Ctg

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Ctg

  1. 1. CTG – INTERPRET WITH CARE 1
  2. 2. Fetal Monitoring in Labor: Two Acceptable Methods• Electronic • Auscultated – In “active” labor – – Prescribed by convention needs intervals to be continuous – Various devices but – High false positives one recorded (K. Nelson 1996) number – Variable – Easy to interpret interpretations – Intermittent – Acceptable for “high” risk patients 2
  3. 3. Why Auscultation?• Simple • Fewer C/S’s• Well liked by • Legally less patients damning- interpretation• Clear cut action/ clear response • Allows changing• Improves ability to entire environment ambulate in L&D• Easier • Decreases patient, family, nurse and physician anxiety 3
  4. 4. 4
  5. 5. Electronic Monitoring:Later Outcome Nigel Paneth 1993 Clin. Invest Med. Michigan St. Univ• “Central hypotheses of EFM has never been tested” – That is, “that its use (EFM) can effectively prevent the... brain damaging birth asphyxia by timely intervention in labor.” 5
  6. 6. For hypothesis to be true: Paneth (1993)• EFM must be reliable (inter-observer agreement on identity and meaning)• EFM must be valid (patterns statistically linked with adverse neurological events)• EFM and adverse outcome are related, specifically association is• causal 6
  7. 7. CRITICISMS TOWARDS CARDIOTOCOGRAPHY• Insufficient understanding of the (patho-)physiologic background• A number of technical pitfalls• Differences in recording techniques• Primarily qualitative information (pattern recognition)• Lack of uniform classification systems• Confusion due to the many influences on the fetal heart rhythm• Substantial intra- and inter-observer variation regarding the interpretation• Low validity, high incidence of false-positive findings• Primarily screening method, too often applied as a diagnostic• Leads to an increase in artificial deliveries• Lack of agreement on how, when, and whom to monitor• Contributes to medico-legal vulnerability 7
  8. 8. ARGUMENTS AGAINST AUSCULTATION• Hard to do! – No, not really! • Will cause fetal harm, or CP?• Requires more staff – No more so than – Shouldn’t have to continuous EFM• Does not meet May miss something? standard of care -Such as?? – Untrue! • Not legally defensible – Hardly 8
  9. 9. THEN WHY DISCUSS CTG???• USEFUL IN HIGH RISK CASES.• STANDARDISED EVIDENCE BASED GUIDELINES ARE BEING LAID FOR CORRECT USE,INTERPRETATION , FURTHER DECISION MAKING & RECORD KEEPING. 9
  10. 10. Appropriate monitoring in an uncomplicated pregnancy For a woman who is healthy and has had anotherwise uncomplicated pregnancy,intermittent auscultation should beoffered and recommended in labour to monitorfetal wellbeing. In the active stages of labour, intermittentauscultation should occurafter a contraction, for a minimum of 60seconds, and at least:• every 15 minutes in the first stage• every 5 minutes in the second stage.. Grade A Recommendation 10
  11. 11. Indications for the use of continuous EFM 11
  12. 12. GRADE B RECOMMENDATIONContinuous EFM should be offered andrecommended for high-riskpregnancies where there is an increased risk ofperinatal death,cerebral palsy or neonatal encephalopathy. Continuous EFM should be used where oxytocin isbeing used forinduction or augmentation of labour. 12 REF:RCOG GUIDELINES
  13. 13. ADMISSION CTGCurrent evidence does notsupport the use of theadmission CTG inlow-risk pregnancy and it istherefore not recommended Grade B Recommendation 13
  14. 14. Selected High-Risk Indications for Continuous Monitoring of Fetal Heart Rate Maternal medical illness Gestational diabetes Hypertension Asthma Obstetric complications Multiple gestation Post-date gestation Previous cesarean section Intrauterine growth restriction Oligohydramnios Premature rupture of the membranes Congenital malformations Third-trimester bleeding Oxytocin induction/augmentation of labor Preeclampsia Meconium stained liquor 14
  15. 15. A Continuous EFM should be offered and recommended in pregnancies previously monitored with intermittent auscultation:• if there is evidence on auscultation of a baseline less than 110 bpm or greater 160 bpm• if there is evidence on auscultation of any decelerations• if any intrapartum risk factors develop. 15
  16. 16. Definitions and descriptions ofindividual features of fetal heart-rate (FHR) traces Baseline fetal heart rate :The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm. 16
  17. 17. – Normal Baseline FHR 110–160 bpm– Moderate bradycardia 100–109 bpm– Moderate tachycardia 161–180 bpm– Abnormal bradycardia < 100 bpm– Abnormal tachycardia > 180 bpm 17
  18. 18. Baseline variabilityThe minor fluctuations in baselineFHR occuring at three to fivecycles per minute. It is measuredby estimating the difference inbeats per minute between thehighest peak and lowest trough offluctuation in a one-minutesegment of the trace 18
  19. 19. 19
  20. 20. ACCELERATIONS 20
  21. 21. DECCELERATIONS• EARLY : Head compression• LATE : U-P Insufficiency• VARIABLE : Cord compression Primary CNS dysfn 21
  22. 22. EARLY 22
  23. 23. LATE 23
  24. 24. VARIABLE 24
  25. 25. Atypical Variable decelerations With any of the following additional decelerations components:– lossof primary or secondary rise in baseline rate– slow return to baseline FHR after the end of thecontraction– prolonged secondary rise in baseline rate– biphasic deceleration– loss of variability during deceleration– continuation of baseline rate at lower level 25
  26. 26. 26
  27. 27. Categorisation of fetal heart rate tracesCategory DefinitionNormal All four reassuringSuspicious 1 non-reassuring Rest reassuringPathological 2 or more non- reassuring 1 or more abnormal 27
  28. 28. REDUCED VARIABILITYHypoxia Drugs Extreme prematurity Sleep CNS abno. 28
  29. 29. 29
  30. 30. TACHYCARDIAHypoxia ChorioamnionitisMaternal fever B-Mimetic drugsFetal anaemia,sepsis,ht failure,arrhythmias 30
  31. 31. SPECIALPATTERNS 31
  32. 32. Sinusoidal patternA regular oscillation of the baseline long-termvariability resembling a sine wave. This smooth,undulating pattern, lasting at least 10 minutes, has arelatively fixed period of 3–5 cycles per minute and anamplitude of 5–15 bpm above and below the baseline.Baseline variability is absentAssociated with - Severe chronic fetal anaemia Severe hypoxia & acidosis 32
  33. 33. SINUSOIDAL 33
  34. 34. PSEUDOSINUSOIDAL 34
  35. 35. CHECKMARK PATTERN 35
  36. 36. SALTATORY PATTERN 36
  37. 37. LAMBDA PATTERN 37
  38. 38. 38
  39. 39. 39
  40. 40. SUSPICIOUS CTGCTG CAUSE CLINICALPATTERN MANAGEMENTEARLY 2nd Stage NONELATE Uterine Stop oxytocin hypercontractily Consider terbutaline sc Oxygen @ 8-10 l/min Left lateral decubitusVARIABLE Cord compression Consider amnioinfusion (mild/mod v.d.)TACHYCARD Maternal Infection screenIA fever,tachycardia, Hydrate - crystalloids dehydration Stop tocolysis if 40
  41. 41. PATHOLOGICAL FETAL SCALP STIMULATION TEST FETAL SCALP BLOOD Ph FETAL VIBROACAUSTIC(If facilities available) STIMULATION TEST 41
  42. 42. A Systematic Approach to Reading Fetal Heart Rate Recordings• Evaluate recording--is it continuous and adequate for interpretation?• Identify type of monitor used--external versus internal, first-generation versus second-generation.• Identify baseline fetal heart rate and presence of variability, both long- term and beat-to-beat (short-term).• Determine whether accelerations or decelerations from the baseline occur.• Identify pattern of uterine contractions, including regularity, rate, intensity, duration and baseline tone between contractions.• Correlate accelerations and decelerations with uterine contractions and identify the pattern.• Identify changes in the FHR recording over time, if possible.• Conclude whether the FHR recording is reassuring, nonreassuring or ominous.• Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR.• Document in detail interpretation of FHR, clinical conclusion and plan of management. 42
  43. 43. • Prior to any form of fetal monitoring, the maternal pulse should bepalpated simultaneously with FHR auscultationin order todifferentiate between maternal and fetalheart rates.• If fetal death is suspected despite thepresence of an apparentlyrecordable FHR, then fetal viability should beconfirmed with realtimeultrasound assessment. 43
  44. 44. 44
  45. 45. RECORD KEEPING IN CTG• The date and time clocks on the EFM machine should be correctly set• Traces should be labelled with the mother’s name, date and hospital number• Any intrapartum events that may affect the FHR should be noted contemporaneously on the EFM trace, signed and the date and time noted (e.g. vaginal examination, fetal blood sample, siting of an epidural) 45
  46. 46. •Any member of staff who is asked toprovide an opinion on a trace should notetheir findings on both the trace andmaternal case notes, together with timeand signature• Following the birth, the care-givershould sign and note the date,time andmode of birth on the EFM trace• The EFM trace should be storedsecurely with the maternal notes at the end of the monitoring process. 46
  47. 47. SOMEINTERESTING CASES 47
  48. 48. ACCELERATION OR DECCELERATION ??? 48
  49. 49. BASELINE BRADYCARDIA WITHACCELERATIONS 49
  50. 50. HALVING PHENOMENON 50
  51. 51. EXCESSIVE VARIABILITY??? 51
  52. 52. GESTATIONAL DM ; NST ; 8:30am 52
  53. 53. GDM ; CST ; 12 noon 53
  54. 54. BLUNTED PATTERN WITH VARIABLEDECCELERATIONS – CNS DYSFUNCTION 54
  55. 55. Thank you 55

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