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Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
Cardiotocography: CTG antepartum and intrapartum
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Cardiotocography: CTG antepartum and intrapartum

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Cardiotocography: CTG antepartum and intrapartum

Cardiotocography: CTG antepartum and intrapartum

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  • 1. CTG Aboubakr Elnashar Benha University Hospital, EgyptAboubakr Elnashar
  • 2. Antepartum CTG Aboubakr Elnashar
  • 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. 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. 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.  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. 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. •Reactive: increase of FHR to >15 beats/min for > 15 sec following fetal movements Aboubakr Elnashar
  • 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.  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. 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. 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. 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. A: Absence of accelerations, diminished variability, late decelerations with weak spontaneous contractions. B: Normal accelerations Normal variability 15 beat Aboubakr Elnashar
  • 15. CTG: Tachycardia Sinusoidal pattern Late deceleration Aboubakr Elnashar
  • 16. Intrapartum CTG Aboubakr Elnashar
  • 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. 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. •Fetal bradycardia measured with a scalp electrode in a pregnancy complicated by placental abruption and subsequent fetal death. Aboubakr Elnashar
  • 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. 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. 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. Short-term beat-to-beat variability measured by a fetal scalp electrode (t= time interval between successive fetal R waves). Aboubakr Elnashar
  • 24. long-term beat-to-beat variability ranging between 125 and 135 bpm). Aboubakr Elnashar
  • 25. (1) Undetectable or absent (2) Minimal variability:0 -5 bpm Aboubakr Elnashar
  • 26. 4) Marked variability : >25 bpm (3)Moderate variability : >5-<25 bpm Aboubakr Elnashar
  • 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. 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. •Sinusoidal fetal heart rate pattern associated with maternal intravenous meperidine administration. •Sine waves are occurring at arate of 6 cycles/min. Aboubakr Elnashar
  • 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. Periodic heart rate Activity Acceleration Deceleration Aboubakr Elnashar
  • 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. 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. 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. 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. 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. •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. •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. 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. 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. •Variable decelerations B “shoulders” of acceleration compared with deceleration A. Aboubakr Elnashar
  • 42. FHR effects of partial occlusion and complete occlusion of the umbilical cord Aboubakr Elnashar
  • 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. 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. 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. 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. 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. INTERPRETATION Aboubakr Elnashar
  • 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. 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. 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. Aboubakr Elnashar
  • 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. 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. 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. 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. 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. 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. 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. 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. 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. Thank you Aboubakr Elnashar

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