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CTG – INTERPRET WITH CARE

CTG – INTERPRET WITH CARE. Electronic In “active” labor – by convention needs to be continuous High false positives (K. Nelson 1996) Variable interpretations. Auscultated Prescribed intervals Various devices but one recorded number Easy to interpret Intermittent

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CTG – INTERPRET WITH CARE

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  1. CTG – INTERPRET WITH CARE Dr Mona Shroff www.obgyntoday.info

  2. Electronic In “active” labor – by convention needs to be continuous High false positives (K. Nelson 1996) Variable interpretations Auscultated Prescribed intervals Various devices but one recorded number Easy to interpret Intermittent Acceptable for “high” risk patients Fetal Monitoring in Labor: Two Acceptable Methods Dr Mona Shroff www.obgyntoday.info

  3. Simple Well liked by patients Clear cut action/ response Improves ability to ambulate Easier Fewer C/S’s Legally less damning- interpretation clear Allows changing entire environment in L&D Decreases patient, family, nurse and physician anxiety Why Auscultation? Dr Mona Shroff www.obgyntoday.info

  4. Dr Mona Shroff www.obgyntoday.info

  5. Electronic Monitoring: Later OutcomeNigel Paneth 1993 Clin. Invest Med. Michigan St. Univ • “Central hypotheses of EFM has never been tested” • That is, “that its use (EFM) can effectively prevent the... brain damaging birth asphyxia by timely intervention in labor.” Dr Mona Shroff www.obgyntoday.info

  6. For hypothesis to be true:Paneth (1993) • EFM must be reliable (inter-observer agreement on identity and meaning) • EFM must be valid (patterns statistically linked with adverse neurological events) • EFM and adverse outcome are related, specifically association is • causal Dr Mona Shroff www.obgyntoday.info

  7. CRITICISMS TOWARDS CARDIOTOCOGRAPHY • Insufficient understanding of the (patho-)physiologic background • A number of technical pitfalls • Differences in recording techniques • Primarily qualitative information (pattern recognition) • Lack of uniform classification systems • Confusion due to the many influences on the fetal heart rhythm • Substantial intra- and inter-observer variation regarding the interpretation • Low validity, high incidence of false-positive findings • Primarily screening method, too often applied as a diagnostic • Leads to an increase in artificial deliveries • Lack of agreement on how, when, and whom to monitor • Contributes to medico-legal vulnerability Dr Mona Shroff www.obgyntoday.info

  8. Hard to do! No, not really! Requires more staff Shouldn’t have to Does not meet standard of care Untrue! Will cause fetal harm, or CP? No more so than continuous EFM May miss something? -Such as?? Not legally defensible Hardly ARGUMENTS AGAINST AUSCULTATION Dr Mona Shroff www.obgyntoday.info

  9. THEN WHY DISCUSS CTG??? • USEFUL IN HIGH RISK CASES. • STANDARDISED EVIDENCE BASED GUIDELINES ARE BEING LAID FOR CORRECT USE,INTERPRETATION , FURTHER DECISION MAKING & RECORD KEEPING. Dr Mona Shroff www.obgyntoday.info

  10. Appropriate monitoring in an uncomplicatedpregnancy For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labour to monitor fetal wellbeing. In the active stages of labour, 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. . Grade A Recommendation Dr Mona Shroff www.obgyntoday.info

  11. Indications for the use of continuous EFM Dr Mona Shroff www.obgyntoday.info

  12. GRADE B RECOMMENDATION Continuous EFM should be offered and recommended for high-risk pregnancies where there is an increased risk of perinatal death, cerebral palsy or neonatal encephalopathy. Continuous EFM should be used where oxytocin is being used for induction or augmentation of labour. REF:RCOG GUIDELINES Dr Mona Shroff www.obgyntoday.info

  13. ADMISSION CTG Current evidence does not support the use of the admission CTG in low-risk pregnancy and it is therefore not recommended Grade B Recommendation Dr Mona Shroff www.obgyntoday.info

  14. Selected High-Risk Indications for Continuous Monitoring of Fetal Heart Rate Maternal medical illnessGestational diabetes Hypertension Asthma Obstetric complicationsMultiple gestationPost-date gestationPrevious cesarean sectionIntrauterine growth restriction OligohydramniosPremature rupture of the membranesCongenital malformationsThird-trimester bleedingOxytocin induction/augmentation of laborPreeclampsia Meconium stained liquor Dr Mona Shroff www.obgyntoday.info

  15. A Continuous EFM should be offered and recommended in pregnancies previously monitored with intermittent auscultation: • if there is evidence on auscultation of a baseline less than 110 bpm or greater 160 bpm • if there is evidence on auscultation of any decelerations • if any intrapartum risk factors develop. Dr Mona Shroff www.obgyntoday.info

  16. Definitions and descriptions of individual features of fetal heart-rate (FHR) traces Baseline fetal heart rate :The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm. Dr Mona Shroff www.obgyntoday.info

  17. – Normal Baseline FHR 110–160 bpm – Moderate bradycardia 100–109 bpm – Moderate tachycardia 161–180 bpm – Abnormal bradycardia < 100 bpm – Abnormal tachycardia > 180 bpm Dr Mona Shroff www.obgyntoday.info

  18. Baseline variability The minor fluctuations in baseline FHR occuring at three to five cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace Dr Mona Shroff www.obgyntoday.info

  19. Dr Mona Shroff www.obgyntoday.info

  20. ACCELERATIONS Dr Mona Shroff www.obgyntoday.info

  21. DECCELERATIONS • EARLY : Head compression • LATE : U-P Insufficiency • VARIABLE : Cord compression Primary CNS dysfn Dr Mona Shroff www.obgyntoday.info

  22. EARLY Dr Mona Shroff www.obgyntoday.info

  23. LATE Dr Mona Shroff www.obgyntoday.info

  24. VARIABLE Dr Mona Shroff www.obgyntoday.info

  25. Atypical Variable decelerations With any of the following additional decelerations components: – loss of primary or secondary rise in baseline rate – slow return to baseline FHR after the end of the contraction – prolonged secondary rise in baseline rate – biphasic deceleration – loss of variability during deceleration – continuation of baseline rate at lower level Dr Mona Shroff www.obgyntoday.info

  26. Categorisation of fetal heart rate traces Dr Mona Shroff www.obgyntoday.info

  27. REDUCED VARIABILITY Hypoxia Drugs Extreme prematurity Sleep CNS abno. Dr Mona Shroff www.obgyntoday.info

  28. Dr Mona Shroff www.obgyntoday.info

  29. TACHYCARDIA Hypoxia ChorioamnionitisMaternal fever B-Mimetic drugsFetal anaemia,sepsis,ht failure,arrhythmias Dr Mona Shroff www.obgyntoday.info

  30. SPECIAL PATTERNS Dr Mona Shroff www.obgyntoday.info

  31. Sinusoidal pattern A regular oscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed period of 3–5 cycles per minute and an amplitude of 5–15 bpm above and below the baseline. Baseline variability is absent Associated with - Severe chronic fetal anaemia Severe hypoxia & acidosis Dr Mona Shroff www.obgyntoday.info

  32. SINUSOIDAL Dr Mona Shroff www.obgyntoday.info

  33. PSEUDOSINUSOIDAL Dr Mona Shroff www.obgyntoday.info

  34. CHECKMARK PATTERN Dr Mona Shroff www.obgyntoday.info

  35. SALTATORYPATTERN Dr Mona Shroff www.obgyntoday.info

  36. LAMBDA PATTERN Dr Mona Shroff www.obgyntoday.info

  37. Dr Mona Shroff www.obgyntoday.info

  38. Dr Mona Shroff www.obgyntoday.info

  39. SUSPICIOUS CTG Dr Mona Shroff www.obgyntoday.info

  40. PATHOLOGICAL FETAL SCALP STIMULATION TEST FETAL VIBROACAUSTIC STIMULATION TEST FETAL SCALP BLOOD Ph (If facilities available) Dr Mona Shroff www.obgyntoday.info

  41. A Systematic Approach to Reading Fetal Heart Rate Recordings • Evaluate recording--is it continuous and adequate for interpretation? • Identify type of monitor used--external versus internal, first-generation versus second-generation. • Identify baseline fetal heart rate and presence of variability, both long-term and beat-to-beat (short-term). • Determine whether accelerations or decelerations from the baseline occur. • Identify pattern of uterine contractions, including regularity, rate, intensity, duration and baseline tone between contractions. • Correlate accelerations and decelerations with uterine contractions and identify the pattern. • Identify changes in the FHR recording over time, if possible. • Conclude whether the FHR recording is reassuring, nonreassuring or ominous. • Develop a plan, in the context of the clinical scenario, according to interpretation of the FHR. • Document in detail interpretation of FHR, clinical conclusion and plan of management. Dr Mona Shroff www.obgyntoday.info

  42. Prior to any form of fetal monitoring, the maternal pulse should be • palpated simultaneously with FHR auscultation in order to • differentiate between maternal and fetal heart rates. • If fetal death is suspected despite the presence of an apparently • recordable FHR, then fetal viability should be confirmed with realtime • ultrasound assessment. Dr Mona Shroff www.obgyntoday.info

  43. Dr Mona Shroff www.obgyntoday.info

  44. RECORD KEEPING IN CTG • The date and time clocks on the EFM machine should be correctly set • Traces should be labelled with the mother’s name, date and hospital number • Any intrapartum events that may affect the FHR should be noted contemporaneously on the EFM trace, signed and the date and time noted (e.g. vaginal examination, fetal blood sample, siting of an epidural) Dr Mona Shroff www.obgyntoday.info

  45. Any member of staff who is asked to provide an opinion on a trace should note their findings on both the trace and maternal case notes, together with time and signature • • Following the birth, the care-giver should sign and note the date,time and mode of birth on the EFM trace • • The EFM trace should be stored securely with the maternal notes at the end of the monitoring process. Dr Mona Shroff www.obgyntoday.info

  46. SOME INTERESTING CASES Dr Mona Shroff www.obgyntoday.info

  47. ACCELERATION OR DECCELERATION ??? Dr Mona Shroff www.obgyntoday.info

  48. BASELINE BRADYCARDIA WITH ACCELERATIONS Dr Mona Shroff www.obgyntoday.info

  49. HALVING PHENOMENON Dr Mona Shroff www.obgyntoday.info

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