CTG Monitoring


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CTG Monitoring

  1. 1. CTG NESD Staff
  2. 2. Cardiotocograph (CTG) OUTLINE <ul><li>Definition of terms </li></ul><ul><li>Classification of CTGs </li></ul><ul><li>Indications for intrapartum fetal surveillance </li></ul><ul><li>Process </li></ul><ul><li>Interpretation and documentation </li></ul><ul><li>CTG sticker </li></ul><ul><li>Algorithm: Cardiotocograph (CTG) interpretation and action </li></ul>
  3. 3. Fetal heartbeat Cardio- Uterine contractions -Toco- <ul><li>is a technical means of recording ( -graphy ) the </li></ul>+ during childbirth CARDIOTOCOGRAPHY <ul><li>used to identify signs of fetal distress </li></ul>is a transducer, moveable w/ sensor use to measure contraction frequency & duration
  4. 4. Cardiotocograph <ul><li>is used to monitor a pregnant woman, typically in the third trimester. </li></ul><ul><li>A cardiotocograph measures simultaneously both the fetal heart rate and the uterine contractions </li></ul><ul><li>An ultrasound transducer similar to a Doppler fetal monitor measures the fetal heartbeat. </li></ul><ul><li>A pressure-sensitive transducer, called a tocodynamometer (toco), measures the frequency of uterine contractions. </li></ul>Dr. Orvan Hess
  5. 5. <ul><li>this machine is use during the third trimester to monitor fetal wellbeing called a nonstress test . </li></ul><ul><li>A positive (good) result is indicated by a reactive non-stress test. </li></ul><ul><li>This means that the fetal heart rate increased (acceleration) by at least 15 beats per minute for at least 15 seconds at least twice during a 20 minute interval. </li></ul>
  6. 6. Method <ul><li>A typical CTG reading is printed on paper and/or stored on a computer for later reference. </li></ul><ul><li>Use of CTG and a computer network allows continual remote surveillance: </li></ul><ul><li>a single nurse, midwife, or physician can watch the CTG traces of multiple patients simultaneously , via a computer nurses station </li></ul>Recordings are done by two separate transducers one for the measurement of the fetal pulse a second one for the contractions
  7. 7. External measurement <ul><li>means taping or strapping the two sensors to the abdominal wall </li></ul><ul><li>with the heart ultrasonic sensor overlying the fetal heart and </li></ul><ul><li>the contraction sensor measuring the tension of the maternal abdominal wall </li></ul><ul><li>an indirect measure of the intrauterine pressure. </li></ul>Hint: Determination intensity of contraction palpate fundus use your fingertips if touch like tip of nose= mild Chin= moderate intensity Pushing on forehead= strong
  8. 8. External Fetal Monitor (EFM) <ul><li>ADVANTAGES </li></ul><ul><ul><li>Non invasive & does not pose risk for infection </li></ul></ul><ul><ul><li>Provides continuous tracing of FHT </li></ul></ul><ul><ul><li>Enable the nurse to detect signs of fetal distress </li></ul></ul><ul><li>DISADVANTAGES </li></ul><ul><ul><li>May not be able to detect short term variability </li></ul></ul><ul><ul><li>Fetal and maternal movement may interfere continuous monitoring </li></ul></ul><ul><ul><li>Limit changing position </li></ul></ul>
  9. 9. Internal measurement <ul><li>requires a certain degree of cervical dilatation </li></ul><ul><li>it involves inserting a pressure catheter into the uterine cavity </li></ul><ul><li>attaching a scalp electrode to the child's head to adequately measure the pulse </li></ul>Internal measurement is more precise, and might be preferable when a complicated childbirth is expected .
  10. 10. INTERNAL FETAL MONITOR <ul><li>ADVANTAGES </li></ul><ul><ul><li>Not affected by fetal movement </li></ul></ul><ul><ul><li>Provides continuous and accurate recording even if woman moves and changes position </li></ul></ul><ul><ul><li>Provides accurate information regarding variability. </li></ul></ul><ul><li>DISADVANTAGES </li></ul><ul><ul><li>Invasive procedure </li></ul></ul><ul><ul><li>Risk for infection </li></ul></ul><ul><ul><li>Trained practitioner must insert the electrode </li></ul></ul>
  11. 11. <ul><li>Definition of Terms </li></ul>
  12. 12. Baseline fetal heart rate (FHR) <ul><li>is the mean level of the FHR when this is stable, excluding accelerations and decelerations. </li></ul><ul><li>It is determined over a time period of 5-10 minutes, expressed as beats per minute (bpm). </li></ul><ul><li>Preterm fetuses tend to have values towards the upper end of the normal range. </li></ul>
  13. 13. Baseline variability <ul><li>is the minor fluctuation in baseline FHR. </li></ul><ul><li>It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in one minute segments of the trace. </li></ul>Uterine activity Normal variability is reassuring Sign that fetus nervous system is intact FHR bpm
  14. 14. 2 types of Variability <ul><li>Short- Term variability or Beat to Beat variability </li></ul><ul><ul><li>Is the difference between successive heartbeats or the moment </li></ul></ul><ul><li>Long Term Variability </li></ul><ul><ul><li>Is wider fluctuations </li></ul></ul><ul><ul><li>Over one (1) minute that causes wavy appearance in the monitor </li></ul></ul>Absent - No fluctuation Minimal - 5 bpm or less Moderate/Normal – 5bpm to 25
  15. 15. Accelerations <ul><li>are transient increases in FHR of 15bpm or more above the baseline and lasting 15 seconds. </li></ul><ul><li>Accelerations in preterm fetuses may be of lesser amplitude and shorter duration. </li></ul>Fetal Rate (FHR) Activity Maternal Uterine Activity
  16. 16. Decelerations <ul><li>are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds, which are: </li></ul><ul><ul><li>Early, Variable and Delayed </li></ul></ul><ul><li>Time relationships with contraction cycle may be variable but most commonly occur simultaneously with contractions. </li></ul>
  17. 17. Early Deceleration <ul><li>uniform, repetitive decrease of FHR with slow onset early in the contraction and slow return to baseline by the end of the contraction </li></ul>onset contraction Recovery
  18. 18. Variable Deceleration <ul><li>repetitive or intermittent decreasing of FHR with rapid onset and recovery. </li></ul>Variable onset
  19. 19. Complicated variable decelerations <ul><li>the following additional features indicate the likelihood of fetal hypoxia: </li></ul><ul><li>Rising baseline rate or fetal tachycardia </li></ul><ul><li>Reducing baseline variability </li></ul><ul><li>Slow return to baseline FHR after the end of the contraction </li></ul><ul><li>Large amplitude (by 60bpm or to 60bpm) and /or long duration (60 seconds) </li></ul><ul><li>Loss of pre and post deceleration shouldering </li></ul><ul><li>(abrupt brief increases in FHR baseline). </li></ul><ul><li>Presence of post deceleration smooth overshoots </li></ul><ul><li>(temporary increase in FHR above baseline) </li></ul>
  20. 20. Prolonged decelerations <ul><li>decrease of FHR below the baseline of more than 15 bpm for longer than 90 seconds but less than 5 minutes. </li></ul>Identify the features of the FHR trace which have the highest information content
  21. 21. Late decelerations <ul><li>uniform, repetitive decreasing of FHR with, usually, slow onset mid to end of the contraction and nadir more than 20 seconds after the peak of the contraction and ending after the contraction </li></ul>Onset Recovery
  22. 22. Classification of C T G
  23. 23. Normal antenatal CTG trace : <ul><li>The normal antenatal CTG is associated with a low probability of fetal compromise and has the following features: </li></ul><ul><li>Baseline fetal heart rate (FHR) is between 110-160 bpm </li></ul><ul><li>Variability of FHR is between 5-25 bpm </li></ul><ul><li>Decelerations are absent or early </li></ul><ul><li>Accelerations x2 within 20 minutes. </li></ul>
  24. 24. Features of the CTG in Labour
  25. 25. Normal intrapartum CTG trace: <ul><li>Features: </li></ul><ul><li>Baseline FHR is between 110-160 bpm </li></ul><ul><li>Variability of FHR is between 5-25 bpm </li></ul><ul><li>Decelerations are absent or early </li></ul><ul><li>The significance of the presence or absence of accelerations is unclear therefore, exclude accelerations during interpretation. </li></ul>
  26. 26. Non-reassuring CTG trace <ul><li>is where one of the following features is present: </li></ul><ul><li>The presence of two or more features is considered abnormal as these may be associated with fetal compromise and require further action </li></ul><ul><li>Baseline FHR is between 100-109 bpm or between 161-170 bpm </li></ul><ul><li>Variability of FHR is reduced (3-5 bpm for >40 minutes) </li></ul><ul><li>Decelerations are variable without complicating features </li></ul><ul><li>Do not consider the absence of accelerations in intrapartum interpretation as abnormal. </li></ul>
  27. 27. Abnormal CTG trace is where: <ul><li>The following features are very likely to be associated with significant fetal compromise and require further action: </li></ul><ul><li>Two of the features described in non-reassuring CTG trace are present, OR </li></ul><ul><li>Baseline FHR is <100 bpm or >170 bpm </li></ul><ul><li>Variability is absent or <3 bpm </li></ul><ul><li>Variability is sinusoidal </li></ul><ul><li>Decelerations are prolonged for >3 minutes / late / have complicated variables </li></ul>
  28. 28. Indications for intrapartum fetal surveillance <ul><li>Antenatal risk factors , increasing the risk of fetal compromise including: </li></ul><ul><li>Abnormal antenatal CTG </li></ul><ul><li>Abnormal Doppler umbilical artery velocimetry </li></ul><ul><li>Suspected or confirmed intrauterine growth restriction </li></ul><ul><li>Oligohydramnios or polyhydramnios </li></ul><ul><li>Prolonged pregnancy >42 weeks gestation </li></ul><ul><li>Multiple pregnancy </li></ul><ul><li>Breech presentation </li></ul><ul><li>Antepartum haemorrhage </li></ul><ul><li>Prolonged rupture of membranes (>24 hours) </li></ul><ul><li>Known fetal abnormality which requires monitoring </li></ul><ul><li>Prior uterine scar / caesarean section </li></ul><ul><li>Pre-eclampsia </li></ul><ul><li>Diabetes (on insulin or poorly controlled or with fetal macrosomia) </li></ul><ul><li>Other current or previous obstetric or medical conditions which constitute a significant risk of fetal compromise </li></ul>
  29. 29. Intrapartum risk factors , including: <ul><li>Induction of labour with prostaglandin / oxytocin </li></ul><ul><li>Abnormal auscultation or CTG </li></ul><ul><li>Oxytocin augmentation </li></ul><ul><li>Epidural analgesia </li></ul><ul><li>Abnormal vaginal bleeding in labour </li></ul><ul><li>Maternal pyrexia </li></ul><ul><li>Meconium or blood stained liquor </li></ul><ul><li>Absent liquor following amniotomy </li></ul><ul><li>Active first stage of labour >12 hours (i.e. regular uterine activity cervix 4cm dilated) </li></ul><ul><li>Active second stage (i.e. pushing) >1 hour where delivery is not imminent </li></ul><ul><li>Preterm labour less than 37 completed weeks1 </li></ul>
  30. 30. Equipment <ul><li>Cardiotocograph and paper </li></ul><ul><li>Cardiotocograph sticker </li></ul><ul><li>Progress notes </li></ul>
  31. 31. Process Preparation <ul><li>Determine indication for fetal monitoring </li></ul><ul><li>Discuss fetal monitoring with the woman and obtain permission to commence </li></ul><ul><li>Perform abdominal examination to determine lie and presentation </li></ul><ul><li>Give the woman the opportunity to empty her bladder ‘The woman should be in an upright or lateral position (not supine) Check the accurate date and time has been set on the CTG machine, and paper speed is set at 1cm per minute1 CTGs must be labelled with the mother’s name, UR number and date / time of commencement. </li></ul><ul><li>Maternal heart rate must be recorded on the CTG at commencement of the CTG in order to differentiate between maternal and fetal heart rates. </li></ul>
  32. 32. Subjective analysis of FHR traces in labour
  33. 33. Interpretation and documentation <ul><li>all features must be documented every hour in the Progress Notes </li></ul><ul><li>For women receiving continuous electronic fetal monitoring (EFM) the CTG should be reviewed at least every 15 to 30 minutes. Interpretation and response to findings must be documented on an hourly basis. Response to the CTG trace should be DOCUMENTED/RECORDED </li></ul><ul><li>and must be REPORTED IMMEDIATELY especially IF THERE ARE ABNORMALITIES </li></ul><ul><li>The senior midwife in birth suite, and / or </li></ul><ul><li>The registrar rostered to birth suite, and / or </li></ul><ul><li>The consultant obstetrician rostered to birth suite. </li></ul>
  34. 34. Interpretation <ul><li>CTG times the contractions and the variability in the fetal heart rate. </li></ul><ul><li>Baseline abnormalities in the heart rate (brady- or tachycardia) </li></ul><ul><li>Decelerations (slowing of the fetal heart rate) during a uterine contraction is normal (type 1 deceleration, or type I dips ), </li></ul><ul><li>but further slowing after resolution of the contraction ( type II dips ) is generally regarded as pathological and may be taken as a sign of fetal distress . </li></ul>
  35. 35. CTG sticker <ul><li> </li></ul>