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Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
Intra Partum Cardiotocography - dr vivek patkar
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Intra Partum Cardiotocography - dr vivek patkar

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Cardiotocography ( CTG ) …

Cardiotocography ( CTG )
is a procedure of graphically ( graph) recording fetal heart activity and uterine contractions ( Toco ) – both recorded in the same time scale simultaneously and continuously through uterine quiscience and contractions

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  • 1. Intra Partum Cardiotocography Dr. Vivek D. Patkar Ex. Hon. Prof. LTMGH & LTMMC, Sion V.D.P.
  • 2. Definition
    • Cardiotocography ( CTG )
    • is a procedure of graphically ( graph) recording fetal heart activity and uterine contractions ( Toco ) – both recorded in the same time scale simultaneously and continuously through uterine quiscience and contractions
    V.D.P.
  • 3. Importance of Cardiotocography
    • Scientific
    • Social
    • Medico legal
    V.D.P.
  • 4. Pioneers
    • The main credit for CTGs goes to the following
    • Prof. E. H. Hon California
    • Prof. Caldeyro Barcia Uruguay
    • Prof. G. S. Dawes U.K.
    • Prof. C. Redman U.K.
    V.D.P.
  • 5. Specifications of an Intrapartum Monitor
    • Reliable
    • FHR by external doppler ultrasound ( US ) with auto co – relation
    • FHR by fetal electrode ( ECG )
    • Twin monitoring US & ECG
    • External & Internal tocography
    • Maternal Heart Rate & Event Marker
    • Mode, Date & Time printout
    • No machine or printing errors
    V.D.P.
  • 6. Control of the Fetal Heart Rate
    • Activity of the sino atrial node ( fast )
    • Atrio ventricular node ( slow )
    • C.N.S – cortical & sub cortical influence
    • Cardioregulatory centre in brain stem
    • Baro & chemo receptors & catecholamines
    • Autonomic Nervous System
        • Sympathetic ↑ Parasympathetic ↓
    V.D.P.
  • 7. Terminology
    • Baseline Heart Rate ( BHR ) – 110 – 150 bpm
    • Bradycardia – BHR < 110 bpm
            • Mod – 100 – 110 bpm
    • Tachycardia - BHR > 150 bpm
            • Mod – 150 – 170 bpm
    • Acceleration / Deceleration - > 15 bpm for 15 sec.
    • Baseline Variability - 10 – 25 bpms
            • Silent - 0 – 5 bpm
            • Reduced - 5 – 10 bpm
            • Saltatory - > 25 bpm
    • (Sleep or Quiet phase, Prematurity, Anaemia, Infection, Anaesthetics, Sedatives, Anti hypertensive all ↓ variablity )
    V.D.P.
  • 8. Terminology ( contd.)
    • Deceleration
      • Early – Synchronous with uterine contractions. ( Head compression, ARM, PV exam)
      • Late – Onset, nadir, recovery out of phase with ut. Ctr. ( Pathological )
      • Variable – shape, size & timing ( Cord compression )
      • Deceleration > 60 bpm and > 60 sec – hypoxia
      • Biphasic Deceleration ~ ~ Late deceleration
    • Shouldering – Acceleration before / after deceleration ( good ANS response )
      • Exaggeration – Pre pathological
      • Loss - Pathological
    V.D.P.
  • 9. Late deceleration
    • Late deceleration followed by normal baseline – mild compromise
    • Late deceleration followed by reduced baseline variability and tachycardia – severe compromise
    V.D.P.
  • 10. Interpretation – FIGO Normal Pattern
    • BHR – 110 – 150 bpm
    • Baseline variability – 5 – 25 bpm
    • FIGO does not refer to accelerations but must be present
    V.D.P.
  • 11. Interpretation – FIGO Suspicious Pattern
    • BHR – 150 – 170 bpm
    • Baseline variability 5 – 10 bpm for 40 min
    • Increased variability > 25 bpm
    • Variable decelerations
    V.D.P.
  • 12. Interpretation – FIGO Pathological Pattern
    • BHR < 100 bpm or > 170 bpm
    • Baseline variability < 5 bpm for > 40 min.
    • Severe variable decelerations
    • Severe repetitive decelerations
    • Prolonged decelerations.
    • Late decelerations w/o baseline variability
    • Sinusoidal pattern
    V.D.P.
  • 13. Cardiotocography
    • Antenatal
    • Admission Test
    • Intrapartum
    V.D.P.
  • 14. Proper Assessment
    • In order to interpret and logically conclude findings in an intrapartum strip , it is preferable to have an antenatal or an admission test strip, though not absolutely mandatory .
    V.D.P.
  • 15. Admission test
    • It is a dynamic screening method of the state of oxygenation of the fetus on admission.
    • Importance:
    • Low risk or normal trace – clinical monitoring
    • High risk –
    • suspicious : intermittent monitoring
    • gross : continuous monitoring or unsafe for labour
    • ( Arulkumaran)
    V.D.P.
  • 16. Indications for intrapartum monitoring
    • All cases of BOH ( previous still birth, asphyxia, low Apgar, recurrent abortion, neonatal death)
    • High premium babies ( elderly, diabetic, infertility, IVF )
    • All cases where fetus can be hypoxic ( IUGR, postdatism, hypertension, MSAF, induction of labour, prolonged labour)
    • Patients with epidural .
    V.D.P.
  • 17. CLINICAL SCENARIOS V.D.P.
  • 18.
    • SECOND STAGE OF LABOUR : mechanical effects resulting from descent of fetus causing head compression, resulting in early decelerations returning to normal in between contractions ,
    V.D.P.
  • 19. SECOND STAGE OF LABOUR
    • SECOND STAGE OF LABOUR
    Delivery Within 15 Minutes V.D.P.
  • 20.
    • Obstructed Labour – gradual tachycardia, reduced variability and late decelerations- deliver in 15 mins, or irreversible hypoxia
    • contd.
    V.D.P.
  • 21. Obstructed Labour Lost baby, multi-para with macrosomic baby sudden hypoxia V.D.P.
  • 22.
    • TWINS - require a three channel trace or a two channel trace
    V.D.P.
  • 23. TWINS
  • 24.
    • BREECH: look for cord compression and relative IUGR, compression of skull above orbits causing variable deceleration
    • Patient had cord prolapse, lost baby before LSCS
    V.D.P.
  • 25.
    • BROW PRESENTATION : head compression and variable deceleration
    • LSCS done baby healthy
    V.D.P.
  • 26.
    • PREVIOUS SCAR : prolonged bradycardia – indicative of scar dehiscence or rupture possible
    • Transferred case of previous LSCS. Ruptured, baby lost.
    V.D.P.
  • 27. PREVIOUS SCAR Scar dehiscence recognized on CTG, immediate section, baby salvaged, AS-8 V.D.P.
  • 28.
    • HYPERTENSIVE DISORDERS: IUGR causes baseline bradycardia , antihypetensive drugs like methyldopa, B blockers causes baseline variability and accelerations
    V.D.P. Patient on alhpamethyldopa normal delivery
  • 29.
    • ECLAMPSIA : prolonged deceleration during a fit
    V.D.P. Patient on Magsulf and occ nefidenpene 1.8 KGs Baby, Baby depressed, but made good recovery
  • 30.
    • PLACENTAL ABRUPTION – Frequent low amplitude contractions – irritable UTERUS, Fetal Tachycardia with no acceleration, reduced base line variability with deceleration and bradychardia contd.
    V.D.P.
  • 31.
    • PLACENTAL ABRUPTION – Frequent low amplitude contractions – irritable UTERUS, Fetal Tachycardia with no acceleration, reduced base line variability with deceleration and bradychardia
    • Baby Lost, retro placental clot of 600 gms
    V.D.P.
  • 32. EPIDURAL ANESTHESIA EPIDURAL ANESTHESIA : short tachycardia, deep deceleration, loss of beat to beat variability t/t: Ringer’s, oxygen, change of position Immediately after epidural contd. V.D.P.
  • 33.
    • EPIDURAL ANESTHESIA : short tachycardia, deep deceleration, loss of beat to beat variability
    • t/t: Ringer’s, oxygen, change of position
    • After Ringer’s and Oxygen
    V.D.P.
  • 34.
    • NARCOTIC DRUGS : pethidine, diazepam- cause decreased beat to beat variability, decreased baseline FHR, reduced amplitude of acceleration
    • t/t: naloxone
    • Case of toxaemia of pregnancy, forceps applied good AS
    V.D.P.
  • 35.
    • OXYTOCIN DRIP : regular dose- type 1 deceleration, excessive dose- sustained / hypertonic contraction with bradycardia . 45 mins for effect to go and blood pH to return to normal.
    • t/t: tocolytics, if no change in 45 mins
    • 5 units drip for augmentation at 30 drops PM
    • contd.
    V.D.P.
  • 36. OXYTOCIN DRIP Drip reduced to 20 drops and then stopped all together contd. V.D.P.
  • 37. OXYTOCIN DRIP Normal delivery after 8 hours V.D.P.
  • 38.
    • SINUSOIDAL PATTERN : amplitude and period of variation remains constant , trace is smooth regular and wavy , 5 – 10 bpm- in fetal anemia, Rh, fetal hhage, cordocentesis, vasa previa, anticoag therapy.
    • Vasa Previa, Baby lost
    V.D.P.
  • 39. SINUSOIDAL PATTERN RH –ve, IUGR COOMBS +ve,1:64, 34 weeks LSCS , died after 5 days V.D.P.
  • 40.
    • PROLONGED BRADYCARDIA - r. acidosis- m. acidosis, can be a signal for cord prolapse, abruptio, scar dehiscence, extreme uterine hyperstimulation
    • 3 mins - attention!
    • 6 mins – expect recovery LSCS baby fine
    • 9 mins – prepare for operative delivery
    • 12 -15 mins – deliver baby
    V.D.P.
  • 41. PROLONGED BRADYCARDIA Immediate LSCS, AS-8 on birth V.D.P.
  • 42.
    • TERMINAL BRADYCARDIA : after prolonged bradycardia or tachycardia, random uncontrolled undulatory pattern with no baseline variability , suggests a CNS damage, mostly irreversible
    • Severe IUGR due to high BP, AFI 2, baby lost
    V.D.P.
  • 43. TERMINAL BRADYCARDIA Severe IUGR , viral encephalitis at 8 months, baby could not be salvaged V.D.P.
  • 44. Tracing character sequence and degree of hypoxia
    • Normal trace
    • Early hypoxia- Disappearance of acceleration with FM and then uterine contraction
    • Further hypoxia- Rising baseline FHR- baseline tachycardia
    • Further hypoxia- Reduction in baseline variability <5 bpm (straight line)
    • Further hypoxia- Late deceleration
    • ( Arulkumaran, Gibbs, Debdas)
    V.D.P.
  • 45. Abnormal tracing- acidosis interval
    • With repeated late decelerations – 2 hours
    • With repeated variable decelerations – 2 1/2 hours
    • With flat trace ( baseline variability < 5 bpm) – 3 hours
    • ( Fleischer et al)
    V.D.P.
  • 46. Interpretation of IPCTG
    • Integrated approach :
    • Antepartum strip , USG
    • Biophysical profile ( esp. AFI)
    • Doppler of vessels
    • Fetal pH , if possible
    • Sudden intrapartum event ( cord prolapse , acci hhage, rupture, oxytocin drip, AFE)
    V.D.P.
  • 47. Alternative Methods of Intrapartum Surveillance
    • Fetal ECG waveform analysis
    • Time intervals of fetal cardiac cycles
    • Pulse oximetry
    • Doppler ultrasound
    • Continuous pH measurements
    V.D.P.
  • 48. Computers and Cardiotocography
    • Data management
    • Storage
    • Archiving and Retrieval
    • Teleconferencing and sharing
    • Interpretation and decision making
    • The best computer is the human BRAIN !
    V.D.P.
  • 49. Medicolegal issues
    • Use of modern generation CTG machines
    • Rechecking an abnormal tracing by added biophysical profile, Doppler velocimetry and fetal blood pH
    • Minute analysis of all tracings
    • CTG tracings to be kept for 25 years (Carter and Steer, 1993)
    • A high standard of note keeping, good practice, good care and good communication
    V.D.P.
  • 50. Cardiotocography is useful if :
    • Adequate knowledge is available to interpret the trace.
    • Its limitations are known.
    • It is used appropriately.
    • The clinical picture is incorporated.
    • Additional tests are used when in doubt.
    • Common sense prevails!
    V.D.P.
  • 51.
    • THANK YOU !!!
    V.D.P.

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