cardiotocography (ctg) warda
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CARDIOTOCOGRAPHY
By
Osama M Warda , MD Professor of Obstetrics & Gynecology
Mansoura University- EGYPT
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BACKGROUND
� Cardiotocography (CTG) is a test used in pregnancy to monitor both the fetal heart pattern as well as the uterine contractions.
� It should only used in the 3rd trimester when fetal neural reflexes are present.
� Its purpose is to monitor fetal well-being & allows early detection of fetal distress antenatal or intra-partum.
� An abnormal CTG indicates the need for further invasive investigation & ultimately may lead to emergency CS
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When to do CTG?
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Frequency of testing
- Usually every 7 days (i.e. weekly)
- Twice-weekly testing is advocated by some in :
� Post term pregnancy
� Diabetes mellitus
� Fetal growth restriction,
� Gestational hypertension
- Additional testing is performed for maternal or fetal deterioration regardless of time elapsed
- Others perform non-stress tests daily or even more frequently
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The Machine
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Application: external; antenatal
� The machine used is called cardio-tocograph.
� It involves the placement of 2 transducers on the abdomen of a pregnant woman: one transducer records the fetal heart rate using ultrasound beam , the other transducer records uterine contractions by measuring the tension of the maternal abdominal wall. This provides indirect indication of the intrauterine pressure.
� These recordings are blotted on a special paper.
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Application of the transducers
O Warda 8 Internal fetal monitoring
FSE
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Application: internal; intra-partum
� The machine used is called cardio-tocograph.
� It involves the placement of 2 transducers: a fetal scalp electrode( FSE): an internal fetal heart monitor , and intrauterine pressure catheter(IUPC): an internal uterine contraction monitor
� These recordings are shown on a screen and
may be blotted on a special paper.
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Setting the CTG machine
Horizontal Scale
Paper speed is set to 1,2,or 3 cm /minute.
Vertical Scale:
� Sensitivity displays are set to 20 or 30 beats per minute (bpm) /cm.
� FHR range displays of 30–240 bpm .
� Uterine Activity: Internal 0-100 mmHg
External 0-100 relative units
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Setting the CTG machine
O Warda 11
3cm / min 1cm / min
3 small vertical spaces / cm 10 beats / small space
F H R
Ut.
Cont.
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Setting the CTG machine
� Fetal heart rate is commonly recorded with paper speed at 1 cm/ min compared with 3 cm/min chart recorder.
� 3 cm: is the more accurate for abnormalities
� 1cm: less paper but less accurate : Used for screening
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ACOUSTIC STIMULATION TESTS
� Provoking acceleration of FHR.
� The acoustic stimulator is positioned on the
maternal abdomen and a stimulus of 1 to 2 sec .
� It may be repeated up to three times.
� It shortened the average time for non-stress
testing from 24 to 15 minutes.
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Interpretation of CTG
� To interpret a CTG you need a structured method of assessing its various characteristics.
� The most popular method can be remembered using the acronym DR C BRAVADO
- DR=Define Risk . - C= Contractions
- Bra= Baseline Rate - V=Variability
- A= Accelerations - D= Decelerations
- O= Overall impression
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Define Risk
� You first need to assess if this pregnancy is high or low risk
� This is important as it gives more context to the CTG reading ;e.g. If the pregnancy is high risk, your threshold for intervening may be lowered.
O Warda 15
DR C BRAVADO
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Define Risk
High-risk pregnancies:
O Warda 16
DR C BRAVADO
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Contraction
� Record the number of contractions present in a 10 minute period - e.g. 3 in 10
� Each big square is equal to 1 minute, so you look how many contractions occurred in 10 squares
� Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity
� You should assess contractions for the following:
� Duration – how long do the contractions last?
� Intensity – how strong are the contractions? (assessed using palpation)
O Warda 17
DR C BRAVADO
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O Warda 18
In this example there are 2-3 contractions in a 10 minute period - e.g. 3 in 10
Contraction DR C BRAVADO
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Baseline Rate of fetal heart
� The baseline rate is the average heart rate of the fetus in a 10 minute window.
� Look at the CTG & assess what the average heart rate has been over the last 10 minutes
� Ignore any Accelerations or Decelerations
� A normal fetal heart rate is between 120-160 bpm.
O Warda 19
DR C BRAVADO
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Baseline Rate of fetal heart
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DR C BRAVADO
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Baseline Rate of fetal heart
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DR C BRAVADO
If the causes of tachy-or-bradycardia cannot be identified and corrected, immediate delivery is recommended
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Variability
� Baseline variability refers to the variation of fetal heart rate from one beat to the next.
� Variability occurs as a result of the interaction between the nervous system, chemoreceptors, barorecptors & cardiac responsiveness.
� Therefore it is a good indicator of how healthy the fetus is at that time.
� This is because a healthy fetus will constantly be adapting it’s heart rate to respond to changes in it’s environment.
� Normal variability is between 10-25 bpm
� To calculate variability you look at how much the peaks & troughs of the heart rate deviate from the baseline rate (in bpm)
O Warda 22
DR C BRAVADO
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Variability
O Warda 23
DR C BRAVADO
Variability can be categorized as: • Reassuring – ≥ 5 bpm • Non-reassuring – < 5bpm for between 40-90 minutes
• Abnormal – < 5bpm for >90 minutes
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Variability
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Reduced variability can be caused by: 1. Fetus sleeping - this should last no longer than 40 minutes – most common cause 2. Fetal acidosis (due to hypoxia) – more likely if late decelerations also present 3. Fetal tachycardia
4. Drugs – opiates, benzodiazipine’s, methyldopa, magnesium sulphate 5. Prematurity – variability is reduced at earlier gestation (<28 weeks) 6. Congenital heart abnormalities
DR C BRAVADO
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Accelerations
� Accelerations are an abrupt increase in baseline heart rate of >15 bpm for >15 seconds. Its presence is reassuring
� Ante-natal there should be at least 2 accelerations every 15 minutes.
� Accelerations occurring alongside uterine contractions is a sign of a healthy fetus
� However the absence of accelerations with an otherwise normal CTG is of uncertain significance
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DR C BRAVADO
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Decelerations
� Decelerations are an abrupt decrease in baseline heart rate of >15 bpm for >15 seconds
� There are a number of different types of decelerations, each with varying significance
1. Early decelerations
2. Variable decelerations
3. Late decelerations
4. Prolonged decelerations
5. Sinusoidal pattern
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DR C BRAVADO
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Decelerations
1. Early deceleration
� Early decelerations start when uterine contraction begins & recover when uterine contraction stops
� This is due to increased fetal intracranial pressure causing increased vagal tone
� It therefore quickly resolves once the uterine contraction ends & intracranial pressure reduces
� This type of deceleration is therefore considered to be physiological .
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DR C BRAVADO
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Decelerations
2. Variable Decelerations:
� Variable decelerations are seen as a rapid fall in baseline rate with a variable
recovery phase.
� They are variable in their duration & may not have any relationship to uterine
contractions
� They are most often seen during labor & in patients with reduced amniotic fluid
volume
� Variable decelerations are usually caused by umbilical cord compression.
� The umbilical vein is often occluded first causing an acceleration in response. Then the
umbilical artery is occluded causing a subsequent rapid deceleration.
� When pressure on the cord is reduced another acceleration occurs & then the baseline
rate returns.
� Accelerations before & after a variable deceleration are known as the “shoulders of
deceleration”. Their presence indicates the fetus is not yet hypoxic & is adapting to
the reduced blood flow.
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DR C BRAVADO
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Decelerations
2. Variable Decelerations: (continued)
� Variable decelerations can sometimes resolve if the mother changes position
� The presence of persistent variable decelerations indicates the need for close monitoring
� Variable decelerations without the shoulders is more worrying as it suggests the fetus is hypoxic
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DR C BRAVADO
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Decelerations
3. Late deceleration � Late decelerations begin at the peak of uterine contraction & recover after the
contraction ends.
� This type of deceleration indicates there is insufficient blood flow through the uterus
& placenta. As a result blood flow to the fetus is significantly reduced causing fetal
hypoxia & acidosis
Reduced utero-placental blood flow can be caused by:
� Maternal hypotension
� Pre-eclampsia
� Uterine hyper-stimulation
NOTE: The presence of late decelerations is
taken seriously & fetal blood sampling for pH
is indicated, If fetal blood pH is acidotic it
indicates significant foetal hypoxia & the
need for emergency C-section
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DR C BRAVADO
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Decelerations
4.Prolonged deceleration
� A deceleration that last more than 2 minutes
� If it lasts between 2-3 minutes it is classed as Non-Reasurring
� If it lasts longer than 3 minutes it is immediately classed as Abnormal
� Action must be taken quickly – e.g. Fetal blood sampling / emergency C-section
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DR C BRAVADO
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Decelerations
5. Sinusoidal Pattern
� This type of pattern is rare, however if present it is very serious
� It is associated with high rates of fetal morbidity & mortality
� It is described as:
� A smooth, regular, wave-like pattern
� Frequency of around 2-5 cycles a minute
� Stable baseline rate around 120-160 bpm
� No beat to beat variability
A sinusoidal pattern indicates:
� Severe fetal hypoxia
� Severe fetal anaemia
� Fetal/Maternal Hemorrhage
Immediate C-section is indicated
for this kind of pattern. Outcome is usually poor
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DR C BRAVADO
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Overall impression
- Once you have assessed all aspects of the CTG you need to give your overall impression. The overall impression can be described as either:
� Reassuring
� Suspicious
� Pathological
-The overall impression is determined by how many of the CTG features were
either reassuring, non-reassuring or abnormal. The NICE guideline
demonstrates how to decide which category a CTG falls into:
1- Normal CTG= All four features are classified as reassuring.
2-Suspicious CTG= One feature is classified as non-reassuring while the remaining features are reassuring
3- Pathological CTG= ≥ 2 features non-reassuring, or ≥ 1 feature classified as abnormal
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DR C BRAVADO
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Overall impression
O Warda 35
DR C BRAVADO
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INTRAPARTUM FETAL MONITORING
Monitoring uncomplicated pregnancy:
- For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labor to monitor fetal well-being using Doppler or Pinard.
- In the active stages of labor, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least:
- Every 15 minutes in the first stage
- Every 5 minutes in the second stage
- The maternal pulse should be palpated if FHR abnormality detected to differentiate the 2 heart rates.
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NICE 2007
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INTRAPARTUM FETAL MONITORING
Continuous EFM In Low-risk Women:
Indications:
1. Significant or light Meconium-stained liquor
2. Abnormal FHR detected by intermittent auscultation (< 110 bpm; or > 160 bpm, or any decelerations after a contraction.
3. Maternal pyrexia (defined as 38.0 °C once or 37.5 °C on two occasions 2 hours apart)
4. Fresh bleeding developing in labor
5. Oxytocin use for augmentation
6. The woman’s request.
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NICE 9- 2007
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INTRAPARTUM FETAL MONITORING
Continuous EFM In Low-risk Women:
Evaluation :
� There was a borderline evidence that continuous EFM were more likely to have an instrumental birth compared with the auscultation group although there was no evidence of differences in:
� Augmentation
� Perinatal mortality
� Other neonatal morbidities
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NICE 9- 2007
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O Warda 39