Intrapartum CTG

Intermittent Auscultation Aim - timely identification of fetuses with hypoxia/acidosis to enable appropriate action before the occurrence of injury

Advantages: Frequent contact between healthcare professionals and the laboring woman - social and clinical support. Easier availability and sustainability of the technology, which allows it to be undertaken in even the lowest resource settings.

Disadvantage Requires clinical expertise - slow learning curve for the identification of accelerations and decelerations. It is difficult to recognize subtle features of the FHR, such as variability. Subjective variation is a concern No record is obtained, hence uncertainty in case reviews and medico-legal cases

Technique Clearly explain the procedure to the labouring woman Assess the fetal position Localize the heart rate. Confirm with the maternal pulse that it is the FHR Just before and during intermittent auscultation, monitor timing of uterine contractions and check fetal movements

Features to evaluate What to register FHR Duration: for at least 60 seconds; for 3 contractions if the FHR is not always in the normal range (110-160 bpm) Timing: during and at least 30 seconds after a contraction Interval: Every 15 minutes in the active phase of the first stage of labor. Every five minutes in the second stage of labor. Also note the fetal movements and uterine contractions Make sure you are not auscultating the maternal pulse Baseline (as a single counted number in bpm), presence or absence of accelerations and decelerations

CTG Do not perform cardiotocography for low-risk women in established labour. The routine use of admission CTG for low-risk women has been associated with an increase in cesarean delivery rates and no improvement in perinatal outcomes

Continuous CTG Continuous CTG for Intrapartum monitoring in both low- and high-risk women, have shown that CTG is associated lower risk of neonatal seizures higher cesarean and instrumental vaginal delivery rates

Indications Suspected chorioamnionitis or sepsis, Temperature of 38°C or above Severe hypertension (160/110 mmHg or above) Oxytocin use The presence of significant meconium (dark green or black amniotic fluid that is thick or tenacious, or any meconium-stained amniotic fluid containing lumps of meconium) Fresh vaginal bleeding that develops in labour. Obstetric emergency – cord prolapse,maternal seizure or collapse Vaginal birth after cesarean section Second stage of labour ( FIGO 2015)

Continuous cardiotocography for at least 30 minutes during establishment of regional analgesia and after administration of each further bolus of 10 ml or more

If 2 or more of these risk factors Maternal Factors: Mild to moderate hypertension (150/100 to 159/109 mmHg) with or without albuminuria Pulse over 120 beats/minute on 2 occasions 30 minutes apart Pain reported by the woman that differs from the pain normally associated with contractions Any abnormal presentation, including cord presentation , transverse or oblique lie High (4/5–5/5 palpable) or free-floating head in a nulliparous woman

Fetal factors Suspected fetal growth restriction, macrosomia, anhydramnios or polyhydramnios fetal heart rate below 110 or above 160 beats/minute or abnormality on intermittent auscultation Labour: Confirmed delay in the first stage of labour(>12 hours) Prolonged period since rupture of membranes (24 hours or more) The presence of non-significant meconium

If continuous CTG has been used because of concerns arising from intermittent auscultation but there are no non-reassuring or abnormal features on the cardiotocograph trace after 20 minutes, remove the cardiotocograph and return to intermittent auscultation

Case SCenarios

Case 1 A primigravida with 38 weeks gestation with BP 150/100mm Hg, urine albumin 2+ in active labour P/V – 4 cm dilated, well effaced. Vx at 0 station. Membranes absent. Clear liquor Will you perform an admission CTG Is continuous CTG required or not

Case 2 G2 P1 L1 with 39 weeks of gestation with previous LSCS with temperature > 38o C in latent phase of labour. Inter delivery interval is 18 months. Will you perform an admission CTG Will you perform continuous CTG

Case 3 Primi gravida with term gestation with Vx presentation in active labour. FHR – 120b/min P/V – 5cm dilated, well effaced, Vx at -1 station, membranes absent, non significant meconium When will you perform continuous CTG