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Admission cardiotocography at first stage of labour and fetal outcomes in Magway Teaching Hospitals Ngu Wah Linn1, Khaing Yu Swe2, Nwe Mar Tun2 1Department of Obstetrics and Gynaecology, University of Medicine, Magway 2Department of Obstetrics and Gynaecology, University of Medicine, Mandalay
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Contents Introduction Research methodology Ethical considerations
Results Discussion Conclusion Recommendations Acknowledgement
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Introduction Labour , the most crucial period for the fetus because it can sustain hypoxia due to stress of contraction.1 The majority of fetuses cope well during labour, but the journey through the birth canal is stressful and fetuses mount a stress response during labour.1 Fetuses with utero-placental insufficiency develop hypoxia in labour that may be over minutes or gradually.1 1. Nagure, A., Umashanakar, K.M., Dharmavijay, M.N. and Saleem, M. (2013), Admission cardiotocography: its role in predicting fetal outcome in high risk obstetric patient . Indian journal of Basic and Applied Medical Research: 3(1), pp
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Intrapartum asphyxia to fetal death or short term or long term morbidity, thus monitoring of the fetus during labour is very important to identify the fetal problems.2 Current methods of fetal monitoring during labour - fetal heart rate monitoring such as intermittent auscultation of fetal heart rate and continuous electronic fetal monitoring, fetal blood sampling, fetal electrocardiogram, fetal stimulation tests, fetal pulse oximetry etc.2 2.Gauge, S. (2012) CTG made easy. 4th ed. ELSEVIER:Churchill Livingstone. pp.1-25.
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The standard of intermittent auscultation , auscultation for one complete minute beginning immediately after the ends of the contractions, repeated every fifteen minutes during the first stage of labour and after every contraction in the second stage of labour.3 Measure the baseline fetal heart rate but cannot assess baseline variability, accelerations and decelerations.3 3. Gibb, D. and Arulkumaran, S. (2017) Fetal Monitoring In Practice. 4th ed. ELSEVIER. pp
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Routine electronic monitoring of the fetal heart rate in labour ,an established obstetric practice in world.4 The use of antepartum and intrapartum cardiotocography (CTG) increased over the last fifteen years. 4.Resh, P., Vishwanathas, S. and Sujani, B.K. (2011), Admission test cardiotocography during labour as a predictor of fetal outcome. JK Practitioner. 16, pp.1-2.
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A short recording of fetal heart rate and uterine contraction pattern during labour by electronic fetal monitoring device for a period of minutes on admission to labour room ,“Admission CTG”.5 A better impression of the fetal condition than traditional assessment.3 5.Dwarakanath, L., Lakshmikantha, G. and Chaitra, S.K. (2013), Efficacy of admission cardiotocography (admission test) to predict obstetric outcome. Journal Of Evolution Of Medical And Dental Sciences. 2(5), pp 3.Gibb, D. and Arulkumaran, S. (2017) Fetal Monitoring In Practice. 4th ed. ELSEVIER. pp
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Objectives General Objective
To study the admission cardiotocography (CTG) at first stage of labour and fetal outcomes in Teaching Hospitals of University of Medicine, Magway. Specific Objectives To describe the results of admission CTG of obstetric patients who admitted to hospital at first stage of labour. To determine the fetal outcomes of study population. To identify the relationship between the admission CTG results and fetal outcomes .
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Research methodology Study Design
a hospital-based cross sectional descriptive study. Study Area labour wards of Teaching Hospitals of University of Medicine, Magway (Magway Regional Hospital, Magway Teaching Hospital, Minbu General Hospital).
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Study Period from 1st August 2015 to 31st July 2016. Study Population All pregnant women with singleton term pregnancy admitted to labour wards in the first stage of labour.
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Inclusion criteria All pregnant women with singleton term pregnancy admitted in first stage of labour with the fetus in cephalic presentation
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Exclusion criteria Maternal pyrexia (temperature >37.5˚C) Patients with severe medical conditions like acute pulmonary edema, active bronchial asthma etc Patients with eclampsia, abruptio placenta and chorioamnionitis Known case of fetal congenital abnormality
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Figure 1. CTG machine model – GIMA FC 700
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Algorithm All pregnant women with singleton pregnancy with cephalic presentation at term in first stage of labour Participation in the study Intervention and delivery according to on call consultant Fetal outcomes Thick meconium stained liquor at birth Five minute Apgar score ≤7 Need for resuscitation SCBU admission Perinatal death Data collection Data analysis Informed consent Inclusion criteria and exclusion criteria Admission CTG
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The patterns of CTG of patients were categorized as normal, suspicious and pathological according to National Institute for health and Clinical Excellence (NICE) guidelines (2007).6 6.National Institute for Health and Clinical Excellence (NICE) (2007) Intrapartum care: care of healthy women and their babies during childbirth. London: NICE.
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Definition of normal, suspicious and pathological fetal heart rate traces by NICE Guideline (2007)
Category Definition Normal All four features are classified as reassuring Suspicious One feature is classified as non- reassuring and the remaining features are classified as reassuring Pathological Two or more features are classified as non-reassuring or one or more classified as abnormal
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Single prolonged deceleration for up to 3 minutes
Classification of fetal heart rate trace features Feature Baseline heart rate Bpm Variability Decelerations Accelerations Reassuring ≥5 None Present Non Reassuring <5 for 40-90 Minutes Typical variable decelerations with over 50% of contractions, occurring for over 90 minutes. Single prolonged deceleration for up to 3 minutes The absence of accelerations with otherwise normal trace is of uncertain significance Abnormal <100 >180 Sinusoidal pattern ≥10 minutes for 90 minutes Either atypical variable decelerations with over 50 percent of contractions or late decelerations, both for over 30 minutes. Single prolonged deceleration for more than 3 minutes
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Ethical Considerations
This study was done according to the guidelines of the University of Medicine, Magway. The research protocol was permitted by the Academic Board of the University of Medicine, Magway. The research procedures were done only after the approval of this Academic Board. Informed consent was taken before the participation of research Confidentiality of participant’s data and results are strongly maintained by the researcher.
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Results Admission CTG results of study group CTG results Frequency
Percentage Normal 111 92.5 Suspicious 4 3.3 Pathological 5 4.2 Total 120 100
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Fetal outcomes of study group
Table 2. Fetal outcomes of study group Fetal outcomes of study group Fetal outcomes CTG results Total Normal Suspicious Pathological Thick meuconium stained liquor at birth 24 2 3 29 Five Minute Apgar Score≤7 18 1 21 Need for resuscitation 20 SCBU admission 31 36 Perinatal death -
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Figure 2. Fetal outcomes of study group
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Discussion The proportion of suspicious and pathological CTG in the present study (3.3% and 4.2% respectively) is less than the results of Nan-Pan-Pa-Pa-Htay study( 22.5% and 8.5% respectively) and Nagure's study (14.4% and 8.7% respectively) as those studies were done on high risk patients. Nan- Pan- Pa- Pa-Htay. (2011) Correlation between admission cardiotocography and fetal outcome of high risk obstetric patients . M.Med.Sc (OG) dissertation, University of Medicine 1,Yangon. Nagure, A., Umashanakar, K.M., Dharmavijay, M.N. and Saleem, M. (2013), Admission cardiotocography: its role in predicting fetal outcome in high risk obstetric patient . Indian journal of Basic and Applied Medical Research: 3(1), pp
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Discussion Continued;
In the present study, there were only ten high risk patients. Three patients had previous scar, five patients had gestational hypertension, one patient had pre-eclampsia and one patient had medical history of hypertension. All high risk patients had normal admission CTG except one patient with history of hypertension who had suspicious CTG.
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Discussion Continued;
In Resh et al. study (2011), out of 120 patients, 82.5 % was normal, 15 % was suspicious and 2.5 % was pathological. Although it was done on low risk patients, it was different from this study in terms of suspicious CTG. Resh, P., Vishwanathas, S. and Sujani, B.K. (2011), Admission test cardiotocography during labour as a predictor of fetal outcome. JK Practitioner. 16, pp.1-2.
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Discussion Continued;
In the study of Nagure et al. (2013), about 72 percent of patients with pathological CTG pattern had thick meconium stained liquor compared to 39 percent and 9 percent in the suspicious and normal CTG group respectively. Nagure, A., Umashanakar, K.M., Dharmavijay, M.N. and Saleem, M. (2013), Admission cardiotocography: its role in predicting fetal outcome in high risk obstetric patient . Indian journal of Basic and Applied Medical Research: 3(1), pp
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Discussion Continued;
In the present study, about 60 percent of patients with pathological CTG pattern had thick meconium stained liquor compared to 50 percent and 21.6 percent in the suspicious and normal CTG group respectively. The admission test delivery interval of most of normal CTG obtaining thick meconium stained liquor prolonged more than 6 hours.
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Discussion Continued;
Thirteen patients with thick meconium stained liquor had five minute Apgar score > 7 . The significance of meconium stained amniotic fluid as a sign of fetal distress remains controversial and its reliability as a predictor of fetal compromise has been questioned.7 7.Wiswell, T.E. and Bent, R.C. (1993) Meconium stainnig and the MAS. Paediatrics.Clin.NorthAm. 40, pp.955.
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Discussion Continued;
In the study, 18 babies (16.2 percent) of normal CTG group had five minute Apgar score ≤7, one baby (25 percent) in suspicious CTG group and two babies (40 percent) in pathological group. Five babies of normal CTG group with five minute Apgar score ≤7 had clear amniotic fluid.
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Discussion Continued;
Clear amniotic fluid is frequently considered a reassuring sign during labour but its presence does not guarantee fetal well being.8 Apgar score is subjective to a larger extent and will differ between different institutions and different observers. 8.Greenwood, C., Lalchandani, S. and MacQuillan, K. (2003), Meconium passed in labour. How reassuring is clear amniotic fluid. Obest.Gynaecol. 102,; pp.89.
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Discussion Continued;
Of 120 babies of study population, 24 babies needed resuscitation. (60% of pathological CTG , 25% of suspicious and 18.1 % of normal CTG ) Five babies needed advanced resuscitation and 19 babies needed simple resuscitation.
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Discussion Continued;
Among babies who needed advanced resuscitation, only one patient had pathological admission CTG and others were from normal CTG group. All babies had thick meconium stained liquor.
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Discussion Continued;
27.9 % ( 31 babies ) of normal CTG group, 75 % ( 3 babies) of suspicious CTG group and 40 % ( 2 babies ) of pathological CTG group required admission to SCBU. Among 36 babies admitted to SCBU, 11 babies admitted with birth asphyxia and 3 babies with meconium aspiration syndrome.
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Discussion Continued;
Among the birth asphyxia babies, only two babies were pathological CTG and others were normal CTG. From normal CTG group, 6 babies had thick meconium stained liquor. Others admitted with neonatal jaundice and neonatal sepsis later.
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Conclusion Among the available methods of fetal monitoring, admission cardiotocography is non invasive, not expensive. The admission CTG has two potential roles. It can be used as a screening test in early labour to detect compromised fetuses on admission and to select the women in need of continuous fetal electronic monitoring during labour (Blix et al. 2005)9. 9.Blix, E., Reinar, L.M., Klovning, A. and Oian, P. (2005), Prognostic value of the labour admission test and its effectiveness compared with auscultation only: A systematic review. Br J OG: 112, pp
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As CTG has a high false-positive rate to predict outcome and, in the absence of facilities for fetal blood sampling, it is associated with an increased rate of operative deliveries for presumed "fetal distress". In the presence of pathological fetal heart rate patterns, the use of fetal blood sampling can lead to a significant reduction in the rates of Caesarean section, neonatal morbidity and perinatal mortality (Okosun and Arulkumaran, 2005)10. 10.Okosun, H. and Arulkumaran, S. (2005), Intrapartum fetal surveillance. Current Obstetric and Gynaecology.15, pp
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Admission CTG is not effective in screening for fetal disress in low risk patients.
So, it is necessary to continue the FHR monitoring by alternative methods such as intermittent auscultation, continuous electronic monitoring during the whole process of labour to make sure that the baby is safe.
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Recommendations The admission CTG could detect fetal distress already present at admission and plan early intervention to prevent adverse perinatal outcome. The result of admission CTG testing can be used to identify patients likely to develop adverse foetal outcomes and help in optimal utilization of limited labour room resources. This is particularly useful in situation where the antenatal attendance and follow-up has been inadequate, and one-to-one midwifery care is not possible.
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Acknowledgement I would like to give special thanks to all members of the Academic Board of Postgraduate studies for allowing me to undertake this study and to submit my dissertation proposal to the Board of Postgraduate Studies. I would like to express my deep appreciation to those who provided invaluable advices and incessant guidances in preparation of both protocol and dissertation. I would like to extend a heartfelt thanks to the patients for willingly participating in this study.
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THANK YOU
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