Yuyun Lisnawati

A continuous recording of the fetal heart rate obtained via an ultrasound transducer placed on the mothers abdomen.
CTG is widely used in pregnancy as a method of assessing fetal well-being.

 EFM

was introduced with an aim of reducing perinatal mortality and cerebral palsy. wellbeing could monitor antenatally and during labor to save babies from the potentially catastrophic effects of hypoxia during labor.

Fetal

 Uterine

activity (contractions) Baseline fetal heart rate Baseline FHR variability Presence of accelerations Periodic or episodic decelerations

SOGC, RCOG 2001

Categorisation of Fetal Heart Rate (FHR) Features

RCOG- NICE 2001

The NICHD workgroup proposed terminology of a three-tiered system to replace the older undefined terms "reassuring" and "nonreassuring:

Category I (Normal) : strongly predictive of normal fetal acid-base status at the time of observation :

Baseline rate 110-160 bpm, Moderate variability, Absence of late, or variable decelerations, Early decelerations and accelerations may or may not be present.

Category II (Indeterminate) : Tracing is not predictive of abnormal fetal acid-base status, but evaluation and continued surveillance and reevaluations are indicated.
Category III (Abnormal) : predictive of abnormal fetal acid-base status at the time of observation :

Absence of baseline variability with recurrent late or variable decelerations or bradycardia; or Sinusoidal fetal heart rate.

Macones GA, Hankins GD, et al. NICHD. Obstet Gynecol (2008) 112

 Initial

observational studies showed a strong correlation between an abnormal CTG and poor fetal outcome.
(Freeman 1982a; Freeman 1982b; Phelan 1981).

In

high-risk pregnancies in particular, nonreactive CTGs were associated with increased morbidity and mortality for the baby.

(Boehm 1986; Flynn 1977).

An evaluation of antenatal CTG in Nigeria (2008) found a non-reactive non-stress test were :

significantly more likely to deliver by CS experience high perinatal mortality, and have small-for-gestational-age infants

Fawole et al concluded, that the non-reactive

non-stress test was a valuable tool for early detection of fetal compromise.
Fawole Ao, et al. Antenatal cardiotocography: experience in a Nigerian tertiary hospital. Nigerian Postgraduate Med Jou 2008;15.

 There

was no improvement in neonatal outcome when low risk women were continuously monitoried.

MacDonald D, Grant A, Sheridan-Pereira M et al. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol 1985;152:524-39.

Nelson et al, reviewed women with a highly abnormal CTG in labor i.e. fetal tachycardia with reduced variability and late decelerations : - Only 58% of these fetuses with a highly
abnormal CTG were acidotic at birth as judged by umbilical artery pH. - Only 0.2% went on to develop CP.

Nelson KB, Dambrosia JM, et al. N Engl J Med. 1996;334:613-8.

 The

use of CTG reduces the rate of seizures in the newborn, but

is no clear benefit in the prevention of cerebral palsy, perinatal death and other complications of labour.

There

Nelson KB, Dambrosia JM, et al. N Engl J Med. 1996;334 Cochrane Database of Systematic Reviews 2006 ACOG Practice Bulletin, 2005 RCOG-NICE 2001

 The

false-positive rate of CTG for cerebral palsy is given as high as 99%, meaning that only 1-2 of one hundred babies with nonreassuring patterns will develop cerebral palsy.

Cochrane Database of Systematic Reviews 2006 ACOG Practice Bulletin, 2005 RCOG-NICE 2001

 CTG

has a lack of specificity and high false positive rates when using it to detect fetal compromise. (Sadovsky 1981; Trimbos 1978a).
variability when a subjective visual assessment was used was as low as 57%. (Trimbos 1978b).

Intra-observer

 Poor

agreement of both visual interpretation and classification or scoring of antenatal CTGs.

(Ayres-de-Campos1999; Bernades 1997;Devane 2005).

Inter-

and intra-observer variability affect the reliability and reproducibility of the test.
(Borgotta 1988; Lotgering 1982).

Six studies (involving 2105 women)

Comparison of traditional CTG versus no CTG showed :

- no significant difference identified in perinatal mortality (risk ratio (RR) 2.05, 95% (CI) 0.95 to 4.42, 2.3% versus 1.1%, four studies, N = 1627) - no significant difference identified in potentially preventable deaths (RR 2.46, 95% CI 0.96 to 6.30, four studies, N = 1627, though the meta-analysis was underpowered to assess this outcome.
RHL WHO Laboratory 2010 Cochrane Review2010

There were no eligible studies that compared computerised CTG with no CTG. Comparison of computerised CTG versus traditional CTG showed : - a significant reduction in perinatal mortality with computerised CTG (RR 0.20, 95% CI 0.04 to 0.88, two studies, 0.9% versus 4.2%, 469 women). - no significant difference identified in potentially preventable deaths (RR 0.23, 95% CI 0.04 to 1.29, two studies, N = 469), though the metaanalysis was underpowered to assess this outcome.

 In

contrast, labour monitored by CTG is slightly more likely to result in instrumental delivery (forceps or vacuum extraction) or Cesarean section.
relative risk was 1.41 (95% CI 1.23-1.61), compared to that with intermittent auscultation of the fetal heart.

The

Cochrane Database of Systematic Reviews 2006 ACOG Practice Bulletin, 2005

The RCOG and the NICE reviewed the whole issue of FHR monitoring (2001)

 The

BPP uses ultrasound to assess : 1) fetal movement 2) tone 3) breathing and 4) the amniotic fluid volume that surrounds the baby

modified BPP (MBPP) : involving the CTG trace and the amniotic fluid volume only.
Manning, 1985

 Five

trials involving 2974 women with pregnancies with a high risk of poorer fetal outcome were found. data are insufficient to reach a conclusion about the benefit or otherwise of the BPP as a test of fetal wellbeing.

The

The Cochrane Database of Systematic Reviews 2011

SKOR PENILAIAN Reaktifitas DJJ Akselerasi stimulasi Rasio SDAU

2 >2 >2 <3

0 <2 <2 >3

Gerak napas stimulasi

Indeks Cairan Amnion

>= 2 episode

< 2 episode

>= 10 cm

< 10 cm

Wiknjosastro G. Tesis, 1992

 Sensitivity

80% 13% and spesifisity 89%, in predicting fetal acidosis in cases of preeclampsia and eclampsia.
score < 5, the fetal is likely to suffer acidosis , so it is recommended to be delivered with caesarea. score > 5 it is recommended to be delivered normally.
Wiknjosastro G. Tesis, 1992

FDJP

FDJP

 Test

scores FDJP < 5 in cases of high risk pregnancy related meaning with medium to heavy asphyxiation incident on neonatal, with RR 6.35 and 8.4 times for events the minute Apgar score 1st and 5th of less than 7. scores FDJP < 5 statistically increases the risk of 8.8 times with care needs neonatal in NICU
Purnawan. Tesis, 2009

Test

Low risk pregnancies Intermittent auscultation (IA) should be offered and recommended High risk pregnancies There is some evidence that continuous EFM improves the outcome in high risk pregnancies, and should be recommended.
RCOG-NICE 2001

Lahir bayi SC 3100 gr/45 cm AS 9/10

Lahir bayi SC 3200 gr/50 cm AS 8/9 LTP 1x di leher Air ketuban hijau, jumlah sangat sedikit

Lahir bayi SC 3300 gr, AS 8/9. Air ketuban hijau encer, jumlah sedikit. Ibu dan bayi baik di ruangan rawat gabung

Lahir bayi laki-laki 3000 g AS 7/8 postmaturitas gr III Air ketuban hijau kental, sangat sedikit

Lahir bayi laki-laki 3400g/49 cm AS 7/8, air ketuban keruh , jumlah sedikit

 The

FHR is only an indirect measure of fetal wellbeing and fetal hypoxia.

CTG

has a lack of specificity, high false positive rates and intra-observer variability.

 More

valuable information would be gained : blood pressure and cerebral flow or cerebral oxygen saturation. measurements are technically difficult at the moment, at least in human fetuses, and hence all we have to rely on is the FHR.

Such

 More

studies are needed now to see if outcomes for babies at increased risk of complications can be improved with antenatal CTG, particularly computerised CTG.