This document discusses intrapartum fetal assessment using continuous electronic fetal monitoring (CTG). It describes how to interpret CTG readings, including baseline heart rate, variability, accelerations, decelerations, and patterns. Normal CTG findings are reassuring of fetal wellbeing. Non-reassuring findings require closer monitoring and investigation of potential issues. Abnormal findings indicate high risk of fetal hypoxia or acidosis and may require expedited delivery. The document provides guidelines for clinical management based on CTG categorization.
Maternal Care: Assessment of fetal growth and condition during pregnancySaide OER Africa
Maternal Care addresses all the common and important problems that occur during pregnancy, labour, delivery and the puerperium. It covers: the antenatal and postnatal care of healthy women with normal pregnancies, monitoring and managing the progress of labour, specific medical problems during pregnancy, labour and the puerperium, family planning, regionalised perinatal care
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CME presentation slides on Antepartum Haemorrhage
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The tests used to monitor fetal health include fetal movement counts, the nonstress test, biophysical profile, modified biophysical profile, contraction stress test, and Doppler ultrasound exam of the umbilical artery.
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4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
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- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
1. Intrapartum assessment
of fetal wellbeing
Dr. Mahmoud El Naggar
Egyptian Board of Neonatology
Hera General Hospital
Makkah
11/28/20161Mahmoud El naggar
4. What is cardiotocography (CTG)?
CTG is used during pregnancy to monitor both the fetal heart and the
uterine contractions.
It is usually only used in the 3rd trimester.
It’s purpose is to monitor fetal well-being and allow early detection of
fetal distress.
An abnormal CTG indicates the need for more invasive investigations
and may lead to the need for emergency caesarian section
11/28/2016 4Mahmoud El naggar
8. 1- Uterine contractions
O Record the number of contractions present in a 10 minute
period – e.g. 3 in 10
O Individual contractions are seen as peaks on the part of
the CTG monitoring uterine activity.
O You should assess contractions for duration and intensity
O Normal: ≤ 5 contractions in 10 minutes
O Tachy-systole: >5 contractions in 10 minutes
11/28/2016 8Mahmoud El naggar
11. 1- Base line fetal heart rate
Base line= 110- 160 beats/ min
Bradycardia, HR< 110 beats/ min
Tachycardia, HR > 160 beats/ min
11/28/2016 11Mahmoud El naggar
12. 1- Normal base line HR 110-160
11/28/2016 12Mahmoud El naggar
13. 1- Normal base line HR 110-160
11/28/2016 13Mahmoud El naggar
15. Causes of prolonged severe
bradycardia are:
Severe prolonged bradycardia (< 80 bpm for > 3 minutes)
indicates severe hypoxia.
• Prolonged cord compression
• Cord prolapse
• Epidural & spinal anesthesia
• Maternal seizures
• Rapid fetal descent
If the cause cannot be identified and corrected,
immediate delivery is recommended.
11/28/2016 15Mahmoud El naggar
17. Fetal tachycardia HR> 160
Fetal hypoxia
Chorioamnionitis – if maternal fever also present
Hyperthyroidism
Fetal or maternal anemia
Fetal tachyarrhythmia
11/28/2016 17Mahmoud El naggar
18. 2- Beat to beat variability
11/28/2016 18Mahmoud El naggar
19. 2- Beat to beat variability
To calculate variability
you look at how much the
peaks and troughs of the
heart rate deviate from
the baseline rate (in bpm)
11/28/2016 19Mahmoud El naggar
20. 2- Beat to beat variability
Baseline variability refers to the variation of fetal heart rate from one
beat to the next.
Variability occurs as a result of the interaction between the nervous
system, chemoreceptors, baroreceptors and cardiac responsiveness.
Therefore it is a good indicator of how healthy the fetus is at that
particular moment in time.
This is because a healthy fetus will constantly be adapting its heart
rate to respond to changes in its environment.
11/28/2016 20Mahmoud El naggar
22. 2- Beat to beat variability
Absent = no variation in the fetal heart rate
Minimal= < 5
Moderate= 6- 25
Marked= > 26
Moderate variability is reassuring sign of adequate fetal
oxygenation and normal brain function
Normal reassuring
11/28/2016 22Mahmoud El naggar
23. Decrease beat to beat variability
1- hypoxia
2- acidemia
3- tachycardia
4- drugs that depress the fetal CNS
5- prolonged uterine contraction
6- CNS and cardiac anomalies
11/28/2016 23Mahmoud El naggar
25. 3- Accelerations
Elevation of the heart rate above the base line ≥ 15 beats for ≥ 15 seconds but
less than 2 minutes ( 15 x 15 )
Normal in case of fetal movement due to sympathetic stimulation
Reassuring if there is to 2 acceleration or more within 20 minutes
Before 32 weeks’ gestation, accelerations are defined by an increment ≥ 10 beats/min above the most recently determined baseline for ≥ 10 seconds
Prolonged acceleration lasts > 2 minutes but <10 minutes
11/28/2016 25Mahmoud El naggar
28. 4- Decelerations( 15x 15)
O Decrease of fetal heart rate by ≥ 15 beats for ≥ 15 seconds
( 15 x 15)
O 3 types of decelerations in relation to uterine contraction
a) Early b) Late c) Variable
11/28/2016 28Mahmoud El naggar
34. a) Early deceleration
Deceleration will start slowly at the beginning of uterine contraction (onset to nadir
>30 seconds)
Nadir of deceleration opposite to the peak of contraction
Recovery of deceleration slowly with the end of contraction
Caused by head compression during uterine contraction will increase the vagal
tone
Considered a periodic pattern because it occurs with uterine contractions
11/28/2016 34Mahmoud El naggar
37. b) late deceleration
Deceleration will start slowly at the peak of uterine contraction
Nadir will be opposite to the end of uterine contraction
Recovery of deceleration will be slowly later after the end of uterine contraction and in severe
cases may be it will not return back to the previous base line heart rate
Also considered a periodic pattern
Caused by utero-placental insufficiency or decreased uterine blood flow
Indicate fetal metabolic acidosis 11/28/2016 37Mahmoud El naggar
43. c) Variable deceleration
variable in the time as regarding uterine contraction
Variable in intensity
Variable in duration
Variable in shape v or w
May be episodic (occurs without a contraction) or periodic
Rapid decrease and rapid increase
Due to umbilical cord compression 11/28/2016 43Mahmoud El naggar
45. Prolonged deceleration
Decrease in the FHR ≥ 15 beats/min below the most recently
determined baseline lasting > 2 minutes but <10 minutes from
onset to return to baseline
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as
abnormal.
11/28/2016 45Mahmoud El naggar
46. Recurrent or intermittent
Recurrent decelerations if they occur with
≥ 50% of uterine contractions in a 20-
minute period.
Intermittent decelerations occurring with
<50% of uterine contractions in a 20-
minute segment.
11/28/2016 46Mahmoud El naggar
48. Late deceleration placental insufficiency
Acceleration ok
Early deceleration Head compression
Variable deceleration cord compression
11/28/2016 48Mahmoud El naggar
49. 5- Sinusoidal pattern
A smooth, regular,
wave-like pattern
Frequency of around
2-5 cycles a minute
Stable baseline rate
around 120-160 bpm
No beat to beat
variability
11/28/2016 49Mahmoud El naggar
50. A sinusoidal pattern indicates:
Severe fetal
hypoxia
Severe fetal
anemia
Fetal/maternal
hemorrhage
Immediate C-
section is
indicated for this
kind of pattern.
Outcome is
usually poor
11/28/2016 50Mahmoud El naggar
51. Fetal heart rate tracing categories
I. Reassuring (Normal)
II. Suspicious( Non reassuring)
III. Pathological (Abnormal)
11/28/2016 51Mahmoud El naggar
52. Fetal heart rate tracing categories
DefinitionType
All 4 features are classified as reassuringI. Reassuring
( normal)
One feature classified as non-reassuring +
AND
the remaining 3 features classified as reassuring
II. Non-reassuring
( suspicion)
Two or more features classified as non-reassuring /
OR
One or more classified as abnormal
III. Abnormal
( pathological)
11/28/2016 52Mahmoud El naggar
54. I.Reassuring
• Baseline: 110-
160
• Moderate
variability
• Late or variable
deceleration: -
• Early
deceleration : +/-
• Acceleration : +/-
II.Non-reassuring
• inbetween
I and III
III.Abnormal
• Loss of beat
to beat
variability +
one of:
• 1- Recurrent late
decelerations
• 2- Recurrent
variable
decelerations
• 3-Bradycardia
• Or
sinusoidal
wave pattern
11/28/2016 54Mahmoud El naggar
55. Pathophysiological interpretation
IReassuring
• Fetus
with no
hypoxia
or
acidosis
IINon-reassuring
• Fetus with
a low
probability
of having
hypoxia
or
acidosis
IIIAbnormal
• Fetus with
a high
probability
of having
hypoxia
or
acidosis
11/28/2016 55Mahmoud El naggar
56. Clinical management
IReassuring
• No
intervention
necessary
to improve
fetal
oxygenatio
n state
• Follow up
IINon-reassuring
• Action to
correct the
reversible
causes if
identified
• Close
monitoring
• Additional
methods to
evaluate fetal
oxygenation
IIIAbnormal
• Immediate action to
correct reversible
causes
• Additional methods
to evaluate fetal
oxygenation
• If it is not possible
expedite delivery
• In acute cases
immediate delivery
11/28/2016 56Mahmoud El naggar
57. Examples of type II tracings
O Bradycardia not accompanied by absent variability
O Tachycardia
O Minimal or marked baseline variability
O Absent variability without recurrent decelerations
O Absence of induced accelerations after fetal stimulation
O Recurrent variable decelerations with minimal or moderate
variability
O Prolonged decelerations
O Recurrent late decelerations with moderate Variability
O Variable decelerations with other characteristics, such as slow
return to baseline
11/28/2016 57Mahmoud El naggar
60. B) Fetal scalp blood sample
11/28/2016 60Mahmoud El naggar
61. B) Fetal scalp blood sample
O Fetal scalp blood sampling is used during labor to determine
the fetal acid-base status when the FHR tracing is non-
reassuring or abnormal.
O It can be performed only after rupture of membranes.
O It is contraindicated in cases of possible blood dyscrasias in
the fetus and with maternal infections caused by herpes virus
or HIV.
O An intrapartum scalp pH >7.20 with a base deficit <9 mmol/L is
normal.
O Many obstetric units have replaced fetal scalp blood sampling
with noninvasive techniques to assess fetal status.
11/28/2016 61Mahmoud El naggar
63. INTRAUTERINE FETAL
RESUSCITATION
If CTG monitoring indicates serious fetal compromise, or FBS result is abnormal, a decision
to deliver, often by emergency caesarean section, should be made.
A number of maneuvers can be performed to improve fetal oxygenation before delivery.
These may be performed with continuous CTG monitoring
If successful may reduce the urgency to deliver allowing time to provide neuraxial anesthesia.
11/28/2016 63Mahmoud El naggar
65. Case 1(NR may 2015) O Variability: Moderate
O Baseline rate: 140 beats per
minute
O Acceleration: None
O Deceleration: None
O Uterine contractions: Irregular,
mild per palpation
O Interpretation: Category I,
normal tracing, predictive of
normal acid-base status
O Differential diagnosis: Transient
compression of the umbilical
cord during ultrasonography
O Action: It was decided that she
would return for twice weekly
nonstress tests for the next 2
weeks, and further follow-up
would be determined at that
time 11/28/2016 65Mahmoud El naggar
66. After 2 w O Variability: Moderate in the beginning
of the tracing to minimal in the last
few minutes
O Baseline rate: 140 beats per minute
O Acceleration: None
O Deceleration: Prolonged deceleration
with a nadir to 50 beats per minute
O Uterine contractions: Unable to
determine, palpation is required to
assess contraction frequency and
intensity, although not perceived by
patient
O Interpretation: Category II
O Differential diagnosis: Tachysystole,
umbilical cord compression, abnormal
placental umbilical cord insertion
O Action: The patient was repositioned,
given oxygen by face mask, and
received a bolus of fluid with fetal
tracing returning to category I
11/28/2016 66Mahmoud El naggar
67. After 2 hours O Variability: Moderate
O Baseline rate: 140 beats per
minute
O Acceleration: None
O Deceleration: None
O Uterine contractions: Every 2
to 8 minutes, mild by
palpation
O Interpretation: Category I
O Differential diagnosis:
Normally oxygenated infant
O Action: Continued fetal
monitoring
11/28/2016 67Mahmoud El naggar
68. After an other 2 hours O Variability: Moderate in the beginning
of the tracing to minimal in the last
few minutes
O Baseline rate: 150 beats per minute
O Acceleration: None
O Deceleration: Prolonged deceleration
with nadir to 50 beats per minute
O Uterine contractions: Unable to
determine, palpation is required to
assess contraction frequency and
intensity, although not perceived by
the patient
O Interpretation: Category II
O Differential diagnosis: Tachysystole,
umbilical cord compression, abnormal
umbilical cord insertion
O Action: The patient was repositioned
and fetal status returned to overall
reassuring with moderate variability
11/28/2016 68Mahmoud El naggar
69. Case 2(NR march 2015) O Variability: Moderate
O Baseline rate: 135 beats per
minute
O Episodic patterns:
Accelerations
O Periodic patterns: None
O Uterine contractions: None
O Interpretation: Category I
O Differential diagnoses:
Normal FHR and variability,
gestational hypertension, rule
out preeclampsia
O Action: No intervention was
required for the fetus at this
point. 11/28/2016 69Mahmoud El naggar
70. After 2 hours O Variability: Moderate
O Baseline rate: 130 beats per
minute
O Episodic patterns: None
O Periodic patterns: Variable
decelerations
O Uterine contractions: Every 2 to
3 minutes, requires palpation for
intensity and tone
O Interpretation: Category II
O Differential diagnosis: Cord
compression due to
anhydramnios or nuchal cord
O Action: Appropriate
interventions to relieve the cord
compression are lateral
repositioning, hydration, and an
amnioinfusion.
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71. After some hours O Variability: Moderate
O Baseline rate: 130 to 140 beats
per minute toward the end of the
tracing
O Episodic patterns: None
O Periodic patterns: Recurrent
variable decelerations
O Uterine contractions: Unable to
determine; palpation is required
to assess contraction frequency
and intensity
O Interpretation: Category II
O Differential diagnosis: Cord
compression most likely due to
anhydramnios or nuchal cord
O Action:requires close
surveillance for loss of variability
and lack of accelerations,
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72. After 4 hours O Variability: Minimal to moderate
O Baseline rate: 120 beats per
minute
O Episodic patterns: None
O Periodic patterns: Recurrent
variable decelerations
O Uterine contractions: Not
recording well but appears to be
every 2 to 3 minutes; palpate
contractions for frequency and
intensity
O Interpretation: Category II
O Differential diagnosis: No
change
O Action: Recurrent variable
decelerations continue and have
not improved with repositioning
and hydration.
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73. After 30 min O Variability: Minimal
O Baseline rate: 135 beats per
minute
O Episodic patterns: None
O Periodic patterns: Appears to be
recurrent variable decelerations
but difficult to determine
because of gaps in the tracing
O Uterine contractions: Monitor
needs to be adjusted; palpate
contractions for frequency and
intensity
O Interpretation: Category II
O Differential diagnosis: No
change
O Action: Physician at bedside,
NICU staff present, patient is
prepared for delivery
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74. Case 3 (NR sept 2014)
O Variability: Moderate
O Baseline rate: 140 initially, and
then appears to have
characteristics of a sinusoidal-
type pattern, but not definitive.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions: Irregular,
mild per palpation
O Interpretation: Category I,
normal tracing, predictive of
normal acid-base status.
O Differential diagnosis: R/o fetal
anemia due to isoimmunization.
O Action: at this point, the
increasing MCA Dopplers and
possible sinusoidal-like pattern
is concerning.
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75. One hour later O Variability: Absent
O Baseline rate: Indeterminate
due to sinusoidal pattern.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions:
Irregular, palpate for intensity
and tone.
O Interpretation: Category III
tracing.
O Differential diagnosis:
Abnormal tracing associated
with an increased risk of
abnormal acid-base status,
most likely secondary to fetal
anemia.
O Action: planned for CS
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76. After 1 hour O Variability: Absent
O Baseline rate: Indeterminate
due to sinusoidal pattern.
O Episodic pattern: None
O Periodic pattern: None
O Uterine contractions: Unable
to determine, palpate for
intensity and tone.
O Interpretation: Category III
tracing.
O Differential diagnosis:
Abnormal tracing associated
with an increased risk of
abnormal acid-base status.
O Action: A persistent sinusoidal
pattern should prompt an
immediate C/S;11/28/2016 76Mahmoud El naggar
77. References
- Most of volumes of neoreviews since 2008 till the
moment includes strip of the months, mention regularly
the previous summary of the terminology, definitions and
assumptions found in the 2008 NICHD work shop report.
-In 2008, ACOG, NICHD, and the Society for Maternal-Fetal
Medicine reviewed and updated the definitions for fetal
heart rate patterns, interpretation, and research
recommendations
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