2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Tracing analysis Basic CTG features Tracing classification 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Baseline Mean level of the most horizontal and less oscillatory FHR segments. Estimated in 10-min periods, expressed in bpm 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Normal 110-160 bpm Tachycardia > 160 bpm for more than 10 min (pyrexia, epidural, early stages of non-acute hypoxemia, β agonist or parasympathetic drugs, arrhythmias) Bradycardia < 110 bpm for more than 10 min (hypothermia, beta-blockers and fetal arrhythmias) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Variability Average bandwidth amplitude in 1-min segments 1 min 125 120 115 Subjectivity in visual evaluation 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Reduced variability < 5 bpm for more than 50 min in baseline or more than 3 min in decelerations Hypoxia/acidosis of CNS, previous cerebral injury, infection, CNS depressants or parasympathetic blockers 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Increased variability (saltatory) Bandwidth > 25 bpm for more than 30 min Incompletely understood Hypoxia/acidosis of rapid evolution 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Accelerations Abrupt increases in FHR above baseline, > 15 bpm amplitude, > 15 secs 150 130 140 120 >15 s >15 bpm Most coincide with fetal movements Reactive fetus without hypoxia/acidosis 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Decelerations Abrupt decreases in FHR below baseline, > 15 bpm amplitude, > 15 secs 150 130 140 120 >15 s >15 bpm 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Early decelerations Shallow, short-lasting, with normal variability and coincident with contractions Believed to be caused by fetal head compression Do not indicate fetal hypoxia/acidosis 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Variable decelerations Rapid drop (onset-nadir in < 30 sec), rapid recovery, good variability. Varying size, shape and relation to uterine contractions Baroreceptor-mediated response to ↑ BP (cord compression) Seldom associated with important hypoxia/acidosis Majority of decelerations 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Late decelerations Gradual onset and/or gradual return to baseline, and/or reduced variability. Onset > 20 sec after start of contraction, nadir after acme and return to baseline after end Chemoreceptor-mediated response to hypoxemia With  variability and no accelerations, amplitude only > 10 bpm 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Prolonged deceleration > 3 min Likely to include a chemoreceptor-mediated component If > 5 min,  variability, and FHR < 80 bpm  emergency intervention 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Sinusoidal pattern Regular, smooth, undulating, resembling sine wave. Amplitude 5-15 bpm, frequency 3-5 cycles/min, > 30 min, no accelerations Severe anemia, acute hypoxia/acidosis, infection, cardiac malformations, hydrocephalus, gastroschisis 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Pseudo- sinusoidal pattern Jagged “saw-tooth” appearance. Duration seldom exceeds 30 min. Normal patterns before and after Pseudo-sinusoidal pattern Analgesic administration, fetal sucking and other mouth movements 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Tachysystole > 5 contractions in 10 min in two successive 10-min periods, or averaged over 30 min. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Behavioural states Body movements Eye movements CTG Deep sleep - - Active sleep + + +++ + Active awakeness Cycling represents the hallmark of neurological responsiveness Transitions become clearer > 32-34 weeks Deep sleep may last 50 min 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Deep sleep Active sleep 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Active awakeness (difficulty in baseline estimation) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Tracing classification   Baseline Variability Decelerations Interpretation Clinical Management Normal 110-160 bpm 5-25 bpm No repetitive* decelerations Suspicious  Lacking at least one characteristic of normality, but with no pathological features  Pathological < 100 bpm Reduced variability. Increased variability. Sinusoidal pattern. Repetitive* late or prolonged decelerations for > 30 min (or > 20 min if reduced variability). Deceleration > 5 min No hypoxia/acidosis No intervention necessary to improve fetal oxygenation state Low probability of hypoxia/acidosis Action to correct reversible causes if identified, close monitoring, or adjunctive methods High probability of hypoxia/acidosis Immediate action to correct reversible causes, adjunctive methods or if this is not possible expedite delivery. In acute situations, immediate delivery should be accomplished. *Decelerations are repetitive when associated with > 50% contractions. Absence of accelerations in labour is of uncertain significance. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Clinical decision gestational age medication administered to the mother integrated with clinical information 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 1 Baseline 130 bpm Accelerations Non-repetitive decelerations Normal variability Normal 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 2 Baseline 154 bpm No accelerations Non-repetitive decelerations Normal variability Normal 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 3 Baseline 180 bpm No accelerations Repetitive late decelerations (> 30 min) Reduced variability (> 50 min) Pathological 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 4 Baseline 140 bpm No accelerations Repetitive variable decels. (1 late+ prol) Normal variability Suspicious 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 5 Baseline 148 bpm Accelerations Repetitive decelerations, one > 5 min Reduced variability at the end Pathological 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 6 Baseline 130 bpm Accelerations Repetitive decels (not late/prolonged) Normal variability Suspicious 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 7 Baseline 132 bpm Acceleration Deceleration > 5 min Reduced variability in deceleration Pathological 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Case 8 Baseline 146 bpm No accelerations Repetitive variable decels (1 prolonged) Normal variability Suspicious 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Maternal or mechanical complications Reversible causes Excessive uterine activity ( oxytocics, tocolysis) Supine position (change maternal positions) Sudden hypotension (fluids, ephedrine) Irreversible causes Uterine rupture Major placental abruption Umbilical cord prolapse Fetal haemorrhage Maternal or mechanical complications 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Intravenous salbutamol started 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Limitations of CTG 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Signal loss 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING MHR monitoring 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

CTG analysis is subject to considerable intra- and interobserver disagreement (decelerations, variability, suspicious-pathological) 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Limited predictive value of abnormal CTGs High predictive value for NO hypoxia/acidosis Low predictive value for hypoxia/acidosis BJOG 1993;100(suppl 9):4-7 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING RCTs comparing CTG with IA 12 trials (circa 37,000 women) ↓ neonatal seizures (RR=0.50, 95%CI 0.31-0.80) ↑ c-sections (RR=1.66, 95%CI 1.30-2.13) ↑ instrumental deliveries (RR=1.16, 95%CI 1.01-1.32) = perinatal mortality (RR=0.85, 95%CI 0.59-1.23) = cerebral palsy (RR=1.20, 95%CI 0.52-2.79) Cochrane Database Syst Rev. 2013 May 31;5:CD006066 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Trials carried out > 25 years ago Different CTG monitor technologies Different interpretation guidelines Different experience with CTG Different use of adjunctive methods 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Difficult to establish how these RCTs relate to current clinical practice The evidence for the benefits of CTG when compared to IA is inconclusive 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING CTG monitoring should not be regarded as a substitute for good clinical observation and judgement, or as an excuse for leaving the mother unattended 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING 2nd BREAK 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING