Saltatory pattern with wide variability. The Saltatory pattern with wide variability. The oscillations of the fetal heart rate above and oscillations of the fetal heart rate above and

below the baseline exceed 25 bpm below the baseline exceed 25 bpm

Fetal tachycardia with possible onset of decreased Fetal tachycardia with possible onset of decreased variability variability (right)(right) during the second stage of labor. during the second stage of labor. Fetal heart rate is 170 to 180 bpm. Mild variable Fetal heart rate is 170 to 180 bpm. Mild variable

decelerations are present. decelerations are present.

Fetal tachycardia that is due to fetal tachyarrhythmia Fetal tachycardia that is due to fetal tachyarrhythmia associated with congenital anomalies, in this case, associated with congenital anomalies, in this case,

ventricular septal defect. Fetal heart rate is 180 bpm. ventricular septal defect. Fetal heart rate is 180 bpm. Notice the "spike" pattern of the fetal heart rate. Notice the "spike" pattern of the fetal heart rate.

Early deceleration in a patient with an unremarkable Early deceleration in a patient with an unremarkable course of labor. Notice that the onset and the return of course of labor. Notice that the onset and the return of the deceleration coincide with the start and the end of the deceleration coincide with the start and the end of the contraction, giving the characteristic mirror image. the contraction, giving the characteristic mirror image.

Nonreassuring pattern of late decelerations with Nonreassuring pattern of late decelerations with preserved beat-to-beat variability. Note the onset at preserved beat-to-beat variability. Note the onset at

the peak of the uterine contractions and the return to the peak of the uterine contractions and the return to baseline after the contraction has ended. The second baseline after the contraction has ended. The second uterine contraction is associated with a shallow and uterine contraction is associated with a shallow and

subtle late deceleration. subtle late deceleration.

Late deceleration with loss of variability. This is an Late deceleration with loss of variability. This is an ominous pattern, and immediate delivery is ominous pattern, and immediate delivery is

indicated. indicated.

Variable deceleration with pre- and post-Variable deceleration with pre- and post-accelerations ("shoulders"). Fetal heart rate is 150 to accelerations ("shoulders"). Fetal heart rate is 150 to 160 beats per minute, and beat-to-beat variability is 160 beats per minute, and beat-to-beat variability is

preserved preserved

Severe variable deceleration with overshoot. Severe variable deceleration with overshoot. However, variability is preserved. However, variability is preserved.

Late deceleration related to bigeminal Late deceleration related to bigeminal contractions. Beat-to-beat variability is contractions. Beat-to-beat variability is preserved. Note the prolonged contraction preserved. Note the prolonged contraction pattern with elevated uterine tone between pattern with elevated uterine tone between the peaks of the contractions, causing the peaks of the contractions, causing hyperstimulation and uteroplacental hyperstimulation and uteroplacental insufficiency. Management should include insufficiency. Management should include treatment of the uterine hyperstimulation. This treatment of the uterine hyperstimulation. This deceleration pattern also may be interpreted deceleration pattern also may be interpreted as a variable deceleration with late return to as a variable deceleration with late return to the baseline based on the early onset of the the baseline based on the early onset of the deceleration in relation to the uterine deceleration in relation to the uterine contraction, the presence of an acceleration contraction, the presence of an acceleration before the deceleration (the "shoulder") and before the deceleration (the "shoulder") and the relatively sharp descent of the the relatively sharp descent of the deceleration. However, late decelerations and deceleration. However, late decelerations and variable decelerations with late return have variable decelerations with late return have the same clinical significance and represent the same clinical significance and represent nonreassuring patterns. This tracing probably nonreassuring patterns. This tracing probably represents cord compression and represents cord compression and uteroplacental insufficiency.uteroplacental insufficiency.

Pseudosinusoidal pattern. Note the decreased regularity and the preserved beat-to-beat variability

a true sinusoidal patterna true sinusoidal pattern

List 6 Causes of Severe Fetal List 6 Causes of Severe Fetal Bradycardia ?Bradycardia ?

Prolonged cord compressionProlonged cord compression Cord prolapse Cord prolapse Tetanic uterine contractionsTetanic uterine contractions Paracervical blockParacervical block Epidural and spinal anesthesia Epidural and spinal anesthesia Maternal seizuresMaternal seizures Rapid descentRapid descent Vigorous vaginal examination Vigorous vaginal examination

list 6 Causes of Severe Fetal list 6 Causes of Severe Fetal Bradycardia ?Bradycardia ?

Prolonged cord compressionProlonged cord compression Cord prolapse Cord prolapse Tetanic uterine contractionsTetanic uterine contractions Paracervical blockParacervical block Epidural and spinal anesthesia Epidural and spinal anesthesia Maternal seizuresMaternal seizures Rapid descentRapid descent Vigorous vaginal examination Vigorous vaginal examination

What is the Signs of Nonreassuring What is the Signs of Nonreassuring Variable Decelerations that Indicate Variable Decelerations that Indicate Hypoxemia ?Hypoxemia ?

Increased severity of the decelerationIncreased severity of the deceleration Late onset and gradual return phaseLate onset and gradual return phase Loss of "shoulders" on FHR recording Loss of "shoulders" on FHR recording A blunt acceleration or "overshoot" A blunt acceleration or "overshoot"

after severe decelerationafter severe deceleration Unexplained tachycardiaUnexplained tachycardia Saltatory variabilitySaltatory variability Late decelerations or late return to Late decelerations or late return to

baseline baseline Decreased variability Decreased variability

what is the Nonreassuring patterns what is the Nonreassuring patterns in the CTG?in the CTG?

Fetal tachycardiaFetal tachycardia Fetal bradycardia Fetal bradycardia Saltatory variabilitySaltatory variability Variable decelerations associated with a Variable decelerations associated with a

nonreassuring pattern nonreassuring pattern Late decelerations with preserved beat-Late decelerations with preserved beat-

to-beat variability to-beat variability

what is the Ominous patterns of the what is the Ominous patterns of the CTG?CTG?

Persistent late decelerations with loss of Persistent late decelerations with loss of beat-to-beat variability beat-to-beat variability

Nonreassuring variable decelerations Nonreassuring variable decelerations associated with loss of beat-to-beat associated with loss of beat-to-beat variability variability

Prolonged severe bradycardia Prolonged severe bradycardia Sinusoidal pattern Confirmed loss of beat-Sinusoidal pattern Confirmed loss of beat-

to-beat variability not associated with to-beat variability not associated with fetal quiescencefetal quiescence

medications or severe prematurity medications or severe prematurity

Emergency Interventions for Nonreassuring Emergency Interventions for Nonreassuring Patterns Patterns

Call for assistance Call for assistance Administer oxygen through a tight-fitting face Administer oxygen through a tight-fitting face

maskmask Change maternal position (lateral or knee-chest) Change maternal position (lateral or knee-chest) Administer fluid bolus (lactated Ringer's solution) Administer fluid bolus (lactated Ringer's solution) Perform a vaginal examination and fetal scalp Perform a vaginal examination and fetal scalp

stimulation When possible, stimulation When possible, determine and correct the cause of the pattern determine and correct the cause of the pattern

Consider tocolysis (for uterine tetany or Consider tocolysis (for uterine tetany or hyperstimulation)hyperstimulation)

Discontinue oxytocin if used Consider Discontinue oxytocin if used Consider amnioinfusion (for variable decelerations) amnioinfusion (for variable decelerations)

Determine whether operative intervention is Determine whether operative intervention is warranted and, if so, how urgently it is needed warranted and, if so, how urgently it is needed

Causes of Fetal TachycardiaCauses of Fetal Tachycardia Fetal hypoxia Fetal hypoxia Maternal fever Maternal fever Hyperthyroidism Maternal or fetal Hyperthyroidism Maternal or fetal anemia Parasympatholytic drugs  anemia Parasympatholytic drugs   Atropine  Atropine   Hydroxyzine (Atarax)Hydroxyzine (Atarax) Sympathomimetic drugs  Sympathomimetic drugs   Ritodrine (Yutopar)  Ritodrine (Yutopar)   Terbutaline (Bricanyl)Terbutaline (Bricanyl) Chorioamnionitis Chorioamnionitis Fetal tachyarrhythmia Fetal tachyarrhythmia Prematurity Prematurity

This patient was induced with prostin E2 gel. This patient was induced with prostin E2 gel. One hour after administration the One hour after administration the cardiotocograph (CTG) was recorded.cardiotocograph (CTG) was recorded.

1.What CTG abnormalities do you see?1.What CTG abnormalities do you see?

Reduced baseline variabilityReduced baseline variabilityLate deccelerationsLate deccelerationsExcessive uterine activity Excessive uterine activity (approximately 7 in 10 minutes)(approximately 7 in 10 minutes)

2.What is the diagnosis?2.What is the diagnosis?

Uterine hyperstimulation leading to fetal Uterine hyperstimulation leading to fetal comprimisecomprimise

3.What is your management?3.What is your management?

Move the patient onto her left side to Move the patient onto her left side to reduce the risk of aortocaval reduce the risk of aortocaval compression. Facial oxygen may compression. Facial oxygen may improve fetal oxygenation.improve fetal oxygenation.Use of an intravenous tocolytic Use of an intravenous tocolytic agent will reduce the uterine agent will reduce the uterine activity. Suitable drugs include activity. Suitable drugs include salbutamol or ritodrine, both of salbutamol or ritodrine, both of which are beta-2 agonists.which are beta-2 agonists.The resulting CTG is shown below.The resulting CTG is shown below.

Q7Q732 Y OLD PG who present at 38 week gestation 32 Y OLD PG who present at 38 week gestation

with reduce fetal movement with reduce fetal movement CTG done,showCTG done,show

1.What abnormality are shown in 1.What abnormality are shown in the CTG?the CTG?

2.What will be the most likely plan 2.What will be the most likely plan of management?of management?

3.further CTG show persistent of 3.further CTG show persistent of this pattern what will you advice?this pattern what will you advice?

4.if she went into labour ,what 4.if she went into labour ,what must you do?must you do?

1.What abnormality are shown in 1.What abnormality are shown in the CTG?the CTG?

1.Fetal tachycardia with possible 1.Fetal tachycardia with possible onset of decreased variabilityonset of decreased variability

2.What will be the most likely plan 2.What will be the most likely plan of management?of management?

Admit into the labour word with Admit into the labour word with continuous monitoringcontinuous monitoring

3.further CTG show persistent of 3.further CTG show persistent of this pattern what will you advice?this pattern what will you advice?

Delivery by CS if cervix un Delivery by CS if cervix un favorable orARM if cervix favorable orARM if cervix favorable,and thin start syntocinonfavorable,and thin start syntocinon

4.if she went into labour ,what 4.if she went into labour ,what must you do?must you do?

Ensure that fetus monitored Ensure that fetus monitored continuously and perform a fetal continuously and perform a fetal blood sample if this pattern persistblood sample if this pattern persist

Q#1Q#139y old G3P2 admitted in active labour after 39y old G3P2 admitted in active labour after

3hr CTG show3hr CTG show

1.Describe the CTG finding?1.Describe the CTG finding?2.what is the next action you will do?2.what is the next action you will do?3.on examination cervix was fully 3.on examination cervix was fully

dilated head at +2 station with caput dilated head at +2 station with caput ++ CTG persist the same.++ CTG persist the same.

how you are going to manage this how you are going to manage this patient?patient?

4.What other indication for its use?4.What other indication for its use?

5. What 6 condition must be fulfilled 5. What 6 condition must be fulfilled before the application of this before the application of this instrument?instrument?

6.what 4 complication may arise from 6.what 4 complication may arise from use of this instrument?use of this instrument?

1.Describe the CTG finding?1.Describe the CTG finding? Late deceleration with loss of variability. Late deceleration with loss of variability.

This is an ominous pattern, and immediate This is an ominous pattern, and immediate delivery is indicated delivery is indicated

2.what is the next action you will do?2.what is the next action you will do? Put the patient in lateral side ,give oxygen Put the patient in lateral side ,give oxygen

,fast iv drip ,and examine the patient to ,fast iv drip ,and examine the patient to decide about the mode of the deliverydecide about the mode of the delivery

3.on examination cervix was fully dilated 3.on examination cervix was fully dilated head at +2 station with caput ++ CTG head at +2 station with caput ++ CTG persist the same.persist the same.

how you are going to manage this patient?how you are going to manage this patient?

Immediate delivery is indicated ,forceps Immediate delivery is indicated ,forceps delivery is appropriate for this ptdelivery is appropriate for this pt

QQ22Uterine artery DopplerUterine artery Doppler

Q3Q3

Q4Q4

Q5Q5

Q6Q6

Q7Q7

Q8Q8

Q9Q9

Q10Q10

Q11Q11

22..Uterine artery Doppler is a promising Uterine artery Doppler is a promising technique for assessment of the level of technique for assessment of the level of risk of pre-eclampsia and IUGR. Doppler risk of pre-eclampsia and IUGR. Doppler

ultrasound provides a non-invasive ultrasound provides a non-invasive method of assessing the utero-placental method of assessing the utero-placental

circulationIn normal pregnancy , circulationIn normal pregnancy , impedance to flow in the uterine artery impedance to flow in the uterine artery

decreases with gestation and this decreases with gestation and this presumably reflects the trophablastic presumably reflects the trophablastic

invasion of the spiral ateries and their invasion of the spiral ateries and their change into low resistance vesselsThe change into low resistance vesselsThe

uterine artery is a branch of the internal uterine artery is a branch of the internal iliac artery close to the bifurcation of the iliac artery close to the bifurcation of the common iliac. Colour flow Doppler is the common iliac. Colour flow Doppler is the

method of choice for accurate screening of method of choice for accurate screening of uterine artery waveformsuterine artery waveforms . .

The resistance index (RI) is the most commonly used The resistance index (RI) is the most commonly used index to measure the uterine artery flow as it is index to measure the uterine artery flow as it is

unlikely to have absent or reverse endunlikely to have absent or reverse end Diastolic (EDF) flow. Although the pulsatility index Diastolic (EDF) flow. Although the pulsatility index

(PI) can also be used(PI) can also be used33..High resistance waveforms in the uterine artery High resistance waveforms in the uterine artery

with early diastolic notching in the second with early diastolic notching in the second trimester are asssociated with the later trimester are asssociated with the later

development of pre-eclampsia, IUGR, placental development of pre-eclampsia, IUGR, placental abruption and intra-uterine deathabruption and intra-uterine death..

44 . .notches of the uterine artery waveform with a high notches of the uterine artery waveform with a high RI, hold the most risk of complicated RI, hold the most risk of complicated

pregnancies, although it is still to be established pregnancies, although it is still to be established wether the notch or the high RI is the best wether the notch or the high RI is the best

indicator of poor outcomeindicator of poor outcome55 . .Systole (Sys) and diastole (D) are identified in Systole (Sys) and diastole (D) are identified in

green Note that diastole is less at 20 weeks green Note that diastole is less at 20 weeks (yellow ellipse) than at 36 weeks (red ellipse)(yellow ellipse) than at 36 weeks (red ellipse) . .

66 . .This illustrates absent diastolic flow during This illustrates absent diastolic flow during diastole. When this occurs there is abnormal diastole. When this occurs there is abnormal resistance in the placenta which results in a resistance in the placenta which results in a

marked decrease in blood flow from the fetus to marked decrease in blood flow from the fetus to the placentathe placenta..

77 . .Color Doppler of umbilical cord insertionColor Doppler of umbilical cord insertion88 . .Color Doppler and spectral Doppler of ovarian Color Doppler and spectral Doppler of ovarian

arteryartery 99 . .Color Doppler and spectral Doppler of Color Doppler and spectral Doppler of

umbilical arteryumbilical artery 1010 . .Color Doppler of left ventricular outflow tractColor Doppler of left ventricular outflow tract 1111 . .Color Doppler of umbilical cordColor Doppler of umbilical cord   1212 . .Chromosome pattern of a person with Chromosome pattern of a person with

Down's syndrome. Arrow points to an Down's syndrome. Arrow points to an extra chromosome No.21extra chromosome No.21

         

What is the Signs of Nonreassuring What is the Signs of Nonreassuring Variable Decelerations that Indicate Variable Decelerations that Indicate Hypoxemia ?Hypoxemia ?

Increased severity of the decelerationIncreased severity of the deceleration Late onset and gradual return phaseLate onset and gradual return phase Loss of "shoulders" on FHR recording Loss of "shoulders" on FHR recording A blunt acceleration or "overshoot" A blunt acceleration or "overshoot"

after severe decelerationafter severe deceleration Unexplained tachycardiaUnexplained tachycardia Saltatory variabilitySaltatory variability Late decelerations or late return to Late decelerations or late return to

baseline baseline Decreased variability Decreased variability

what is the Nonreassuring patterns what is the Nonreassuring patterns in the CTG?in the CTG?

Fetal tachycardiaFetal tachycardia Fetal bradycardia Fetal bradycardia Saltatory variabilitySaltatory variability Variable decelerations associated with a Variable decelerations associated with a

nonreassuring pattern nonreassuring pattern Late decelerations with preserved beat-Late decelerations with preserved beat-

to-beat variability to-beat variability

what is the Ominous patterns of the what is the Ominous patterns of the CTG?CTG?

Persistent late decelerations with loss of Persistent late decelerations with loss of beat-to-beat variability beat-to-beat variability

Nonreassuring variable decelerations Nonreassuring variable decelerations associated with loss of beat-to-beat associated with loss of beat-to-beat variability variability

Prolonged severe bradycardia Prolonged severe bradycardia Sinusoidal pattern Confirmed loss of beat-Sinusoidal pattern Confirmed loss of beat-

to-beat variability not associated with to-beat variability not associated with fetal quiescencefetal quiescence

medications or severe prematurity medications or severe prematurity

Emergency Interventions for Nonreassuring Emergency Interventions for Nonreassuring Patterns Patterns

Call for assistance Call for assistance Administer oxygen through a tight-fitting face Administer oxygen through a tight-fitting face

maskmask Change maternal position (lateral or knee-chest) Change maternal position (lateral or knee-chest) Administer fluid bolus (lactated Ringer's solution) Administer fluid bolus (lactated Ringer's solution) Perform a vaginal examination and fetal scalp Perform a vaginal examination and fetal scalp

stimulation When possible, stimulation When possible, determine and correct the cause of the pattern determine and correct the cause of the pattern

Consider tocolysis (for uterine tetany or Consider tocolysis (for uterine tetany or hyperstimulation)hyperstimulation)

Discontinue oxytocin if used Consider Discontinue oxytocin if used Consider amnioinfusion (for variable decelerations) amnioinfusion (for variable decelerations)

Determine whether operative intervention is Determine whether operative intervention is warranted and, if so, how urgently it is needed warranted and, if so, how urgently it is needed

Causes of Fetal TachycardiaCauses of Fetal Tachycardia Fetal hypoxia Fetal hypoxia Maternal fever Maternal fever Hyperthyroidism Maternal or fetal Hyperthyroidism Maternal or fetal anemia Parasympatholytic drugs  anemia Parasympatholytic drugs   Atropine  Atropine   Hydroxyzine (Atarax)Hydroxyzine (Atarax) Sympathomimetic drugs  Sympathomimetic drugs   Ritodrine (Yutopar)  Ritodrine (Yutopar)   Terbutaline (Bricanyl)Terbutaline (Bricanyl) Chorioamnionitis Chorioamnionitis Fetal tachyarrhythmia Fetal tachyarrhythmia Prematurity Prematurity

EFM- 4 Basic Features of FH EFM- 4 Basic Features of FH TraceTrace

EFM- 4 Basic Features of FH EFM- 4 Basic Features of FH TraceTrace

Fig 3 Early Decelerations

EFM- 4 Basic Features of FH EFM- 4 Basic Features of FH TraceTrace

Fig 3 Early Decelerations

Fig 2 Sinusoidal patternFig 2 Sinusoidal pattern

Interpretation of the CTGInterpretation of the CTG

Case # 1Case # 1

A 26 years old, G 3 p 3 with H/O twin delivery in the first A 26 years old, G 3 p 3 with H/O twin delivery in the first pregnancypregnancy,,

admitted to the hospital at 31 weeksgestation with labour admitted to the hospital at 31 weeksgestation with labour pains andpains and

preterm premature rupture of membranes for 4 weekspreterm premature rupture of membranes for 4 weeks . .

Her temperature was 39º C, the cervix cm dilated, clear Her temperature was 39º C, the cervix cm dilated, clear liquor drainingliquor draining . .

The WBCs were 25 x 10The WBCs were 25 x 1099

Sinus TachycardiaSinus Tachycardia

ActionsActionsHigh vaginal swab for bacterial culture and sensitivity testHigh vaginal swab for bacterial culture and sensitivity test(yes)(yes)

Parentral antibioticsParentral antibiotics(yes)(yes) Antipyretics and review after 2 hoursAntipyretics and review after 2 hours(no)(no)

Adjust tocodynamometer and review Adjust tocodynamometer and review (yes)(yes)Cesarean section immediatelyCesarean section immediately(no)(no)

Fetal blood sampling for PHFetal blood sampling for PH(no)(no)

Course and OutcomeCourse and Outcome Labour was augmented with syntocinon, and intravenous tripleLabour was augmented with syntocinon, and intravenous triple

antibiotics were given. After 5 hours, the patient had normalantibiotics were given. After 5 hours, the patient had normal vaginal delivery of a baby boy weighing 1.9 kg. Apgar score wasvaginal delivery of a baby boy weighing 1.9 kg. Apgar score was

55 at one minute and 8 at five minutes. Cord blood PH was 7.061at one minute and 8 at five minutes. Cord blood PH was 7.061,,PO2 11.3, PCO2 61 , base excess – 13.9, and O2 saturation PO2 11.3, PCO2 61 , base excess – 13.9, and O2 saturation

6.4%6.4%..The baby died after 10 hours due to septicemiaThe baby died after 10 hours due to septicemia..

Case # 2Case # 2

A 31 years old patient G 2 p 1 was admitted at 41 weeks of A 31 years old patient G 2 p 1 was admitted at 41 weeks of gestationgestation

in active labour. Received pethidine and Phenrgan earlierin active labour. Received pethidine and Phenrgan earlier..

The cervix is 9 cm dilated and meconium stained liquor is The cervix is 9 cm dilated and meconium stained liquor is drainingdraining..

Sinus Tachycardia With Deceleration And No Sinus Tachycardia With Deceleration And No Variability: Mixed PatternVariability: Mixed Pattern

ActionsActions Wait and review after 30 minutesWait and review after 30 minutes(no)(no)

Change the position of the patientChange the position of the patient(yes)(yes) Fetal scalp blood samplingFetal scalp blood sampling(no)(no)

Immediate cesarean sectionImmediate cesarean section (yes) (yes) Give naloxone Give naloxone (no) (no)

Explain and reassure the patientExplain and reassure the patient(yes)(yes)

Course and OutcomeCourse and OutcomeCesarean section was carried out. A baby girl weighing 3898 Cesarean section was carried out. A baby girl weighing 3898

gmgmwas delivered from vertex presentation. Apgar score was 1/5was delivered from vertex presentation. Apgar score was 1/5

at one and five minutes. The position of the cord was not at one and five minutes. The position of the cord was not notednoted . .

The baby had meconium aspiration pneumonitis and wasThe baby had meconium aspiration pneumonitis and was discharged after 10 daysdischarged after 10 days..

Case # 3Case # 3

A 25 years old patient admitted at 36 weeks of A 25 years old patient admitted at 36 weeks of gestation in labour. No sedation is given yetgestation in labour. No sedation is given yet

Rebound TachycardiaRebound TachycardiaActionsActions

Facial oxygenFacial oxygen(no)(no) Give sedation Give sedation (no)(no)

Fetal scalp blood sampling for PHFetal scalp blood sampling for PH (yes) (yes)Augmentation of labour with syntocinon Augmentation of labour with syntocinon (no)(no)

Cesarean sectionCesarean section (no)(no)Maternal hydrationMaternal hydration (no) (no)

Course and OutcomeCourse and OutcomeAfter recovery from prolonged deceleration, After recovery from prolonged deceleration,

scalp PHscalp PH were 7.28, 7.36 and 7.36.the patient had normal were 7.28, 7.36 and 7.36.the patient had normal

vaginalvaginaldelivery of baby girl weighing 2070gm(small for delivery of baby girl weighing 2070gm(small for

age)age) . .Apgar score was 9/10 at one and five minutesApgar score was 9/10 at one and five minutes..

Case # 4Case # 4A 24 years old patient, G 3 p1+1, with H/O cesarean A 24 years old patient, G 3 p1+1, with H/O cesarean

section in the lastsection in the last

pregnancy due to breech presentation. Currently admitted pregnancy due to breech presentation. Currently admitted in activein active

labour at 39 weeks of pregnancy. The cervix was 6cm labour at 39 weeks of pregnancy. The cervix was 6cm dilated and thedilated and the

head was at 0 station 2hours prior to this tracehead was at 0 station 2hours prior to this trace

““Variable” Variable DecelerationVariable” Variable DecelerationActionsActions::

Vaginal examination and deliver if fullyVaginal examination and deliver if fully(yes)(yes)Immediate cesarean sectionImmediate cesarean section(no)(no)Fetal blood sampling for PHFetal blood sampling for PH(yes)(yes)

Facial oxygenFacial oxygen(no)(no)Change maternal positionChange maternal position(yes)(yes)

Review after 1 hourReview after 1 hour(no)(no)

Course and OutcomeCourse and OutcomeVaginal examination showed fully dilated cervix with Vaginal examination showed fully dilated cervix with

thethehead at +1 station. Progressed to normal vaginal head at +1 station. Progressed to normal vaginal

deliverydeliveryof baby girl weighing 2.7kg and Apgar score 9/10 at of baby girl weighing 2.7kg and Apgar score 9/10 at

oneoneand five minutes. The position of the cord was not and five minutes. The position of the cord was not

notednoted . .The infant followed normal newborn courseThe infant followed normal newborn course..

Case # 5Case # 5

A 19 years old primigravid patient admitted in labour at A 19 years old primigravid patient admitted in labour at 34 weeks34 weeks . .

She had pyelonephritis and chorioamnionitisShe had pyelonephritis and chorioamnionitis . .

Pethidene was given 90 minutes prior to this tracePethidene was given 90 minutes prior to this trace..

No variability, flat line-unfavorable No variability, flat line-unfavorable outcomeoutcome

ActionsActionsUltrasound toUltrasound to exclude anomalies exclude anomalies

(yes)(yes)Fetal vibroacuastic stimulationFetal vibroacuastic stimulation (yes)(yes)

Fetal blood sampling for acid base statusFetal blood sampling for acid base status(yes)(yes)Observe and review after one hoursObserve and review after one hours(no)(no)

Immediate cesarean sectionImmediate cesarean section(no)(no)Stop fetal monitoringStop fetal monitoring(no)(no)

Course and OutcomeCourse and OutcomeThe mean of serial fetal blood sampling four times were showingThe mean of serial fetal blood sampling four times were showing

nonacidotic intrapartum capillary PH of 7.2, so she was allowed nonacidotic intrapartum capillary PH of 7.2, so she was allowed toto

progress in labour.had Normal vaginal delivery of female progress in labour.had Normal vaginal delivery of female weighingweighing

23812381 gm. Apgar score was 2/3 at one and five minutes. The gm. Apgar score was 2/3 at one and five minutes. The newbornnewborn

required intubation. It survived and was discharged after 9 daysrequired intubation. It survived and was discharged after 9 days . .

Case # 6Case # 6

A 21 years old primigravid patient complaining of A 21 years old primigravid patient complaining of reduced fetalreduced fetal

movement at 42 weeks of gestation was admitted for movement at 42 weeks of gestation was admitted for induction ofinduction of

labour. Received prostin and started labouring. The labour. Received prostin and started labouring. The cervix was 3cmcervix was 3cm

dilated, so amniotomy was done and liquor was clear. dilated, so amniotomy was done and liquor was clear. SyntocinonSyntocinon

infusion was started 30 minutes agoinfusion was started 30 minutes ago

Increased variability with hypertonic Increased variability with hypertonic labourlabour

ActionsActionsObserve and review after 30 minutesObserve and review after 30 minutes(no)(no)

Vaginal examination to asses progress Vaginal examination to asses progress (no)(no)Reduce syntocinon infusion rate Reduce syntocinon infusion rate (yes)(yes)

Immediate cesarean sectionImmediate cesarean section(no)(no)Oxygen by facial maskOxygen by facial mask (yes)(yes)

Fetal blood sampling for PHFetal blood sampling for PH(no)(no)

Course and OutcomeCourse and OutcomeSyntocinon infusion was reduced and fetal heart returned to Syntocinon infusion was reduced and fetal heart returned to

normalnormal . .33 hours later CTG started to show late and late variable hours later CTG started to show late and late variable

decelerationsdecelerations , ,so cesarean section was performed for fetal distress. Outcome so cesarean section was performed for fetal distress. Outcome

waswasbaby girl weighing 3 kg with 3 tight loops of the cord around the baby girl weighing 3 kg with 3 tight loops of the cord around the

neckneck . .Apgar score was 9/10 at one and five minutesApgar score was 9/10 at one and five minutes..

The infant had normal newborn courseThe infant had normal newborn course . .

Case # 7Case # 7

A 28 years old patient G 5 p 4+ 0 was admitted in labour A 28 years old patient G 5 p 4+ 0 was admitted in labour at 39½ weeksat 39½ weeks’’

gestation. Her blood group was O positive, without gestation. Her blood group was O positive, without antibodiesantibodies . .

She received pethidine and phenrgan for sedationShe received pethidine and phenrgan for sedation..

Sinusoidal PatternSinusoidal Pattern

ActionsActionsObserve and review after 1 hourObserve and review after 1 hour (no)(no)

Fetal blood sampling if feasible for PH Fetal blood sampling if feasible for PH (yes)(yes)

Fetal blood sampling if feasible for haematocrit &Hg Fetal blood sampling if feasible for haematocrit &Hg (yes)(yes)

Maternal Kleihaure-Betke testMaternal Kleihaure-Betke test (yes)(yes)Immediate cesarean sectionImmediate cesarean section (yes) (yes)

U/S scan for fetal hydrops and abruptio placenta U/S scan for fetal hydrops and abruptio placenta (yes)(yes)

Course and OutcomeCourse and OutcomeCesarean section was performed due to fetal distressCesarean section was performed due to fetal distress . .

Outcome was baby girl weighing 960 gm with Apgar 1/6 Outcome was baby girl weighing 960 gm with Apgar 1/6 atat

one and five minutes with intrauterine growth one and five minutes with intrauterine growth restrictionrestriction . .

Umbilical arterial PH was 7.37 and venous 7.41Umbilical arterial PH was 7.37 and venous 7.41 . .The infant had intracrebral hemorrhage and died afterThe infant had intracrebral hemorrhage and died after

5days5days..

Case # 8Case # 8

Fifteen years old primigravid patient was Fifteen years old primigravid patient was admitted inadmitted in

labour at approximately 40 weeks gestationlabour at approximately 40 weeks gestation . .

She received epidural anesthesiaShe received epidural anesthesia

Increased variability with variable Increased variability with variable decelerationdeceleration

ActionsActionsObserve and review after 30 minutesObserve and review after 30 minutes (no)(no)

Reduce the rate of syntocinon infusion if it is in usReduce the rate of syntocinon infusion if it is in us (yes)(yes)

Vaginal examination to determine if delivery isimminent Vaginal examination to determine if delivery isimminent (yes)(yes)

Cesarean section even if delivery is imminentCesarean section even if delivery is imminent (no)(no)

Fetal blood samplingFetal blood sampling (no)(no)

Course and OutcomeCourse and OutcomeProgressed to normal vaginal delivery of a female fetus Progressed to normal vaginal delivery of a female fetus

weighingweighing 30763076 gm and Apgar score 3/9 at one and five minutesgm and Apgar score 3/9 at one and five minutes . .

Meconium was present requiring tracheal suctioning, whichMeconium was present requiring tracheal suctioning, whichaccounted for the initial low Apgar score. There was one nuchalaccounted for the initial low Apgar score. There was one nuchalcord and 10% placental abruption. The infant followed a normalcord and 10% placental abruption. The infant followed a normal

newborn coursenewborn course

Case # 9Case # 9

A 21 years old primigravid patient admitted in labour at A 21 years old primigravid patient admitted in labour at 4040 weeks’ gestationweeks’ gestation

Marked AccelerationsMarked Accelerations

ActionsActionsObserve for the development of other types of declarations Observe for the development of other types of declarations

(yes)(yes)Change maternal position Change maternal position

(no)(no)Prepare for cesarean section Prepare for cesarean section (no) (no)

Exclude maternal hypotention especially if > 50BPMExclude maternal hypotention especially if > 50BPM (yes)(yes)

Fetal blood sampling for PHFetal blood sampling for PH (no) (no)

Course and ActionCourse and ActionProgressed to normal vaginal delivery of male infant weighing Progressed to normal vaginal delivery of male infant weighing

3374gm3374gmApgar score was 7/9 at one and five minutes and one nuchal cord Apgar score was 7/9 at one and five minutes and one nuchal cord

waswas noted. The infant followed normal newborn coursenoted. The infant followed normal newborn course..

Case # 10Case # 10

A 23 years old primigravid patient was admitted in A 23 years old primigravid patient was admitted in labour at 40 weeks’ gestation. The cervix was 4 cm labour at 40 weeks’ gestation. The cervix was 4 cm

dilated. Amniotomy was done and excessive clear liquor dilated. Amniotomy was done and excessive clear liquor draineddrained..

Baseline obscured by acceleration Baseline obscured by acceleration with variable decelerationswith variable decelerations

ActionsActionsAdjust tocodynamometerAdjust tocodynamometer(yes)(yes)

Give sedation to the motherGive sedation to the mother (no)(no)Start syntocinonStart syntocinon(no)(no)

Fetal blood sampling for PHFetal blood sampling for PH (no) (no)Immediate cesarean sectionImmediate cesarean section (no)(no)

Course and OutcomeCourse and OutcomeProgressed to the second stage of labour and had normal Progressed to the second stage of labour and had normal

vaginalvaginal delivery. The outcome was female weighing 3218 gm. Apgar delivery. The outcome was female weighing 3218 gm. Apgar

scorescorewas 9/9 at one and five minuteswas 9/9 at one and five minutes . .

The infant followed an uncomplicated newborn outcomeThe infant followed an uncomplicated newborn outcome . .

Case # 11Case # 11

A 27 years old G 4 p 3 + 0 was admitted in labour at 41 A 27 years old G 4 p 3 + 0 was admitted in labour at 41 ½ weeks½ weeks’’

gestation. 15 minutes prior to this recording the cervix gestation. 15 minutes prior to this recording the cervix was 4cmwas 4cm

dilated with the head at –1 station. Artificial rupture of dilated with the head at –1 station. Artificial rupture of membranesmembranes

was performed and clear liquor drainedwas performed and clear liquor drained..

Early decelerationsEarly decelerations

ActionsActionsOxygen by facial maskOxygen by facial mask (no) (no)

Change maternal positionChange maternal position (no)(no)Cesarean section Cesarean section (no) (no)

Observe for the development of other types of declarations Observe for the development of other types of declarations (yes)(yes)

Vaginal examination for progress assessmentVaginal examination for progress assessment (no)(no)Fetal blood samplingFetal blood sampling (no)(no)

Course and outcomeCourse and outcomeProgressed to normal vaginal delivery of female Progressed to normal vaginal delivery of female

infantinfant weighing 3969 gm. Apgar score was 8/9 at one and weighing 3969 gm. Apgar score was 8/9 at one and

fivefive minutes. The infant followed a normal newborn minutes. The infant followed a normal newborn

coursecourse..

Case # 12Case # 12A 21 years old primigravid admitted in labour at 40 A 21 years old primigravid admitted in labour at 40

weeksweeks ‘ ‘

gestation.The vertex was in occipitoanterior position gestation.The vertex was in occipitoanterior position and liquorand liquor

was meconium stainedwas meconium stained..

Progression from Early to Variable Progression from Early to Variable DecelerationsDecelerations

ActionsActionsCesarean sectionCesarean section (no) (no)

Syntocinon infusionSyntocinon infusion (no)(no)Observe for the development of other types of declarations Observe for the development of other types of declarations

(yes)(yes)Fetal blood sampling for PHFetal blood sampling for PH (no)(no)

Oxygen by facial maskOxygen by facial mask (no)(no)

Course and OutcomeCourse and OutcomeNo other types of declarations developed. Progressed to No other types of declarations developed. Progressed to

normalnormalvaginal delivery of male infant weighing 3374 gm. Apgar vaginal delivery of male infant weighing 3374 gm. Apgar

scorescore was 7/9 at one and five minutes. The infant followed a normalwas 7/9 at one and five minutes. The infant followed a normal

newborn coursenewborn course..

Case # 13Case # 13 A 35 years old patient G 7 p 6 admitted at 42 weeks’ A 35 years old patient G 7 p 6 admitted at 42 weeks’

gestation ingestation in

labour. The cervix was 6 cm dilated with the head at - 2 labour. The cervix was 6 cm dilated with the head at - 2 stationstation , ,

liquor was stained with meconiumliquor was stained with meconium..

Late decelerationsLate decelerations

ActionsActionsObserve and review after1 hourObserve and review after1 hour (no)(no)

Cesarean section unless the fetus is about to be delivered Cesarean section unless the fetus is about to be delivered (yes)(yes)

Correct maternal hypotention if present Correct maternal hypotention if present (yes) (yes)

Fetal scalp blood for PHFetal scalp blood for PH (no)(no)Maternal Kleihaure-Betke testMaternal Kleihaure-Betke test

(yes)(yes)

Course and OutcomeCourse and OutcomeCesarean section was done. The outcome was male baby Cesarean section was done. The outcome was male baby

weighingweighing 31003100 gm. Apgar score was 2/8 at one and five minutesgm. Apgar score was 2/8 at one and five minutes . .

The infant had meconium aspirationThe infant had meconium aspiration..

Case # 14Case # 14

A 21 years old primigravid patient complaining of A 21 years old primigravid patient complaining of reduced fetalreduced fetal

movement at 42 weeks of gestation was admitted for movement at 42 weeks of gestation was admitted for induction ofinduction of

labour. Received prostin and started labouring. The labour. Received prostin and started labouring. The cervix wascervix was

3cm dilated, so amniotomy was done and liquor was 3cm dilated, so amniotomy was done and liquor was clearclear . .

Syntocinon infusion was started 30 minutes agoSyntocinon infusion was started 30 minutes ago..

Classic Variable DecelerationClassic Variable Deceleration

ActionsActionsObserve for development of other abnormal forms Observe for development of other abnormal forms (no)(no)

Cesarean sectionCesarean section(yes)(yes)Fetal blood sampling for PHFetal blood sampling for PH(no)(no)

Oxygen by facial maskOxygen by facial mask(no)(no)AmnioinfusionAmnioinfusion(no)(no)

Course and OutcomeCourse and OutcomeSyntocinon infusion was reduced and fetal heart returned to Syntocinon infusion was reduced and fetal heart returned to

normalnormal . .33 hours later CTG started to show late and late variable hours later CTG started to show late and late variable

decelerationsdecelerations , ,so cesarean section was performed for fetal distressso cesarean section was performed for fetal distress . .

Outcome was baby girl weighing 3 kg with 3 tight loops of the Outcome was baby girl weighing 3 kg with 3 tight loops of the cordcord

around the neck. Apgar score was 9/10 at one and five minutesaround the neck. Apgar score was 9/10 at one and five minutes . .The infant had normal newborn courseThe infant had normal newborn course . .

Case # 15Case # 15

A 29 years old G 4 p 2 + 1 patient admitted at 40 A 29 years old G 4 p 2 + 1 patient admitted at 40 weeks’ gestationweeks’ gestation

in labour. The head of the fetus was in in labour. The head of the fetus was in occipitoposterior positionoccipitoposterior position..

Sinus bradycardia with deceleration: Sinus bradycardia with deceleration: mixed patternmixed pattern

ActionsActionsCheck maternal pulseCheck maternal pulse(yes)(yes)

Change maternal positionChange maternal position(yes)(yes)Cesarean sectionCesarean section(no)(no)

Fetal blood sampling for PHFetal blood sampling for PH(yes)(yes)Oxygen by facial maskOxygen by facial mask (no) (no)

Reduce syntocinon infusion rate if it is in useReduce syntocinon infusion rate if it is in use (yes)(yes)

Course and outcomeCourse and outcomeProgressed to normal vaginal delivery of male baby Progressed to normal vaginal delivery of male baby

weighingweighing 26652665 gm. Apgar score was 9/9 at one and five minutesgm. Apgar score was 9/9 at one and five minutes . .

The infant followed normal courseThe infant followed normal course . .

Case # 16Case # 16

A 30 years old G 4 p 3 patient was admitted in labour A 30 years old G 4 p 3 patient was admitted in labour at 36 weeksat 36 weeks’’

gestation. She had H/O cesarean section in her second gestation. She had H/O cesarean section in her second deliverydelivery . .

One hour prior to this trace, the cervix was 8cm dilated One hour prior to this trace, the cervix was 8cm dilated and clearand clear

liquor was drainingliquor was draining

Prolonged DecelerationProlonged Deceleration

ActionsActionsVaginal examinationVaginal examination (yes) (yes)

Check maternal vital signsCheck maternal vital signs (yes)(yes)Fetal blood sampling for PHFetal blood sampling for PH (no)(no)

Cesarean sectionCesarean section (yes)(yes)Oxygen by facial maskOxygen by facial mask (no) (no)

Course and outcomeCourse and outcomeRupture uterus was suspected and laparatomy was Rupture uterus was suspected and laparatomy was

performedperformed..There was complete scar dehiscence and the infant was in There was complete scar dehiscence and the infant was in

thethe peritoneal cavity. It was male 3.1 00 gmand fresh stillbirthperitoneal cavity. It was male 3.1 00 gmand fresh stillbirth . .

The uterus was repairedThe uterus was repaired..

Case # 17Case # 17 A 29 years G 3 p 1 + 1 was admitted at her first antenatal A 29 years G 3 p 1 + 1 was admitted at her first antenatal

care visit atcare visit at

3838 weeks’ gestation for blood sugar control, as blood weeks’ gestation for blood sugar control, as blood sugar wassugar was

found high. Polyhydraminous and big baby were found high. Polyhydraminous and big baby were diagnoseddiagnosed . .

She started to complain of labour painsShe started to complain of labour pains

Absent Long Term, Present Short Absent Long Term, Present Short Term VariabilityTerm Variability

ActionsActionsVaginal examinationVaginal examination (yes) (yes)

Vibroa-acouastic stimulationVibroa-acouastic stimulation (no)(no)Oxygen by facial maskOxygen by facial mask (no)(no)Maternal blood sugarMaternal blood sugar (yes)(yes)

Immediate cesarean sectionImmediate cesarean section (no) (no)Wait for another 10 minutesWait for another 10 minutes (yes)(yes)

Course and OutcomeCourse and OutcomeFetal heart returned to normal with good variability and Fetal heart returned to normal with good variability and

accelerationsaccelerations . .Cesarean section was done as plannedCesarean section was done as planned . .

The outcome was baby boy weighing 4100gm. Apgar score The outcome was baby boy weighing 4100gm. Apgar score waswas

9/99/9 at one and five minutesat one and five minutes..

Case # 18Case # 18

A 23 years old primigravid patient, twin pregnancy was A 23 years old primigravid patient, twin pregnancy was admitted inadmitted in

labour at 40 weeks’ gestation. The first twin was in labour at 40 weeks’ gestation. The first twin was in cephaliccephalic

presentation and second twin was in breech presentation. presentation and second twin was in breech presentation. The cervixThe cervix

was 3 cm dilated with intact membranes one hour earlierwas 3 cm dilated with intact membranes one hour earlier

Dual channel monitoring: Dual channel monitoring: twins single scaletwins single scale

ActionsActionsContinue observation as for uncomplicated twinContinue observation as for uncomplicated twin(yes)(yes)

Amniotomy and fetal scalp electrode Amniotomy and fetal scalp electrode (no)(no)Cesarean sectionCesarean section(no)(no)

Oxygen by facial maskOxygen by facial mask(no)(no)Change maternal positionChange maternal position(no)(no)

Course and OutcomeCourse and OutcomeCesarean section was done for arrest of cervical dilatation at 6 Cesarean section was done for arrest of cervical dilatation at 6

cm andcm andfailure to descent of fetal head. First twin was male with failure to descent of fetal head. First twin was male with

deflexed headdeflexed head weighing 3000 gm. Apgar score was 5/8 at one and five weighing 3000 gm. Apgar score was 5/8 at one and five

minutesminutes . .Second twin was breech, male weighing 2150 gm. Apgar score Second twin was breech, male weighing 2150 gm. Apgar score

6/8 at6/8 at one and five minutes. There was one placenta. Both twins had one and five minutes. There was one placenta. Both twins had

normalnormal newborn coursenewborn course..

Case # 19Case # 19

A 25 years old primigravid patient, diabetic on diet A 25 years old primigravid patient, diabetic on diet control with mild pregnancy induced control with mild pregnancy induced

hypertension.Labour was induced at 38 weeks gestation hypertension.Labour was induced at 38 weeks gestation with vaginal prostin. She had spontaneous rupture of with vaginal prostin. She had spontaneous rupture of

membranes 24 hours before this trace and clear liquor membranes 24 hours before this trace and clear liquor draineddrained..

Late Deceleration and Severe Variable Late Deceleration and Severe Variable

DecelerationDeceleration ActionsActions

Change maternal positionChange maternal position(yes)(yes)Fetal blood samplingFetal blood sampling(no)(no)

Immediate cesarean sectionImmediate cesarean section(no)(no)

Exclude cord prolapseExclude cord prolapse (yes)(yes)

Wait and review as normal patientWait and review as normal patient(no)(no)

Administration of tocolytics if the pattern continuesAdministration of tocolytics if the pattern continues(yes)(yes)

Course and outcomeCourse and outcomeCesarean section was performed for failed induction of Cesarean section was performed for failed induction of

labourlabour . .Outcome was female infant weighing 3200 gm. Apgar Outcome was female infant weighing 3200 gm. Apgar

score wasscore was 9/109/10 at one and five minutesat one and five minutes..

The infant followed normal newborn outcomeThe infant followed normal newborn outcome..

Case # 20Case # 20

A 35 years old G 3p 1 + 1 had induction of labour at 39 A 35 years old G 3p 1 + 1 had induction of labour at 39 weeks forweeks for

premature rupture of membranes. She had received premature rupture of membranes. She had received pethidine 90pethidine 90

minutes prior to this segment. The fetus was in vertexminutes prior to this segment. The fetus was in vertex

presentation in occipetoanteror position at that timepresentation in occipetoanteror position at that time . .

Absent short term, present long Absent short term, present long term variabilityterm variability

ActionsActionsReview previous segments of the trace to compare Review previous segments of the trace to compare

(yes)(yes)Fetal blood sampling for PHFetal blood sampling for PH

(yes)(yes)Change maternal positionChange maternal position(no)(no)

Immediate cesarean sectionImmediate cesarean section (no)(no)

Observe and review vaginally after 30 minutesObserve and review vaginally after 30 minutes(yes)(yes)

Course and outcomeCourse and outcomeThe tracing improved and the patient had normal vaginal The tracing improved and the patient had normal vaginal

delivery ofdelivery of female baby weighing 3600 gm. Apgar score was 8/9 at female baby weighing 3600 gm. Apgar score was 8/9 at

one and fiveone and five

minutes. The infant had normal newborn courseminutes. The infant had normal newborn course..

Case # 21Case # 21 A19 years old G 2 p1 patient was admitted in active A19 years old G 2 p1 patient was admitted in active

labour at 30weeks gestationlabour at 30weeks gestation

DecreasedDecreased uterineuterine activityactivity producedproduced byby tocodynamometertocodynamometer placement:placement: artifactartifact

ActionsActionsAdjust tocodynamometer belt Adjust tocodynamometer belt (yes)(yes)

Observe for development of other forms of decelerationsObserve for development of other forms of decelerations(yes)(yes)Administration of tocolyticsAdministration of tocolytics(no)(no)

Start augmentation with syntocinonStart augmentation with syntocinon(no)(no)Immediate cesarean sectionImmediate cesarean section(no)(no)

Course and outcomeCourse and outcomeUterine contractions were properly recorded after adjustment Uterine contractions were properly recorded after adjustment

of theof the tocodynamometer belt. The patient had normal vaginal tocodynamometer belt. The patient had normal vaginal

delivery of adelivery of a Male baby weighing 1304 gm. Apgar score was 7/7 at one and Male baby weighing 1304 gm. Apgar score was 7/7 at one and

fivefiveminutes. The cord was wrapped around the arm of the baby minutes. The cord was wrapped around the arm of the baby

whowho developed largeintraventricular haematoma . it was developed largeintraventricular haematoma . it was

discharged fromdischarged from the hospital after 58 daysthe hospital after 58 days . .

Case # 22Case # 22

A 25 years old primigravida admitted in labour at 40 A 25 years old primigravida admitted in labour at 40 weeksweeks

gestation.The fetus was in occipitoanterior positiongestation.The fetus was in occipitoanterior position

W –shaped Variable deceleration with W –shaped Variable deceleration with

maternalmaternal strainingstraining

ActionsActions::Observe and allow labour to progressObserve and allow labour to progress(yes)(yes)

Cesarean section Cesarean section (no)(no)Syntocinon infusion for augmentation of labourSyntocinon infusion for augmentation of labour(no)(no)

Adjust tocodynamometer beltAdjust tocodynamometer belt(no)(no)Oxygen by facial maskOxygen by facial mask(no)(no)

Course and Course and outcomeoutcome Progressed and had normal vaginal delivery of a female Progressed and had normal vaginal delivery of a female

weighingweighing34453445 gm. Apgar score was 9/9 at one and five minutesgm. Apgar score was 9/9 at one and five minutes . .

The infant followed a normal newborn courseThe infant followed a normal newborn course..