Interesting CTGs- Discussion Dr. Latha Venkatram

Case 1 Archana 28 year old low risk primi at 38 weeks with SROM-clear liquor since early morning VE-2 cm dilated

Causes of Fetal Tachycardia Premature fetus Fetal Hypoxia Maternal pyrexia Infections Beta Agonist Hyperthyroidism Fetal Anemia Fetal SVT

LSCS in view of tachycardia and concerns with chorioamnionitis

Learning points Continue the trace Think of the etiology Appropriate corrective measures

Case 2 Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor

01:30pm Syntocinon commenced Epidural sited Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited

03:00pm Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited

A 15° lateral tilt can increase cardiac output by 20–25% and stroke volume by 25–30%, and decrease heart rate by 5–6 bpm

04:20pm Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited

Mrs. S, 26 year old primi, uncomplicated pregnancy Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited

Reducing or discontinuing an oxytocin infusion After 15 minutes of cessation, there is a 22% reduction in uterine activity By 30 minutes, there is a 39% reduction in uterine activity By 45 minutes there is a 48% reduction in uterine activity

TOCOLYTICS More rapid reduction in uterine activity Terbutaline at a dose of 250 μg given subcutaneously Rapid onset of action with a reduction in uterine activity of up to 87.3% in 15 minutes Glyceryl trinitrate (GTN) has a half-life of 3 minutes sublingual spray to acutely reduce uterine activity

06:20pm Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited

07:20pm 07:30pm PV Findings- FD,OA ,+1station Ventouse delivery-3 kg Mrs.S, 26 year old primi, uncomplicated pregnancy. Scan at 40 weeks-Normal growth, AFI 4. IOL planned Misoprostol -2 doses; Contractions commenced 01:30pm-3 cm dilated,0.5cms long. ARM-Clear liquor Syntocinon commened Epidural sited Ventouse delivery-3 kg Cord gases A-7.25 ; -6 V-7.35; -2

Learning points-Umbilical cord blood gases Most objective determinant of foetal metabolic acidosis at birth But Retrospective Paired sample essential Arterial pH is < the venous pH (the A-V difference should be >0.02 pH units, and for pCO2 the A-V difference should be >0.5 kPa (3.75 mmHg).

Learning points-Intra uterine resuscitation Remember the SPOILT mnemonic: Stop oxytocin Position – adopt left lateral position Oxygen – before anaesthesia IV fluid bolus Low BP – consider vasopressors, ephedrine Tocolysis- Discontinue oxytocin, tocolytics

Case 3 28 year old G2P1L1 , 37 weeks admitted with conts- Ultrasound findings- EFW 2 kg< 4th centile AFI-2.5 Umb Art-Increased resistance Planned for IOL VE- 1-2 cm dilated

Beware of MOTHERS Meconium Oxytocin Temperature When a CTG is reviewed look at the clincial picture. Beware of MOTHERS Meconium Oxytocin Temperature Hyperstimulation/haemorrhage Epidural Rate of progress Scar

Categorising decelerations Variables without concerning characteristics Upto 90 mins-reassuring 90 mins or more-Non reassuring Variables with concerning characteristics More than 50 % of conts- 30 mins or more-abnormal up to 30 mins-non reassuring Upto 50% of conts 30 mins or more-Non reassuring

Concerning characteristics of variable decelerations-Nice 2017 Lasting more than 60 seconds Reduced baseline variability within the deceleration Failure to return to baseline Biphasic (W) shape No shouldering.

05:00am 05:00 am PV Findings- 1-2 cm ARM-Minimal clear liquor Synt commenced

06:00am

07:00am SVD; 2 kg baby Apgar's-8,9

Significance of FHR changes relative to pH Learning points Significance of FHR changes relative to pH R. W. Beard, et al. The significance of the changes in the continuous foetal heart rate in the first stage of labour. J Obstet Gynaecol Br Commonw 78:865-881, 1971.

Case 4 Mrs. D, G2 P1 L1 in spontaneous labour (previous lscs) VE-Almost fully dilated; Vx at spines

IMPORTANT Exclude four major accidents during labour caesarean scar rupture Abruption cord prolapse Uterine Hypertonicity

Acute HYPOXIA Acute hypoxia FHR <80 bpm > 3 mins CHEMORECEPTOR STIMULATION- Vagal Stimulation- FHR decrease Acute hypoxia SUSTAINED INSULT-Myocardial Ischemia- FHR decrease FHR <80 bpm > 3 mins pH drop by 0.01/min

Guidance on Management 3,6,9,12 and 15 minute Rule 3 minutes Review the clinical situation 6 minutes Appropriate interventions 90% recovery if no pathology Call theatre/ anaesthetist 9 minutes 95%should recover Move to theatre 12 minutes Commence attempt to delivery 15 minutes Delivery by LSCS/ assisted vaginal

Case 5 Primi gravida at 35 weeks gestation with vague abdominal pain and decreased FM. BP- 140/100. Was diagnosed as gestational hypertension 1 week back. Was on lobet 100mg TID. Scan -normal.

Causes of Decreased Variability Sleep Prematurity When combined with deceleration, sign of fetal acidosis Analgesic drugs in labour- Narcotics MgSO4 when given in eclampsia and preterm labour

DECIDED ON LSCS INTRAOP- RETROPLACENTAL CLOT – 150ML- ABRUPTION. CORD BLOODS – WNL

Learning points Consider the full clinical picture Commence appropriate Intrauterine resus measures Be prepared for delivery if non reassuring features persist

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