1. Interesting CTGs- Discussion
Dr. Latha Venkatram

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

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

8. LSCS in view of tachycardia and concerns with chorioamnionitis

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

10. 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

11. 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

12. 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

14. 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

16. 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

17. 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

19. 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

21. 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

22. 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

23. 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

25. 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).

26. 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

27. 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

30. 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

31. 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

32. 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.

33. 05:00am
05:00 am PV Findings-
1-2 cm
ARM-Minimal clear liquor
Synt commenced

34. 06:00am

35. 07:00am
SVD; 2 kg baby
Apgar's-8,9

37. 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: , 1971.

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

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

41. 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

42. 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

43. 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.

45. 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

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

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

50. THANK YOU