CTG – INTERPRET

WITH CARE

1
Fetal Monitoring in Labor:
Two Acceptable Methods
• Electronic • Auscultated
– In “active” labor – – Prescribed intervals
by convention – Various devices but
needs to be one recorded
continuous number
– High false positives – Easy to interpret
(K. Nelson 1996) – Intermittent
– Variable
– Acceptable for
interpretations
“high” risk patients

2
 Why Auscultation?

• Simple • Fewer C/S’s

• Well liked by • Legally less
damning-
patients
interpretation clear
• Clear cut action/
• Allows changing
response
entire environment
• Improves ability to in L&D
ambulate
• Decreases patient,
• Easier family, nurse and
physician anxiety
3
4
 Electronic Monitoring:
Later Outcome Nigel Paneth 1993
Clin. Invest Med. Michigan St. Univ

• “Central hypotheses of EFM has

never been tested”
– That is, “that its use (EFM) can
effectively prevent the... brain
damaging birth asphyxia by timely
intervention in labor.”

5
 For hypothesis to be
true: Paneth (1993)
• EFM must be reliable (inter-observer
agreement on identity and meaning)
• EFM must be valid (patterns statistically
linked with adverse neurological
events)
• EFM and adverse outcome are related,
specifically association is
• causal

6
CRITICISMS TOWARDS CARDIOTOCOGRAPHY
• Insufficient understanding of the (patho-)physiologic
background
• A number of technical pitfalls
• Differences in recording techniques
• Primarily qualitative information (pattern recognition)
• Lack of uniform classification systems
• Confusion due to the many influences on the fetal heart
rhythm
• Substantial intra- and inter-observer variation regarding
the interpretation
• Low validity, high incidence of false-positive findings
• Primarily screening method, too often applied as a
diagnostic
• Leads to an increase in artificial deliveries
• Lack of agreement on how, when, and whom to
monitor
• Contributes to medico-legal vulnerability
7
 ARGUMENTS
AGAINST
AUSCULTATION
• Hard to do!
– No, not really! • Will cause fetal
harm, or CP?
• Requires more
staff – No more so than
continuous EFM
– Shouldn’t have
to May miss
something?
• Does not meet
standard of care -Such as??
– Untrue! • Not legally
defensible
– Hardly
8
 THEN WHY DISCUSS
CTG???
• USEFUL IN HIGH RISK CASES.

• STANDARDISED EVIDENCE
BASED GUIDELINES ARE
BEING LAID FOR CORRECT
USE,INTERPRETATION ,
FURTHER DECISION MAKING &
RECORD KEEPING.

9
Appropriate monitoring in an
uncomplicated
pregnancy

For a woman who is healthy and has had

an otherwise uncomplicated pregnancy,
intermittent auscultation should be
offered and recommended in labour to
monitor fetal wellbeing.
In the active stages of labour, intermittent
auscultation should occur
after a contraction, for a minimum of 60
seconds, and at least:
• every 15 minutes in the first stage
• every 5 minutes in the second stage.
. Grade A
Recommendation 10
Indications
for the
use of
continuou
s EFM

11
GRADE B RECOMMENDATION

Continuous EFM should be offered and

recommended for high-risk
pregnancies where there is an increased risk of
perinatal death,
cerebral palsy or neonatal encephalopathy.

Continuous EFM should be used where

oxytocin is being used for
induction or augmentation of labour.

12
REF:RCOG GUIDELINES
 ADMISSION CTG
Current evidence does not
support the use of the
admission CTG in
low-risk pregnancy and it is
therefore not recommended

Grade B
Recommendation
13
Selected High-Risk Indications for
Continuous Monitoring of Fetal
Heart Rate
Maternal medical illness
Gestational diabetes
Hypertension
Asthma
Obstetric complications
Multiple gestation
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Oligohydramnios
Premature rupture of the membranes
Congenital malformations
Third-trimester bleeding
Oxytocin induction/augmentation of labor
Preeclampsia
Meconium stained liquor

14
 A Continuous EFM should be offered and
recommended in pregnancies previously
monitored with intermittent auscultation:
• if there is evidence on auscultation of a
baseline less than 110 bpm or greater
160 bpm
• if there is evidence on auscultation of
any decelerations
• if any intrapartum risk factors develop.

15
Definitions and descriptions of
individual features of fetal heart-
rate (FHR) traces

Baseline fetal heart rate :The

mean level of the FHR when this
is stable, excluding accelerations
and decelerations. It is
determined over a time period of
5 or 10 minutes and expressed in
bpm.
16
– Normal Baseline FHR 110–160
bpm
– Moderate bradycardia 100–109
bpm
– Moderate tachycardia 161–180
bpm
– Abnormal bradycardia < 100 bpm
– Abnormal tachycardia > 180 bpm17
 Baseline variability
The minor fluctuations in
baseline FHR occuring at three
to five
cycles per minute. It is
measured by estimating the
difference in beats per minute
between the highest peak and
lowest trough of fluctuation in
a one-minute segment of the
trace
18
19
ACCELERATIONS

20
 DECCELERATIONS

• EARLY : Head compression

• LATE : U-P Insufficiency

• VARIABLE : Cord compression

Primary CNS dysfn

21
EARLY

22
LATE

23
VARIABLE

24
 Atypical Variable
decelerations
With any of the following additional
decelerations components:

–loss of primary or secondary rise in baseline

rate
– slow return to baseline FHR after the end of
the contraction
– prolonged secondary rise in baseline rate
– biphasic deceleration
– loss of variability during deceleration
– continuation of baseline rate at lower level
25
26
 Categorisation of fetal heart rate
traces
Category Definition

Normal All four reassuring

Suspicious 1 non-reassuring
Rest reassuring
Pathological 2 or more non-
reassuring
1 or more abnormal
27
 REDUCED VARIABILITY

Hypoxia Drugs Extreme

prematurity
Sleep CNS abno.

28
29
 TACHYCARDIA
Hypoxia Chorioamnionitis
Maternal fever B-Mimetic drugs
Fetal anaemia,sepsis,ht failure,arrhythmias

30
 SPECIAL
PATTERNS
31
 Sinusoidal pattern
A regular oscillation of the baseline long-term
variability resembling a sine wave. This smooth,
undulating pattern, lasting at least 10 minutes, has a
relatively fixed period of 3–5 cycles per minute and an
amplitude of 5–15 bpm above and below the baseline.
Baseline variability is absent

Associated with -
Severe chronic fetal anaemia
Severe hypoxia & acidosis

32
SINUSOIDAL

33
PSEUDOSINUSOIDAL

34
CHECKMARK PATTERN

35
SALTATORY PATTERN

36
LAMBDA PATTERN

37
38
39
 SUSPICIOUS CTG

CTG CAUSE CLINICAL

PATTERN MANAGEMENT
EARLY 2nd Stage NONE
LATE Uterine Stop oxytocin
hypercontractil Consider terbutaline
y sc
Oxygen @ 8-10 l/min
Left lateral
decubitus
VARIABLE Cord Consider
compression amnioinfusion
(mild/mod v.d.)
TACHYCAR Maternal Infection screen
DIA fever,tachycard Hydrate - 40
 PATHOLOGICAL

FETAL SCALP
STIMULATION TEST
FETAL SCALP
BLOOD Ph FETAL VIBROACAUSTIC
(If facilities available) STIMULATION TEST

41
 A Systematic Approach to Reading Fetal
Heart Rate Recordings
• Evaluate recording--is it continuous and adequate for
interpretation?
• Identify type of monitor used--external versus internal, first-
generation versus second-generation.
• Identify baseline fetal heart rate and presence of variability,
both long-term and beat-to-beat (short-term).
• Determine whether accelerations or decelerations from the
baseline occur.
• Identify pattern of uterine contractions, including regularity,
rate, intensity, duration and baseline tone between
contractions.
• Correlate accelerations and decelerations with uterine
contractions and identify the pattern.
• Identify changes in the FHR recording over time, if possible.
• Conclude whether the FHR recording is reassuring,
nonreassuring or ominous.
• Develop a plan, in the context of the clinical scenario, according
to interpretation of the FHR.
• Document in detail interpretation of FHR, clinical
conclusion and plan of management. 42
• Prior to any form of fetal monitoring, the
maternal pulse should be
palpated simultaneously with FHR
auscultation in order to
differentiate between maternal and fetal
heart rates.
• If fetal death is suspected despite the
presence of an apparently
recordable FHR, then fetal viability should
be confirmed with realtime
ultrasound assessment.

43
44
 RECORD KEEPING IN
CTG
• The date and time clocks on the EFM
machine should be correctly set
• Traces should be labelled with the mother’s
name, date and hospital number
• Any intrapartum events that may affect the
FHR should be noted contemporaneously
on the EFM trace, signed and the date and
time noted (e.g. vaginal examination, fetal
blood sample, siting of an epidural)

45
•Any member of staff who is asked to
provide an opinion on a trace should
note their findings on both the trace
and maternal case notes, together
with time and signature
• Following the birth, the care-giver
should sign and note the date,time
and mode of birth on the EFM trace
• The EFM trace should be stored
securely with the maternal notes at
the end of the monitoring process.

46
 SOME
INTERESTING
CASES

47
ACCELERATION OR DECCELERATION ???

48
BASELINE BRADYCARDIA WITH
ACCELERATIONS

49
HALVING PHENOMENON

50
EXCESSIVE VARIABILITY???

51
GESTATIONAL DM ; NST ; 8:30am

52
GDM ; CST ; 12 noon

53
BLUNTED PATTERN WITH VARIABLE
DECCELERATIONS – CNS DYSFUNCTION

54
Thank
you

55