Cardiotocography ( CTG )Cardiotocography ( CTG )Electronic Fetal MonitoringElectronic Fetal Monitoring

Ali SungkarAli SungkarDivisi FetomaternalDivisi Fetomaternal

Bagian Obstetri dan Ginekologi FKUI/RSUPN - CMBagian Obstetri dan Ginekologi FKUI/RSUPN - CM

Electronic MonitoringElectronic Monitoring Indirect (external monitoring)Indirect (external monitoring)

Direct (internal)Direct (internal)

EFM-ISSUESEFM-ISSUES Detect fetal hypoxia i.e reduce and avoid Detect fetal hypoxia i.e reduce and avoid

harm to the fetus and improve fetal and harm to the fetus and improve fetal and baby out-come.baby out-come.

Severe acidosis may result in FHR Severe acidosis may result in FHR changes.changes.

Could occur in Normal physiological Could occur in Normal physiological response in labor.response in labor.

Misunderstanding the physiological and Misunderstanding the physiological and pathphysiological CTGs will improve the pathphysiological CTGs will improve the Mx.Mx.

EFM Problems and RealitiesEFM Problems and Realities Electronic Intra-partum FHR Monitoring Electronic Intra-partum FHR Monitoring

is now considered mandatory for high-is now considered mandatory for high-risk pregnancies.risk pregnancies.

Difficulties with interpretation include Difficulties with interpretation include over confidence and not-only difference over confidence and not-only difference in opinion between practitioners but, in opinion between practitioners but, also when the same practitioner also when the same practitioner examines the same CTG twice.examines the same CTG twice.

Increases CS rates 1.41%rr.Increases CS rates 1.41%rr.

EFM Problems and RealitiesEFM Problems and Realities

Increases operative vaginal delivery Increases operative vaginal delivery 1.20%rr.1.20%rr.

And no change in incidence of C And no change in incidence of C Palsy.Palsy.

Reduction in Neonatal seizures rates Reduction in Neonatal seizures rates 0.51%0.51%

No difference in APGAR scores.No difference in APGAR scores. ? About the efficacy.? About the efficacy.

EFM- FactsEFM- Facts

Reliability of interpretation-50-75% Reliability of interpretation-50-75% are false positive .are false positive .

False positive Dx reduces to 105 False positive Dx reduces to 105 with FBS.with FBS.

FBS 93% sensitivity, 6% false FBS 93% sensitivity, 6% false positive.positive.

PH Vs Lactate -39% Vs 2.3(rr 16.7).PH Vs Lactate -39% Vs 2.3(rr 16.7).

Electronic Fetal Monitoring-Electronic Fetal Monitoring-IndicationsIndications

Indications for the continuous Indications for the continuous EFMEFM

High risk pregnancies High risk pregnancies IOL and Augmentation IOL and Augmentation

of Labour.of Labour. Reduced FM.Reduced FM. Premature labour/TPL.Premature labour/TPL. APH/IPHAPH/IPH

OligohydramniosOligohydramnios Hypertension.Hypertension. Abnormal FHR Abnormal FHR

detected.detected. Malpresentation and Malpresentation and

in labour.in labour. DM,Multiple DM,Multiple

Gestation.Gestation. Previous CS.Previous CS. Abdominal Trauma.Abdominal Trauma. Prolonged ROM.Prolonged ROM. Meconium Liq.Meconium Liq.

EFM- InterpretationEFM- Interpretation

Consider :Consider : Intrapartum/antepartum trace.Intrapartum/antepartum trace. Stage of labour.Stage of labour. Gestation.Gestation. Fetal presentation, ? Malpresentation.Fetal presentation, ? Malpresentation. Any augmentation,? IOL MedicationsAny augmentation,? IOL Medications Direct or indirect monitoringDirect or indirect monitoring//

EFM- 4 Basic Features of EFM- 4 Basic Features of FH TraceFH Trace

EFM-4 Basic Features.EFM-4 Basic Features.

Baseline FHR - Mean level of FHR when this is stable, Baseline FHR - Mean level of FHR when this is stable, excluding Accelerations and Decelerations (110-160 excluding Accelerations and Decelerations (110-160 bpm)bpm)-Tachycardia-Tachycardia-Bradycardia-Bradycardia

Baseline Variability-5 bpm or greater than or equal to Baseline Variability-5 bpm or greater than or equal to 5bpm, between contractions5bpm, between contractions-Normal-Normal-Non-reassuring-Less than 5 bpm or less but less -Non-reassuring-Less than 5 bpm or less but less than 30 minthan 30 min-Abnormal-less than 5 bpm for 90 min or more.-Abnormal-less than 5 bpm for 90 min or more.

Baseline variability CTGBaseline variability CTGBaseline variabilityBaseline variability

FHR: VariabilityFHR: Variability

DefinitionsDefinitions Short termShort term Long termLong term

Baseline variabilityBaseline variability

The minor fluctuations on baseline The minor fluctuations on baseline FHR at 3-5 cycles p/m produces FHR at 3-5 cycles p/m produces Baseline variability.Baseline variability.

Examine imin segment and estimate Examine imin segment and estimate highest peak and lowest trough.highest peak and lowest trough.

Normal is more than or equal to 5 Normal is more than or equal to 5 bpm.bpm.

Factors affecting Baseline Factors affecting Baseline variability.variability.

Para-Sympathetic affects short term Para-Sympathetic affects short term variability whilst Long Term is more Symp.variability whilst Long Term is more Symp.

CNS ,Drugs reduce VariabilityCNS ,Drugs reduce Variability High gestation increases variabilityHigh gestation increases variability Mild Hypoxia may cause both S and para S Mild Hypoxia may cause both S and para S

stimulation.stimulation.

Non-reassuring Baseline Non-reassuring Baseline variability.variability.

NRCTGs- reduced or less than 5 bpm NRCTGs- reduced or less than 5 bpm for 40 min or more but less than 90 for 40 min or more but less than 90 mins..mins..

B-B or short Term V is varying B-B or short Term V is varying intervals between successive heart intervals between successive heart beats .beats .

Long Term v is irregular waves on the Long Term v is irregular waves on the CTG 3-5 bpm.CTG 3-5 bpm.

Normal is 5-25 bpm– this indicates N-Normal is 5-25 bpm– this indicates N-CNS.CNS.

EFM-AccelerationsEFM-Accelerations

Accelerations- transient increase in Accelerations- transient increase in FHR of 15 bpm or more lasting for 15 FHR of 15 bpm or more lasting for 15 sec.sec.

Absence of accelerations on an Absence of accelerations on an otherwise normal CTG remains otherwise normal CTG remains unclear.unclear.

Presence of FHR Accelerations have Presence of FHR Accelerations have Good outcome.Good outcome.

EFM DecelerationsEFM Decelerations

Decelerations- Decelerations-

transient slowing of transient slowing of

FHR below the FHR below the

baseline level of baseline level of

more than 15 bpm more than 15 bpm

and lasting for 15 and lasting for 15 sec. sec.

or more.or more.

Electronic Fetal MonitoringElectronic Fetal Monitoring a) Early Decelerations (fig 3)a) Early Decelerations (fig 3)

Head compressionHead compression Begins on the onset of contraction Begins on the onset of contraction

and returns to baseline as the and returns to baseline as the contraction ends.contraction ends.

Should not be disregarded if they Should not be disregarded if they appear early in labor or Antenatal.appear early in labor or Antenatal.

Clinical situation should be r/vClinical situation should be r/v

Fig 3 Early Decelerations

Late Decelerations.Late Decelerations.

Uniform periodic slowing of FHR Uniform periodic slowing of FHR with the on set of the contractions .with the on set of the contractions .

Repetitive late decels increases Repetitive late decels increases risk of Umbilical artery acidosis risk of Umbilical artery acidosis and Apgar score of less than 7 at 5 and Apgar score of less than 7 at 5 mins and Increased risk of CP.mins and Increased risk of CP.

Electronic Fetal MonitoringElectronic Fetal Monitoringb) Late Decelerations (Fig 4)b) Late Decelerations (Fig 4)

• Due to acute and chronic feto-placental Due to acute and chronic feto-placental vascular insufficiencyvascular insufficiency

Occurs after the peak and past the length of Occurs after the peak and past the length of uterine contraction, often with slow return to uterine contraction, often with slow return to the baseline.the baseline.

Are precipitated by hypoxemiaAre precipitated by hypoxemia Associated with respiratory and metabolic Associated with respiratory and metabolic

acidosisacidosis Common in patients with PIH, DM, IUGR or Common in patients with PIH, DM, IUGR or

other form of placental insufficiency.other form of placental insufficiency.

Fig 4 Late Decelerations

Late DecelerationsLate Decelerations

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

EFM- Variable DecelerationsEFM- Variable Decelerations Variable intermittent periodic slowing of Variable intermittent periodic slowing of

FHR with rapid onset recovery and FHR with rapid onset recovery and isolation.isolation.

They can resemble other types of They can resemble other types of deceleration in timing and shape.deceleration in timing and shape.

Atypical VD are associated with an Atypical VD are associated with an increased risk of umbilical artery increased risk of umbilical artery acidosis and Apgar score less than 7 at acidosis and Apgar score less than 7 at 5 min5 min

EFM- Variable DecelerationsEFM- Variable DecelerationsAdditional components:Additional components: Loss of 1 degree or 2 degree rise in baseline Loss of 1 degree or 2 degree rise in baseline

RateRate Slow return to baseline FHR after and end of Slow return to baseline FHR after and end of

contraction.contraction. Prolonged secondary rise in Base FHR Prolonged secondary rise in Base FHR Biphasic decelerationBiphasic deceleration Loss of variability during deceleration Loss of variability during deceleration Continuation of base line at a lower level.Continuation of base line at a lower level.

Electronic Fetal MonitoringElectronic Fetal Monitoring

cc) Variable Deceleration (Vagal activity) (Fig 5)) Variable Deceleration (Vagal activity) (Fig 5) Inconsistent in configuration, Inconsistent in configuration, No uniform temporal r-ship to the onset of No uniform temporal r-ship to the onset of

contraction, are variable and occur in isolation.contraction, are variable and occur in isolation. Worrisome when Rule of 60 is exceeded (i.e. decrease Worrisome when Rule of 60 is exceeded (i.e. decrease

of 60 bpm,or rate of 60 bpm and longer than 60 sec) of 60 bpm,or rate of 60 bpm and longer than 60 sec) Caused by cord compression of the umbilical cordCaused by cord compression of the umbilical cord Often associated with Oligo-hydroaminos with or Often associated with Oligo-hydroaminos with or

without ROMwithout ROM Can cause short lived RDS if they MILDCan cause short lived RDS if they MILD Acidosis if prolonged and Recurrent.Acidosis if prolonged and Recurrent.

Fig 5 Variable Decelerations

EFM Prolonged decelerationEFM Prolonged deceleration

Prolonged Deceleration (Fig 6)Prolonged Deceleration (Fig 6) Drop in FHR of 30 bpm or More lasting for Drop in FHR of 30 bpm or More lasting for

at least 2 minat least 2 min Is pathological when crosses 2 Is pathological when crosses 2

contractions i.e 3 mins.contractions i.e 3 mins. Reduction in O2 transfer to placenta.Reduction in O2 transfer to placenta. Associated with poor neonatal outcome.Associated with poor neonatal outcome.

EFM- Prolonged DecelerationsEFM- Prolonged DecelerationsCAUSESCAUSES

Cord prolapse.Cord prolapse. Maternal hypertensionMaternal hypertension Uterine HypertoniaUterine Hypertonia Followed by a VE or ARM or SROM Followed by a VE or ARM or SROM

with High PP.with High PP.

Fig 6 Prolonged Deceleration

EFM Mx Prolonged EFM Mx Prolonged DecelerationDeceleration

Maternal positionMaternal position IV fluidsIV fluids V.E to exclude cord prolapse V.E to exclude cord prolapse Assess BPAssess BP FBS if cx dilated and well applied PPFBS if cx dilated and well applied PP Mx DependingMx Depending on the clinical situation.on the clinical situation.

Baseline BradycardiaBaseline Bradycardia FH below 110bpm(FIGO ).FH below 110bpm(FIGO ). less than 100bpm (RANZCOG).less than 100bpm (RANZCOG).

Causes :Causes : Postdates, Drugs, Idiopathic,Postdates, Drugs, Idiopathic, Arrythmias, hypothermia(increased Vagal Arrythmias, hypothermia(increased Vagal

Tone)Tone) Cord Compression (Acute Hypoxia, Cord Compression (Acute Hypoxia,

congenital H/disease and Drugs).congenital H/disease and Drugs). Mx depends on the clinical situation.Mx depends on the clinical situation.

(FBS,VE Observation or expedite delivery)(FBS,VE Observation or expedite delivery)

TypesTypes

Moderate Bradycardia 100-109 bpmModerate Bradycardia 100-109 bpm Abnormal bradycardia less than Abnormal bradycardia less than

100bpm.100bpm. Tachycardia 161-180 bpmTachycardia 161-180 bpm Abnormal Tachycardia more than 180 Abnormal Tachycardia more than 180

bpmbpm Ranzcog Australian more than 170 Ranzcog Australian more than 170

bpmbpm

Baseline tachycardia and Baseline tachycardia and Bradycardia.Bradycardia.

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

Causes of B Tachycardia.Causes of B Tachycardia. AsphyxiaAsphyxia DrugsDrugs PrematurityPrematurity Maternal FeverMaternal Fever Maternal thyrotoxicosisMaternal thyrotoxicosis Maternal AnxietyMaternal Anxiety IdiopathyIdiopathy Mx depends on the clinical situationMx depends on the clinical situation

Electronic Fetal MonitoringElectronic Fetal Monitoring

Baseline BradycardiaBaseline Bradycardia FH Rate below 110bpm (FIGO Recommended)FH Rate below 110bpm (FIGO Recommended) PostdatesPostdates DrugsDrugs Idiopathic Idiopathic Arrhythmia's Arrhythmia's Hypothermia.(Increased Vagal tone),Hypothermia.(Increased Vagal tone), Cord compression(Acute Hypoxia,Congenital Cord compression(Acute Hypoxia,Congenital

H/disease, and drugs)H/disease, and drugs)Mx depends on the clinical situation. (FBS, VE, Mx depends on the clinical situation. (FBS, VE, Observation or expedite Delivery).Observation or expedite Delivery).

Electronic Fetal MonitoringElectronic Fetal Monitoring

Baseline TachycardiaBaseline Tachycardia AsphyxiaAsphyxia DrugsDrugs PrematurityPrematurity Maternal feverMaternal fever Maternal thyrotoxicosisMaternal thyrotoxicosis Maternal AnxietyMaternal Anxiety IdiopathyIdiopathy

Mx depends on the clinical situationMx depends on the clinical situation

Fig 2 Sinusoidal patternFig 2 Sinusoidal pattern

Interpretation of the CTGInterpretation of the CTG

EFM-Sinusoidal PatternEFM-Sinusoidal Pattern

Regular Oscillation of the Baseline long-term Regular Oscillation of the Baseline long-term Variability resembling a Sine wave ,with no B-b Variability resembling a Sine wave ,with no B-b Variability (Fig 2),Variability (Fig 2),

Has fixed cycle of 3-5 p min. with amplitude of Has fixed cycle of 3-5 p min. with amplitude of 5-15 bpm and above but not below the baseline.5-15 bpm and above but not below the baseline.

Should be viewed with suspicion as poor Should be viewed with suspicion as poor outcome has been seen (eg Feto-maternal outcome has been seen (eg Feto-maternal haemorrhage)haemorrhage)

Electronic Fetal MonitoringElectronic Fetal Monitoring

Sinusoidal pattern - distinctive smooth undulating Sinusoidal pattern - distinctive smooth undulating Sine-wave baseline with no B-b variability ( Fig 2 )Sine-wave baseline with no B-b variability ( Fig 2 ) 0.3 % (Young 1980)0.3 % (Young 1980) cord compressioncord compression hypovolemiahypovolemia ascitesascites idiopathic(fetal thumb sucking)idiopathic(fetal thumb sucking) AnalgesicsAnalgesics AnaemiaAnaemia AbruptionAbruption Mx r/v clinical situationMx r/v clinical situation

EFM- Saltatory patternEFM- Saltatory pattern

Seen During Fetal thumb sucking.Seen During Fetal thumb sucking. Could be associated with Hypoxia.Could be associated with Hypoxia.

NR CTGsNR CTGs

Difficult to interpretation,leads to Difficult to interpretation,leads to Increased rate of C Section.Increased rate of C Section.

50% CTG in Labour have 1 abnormal 50% CTG in Labour have 1 abnormal featurefeature

15-20% Nr CTGs (pathological).15-20% Nr CTGs (pathological). ?? To reduce CS….?? To reduce CS….

EFM-SummaryEFM-Summary

Normal - CTG with all 4 FeaturesNormal - CTG with all 4 Features Suspicious -one non reassuring Suspicious -one non reassuring

category and reminder are reassuringcategory and reminder are reassuring Pathological -2 or more non-Pathological -2 or more non-

reassuring categories or one or more reassuring categories or one or more abnormal categories.abnormal categories.

Caring for the Mom, Caring for the Mom, Not the Monitor!Not the Monitor!

ReferencesReferences

Manual Obs and Gyn. by Niswander, MDManual Obs and Gyn. by Niswander, MD Fetal Monitoring RCOG UKFetal Monitoring RCOG UK CTGs RANZCOGCTGs RANZCOG Literature review articles American Family Literature review articles American Family

PhysicianPhysician CTG Made EasyCTG Made Easy D. Lata Sharma, MD, FRANZCOG, Senior

Lecturer, University Of Queensland, Australia Charles Kawada, M.D,Harvard Medical School

AmnioinfusiAmnioinfusi

Hamil Hamil ≥ 37 minggu, bukan bekas SC, ≥ 37 minggu, bukan bekas SC, ICA < 5 cmICA < 5 cm

600 mL-1000 mL dlm 1 jam + 150-180 600 mL-1000 mL dlm 1 jam + 150-180 mL/jam, hangat 37mL/jam, hangat 3700 C C

Transervikal NGT no.8Transervikal NGT no.8 Bila keluar < 100 mL, ukur ICA Bila keluar < 100 mL, ukur ICA

hindari distensi uterushindari distensi uterus Pembukaan ≤5-6 cmPembukaan ≤5-6 cm

Review CochraneReview Cochrane