FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Safe Motherhood and Newborn Health Committee Co-ordinator for guideline development: Diogo Ayres-de-Campos FIGO 2015

1960’s Hon, Caldeyro-Barcia, Hammacher 3 different classifications

1970’s - 1980’s Myer-Menk/Fischer, Cardiff, Birmingham, Krebs 21 different CTG classifications 1974-1984 Devoe LD et al. AJOG 1985;152:1047-53

FIGO 1987 FIGO. IJOG 1987;25:159-67

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Safe Motherhood and Newborn Health Committee Co-ordinator for guideline development: Diogo Ayres-de-Campos FIGO 2015

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Wide consensus Include all currently available methods of intrapartum fetal monitoring Language accessible to all professionals Simple and objective FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING RCOG contacted to appoint person for writing of CTG chapter (Dec 2012). Nominated (Feb 2013) ACOG contacted to appoint person for writing of CTG chapter (Dec 2012). Nominated (Jan 2013) All FIGO member societies contacted to appoint one subject matter expert (Feb 2013) Wide knowledge of the fetal monitoring scientific literature. Good written English Available to provide written feedback in less than 15 days FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING 34 experts nominated by FIGO scientific societies (Feb 2013 to May 2013) 13 experts invited by FIGO based on literature search (May 2013 – Jul 2013) Lawrence Devoe (USA), Gerard Visser (Netherlands), Richard Paul (USA), Barry Schifrin (USA), Julian Parer (USA), Philip Steer (UK), Vincenzo Berghella (USA), Isis Amer-Wahlin (Sweden), Susanna Timonen (Finland), Austin Ugwumadu (UK), João Bernardes (Portugal), Justo Alonso (Uruguay), Ingemar Ingemarson (Sweden). ICM invited to write the chapter on intermittent auscultation (Jul 2013). Nominated (Oct 2013) FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING 3 round email consensus process (3 weeks to reply) Final agreement for name to be included in the panel 1st and 2nd chapters (2 Oct 2013 – 10 Feb 2014) 4th chapter (5 Mar 2014 – 31 Aug 2014) 3rd chapter (20 Aug 2014 – 2 Jan 2015) 5th chapter (5 Jan 2015 – 15 Mar 2015) FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING No internal or external funding 10 months to prepare 18 months for the consensus process 2029 emails exchanged FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING PHYSIOLOGY OF FETAL OXYGENATION AND THE MAIN GOALS OF INTRAPARTUM FETAL MONITORING Diogo Ayres-de-Campos, Sabaratnan Arulkumaran for the FIGO intrapartum fetal monitoring consensus panel FIGO 2015

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Aims of intrapartum fetal monitoring Avoid adverse fetal outcome related to intrapartum hypoxia/acidosis Avoid unnecessary intervention, associated with increased maternal and fetal risks FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Blood gas or lactate analysis in the umbilical cord, or in the newborn circulation during the first minutes of life, is the only objective way of quantifying hypoxia/acidosis occurring just prior to birth FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Cord blood sampling Unnecessary to clamp the cord As soon as possible after birth (< 15 min) Artery and vein Analysis within 30 min FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Metabolic acidosis Arterial pH < 7.00 and BD >12 mmol/l already associated with adverse outcome when pH < 7.05 and BDecf > 10 mmol/l Arterial lactate > 10 mmol/l is an alternative, but reference values may vary according to device FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING BDecf believed by some experts to be the best representative of H+ concentration of metabolic origin in the different fetal compartments BDblood calculated by blood gas analysers, slightly higher, can also be used FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING 1-minute Apgar important to decide newborn resuscitation low association with intrapartum hypoxia/acidosis 5-minute Apgar stronger association with short- and long-term neurological outcome and neonatal death FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Apgar scores Unaffected by minor degrees of hypoxia/acidosis Subject to interobserver disagreement Affected by non-hypoxic causes:: prematurity birth trauma infection meconium aspiration congenital anomalies pre-existing neurological lesions medication administered to the mother early endotracheal aspiration FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Metabolic acidosis and low Apgars vast majority recover quickly and have no short- or long-term complications few cases are of sufficient intensity and duration to cause death or long-term morbidity FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Hypoxic-ischemic encephalopathy (HIE) Short-term neurological dysfunction caused by hypoxia/acidosis Metabolic acidosis, low Apgars, early imaging of cerebral edema, changes in muscle tone, sucking difficulties, seizures or coma in first 48 h of life May be accompanied by other system dysfunctions FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Neonatal encephalopathy other non-hypoxic causes need to document metabolic acidosis in umbilical artery or in newborn circulation during the first minutes of life for HIE FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Cerebral palsy (spastic quadriplegic , dyskinetic ) Manifests at 1-4 years Long-term neurological complication more commonly associated with term intrapartum hypoxia/acidosis Only 10-20% cases are caused by hypoxia/acidosis Infection Congenital diseases Metabolic diseases Coagulation disorders Antepartum and post-natal hypoxia Birth trauma FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Intrapartum hypoxia/acidosis as the cause of cerebal palsy in term infants Metabolic acidosis Low 1 and 5-minute Apgar scores Grade 2 or 3 HIE Early imaging of acute non-focal cerebral anomaly Spastic quadriplegic or dyskinetic type Exclude other identifiable etiologies FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Intrapartum fetal monitoring should indicate intervention at an early stage of hypoxia/acidosis in order to prevent rather than to predict adverse newborn outcomes FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING CARDIOTOCOGRAPHY Diogo Ayres-de-Campos, Catherine Y. Spong, Edwin Chandraharan for the FIGO intrapartum fetal monitoring consensus panel FIGO 2015

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Cardiotocography (kardia=heart, tokos=labour) …is the term that best describes the continuous monitoring of the FHR and uterine contractions FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Paper speed 1 cm/min 2 cm/min 3 cm/min FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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

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, βagonist or parasympathetic drugs, arrhythmias) Bradycardia < 110 bpm for more than 10 min (hypothermia, beta-blockers and fetal arrhythmias) FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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

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

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 (umbilical compression) Seldom associated with important hypoxia/acidosis Majority of decelerations FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 Tracings with  variability and no accelerations, amplitude > 10 bpm FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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

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 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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, or sinusoidal pattern Repetitive* late or prolonged decelerations > 30 min or > 20 min if variability is reduced. Prolonged deceleration > 5 min No hypoxia/acidosis No intervention necessary Low probability of hypoxia/acidosis Action to correct reversible causes, close monitoring, or adjunct technologies High probability of hypoxia/acidosis Immediate action to correct reversible causes, adjunct technologies or if not possible expedite delivery. In acute situations, immediate delivery must be accomplished. *Decelerations are repetitive when associated with > 80% contractions. Absence of accelerations during labour is of uncertain significance. FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Reversible hypoxia/acidosis Tachyssystole Iatrogenic/spontaneous excessive contraction frequency Maternal supine position (aorto-caval compression by pregnant uterus) Sudden maternal hypotension (following epidural or spinal analgesia) Maternal respiratory complications Acute asma, etc. FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Excessive uterine activity should be avoided, irrespective of FHR changes, reversed by  ocytocin or acute tocolysis Salbutamol Terbutaline Ritodrine Atosiban Nitroglycerine FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

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

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Irreversible Uterine rupture Major placental abruption Fetal hemorrhage FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Mechanical complications of labour Cord prolapse Retention of aftercoming head Shoulder dystocia FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING INTERMITTENT AUSCULTATION Debrah Lewis, Soo Downe for the FIGO intrapartum fetal monitoring consensus panel FIGO 2015

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING The evidence for the benefits of continuous CTG monitoring, as compared to IA, in both low and high risk labours is scientifically inconclusive Alfirevic Z et al. Cochrane 2013 May 31;5:CD006066 Vintzileos AM et al. Obstet Gynecol 1995;85:149-55 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Intermittent auscultation (IA) Recommended in all labours where there is no access to CTG Where CTG is available, may be used in low-risk cases ≈ ½ panel members believe that CTG should be preferred during the 2nd stage FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

contractions MHR FHR

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Features to evaluate What to register FHR   Duration: ≥ 60 secs (for 3 UC if abormal) Number of bpm Accelerations and decelerations (presence or absence) Timing: during and ≥ 30 secs after UC Interval: Every 15 min in active phase. Every 5 min in 2nd stage Uterine contractions Before and during IA (in order to detect ≥ 2 UCs) Frequency (in 10 min) Fetal movements At the same time as UCs Presence or absence MHR At the time as IA FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Abnormal findings Baseline < 110 bpm or > 160 bpm Decelerations Presence of repetitive or prolonged (>3 mins) decelerations Contractions More than 5 contractions in 10 mins FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING IJGO supplement to be distributed at the FIGO congress in Vancouver, Oct 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING

Powerpoint presentation Courses

FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING Common terminology Shared knowledge Basis for research and progress Widespread clinical use