cardiotocogram(ctg)

5/26/2018 Cardiotocogram(Ctg)

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CARDIOTOCOGRAM

DR IMRAN KHANSUPERVISER

DR.AFIFUDDIN


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Definition

Cardiotocography (CTG)

CTG is technical means of recording (-grahpy) the fetal heart beat(cardio-) and the uterine contraction (-toco-). The machine used toperform this monitoring is called a cardiotocograph. CTG monitoring

is essentially the used of cardiotocograph for evaluation of fetalwellbeing in labour


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Basic features and fetal heart rate pattern

Fetal heart rate pattern has 4 recognizable

features : Baseline heart rate 110 160

Baseline variability 5 25

Acceleration

Deceleration


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Baseline FHR : the mean level of FHR when this is stable,

excluding acceleration and deceleration. It is determined overperiod of 5 10 minutes and expressed in beats per minute(BPM).

Baseline variability : the minor fluctuation in baseline FHRoccurring at 3 5 cycle per minute. It is measured byestimating the difference in beat per minutes betweenhighest peak and the lowest trough of fluctuation in oneminute segment of trace. It is consider to reduce if less 5


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Acceleration: transient increase in FHR of 15 bpm or moreand lasting 15 second or more.

Deceleration: Transient episodes of slowing FHR below thebaseline level of more than 15bpm and lasting 15 second or

more


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Classification of CTG and Intrapartum trace ( RCOG 2001)

Classification Definition

Normal All four features fall into the category

Suspicious A CTG whose features fall into one ofthe non reassuring categories and theremainder of the features arereassuring

Pathological A CTG whose features fall into two ormore non reassuring categories or

one or more abnormal categories


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Baseline Variability Deceleration Acceleration

Reassuring 110 - 160 > 5 None Present

Non reassuring 100 109161 - 180

< 5 for >40min but 180

< 5 for > 90min

Atypical variabledeceleration, latedeceleration,single prolongeddeceleration >3min


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Types of deceleration

Early deceleration

Late deceleration

Variable deceleration

Atypical deceleration

Prolonged deceleration


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Early deceleration : Uniform, repetitive, periodic slowing of FHR

with onset early in the contraction and return to baseline at the endof contraction

Late deceleration : Uniform repetitive periodic slowing of FHRwith onset mid to end of contraction and nadir more than 20 secondafter the peak of contraction and ending after the contraction

Variable deceleration : variable, intermittent periodic slowing ofFHR with rapid onset and recovery. Time relationships withcontraction cycle are variable and they may occur in isolation

Prolonged deceleration : An abrupt decrease in FHR to levelbelow baseline last atleast 60 90 seconds. These decelerationbecome pathological if they cross to contraction,i.e. greater than 3minutes


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Atypical variable : variable deceleration with any of following

additional deceleration component : loss of primary or secondary rise in baseline rate

Slow return to baseline FHR after the end of contraction

Prolonged secondary rise in baseline rate

Biphasic deceleration

Continuation of baseline rate at lower level

Sinusoidal pattern : A regular oscillation of baseline long termvariability resembling a sine wave. This smooth, undulating patternlasting at least 10 minutes, has a relatively fixed period of 3 5cycle per minute and amplitude of 5 -15


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Modes of fetal heart monitoring

Continuous CTG

Intermittent CTG

Internal / direct monitoring ( fetal scalp electrode )

Intermittent auscultation


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INDICATION FOR CONTINUOUS CTG MONITORING

Maternal condition

Antenatal Hypertension Diabetes mellitus Antepartum hemorrhage Cardiac disease Severe anemia

Hyperthyroidism Renal disease

Intrapartum Vaginal bleeding Maternal pyrexia Chorioamnionitis Epidural / reginonal anesthesia

Labour Previous ceaseran section Prolonged ROM Induced / augmented labour Uterine hyperstimulation

Fetal condition

Growth restricted fetus Oligohydramion Prematurity Rhesus isoimmunization Multiple pregnancy Breech

Meconium stained liquor Post term pregnancy


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Intermittent CTG monitoring ( 2Hourly )

For all other patient not listed above

Internal or direct monitoring / Fetal scalp electrode

Indication

External tracing inadequate / poor quality for interpretation

Monitoring 1sttwin in twin pregnancy in labour

Contraindication Face presentation

Unknown presentation

HIV seropositive / Hep B,C

Suspected thrombocytopenia

Intermittent auscultation

Auscultation of FHR at regular intervals for at least 60 second


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It is equally as effective as continuous CTGmonitoring for low risk women in labour.

continuous EFM should be offered andrecommended if;A)there is evidence on auscultation of abaseline 160bpm.

B)there is evidence on auscultation of anydecelerations.C)If any intrapartum risk facrors develop.Intermittent auscultation should be done;A)every 15-30min(throughout and aftercontraction) in active first stage of labour.B)every 5 min in active secondstage(throughout and after contraction)


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RESPONSIBILITIES ASSOCIATED WITH EFM(electronic fetal

monitoring)

a)Reason, benefits and limitation should be explained to

patient

b)The date, time on the machine should be correctly set.

C)paper speed should be set at 1cm/min

d)Traces should be labeled with mothers name, date,time,RN.

E)Any intrapartum events that affect FHR should be recorded

on the tracing, signed, date and time.

F)Any member of staff who reviewed the CTG tracing should

note their findings on tracing together with time ,date,

signature and chop.


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G)If CTG is suspicious/pathological, staff and house

officer should ;.inform medical officer OR specialist.

.change maternal position left lateral

.Withhold oxytocin infusion if required

.Vaginal examination


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Causes of fetal heart rate bradycardia

.fetal bradycardia is define as a decrease in the baseline

FHR to less than 100beats per minute1.FETAL HYPOXIA; bradycardia is a late sign of fetal

hypoxia(a continual lack of oxygen)

.The heart rate slow in response to a depression of

heart muscle(myocardial)activity caused by this

continued decrease in needed oxygen.

2.MEDICATION; Medication such as narcotics cause

bradycardia by preventing receptors sites in the fetal

heart muscle from accepting epinephrine, which works

to increase heart rate.


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3.EPIDURAL;Causes vasodilation, which leads toan increase in the incidence of maternal hypotension

during labour which causes bradycardia indirectly due

to reflex mechanism, a potential complication forregional anesthesia.

4.SYNTHETIC OXYTICIN(PITOCIN)may produced

bradycardia by causing hyperstimulation of the

uterine muscle(myometrium),resulting in hypoxia.

.


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5.MATERNAL HYPOTENSION;

supine hypotension syndrome caused

by pressure of the uterus and its

content on the inferior vena cava ,

when you lay on your back, results in

decrease in maternal blood pressure


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Causes of fetal heart rate

tachycardia.Tachycardia; suspicious tachycardia is defined as beingbetween 161-180 whereas a pathological pattern is above

180.

1.FETAL HYPOXIA; Tachycardia may be early sign of

hypoxia(fetal lack of adequate oxygen).

2.MEDICATION; Medication used to prevent/stop premature

labor such as terbutaline(sympathomimetic),have a

stimulating effect on the fetal heart, which increase the heart

rate.


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THANKS


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3.PREMATURITY;Apremature baby hasan immature nervous system resulting

in increased heart rate.4.MATERNAL FEVER; Both themothers and the babys metabolism isincrease, which result in increaseheart rate.5.FETAL INFECTION;This may be anearly sign of an intrauterine

infection(a stress reaction tosepsis)prolonged ruptured ofmembrane may lead to maternal and

f t l i f ti

cardiotocogram(ctg)

Documents

baseline heart rate

baseline fhroccurring

levelbelow baseline

baseline rate slow return

peak of contraction

basic features

classification of ctg

mean level of fhr