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Ctg 2016
This document discusses fetal monitoring techniques used at SGH including intermittent auscultation, electronic fetal monitoring, and cardiotocography. It describes the goals of fetal monitoring and provides details on the different monitoring modalities, terminology used in CTG interpretation, guidelines for monitoring based on risk level, and management of abnormal tracings. Fetal scalp blood sampling is also discussed as a technique to determine fetal acid-base status when CTG changes are non-reassuring.
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Ctg 2016
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- 2. GOALS 1. To havestandardized terminology and approach in interpretation of CTG 2. To identify abnormal CTG and appropriate intervention 3. Risk management and documentation
- 3. MODALITIES IN SGH… Intermittent auscultation (Pinard stetoscope) Electronic FHR monitoring (Daptone) Cardiotocograph (CTG)- external or internal Fetal scalp blood sampling (pH testing)
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- 5. • 17th century- 1818 Francis-Isaac • Professor John Ferguson described fetal heart sound in 1827 Hohl fetal stethoscope Depaul fetal stethoscope
- 6. Procedure Rationale 1 PerformLeopold’s manoeuver by palpating the maternal abdomen To identify fetal presentation and position 2 Place the listening device over the area of maximum intensity, which is usually over the back of the fetus, and clarity of the fetal heart sound To obtain the clearest and loudest sound, this is easier to count. 3 Count the maternal radial pulse To differentiate it from the fetal rate 4 Palpate the abdomen for the absence of uterine activity To be able to count FHR between contraction 5 Count the FHR for 30 to 60 seconds between contractions To identify the basal heart rate (BHR) which can only be assessed during the absence of uterine activity 6 Auscultate the FHR during contraction, if possible, and for 30 seconds after the end of the contraction To identify the FHR during the contraction and as a response to the contraction 7 When there are distinct discrepancies in FHR during or between listening periods, auscultate for a longer period during, after and between contraction To identify changes from the baseline that indicate the need for another mode of FHR monitoring
- 7. FREQUENCY OF AUSCULTATION StageoflabourLowrisk Highrisk Latentphase Every30-60minutes Every30minutes Activephase Every30minutes Every15minutes Secondstage Every15minutes Every5minutes
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- 9. Doppler principle toproduce excellent external traces
- 10. FREQUENCY OF AUSCULTATION StageoflabourLowrisk Highrisk Latentphase Every30-60minutes Every30minutes Activephase Every30minutes Every15minutes Secondstage Every15minutes Every5minutes
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- 12. DEFINITION (CTG) isa technical means of recording (-graphy) the fetal heartbeat (cardio-) and the uterine contractions (- toco-) during pregnancy The machine used to perform the monitoring is called a cardiotocograph (CTG), more commonly known as an electronic fetal monitor (EFM)
- 13. Ultrasound Doppler technologyhas produce excellent quality external traces Corometric 170 series Avalon FM 20
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- 15. ADVANTAGES FHR &contraction can be monitored & recorded at the same time Reduce rates of seizure in newborn DISADVANTAGES Prevent mother from moving Unable to change position Increase interventions (instrumental deliveris or C-sec)
- 16. TYPES EXTERNAL CTG Anultrasound transducer over the abdomen that will pick up the baby's heartbeat. The heartbeat will be recorded continuously on a paper strip. Tocogram- a pressure gauge that measures the frequency of your contractions. INTERNAL CTG This method can only be used if membranes (fore- waters) and your cervix have ruptured either spontaneously or artificially. An electrode is placed on the baby’s scalp to directly monitor the fetal heart rate. An electrode is called a fetal scalp electrode (FSE)
- 18. The lengthof the CTG strip depends on the paper speed. In the UK it is usually 1cm/min. Each vertical division on the paper is 1cm and therefore 1 min. SALSO 2015 ELECTRICAL FETAL MONITORING: TERMINOLOGY
- 19. A=Fetal heart rate B=Movementby mother C=Fetal movement D=Contraction
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- 21. DR DEFINE RISK CCONTRACTION BR BASELINE HEART RATE A ACCELARATION VA VARIABILITY D DECELARATION O OVERALL INTERPRETATION OF CTG: DR C BR A VA DO
- 22. The processof birth is the most dangerous journey any individual undertakes Assess from the history and examination either low risk or high risk pregnancy Admission CTG performed, then intermittent ascultation vs continuous monitoring 1. DR = DEFINE RISK
- 23. *ALL ANTENATAL PATIENTCAME TO LABOUR ROOM WILL HAVE AN ADMISSION CTG AT LEAST 20 MINS TRACING RISK CTG MONITORING LOW - Intermittent tracing 2-4hly - Continous CTG is unnecessary MODERATE - Intermittent CTG trace to be decide by registra or specialist - Frequency & length of CTG tracing depends on individual case & previous trace HIGH - Intermittent CTG trace to be decide by registrar or specialist - Continous CTG may be needed
- 24. Assess contractionpain from the tocogram- quantifying the number of contractions present in a 10-minute window There are several factors used in assessing uterine activity. Frequency Duration Normal- less than or equal to 5 contractions in 10 minutes, averaged over a 30-minute window Tachysystole- more than 5 contractions in 10 minutes, averaged over a 30-minute window 2. C = CONTRACTION
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- 27. Level ofthe fetal heart rate when this stable with accelerations and decelerations excluded. Determined over a period of 5 or 10 min and expressed in bpm. Normal range is 100-160bpm. 3. BR = BASELINE FETAL HEART RATE
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- 29. Is it fetalor maternal? Always use the fetal stethoscope before applying the machine
- 30. Tachycardia – isa baseline heart rate of > 160bpm Causes?
- 31. Bradycardia- baseline fetalheart rate < 100bpm * A stable basline fetal heart rate between 90-99 bpm with normal baseline variability may be a normal variation
- 32. Transient increasein heart rate of 15bpm or more and lasting 15s or more. The recording of at least 2 accelerations in a 20 min period is considered a reactive trace Accelerations are the hallmark of fetal health. 4. A = ACCELERATION
- 33. NICE GUIDELINES 2014 Acceleration is not a feature to categorise CTG Fetal heart rate accelerations is generally a sign that unborn baby is healthy Abscence of accelerations in an otherwise normal CTG does not indicate acidosis If FBS is indicated and sample cannot be obtained,but scalp stimulation results in fetal heart rate acceleration,decide whether to continue labour or expedite the birth in light of the clinical circumstances and in discussion with the woman
- 34. Baseline varies withina particular band width excluding accelerations and decelerations. It indicates the integrity of the autonomic nervous system Silent , 0-5bpm Reduced, 5- 10bpm Normal, 10-25bpm Saltatory, >25bpm 5. VA = VARIABILITY
- 36. BASELINE VARIABILITY Normal/ reassuring Non- reassuring Abnormal 5 ormore <5 for 30-90min <5 for > 90min *Intermittent period of reduced baseline variability are normal, especially during periods of “sleep”
- 37. Reduced baseline variability: Thecommonest reasons : sleep phase of the FHR cycle • Hypoxia • prematurity • tachycardia • drugs (sedatives, antihypertensive acting on CNS, anaesthetics) • Fetal anaemia (Rhesus disease or fetomaternal haemorrhage ) • congenital malformations • cardiac arrhythmias • fetal infection
- 38. Transient episodeof slowing of the heart rate below the baseline level of > 15bpm and lasting 15s or more 6. D = DECELERATION
- 39. Early deceleration in 2ndstage of labour TYPE 1 OR EARLY.. Onset of deceleration consistent with contraction
- 40. The onset of decelerationafter the contraction. Late deceleration in 2nd stage of labour TYPE 2 OR LATE….
- 41. Vary in shape,size and in timing with respect to each other. A manifestation of compression of the umbilical cord VARIABLE
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- 43. Normal/ reassuring Non- reassuring Abnormal None or earlyVariable deceleration dropping from baseline less than 60 beats AND taking less than 60 sec to recover Present over 90min Occuring over 50% of contraction Non-reassuring variable deceleration Still observed 30min after starting conservative measures Variable deceleration dropping from baseline >60 bpm OR taking > 60sec to recover Present for up to 30min Occuring over 50% of contractions Bradycardia or single prolonged deceleration lasting 3min or more Late deceleration present for up to 30min Occuring over 50% of contractions Late deceleration present for >30 min Occuring over 50% of contraction Do not improve with conservative measures
- 44. Decelerations (variable orlate) accompanied by fetal tachycardia or reduced baseline variability Take action sooner than 30min
- 45. Normal/Reassuring Non-reassuring Abnormal 7. O=OVERALL CATEGORISATION OF FHR TRACE
- 46. 4 FEATURES OFCTG 1) Acceleration – no longer include 2) Baseline fetal heart rate 3) Baseline variability 4) Deceleration Used to categorise CTG
- 47. CTG catogories Normal /reassuringAll 3 features are normal Non-reassuring 1 non-reasuring feature AND 2 normal/reassuring features • Conservative measures Abnormal (need for conservative measures AND further testing) 1 abnormal feature OR 2 non-reasuring features • Conservative measures • Offer FBS or Expedite birth if FBS cannot be obtained and no accelerations are seen as a result of scalp stimulation Abnormal (need for urgent intervention) Bradycardia or single prolonged deceleration with baseline below 100bpm persisting 3min or more • Start Conservative measure • Prepare for urgent birth • Expedite birth if persist for 9min • If heart rate recovers before 9 min, reassess decision to expedite birth in discussion with the woman
- 48. OVERALL CARE Donot make any decision about woman’s care in labour on the basis of CTG findings alone Make a documented systematic assessment of the condition of woman and the unborn baby hourly or more frequently if there is concern
- 49. HOW TO MANAGE?? DEPENDS ON VARIOUS FACTORS 1.Severity of abnormal trace 2.Antenatal risk 3.Patient’s age & parity 4.How advance she is in labour 5.Progress of labour 6.Colour of liquour 7.Patient’s opinion
- 50. CTG GOALS DODON’T Recurrent Type 2 decelerations Improve placenta perfusion -Left lateral position -Reducing frequency of uterine contractions -Administer O2 -IV Fluid bolus Prolonged deceleration or bradycardia Improve placenta perfusion -Tocolytic agents Minimal or absent variability Improve placenta perfusion -Lateral position -Fetal stimulation Hyperstimulation Reduce uterine contractility -Stop oxytocin -Tocolytic agents Recurrent variable deceleration Reduce cord compression -Maternal position Amnioinfussion
- 51. ** In anemergency setting- acceptable time for decision to the delivery of the baby is 30 minutes
- 52. SECOND STAGE CTG Most of the time CTG is abnormal Early deceleration or variable deceleration is acceptable Which CTG changes require interventions? Prolonged bradycardia Reduced variability
- 53. 4. FETAL SCALPBLOOD SAMPLING
- 54. Fetal scalpPH testing is essentially an invasive vaginal procedure performed when a woman is in active labour to determine if the baby is getting enough oxygen If possible should be performed before a decission of C- Sec is made where the CTG changes are not conclusive or suspicious
- 55. RESULT… pH RESULT ACTION NORMAL7.25-7.35 REPEAT IF ABNORMALITY PERSIST BORDERLINE 7.20-7.25 REPEAT TEST EVERY 30 MINS TILL DELIVERY IF VAGINAL DELIVERY IS EXPECTED SOON ABNORMAL < 7.20 EXPEDITE DELIVERY
- 56. RISKS Bleedingfrom puncture site Infection Bruising on fetal’s scalp CONTRAINDICATIONS Infections- hep C or HIV Thrombocytopenia Non cephalic presentation Prematurity <34 weeks
- 57. RISK MANAGEMENT Properdocumentation in case notes- date, time, signature Document paired cord blood gases & accurate Apgar Score Photocopy the CTG and store properly Frequent training of staff