Cardiotocography ( CTG ) Fetal Monitoring

Electronic Fetal Monitoring

Track the babys heart
rate during labor.
Ali Sungkar
Sub Bagian Fetomaternal
Bagian Obstetri dan Ginekologi FKUI/RSUPN - CM
Safe procedure that has
saved the lives of many
babies in high-risk
situations.

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Electronic Monitoring Fetal response to hypoxemia

Indirect Direct More effective uptake of oxygen
(External monitoring) (Internal monitoring)
Reduced activity
saturation

Decrease in growth rate

Oxygen

Hypoxemia Maintained energy balance

Hypoxia

Asphyxia
Days and weeks Hours Minutes
3 Time 4

The fetal response to hypoxia Fetal response to asphyxia

Surge of stress hormones

Redistribution of blood flow
saturation

saturation
Oxygen

Anaerobic metabolism in the

Oxygen

Alarm reaction
peripheral tissues
Hypoxemia
Maintained energy balance
Hypoxemia Anaerobic metabolism in
peripheral tissues
Hypoxia Hypoxia
Brain and heart organ
failure
Asphyxia Asphyxia
Days and weeks Hours Minutes
5
Days and weeks Hours Minutes
6
Time Time

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 Hypoxia from reduced cord blood flow

Oxygen reduces and CO2 increases

(respiratory acidosis develops)

If cord flow is not improved then base

excess used up and bicarbonate reduces
(metabolic acidosis develops)

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Major fetal organ damage 8

EFM-ISSUES EFM Problems and Realities

Electronic Intra-partum FHR Monitoring is now
Detect fetal hypoxia i.e reduce and avoid considered mandatory for high-risk pregnancies.

harm to the fetus and improve fetal and
baby out-come.
Severe acidosis may result in FHR changes.
Could occur in Normal physiological
response in labor.
Misunderstanding the physiological and
pathphysiological CTGs will improve the Mx
( management).
Difficulties interpretation include over confidence & not-
only difference in opinion between practitioners but, also
when the same practitioner examines the same CTG twice.
Increases CS rates 1.41%rr.
Increases operative vaginal delivery 1.20%rr.
And no change in incidence of C Palsy.
Reduction in Neonatal seizures rates 0.51%
No difference in APGAR scores.
9 10
? About the efficacy.

EFM- Facts Electronic Fetal Monitoring-

Indications
Indications for the continuous EFM
Reliability of interpretation-50-75% are
Oligohydramnios
false positive . High risk
Hypertension.
pregnancies
False positive Dx reduces to 105 with FBS. Abnormal FHR
IOL and detected.
FBS 93% sensitivity, 6% false positive. Augmentation of Malpresentation and
Labour. in labour.
PH Vs Lactate -39% Vs 2.3(rr 16.7).
Reduced FM. DM,Multiple Gestation.
Previous CS.
Premature
Abdominal Trauma.
labour/TPL.
Prolonged ROM.
APH/IPH
11 Meconium Liq. 12

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 EFM- Interpretation EFM- 4 Basic Features.

Consider : Baseline FHR - Mean level of FHR when this is

stable, excluding Accelerations and
Decelerations (110-160 bpm)
Intrapartum / antepartum trace.
-Tachycardia
Stage of labour.
-Bradycardia
Gestation.
Baseline Variability-5 bpm or greater than or
Fetal presentation, ? Malpresentation. equal to 5bpm, between contractions
Any augmentation,? Induction labor -Normal
Medications ? -Non-reassuring-Less than 5 bpm or less but
Direct or indirect monitoring less than 30 min
13 -Abnormal-less than 5 bpm for 90 min or more. 14

Uterine Contraction

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Baseline variability CTG Baseline variability

Baseline variability
The minor fluctuations on baseline FHR
at 3-5 cycles p/m produces Baseline
variability.

Examine imin segment and estimate

highest peak and lowest trough.

Normal is more than or equal to 5 bpm.

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Factors affecting Baseline variability. Non-reassuring Baseline variability.

Para-Sympathetic affects short term NR CTGs- reduced or less than 5 bpm for
variability whilst Long Term is more Symp. 40 min or more but less than 90 mins..

CNS ,Drugs reduce Variability B-B or short Term V is varying intervals

High gestation increases variability between successive heart beats .

Mild Hypoxia may cause both S and para S Long Term v is irregular waves on the CTG
stimulation. 3-5 bpm.

19 Normal is 5-25 bpm this indicates N-CNS. 20

EFM-Accelerations EFM Decelerations

Accelerations- transient increase in FHR

Decelerations-
of 15 bpm or more lasting for 15 sec. transient slowing of
FHR below the
Absence of accelerations on an otherwise
baseline level of
normal CTG remains un clear. more than 15 bpm
and lasting for 15 sec.
Presence of FHR Accelerations have Good
Or more.
outcome.
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Electronic Fetal Monitoring Early Decelerations

a) Early Decelerations
Head compression
Begins on the onset of contraction
and returns to baseline as the
contraction ends.
Should not be disregarded if they
appear early in labor or Antenatal.
Clinical situation should be r/v
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 Electronic Fetal Monitoring
Late Decelerations.
b) Late Decelerations
Uniform periodic slowing of FHR with the Due to acute and chronic feto-placental
vascular insufficiency
on set of the contractions .
Occurs after the peak and past the length of
Repetitive late decels increases risk of uterine contraction, often with slow return to
the baseline.
Umbilical artery acidosis and Apgar score Are precipitated by hypoxemia
of less than 7 at 5 mins and Increased risk Associated with respiratory and metabolic
acidosis
of CP.
Common in patients with PIH, DM, IUGR or
other form of placental insufficiency.
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Late Decelerations

27 28

Late Decelerations EFM- Variable Decelerations

Reduces Baseline variability together
with Late Decelerations or Variable
Decelerations is associated with
increased risk of CP.
29
Variable intermittent periodic slowing of FHR
with rapid onset recovery and isolation.
They can resemble other types of deceleration in
timing and shape.
Atypical VD are associated with an increased risk
of umbilical artery acidosis and Apgar score less
than 7 at 5 min
Additional components:
Loss of 1 degree or 2 degree rise in baseline Rate
Slow return to baseline FHR after and end of
contraction.
Prolonged secondary rise in Base FHR
Biphasic deceleration
Loss of variability during deceleration
Continuation of base line at a lower level. 30

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 Electronic Fetal Monitoring Variable Decelerations

c) Variable Deceleration (Vagal activity)

Inconsistent in configuration,
No uniform temporal r-ship to the onset of
contraction, are variable and occur in isolation.
Worrisome when Rule of 60 is exceeded (i.e.
decrease of 60 bpm,or rate of 60 bpm and longer
than 60 sec)
Caused by cord compression of the umbilical cord
Often associated with Oligo-hydroaminos with or
without ROM
Can cause short lived RDS if they MILD
Acidosis if prolonged and Recurrent.
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References

33 34

EFM Prolonged deceleration

Prolonged Deceleration
Drop in FHR of 30 bpm or More lasting for
at least 2 min
Is pathological when crosses 2 contractions
i.e 3 mins.
Reduction in O2 transfer to placenta.
Associated with poor neonatal outcome.

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 EFM- Prolonged Decelerations Prolonged Deceleration
CAUSES

Cord prolapse.

Maternal hypertension

Uterine Hypertonia

Followed by a Vag Exam or ARM or

SROM with High PP.

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EFM Mx Prolonged Deceleration Baseline Bradycardia

FH below 110bpm(FIGO ).
Maternal position
less than 100bpm (RANZCOG).
IV fluids
Causes.
V.E to exclude cord prolapse
Postdates, Drugs, Idiopathic,
Assess BP Arrythmias, hypothermia(increased Vagal Tone)
Cord Compression (Acute Hypoxia, congenital H
FBS if cx dilated and well applied PP
disease and Drugs).
Mx Depending on the clinical situation.
Mx depends on the clinical situation.(FBS,Vag
39 Exam, Observation or expedite delivery) 40

Types Baseline tachycardia and

Moderate Bradycardia 100-109 bpm
Abnormal bradycardia less than 100bpm.
Tachycardia 161-180 bpm
Abnormal Tachycardia more than 180
bpm
Ranzcog Australian more than 170 bpm
Bradycardia.
Uncomplicated baseline tachycardia
161-180 bpm or bradycardia 101-109
do not appear to be associated with
poor NN outcome.

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 Causes of B Tachycardia. Electronic Fetal Monitoring
Baseline Bradycardia
Asphyxia FH Rate below 110bpm (FIGO Recommended)
Drugs Postdates
Drugs
Prematurity
Idiopathic
Maternal Fever Arrhythmia's
Hypothermia.(Increased Vagal tone),
Maternal thyrotoxicosis
Cord compression(Acute Hypoxia,Congenital
Maternal Anxiety H/disease, and drugs)

Idiopathy Mx depends on the clinical situation. (FBS, Vag Exam ,

Observation or expedite Delivery).
Mx depends on the clinical situation
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Sinusoidal pattern
Electronic Fetal Monitoring
Interpretation of the CTG
Baseline Tachycardia
Asphyxia
Drugs
Prematurity
Maternal fever
Maternal thyrotoxicosis
Maternal Anxiety
Idiopathy
Mx depends on the clinical situation

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EFM-Sinusoidal Pattern Electronic Fetal Monitoring

Sinusoidal pattern- distinctive smooth undulating
Regular Oscillation of the Baseline long-term Sine-wave baseline with no B-b variability
Variability resembling a Sine wave ,with no B- 0.3 % (Young 1980)
b Variability cord compression
Has fixed cycle of 3-5 p min. with amplitude hypovolemia
of 5-15 bpm and above but not below the ascites
baseline. idiopathic(fetal thumb sucking)
Should be viewed with suspicion as poor Analgesics
outcome has been seen (eg Feto-maternal Anaemia
haemorrhage) Abruption
47 Mx r/v clinical situation 48

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 EFM- Saltatory pattern NR CTGs

Difficult to interpretation,leads to Increased

Seen During Fetal thumb sucking. rate of C Section.
Could be associated with Hypoxia. 50% CTG in Labour have 1 abnormal
feature
15-20% Nr CTGs (pathological).
?? To reduce CS.

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EFM-Summary Caring for the Mom,

Not the Monitor!
Normal - CTG with all 4 Features
Suspicious -one non reassuring category
and reminder are reassuring
Pathological -2 or more non-reassuring
categories or one or more abnormal
categories.

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References

Manual Obs and Gyn. by Niswander, MD

Fetal Monitoring RCOG UK

CTGs RANZCOG

Literature review articles American Family Physician

CTG Made Easy

D. Lata Sharma, MD, FRANZCOG, Senior Lecturer, University Of

Queensland, Australia

Charles Kawada, M.D,Harvard Medical School

S Arulkumaran,St.Georges Hospital Medical School, University of

London. Introducing Fetal ECG waveform analysis for Intrapartum Care
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