CTG & Partogram PDF

CTG Interpretation Dr. Areen Alnasan CTG ► Cardiotocography (CTG) is a continuous electronic record of the fetal’s heart rate obtained via a transducer placed on the mother’s abdomen. ► It is sometimes referred to as ‘electronic fetal monitoring. Methods ► External Cardiotoco...

CTG Interpretation Dr. Areen Alnasan CTG ► Cardiotocography (CTG) is a continuous electronic record of the fetal’s heart rate obtained via a transducer placed on the mother’s abdomen. ► It is sometimes referred to as ‘electronic fetal monitoring. Methods ► External Cardiotocography: ► For continuous or intermittent monitoring of the fetal heart rate and the activity of the uterine muscle. ► Two transducers on the mother's abdomen(one above the fetal heart and the other at the fundus). ► The tocodynamometer (“toco”) is placed over the uterine fundus. It provides information that can be used to monitor uterine contractions.It monitors the contractions of the uterus by measuring the tension of the maternal abdominal wall (providing an indirect indication of intrauterine pressure. ► The second tranducer is placed over the area of the fetal back. This device transmits information about the FHR. ► Internal Cardiotocography: ► Uses an electronic transducer connected directly to the fetal scalp through the cervical opening and is connected to the monitor. ► Amniotic membranes must be ruptured ► Cervix dilated 2 cm. ► Presentation must be cephalic ► Presenting part down against the cervix.  Intrapartum CTG Interpretation ► Baseline fetal heart rate (FHR) ► Baseline FHR variability ► Presence of accelerations ► Decelerations ► Uterine activity (contractions) Contractions ► You need to record the number of contractions present in a 10 minute period. ► Each big square on the example CTG chart is equal to one minute, so look at how many contractions occurred within 10 big squares. ► Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity. ❑ Fetal heart bseline ► differentiate between fetal and maternal heartbeats ► baseline fetal heart rate will usually be between 110 and 160 beats/minute. ► Fetal Tachycardia :Baseline FHR greater than 160 beats per min ► Fetal bradycardia : Sustained fetal heart rate less than 110 beats per minute ❑ causes of fetal tachycardia : ► Maternal fever ► Chorioamnionitis ► Fetal sepsis ► Drugs (Atropine, Phenothiazines, Beta-sympathomimetics) ► Tachyarrhythmias ► Fetal heart failure ► Severe fetal anemia, fetal hydrops ► Maternal hyperthyroidism Variability ❑ Variability: ► variability will usually be between 5 and 25 beats/minute ► intermittent periods of reduced baseline variability are normal, especially during periods of quiescence ('sleep'). ❑ Causes of decreased variability include: ► Fetal sleeping: this should last no longer than 40 minutes ► Fetal acidosis (due to hypoxia) ► Fetal arrhythmia ► Drugs: opiates, benzodiazepines, methyldopa and magnesium sulphate ► Prematurity: variability is reduced at earlier gestation ( 15 beats per minute measured from the most recently determined baseline rate. ► The onset of deceleration to nadir is less than 30 seconds. The deceleration lasts > 15 seconds and less than 2 minutes. ► Related to cord compression. Variable decelerations Variable decelerations ❑ Concerning characteristics of variable decelerations: ► Lasting more than 60 seconds ► Reduced baseline variability within the deceleration ► Failure to return to baseline ► Biphasic (W) shape ► No shouldering: (The accelerations before and after a variable deceleration are known as the shoulders of deceleration. Their presence indicates the fetus is not yet hypoxic and is adapting to the reduced blood flow) ❑ Late Decelerations: Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. Onset of the decleration occurs after the beginning of the contraction, and the nadir of the deceleration occurs after the peak of the contraction. Related to decreased uteroplacental perfusion Late Decelerations Late Decelerations ❑ It is important to remember the following learning points regarding EFM: It is used to identify intrapartum hypoxia – a significant cause of fetal death and disability; fetal hypoxia can lead on to fetal asphyxia and death. It should not be used unless indicated as it increases the rates of caesarean section and instrumental delivery in low-risk women. It has become an integral component of labour management in high-risk women. ► Intermittent auscultation of the fetal heart rate to women at low risk of complications in established first stage of labour: ► Intermittent auscultation immediately after a contraction for at least 1 minute, at least every 15 minutes in the first stage of labour and and at least every 5 minutes in the second stage and record it as a single rate. ► Palpate the maternal pulse hourly, or more often if there are any concerns, to differentiate between the maternal and fetal heartbeats. ► High-Risk pregnancies need continuous FHM : ► 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. ❑ Continuous cardiotocography if any of the following risk factors : ► Maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart ► Temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart ► Suspected chorioamnionitis or sepsis ► Pain reported by the woman that differs from the pain normally associated with contractions ► The presence of significant meconium ► Fresh vaginal bleeding that develops in labour ► Severe hypertension: a single reading of either systolic blood pressure of 160 mmHg or more or diastolic blood pressure of 110 mmHg or more, measured between contractions ► Hypertension: either systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90 mmHg or more on 2 consecutive readings taken 30 minutes apart, measured between contractions ► A reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure (140 mmHg or more) or raised diastolic blood pressure (90 mmHg or more) ► Confirmed delay in the first or second stage of labour ► Contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes (tachysystole) ► Oxytocin use. ❑ Categorise Cardiotocography traces as follows: ► normal: all features are reassuring ► suspicious: 1 non-reassuring feature and 2 reassuring features (but note that if accelerations are present, fetal acidosis is unlikely) ► pathological: 1 abnormal feature or 2 non-reassuring features CTG interpretation and further management If CTG is normal: continue CTG or if it was started because of concerns arising from intermittent auscultation, remove CTG after 20 minutes if there are no non-reassuring/abnormal features and no ongoing risk factors. If suspicious: commence conservative measures – left lateral position, oral/intravenous fluids, stop oxytocin, consider tocolysis. If the CTG is abnormal: Offer to take fetal blood sample (FBS; for lactate or pH) after implementing conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as a result of scalp stimulation. The pH of the fetus has been shown to drop at the rate of 0.01 every 2–3 minutes. Fetal blood sampling interpretation ► Normal(PH:>=7.25): and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 1 hour later if this is still indicated by the cardiotocograph trace. ► Borderline (PH 7.24-7.21): and there are no accelerations in response to fetal scalp stimulation, consider taking a second fetal blood sample no more than 30 minutes later if this is still indicated by the cardiotocograph trace. ► Abnormal (PH