Cardiotocography: CTG antepartum and intrapartum


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Cardiotocography: CTG antepartum and intrapartum

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Cardiotocography: CTG antepartum and intrapartum

  1. 1. CTG Aboubakr Elnashar Benha University Hospital, EgyptAboubakr Elnashar
  2. 2. Antepartum CTG Aboubakr Elnashar
  3. 3. Fetal heart rate recording 1.CTG 2.NST 3.Contraction stress test 4.Nipple stimulation test 5.Acoustic stimulation test 6.Computerized CTG Aboubakr Elnashar
  4. 4. 1. The Non-Stress Test (NST) (Hammacher et al, 1960) Idea: • FHR accelerations: linked closely with fetal movements {increased sympathetic output}. • The long term variability: {balance between sympathetic & parasympathetic tone} • The short term variability (baseline or bandwidth variability) {parasympathetic tone}. Aboubakr Elnashar
  5. 5. Steps: 1. left lateral recumbent position. 2. Place and adjust the external tocodynamometer and ultrasound transducer to obtain the best possible tracing. 3. Instruct the patient to record fetal movements on the monitor tracing using the event marker. 4. Observe the EFM tracing until the criteria for a reactive test are met (minimum of 20 mins and maximum of 60 mins). Aboubakr Elnashar
  6. 6.  In the event of lack of fetal movement, apply stimulation e.g. fetal acoustic stimulator.  Record any relevant clinical information on the EFM tracing e.g. blood pressure, temperature, maternal heart rate, loss of contact changes in maternal position. Aboubakr Elnashar
  7. 7. Interpretation: Reactive: 2 accelerations of FHR in 20 min. Each acceleration 15 beat & lasts 15 secs. Non-reactive: no accelerations in 40 min. Aboubakr Elnashar
  8. 8. •Reactive: increase of FHR to >15 beats/min for > 15 sec following fetal movements Aboubakr Elnashar
  9. 9. •Nonreactive nonstress test followed by contraction stress test showing mild late decelerations. •CS was performed and the severely acidemic fetus could not be resuscitated. Aboubakr Elnashar
  10. 10.  Positive CST= late deceleration in 50% of UC.  Non reactive NST= No HR acceleration  Cessation of fetal movement  Basal line tachycardia > 160 bpm  Basal line bradycardia <110 bpm Sequence of events with placental insufficiency or hypoxia Aboubakr Elnashar
  11. 11. 2. Fetal heart rate tracings (CTG) 1.Normal/Reassuring  Baseline HR: 110-150 b/m Variability: 10-25 b/m  At least 2 accelerations (>15 beats for> 15 seconds in 20 min) No decelerations. Aboubakr Elnashar
  12. 12. 2. Suspicious/Equivocal Trace.  Baseline HR: 150-170 b/m or 100-110 b/m Variability: Reduced (5-10 b/m for >40 m)  Absence of accelerations for >40 m Sporadic deceleration of any type. Aboubakr Elnashar
  13. 13. 3. Abnormal/Pathological  Baseline HR: <100 b/m or > 170 b/m Variability: No area of normal baseline variability Silent Pattern (<5 b/m) for >40 min Sinusoidal pattern (oscillation frequency= 2-5 cycles/min, amplitude of 5-15 b/m) for >40 m  No accelerations Repeated late, prolonged (> 1 minute) and severe variable (>40 b/m) decelerations. Aboubakr Elnashar
  14. 14. A: Absence of accelerations, diminished variability, late decelerations with weak spontaneous contractions. B: Normal accelerations Normal variability 15 beat Aboubakr Elnashar
  15. 15. CTG: Tachycardia Sinusoidal pattern Late deceleration Aboubakr Elnashar
  16. 16. Intrapartum CTG Aboubakr Elnashar
  17. 17. Basal Heart Rate Activity • Rate: Normal:110-160 increment 5 bpm (10 m segment) Bradycardia: < 110 bpm Tachycardia: > 160bpm • Variability :Short term= instantaneous (beat to beat v.) :Long term= oscillatory changes in 1 m • Sinusoidal: :Mild is due to sedation :Marked is due to fetal anemia  Arrhythmia: Abrupt spiking, bradycardia or tachy Periodic heart rate Activity • Acceleration • Deceleration Aboubakr Elnashar
  18. 18. Baseline The mean FHR rounded to increments of 5 bpm during a 10-min segment, excluding: — Periodic or episodic changes — Periods of marked FHR variability — Segments of baseline that differ > 25 bpm Tachycardia Baseline FHR > 160 bpm Bradycardia Baseline FHR < 110 bpm Aboubakr Elnashar
  19. 19. •Fetal bradycardia measured with a scalp electrode in a pregnancy complicated by placental abruption and subsequent fetal death. Aboubakr Elnashar
  20. 20. Placental abruption. In the upper panel, the fetal scalp electrode first detected the heart rate of the dying fetus. After fetal death, the maternal electrocardiogram complex is detected and recorded. The second panel displays an absence of uterine contractions. Aboubakr Elnashar
  21. 21. Variability Reduced variability is the single most reliable sign of fetal compromise The baseline must be for a minimum of 2 min in any 10-min segment Fluctuations in the FHR of two cycles per min or greater Aboubakr Elnashar
  22. 22. Variability is visually quantified as the amplitude of peak-to-trough in bpm Absent: amplitude range undetectable Minimal: amplitude range detectable but 5 bpm Moderate (normal): amplitude range 6–25 bpm Marked: amplitude range > 25 bpm Aboubakr Elnashar
  23. 23. Short-term beat-to-beat variability measured by a fetal scalp electrode (t= time interval between successive fetal R waves). Aboubakr Elnashar
  24. 24. long-term beat-to-beat variability ranging between 125 and 135 bpm). Aboubakr Elnashar
  25. 25. (1) Undetectable or absent (2) Minimal variability:0 -5 bpm Aboubakr Elnashar
  26. 26. 4) Marked variability : >25 bpm (3)Moderate variability : >5-<25 bpm Aboubakr Elnashar
  27. 27. External fetal heart recording: A. lack of long-term variability at 31 w during maternal diabetic ketoacidosis (pH 6.09). B. Recovery of fetal long- term variability after correction of maternal acidemia. Aboubakr Elnashar
  28. 28. Sinusoidal Heart Rate • Flat short term variability • Ampllitude: 5-15bpm • 2- 5 cycle/m • Absence of accelerations Mild: due to sedation Marked: due to fetal anemia Aboubakr Elnashar
  29. 29. •Sinusoidal fetal heart rate pattern associated with maternal intravenous meperidine administration. •Sine waves are occurring at arate of 6 cycles/min. Aboubakr Elnashar
  30. 30. •Arrhythmia: •Abrupt spiking Internal fetal monitoring: •occasional abrupt beat- to-beat fetal heart rate spiking due to erratic exrasystoles shown in the superimposed fetal electrocardiogram. •The normal infant was delivered spontaneously and had a normal cardiac rhythm in the nursery. Aboubakr Elnashar
  31. 31. Periodic heart rate Activity Acceleration Deceleration Aboubakr Elnashar
  32. 32. Acceleration A visually apparent increase (onset to peak in less than 30 sec) in the FHR from the most recently calculated baseline The duration= time from the initial change in FHR from the baseline to the return of the FHR to the baseline Aboubakr Elnashar
  33. 33. At 32 w and beyond an acceleration has an acme of 15 bpm above baseline, with a duration of 15 sec but < 2 min Before 32 w an acceleration has an acme 10 bpm above baseline, with a duration of 10 sec but < 2 min Prolonged acceleration lasts 2 min, but < 10 min If an acceleration lasts 10 min, it is baseline change Aboubakr Elnashar
  34. 34. Deceleration 1. Early deceleration In association with a uterine contraction, a visually apparent, usually symmetrical, gradual— onset to nadir 30 sec—decrease in FHR with return to baseline Nadir of the deceleration occurs at the same time as the peak of the contraction Aboubakr Elnashar
  35. 35. Early deceleration: Gradual decrease in the heart rate with both onset and recovery coincident with the onset and recovery of the contraction. Nadir of the deceleration is 30seconds or more after the onset of the deceleration. Aboubakr Elnashar
  36. 36. 2. Late deceleration In association with a uterine contraction, a visually apparent, gradual—onset to nadir 30 sec decrease in FHR with return to baseline Onset, nadir, and recovery of the deceleration occur after the beginning, peak, and end of the contraction, respectively Aboubakr Elnashar
  37. 37. •Late deceleration. Gradual decrease in the heart rate Nadir and recovery occurring after the end of the contraction. Nadir of deceleration occurs 30 seconds or more after the onset of the deceleration. Aboubakr Elnashar
  38. 38. •Late decelerations {uteroplacental insufficiency resulting from placental abruption}. ImmediateCS •Umbilical artery pH was 7.05 and the Po2 was 11 mm Hg. Aboubakr Elnashar
  39. 39. 3. Variable deceleration An abrupt onset to nadir < 30 sec, visually apparent decrease in the FHR below the baseline The decrease in FHR is 15 bpm, with a duration of 15 sec but < 2 min Complicated variable decelerations depth >60 bpm for >60 seconds changes in shape: over-shoot, decreased or increased baseline FHR following the decelerations,or absence of baseline variability in or between decelerations, slow recovery Aboubakr Elnashar
  40. 40. Variable decelerations. abrupt decrease in the heart rate with onset commonly varying with successive contractions. decelerations measure ≥ 15 bpm for 15 seconds or longer Onset to nadir phase of less than 30 seconds. Total duration is less than 2 minutes. Aboubakr Elnashar
  41. 41. •Variable decelerations B “shoulders” of acceleration compared with deceleration A. Aboubakr Elnashar
  42. 42. FHR effects of partial occlusion and complete occlusion of the umbilical cord Aboubakr Elnashar
  43. 43. 4. Prolonged deceleration Visually apparent decrease in the FHR below the baseline Deceleration is 15 bpm, lasting 2 min but < 10 min from onset to return to baseline Aboubakr Elnashar
  44. 44. Abrupt decrease >15 bpm Often drops<100 >2 m & < 10 m Variable pattern •Prolonged deceleration {uterine hyperactivity} Approximately 3 minutes are shown but FHR returned to normal after uterine hypertonus resolved. Vaginal delivery later ensued. Aboubakr Elnashar
  45. 45. Fetal heart rate effects of manual compression of a prolapsed umbilical cord in a 25-week footling breech. A shows the effects of 25- second compression compared with 40 seconds in B. Aboubakr Elnashar
  46. 46. Early Deceleration Late Deceleration Variable Deceleration Abrupt decrease  >15 bpm Often drops<100 >15 S& < 2 m Variable pattern Abrupt decrease  >15 bpm Often drops<100 >2 m & < 10 m Variable pattern Prolonged Deceleration may drops<100 Usually did not drops<100 Decelerations Aboubakr Elnashar
  47. 47. Indications for continuous EFM 1. High-risk pregnancies where there is an increased risk of perinatal death, cerebral palsy or neonatal encephalopathy.•B 2. Where oxytocin is being used for induction or augmentation of labour.•C Aboubakr Elnashar
  48. 48. INTERPRETATION Aboubakr Elnashar
  49. 49. a)Normal/Reassuring Trace - At least two accelerations (> 15 beats per minute for >15 seconds) in 20 minutes - Baseline heart rate: 110-150 bpm - Baseline variability: 5-25 bpm - Early decelerations (in late first stage of labour) Aboubakr Elnashar
  50. 50. b)Suspicious/Equivocal Trace - Absence of accelerations for >40 minutes (non reactive) - Baseline heart rate: 150-170 bpm or 100-110 bpm (normal variability, no decelerations) - Silent pattern (<5 bpm for >40 minutes) although normal baseline (110-150 bpm), no decelerations - Baseline variability >25 bpm in the absence of accelerations - Variable decelerations (depth <60 bpm, duration <60 seconds) - Occasional transient prolonged bradycardia if FHR drops to <80 bpm for >2 minutes or <100 bpm For >3 minutes Aboubakr Elnashar
  51. 51. b)Abnormal/Pathological Trace - Baseline FHA> 150 bpm + silent pattern and/or repeated late or variable decelerations - Silent pattern for >90 minutes - Complicated variable decelerations (depth >60 bpm for >60 seconds, changes in shape: over-shoot, decreased or increased baseline FHR following the decelerations, or absence of baseline variability in or between decelerations, slow recovery) - Combined/biphasic decelerations (variable followed by late) - Prolonged bradycardia in a suspicious trace - Prolonged bradycardia> 10 minutes with no signs of recovery - Repeated late decelerations - Pronounced loss of baseline variability regardless of baseline FHR with shallow late decelerations - Sinusoidal pattern with no accelerations Aboubakr Elnashar
  52. 52. Aboubakr Elnashar
  53. 53. MANAGEMENT a)Normal/Reassuring risk of fetal hypoxia in spontaneous labour is low. Manage normally. b)Suspicious/Equivocal continue EFM amniotomy should be performed +/- fetal scalp blood pH if meconium stained liquor is present. Aboubakr Elnashar
  54. 54. Initial Evaluation and Treatment of Nonreassuring Fetal Heart Rate Patterns Discontinuation of any labor stimulating agent Cervical examination: umbilical cord prolapse or rapid cervical dilation or descent of the fetal head Changing maternal position to left or right lateral recumbent position, reducing compression of the vena cava and improving uteroplacental blood flow Aboubakr Elnashar
  55. 55. Monitoring maternal blood pressure level for evidence of hypotension, especially in those with regional anesthesia—if present, treatment with ephedrine or phenylephrine may be warranted Assessment of patient for uterine hyperstimulation by evaluating uterine contraction frequency and duration Aboubakr Elnashar
  56. 56. During episodes of abnormal FHR patterns when the mother is lying supine, the mother should adopt the left-lateral position.•B In the presence of abnormal FHR patterns and uterine hypercontractility not secondary to oxytocin infusion, tocolysis should be considered. A suggested regime is subcutaneous terbutaline 0.25 milligrams.•A Aboubakr Elnashar
  57. 57. c)Abnormal/Pathological Amniotomy Fetal scalp blood pH if meconium stained liquor to determine subsequent management or Deliver if clinically indicated. Deliver if fetal scalp pH required but not obtainable i.e. if cervix not sufficiently dilated or equipment not available. Aboubakr Elnashar
  58. 58. In cases of suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible, accounting for the severity of the FHR abnormality and relevant maternal factors. The accepted standard has been that ideally this should be accomplished within 30 minutes. •B Aboubakr Elnashar
  59. 59. Fetal blood sampling  should be undertaken with the mother in the left-lateral position.•B Contraindications to fetal blood sampling :•B Maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus) Fetal bleeding disorders (e.g. haemophilia) Prematurity (< 34 weeks). Where there is clear evidence of acute fetal compromise (e.g. prolonged deceleration greater than three minutes), fetal blood sampling should not be undertaken and the baby should be delivered urgently.•. Aboubakr Elnashar
  60. 60. All scalp pH estimations should be interpreted taking into account the previous pH measurement, the rate of progress in labour and the clinical features of the mother and baby. Aboubakr Elnashar
  61. 61. Maternal facial oxygen therapy Prolonged use of maternal facial oxygen therapy may be harmful to the fetus and should be avoided. There is no research evidence evaluating the benefits or risks associated with the short-term use of maternal facial oxygen therapy in cases of suspected fetal compromise .•C Aboubakr Elnashar
  62. 62. Thank you Aboubakr Elnashar