1. Electronic Fetal Monitoring
Prof Diana du Plessis
Independent Midwifery Consultant
2017

2. Why fetal heart monitoring? Introduction
Steady increase in the number of malpractice claims in especially midwifery care
Eruption of court cases over the last 4 years
Most court cases are the result of Cerebral Palsy children

3. News headlines: Hospital horrors costing SA plenty

4. Why do we lose court cases?
Lack of assessment
Partograph
Foetal surveillance
Lack of interpretation
Inability to resuscitate

5. Foetal surveillance
The FHR is under constant and minute adjustment in response to the constant changes in the fetal environment and external stimuli

6. The principle aim of foetal surveillance:
To prevent adverse perinatal outcomes as a result of foetal metabolic acidosis
Used as an indication of whether or not the foetus is well oxygenated
FHR monitoring does not provide evidence of the neurological status

7. CTG Features in labour
FHR pattern, level of activity and muscular tone of foetus are all sensitive to hypoxemia and acidemia
FHR is controlled by CNS and mediated by sympathetic and parasympathetic nerve impulses originating in the brain stem
The presence of accelerations and foetal movement is believed to be an indicator of adequate oxygenation
Factors [prematurity, sleep cycle, medication, foetal CNS abnormalities] impact biophysical parameters

8. Foetal surveillance includes:
CFM which measures both FHR and contractions
Intermittent auscultation of foetal heart
Foetal blood sampling for indications of metabolic acidosis [pH and or lactate]

9. Consensus statement 1 CFM
In the absence of risk factors – CFM has no proven benefits
May increase the intervention rate in a normal spontaneous labour
Increase the rate of C/S

10. Before, during and after a contraction
Consensus statement 2:
The fetal heart rate should be evaluated in relation to the uterine contractions during the intra partum period
Before, during and after a contraction

11. Why? Uterine contractions Reduces placental blood flow
Reduction in fetal oxygenation

12. Deviation 1: Contractions
Basal tone: mmHg (Resting tone)
Intensity: mmHg (How strong?)
Duration: seconds (How long?)
Frequency: in 10 minutes (How often?)

13. Consensus statement 3: intermittent auscultation
Use in healthy women at low risk for complications
Doppler more reliable than a Pinard
Confirm foetal movement
Document findings including when accelerations and decelerations are heard
Palpate maternal pulse

14. Deviation 1b: Maternal pulse
Baseline maternal HR is significantly lower than baseline FHR
Maternal “accelerations”
More rounded and uniform
Increases at beginning of contraction or pushing effort
Foetal accelerations:
Differ in duration
Have irregular shape
Are asymmetric
Occur at variable intervals

15. Example of maternal pulse

16. explanation
Although this appears to be a bradycardia, this is registration of the maternal pulse through a dead baby.
A typical contraction pattern of placenta abruption is present (high frequency, low amplitude

17. Deviation 2: Risk factors
Abnormal NST, Doppler, ultrasound
IUGR
Oligo/polyhydramnios
Malpresentations
PROM
C/S
Increased BMI
Maternal age
Maternal illness
IOL
Abnormal CTG
Regional anaesthesia
Bleeding
Maternal pyrexia
MSL
Absent liquor
Prolonged labour
Preterm
Antenatal
Intrapartum

18. Consensus statements 4: duration and frequency of auscultation
Evidence for frequency and duration of auscultation from clinical trials are not available
Before during and after contractions – at least 1 minute
Every minutes in active phase
Second stage: every 5 minutes

19. When to transition to cfm:
IOL or augmentation
Transfer from MOU to hospital
Development of intrapartum complications
MSL
Bleeding
Maternal pyrexia
Baseline lower than 110 bpm or > 160 bpm
Any deceleration after a contraction

20. Consensus statement 5: nursing management principles
Review CTG-tracing every minutes
Interpret systematically:
Contractions
Baseline [variability, accelerations, decelerations]
Other findings and information [sleep pattern]
Category of tracing
Plan of action
Differentiate maternal pulse

21. Machine setting Principle 2 Paper speed of 1 cm per minute
Validate date and time settings

22. CTG-labelling and documentation
Principle 3
Name
Hospital number
Date and time
Maternal observations
Intrapartum events
Interpretation of tracing
Date; time and signatures

23. Communication of information
Principle 4
Keep mother and doctor informed
Obtain assistance if needed
Include CTG interpretation during handover
Write short notes in progress reports
Do not write “reactive”

24. Reactive heart pattern
[a] Baseline of between bpm
[b] Normal variability of more than 5 bpm
[i] Absence of decelerations
[ii] At least 2 accelerations with an amplitude of 15 bpm and a duration of 15 seconds
Does not have the characteristics of either the reactive or the pathological patterns
Reactive heart pattern
Non-reactive pattern

25. Deviation 3 The baseline
A resting FHR not a sleeping rate
The normal FHR: bpm taken over minutes
The baseline rate is interpreted as changed if the alteration persists for more than 15 minutes
Prematurity, maternal anxiety and maternal fever may increase the baseline rate
Foetal maturity decreases the baseline rate

26. Why? Progressive vagal dominance occurs As the foetus approaches term
Results in a gradual decrease in the baseline FHR

27. Vagus nerve Influence the FHR in response to
Almost any stressful situation in the foetus
Hypoxia
Uterine contractions
Foetal head compression
Perhaps
foetal grunting or
Defecation

28. Deviation 4: Variability
Minor fluctuations in FHR of more than 5 beats per minute
This indicates a well- perfused CNS

29. Interpretation?

30. Conclusion: Normal Foetal Heart Tracing
Good beat to beat variability (alterations in baseline over 1 min)
Reassuring : Accelerations more than 15 beats above baseline during fetal movement and some contractions

31. Example of poor variability
If associated with foetal distress:
Turn mother on her side
Give oxygen by face mask
If associated with drugs:
Administer Narcan to mother before birth

32. Storing of information
Principle 6
Keep original
Make photocopies or scan when there are adverse outcomes
Death
Apgar score at 5 min < 5
Active resuscitation needed
ICU admissions

33. finally Confirmatory CTG Abnormal Problem resolved Normal Baseline
Variability;
Accelerations
Decelerations
Abnormal
Reversible causes
Cord compression
Uterine hyperstimulation
Maternal pyrexia
Inadequate CTG quality
Problem resolved No
medical assistance
expedite birth
CFM
Yes
CFM and reassess in 30 minutes

34. DO NOT PUSH FOR A VAGINAL BIRTH AT ALL COST
THE END