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Intra Partum Cardiotocography - dr vivek patkar

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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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Intra Partum Cardiotocography - dr vivek patkar

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

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