2. intrapartum Fetal Monitoring
Elahe zarean

3. Suggestion to improve CTG training courses
CTG weekly meeting to discuss interesting cases
Make the definition of the CTG as standard.
Make the speed of the machine standard
When in doubt ask for the second opinion.
Practice ,practice,practice
Good documentation
Legal cases to be judged by CTG experts in interpretation and labor management

4. Fetal Surveillance
The goal of antepartum fetal surveillance is to prevent fetal death.
The goal of intrapartum fetal heart rate monitoring is to prevent fetal death and neurologic injury.

5. Interpretation of the Fetal Heart Tracing
The interpretation of the fetal heart rate tracing should follow a systematic approach with a full qualitative and quantitative description of the following:
Baseline FHR
rate
variability
Periodic changes
accelerations
decelerations
Frequency and intensity of uterine contractions

6. DR C BRAVADO
DR = determine risk C=contractions BRA = baseline rate V = variability A = accelerations D = decelerations O = overall assessment

7. Baseline Fetal Heart Rate
The baseline FHR is the heart rate during a 10 minute segment rounded to the nearest 5 beat per minute increment excluding periods of marked FHR variability, periodic or episodic changes, and segments of baseline that differ by more than  25 beats per minute.
The minimum baseline duration must be at least 2 minutes. 
If minimum baseline duration is < 2 minutes then the baseline is indeterminate.
Normal baseline = bpm

8. Baseline Fetal Heart Rate
Two Minutes

9. bradycardia Distinguish between bradycardia & prolonged deceleration
Drug , hypothermia ,hypoglycemia
Complete heart block

12. Baseline variability
The minor fluctuations in baseline FHR occuring at three to five cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace.

14. FHR Variability Absent variability = Amplitude range undetectable
Minimal = < 5 BPM
Moderate = 6 to 25 BPM
Marked = > 25 BPM

15. Causes of Decreased Variability
Fetal metabolic acidosis
CNS depressants
Fetal sleep cycles
Congenital anomalies
Prematurity
Fetal tachycardia
betamethasone

16. Sinusoidal and Pseudosinusoidal Patterns
A smooth, undulating pattern, lasting at least 10 minutes with a fixed period of three to five cycles per minute and an amplitude of 5-15 bpm.
Pseudosinusoidal:
Usually caused by drugs such
as Nubain or Stadol.

17. Accelerations
An acceleration is an abrupt increase in FHR above baseline with onset to peak of the acceleration less than < 30 seconds and less than 2 minutes in duration. The duration of the acceleration is defined as the time from the initial change in heart rate from the baseline to the time of return to the FHR to baseline.
<32 weeks' : >10 BPM above baseline for >10 seconds .
>32 weeks' : >15 BPM above baseline for > 15 seconds.
Prolonged acceleration: Increase in heart rate lasts for  2 to 10 minutes.
The absence of accelerations for more than 80 minutes correlates with increased neonatal morbidity.

18. DECCELERATIONS EARLY : Head compression LATE : U-P Insufficiency
VARIABLE : Cord compression &
Cord stretch

19. Decelerations
The type of the deceleration is distinguished on the basis of its waveform :
Abrupt (variables) decrease in FHR below baseline with onset to nadir < 30 seconds.
Gradual decrease and return to baseline with time from onset of the deceleration to nadir >30 seconds.

20. Early Deceleration
Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. The nadir occurs with the peak of a contraction.

21. Late Deceleration
Gradual decrease in FHR with onset of deceleration to nadir >30 seconds. The nadir of the deceleration occurs after the peak of the contraction

22. Late Deceleration
Reflex
Myocardial depression

23. Late deceleration related to bigeminal contractions
Late deceleration related to bigeminal contractions. Beat-to-beat variability is preserved. Note the prolonged contraction pattern with elevated uterine tone between the peaks of the contractions, causing hyperstimulation and uteroplacental insufficiency. Management should include treatment of the uterine hyperstimulation. This deceleration pattern also may be interpreted as a variable deceleration with late return to the baseline based on the early onset of the deceleration in relation to the uterine contraction, the presence of an acceleration before the deceleration (the "shoulder") and the relatively sharp descent of the deceleration. However, late decelerations and variable decelerations with late return have the same clinical significance and represent nonreassuring patterns.

25. Variable Deceleration
Abrupt  decrease in FHR of > 15 beats per minute measured from the most recently determined baseline rate.  The onset of deceleration to nadir is less than 30 seconds. The deceleration lasts   > 15 seconds and less than 2 minutes. A shoulder, if present, is not included as part of the deceleration.
Variable decelerations may be observed in up to 50% of NSTs. If nonrecurrent and <30 seconds, they are of no clinical significance.

27. Variable Deceleration
Typical:
shoulders
Atypical :
Overshoot
Loss of primary shoulder
Slow return to baseline (late component)
Baseline returns to a lower level(after deceleration)
Biphasic(W shape)
loss of variability during deceleration

28. Classification severity of variable deceleration
Mild: duration < 30 second or depth up to 80bpm
Moderate : deceleration < 80bpm
Severe : deceleration < 70bpm for more than 60 second

29. Red flags
Loss of variability
Complicated tachycardia

31. Confusing aspect Late component Combined pattern absent variability
post blunted acceleration (overshoot)
no acceleration

36. Causes of cord compression pattern
Oligohydramnious
Dilatation 8-9 cm
Rapid descending
True umbilical cord prolapse(rare)

37. Complicated variable deceleration
Indicated fetal hypoxia
Tachycardia
Lack of variability
Slow return to baseline
Large amplitude(to 60bpm or duration 60 second)
Loss of pre and post shouldering
Smooth overshoot

38. Recurrent Decelerations
Decelerations occur with > 50% of uterine contractions in any 20 minute segment.
Recurrent variable decelerations (at least 3 in 20 minutes) may be observed. However, close follow up is recommended because cord accidents with subsequent fetal death may occur even in the presence of normal amounts of amniotic fluid.
Recurrent late decelerations should lead to consideration of cesarean delivery unless the abnormal results are believed to be the result of a reversible maternal condition such as diabetic ketoacidosis or pneumonia with hypoxemia.

39. Prolonged Decelerations
A decrease in FHR of > 15 beats per minute measured from the most recently determined baseline rate. The deceleration lasts >= 2 minutes but less than 10 minutes.
Causes:
Rapid descent of fetal head
Abruption
Artifact (maternal heart rate)
Maternal seizure
Maternal hypotension
Uterine hyperactivity
Cord prolapse
Cord compression*

40. Early deceleration

41. acceleration

42. Late deceleration

43. Variable deceleration

45. variable decelerations with absent to minimal variability

47. Variable decelerations with minimal to absent variability

49. Tachycardia and variable decels with late recovery

50. Variable decelerations with shoulder pattern

55. Category I
All of the following criteria must be present. Tracings meeting these criteria are predictive of normal fetal acid-base balance at the time of observation.
Baseline rate: 110 to 160 bpm
Moderate baseline FHR variability
No late or variable decelerations
Early decelerations may be present or absent
Accelerations may be present or absent

56. Category III
Category III tracings are predictive of abnormal fetal acid-base status at the time of observation.
(1) Absent baseline FHR variability and any of the following:
Recurrent late decelerations
Recurrent variable decelerations
Bradycardia
(2) Sinusoidal pattern

57. Category III
Category III tracings are predictive of abnormal fetal acid-base status at the time of observation. Prompt evaluation is indicated and most parturients will require expeditious intervention, such as provision of supplemental oxygen, change in position, treatment of hypotension, and discontinuation of any uterotonic drugs being administered

58. Category II
FHR tracing does not meet criteria for either category I or III and is considered indeterminate.

60. CardioTocoGraphy
Normal
Suspicious
pathological

61. Categorisation of fetal heart rate traces
Category
Definition
Normal
All four reassuring
Suspicious
1 non-reassuring
Rest reassuring
Pathological
2 or more non-reassuring
1 or more abnormal

63. ACTION 1. Change maternal position
2. Assess maternal vital signs (temperature, blood pressure, pulse)
3. Discontinue oxytocin infusion
4. Initiate oxygen at 6 to 10 L per minute
5. Perform a vaginal examination (check for cord prolapse, rapid descent of the head, or vaginal bleeding suggestive of placental abruption)

64. ACTION
6. Give intravenous fluids if not already administered; consider bolus
7. Assess fetal pH (fetal scalp PH, fetal scalp stimulation or acoustic stimulation)
8. Give amnioinfusion for recurrent, moderate to severe variable decelerations
9. Consider need for expedited delivery (operative vaginal delivery or cesarean delivery

65. (If facilities available)
PATHOLOGICAL
FETAL SCALP
STIMULATION TEST
FETAL VIBROACAUSTIC
FETAL SCALP
BLOOD Ph
(If facilities available)

66. Guidelines ACOG LOW RISK Intermittent auscultation First stage :q30min
Second stage :q15 min
High risk
Intermittent auscultation
Continuous monitoring
First stage :q15min
Second stage :q5 min

67. pathologic CTG in first stage
Silent pattern > 90 min
Complicated variable deceleration
Combined deceleration
Prolonged bradycardia
Action : fetal blood sampling

68. pathologic CTG in second stage
Baseline < 100 bpm
Baseline tachycardia with reduced variability and severe variable and late deceleration
Action : delivery

69. Continuous EFM for in pregnancies previously monitored with intermittent auscultation
baseline less than 110 bpm or greater 160 bpm
• any decelerations
• any intrapartum risk factors develop.

70. conditions not forgot
Meconium
Infection
abruption

71. RECORD KEEPING IN CTG
check date and time clocks on the EFM . (how reliable is the clock in the labor?)
Lable FHR traces with mother’s name, date and hospital number.
Sign trace & record date ,time and mode of birth.
Note any intrapartum events (e.g. vaginal examination, fetal blood sample, siting of an epidural).
Store trace securely.

72. Risk management
Consider the time taken for instrument vaginal birth and C/S .
Keep FHR traces for 25 years.
If the baby may suffer developmental delay , photocopy and store FHR traces indefinitely.
Don’t forget ABG.

73. Absent acceleration in category I:
rare acidosis.
Absent acceleration in category II : acidosis.

74. Fetal blood sampling
Acceleration
variability

75. How long wait for recovery ?
Determinate by
depth of deceleration
loss of variability during deceleration
heart rate returning toward baseline
evidence hypoxia preceded deceleration

76. Asphyxiation for 7-12 min resulted in
transient motor and behavioral changes.

77. CHECKMARK PATTERN

78. PSEUDOSINUSOIDAL

79. SALTATORY PATTERN

80. LAMBDA PATTERN

81. ACCELERATION OR DECCELERATION ???

82. BASELINE BRADYCARDIA WITH ACCELERATIONS

83. EXCESSIVE VARIABILITY???