EFM- Electerical Fetal Monitoring- Legal issues,Problems,Facts, define, Indication,Basic Features,Type, it's management, CTG,Fetal Blood Sampling- Define, Indication, Erros, contraindication,protocols, issues in PPT made by sonal Patel

1. Electronic
Fetal
Monitoring

2. Electronic Fetal Monitoring
 Pioneered in 1958 by Hon.in USA and
Hammacher in Europe
 Commercially available 1968
 Continues monitoring of FH in low risks
pregnant -lacks evidence
 Needs to be viewed in conjunction with other
assessment e.g. FBS and clinical situation.
 Should be used for the right reason and with
appropriate degree of skill.

3. EFM-ISSUES
 Detect fetal hypoxia i.e reduce and avoid harm to the
fetus and improve fetal and baby out-come.
 Severe acidosis may result in FHR changes.
 Could occur in Normal physiological response in labor.
 Misunderstanding the physiological and
pathphysiological CTGs will improve the Mx.

4. EFM Problems and Realities
 Electronic Intra-partum FHR Monitoring is now considered mandatory
for high-risk pregnancies.
 Difficulties with interpretation include over confidence and not-only
difference in opinion between practitioners but, also when the same
practitioner examines the same CTG twice.
 Increases CS rates 1.41%rr.
 Increases operative vaginal delivery 1.20%rr.
 And no change in incidence of C Palsy.
 Reduction in Neonatal seizures rates 0.51%
 No difference in APGAR scores.
 ? About the efficacy.

5. EFM- Facts
 Reliability of interpretation-50-75% are false
positive .
 False positive Dx reduces to 105 with FBS.
 FBS 93% sensitivity, 6% false positive.
 PH Vs Lactate -39% Vs 2.3(rr 16.7).

6. Electronic Fetal Monitoring-
Indications
Indications for the
continuous EFM
 High risk
pregnancies
 IOL and
Augmentation of
Labour.
 Reduced FM.
 Premature
labour/TPL.
 APH/IPH
• Oligohydramnios
• Hypertension.
• Abnormal FHR detected.
• Malpresentation and in
labour.
• DM,Multiple Gestation.
• Previous CS.
• Abdominal Trauma.
• Prolonged ROM.
• Meconium Liq.

7. EFM- Interpretation
• Consider :
• Intrapartum/antepartum trace.
• Stage of labour.
• Gestation.
• Fetal presentation, ?Malpresentation.
• Any augmentation,?IOL Medications
• Direct or indirect monitoring/

8. EFM- 4 Basic Features of FH Trace

9. EFM-4 Basic Features.
• Baseline FHR - Mean level of FHR when this is stable, excluding
Accelerations and Decelerations (110-160 bpm)
-Tachycardia
-Bradycardia
 Baseline Variability-5 bpm or greater than or equal to 5bpm,
between contractions
-Normal
-Non-reassuring-Less than 5 bpm or less but less than 30 min
-Abnormal-less than 5 bpm for 90 min or more.

10. Baseline variability CTG
Baseline variability

11. Baseline variability
• The minor fluctuations on baseline FHR at 3-5
cycles p/m produces Baseline variability.
• Examine imin segment and estimate highest
peak and lowest trough.
• Normal is more than or equal to 5 bpm.

12. Factors affecting Baseline variability.
• Para-Sympathetic affects short term variability
whilst Long Term is more Symp.
• CNS ,Drugs reduce Variability
• High gestation increases variability
• Mild Hypoxia may cause both S and para S
stimulation.

13. Non-reassuring Baseline variability.
• NRCTGs- reduced or less than 5 bpm for 40 min or
more but less than 90 mins..
• B-B or short Term V is varying intervals between
successive heart beats .
• Long Term v is irregular waves on the CTG 3-5 bpm.
• Normal is 5-25 bpm– this indicates N-CNS.

14. EFM-Accelerations
• Accelerations- transient increase in FHR of 15 bpm or more
lasting for 15 sec.
• Absence of accelerations on an otherwise normal CTG
remains un clear.
• Presence of FHR Accelerations have Good outcome.

15. EFM Decelerations
• Decelerations-
transient slowing of
FHR below the
baseline level of
more than 15 bpm
and lasting for 15 sec.
Or more.

16. Electronic Fetal Monitoring
• a) Early Decelerations (fig 3)
 Head compression
 Begins on the onset of contraction and
returns to baseline as the contraction
ends.
 Should not be disregarded if they appear
early in labor or Antenatal.
 Clinical situation should be r/v

17. Fig 3 Early Decelerations

18. Late Decelerations.
• Uniform periodic slowing of FHR with the on
set of the contractions .
• Repetitive late decels increases risk of
Umbilical artery acidosis and Apgar score of
less than 7 at 5 mins and Increased risk of CP.

19. Electronic Fetal Monitoring
b) Late Decelerations (Fig 4)
• Due to acute and chronic feto-placental
vascular insufficiency
 Occurs after the peak and past the length of uterine
contraction, often with slow return to the baseline.
 Are precipitated by hypoxemia
 Associated with respiratory and metabolic acidosis
 Common in patients with PIH, DM, IUGR or other form of
placental insufficiency.

20. Fig 4 Late Decelerations

21. Late Decelerations
• Reduces Baseline variability together with Late
Decelerations or Variable Decelerations is
associated with increased risk of CP.

22. EFM- Variable Decelerations
• Variable intermittent periodic slowing of FHR with rapid onset recovery
and isolation.
• They can resemble other types of deceleration in timing and shape.
• Atypical VD are associated with an increased risk of umbilical artery
acidosis and Apgar score less than 7 at 5 min
• Additional components:
• Loss of 1 degree or 2 degree rise in baseline Rate
• Slow return to baseline FHR after and end of contraction.
• Prolonged secondary rise in Base FHR
• Biphasic deceleration
• Loss of variability during deceleration
• Continuation of base line at a lower level.

23. Electronic Fetal Monitoring
c) Variable Deceleration (Vagal activity) (Fig 5)
• Inconsistent in configuration,
• No uniform temporal r-ship to the onset of contraction, are
variable and occur in isolation.
• Worrisome when Rule of 60 is exceeded (i.e. decrease of 60
bpm,or rate of 60 bpm and longer than 60 sec)
• Caused by cord compression of the umbilical cord
• Often associated with Oligo-hydroaminos with or without ROM
• Can cause short lived RDS if they MILD
• Acidosis if prolonged and Recurrent.

24. Fig 5 Variable Decelerations

25. EFM Prolonged deceleration
Prolonged Deceleration (Fig 6)
• Drop in FHR of 30 bpm or More lasting for at least 2
min
• Is pathological when crosses 2 contractions i.e 3 mins.
• Reduction in O2 transfer to placenta.
• Associated with poor neonatal outcome.

26. EFM- Prolonged Decelerations
CAUSES
• Cord prolapse.
• Maternal hypertension
• Uterine Hypertonia
• Followed by a VE or ARM or SROM with High
PP.

27. Fig 6 Prolonged Deceleration

28. EFM Mx Prolonged
Deceleration
• Maternal position
• IV fluids
• V.E to exclude cord prolapse
• Assess BP
• FBS if cx dilated and well applied PP
• Mx Depending on the clinical situation.

29. Baseline Bradycardia
• FH below 110bpm(FIGO ).
• less than 100bpm (RANZCOG).
Causes.
Postdates, Drugs, Idiopathic,
Arrythmias, hypothermia(increased Vagal Tone)
Cord Compression (Acute Hypoxia, congenital
H/disease and Drugs).
Mx depends on the clinical situation.(FBS,VE
Observation or expedite delivery)

30. Types
• Moderate Bradycardia 100-109 bpm
• Abnormal bradycardia less than 100bpm.
• Tachycardia 161-180 bpm
• Abnormal Tachycardia more than 180 bpm
• Ranzcog Australian more than 170 bpm

31. Baseline tachycardia and Bradycardia.
• Uncomplicated baseline tachycardia 161-180
bpm or bradycardia 101-109 do not appear to
be associated with poor NN outcome.

32. Causes of B Tachycardia.
• Asphyxia
• Drugs
• Prematurity
• Maternal Fever
• Maternal thyrotoxicosis
• Maternal Anxiety
• Idiopathy
• Mx depends on the clinical situation

33. Electronic Fetal Monitoring
Baseline Bradycardia
 FH Rate below 110bpm (FIGO Recommended)
 Postdates
 Drugs
 Idiopathic
 Arrhythmia's
 Hypothermia.(Increased Vagal tone),
 Cord compression(Acute Hypoxia,Congenital H/disease, and
drugs)
Mx depends on the clinical situation. (FBS, VE,
Observation or expedite Delivery).

34. Electronic Fetal Monitoring
Baseline Tachycardia
 Asphyxia
 Drugs
 Prematurity
 Maternal fever
 Maternal thyrotoxicosis
 Maternal Anxiety
 Idiopathy
Mx depends on the clinical situation

35. Fig 2 Sinusoidal pattern
Interpretation of the CTG

36. EFM-Sinusoidal Pattern
• Regular Oscillation of the Baseline long-term
Variability resembling a Sine wave ,with no B-b
Variability (Fig 2),
• Has fixed cycle of 3-5 p min. with amplitude of 5-
15 bpm and above but not below the baseline.
• Should be viewed with suspicion as poor
outcome has been seen (eg Feto-maternal
haemorrhage)

37. Electronic Fetal Monitoring
Sinusoidal pattern - distinctive smooth undulating
Sine-wave baseline with no B-b variability ( Fig 2 )
• 0.3 % (Young 1980)
• cord compression
• hypovolemia
• ascites
• idiopathic(fetal thumb sucking)
• Analgesics
• Anaemia
• Abruption
• Mx r/v clinical situation

38. EFM- Saltatory pattern
• Seen During Fetal thumb sucking.
• Could be associated with Hypoxia.
• See slide 11.

39. NR CTGs
• Difficult to interpretation,leads to Increased
rate of C Section.
• 50% CTG in Labour have 1 abnormal feature
• 15-20% Nr CTGs (pathological).
• ?? To reduce CS….

40. F O R E M O S T Feta oximetry randomised evaluation
Multi Oxygen saturation Trial
• To evaluate the role of F Sats P02
• Had a Multicentre Randomised trial-
• RWB Brisbane
• MMH Brisbane
• RWH Melbourne
• RWH Sydney

41. End points
• To reduce Operative deliveries for the Nr CTG by 1/3
• The Sample size was 600 participants.
• Secondary Endpoint-
• Investigate the incidence of Dystocia
• F/up outcomes
• Low Umbilical arterial PH
• NICu admissions
• HIE (Enchelopathy)
• Maternal perception of monitoring
• Clinician perception of sensor placement.

42. NR CTG (Foremost)
• Any of the following for more than 15min-
Persistent Late decelerations
Sinusoidal pattern
Variable decels
Less than 70 bpm for more than 60 sec
Persistent slow return to the baseline
Long term variability less than 5 bpm
Tachycardia more than 160 bpm.
Recurrent prolonged deceleration 2 or more in15 min and less than
70bpm for 90 sec .
Any on of the following for more than 60 min
Tachycardia with variability less than 5bpm
Persistent reduced baseline variability less than 5 bpm for more than
60min.

43. Inclusion Criteria
• NR CTG
• Consent
• Gest age more than 36 k
• Early or active labour
• ROM or eligible for

44. Exclusion criteria
• Multiple gestation
• Non-Vertex
• Pl Praevia
• APH
• Fetal anomaly
• HIV other
• Thrombocytopenia.

45. Clinical Mx Protocol
• CTG Only
• Reassuring –continue labour unless otherwise
indicated
• NR CTG –Evaluate and manage NR CTG
• Suspicious CTG
• Deliver for NR Fetal Status.

46. CTG and Oximetry
• Reassuring CTG Continue
• NR CTG Continue unless otherwise indicated(
FSp02 Reassuring) If FSp02 less than 30%-
Further Evaluation and MX
• Suspicious CTG -Deliver

47. Conclusion
• R/v NR CTG Mx tools & decision making
• Responsibility to assess new technology
before widespread introduction
• Overview of Multicentre RCT
• Case presentation.

48. Reliability of CGT Interpretation
• 50%-75% false positive
• False Positive Dx is reduced to 10% with FBS
• PH Vs lactate 39% Vs 2.3%(rr16.79).

49. Fetal Blood Sampling
• information on the acid base balance
• Has 6%-20% false- normal
• 8-10% False Low values
Why and when to do-
Persistent Abnormal CTG after reversible factors have been corrected,
Persistent late decels and 2 abnormal other features e.g baseline
tachycardia or reduced B-B variability or just difficult to interpret the CTG
Rom, PP accessible and well applied Cx dilatation at least 3 cm or more
Left lateral maternal position
Sterile environment and good light and equipment.
Good analgesia

50. FBS-PH
• Introduced by Sailing –fairly reliable predictor
of fetal PH in presence of abnormal FHR
• Has an error of 15% falsely low and 5 % falsely
increased, however in presence of abnormal
FHR a scalp PH of less 7.2 is pathologonomic
of fetal asphyxia.

51. FBS-Cord PH
• FBS-Arterial
• Normal-7.25-7.35 Normally good agreement
between Apgar,cord PH .
• Less than 7.20-significant asphyxia
• Values between 7.2 and 7.24 need further evaluation
• Low –normal PH should be repeated in 30 min
• Less than 7.20- eminent delivery

52. FBS- Lactate
• FBS easier to interpret, difficult to perform
• Anaerobic metabolism can lead to metabolic acidosis
• Lactate is major end product of metabolic acidosis
• Lactate levels more specific for degree of metabolic
acidosis than Ph
• Lactate rises quicker takes longer to resolve than Ph.

53. FBS Contraindications
Fetal
Premature –less than 34 ks
Active Herpes
Known HIV,Hep B,C positive status.
Thrombocytopenia.
Maternal-
Unfavourable Cx
Mobile PP
Malpresentation(face etc) uncertain??
Pl Praevia or APH
Sepsis

54. FBS-Sampling errors
• Between decelerations if possible
• Avoid Excess pressure on PP reduces perfusion
• Do not sample on the caput.
• Failure of scalp to bleed –due to peripheral
shut down.

55. EFM-Summary
• Normal - CTG with all 4 Features
• Suspicious -one non reassuring category and
reminder are reassuring
• Pathological -2 or more non-reassuring
categories or one or more abnormal
categories.

56. At Birth
Need to Consider
Cord PH if CTG suspicious
Preterm labour
Mec Liquor
FBS intrapartum
Flat baby at delivery
Operative or instrumental delivery.

57. Mx of FBS Results
• If PH /Lactate normal –Observe
• Pre-acidotic were CTG remains to be Suspicious –Rpt
after 30 min.
• Acidotic-eminent delivery
• Instrumental or CS depending on the clinical
situation.
Lactate
• 4.8 upper limit-average 2.8 in 1st stage– changes in
labour

58. Electronic Fetal Monitoring
Education and training
• Improves Knowledge for all staff
• Improves clinical skills
• Training should include instruction on documenting
traces and storage
• Training should include appropriate clinical
responses to suspicious or pathological traces
• Training should include local guidelines relating to
fetal monitoring both intermittent and EFM

59. EFM-Legal Issues
CTG in Litigation
• Unsatisfactory or Missing
• Abnormal CTG ignored or not recognized
• Traces not done.
Risk Mx
• EFM traces should be kept up to 25 years.
• If removed for teaching purposes or etc, should be
easily located
• Minimize incidence of adverse outcome

60. Legal Issues
• In the U.K
• 70% of cases are due to EFM.
• In U S A 45.8% involve E F M,
3.8% more $1Million payouts and only17% are
due to delay or failure to diagnose fetal
distress.

61. What Influences Litigation
• Consumer Expectation
• The profession –education
• The employer (policies/procedures)
• Legislation (duty of care/scope of practise/
registration)

62. Legal issues- Consumer expectation
• Are for a good outcome (healthy
baby/mother)
Bad outcome
• Someone to blame
• Someone must pay

63. Professional Responsibility
• To act within scope of practise.
• To seek support and guidance
• Work within organisational standards
• Duty of care to the woman and employer
• Maintain knowledge and skills (evidence
Based Practise)
• Be prepared to defend ones practise.

64. When EFM is the focus of Malpractice
• Comparison of consistency of documentation
contained on the trace and in the chart will be made
• Lapse in documentation may leave doubt about the
quality of care.
• Hospital policy and procedure manuals will be
examined
• Competency levels will be evaluated expert witness
(plaintiff/defence)-to determine if acceptable
standards were applied.

65. Major Omission in Liability
• Failure to appropriately monitor the mothers
and fetus status
• In appropriate Syntocinon monitoring
• Failure to notify the physician in a timely
manner.
• Initiation of procedures without adequate
client information or consent

66. Elements of successful Malpractice Action
• The clinician had a duty to the woman
• The clinician had committed a breach of duty
• The woman suffered damages
• There was a casual connection between the
clinician’s actions and the woman's damage.
(MacRae,1993)

67. Legal issues
• If you are going to use the CTG You must be
able to Interpret the trace and respond
accordingly-
• It’s a permanent record
• One that is scrutinized in litigation case
• May be pivotal in determining liability

68. Legal issues
• A normal CTG can be used to indicate that that were
no abnormalities and no indication for intervention.
• An abnormal CTG or suspicious trace may provide
evidence that inappropriate or lack of treatment may
give rise to litigation,whilst CTGs could be viewed as
part of “defensive medicine”, litigation is reported to
be on the increase but there is not enough data
reporting system in Australia to support this.