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Posted: 08 Sep 2012 08:43 PM PDT

Non-reassuring foetal status in labour is usually something that just happens without any foreseeable reason. There is nothing that the mother could have done to prevent it.

THE term "foetal distress" is commonly used to describe the signs indicating that the foetus is not well or not coping well with labour.

However, it is an imprecise and non-specific term as it has poor predictive value in those who are at increased risk. It is often associated with a baby who is born in good condition, as evidenced by the Apgar score (a simple, rapid method that assesses the health of newborns), umbilical cord blood gas analysis, or both. Because of the implications of the term "foetal distress", inappropriate actions like unnecessary urgent delivery have often been taken.

As such, most obstetricians, acknowledging the imprecision in data interpretation, use the phrase "non-reassuring foetal status" instead.

Challenges to foetal health

Challenges to foetal health can occur in pregnancy, or more commonly, during labour. The reasons are varied, and include insufficient oxygen, biochemical changes, and a sick foetus.

Insufficient oxygen can occur when there is inadequate blood flow to the foetus through the placenta and umbilical cord. It can occur during a contraction in labour.

However, when the uterus relaxes, the blood flow increases. This process is normal, and does not affect a healthy foetus.

However, there are situations in which the blood flow to the foetus is reduced, leading to oxygen insufficiency over time, or suddenly, if it is acute.

The situations include placental insufficiency – in which placental function is less than optimum due to maternal high blood pressure, bleeding in late pregnancy, maternal heart conditions, or growth-retarded or post-date foetuses; excessive uterine contractions in augmented or induced labour; marked decrease in maternal blood pressure, as in heavy bleeding, epidural analgesia and prolonged lying on the back in labour; umbilical cord compression or prolapse; and placental abruption, in which the placenta separates prematurely from the uterine wall, and when twins share one placenta.

Maternal biochemical changes in an ill mother can affect the foetus. This can occur in conditions like diabetes, kidney disease, or reduction of the flow of bile from the liver to the intestine.

The foetus may be unwell for a variety of reasons, like a foetal abnormality, an inherited condition, infection and maternal fever.

The foetus can cope with many of the challenges to its health. However, the likelihood of the foetus being affected is increased if there is maternal diabetes or high blood pressure, multiple pregnancy, or increased maternal age.

Assessment of foetal well being

Foetal movements

Foetal movements are the best form of reassurance that the foetus is well. They have been described as a kick or flutter.

Most women are aware of foetal movements at 18 to 20 weeks gestation. The first-time mother may be aware after 20 weeks, and the mother who has been pregnant before may be aware as early as 16 weeks.

The movements are felt throughout pregnancy and during labour. Its frequency and type change with advancing pregnancy. There are periods of maximum activity, and there are periods when the foetus is asleep, lasting 20 to 40 minutes, during which there will be no movements.

The number of movements increases until 32 weeks gestation, and remain the same until delivery, although the type may alter nearer to the estimated date of delivery.

Foetal movements are less noticeable if one is busy, and during labour.

There is no specific number of movements that is considered normal. Every mother should be aware of their child's individual pattern of movements.

If you're unsure whether there is a reduction, all that is needed is to lie on the left side and concentrate on the movements for the next two hours. If there are less than 10 or more separate movements during this time, medical attention should be sought. This should be done immediately if the pregnancy is more than 28 weeks.

Foetal heart rate

The foetal heart rate (FHR) is monitored during pregnancy and labour by the midwife, who will ask the attending doctor to check mother and foetus, if she has any concerns. It is measured either at regular intervals (intermittent), or continuously during labour. The former is the usual mode of monitoring when there are no pregnancy complications.

In addition to intermittent monitoring, the FHR will also be checked before and after vaginal examinations, or when the membranes rupture.

There are situations in which continuous FHR monitoring will be advised. This would include maternal or foetal health, labour reasons, or abnormal FHR on intermittent monitoring, ie less than 110, or more than 160, beats per minute, or slowing of the heart rate (deceleration) after a contraction. The maternal reasons include raised blood pressure, diabetes, infection, and heart or kidney problems. The foetal reasons include pregnancy past 42 weeks, foetus that is small for date or premature, attempted vaginal breech delivery, and multiple pregnancies.

Continuous monitoring is also advised when the mother's labour is augmented or induced, there is vaginal bleeding prior to or during labour, significant meconium staining of the liquor, maternal fever, and if the mother had a previous Caesarean section, or has epidural or spinal analgesia. Some mothers who have no pregnancy or labour problems may also request continuous monitoring.

There are two graphs on the cardiotocograph (CTG) – the upper graph records the FHR in beats per minute, and the lower graph, the maternal contractions in millimetre mercury.

The normal FHR is between 120 and 160 beats per minute. The constant up and down fluctuations of five to 25 beats from the baseline (variability) reflects a healthy foetus. An increase above the baseline with foetal movement is reassuring.

The FHR may decrease slightly during a contraction (deceleration). This is normal, provided the FHR recovers rapidly once the contraction stops.

Decelerations are described as early or late, depending on its occurrence in relation to uterine contractions.

Change in the baseline, especially if prolonged, has loss of or increase in variability, and late or prolonged decelerations are not reassuring.

False positive CTGs (ie changes indicative of a problem when there is none) are common. They are associated with increased assisted deliveries with ventouse or forceps, and Caesarean sections. This is the reason why the term non-reassuring foetal status is preferred.

Meconium

Meconium is produced by the foetal gut, and comprises materials ingested by the foetus in the uterus, ie intestinal epithelial cells, lanugo, mucous, amniotic fluid, bile, and water. It is the earliest faeces of an infant, and is dark green, almost odourless, viscous, and sticky like tar. It is usually stored in the foetal gut until after birth, but sometimes, it is expelled into the amniotic fluid before or during labour, and delivery.

It is completely passed after the first few days of life, with the stools becoming yellow.

Amniotic fluid is usually clear. But if it is of various shades of green or brown, it is an indicator that the foetus has passed meconium. Meconium may be a sign that the foetus has problems, although it is common to find meconium in the amniotic fluid of women past their estimated date of delivery.

Thick meconium is of concern as it may get into the foetal airways and cause meconium aspiration syndrome (MAS). Meconium irritates the lungs, causes infection of the airways and may block it, thereby leading to breathing difficulties at birth.

Foetal blood sampling

Foetal blood sampling (FBS) assists in clarifying the significance of abnormal FHR changes and confirms if the foetus is short of oxygen (hypoxic). It involves taking a few drops of blood from the foetal scalp through the vagina.

It is checked for the levels of oxygen, carbon dioxide and pH. This will provide information about how the foetus is coping with the stress of labour.

FBS is not carried out sometimes because of maternal infection or when such facilities are not available in the hospital.

Dealing with non-reassuring foetal status

If the FBS results are within normal range, labour will usually be allowed to proceed. The FBS may be repeated if they are borderline normal.

If there are concerns about the results, the therapeutic measures taken will include giving the mother oxygen by face mask; turning her to her left to reduce uterine pressure on a large vein in the back (vena cava), thereby improving the blood flow back to the heart and consequent blood flow to the placenta and foetus; temporarily stopping medicines that increase uterine contractions; and increasing fluid intake through an intravenous drip.

If the above measures do not lead to an improvement in the FHR, delivery of the foetus will be expedited. Depending on the stage of labour and the cervical dilatation, assisted vaginal delivery with a forceps or ventouse, or emergency Caesarean section will be carried out.

As the patient may be alarmed at the turn of events, the obstetrician or midwife will provide an explanation and the reasons for the measures being taken.

■ Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. For further information, e-mail starhealth@thestar.com.my. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

Mummy, peeing hurts!

Posted: 08 Sep 2012 08:42 PM PDT

If your child runs to the washroom frequently or complains of pain while urinating, it's possible the cause is a urinary tract infection.

A URINARY tract infection (UTI) is an infection affecting the urinary system, most commonly caused by the bacteria Escherichia coli (E. coli), which resides in the intestinal tract. The urinary tract, which makes and carries urine out of the body, includes the kidneys, ureters, bladder and urethra.

How does bacteria get in and cause UTI?

Bacteria or germs usually get into the body through the urethra, the tube that carries urine from the bladder to be passed outside. Once inside the urethra, these germs may travel up into the bladder and cause cystitis, the most common type of UTI.

If this bladder infection is not swiftly treated, it can spread to the kidneys and cause pyelonephritis, a more serious type of kidney infection. While bladder infections can cause slight discomfort and inconvenience, a kidney infection can cause back pains and abdominal pains, high fever, cloudy or bloody urine, nausea and vomiting.

Girls tend to get UTIs more frequently than boys. A probable reason for this is that the urethra of a female is shorter than that of a male, thus making it easier for bacteria to move up into the bladder.

Another reason is the close proximity of the urethral opening to the vagina and rectum, where bacteria are likely to be.

Some children may get UTIs more frequently because they have other problems, like an abnormality in the urinary tract that makes them more prone to infection.

A child is more likely to get a UTI if he or she does not drink enough water or fluids to keep the bladder active and bacteria-free.

The chances of getting a bladder infection are higher if something blocks the flow of urine from the bladder, for example, having kidney stones or an enlarged prostate gland in adults.

In babies and children, a congenital abnormality of the urinary system is a possible cause.

Those who are sexually active also face the risk of UTI. During sexual intercourse, the germs or bacteria in the vaginal area may be pushed into the urethra and up into the bladder, where the urine provides a good environment for the bacteria to grow.

Bacteria can also get into a girl's bladder when she wipes from back to front after urination and bowel movement.

Bladder infection symptoms may include:

·Frequent urination

·A burning sensation or pain during urination

·Feeling the need to urinate, but little or no urine comes out

·Pain above the pubic bone

·Mild fever and fatigue

In babies less than one month old, infection usually starts from the blood. However, because blood very seldom appears in a baby's urine, it cannot be assumed that he or she does not have a UTI.

Babies will not complain of pain during urination. They will just have fever, painful or tender abdomen, reduced feeding, or cry incessantly. You may also notice prolonged jaundice in these babies. Therefore, admission and aggressive treatment is required for a baby with a UTI as this could be an early sign that the baby's urinary tract is not normal.

Urine needs to be collected to confirm the infection, and appropriate treatment commenced. Repeated or persistent bacteria in the urine will need further investigation to look at any abnormality in the urinary tract.

Young children who can already talk may complain of pain when passing urine, or in the abdomen near the kidneys. Bed-wetting in a child who previously stayed "dry" all night may also be a symptom of a UTI.

If your child has any of the above symptoms, take him or her to see a doctor right away. These symptoms will not simply disappear, and may become worse. The earlier your child is treated, the less uncomfortable he or she will be.

Fighting the infection

If your child or teenager suffers from most of the above symptoms, the doctor will confirm if he or she has a UTI by taking a urine sample for urinalysis. If your child's symptoms and urinalysis show an uncomplicated urinary tract infection, then the doctor will probably prescribe antibiotics.

However, if unusual UTI symptoms occur, such as symptoms that last longer than seven days of UTI in infants, or symptoms of a kidney infection, then the doctor will order a a urine culture to identify what type of bacteria is causing the infection, so that the most effective antibiotic for that bacteria can be used.

He or she may proceed to do other tests to look at the kidneys. Your child will be prescribed antibiotics for seven to 14 days, and the entire course must be completed so that the bacteria can be completely killed.

Preventing UTIs

There are several ways to reduce your child's risk of getting a UTI.

Advise your child to always go to the bathroom as frequently as possible, and to keep the genital area clean and dry after washing up.

For girls, after urination or bowel movement, advise her to wipe from front to back to avoid the spread of germs from the rectal area to the urethra.

For those who are sexually active, be sure to wash the genital area after intercourse in order to remove bacteria.

Advise your child to refrain from holding in urine for long periods of time. He or she should also drink the equivalent of eight glasses of water a day.

Girls should change their tampons or sanitary pads regularly during menstruation. Advise them to avoid prolonged exposure of moisture in the genital area by not wearing wet undergarments, and to limit the use of feminine hygiene sprays as this may irritate the urethra.

Although UTIs are often painful and uncomfortable, they can be easily treated and prevented.

If you suspect that your child may be suffering from a UTI, take him or her to a doctor immediately. In such circumstances, taking swift action is the most important thing to do.

■ Datuk Dr Zulkifli Ismail is a consultant paediatrician and paediatric cardiologist. This article is courtesy of Positive Parenting Programme by Malaysian Paediatric Association. The opinions expressed in the article are the view of the author. For more information, please visit www.mypositiveparenting.org.

Exposing Malaysian hearts

Posted: 08 Sep 2012 08:38 PM PDT

Heart exhibition aims to educate Malaysians about heart disease.

HEART disease has been the number one killer of Malaysians for more than three decades. Not only do the statistics show no signs of decreasing, but the figures are actually rising at quite a startling rate.

Today, we have 10 million Malaysians who have unhealthy cholesterol levels; one in five Malaysians are diabetic; and just under 50% are overweight or obese. They are all at increased risk of heart disease. Not very reassuring, is it?

Cognizant of these dismal figures, Institut Jantung Negara (IJN) and Yayasan Jantung Malaysia (YJM) have initiated an awareness programme, The Heart 2012.

The event is currently on at the Mid Valley Exhibition Centre, Kuala Lumpur.

The Heart 2012 aims to provide you, your family and friends with a fun-filled, yet educational exhibition. Today is the second and last day of the two-day event.

There will be free health screenings and counselling by qualified professionals, and what's more, you need not pay a hefty bill to get tips and advice from cardiologists and heart-health professionals at the exhibition.

The event will also feature Malaysia's first 3-D mega heart structure. Here's your chance to take an adventurous ride through one of the most vital organs in our bodies – the heart.

There's no better way to understand one's own cardiovascular health than to begin with recognising the structure and functioning of the heart, inside-out.

You can also learn about how arteries clog up, and other interesting heart-related facts.

Other major attractions throughout the two-day event will be hourly lucky draws, premiums and special discounts by over 25 exhibitors.

For more information on the exhibition, visit www.theheart.com.my.

Kredit: www.thestar.com.my

Isnin, 10 September 2012

The Star Online: Lifestyle: Health

The Star Online: Lifestyle: Health

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