al, 2005).

It is good practice to use our clinical skills in conjunction with any electronic form of monitoring, and the maternal pulse was taken using the radial artery, which was 50bpm between contractions. Simultaneous monitoring of maternal and fetal heart rate helps prevent confusion and potential litigation cases (Neilson et al, 2008).

This case example highlights the importance of the correct identification of maternal and fetal heart rates. From comparison of the 2 traces, it is clear to see improved clinical picture provided by the Monica AN24, helping to make better assessment of health. The addition of wireless mobility will benefit both the patient and nurse.

Karnie Bhogal

Clinical Specialist RGN RM, Monica Healthcare Ltd.