1. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Tracing analysis
Basic CTG features
Tracing classification
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

2. 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

3. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Normal
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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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 > weeks
Deep sleep may last 50 min
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

17. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Deep sleep
Active sleep
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

18. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Active awakeness
(difficulty in baseline estimation)
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

19. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Tracing classification
Baseline
Variability
Decelerations
Interpretation
Clinical Management
Normal
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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Intravenous salbutamol started
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

31. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Limitations of CTG
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

32. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
Signal loss
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

33. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
MHR monitoring
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

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

35. 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

36. 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 )
↑ c-sections (RR=1.66, 95%CI )
↑ instrumental deliveries (RR=1.16, 95%CI )
= perinatal mortality (RR=0.85, 95%CI )
= cerebral palsy (RR=1.20, 95%CI )
Cochrane Database Syst Rev May 31;5:CD006066
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING

37. 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

38. 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

39. 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

40. 2015 FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
2nd BREAK
2015 FIGO CONSENSUS GUIDELINES ON
INTRAPARTUM FETAL MONITORING