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CTG introduction

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CTG introduction

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CTG introduction

  1. 1. CTG Introduction Aboubakr Elnashar Benha university, Egypt ABOUBAKR ELNASHAR
  2. 2. 1. Fetal response to hypoxia 2. Fetal monitoring in labor 3. Indications 4. Types of CTG monitoring 5. Important considerations 6. Why care about CTG 7. Steps 8. Components of CTG paper ABOUBAKR ELNASHAR
  3. 3. 1. FETAL RESPONSE TO HYPOXIA  Hypoxia ← ↓ Blood Flow ↓↓  ↓ PO2 ↑PCO2 ↓ ↓ Metabolic acidosis ← Respiratory acidosis ⇓  Redistribution of blood flow to vital organs  Bradycardia, and slightly ↓cardiac output  ↓oxygen consumption ABOUBAKR ELNASHAR
  4. 4. ↓ ↓ FHR, variability FHR,↓ variability, retained / ↑ rate, decelerations ⇓⇓ Compensated State Decompensated State (Normal cortical functions (Decrease cerebral cerebral oxygenation oxygenation, eventual maintained cellular damage ABOUBAKR ELNASHAR
  5. 5. Important definitions  Hypoxia: Decreased po2 level in tissues.  Hypoxima: Decreased po2 level in blood.  Acidosis: Decreased PH in tissues.  Acidemia: Decreased PH in blood.  Ashyxia: Hypoxia + acidosis. ABOUBAKR ELNASHAR
  6. 6. 2. FETAL MONITORING IN LABOR 1. Intermittent auscultation 2. CTG Fetal electrocardiography Scalp stimulation Vibroacoustic stimulation 3. Fetal scalp sampling  PH determination 4. Fetal pulse oximetry ABOUBAKR ELNASHAR
  7. 7. ABOUBAKR ELNASHAR
  8. 8.  1968: Hammacher and Hewitt-Packard, developed 1st commercial fetal monitor.  Assessment of fetal well being during late pregnancy and labor.  Expectations at the time it would lead to a decreased incidence of perinatal death and cerebral palsy.  Reality has fallen very short of these expectations ABOUBAKR ELNASHAR
  9. 9. 3. INDICATIONS OF CONTINUOUS EFM 1. High-risk pregnancies where there is an increased risk of perinatal death, cerebral palsy or neonatal encephalopathy. 2. Where oxytocin is being used for induction or augmentation of labour. ABOUBAKR ELNASHAR
  10. 10. The admission CTG test Commonly used screening test consisting of a short (usually 20 minutes) recording of FHR and uterine activity performed on the mother's admission to the labour ward. Admission CTG not be used for women who are low risk on admission in labour. (Cochrane SR, 2012) {:an increase in the incidence of CS without evidence of benefit}. ABOUBAKR ELNASHAR
  11. 11. 4. TYPES OF CTG MONITORING External monitoringInternal monitoring ABOUBAKR ELNASHAR
  12. 12.  CTG is best regarded as a screening tool (not diagnostic)  High negative predictive value (Specificity= Healthy, 98%) >98% of fetuses with a normal CTG will be OK  Poor positive predictive value (Sensitivity) with unnecessary operative intervention for f distress. 50% of fetuses with an abnormal CTG will be hypoxic and acidotic but 50% will be OK  CTG should always be interpreted in its clinical context and backed by fetal blood sampling PRN 5. IMPORTANT CONSIDERATIONS ABOUBAKR ELNASHAR
  13. 13.  Normal CTG indicate that there were no abnormalities no indication for intervention. CTG could be viewed as part of Defensive Medicine (permanent record)  Abnormal/suspicious CTG may provide: an evidence that inappropriate or lack of tt: litigation  In spite of it is poor indicator of overall fetal status but it remains The best we have ABOUBAKR ELNASHAR
  14. 14. Disadvantages  Insufficient understanding of the (patho-)physiologic background  Confusion due to the many influences on the FH rhythm  Lack of agreement on how, when, and whom to monitor  Lack of uniform classification systems  Poor positive predictive value (Sensitivity): unnecessary operative intervention for f distress.  Substantial intra- and inter-observer variation regarding the interpretation  Contributes to medico-legal vulnerability  Primarily qualitative information (pattern recognition) ABOUBAKR ELNASHAR
  15. 15. 7. STEPS External monitoring • Explain the processes and reasons for the CTG, verbal consent  Ask to empty her bladder  Ascertain the lie, presentation and position of the fetus  Place and secure the FHR ultrasound transducer over the fetal anterior shoulder  Place and secure the toco-transducer on the fundus  Position the woman: comfortable: sitting upright or laterally  Ensure ultrasound contact is maintained  Document on the FHR pattern: date and time, gestation, indication for monitoring, maternal pulse/30 min  Record the FHR pattern at the rate of 1cm or 3cm/min ABOUBAKR ELNASHAR
  16. 16. Internal monitoring Membranes: absent Cervix: dilated enough. 1. Fetal scalp electrode:  A device that monitors FHR.  consists of a small clip that is placed on the fetal scalp.  The electrode is attached to a cable. ABOUBAKR ELNASHAR
  17. 17. 2. Intrauterine pressure catheter (IUPC): directly measures the strength of contractions and resting tone in millimeters of Hg. It provides more accurate information as to the strength of contractions than an external monitor (tocodynameter). can also be used to instill an amnioinfusion. ABOUBAKR ELNASHAR
  18. 18. 8. COMPONENTS OF FETAL HEART RATE PAPER Date Time Paper speed: 3 cm/minute. There are 6 in one minute between the dark lines so each little box represents ten (10) seconds. Dark red lines are one minute apart Maternal vital signs ABOUBAKR ELNASHAR
  19. 19. LITIGATION  Traces: not done. Unsatisfactory or Missing: EFM traces should be kept up to 25 ys  Abnormal CTG: ignored or not recognized ABOUBAKR ELNASHAR
  20. 20. EDUCATION AND TRAINING If you are going to use the CTG You must be able to Interpret the trace & respond accordingly Improves Knowledge/clinical skills for all staff Training should include instructions on documenting traces and storage appropriate clinical responses to suspicious or pathological traces local guidelines ABOUBAKR ELNASHAR
  21. 21. Thank You ABOUBAKR ELNASHAR

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