1. CTG

2. Overall care
Do not make any decision about a woman’s care in labour on the basis of cardiotocography (CTG) findings alone.
Take into account any antenatal and intrapartum risk factors, the current wellbeing of the woman and baby and the progress of labour when interpreting the CTG trace.
Remain with the woman at all times in order to continue providing one-to-one support.
Ensure that the focus of care remains on the woman rather than the CTG trace.
Make a documented systematic assessment of the condition of the woman and the baby (including CTG findings) hourly, or more frequently if there are concerns

3. Principles for intrapartum CTG trace interpretation
When reviewing the CTG trace, assess and document all 4 features (baseline fetal heart rate, baseline variability, presence or absence of decelerations, presence of accelerations).
It is not possible to categorize or interpret every CTG trace.
Senior obstetric input is important in these cases

4. Accelerations
The presence of fetal heart rate accelerations is generally a sign that the baby is healthy.
If FBS is indicated and sample cannot be obtained, but scalp stimulation results in FHR accelerations, decide whether to continue labour or expedite the birth in the light of clinical circumstances

5. NICE 2014 CTG Classification

6. Management

7. Management

8. Management

9. Case scenarios Case 1 part 1
A 30-year-old at 35 weeks of gestation is admitted in spontaneous labour. She is fully dilated. On examination the head is 0/5 palpable per abdomen, in LOA position with minimal caput and no moulding. She has made good progress from 3 cm to full dilation in 3 hours. She has been pushing for 1 hour. You are asked to assess the CTG.

10. Patient’s CTG

11. Determine the mnemonic (DR C BRAVADO) for this trace
Determine risk: Contractions: Baseline rate: Accelerations: Variability: Decelerations: Overall impression:

12. Answer: Determine risk -High risk (preterm)
Contractions-4–5 in 10; maximal amount, any more would be hyperstimulation
Baseline rate-170 bpm
Accelerations- None (uncertain significance)
Variability-5–10 bpm (reassuring)
Decelerations-there are variable decelerations lasting >60 seconds and dropping >60 beats. Also, they occur with over 50% of contractions in a 30 minute segment of trace,for up to 30 minutes (non-reassuring)
Overall impression
 Abnormal

13. What would your next action be?
Answer whether the following statements are true or false? Affix the fetal scalp electrode/ST analysis CTG machine? True or false?

14. The answer is false. Fetal scalp electrode/ST analysis CTG should only be used on term fetuses, and should be applied before the second stage of labour.

15. Start an oxytocin infusion to speed up delivery
True or False?

16. The answer is false. Labour is already progressing quickly.

17. Consider instrumental delivery
True or False

18. The answer is true. This should ensure safe delivery unless the head is visible or delivery is imminent.

19. Outcome
After determining the results of the CTG as abnormal, the next action would be to consider instrumental delivery. This would ensure safe delivery, unless the fetal head is visible or delivery is imminent.
This would result in a good outcome, with the following measurements:
UA pH = 7.29
UV pH = 7.39
BE –5.1
Apgars 9,10.

20. Case study 2
A 35-year-old with an IVF pregnancy is at 42 weeks of gestation. She has been induced into labour and had an oxytocin drip for the last six hours. You are asked to assess the CTG at 8 cm dilation

21. CTG

22. Determine the mnemonic (DR C BRAVADO) for this trace.
Determinerisk- High risk (42+ weeks of gestation)
Contractions-4–5 in 10; maximal amount, any more would be hyperstimulation
Baseline rate-155–160 bpm
Accelerations- None
Variability- 5–10 bpm (reassuring)
Decelerations-Variables decelerations, some lasting more than 60 seconds. They occur with over 50% of contractions in a 30-minute segment of trace (abnormal)
Overall impression
Abnormal

23. What would your next action be?
Increase oxytocin?
True or False

24. The answer is false. This would be negligent because you would reduce further oxygen supply to the fetus.

25. Stop oxytocin infusion?
True or False

26. The answer is true. This will allow the oxygen supply to the fetus to improve, and even giving terbutaline 250 micrograms subcutaneously may improve the trace.

27. Unfortunately the oxytocin was not stopped, and the labour was allowed to continue because the trace was erroneously interpreted as having accelerations.
The woman is still 8 cm dilated, head 2/5 palpable per abdomen and left OP position with caput +++ and moulding ++. She has made a 2 cm progress over the last eight hours.

28. Her CTG

29. Again, determine the mnemonic (DR C BRAVADO) for this trace.
Determinerisk-High risk (42+ weeks of gestation)
Contractions-5 in 10 – indicative of hyperstimulation
Baseline rate-170 bpm in the first half of the trace, and then dropping to 140 bpm in the second half of the trace (non-reassuring)
Accelerations-None
Variability-5–10 bpm (reassuring)
Decelerations-Variables decelerations, lasting more than 60 seconds and deeper than 60 beats,occuring with over 50% of contractions in a 30-minute segment of trace (abnormal)
Overall impression
Abnormal

30. Answer whether the following statements are true or false.
Perform FBS
True or False?

31. The answer is false.
While this is not altogether incorrect, given the lack of progress with signs of disproportion and a worsening CTG, a caesarean section may be the safer option.

32. Perform a caesarean section
True False

33. The answer is true.
Given the lack of progress with signs of disproportion and worsening CTG, a caesarean section may be the safer option here. Also stop the syntocinon and consider terbutaline if there is any delay in the transfer to theatre.

34. Give maternal oxygen at a fast flow rate of 5 l/min via a face mask
True or False?

35. The answer is false.
This is unlikely to improve fetal outcome, and there is some evidence that it may be harmful to the fetus.

36. Outcome
After determining the results of the second CTG as abnormal, the next action would be to consider performing a caesarean section because of the lack of progress with signs of disproportion and worsening CTG.
Also consider stopping the oxytocin and initiating terbutaline if there is any delay in the transfer to theatre.
This would result in a good outcome, with the following measurements:
UA pH = 7.19
UV pH = 7.29
BE –8.1
Baby outcome: good
Apgars 5,10.