CTG INTERPRET

WITH CARE

Dr Mona Shroff

Fetal Monitoring in Labor:

Two Acceptable Methods
Electronic
In active labor
by convention needs
to be continuous
High false positives
(K. Nelson 1996)
Variable
interpretations

Auscultated
Prescribed intervals
Various devices but
one recorded number
Easy to interpret
Intermittent
Acceptable for
high risk patients

Dr Mona Shroff

Why Auscultation?
Simple
Well liked by
patients
Clear cut action/
response
Improves ability to
ambulate
Easier
Dr Mona Shroff
www.obgyntoday.info

Fewer C/Ss
Legally less
damninginterpretation clear
Allows changing
entire environment
in L&D
Decreases patient,
family, nurse and
physician anxiety
3

Dr Mona Shroff
www.obgyntoday.info

Electronic Monitoring:
Later Outcome Nigel Paneth 1993 Clin.
Invest Med. Michigan St. Univ

Central hypotheses of EFM has

never been tested
That is, that its use (EFM) can
effectively prevent the... brain
damaging birth asphyxia by timely
intervention in labor.

Dr Mona Shroff
www.obgyntoday.info

For hypothesis to be
true: Paneth (1993)
EFM must be reliable (inter-observer
agreement on identity and meaning)
EFM must be valid (patterns statistically
linked with adverse neurological events)
EFM and adverse outcome are related,
specifically association is
causal

Dr Mona Shroff
www.obgyntoday.info

CRITICISMS TOWARDS CARDIOTOCOGRAPHY

Insufficient understanding of the (patho-)physiologic
background
A number of technical pitfalls
Differences in recording techniques
Primarily qualitative information (pattern recognition)
Lack of uniform classification systems
Confusion due to the many influences on the fetal heart
rhythm
Substantial intra- and inter-observer variation regarding th
interpretation
Low validity, high incidence of false-positive findings
Primarily screening method, too often applied as a diagnosti
Leads to an increase in artificial deliveries
Lack of agreement on how, when, and whom to monitor

Contributes to medico-legal vulnerability

Dr Mona Shroff
www.obgyntoday.info

ARGUMENTS AGAINST
AUSCULTATION
Hard to do!
No, not really!
Requires more staff
Shouldnt have to
Does not meet
standard of care
Untrue!

Will cause fetal

harm, or CP?
No more so than
continuous EFM
May miss something?
-Such as??
Not legally defensible
Hardly

Dr Mona Shroff
www.obgyntoday.info

THEN WHY DISCUSS

CTG???
USEFUL IN HIGH RISK CASES.
STANDARDISED EVIDENCE
BASED GUIDELINES ARE
BEING LAID FOR CORRECT
USE,INTERPRETATION ,
FURTHER DECISION MAKING
& RECORD KEEPING.
Dr Mona Shroff
www.obgyntoday.info

Appropriate monitoring in an
uncomplicated
pregnancy
For a woman who is healthy and has had an
otherwise uncomplicated pregnancy,
intermittent auscultation should be
offered and recommended in labour to monitor
fetal wellbeing.
In the active stages of labour, intermittent
auscultation should occur
after a contraction, for a minimum of 60
seconds, and at least:
every 15 minutes in the first stage
every 5 minutes in the second stage.
.
Grade A Recommendation
Dr Mona Shroff
www.obgyntoday.info

10

Indications
for the
use of
continuous
EFM
Dr Mona Shroff
www.obgyntoday.info

11

GRADE B RECOMMENDATION
Continuous EFM should be 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.

Dr Mona Shroff

REF:RCOG GUIDELINES
www.obgyntoday.info

12

ADMISSION CTG
Current evidence does not
support the use of the
admission CTG in
low-risk pregnancy and it is
therefore not recommended
Grade B Recommendation
Dr Mona Shroff
www.obgyntoday.info

13

Selected High-Risk Indications for

Continuous Monitoring of Fetal
Heart Rate
Maternal medical illness
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

Dr Mona Shroff
www.obgyntoday.info

14

A Continuous EFM should 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.
Dr Mona Shroff
www.obgyntoday.info

15

Definitions and descriptions of

individual features of fetal heartrate (FHR) traces
Baseline fetal heart rate :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.
Dr Mona Shroff
www.obgyntoday.info

16

 Normal Baseline FHR 110160 bpm

Moderate bradycardia 100109 bpm

Moderate tachycardia 161180 bpm
Abnormal bradycardia < 100 bpm
Abnormal tachycardia > 180 bpm

Dr Mona Shroff
www.obgyntoday.info

17

Baseline variability

The minor fluctuations in baseline

FHR occuring at three to five
cycles per minute. It is measured
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

Dr Mona Shroff
www.obgyntoday.info

18

Dr Mona Shroff
www.obgyntoday.info

19

ACCELERATIONS

Dr Mona Shroff
www.obgyntoday.info

20

DECCELERATIONS
EARLY

Head compression

LATE

U-P Insufficiency

VARIABLE

Cord compression
Primary CNS dysfn
Dr Mona Shroff
www.obgyntoday.info

21

EARLY

Dr Mona Shroff
www.obgyntoday.info

22

LATE

Dr Mona Shroff
www.obgyntoday.info

23

VARIABLE

Dr Mona Shroff
www.obgyntoday.info

24

Atypical Variable
decelerations
With any of the following additional
decelerations components:
loss

of primary or secondary rise in baseline rate

slow return to baseline FHR after the end of the
contraction
prolonged secondary rise in baseline rate
biphasic deceleration
loss of variability during deceleration
continuation of baseline rate at lower level
Dr Mona Shroff
www.obgyntoday.info

25

26

Categorisation of fetal heart rate traces

Category

Definition

Normal

All four reassuring

Suspicious

1 non-reassuring
Rest reassuring

Pathological

2 or more nonreassuring
1 or more abnormal
Dr Mona Shroff
www.obgyntoday.info

27

REDUCED

Hypoxia
Sleep

VARIABILITY

Drugs

Extreme prematurity
CNS abno.

Dr Mona Shroff
www.obgyntoday.info

28

Dr Mona Shroff
www.obgyntoday.info

29

TACHYCARDIA
Hypoxia
Chorioamnionitis
Maternal fever
B-Mimetic drugs
Fetal anaemia,sepsis,ht failure,arrhythmias

Dr Mona Shroff
www.obgyntoday.info

30

SPECIAL
PATTERNS
Dr Mona Shroff
www.obgyntoday.info

31

Sinusoidal pattern
A regular oscillation 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 35 cycles per minute and an
amplitude of 515 bpm above and below the baseline.
Baseline variability is absent
Associated with Severe chronic fetal anaemia
Severe hypoxia & acidosis
Dr Mona Shroff
www.obgyntoday.info

32

SINUSOIDAL

Dr Mona Shroff
www.obgyntoday.info

33

PSEUDOSINUSOIDAL

Dr Mona Shroff
www.obgyntoday.info

34

CHECKMARK PATTERN

Dr Mona Shroff
www.obgyntoday.info

35

SALTATORY PATTERN

Dr Mona Shroff
www.obgyntoday.info

36

LAMBDA PATTERN

Dr Mona Shroff
www.obgyntoday.info

37

Dr Mona Shroff
www.obgyntoday.info

38

Dr Mona Shroff
www.obgyntoday.info

39

SUSPICIOUS CTG
CTG
PATTERN

CAUSE

CLINICAL
MANAGEMENT

EARLY

2nd Stage

NONE

LATE

Uterine
hypercontractily

Stop oxytocin
Consider terbutaline sc
Oxygen @ 8-10 l/min

VARIABLE

Cord compression

Left lateral decubitus

Consider amnioinfusion
(mild/mod v.d.)

TACHYCARD Maternal
Infection screen
IA
fever,tachycardia, Hydrate - crystalloids
dehydration
Stop tocolysis if
Dr Mona Shroff
40
www.obgyntoday.info

PATHOLOGICAL

FETAL SCALP
BLOOD Ph
(If facilities available)

FETAL SCALP
STIMULATION TEST
FETAL VIBROACAUSTIC
STIMULATION TEST

Dr Mona Shroff
www.obgyntoday.info

41

A Systematic Approach to Reading Fetal Heart

Rate Recordings

Evaluate recording--is it continuous and adequate for interpretation?

Identify type of monitor used--external versus internal, first-generation
versus second-generation.
Identify baseline fetal heart rate and presence of variability, both longterm and beat-to-beat (short-term).
Determine whether accelerations or decelerations from the baseline
occur.
Identify pattern of uterine contractions, including regularity, rate,
intensity, duration and baseline tone between contractions.
Correlate accelerations and decelerations with uterine contractions and
identify the pattern.
Identify changes in the FHR recording over time, if possible.
Conclude whether the FHR recording is reassuring, nonreassuring or
ominous.
Develop a plan, in the context of the clinical scenario, according to
interpretation of the FHR.
Document in detail interpretation of FHR, clinical
conclusion and plan of management.
Dr Mona Shroff
www.obgyntoday.info

42

 Prior to any form of fetal monitoring, the

maternal pulse should be
palpated simultaneously with FHR auscultation
in order to
differentiate between maternal and fetal
heart rates.
If fetal death is suspected despite the
presence of an apparently
recordable FHR, then fetal viability should be
confirmed with realtime
ultrasound assessment.
Dr Mona Shroff
www.obgyntoday.info

43

Dr Mona Shroff
www.obgyntoday.info

44

RECORD KEEPING IN
CTG
The date and time clocks on the EFM machine
should be correctly set
Traces should be labelled with the mothers
name, date and hospital number
Any intrapartum events that may affect the
FHR should be noted contemporaneously on the
EFM trace, signed and the date and time noted
(e.g. vaginal examination, fetal blood sample,
siting of an epidural)
Dr Mona Shroff
www.obgyntoday.info

45

Any member of staff who is asked to

provide an opinion on a trace should note
their findings on both the trace and
maternal case notes, together with time
and signature
Following the birth, the care-giver
should sign and note the date,time and
mode of birth on the EFM trace
The EFM trace should be stored
securely with the maternal notes at the
end of the monitoring process.
Dr Mona Shroff
www.obgyntoday.info

46

SOME
INTERESTING
CASES
Dr Mona Shroff
www.obgyntoday.info

47

ACCELERATION OR DECCELERATION ???

Dr Mona Shroff
www.obgyntoday.info

48

BASELINE BRADYCARDIA WITH

ACCELERATIONS

Dr Mona Shroff
www.obgyntoday.info

49

HALVING PHENOMENON

Dr Mona Shroff
www.obgyntoday.info

50

EXCESSIVE VARIABILITY???

Dr Mona Shroff
www.obgyntoday.info

51

GESTATIONAL DM ; NST ; 8:30am

Dr Mona Shroff
www.obgyntoday.info

52

GDM ; CST ; 12 noon

Dr Mona Shroff
www.obgyntoday.info

53

BLUNTED PATTERN WITH VARIABLE

DECCELERATIONS CNS DYSFUNCTION

Dr Mona Shroff
www.obgyntoday.info

54

Thank you
Dr Mona Shroff
www.obgyntoday.info

55