Cardiotocografi ( CTG ) Electronic Fetal Monitoring

							Cardiotocography ( CTG )
Electronic Fetal Monitoring



              Ali Sungkar
              Divisi Fetomaternal
Bagian Obstetri dan Ginekologi FKUI/RSUPN - CM
      Electronic Monitoring
 Indirect (external monitoring)
Direct   (internal)
              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.
      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.
     EFM Problems and Realities
   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.
               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).
          Electronic Fetal Monitoring-
                  Indications
Indications for the continuous
   EFM
                                     Oligohydramnios
         High risk pregnancies      Hypertension.
         IOL and Augmentation       Abnormal FHR
          of Labour.                  detected.
         Reduced FM.                Malpresentation and
         Premature labour/TPL.       in labour.
         APH/IPH                    DM,Multiple
                                      Gestation.
                                     Previous CS.
                                     Abdominal Trauma.
                                     Prolonged ROM.
                                     Meconium Liq.
          EFM- Interpretation
Consider :
   Intrapartum/antepartum trace.
   Stage of labour.
   Gestation.
   Fetal presentation, ? Malpresentation.
   Any augmentation,? IOL Medications
   Direct or indirect monitoring/
EFM- 4 Basic Features of
       FH Trace
         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.
Baseline variability CTG
  Baseline variability
          FHR: Variability

   Definitions
     Short term
     Long term
        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.
     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.
        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.
         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
  unclear.
 Presence of FHR Accelerations have
  Good outcome.
        EFM Decelerations

 Decelerations-
transient slowing of
FHR below the
baseline level of
more than 15 bpm
and lasting for 15
  sec.
or more.
     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
Fig 3 Early Decelerations
       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.
    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.
Fig 4 Late Decelerations
          Late Decelerations
   Reduces Baseline variability together
    with Late Decelerations or Variable
    Decelerations is associated with
    increased risk of CP.
    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
   EFM- Variable Decelerations
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.
    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.
Fig 5 Variable Decelerations
   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.
    EFM- Prolonged Decelerations
              CAUSES
 Cord prolapse.
 Maternal hypertension

 Uterine Hypertonia

 Followed by a VE or ARM or SROM
  with High PP.
Fig 6 Prolonged Deceleration
          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.
         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)
                 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
       Baseline tachycardia and
             Bradycardia.

   Uncomplicated baseline tachycardia
    161-180 bpm or bradycardia 101-109
    do not appear to be associated with
    poor NN outcome.
       Causes of B Tachycardia.
   Asphyxia
   Drugs
   Prematurity
   Maternal Fever
   Maternal thyrotoxicosis
   Maternal Anxiety
   Idiopathy
   Mx depends on the clinical situation
     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).
  Electronic Fetal Monitoring
Baseline Tachycardia
 Asphyxia

 Drugs

 Prematurity

 Maternal fever

 Maternal thyrotoxicosis

 Maternal Anxiety

 Idiopathy

Mx depends on the clinical situation
Fig 2 Sinusoidal pattern

Interpretation of the CTG
      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)
  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
     EFM- Saltatory pattern

   Seen During Fetal thumb sucking.
   Could be associated with Hypoxia.
           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….
            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.
Caring for the Mom,
 Not the Monitor!
                 References
   Manual Obs and Gyn. by Niswander, MD
   Fetal Monitoring RCOG UK
   CTGs RANZCOG
   Literature review articles American Family
    Physician
   CTG Made Easy
   D. Lata Sharma, MD, FRANZCOG, Senior
    Lecturer, University Of Queensland, Australia
   Charles Kawada, M.D,Harvard Medical School
             Amnioinfusi
   Hamil ≥ 37 minggu, bukan bekas SC,
    ICA < 5 cm
   600 mL-1000 mL dlm 1 jam + 150-180
    mL/jam, hangat 370 C
   Transervikal NGT no.8
   Bila keluar < 100 mL, ukur ICA 
    hindari distensi uterus
   Pembukaan ≤5-6 cm
Review Cochrane