1. Electronic fetal monitoring vs intermittent auscultation
Dr .Pradeep.S Prof in OBG PESIMSR

2. Place for CTG ? No admission CTG for low risk cases
Only Intermittent auscultation for low risk cases in labor
If on auscutation fetal heart is abnormal , connect CTG
Once the CTG becomes normal and no further risk, can switch to intermittent auscultation.

3. Frequency of IA
Auscultate for one whole minute 1st Stage 2nd Stage ACOG q15 mins q5 mins NICE q15mins q5mins/ after every contraction

4. CONTINUOUS ELECTRONIC FETAL MONITORING
Benefits: ▶ Can identify early signs of developing hypoxia ▶ Allows closer monitoring of high risk patients ▶ Excellent predictor of a normally oxygenated fetus ▶ Records FHR & uterine contractions simultaneously

5. THE PROBLEM WITH EFM IS…
▶ Over use in low-risk women
▶ Over reliance on a poor screening tool
▶ 30% false positive rate
▶ Increased rate of interventions with significant increase in morbidity and mortality for women and babies
▶ Difficulty in legal cases due to interpretation disputes
Reduced mobility and lack of support in labour may affect the woman's ability to control and cope with labour pain

6. What does evidence say?

7. NICE guidance
NICE advocate the use of continuous EFM in high-risk labours.

8. COCHRANE REVIEW (2006, 2013)
▶ No difference in incidence of CP between IA & EFM ▶ EFM was associated with a significant increase in C-Sections (1.7times) & instrumental vaginal deliveries

9. Clinical Decision-making Based on Auscultation Findings
Continue Individualized
Assessment and Care
Assess with IA & palpation per pt/care provider preferences, guidelines, & availability
Promote maternal comfort & continued fetal oxygenation(position change; anxiety reduction measures
Notify
Auscultate
Interpretation
Yes
Reassuring FHR Pattern?
Baseline rate
Regular rhythm
Absence of decrease from baseline No

10. Non-Reassuring FHR Pattern
Baseline <110 pbm
Baseline >160 bpm (unexplained persistent tachycardia for > 3 contractions or > minutes
Irregular rhythm
FHR during & 30 seconds after contractions
Gradual or abrupt change in FHR
Intervention/Management
 frequency of Intermittent auscultation
Assess potential cause of FHR characteristics
Attempt to remove problem(s)/cause
Intervene to promote 5 physiologic goals:
Improve uterine blood flow
Improve umbilical blood flow
Improve oxygenation
 uterine activity (e.g. position change, hydration)

11. Continue interventions
Problem Solved ??
YES—Return to Continued Individualized Assessment & Care No
FHR Pattern Persists?
Continue interventions
Apply EFM to clarify pattern interpretation, assess variability, to further assess fetal status
Consider additional assessments (e.g. fetal scalp stimulation; fetal acoustic stimulation)

12. Indications for electronic fetal monitoring
Antenatal indications: maternal
Antenatal indications: fetal
Hypertension
Diabetes
APH
Maternal diseases : cardiac, anemia, renal
Maternal trauma
Morbid obesity
IUGR
Prematurity
Oligohydramnios
Abnormal umblical artery doppler
Isoimmunisation
Intrapartum indications: maternal
Intrapartum indications: fetal
Excess vaginal bleeding
Chorioamnionitis
TOLAC
Induced labor
Augmented labor
Hypertonic uterus
Prolonged pregnancy
Meconium stained liquor
Abnormal fetal heart rate on auscultation

13. Indications for internal fetal monitoring
Obese women where external monitoring is not possible

14. FETAL ELECTROCARDIOGRAM (ECG) OR ST ANALYSIS (STAN)

15. STAN
ST analysis (STAN) involves a combination of fetal heart rate interpretation and analysis of the fetal electrocardiogram.
STAN aims to reduce the incidence of fetal acidaemia and hypoxia by identifying these earlier and with greater sensitivity than cardiotocography (CTG) alone.

16. BASIS FOR STAN
During oxygen deficiency, anaerobic metabolism is used by cardiac myocytes to maintain an energy supply.
The breakdown of glycogen releases potassium ions that can cause an increase in the height of the T wave.
Cardiac hypoxia and ischemia can cause ST depression and inversion of the T wave
The STAN software is able to detect all such changes and prompts the clinician that such changes have occurred.

17. The STAN software analyses the average waveform of the fetal ECG signal over 30 consecutive heartbeats.
It then compares this waveform with the average of each of the subsequent 30 complexes.
STAN should not be started if there is a total loss of fetal heart rate variability.
a spiral fetal scalp electrode (FSE) is attached to the fetal scalp during a vaginal examination.
A skin reference electrode is placed on the mother’s thigh; this attaches both to the FSE and to the STAN monitor.
An abdominal toco is used as in CTG monitoring.

18. A normal ECG complex

19. ST events shown on STAN monitor
The ST analysis is displayed by crosses at the bottom of the screen
Each cross represents an episode of ST analysis of the ECG complexes of 20 beats
Significant changes are displayed as an ST event with a black box to mark the time on the trace

20. There are three types of ST event that can be noted

21. Episodic T/QRS rise.
Increase in the T/QRS ratio that lasts for less than 10 minutes.
An episodic T/QRS rise usually indicates a period in which the fetus had to utilize anaerobic metabolism but has now recovered.
The magnitude of rise is given in the event log as 0.11 or greater

22. Baseline T/QRS rise.
an increase in the T/QRS ratio that has lasted more than 10 minutes.
magnitude of the rise is given in the event log as 0.06 or greater
A baseline T/QRS rise usually indicates that the fetus is utilizing anaerobic metabolism for an extended period of time.

23. Biphasic events Reflects a downward-sloping ST segment
indicate a situation where hypoxia is occurring but the fetus either has not yet had time to respond with anaerobic metabolism or cannot respond.

24. Grade 1 biphasic event
The ST segment is sloping downwards but the entire segment remains above the baseline

25. Grade 2 biphasic event
The ST segment is sloping downwards but it crosses the ECG baseline and is not fully below it.

26. Grade 3 biphasic event
The ST segment is sloping downwards and the entire segment is below the ECG baseline

27. INTERPRETATION OF THE RESULTS
If the CTG is normal then no action is required with any STAN event – this represents an adrenaline surge in a healthy fetus.
If the CTG is classified as preterminal then the fetus should be delivered regardless of the type and magnitude of any STAN events, and even in their absence.

28. The basic principle is if the CTG is more concerning even with smaller ST event it needs intervention.
If the CTG is classified as intermediary or abnormal then the type and magnitude of STAN event should be noted.

30. Limitations to the use of STAN:
already hypoxic fetus
Intrauterine infection
Breech presentation: breech mode
Fetal heart rate >170 bpm
Recording the maternal ECG
Fetal cardiac abnormalities

31. Fetal pulse oximetry (FPO)
Measures fetal oxyhemgolobin saturation by placing a sensor against fetal cheek transcervically after membranes have ruptured

32. Near infrared spectroscopy (NIRS)
When light is passed through detectors placed on the fetal head, it will be reflected back depending on the oxygenation and the amount of blood flow through the fetal head