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View this article online at: patient.info/doctor/fetal-distress

Fetal Distress
Synonym: fetal compromise; non-reassuring fetal heart rate trace

Fetal distress refers to the compromise of the fetus due to inadequate oxygen or nutrient supply. This can occur due to maternal, fetal or
placental factors. At its most severe it may lead to neonatal brain injury or stillbirth. Its presence may be suspected due to various
factors but all have a high false positive rate.

Pathogenesis
The main cause of antepartum fetal distress is uteroplacental insufficiency.

Factors within labour are complex but processes such as uteroplacental vascular disease, reduced uterine perfusion, intrauterine
sepsis, reduced fetal reserves and cord compression can be involved alone or in combination. Gestational and antepartum factors can
modify the fetal response to them.

Reduced liquor volume, maternal hypovolaemia and fetal growth restriction are known associations.

Epidemiology
The overall risk of prompt caesarean delivery needed for fetal concern was shown to be 3.1% in an unselected population [1] . The risk
exceeded 20% in patients with severe pre-eclampsia, post-term or fetal growth-restricted fetuses with abnormal Doppler studies and
also in women with moderate/severe asthma or severe hypothyroidism.

The vast majority of cases of cerebral palsy in otherwise normal term infants are not associated with intrapartum hypoxia-ischaemia [2] .

Risk factors
Includes women with a history of:

Stillbirth.
Intrauterine growth restriction (IUGR).
Oligohydramnios or polyhydramnios.
Multiple pregnancy.
Rhesus sensitisation.
Hypertension.
Obesity.
Smoking.
Diabetes and other chronic diseases.
Pre-eclampsia or pregnancy-induced hypertension.
Decreased fetal movements.
Recurrent antepartum haemorrhage.
Post-term pregnancy.

Maternal age over 35 years, and particularly over 40, is an independent risk factor for uteroplacental insufficiency, fetal distress and
stillbirth; the highest risk is in older women who are also nulliparous [3, 4] .
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Presentation [5]
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Presentation [5]
See also separate Intrapartum Fetal Monitoring article.

Fetal distress presents in varied ways and to differing degrees. It may be suspected by the following, which may also be used for further
evaluation of suspected fetal distress:

Clinical suspicion when decreased fetal movements are felt by the mother or there is a slowing or stopping of the growth of
serial symphysis fundal height.
Abnormal sonographic biometric parameters when IUGR or macrosomia is suspected.
Doppler ultrasound is particularly valuable when performed up to 34 weeks of gestation:
Umbilical artery Doppler may detect changes that reflect increasing placental vascular resistance.
Fetal arterial Doppler of, for example, the middle cerebral artery, may detect reduced resistance which has
developed to maintain blood flow to the fetal brain when placental function is impaired.
Fetal venous Doppler may detect changes indicative of impaired cardiac function and fetal acidosis.

Cardiotocography (CTG) shows the fetal heart rate response to fetal movement and to maternal contractions. The trace it
produces may be described as reassuring, non-reassuring or abnormal:
Antenatal CTG:
A normal fetal heart rate accelerates with fetal movement and is described as reactive.
Stillbirth rates have been shown to be significantly lower after a reactive trace than after a non-reactive
trace [6] .
CTG interpretation is open to inter- and intra-observer variation but can be interpreted by computerised
analysis. CTG should not be used as the only form of surveillance of a high-risk pregnancy [7] .
A contraction stress test, carried out during induced contractions using oxytocin, has no clinical
benefits, a false positive rate as high as 50% and may have significant adverse effects [8] . It is not used
in the UK.

Intrapartum CTG:
See separate Intrapartum Fetal Monitoring article for details.
CTG should not be used routinely as part of the initial assessment of low-risk women in early labour [9] .
No decision about a woman's care should be made on the basis of CTG findings alone [10] .

Biophysical profile (BPP) is time-consuming and rarely abnormal in the presence of normal umbilical arterial Doppler. It
consists of a combination of CTG, fetal behaviour (including movement, tone and breathing) and amniotic fluid volume. This
produces a BPP score to predict the degree of any compromise to the fetus. Available evidence does not support its routine
use in high-risk pregnancies but observational data suggest it has good negative predictive value for fetal compromise [6] .
Amniotic fluid volume, both oligohydramnios and polyhydramnios, has been shown to be associated with poor fetal
outcomes. However, oligohydramnios is itself associated with IUGR and urogenital malformations, which were not controlled
for in the studies demonstrating an association with poor outcomes. Polyhydramnios, when clinically apparent, is related to
poor neonatal outcomes but mild, idiopathic polyhydramnios, detected only on ultrasound, is not associated with adverse
outcomes.
Fetal scalp blood sampling during labour, to measure lactate (in preference to pH if available), may be indicated for an
abnormal intrapartum CTG [10] . See separate Intrapartum Fetal Monitoring article for details.

A composite risk score, based on fetal Doppler flow resistance indices, has shown promise in identifying those fetuses antenatally who
develop fetal distress intrapartum [11] .
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Management
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Management
There have been no recent trials of operative versus conservative management of suspected fetal distress [12] .

Signs of antenatal fetal distress require monitoring with a view to induction of labour or planned caesarean section.
Immediate delivery of a preterm fetus with suspected fetal distress may reduce the risk of intrauterine hypoxia but increases
the risks associated with prematurity. Benefit may be gained by deferring delivery, especially if there is uncertainty; however,
evidence is lacking to guide this decision [13] .
Continuing fetal distress during labour may indicate the need for delivery to be expedited:
Speed of delivery should take into account the severity of fetal heart rate and blood sampling abnormalities and
relevant maternal factors.
The current accepted standard is that expedited delivery should occur as quickly and safely as possible and within
30 minutes if there is an immediate threat to life of either the mother or the fetus [14] . However, this is not achieved
in a substantial proportion of cases, although it is uncertain how significant this is clinically [15] .
There is some evidence that very short 'decision-to-incision' time (<20 minutes) may be inversely proportional to
neonatal outcomes, ie lower umbilical pH and Apgar scores [16] .

Amnioinfusion has been shown to be beneficial in suspected umbilical cord compression (particularly when there is
oligohydramnios), with a reduced risk of caesarean section [17] :
In this process, sodium chloride or Ringer's lactate is infused transcervically or, if the membranes are still intact,
via a needle inserted under ultrasound guidance through the uterine wall.
The potential adverse effects include umbilical cord prolapse, uterine scar rupture and amniotic fluid embolism.
The current evidence on the safety and efficacy of this procedure means it is not recommended in the UK for
intrauterine fetal resuscitation [10] ; it is only undertaken under special arrangements that include audit and
research [18] .

Term or post-mature fetuses may produce meconium-stained liquor. Meconium can be detrimental to the fetal lungs by
producing a chemical pneumonitis if inhaled:
Significant meconium is defined as dark green or black amniotic fluid that is thick or tenacious, or any meconium-
stained amniotic fluid containing lumps of meconium [10] :
If significant meconium is present, fetal blood sampling and advanced neonatal life support may be
required at delivery.
If there has been non-significant meconium, the baby should be observed at one and two hours.

Amnioinfusion has been used to reduce the risk of meconium aspiration by diluting the meconium present;
however, it is unclear whether this is beneficial and it is not used in routine practice [19] .

Further reading & references

1. Chauhan SP, Magann EF, Scott JR, et al; Cesarean delivery for fetal distress: rate and risk factors. Obstet Gynecol Surv. 2003 May;58(5):337-50.
2. MacLennan AH, Thompson SC, Gecz J; Cerebral palsy: causes, pathways, and the role of genetic variants. Am J Obstet Gynecol. 2015 May 21. pii:
S0002-9378(15)00510-4. doi: 10.1016/j.ajog.2015.05.034.
3. Gordon A, Raynes-Greenow C, McGeechan K, et al; Risk factors for antepartum stillbirth and the influence of maternal age in New South Wales
Australia: a population based study. BMC Pregnancy Childbirth. 2013 Jan 16;13:12. doi: 10.1186/1471-2393-13-12.
4. RCOG Statement on later maternal age; Royal College of Obstetricians and Gynaecologists, 15 June 2009
5. Bond DM, Gordon A, Hyett J, et al; Planned early delivery versus expectant management of the term suspected compromised baby for improving
outcomes. Cochrane Database Syst Rev. 2015 Nov 24;(11):CD009433. doi: 10.1002/14651858.CD009433.pub2.
6. Reduced Fetal Movements; Royal College of Obstetricians and Gynaecologists (February 2011)
7. The Investigation and Management of the Small-for-Gestational-Age Fetus; Royal College of Obstetricians and Gynaecologists Green-top guideline
(Mar 2013)
8. S1-Guideline on the Use of CTG During Pregnancy and Labor: Long version - AWMF Registry No. 015/036; Geburtshilfe Frauenheilkd. 2014
Aug;74(8):721-732.
9. Intrapartum care; NICE Quality Standard, December 2015
10. Intrapartum care: care of healthy women and their babies during childbirth; NICE Clinical Guideline (Dec 2014)
11. Prior T, Mullins E, Bennett P, et al; Prediction of fetal compromise in labor. Obstet Gynecol. 2014 Jun;123(6):1263-71. doi:
10.1097/AOG.0000000000000292.
12. Hofmeyr GJ, Kulier R; Operative versus conservative management for 'fetal distress' in labour. Cochrane Database Syst Rev. 2012 Jun
13;6:CD001065. doi: 10.1002/14651858.CD001065.pub2.
13. Stock SJ, Bricker L, Norman JE, et al; Immediate versus deferred delivery of the preterm baby with suspected fetal compromise for improving
outcomes. Cochrane Database Syst Rev. 2016 Jul 12;7:CD008968. doi: 10.1002/14651858.CD008968.pub3.
14. Caesarean section; NICE Clinical Guideline (November 2011)
15. Tolcher MC, Johnson RL, El-Nashar SA, et al; Decision-to-incision time and neonatal outcomes: a systematic review and meta-analysis. Obstet
Gynecol. 2014 Mar;123(3):536-48. doi: 10.1097/AOG.0000000000000132.
16. Hillemanns P, Strauss A, Hasbargen U, et al; Crash emergency cesarean section: decision-to-delivery interval under 30 min and its effect on Apgar
and umbilical artery pH. Arch Gynecol Obstet. 2005 Dec;273(3):161-5. Epub 2005 Jul 26.
17. Hofmeyr GJ, Lawrie TA; Amnioinfusion for potential or suspected umbilical cord compression in labour. Cochrane Database Syst Rev. 2012 Jan
18;1:CD000013. doi: 10.1002/14651858.CD000013.pub2.
18. Therapeutic amnioinfusion for oligohydramnios during pregnancy (excluding labour); NICE Interventional Procedure Guidance, November 2006
19. Hofmeyr GJ, Xu H, Eke AC; Amnioinfusion for meconium-stained liquor in labour. Cochrane Database Syst Rev. 2014 Jan 23;(1):CD000014. doi:
10.1002/14651858.CD000014.pub4.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient
Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor
or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
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Author: Peer Reviewer:

Dr Jacqueline Payne Shalini Patni

Document ID: Last Checked: Next Review:

1342 (v25) 28/09/2016 27/09/2021

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