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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