FIGO 2015
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Safe Motherhood and Newborn Health Committee Co-ordinator for guideline development: Diogo Ayres-de-Campos
FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
1960’s• Hon, Caldeyro-Barcia,
Hammacher• 3 different classifications
1970’s - 1980’s • Myer-Menk/Fischer, Cardiff, Birmingham,
Krebs• 21 different CTG classifications 1974-1984
Devoe LD et al. AJOG 1985;152:1047-53
FIGO1987
FIGO. IJOG 1987;25:159-67
FIGO 2015
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Safe Motherhood and Newborn Health Committee Co-ordinator for guideline development: Diogo Ayres-de-Campos
FIGO CONSENSUS GUIDELINES ON INTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• Wide consensus• Include all currently available methods of
intrapartum fetal monitoring• Language accessible to all professionals• Simple and objective
• RCOG contacted to appoint person for writing of CTG chapter (Dec 2012). Nominated (Feb 2013)
• ACOG contacted to appoint person for writing of CTG chapter (Dec 2012). Nominated (Jan 2013)
• All FIGO member societies contacted to appoint one subject matter expert (Feb 2013)• Wide knowledge of the fetal monitoring scientific literature.• Good written English• Available to provide written feedback in less than 15
days
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• 34 experts nominated by FIGO scientific societies (Feb 2013 to May 2013)
• 13 experts invited by FIGO based on literature search (May 2013 – Jul 2013)
Lawrence Devoe (USA), Gerard Visser (Netherlands), Richard Paul (USA), Barry Schifrin (USA), Julian Parer (USA), Philip Steer (UK), Vincenzo
Berghella (USA), Isis Amer-Wahlin (Sweden), Susanna Timonen (Finland), Austin Ugwumadu (UK), João Bernardes (Portugal), Justo Alonso (Uruguay), Ingemar Ingemarson (Sweden).
• ICM invited to write the chapter on intermittent auscultation (Jul 2013). Nominated (Oct 2013)
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• 3 round email consensus process (3 weeks to reply)• Final agreement for name to be included in the panel• 1st and 2nd chapters (2 Oct 2013 – 10 Feb 2014)• 4th chapter (5 Mar 2014 – 31 Aug 2014)• 3rd chapter (20 Aug 2014 – 2 Jan 2015)• 5th chapter (5 Jan 2015 – 15 Mar 2015)
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• No internal or external funding• 10 months to prepare• 18 months for the consensus process• 2029 emails exchanged
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO 2015
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Diogo Ayres-de-Campos, Sabaratnan Arulkumaranfor the FIGO intrapartum fetal monitoring consensus panel
PHYSIOLOGY OF FETAL OXYGENATION AND THE MAIN GOALS
OF INTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Avoid adverse fetal outcome related to intrapartum hypoxia/acidosisAvoid unnecessary intervention, associated with increased maternal and fetal risks
Aims of intrapartum fetal monitoring
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Blood gas or lactate analysis• in the umbilical cord, or in the newborn circulation during the first minutes of life, is the only objective way of quantifying hypoxia/acidosis occurring just prior to birth
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Cord blood sampling• Unnecessary to clamp the cord• As soon as possible after birth (< 15 min)
• Artery and vein• Analysis within 30 min
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Metabolic acidosisArterial pH < 7.00 and BD >12 mmol/l• already associated with adverse outcome when pH
< 7.05 and BDecf > 10 mmol/l
Arterial lactate > 10 mmol/l is an alternative, but reference values may vary
according to device
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
BDecf believed by some experts to be the
best representative of H+ concentration of metabolic origin in the different fetal compartments
BDblood calculated by blood gas
analysers, slightly higher, can also be used
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
1-minute Apgar• important to decide newborn
resuscitation• low association with intrapartum
hypoxia/acidosis5-minute Apgar• stronger association with short- and long-
term neurological outcome and neonatal death
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Unaffected by minor degrees of hypoxia/acidosisSubject to interobserver disagreementAffected by non-hypoxic causes::
• prematurity• birth trauma• infection• meconium aspiration• congenital anomalies• pre-existing neurological lesions• medication administered to the mother• early endotracheal aspiration
Apgar scores
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Metabolic acidosis and low Apgars• vast majority recover quickly and have no
short- or long-term complications• few cases are of sufficient intensity and
duration to cause death or long-term morbidity
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Hypoxic-ischemic encephalopathy (HIE)• Short-term neurological dysfunction caused
by hypoxia/acidosis• Metabolic acidosis, low Apgars, early imaging
of cerebral edema, changes in muscle tone, sucking difficulties, seizures or coma in first 48 h of life
• May be accompanied by other system dysfunctions
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• other non-hypoxic causes • need to document metabolic acidosis in
umbilical artery or in newborn circulation during the first minutes of life for HIE
Neonatal encephalopathy
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
InfectionCongenital diseasesMetabolic diseasesCoagulation disordersAntepartum and post-natal hypoxiaBirth trauma
• Manifests at 1-4 years• Long-term neurological complication more
commonly associated with term intrapartum hypoxia/acidosis
• Only 10-20% cases are caused by hypoxia/acidosis
Cerebral palsy (spastic quadriplegic , dyskinetic )
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• Metabolic acidosis• Low 1 and 5-minute Apgar scores• Grade 2 or 3 HIE• Early imaging of acute non-focal cerebral
anomaly• Spastic quadriplegic or dyskinetic type• Exclude other identifiable etiologies
Intrapartum hypoxia/acidosis as the cause of cerebal palsy in term infants
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
should indicate intervention at an early stage of hypoxia/acidosis in order to prevent rather than to predict adverse newborn outcomes
Intrapartum fetal monitoring
FIGO 2015
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
CARDIOTOCOGRAPHY
Diogo Ayres-de-Campos, Catherine Y. Spong, Edwin Chandraharanfor the FIGO intrapartum fetal monitoring consensus panel
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Cardiotocography(kardia=heart, tokos=labour)
…is the term that best describes the continuous monitoring of the FHR and uterine contractions
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
1 cm/min
2 cm/min
3 cm/min
Paperspeed
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Mean level of the most horizontal and less oscillatory FHR segments. Estimated in 10-min periods, expressed in bpm
Baseline
Basic CTG features
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Normal 110-160 bpm
Tachycardia
> 160 bpm for more than 10 min (pyrexia, epidural, early stages of non-acute hypoxemia, βagonist or parasympathetic drugs, arrhythmias)
Bradycardia < 110 bpm for more than 10 min (hypothermia, beta-blockers and fetal arrhythmias)
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Average bandwidth amplitude in 1-min segments
Variability
1 min
120
125
115
Subjectivity in visual evaluation
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Reduced variability
< 5 bpm for > 50 min in baseline or > 3 min in decelerations
• CNS hypoxia/acidosis, previous cerebral injury, infection, CNS depressants or parasympathetic blockers
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Increased variability
(saltatory) Bandwidth > 25 bpm for more than 30 min
• Incompletely understood• Hypoxia/acidosis of rapid evolution
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Abrupt increases in FHR above baseline, > 15 bpm amplitude, > 15 secs
Accelerations
• Most coincide with fetal movements• Reactive fetus without hypoxia/acidosis
150
130
140
120
>15 s>15 s
>15 bpm>15 bpm
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Abrupt decreases in FHR above baseline, > 15 bpm amplitude, > 15 secs
Decelerations
150
130
140
120
>15 s>15 s
>15 bpm>15 bpm
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM 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
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM 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 (umbilical compression)• Seldom associated with important hypoxia/acidosis• Majority of decelerations
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM 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• Tracings with variability and no accelerations, amplitude > 10 bpm
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Prolonged deceleration
> 3 min
• Likely to include a chemoreceptor-mediated component• If > 5 min, variability and FHR < 80 bpm emergency intervention
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• Severe anemia, acute hypoxia/acidosis, infection, cardiac malformations, hydrocephalus, gastroschisis
Sinusoidal pattern
Regular, smooth, undulating, resembling sine wave. Amplitude 5-15 bpm, frequency 3-5 cycles/min, > 30 min, no accelerations
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Pseudo-sinusoidal pattern
• Analgesic administration, fetal sucking and other mouth movements
Pseudo- sinusoidal pattern
Jagged “saw-tooth” appearance. Duration seldom exceeds 30 min. Normal patterns before and after
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Tachysystole > 5 contractions in 10 min in two successive 10-min periods, or averaged over 30 min.
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Bodymovements
Eye movements
+ +Active sleep
--
CTG
Deep sleep
+++ +Active awakeness
• Cycling represents the hallmark of neurological responsiveness• Transitions become clearer > 32-34 weeks• Deep sleep may last 50 min
Behavioural states
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Tracing classification
*Decelerations are repetitive when associated with > 80% contractions. Absence of accelerations during labour is of uncertain significance.
Baseline
Variability
Decelerations
Interpretation
Clinical Management
Normal110-160 bpm
5-25 bpm
No repetitive* decelerations
Suspicious
Lacking at least one characteristic of
normality, but with no pathological
features
Pathological< 100 bpm
Reduced variabilityIncreased variability, or sinusoidal
pattern
Repetitive* late or prolonged decelerations > 30 min or > 20
min if variability is reduced. Prolonged deceleration > 5 min
No hypoxia/acidosis
No intervention necessary
Low probability of hypoxia/acidosis
Action to correct reversible causes,
close monitoring, or adjunct technologies
High probability of hypoxia/acidosis
Immediate action to correct reversible causes, adjunct
technologies or if not possible expedite delivery.
In acute situations, immediate delivery must be accomplished.
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Reversible hypoxia/acidosis
TachyssystoleIatrogenic/spontaneous excessive contraction frequency
Maternal supine position(aorto-caval compression by pregnant uterus)
Sudden maternal hypotension(following epidural or spinal analgesia)Maternal respiratory complicationsAcute asma, etc.
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Excessive uterine activity should be avoided, irrespective of FHR
changes, reversed by ocytocin or acute tocolysis
• Salbutamol• Terbutaline• Ritodrine• Atosiban• Nitroglycerine
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Intravenous salbutamol started
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Irreversible
Major placental abruption
Fetal hemorrhage
Uterine rupture
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Mechanical complications of labour
Cord prolapse
Shoulder dystocia
Retention of aftercoming
head
FIGO 2015
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
INTERMITTENT AUSCULTATION
Debrah Lewis, Soo Downefor the FIGO intrapartum fetal monitoring consensus panel
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
The evidence for the benefits of continuous CTG
monitoring, as compared to IA, in both low and high risk
labours is scientifically inconclusive
Alfirevic Z et al. Cochrane 2013 May 31;5:CD006066Vintzileos AM et al. Obstet Gynecol 1995;85:149-55
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Intermittent auscultation (IA)
• Recommended in all labours where there is no access to CTG
• Where CTG is available, may be used in low-risk cases
• ≈ ½ panel members believe that CTG should be preferred during the 2nd stage
MHR
contractions
FHR
Features to evaluate What to register
FHR
Duration: ≥ 60 secs(for 3 UC if abormal)
Number of bpmAccelerations and decelerations (presence or absence)
Timing: during and ≥ 30 secs after UC
Interval: Every 15 min in active phase. Every 5 min in 2nd stage
Uterine contractions
Before and during IA (in order to detect ≥ 2 UCs) Frequency (in 10 min)
Fetal movements
At the same time as UCs Presence or absence
MHR At the time as IA Number of bpm
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
Baseline < 110 bpm or > 160 bpm
Decelerations
Presence of repetitive or prolonged (>3 mins) decelerations
Contractions More than 5 contractions in 10 mins
Abnormal findings
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
IJGO supplement to be distributed at the FIGO congress in Vancouver, Oct 2015
PowerpointpresentationCourses
FIGO CONSENSUS GUIDELINES ONINTRAPARTUM FETAL MONITORING
• Common terminology• Shared knowledge• Basis for research and progress• Widespread clinical use