Cardiotocography ( CTG ) Electronic Fetal Monitoring Ali Sungkar Divisi Fetomaternal Bagian Obstetri dan Ginekologi FKUI/RSUPN - CM

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.

EFM Problems and Realities 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 unclear. 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

EFM- Variable Decelerations 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!

References Manual Obs and Gyn. by Niswander, MD Fetal Monitoring RCOG UK CTGs RANZCOG Literature review articles American Family Physician CTG Made Easy D. Lata Sharma, MD, FRANZCOG, Senior Lecturer, University Of Queensland, Australia Charles Kawada, M.D,Harvard Medical School

Amnioinfusi Hamil ≥ 37 minggu, bukan bekas SC, ICA < 5 cm 600 mL-1000 mL dlm 1 jam + 150-180 mL/jam, hangat 370 C Transervikal NGT no.8 Bila keluar < 100 mL, ukur ICA  hindari distensi uterus Pembukaan ≤5-6 cm

Review Cochrane