Cardiotocography (CTG)

Electronic Fetal Monitoring

 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.
 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
 High risk pregnancies
 IOL and Augmentation of
Labour.
 Reduced FM.
 Premature labour/TPL.
 APH/IPH
 Oligohydramnios
 Hypertension.
 Abnormal FHR
detected.
 Malpresentation and
in labour.
 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 un clear.
 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
 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!