1. Understanding Cardiotocography – “CTGs” Max Brinsmead MB BS PhD May 2015

2. A Normal Antenatal CTG

3. Features of a CTG Baseline Short term variability Accelerations Decelerations Response to stimuli Contractions Fetal movements Other

4. Baseline Fetal Heart Rate 110 to 150 bpm at term Faster in early pregnancy Below 100 = baseline bradycardia Below 80 = severe bradycardia Tachycardia common with maternal fever Tachycardia with reduced STV = early hypoxia

5. Accelerations Must be >15 bpm and >15 sec above baseline Should be >2 per 15 min period Always reassuring when present May not occur when fetus is “sleeping” Should occur in response to fetal movements or fetal stimulation Non reactive periods usually do not exceed 45 min (>90 min and no accelerations is worrying)

6. Short Term Variability (or Beat to Beat Variability with a Scalp Clip) Should be >5 bpm The most important feature of any CTG Is a reflection of competing acceleratory and decelerating CNS influences on the fetal heart And therefore represents the best measure of CNS oxygenation Will be affected by drugs Will be reduced in the pre term fetus

7. Decelerations Early: mirrors the contraction Typically occurs as the head enters the pelvis and is compressed, i.e. it is a vagal response Late: Follows every contraction and exhibits a slow return to baseline Is quite rare but is the response of a hypoxic myocardium Variable: Show no relationship to contractions Mild Moderate Severe In practice many “decels” or “dips” are MIXED

8. An Abnormal Antenatal CTG

9. An Abnormal Antenatal CTG cont’d

10. Abnormal CTG Features Reduced STV No accelerations Decelerations after most contractions with a slow return to baseline

11. In Practice a CTG is best regarded as a screening tool: High negative predictive value >98% of fetuses with a normal CTG will be OK Poor positive predictive value Up to 50% of fetuses with an abnormal CTG will be hypoxic and acidotic but 50% will be OK Therefore the CTG should always be interpreted in its clinical context And backed by fetal blood sampling PRN

12. A Classification of CTGs Normal = all 4 features are reassuring Suspicious = One non reassuring feature Pathological = Two or more non reassuring features or a abnormal pattern

13. Non Reassuring Features of a CTG Baseline 100 or >160<180 STV 40 min but <90 min Early decelerations Variable decelerations A single prolonged deceleration up to 3 min

14. A CTG is abnormal when: Baseline is 180 bpm STV is 90 min Late decelerations are repeated Atypical variable decelerations occur Two prolonged decelerations for >3 min occur Sinusoidal pattern >10 min

15. It is best to regard CTG as screening for fetal hypoxia:

16. An ideal screening test:

17. CTG as a screening test

18. CTG as a Screening Test Positive predictive value = the chance that a screen positive individual will have the disease For CTG this is never more than 50% i.e. at least 50% of the time it will be unnnecessarily alarming

19. A screening test is more likely to be a true positive if

20. It is positive in a high risk group

21. So always consider the clinical context

22. And be prepared to back up with a diagnostic test

23. Which, for the diagnosis of fetal hypoxia, is Scalp Blood pH or lactate

24. Problems with Screening: FALSE POSITIVES – And the resources required to deal with them UNREALISTIC EXPECATATIONS – i.e. misunderstanding about the sensitivity of the test

25. Meta analysis of RCTs of Intrapartum CTG monitoring 12 Trials (as of 2008) In 10 centres in the US, Australia, Europe and Africa 58,855 women and 59,324 babies Both high and low risk pregnancies Compared routine EFM with intermittent auscultation

26. Meta analysis Results A significant decrease in: – rate of 1 minute Apgar scores less than 4 (RR = 0.82 and CI 0.65 - 0.98) – Neonatal seizures (RR=0.50 and CI 0.32 - 0.82)

27. Meta analysis Results A significant increase in: The rate of intervention by Caesarean section and operative delivery (RR=1.23 and CI 1.15 - 1.31)

28. Meta analysis Results No effect on: – rate of 1 min Apgar scores <7 – rate of admissions to NICU – Perinatal death rate – 5 min Apgar scores – rate of Cerebral palsy

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