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Cardiotocography
- 1. Cardiotocography 1 Presented By Nirsuba Gurung MN,WomenHealth and Development 4/24/2016
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- 3. Cardiocotography • Cardiotocography (CTG)is a continuous electronic record of the fetal’s heart rate obtained via an ultrasound transducer placed on the mother’s abdomen • It is sometimes referred to as ‘electronic fetal monitoring’ (EFM) 4/24/2016 3
- 4. CTG Contd….. • Themachine used to perform the monitoring is called a cardiotocograph, more commonly known as an electronic fetal monitor (EFM) 4/24/2016 4
- 5. Invention • The invasivefetal monitoring was invented by Doctors Alan Bradfield, Orvan Hess and Edward Hon. • A refined (antepartal, non- invasive, beat-to-beat) version (cardiotocograph) was later developed for Hewlett Packard by Dr. Konrad Hammacher. 4/24/2016 5
- 8. Purpose • To recordFHS continuously • To check uterine activity • To detect any fetal distress • To gain information about rate, rhythm of the fetal heart rate and fetal movement
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- 10. Indication Continuous EFM shouldbe offered and recommended for high-risk pregnancies where there is an increased risk of perinatal death, cerebral palsy or neonatal encephalopathy. Continuous EFM should be used where oxytocin is being used for induction or augmentation of labour. 104/24/2016
- 11. ADMISSION CTG Current evidencedoes not support the use of the admission CTG in low-risk pregnancy and it is therefore not recommended 114/24/2016
- 12. High-Risk Indications Maternal medicalillness 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 124/24/2016
- 13. A Continuous EFMshould 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. 134/24/2016
- 14. Methods External Cardiotocography- For continuousor intermittent monitoring of • The fetal heart rate and • The activity of the uterine muscle • Placed two transducers on the mother's abdomen(one above the fetal heart and the other at the fundus).
- 15. External(Indirect) Monitoring The tocodynamometer (“toco”) isplaced over the uterine fundus. The toco provides information that can be used to monitor uterine contractions. The ultrasound device is placed over the area of the fetal back. This device transmits information about the FHR.
- 16. The pressure transducer transmitsthe pressure generated by uterine contractions in mm Hg. •Each small vertical square is 5 mm Hg •Each small horizontal square is 10 seconds . •Each large horizontal square is 1 minute . Pressure Transducer Toco sensor
- 17. Ultrasound transducer The ultrasoundprobe transmits the fetal heart rate in beats per minute. •Each small vertical square is 10 beats. •Each small horizontal square is 10 seconds . •Each large horizontal square is 1 minute .4/24/2016 17 Ultrasound Probe
- 18. • Information fromboth the toco and the ultrasound device is transmitted to the electronic fetal monitor. • The FHR is displayed in a digital display (as a blinking light), on the special monitor paper, and audibly (by adjusting a button on the monitor). The uterine contractions are displayed on the special monitor paper as well. 18
- 19. Internal Cardiotocography- • Usesan electronic transducer connected directly to the fetal scalp through the cervical opening and is connected to the monitor. • Internal monitoring provides a more accurate. • Internal monitoring may be used when external monitoring of the fetal heart rate is inadequate. • It need some degree of cervical dilatation.
- 20. Internal Monitoring Criteria forInternal Monitoring: Amniotic membranes must be ruptured Cervix dilated 2 cm. Presentation must be cephalic Presenting part down against the cervix
- 21. • Spiral Electrodeis placed on the fetal occiput which allows for more accurate continuous data than external monitoring. • Also is not affected by mom or fetal movement as with external monitoring. 4/24/2016 21
- 22. Internal Monitoring The spiralelectrode is attached to the fetal scalp Wires that extend from attached spiral electrode are attached to a leg plate and then attached to electronic fetal monitor.
- 23. Procedure Equipments • Cardiotocograph • Transducer(2):Tocoand cardio • Conduction gel or paste • Abdominal binder (two belts) • Monitor paper • Tissue paper 4/24/2016 23
- 25. Preparation for CTG •Determine the indication for fetal monitoring • Explain the purpose, time required for test • Instruct the women for empty the bladder • Place the women in supine position • Uncover the abdomen
- 26. Procedure • Place thetocosensor on the fundus of utreus and fix it with abdominal binder • Identify the presentation and position of the fetus • Localize the FHS and fix it with abdominal binder
- 27. Procedure • Assure therecording of FHS and uterine contraction • Explain the mother to push the bottom when she feel any movements • Labeled the women’s name, I.P. number, date and time in CATAG graph 4/24/2016 27
- 28. Procedure • Turn offthe monitor and replace • Read the CTG and immediately notify the doctor ,if any abnormality seen 4/24/2016 28
- 29. Interpretation • Uterine activity(contractions) • Baseline fetal heart rate (FHR) • Baseline FHR variability • Presence of accelerations • Periodic or episodic decelerations • Changes or trends of FHR patterns over time.
- 30. Uterine activity (contraction) • Frequency-the amount of time between the start of one contraction to the start of the next contraction. • Duration :The amount of time from the start of a contraction to the end of the same contraction • Intensity (strongeness):a measure of how strong a contraction is. In early labour the contractions are weak, with amplitude of about 20 mm Hg and at the end of the first stage 60 mm Hg
- 31. Uterine activity (contraction) • RestingTone- a measure of how relaxed the uterus is between contraction(between 4-10 mm Hg) • Interval- the amount of time between the end of one contraction to the beginning of the next contraction.
- 32. • Record thenumber of contractions present in a 10 minute period - e.g. 3 in 10 • Each big square is equal to 1 minute, so look how many contractions occurred in 10 squares • Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity • assess contractions for duration and
- 33. Baseline fetal heartrate 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. 334/24/2016
- 34. – Normal BaselineFHR 110–160 bpm – Moderate bradycardia 100–109 bpm – Moderate tachycardia 161–180 bpm – Abnormal bradycardia < 100 bpm – Abnormal tachycardia > 180 bpm 344/24/2016
- 36. Baseline Fetal Heartrate Normal Pattern • Baseline FHR = 110 – 160 bpm
- 37. Baseline variability •Variability refersto the normal beat to beat changes in FHR. • Normal variability is between 5- 15 bpm. •Variability can be measured by analysing a one-minute portion of the CTG by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace 37
- 38. Baseline variability The fluctuationsare visually quantities as the amplitude of the peak-to-trough in bpm. Using this definition, the baseline FHR variability is categorized by the quantitated amplitude as: • Absent- undetectable • Minimal- greater than undetectable, but less than or equal to 5 bpm • Moderate- 6-25 bpm • Marked- greater than 25 bpm 4/24/2016 38
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- 43. FHR Variability Absent variability= Amplitude range undetectable Minimal = < 5 BPM Moderate = 6 to 25 BPM Marked = > 25 BPM
- 44. Accelerations • To becalled an acceleration, the peak must be greater than or equal to 15 bpm, and the acceleration must last greater than or equal to 15 seconds from the onset to return to baseline. • Prolonged acceleration: is greater than or equal to 2 minutes but less than 10 minutes in duration. • Before 32 weeks of gestation, accelerations are defined as having a peak greater than or equal to 10 bpm and a duration of greater than or equal to 10 seconds.
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- 47. Deceleration Decreases in fetalheart rate from the base line by at least 15b/m, lasting for at least 15 seconds.
- 48. DECCELERATIONS • EARLY :Head compression • LATE : U-P Insufficiency • VARIABLE : Cord compression Primary CNS dysfn 484/24/2016
- 49. Early Deceleration • EarlyDeceleration: Early begin at start of uterine contraction and end with conclusion of contraction. Early decelerations are not a sign of fetal problems. • In most cases the onset, nadir(lowest point), and recovery of the deceleration are coincident with the beginning, peak, and ending of the contraction, respectively
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- 51. Early Decelerations • Relatedto Head Compression • Intervention – No intervention necessary. Just continue to watch for any changes.
- 52. Early decelerations contd… •Early decelerations are a benign( kind/ gentle) finding caused by a vasovagal response as a result of fetal head compression by the contraction. • Pressure on the fetal skull alters the cerebral blood flow and this in turn stimulates the vagus nerve
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- 57. Variable Deceleration • Variabledecelerations are variable in duration, intensity, and timing
- 58. Variable decelerations Abrupt(sudden) decreasein FHR of > 15 beats per minute measured from the most recently determined baseline rate. The onset of deceleration to nadir is less than 30 seconds. The deceleration lasts > 15 seconds and less than 2 minutes.
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- 60. Variable Decelerations • Relatedto cord compression • Intervention – Reposition – Amnioinfusion
- 62. variable deceleration contd… •The umbilical vein is often occluded first causing an acceleration in response • Then the umbilical artery is occluded causing a subsequent rapid deceleration • When pressure on the cord is reduced another acceleration occurs & then the baseline rate returns • Accelerations before & after a variable deceleration are known as the “shoulders of deceleration” • There presence indicates the foetus is not yet hypoxic & is adapting to the reduced blood flow.
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- 65. Late Deceleration Gradual decreasein FHR with onset of deceleration to nadir >30 seconds. Onset of the decleration occurs after the beginning of the contraction, and the nadir of the deceleration occurs after the peak of the contraction.
- 66. Late Decelerations • Relatedto decreased uteroplacental perfusion
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- 70. Late Deceleration • Thefetal heart tones return to the baseline AFTER end of contraction
- 71. Two varieties oflate decelerations reflex and nonreflex. • Reflex late decelerations: are those which occur in the presence of normal FHR variability • Non-reflex late decelerations occur in association with diminished or absent FHR variability.
- 72. • Reflex latedecelerations are thought to be due to vagal stimulation by chemoreceptors in the head in response to low oxygen tension. • The hypoxemia -----increased sympathetic stimulation ------- increased systemic vascular resistance. The response to this increased pressure is a vagally mediated decrease in heart rate. • This dual reflexive response may explain the delay in the heart rate following a contraction. • Reflex late decelerations are associated with normal FHR variability because CNS system is intact.
- 73. • Nonreflex latedecelerations are associated with a greater degree of relative hypoxemia and result in hypoxic depression of the myocardium coupled with the previously described vagal response. • In reflex late decelerations, variability was maintained because the fetus was able to compensate, shifting oxygenated blood to vital organs (e.g., the heart),
- 74. • But innonreflex late decelerations, the fetus is unable to compensate. It is these late decelerations which are more typically associated with fetal acidosis, and they are more commonly associated with placental dysfunction rather than uterine hypoperfusion or hyperactivity. 4/24/2016 74
- 75. Late Decelerations Management • Placepatient on side •Administer O2 by tight face mask •Discontinue oxytocin. •Correct any hypotension •IV hydration. •If hyperstimulation is present consider terbutaline 0.25 mg SC •If late decelerations persist for more than 30 minutes despite the above maneuvers, fetal scalp pH is indicated. •Scalp pH > 7.25 is reassuring, pH 7.2-7.25 may be repeated in 30 minutes. •Deliver for pH < 7.2 or minimal baseline variability with late or prolonged decelerations and inability to obtain fetal scalp pH These maneuvers are primarily intended to alleviate "reflex" lates.
- 76. Prolonged Deceleration A prolongeddeceleration is present when there is a visually apparent decrease in FHR from the baseline that is greater than or equal to 15 bpm, lasting greater than or equal to 2 minutes, but less than 10 minutes. • If it lasts between 2-3 minutes it is classed as Non- Reasurring • If it lasts longer than 3 minutes it is immediately classed as Abnormal • Action must be taken quickly – e.g. Foetal blood sampling / emergency C-section
- 77. Prolonged Deceleration: A decelerationthat lasts greater than or equal to 10 minutes is a baseline change.
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- 81. Categorisation of fetalheart rate traces Category Definition Normal All four reassuring Suspicious 1 non-reassuring Rest reassuring Pathological 2 or more non- reassuring 1 or more abnormal 814/24/2016
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- 83. Sinusoidal pattern A regularoscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed period of 3–5 cycles per minute and an amplitude of 5–15 bpm above and below the baseline. Baseline variability is absent Associated with - Severe chronic fetal anaemia Severe hypoxia & acidosis 834/24/2016
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- 87. ACCELERATION OR DECCELERATION??? 874/24/2016
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- 91. GESTATIONAL DM ;NST ; 8:30am 914/24/2016
- 92. GDM ; CST; 12 noon 924/24/2016
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- 94. References • Dutta, D.C.(2004).Text book of Obstetrics. Sixth edition, New Central book agency • Arias, F. Daftary, S.N. & Bhide, A. G.(2013). Practical guide to high risk pregnancy and delivery. Third edition, Elsiever • 4/24/2016 94Nirsuba Gurung MN 1st year
- 95. • The RoyalAustralian and New Zealand College of Obstetricians and Gynaecologists (2006) Intrapartum Fetal Surveillance Clinical Guidelines. • Baker L, Beaves M, Trickey D and Wallace E. 2009. Fetal Surveillance: A Practical Guide. Southern Health and RANZCOG 4/24/2016 95
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