Interpretsi Cardiotocography (CTG) Electronic Fetal Monitoring

Interpretsi Cardiotocography ( CTG )
Electronic Fetal Monitoring
Ali Sungkar 1
Divisi Fetomaternal
Departemen Obstetri dan Ginekologi FKUI/RSCM
Fetal Monitoring
• Track the baby s heart
rate during labor.
• Safe procedure that has

saved the lives of many
babies in high-risk
situations.
1
Electronic Monitoring
• Indirect • Direct
(External monitoring) (Internal monitoring)
Fetal response to hypoxemia

More effective uptake of oxygen
Reduced activity
Oxygen saturation
Decrease in growth rate
Hypoxemia Maintained energy balance
Hypoxia
Asphyxia
Days and weeks Hours Minutes
Time 4
2
The fetal response to hypoxia
Surge of stress hormones

Oxygen saturation
Redistribution of blood flow

Anaerobic metabolism in the
peripheral tissues
Hypoxemia Maintained energy balance
Hypoxia
Asphyxia
5
Time
Fetal response to asphyxia

Oxygen saturation
Alarm reaction
Hypoxemia Anaerobic metabolism in
peripheral tissues
Hypoxia Brain and heart organ
failure
Asphyxia
6
Time
3
7
Hypoxia from reduced cord blood flow
Oxygen reduces and CO2 increases

(respiratory acidosis develops)
If cord flow is not improved then base

excess used up and bicarbonate reduces
(metabolic acidosis develops)
Major fetal organ damage 8
4
EFM-ISSUES
• Detect fetal hypoxia i.e reduce and avoid

harm to the fetus and improve fetal and
baby out-come.
• Severe acidosis may result in FHR changes.
• Could occur in Normal physiological
response in labor.
• Misunderstanding the physiological and
pathphysiological CTGs will improve the Mx
( management). 9
EFM Problems and Realities

• Electronic Intra-partum FHR Monitoring is now
considered mandatory for high-risk pregnancies.
• Difficulties interpretation include over confidence & not-only
difference in opinion between practitioners but, also when
the same practitioner examines the same CTG twice.
• Increases CS rates 1.41%rr.
• Increases operative vaginal delivery 1.20%rr.
• And no change in incidence of C Palsy.

• Reduction in Neonatal seizures rates 0.51%
• No difference in APGAR scores.
10
• ? About the efficacy.
5
EFM- Facts
• Reliability of interpretation-50-75% are

false positive .
• False positive Dx reduces to 105 with FBS.
• FBS 93% sensitivity, 6% false positive.
• PH Vs Lactate -39% Vs 2.3(rr 16.7).
11
Electronic Fetal
Monitoring-Indications
Indications for the continuous EFM
• Oligohydramnios
• High risk
• Hypertension.
pregnancies
• Abnormal FHR
• IOL and detected.
Augmentation of • Malpresentation and in
Labour. labour.
• Reduced FM. • DM,Multiple Gestation.
• Previous CS.
• Premature
• Abdominal Trauma.
labour/TPL.
• Prolonged ROM.
• APH/IPH
• Meconium Liq. 12
6
EFM- Interpretation
Consider :
• Intrapartum / antepartum trace.

• Stage of labour.
• Gestation.
• Fetal presentation, ? Malpresentation.
• Any augmentation,? Induction labor
Medications ?
• Direct or indirect monitoring
13
EFM- 4 Basic Features.

• Baseline FHR - Mean level of FHR when this is
stable, excluding Accelerations and Decelerations
(110-160 bpm)
-Tachycardia
-Bradycardia
• Baseline Variability-5 bpm or greater than or
equal to 5bpm, between contractions
-Normal
-Non-reassuring-Less than 5 bpm or less but
less than 30 min
-Abnormal-less than 5 bpm for 90 min or more. 14
7
Uterine Contraction
15
16
8
Baseline variability CTG
Baseline variability
17
Baseline variability
• The minor fluctuations on baseline FHR at

3-5 cycles p/m produces Baseline
variability.
• Examine imin segment and estimate

highest peak and lowest trough.
• Normal is more than or equal to 5 bpm.
18
9
Variability
19
REDUCED VARIABILITY
Hypoxia Drugs Extreme prematurity

Sleep CNS abno.
20
10
21
TACHYCARDIA
Hypoxia Chorioamnionitis
Maternal fever B-Mimetic drugs Sepsis
Fetal anaemia, Heart failure Arrhythmias
22
11
Factors affecting Baseline variability.
• Para-Sympathetic affects short term

variability whilst Long Term is more Symp.
• CNS ,Drugs reduce Variability
• High gestation increases variability
• Mild Hypoxia may cause both S and para S

stimulation.
23
Non-reassuring Baseline variability.
• NR CTGs- reduced or less than 5 bpm for 40
min or more but less than 90 mins..
• B-B or short Term V is varying intervals

between successive heart beats .
• Long Term v is irregular waves on the CTG

3-5 bpm.
• Normal is 5-25 bpm– this indicates N-CNS. 24
12
EFM-Accelerations
• Accelerations- transient increase in FHR of
15 bpm or more lasting for 15 sec.
• Absence of accelerations on an otherwise
normal CTG remains un clear.
• Presence of FHR Accelerations have Good
outcome.
25
ACCELERATIONS
26
13
EFM Decelerations
• Decelerations-
transient slowing of
FHR below the
baseline level of
more than 15 bpm
and lasting for 15 sec.
Or more.
27
DECCELERATIONS
• EARLY : Head compression
• LATE : U-P Insufficiency
• VARIABLE : Cord compression

Primary CNS dysfn
28
14
• a) Early Decelerations
• Head compression
• Begins on the onset of contraction and
returns to baseline as the contraction
ends.
• Should not be disregarded if they
appear early in labor or Antenatal.
• Clinical situation should be r/v
29
EARLY Deceleration
30
15
Late Decelerations.
• Uniform periodic slowing of FHR with the on

set of the contractions .
• Repetitive late decels increases risk of
Umbilical artery acidosis and Apgar score of
less than 7 at 5 mins and Increased risk of
CP.
31

b) Late Decelerations
• Due to acute and chronic feto-placental
vascular insufficiency
• Occurs after the peak and past the length of
uterine contraction, often with slow return to
the baseline.
• Are precipitated by hypoxemia
• Associated with respiratory and metabolic
acidosis
• Common in patients with PIH, DM, IUGR or
other form of placental insufficiency.
32
16
LATE Deceleration
33
Late Decelerations
• Reduces Baseline variability together

with Late Decelerations or Variable
Decelerations is associated with

increased risk of CP.
34
17
EFM- Variable Decelerations
• Variable intermittent periodic slowing of FHR with
rapid onset recovery and isolation.
• They can resemble other types of deceleration in
timing and shape.
• Atypical VD are associated with an increased risk
of umbilical artery acidosis and Apgar score less
than 7 at 5 min
• Additional components:
• Loss of 1 degree or 2 degree rise in baseline Rate
• Slow return to baseline FHR after and end of
contraction.
• Prolonged secondary rise in Base FHR
• Biphasic deceleration
• Loss of variability during deceleration
• Continuation of base line at a lower level. 35
VARIABLE Deceleration
36
18
c) Variable Deceleration (Vagal activity)
• Inconsistent in configuration,
• No uniform temporal r-ship to the onset of
contraction, are variable and occur in isolation.
• Worrisome when Rule of 60 is exceeded (i.e.
decrease of 60 bpm,or rate of 60 bpm and longer
than 60 sec)
• Caused by cord compression of the umbilical cord
• Often associated with Oligo-hydroaminos with or
without ROM
• Can cause short lived RDS if they MILD
• Acidosis if prolonged and Recurrent.
37
References
38
19
39
EFM Prolonged deceleration

Prolonged Deceleration
• Drop in FHR of 30 bpm or More lasting for
at least 2 min
• Is pathological when crosses 2 contractions
i.e 3 mins.
• Reduction in O2 transfer to placenta.
• Associated with poor neonatal outcome.
40
20
EFM- Prolonged
Decelerations CAUSES
• Cord prolapse.
• Maternal hypertension
• Uterine Hypertonia
• Followed by a Vag Exam or ARM or
SROM with High PP.
41
Prolonged Deceleration
42
21
EFM Mx Prolonged Deceleration
• Maternal position
• IV fluids
• V.E to exclude cord prolapse

• Assess BP
• FBS if cx dilated and well applied PP

• Mx Depending on the clinical situation.
43
Baseline Bradycardia
• FH below 110bpm(FIGO ).
• less than 100bpm (RANZCOG).
Causes.
Postdates, Drugs, Idiopathic,
Arrythmias, hypothermia(increased Vagal Tone)
Cord Compression (Acute Hypoxia, congenital H
disease and Drugs).
Mx depends on the clinical situation.(FBS,Vag Exam,

Observation or expedite delivery) 44
22
Types
• Moderate Bradycardia 100-109 bpm

• Abnormal bradycardia less than 100bpm.
• Tachycardia 161-180 bpm
• Abnormal Tachycardia more than 180
bpm
• Ranzcog Australian more than 170 bpm
45
Baseline tachycardia and

Bradycardia.
• Uncomplicated baseline tachycardia
161-180 bpm or bradycardia 101-109

do not appear to be associated with
poor NN outcome.
46
23
Causes of B Tachycardia.
• Asphyxia
• Drugs
• Prematurity
• Maternal Fever
• Maternal thyrotoxicosis
• Maternal Anxiety
• Idiopathy
• Mx depends on the clinical situation
47

Baseline Bradycardia
• FH Rate below 110bpm (FIGO Recommended)
• Postdates
• Drugs
• Idiopathic
• Arrhythmia's
• Hypothermia.(Increased Vagal tone),
• Cord compression(Acute Hypoxia,Congenital
H/disease, and drugs)
Mx depends on the clinical situation. (FBS, Vag Exam ,
Observation or expedite Delivery).
48
24
Baseline Tachycardia
• Asphyxia
• Drugs
• Prematurity
• Maternal fever
• Maternal thyrotoxicosis
• Maternal Anxiety
• Idiopathy
Mx depends on the clinical situation
49
Sinusoidal pattern
Interpretation of the CTG
50
25
EFM-Sinusoidal Pattern
• Regular Oscillation of the Baseline long-term
Variability resembling a Sine wave ,with no B-
b Variability
• Has fixed cycle of 3-5 p min. with amplitude
of 5-15 bpm and above but not below the
baseline.
• Should be viewed with suspicion as poor
outcome has been seen (eg Feto-maternal
haemorrhage)
51

Sinusoidal pattern- distinctive smooth undulating
Sine-wave baseline with no B-b variability
• 0.3 % (Young 1980)
• cord compression
• hypovolemia
• ascites
• idiopathic(fetal thumb sucking)
• Analgesics
• Anaemia
• Abruption
• Mx r/v clinical situation 52
26
EFM- Saltatory pattern
• Seen During Fetal thumb sucking.
• Could be associated with Hypoxia.
53
54
27
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
55
56
28
57
58
29
59
International Journal of Gynecology and Obstetrics 131 (2015) 13–24
Contents lists available at ScienceDirect
International Journal of Gynecology and Obstetrics
journal homepage: www.elsevier.com/locate/ijgo
FIGO GUIDELINES
FIGO consensus guidelines on intrapartum fetal

monitoring: Cardiotocography☆,★
Diogo Ayres-de-Campos a, Catherine Y. Spong b, Edwin Chandraharan c;
for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 1
a
Medical School, Institute of Biomedical Engineering, S. Joao Hospital, University of Porto, Portugal
b
Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
c
St George’s University Hospitals NHS Foundation Trust, London, UK
1.22
Introduction occurrence
D. Ayres-de-Campos et al. / International of of
Journal neonatal seizures,
Gynecology but no effect
and Obstetrics has been
131 (2015) 13–24 demonstrated
on the incidence of overall perinatal mortality or cerebral palsy. Howev-
The purpose
Table 1 of this chapter is to assist in the use and interpretation er, these studies were carried out in the 1970s, 1980s, and early 1990s
ofCardiotocography
intrapartum cardiotocography (CTG),interpretation,
classification criteria, as well as in the
andclinical
recommended where equipment,
man- management. a clinical experience, and interpretation criteria were
agement of specific CTG patterns. In the preparation of these guidelines, very different from current practice, and they were clearly underpow-
it has been assumed that all Normal necessary resources, both human and ma- ered to evaluate differences in major outcomes
Suspicious [3]. These issues are
Pathological
terial, required for intrapartum monitoring and clinical management discussed in more detail in Section 8 of this chapter. In spite of these
Baseline 110−160 bpm Lacking at least one characteristic of normality, but b 100 bpm
are readily available. Unexpected complications may occur during limitations, most experts believe that continuous CTG monitoring
with no pathological features
labor, even in patients without prior evidence of risk, so maternity hos- should be considered in all situations where there is a high risk of fetal
Variability 5−25 bpm Lacking at least one characteristic of normality, but Reduced variability, increased variability, or sinusoidal
pitals need to ensure the presence of trained staff, as well as appropriate hypoxia/acidosis, whether due to maternal health conditions (such as
with no pathological features pattern
facilities and equipment for an expedite bdelivery (in particular emer- vaginal hemorrhage and maternal pyrexia), abnormal bfetal growth
Decelerations No repetitive decelerations Lacking at least one characteristic of normality, but Repetitive late or prolonged decelerations during
gency cesarean delivery). CTG monitoring should never be regarded as during pregnancy, epidural analgesia, meconium stained liquor, or the
with no pathological features N 30 min or 20 min if reduced variability, or one
a substitute for good clinical observation and judgement, or as an excuse possibility of excessive uterine activity, as occurs with induced or aug-
prolonged deceleration with N5 min
for leaving the mother unattended during labor. mented labor. Continuous CTG is also recommended when abnormali-
Interpretation Fetus with no hypoxia/acidosis Fetus with a low probability of having Fetus with a high probability of having hypoxia/acidosis
ties are detected during intermittent fetal auscultation. The use of
hypoxia/acidosis
continuous intrapartum CTG in low-risk women is more controversial,
Clinical
2. Indications management No intervention necessary to improve Action to correct reversible causes if identified, Immediate action to correct reversible causes,
although it has become standard of care in many countries. An alterna-
fetal oxygenation state close monitoring or additional methods to evaluate additional methods to evaluate fetal oxygenation
tive approach is to provide intermittent CTG monitoring alternating
The evidence for the benefits of continuous CTG monitoring, as fetal oxygenation [49] [49], or if this is not possible expedite delivery. In
with fetal heart rate (FHR) auscultation. There is some evidence to sup-
compared with intermittent auscultation, in both low- and high-risk acute situations (cord prolapse, uterine rupture, or
port that this is associated with similar neonatal outcomes in low-risk
labors is scientifically inconclusive [1,2]. When compared with intermit- placental abruption) immediate delivery should be
pregnancies [4]. Intermittent monitoring should be carried out long
tent auscultation, continuous CTG has been shown to decrease the accomplished.
enough to allow adequate evaluation of the basic CTG features (see
a
The presence of accelerations denotes a fetus that does not have hypoxia/acidosis, below). The routine
but their use ofduring
absence admission CTG
labor is for low-risk
of uncertain women on en-
significance.
b
☆ Developed by the areFIGO Safe Motherhood
Decelerations repetitive in nature and
when Newborn Health
they are Committee;
associated with more trance to the
than 50% labor ward
of uterine has been[29].
contractions associated with an increase in cesar-
coordinated by Diogo Ayres-de-Campos.
ean delivery rates and no improvement in perinatal outcomes [5], but
★ The views expressed in this document reflect the opinion of the individuals and not
studies were also underpowered to show such differences. In spite of
1
6. Clinical
necessarily decision
those of the institutions that they represent. patterns, but there is no evidence from randomized clinical trials that
the lack of evidence regarding benefit, this procedure has also become
Consensus panel: Daniel Surbek (Switzerland⁎), Gabriela Caracostea (Romania⁎), Yves
Jacquemyn (Belgium⁎), Susana Santo (Portugal⁎), Lennart Nordström (Sweden⁎), Tulia standard of care this intervention,
in many countries. when performed in isolation, is effective when mater-
Todros Several factors,
(Italy⁎), Branka including
Yli (Norway⁎), gestational
George age and
Farmakidis (Greece⁎), medication
Sandor Valent adminis- nal oxygenation is adequate [47]. Intravenous fluids are also commonly
(Hungary⁎), Bruno Carbonne (France⁎), Kati Ojala (Finland⁎), José Luis Bartha (Spain⁎),
tered
Joscha to the(Germany⁎),
Reinhard mother, can Annekeaffect
KweeFHR features Romano
(Netherlands⁎), (see above), so CTG3.analysis
Byaruhanga used for the purpose of improving CTG patterns, but again there is no
Tracing acquisition
needs to
(Uganda⁎), be integrated
Ehigha with other
Enabudoso (Nigeria⁎), clinical
John Anthony information
(South Africa⁎), Fadi for
Mirzaa comprehen- evidence from randomized clinical trials to suggest that this interven-
(Lebanon⁎), Tak Yeung Leung (Hong Kong⁎), Ramon Reyles (Philippines⁎), Park In Yang 3.1. Maternal position for CTG acquisition
siveKorea⁎),
(South interpretation
Henry Murray and adequate
(Australia and Newmanagement.
Zealand⁎), Yuen As a general rule, if the
Tannirandorn tion is effective in normotensive women [48].
fetus continues
(Thailand⁎), to maintain
Krishna Kumar (Malaysia⁎), a stableAlhaidary
Taghreed baseline andTomoaki
(Iraq⁎), a reassuring
Ikeda
Maternal supine Good
variability, clinical
recumbent judgement
position is aortocaval
can result in requiredcom-to diagnose the underlying
(Japan⁎), Ferdusi Begum (Bangladesh⁎), Jorge Carvajal (Chile⁎), José Teppa (Venezuela⁎),
the Sá
Renato risk of hypoxia
(Brazil⁎), Lawrence to the(USA⁎⁎),
Devoe central organs
Gerard is very unlikely.
Visser (Netherlands⁎⁎), RichardHowever, the
pression cause for
by the pregnant a suspicious
uterus, or pathological
affecting placental CTG,fetal
perfusion and to judge the reversibility of
general
Paul principles
(USA⁎⁎), Barry that should
Schifrin (USA⁎⁎), guide
Julian Parer clinical
(USA⁎⁎), management
Philip Steer (UK⁎⁎), Vincenzo areoxygenation. the conditions
outlined Prolonged monitoringwith which
in this it is should
position associated, and to determine the timing
therefore
Berghella (USA⁎⁎), Isis Amer-Wahlin (Sweden⁎⁎), Susanna Timonen (Finland⁎⁎), Austin be avoided. The oflateral recumbent,
in Table(UK⁎⁎),
Ugwumadu 1. João Bernardes (Portugal⁎⁎), Justo Alonso (Uruguay⁎⁎), Sabaratnam delivery, withhalf-sitting, and upright
the objective positionsprolonged fetal hypoxia/
of avoiding
are preferable alternatives [6].
Arulkumaran (UK⁎⁎). acidosis, as well as unnecessary obstetric intervention. Additional
30
⁎ Nominated by FIGO associated national society; ⁎⁎ Invited by FIGO based on literature CTG acquisition can be performed by portable sensors that transmit
7. Action in situations of suspected fetal hypoxia/acidosis signals wirelesslymethods
search. may
to a remote bemonitor
fetal used to(telemetry).
evaluate fetal oxygenation [49]. When a suspi-
This solution
cious or worsening CTG pattern is identified, the underlying cause
When fetal hypoxia/acidosis is anticipated or suspected (suspicious
http://dx.doi.org/10.1016/j.ijgo.2015.06.020
should be addressed before a pathological tracing develops. If the situa-
and pathological
0020-7292/© 2015 Publishedtracings), and Ltd.
by Elsevier Ireland action is required
on behalf to Federation
of International avoid adverse neo-
of Gynecology tion
and Obstetrics.does not revert and the pattern continues to deteriorate, consider-
natal outcome, this does not necessarily mean an immediate cesarean ation needs to be given for further evaluation or rapid delivery if a
delivery or instrumental vaginal delivery. The underlying cause for the pathological pattern ensues.
appearance of the pattern can frequently be identified and the situation During the second stage of labor, due to the additional effect of ma-
CTG classification
2015 revised FIGO guidelines on intrapartum fetal monitoring
Normal Suspicious Pathological
Baseline 110-160 bpm < 100 bpm
Reduced variability.
Variability 5-25 bpm Lacking at least one Increased variability.
characteristic of Sinusoidal pattern.
normality, but with no Repetitive* late or
pathological features prolonged decelerations
No repetitive*
Decelerations decelerations
for > 30 min (or > 20 min if
reduced variability).
Deceleration > 5 min
Low probability of High probability of
Interpretation No hypoxia/acidosis
hypoxia/acidosis hypoxia/acidosis
Immediate action to
correct reversible causes,
Action to correct
adjunctive methods, or if
No intervention reversible causes if
Clinical this is not possible
necessary to improve identified, close
management fetal oxygenation state monitoring or adjunctive
expedite delivery. In acute
situations immediate
methods
delivery should be
accomplished
D. Lewis, S. Downe / International Journal of Gynecology and Obstetrics 131 (2015) 9–12
*Decelerations are repetitive when associated with > 50% contractions.
61
Absence of accelerations in labour is of uncertain significance.
Table 1 woman, and her consent obtained. T
Advantages and disadvantages of the instruments used for intermittent auscultation. of the fetal position on abdominal
Advantages Disadvantages stethoscope or handheld Doppler ov
Pinard stethoscope Inexpensive May be difficult to use in
the heart rate will usually be heard m
Readily available in most certain maternal positions produced by the fetal heart (usually
countries rather than those created by fetal ve
No consumables needed for a clearer distinction from materna
DeLee stethoscope Inexpensive May be difficult to use in
tion of the maternal pulse provides ad
Readily available in some certain maternal positions
countries is being monitored. Just before and d
No consumables needed hand is placed on the uterine fundus
Handheld Doppler More comfortable for the
More costly to purchase and contractions and to detect fetal mov
woman maintain (requires batteries) be identified unambiguously, ultrasou
International Journal FHR audibleof Gynecology to all present and Obstetrics to determine the FHR and to establish
in the room
j o u r n a l h o m eCan
p a g e :be
w wused
w . e l s ein r . c o m / l o c a t e / i j g o Probe is very sensitive to
v i evarious tent auscultation.
maternal positions and mechanical damage There are no studies comparing th
FIGO GUIDELINES locations (e.g. in water) intervals. In large randomized trials
FIGO consensus guidelines on intrapartum fetal monitoring: May display maternal heart
May calculate and display
auscultation, the latter was usually p
☆,★ FHR values rate
Intermittent auscultation first stage and every five minutes or
Debrah Lewis a, Soo Downe b; for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 1 the second stage [5]. While it is reco
the scheduling of intermittent auscu
a
Mamatoto Resource and Birth Centre, Port of Spain, Trinidad
b
University of Central Lancashire, Preston, UK
Table 2 opinion, standardization of procedu

1. Introduction
Conditions required for considering andThemaintaining intermittent auscultation in settings
first recorded use of an amplification device for auscultation of health care and for medical − legal
where cardiotocography is available. the adult heart rate is attributed to Laënnec in 1816, who overcame
Intermittent auscultation is the technique used to listen to the fetal the embarrassment of placing the ear on a young woman’s chest to for performing intermittent auscultat
heart rate (FHR) for short periods of time without a display of the
Antepartum factors
resulting pattern. Whether it is used for intrapartum fetal monitoring
hear her heart beat by rolling sheets of paper into a tube and listening
Intrapartum factors
through this device [2]. This tool was soon replicated in wood, and
All features listed in Table 3 shou
in low-risk women or for all cases in settings where there are no avail-
able alternatives, allNo serious
healthcare previous
professionals maternal
attending labor and
gained wide usage for fetal heart auscultation. The most common in-
health
strument currentlyNormal
used for thisfrequency
purpose is theof contractions
Pinard stethoscope
charts to provide an ongoing accoun
delivery need to be skilledconditions
at performing intermittent auscultation, (Figs. 1 and 2), but in some countries, notably the USA, the DeLee information between caregivers wh
interpreting its findings, and taking appropriate action. The main aim stethoscope is used as an alternative (Fig. 3). In both cases, the technol-
No maternal
of this chapter is to describe the tools anddiabetes orintermittent
techniques for pre-eclampsiaogy has not changed Nomuchlabor
from theinduction orinaugmentation
original design, which a belled the process.
auscultation in labor.No antenatal vaginal hemorrhage tube creates an amplification No epiduralchamber analgesia
for sound waves that are trans-
mitted from the fetal heart to the examiner’s ear.
Normal fetal growth, amniotic fluid, More recently, handheld
2. Historical background No abnormal vaginal
electronic devices hemorrhage
that rely on the Doppler
and Doppler effect have been used for intermittent auscultation (Fig. 4), a technology 7. Abnormal findings and their man
Hippocrates is said to have described the technique of listening to similar to the external FHR monitoring of cardiotocography (CTG).
Normal
the internal activity of the body byantenatal
placing the ear cardiotocography
on the skin proximal However, as describedNoinfresh or on
the chapter thick meconium
CTG [4], these devices do not
readings
to the organ under examination. However, the perception of fetal heart transmit the actual sound produced by the fetal heart, but rather a rep-
resentation of this, based on ultrasound-detected movements of fetal
7.1. In settings where continuous CTG i
sounds using this method was not reported until the 1600s [1]. Little at-
No previous uterine scar
tention appears to have been given to fetal heart auscultation until No maternal temperature N 38°C
cardiac structures, that are then subject to signal modification and auto-
Normal
1818, when it was discussed fetal
by both Mayormovements
and de Kergaradec [2] to de- correlation. Table 1 Active
compares thefirst stageand
advantages lasting b 12ofhours
disadvantages the
termine whether the fetus was alive or dead. Interest then accelerated,
No rupture of membranes lasting
three instruments currently
Second
used for
stage
intermittent
lasting
auscultation.
b 1 hour
Abnormal findings on intermitten
and in 1833 Kennedy published a book on the subject of obstetric aus-
cultation [3]. N 24 hours 3. Objectives and indications
If there is doubt as to the characteriza
Singleton, term, cephalic presentation
☆ Developed by the FIGO Safe Motherhood and Newborn Health Committee;
As for
Clearly audible fetal heart rate
other approaches to fetal monitoring, the main aim of
should be prolonged in order to cove
sounds
intermittent auscultation is thein normal
timely range
identification of fetuses with An FHR value under 110 bpm la
necessarily the institutions that they represent. hypoxia/acidosis to enable appropriate action before the occurrence of
1
Source: Maude et al. [6].
Consensus panel: Daniel Surbek (Switzerland⁎), Gabriela Caracostea (Romania⁎), Yves injury. It also allows the confirmation of normal FHR characteristics, so when the rate has previously been n
Jacquemyn (Belgium⁎), Susana Santo (Portugal⁎), Lennart Nordström (Sweden⁎), Tulia that unnecessary intervention will be avoided. Systematic reviews of
Todros (Italy⁎), Branka Yli (Norway⁎), George Farmakidis (Greece⁎), Sandor Valent
randomized controlled trials carried out in the 1970s, 1980s, and early prolonged deceleration or of fetal
1990s, comparing intermittent auscultation with continuous CTG for
Joscha Reinhard (Germany⁎), Anneke Kwee (Netherlands⁎), Romano Byaruhanga
(Uganda⁎), Ehigha Enabudoso (Nigeria⁎), Fadi Mirza (Lebanon⁎), Tak Yeung Leung intrapartum monitoring in both low- and high-risk women, have indication for immediate continuou
Many of these disadvantages are overcome by the use of a handheld
(Hong Kong⁎), Ramon Reyles (Philippines⁎), Park In Yang (South Korea⁎), Henry Murray
(Australia and New Zealand⁎), Yuen Tannirandorn (Thailand⁎), Krishna Kumar
shown that CTG is associated with a lower risk of neonatal seizures,
but with higher cesarean and instrumental vaginal delivery rates [5].
160 bpm during three contractions is
Doppler. When this device includes a display showing the FHR, even cardia, and constitutes an indication
(Malaysia⁎), Taghreed Alhaidary (Iraq⁎), Tomoaki Ikeda (Japan⁎), Ferdousi Begum
The limitations of this evidence are analyzed in the chapter on CTG
(Bangladesh⁎), Jorge Carvajal (Chile⁎), José Teppa (Venezuela⁎), Renato Sá (Brasil⁎),
Lawrence Devoe (USA⁎⁎), Gerard Visser (Netherlands⁎⁎), Richard Paul (USA⁎⁎), Barry [4]. There is currently no conclusive evidence for the benefits of contin-
low variability may be suspected. On the other hand, as occurs with ex-
Schifrin (USA⁎⁎), Julian Parer (USA⁎⁎), Philip Steer (UK⁎⁎), Vincenzo Berghella (USA⁎⁎), uous CTG versus intermittent auscultation monitoring in labor. There Sometimes, decelerations occur
Isis Amer-Wahlin (Sweden⁎⁎), Susanna Timonen (Finland⁎⁎), Austin Ugwumadu (UK⁎⁎), are also no trials comparing intermittent auscultation with no FHR aus-
ternal FHR monitoring in CTG, the device can inadvertently pick up the
João Bernardes (Portugal⁎⁎), Justo Alonso (Uruguay⁎⁎), Sabaratnam Arulkumaran (UK⁎⁎),
Catherine Y. Spong (USA⁎⁎), Edwin Chandraharan (UK⁎⁎), Diogo Ayres-de-Campos
cultation during labor. position and resulting aortocaval com
Based on expert opinion, intermittent auscultation should be recom-
(Portugal⁎⁎).
maternal heart rate.
⁎Nominated by FIGO associated national society; ⁎⁎ Invited by FIGO based on literature mended in all labors in settings where there is no access to CTG moni- position may quickly revert the situat
tors or to the resources necessary for using them. When the resources
search.
Whichever method of intermittent auscultation is used, it may be tion does not ensue, or if repetitive o
difficult to guarantee the continued availability of appropriately trained
31
tected, continuous CTG should be sta
0020-7292/© 2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology and Obstetrics.
staff to attend laboring women in busy labor units. Most accelerations coincide with
mother and/or the healthcare profess
6. Technique for performing intermittent auscultation being. However, accelerations occu
for performing intermittent auscultation are considered in Table 3.
Antepartum factors Intrapartum factors All features listed in Table 3 should be recorded in dedicated labor
No serious previous maternal health Normal frequency of contractions charts to provide an ongoing account of their evolution, and to share
conditions information between caregivers who are or may become involved in
No maternal diabetes or pre-eclampsia No labor induction or augmentation the process.
No antenatal vaginal hemorrhage No epidural analgesia
Normal fetal growth, amniotic fluid, No abnormal vaginal hemorrhage
and Doppler 7. Abnormal findings and their management
Normal antenatal cardiotocography No fresh or thick meconium
readings 7.1. In settings where continuous CTG is available
No previous uterine scar No maternal temperature N38°C
Normal fetal movements Active first stage lasting b12 hours
No rupture of membranes lasting Second stage lasting b1 hour
Abnormal findings on intermittent auscultation are listed in Table 4.
N24 hours If there is doubt as to the characterization of FHR findings, auscultation
Singleton, term, cephalic presentation Clearly audible fetal heart rate should be prolonged in order to cover at least three contractions.
sounds in normal range An FHR value under 110 bpm lasting more than three minutes,
Source: Maude et al. [6]. when the rate has previously been normal, is strongly suggestive of a
prolonged deceleration or of fetal bradycardia, and constitutes an
indication for immediate continuous CTG. An FHR value exceeding
Many of these disadvantages are overcome by the use of a handheld 160 bpm during three contractions is strongly suggestive of fetal tachy-
Doppler. When this device includes a display showing
Contents lists the FHR,ateven
available ScienceDirect cardia, and constitutes an indication for continuous CTG.
low variability may be suspected. On the other hand, as occurs with ex- Sometimes, decelerations occur because of the maternal supine
ternal FHR monitoring in International Journal of Gynecologyposition
CTG, the device can inadvertently pick up the and Obstetrics
and resulting aortocaval compression. Changing the maternal
maternal heart rate. position may quickly revert the situation. However, if a rapid normaliza-
Whichever method of intermittent j o u r nauscultation
a l h o m e p a g eis: used,
w w w .it
e lmay r . c o m /tion
s e v i ebe l o c adoes
t e / i j gnot
o ensue, or if repetitive or prolonged decelerations are de-
difficult to guarantee the continued availability of appropriately trained tected, continuous CTG should be started.
staff to
FIGO attend laboring women in busy labor units.
GUIDELINES Most accelerations coincide with fetal movements detected by the
mother and/or the healthcare professional, and are a sign of fetal well-
FIGO consensus
6. Technique guidelines
for performing on intrapartum
intermittent auscultation fetal monitoring: being. However, accelerations occurring just after a contraction do
Intermittent auscultation☆,★ not usually translate to fetal movements and should motivate ausculta-
Before intermittent auscultation is initiated, a clear explanation of tion over at least three contractions in order to rule out the occurrence
Debrah Lewis a, Soo Downe b; for the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 1
a
the technique and its purpose should be provided to the laboring of decelerations.
Mamatoto Resource and Birth Centre, Port of Spain, Trinidad
b
University of Central Lancashire, Preston, UK
Table 3
1. Introduction
Practice recommendations for intermittent auscultation, uterine contraction, and maternalThe firstheart
recorded use of an amplification
rate monitoring during labor. device for auscultation of
the adult heart rate is attributed to Laënnec in 1816, who overcame
Features to evaluate
Intermittent auscultation is the technique used to listen to the fetal the embarrassment of placing the ear onWhat a youngto register
woman’s chest to
heart rate (FHR) for short periods of time without a display of the hear her heart beat by rolling sheets of paper into a tube and listening
FHR pattern. Whether it is used forDuration:
resulting for atfetal
intrapartum leastmonitoring
60 seconds; for through
3 contractions if the FHR
this device Baseline
[2]. This tool was soon (as a single
replicated counted
in wood, and number in bpm), presence
is not always in the normal
in low-risk women or for all cases in settings where there are no avail- range (110−160 bpm). or absence
gained wide usage for fetal heart auscultation. The most of accelerations
common in- and decelerations.
Timing: during
able alternatives, all healthcare professionals and atlabor
attending least 30
andseconds after a contraction.
strument currently used for this purpose is the Pinard stethoscope
delivery need to be skilled at performing intermittent
Interval: Every 15 auscultation,
minutes in the active(Figs. 1 and
phase 2),first
of the butstage
in some countries, notably the USA, the DeLee
interpreting its findings, and taking appropriate action.
of labor. Every five The main aim
minutes stethoscope
in the second stage ofislabor.
used as an alternative (Fig. 3). In both cases, the technol-
of this chapter is to describe the tools and techniques for intermittent ogy has not changed much from the original design, in which a belled
Uterine contractions Before and during FHR auscultation, in order to detect at least Frequency in 10 minutes.
auscultation in labor. tube creates an amplification chamber for sound waves that are trans-
two contractions.
mitted from the fetal heart to the examiner’s ear.
Fetal movements At the same time as evaluation of uterineMore contractions.
recently, handheld electronic Presence or absence.
2. Historical background
Maternal heart rate
12 At the time of FHR auscultation.
D. Lewis, S. devices
Downe that/ rely on the Doppler Journal of Gynecology
International
Single counted
and Obstetrics 131 (2015) 9–12
effect have been used for intermittent auscultation (Fig. 4),number in bpm.
a technology
Hippocrates is said to have described the technique of listening to similar to the external FHR monitoring of cardiotocography (CTG).
Abbreviation: FHR, fetal heart rate; bpm, beats per minute.
the internal activity of the body by placing the ear on the skin proximal However, as described in the chapter on CTG [4], these devices do not
Table 4
to the organ under examination. However, the perception of fetal heart transmit the actual sound produced by the fetal heart, but rather a rep- adrenergic agonists (salbutamol, terbu
sounds using this method Abnormal findings
was not reported on intermittent
until the 1600s [1]. Little at- auscultation.
resentation of this, based on ultrasound-detected movements of fetal
troglycerine (see physiology chapter [
tention appears to have been given to fetal heart auscultation until cardiac structures, that are then subject to signal modification and auto-
1818, when it was discussed by both Mayor and de Kergaradec correlation. Table 1 compares the advantages and disadvantages of the
[2] to de- finding
Abnormal cultation to document the normali
termine whether the fetus was alive or dead. Interest then accelerated, three instruments currently used for intermittent auscultation.
and in 1833 Kennedy published a book on the subject of obstetric aus-
Baseline Below 110 bpm or above 160 bpm
maternal hypotension rarely happen
cultation [3].
Decelerations
3. Objectives and indications
Presence of repetitive or prolonged (N 3 minutes) decelerations conduction analgesia, but should it occ
Contractions
☆ Developed by the FIGO Safe Motherhood and Newborn Health Committee;
More than fiveAscontractions in a to
for other approaches 10-minute period
fetal monitoring, the main aim of celeration, increased intravenous fluid
intermittent auscultation is the timely identification of fetuses with
Abbreviation: bpm, beats per minute.
necessarily the institutions that they represent. hypoxia/acidosis to enable appropriate action before the occurrence of er to her side and administering intr
injury. It also allows the confirmation of normal FHR characteristics, so
revert the situation. When late and/or
1
Jacquemyn (Belgium⁎), Susana Santo (Portugal⁎), Lennart Nordström (Sweden⁎), Tulia that unnecessary intervention will be avoided. Systematic reviews of
Todros (Italy⁎), Branka Yli (Norway⁎), George Farmakidis (Greece⁎), Sandor Valent
randomized controlled trials carried out in the 1970s, 1980s, and early umented during the second stage of la
1990s, comparing intermittent auscultation with continuous CTG for
An interval between two contractions of less than two minutes
Joscha Reinhard (Germany⁎), Anneke Kwee (Netherlands⁎), Romano Byaruhanga
(Uganda⁎), Ehigha Enabudoso (Nigeria⁎), Fadi Mirza (Lebanon⁎), Tak Yeung Leung intrapartum monitoring in both low- and high-risk women, have to stop pushing until this pattern disap
shown that CTG is associated with a lower risk of neonatal seizures,
should lead to evaluation of uterine contractions over 10 minutes. of late and/or prolonged decelerations
(Hong Kong⁎), Ramon Reyles (Philippines⁎), Park In Yang (South Korea⁎), Henry Murray
(Australia and New Zealand⁎), Yuen Tannirandorn (Thailand⁎), Krishna Kumar but with higher cesarean and instrumental vaginal delivery rates [5].
(Malaysia⁎), Taghreed Alhaidary (Iraq⁎), Tomoaki Ikeda (Japan⁎), Ferdousi Begum
More than five contractions detected during this period is considered
(Bangladesh⁎), Jorge Carvajal (Chile⁎), José Teppa (Venezuela⁎), Renato Sá (Brasil⁎),
The limitations of this evidence are analyzed in the chapter on CTG
[4]. There is currently no conclusive evidence for the benefits of contin-
immediate delivery, by cesarean or in
Lawrence Devoe (USA⁎⁎), Gerard Visser (Netherlands⁎⁎), Richard Paul (USA⁎⁎), Barry
tachysystole (see CTG chapter [4]). This constitutes an indication for
Schifrin (USA⁎⁎), Julian Parer (USA⁎⁎), Philip Steer (UK⁎⁎), Vincenzo Berghella (USA⁎⁎), uous CTG versus intermittent auscultation monitoring in labor. There cording to obstetric conditions and loc
Isis Amer-Wahlin (Sweden⁎⁎), Susanna Timonen (Finland⁎⁎), Austin Ugwumadu (UK⁎⁎), are also no trials comparing intermittent auscultation with no FHR aus-
continuous CTG, at least until the situation is reversed.
João Bernardes (Portugal⁎⁎), Justo Alonso (Uruguay⁎⁎), Sabaratnam Arulkumaran (UK⁎⁎), cultation during labor.
Catherine Y. Spong (USA⁎⁎), Edwin Chandraharan (UK⁎⁎), Diogo Ayres-de-Campos
(Portugal⁎⁎). If assessment of the parameters described in Table 3 and the general
⁎Nominated by FIGO associated national society; ⁎⁎ Invited by FIGO based on literature
Based on expert opinion, intermittent auscultation should be recom-
mended in all labors in settings where there is no access to CTG moni-
search. behavior of the mother indicate the continuous well-being of both tors or to the resources necessary for using them. When the resources Conflict of interest
mother andInternational baby,Journal intermittent auscultation
of Gynecology and Obstetrics 131 (2015) 5–8 may continue to be the
0020-7292/© 2015 Published by technique of
Elsevier Ireland Ltd. on choice
behalf for
of International labor.
Federation of Gynecology and Obstetrics. The authors have no conflicts of in
7.2.International
In settings where
Journalcontinuous CTGand
of Gynecology is not available
Obstetrics
References
If an FHR j o u r n avalue
l h o m e p aunder
g e : w w w . e110 l s e v i e r bpm
. c o m / l o clasting
ate/ijgo more than five minutes is [1] O’Dowd MJ, Philipp EE. The History of O
detected—in the absence of maternal hypothermia, known fetal heart Parthenon Publishing Group; 1994.
FIGO GUIDELINES
block, or beta-blocker therapy—consideration should be given to imme- [2] Freeman RK, Garite TJ, Nageotte MP, Mille
Heart Rate Monitoring. Philadelphia: Lippi
FIGO consensus diate guidelines
delivery onby intrapartum
cesarean fetal monitoring: Physiology
or instrumental vaginal delivery, according to [3] Kennedy E. Observations on obstetric auscu
of fetal oxygenation obstetric andconditions
the main goals andoflocal intrapartum resources. https://archive.org/details/observationso
, 2014.
fetal monitoring☆An ★ FHR value exceeding 160 bpm during at least three contractions is
[4] Ayres-de-Campos D, Spong CY, Chandraha
suggestive of fetal tachycardia, and should motivate an evaluation of
Diogo Ayres-de-Campos a, Sabaratnam Arulkumaran b, Expert Consensus Panel. FIGO consensus g
for the FIGO Intrapartum maternal temperature
Fetal Monitoring and signs
Expert Consensus Panelof 1 intrauterine infection. Beta-agonist ing: Cardiotocography. Int J Gynecol Obste
a
drugs
Medical School, Institute of Biomedical (salbutamol,
Engineering, terbutaline,
S. Joao Hospital, University of Porto, Portugal ritodrine, fenoterol) and parasympathetic [5] Alfirevic Z, Devane D, Gyte GM. Continuo
b
St George’s, University of London, London, UK electronic fetal monitoring (EFM) for fe
blockers (atropine, scopolamine) are other possible causes. With isolated Database Syst Rev 2013;5:CD006066.
fetal tachycardia, increased frequency
International Journal of Gynecology
of 25–29
intermittent auscultation and [6] Maude RM, Skinner JP, Foureur MJ. Intellig
1. Introduction may and Obstetrics
result 131 (2015)
in decreased oxygen concentration in fetal arterial blood
treatment of pyrexia and/or(hypoxemia) infection needinto
and ultimately the be tissuesconsidered.
(hypoxia). Some degree of
(ISIA): evaluation of a decision-making f
This article focuses on the Repetitive low-risk women. BMC Pregnancy Childbir
major aspects of the physiology decelerations
of oxygen
Contents lists available are
hypoxemia frequent
occurs
at ScienceDirect during
in almost all fetuses thebutsecond
during labor, it is the inten-stage of
[7] Lawrence A, Lewis L, Hofmeyr GJ, Styles C
supply to the fetus and the main goals of intrapartum fetal monitoring: sity, duration, and repetitive nature of the event, together with the indi-
(1) timely identification labor
of fetuses and may
that are being occuroxygen-
inadequately as a result vidual variation of inaortocaval,
the capacity of each fetus umbilical
to cope with thecord,
situation, or fetal first stage labour. Cochrane Database Syst
headInternational
ated, to enable appropriate action before the occurrence
compression.
and (2) reassurance on adequate fetal oxygenation to avoid unneces-
Journal
of injury; ofthat
Changing Gynecology
will determine the severity
the maternal andpositionObstetrics
of the resulting hypoxia.
may revert the first
Difficulties in carbon dioxide (CO2) elimination across the placenta
[8] Miller FC, Pearse KE, Paul RH. Fetal heart r
auscultation. Obstet Gynecol 1984;64(3):3
sary obstetric interventions. twoIt shouldcauses. However,
be emphasized that to avoidif ad-decelerations
will result in elevatedstart more and
CO2 concentrations, than 20
this gas willseconds
combine after
verse outcome, fetal surveillance requires a jtimely o u r n aclinical
l h o mresponse
e p a g e : w wwith w . ewater
l s e v itoe rincrease
. c o m / carbonic
l o c a t e /acid
i j g o(H2CO3) concentration, a phenom- [9] Schifrin BS, Amsel J, Burdorf G. The accurac
and the ready availability theof onset
both adequate of equipment
a contraction and trained and enon calledtake more
respiratory than
acidemia. 30 seconds
The process to with
is quickly reversible recover to decelerations: a computer simulation. Am
staff in intrapartum care.
baseline values (late decelerations), or when decelerations last
re-establishment of placental gas exchange, as CO2 diffuses rapidly
across the placenta. There is no evidence of injury from isolated respira-
[10] Ayres-de-Campos D, Arulkumaran S. FIG
FIGO GUIDELINES Consensus Panel. FIGO consensus guide
more than three minutes tory (prolonged
acidemia. decelerations), this is strongly
2. The importance of oxygen supply to the fetus Physiology of fetal oxygenation and the m
FIGO consensus guidelines
suggestive of fetal on intrapartum
hypoxia/acidosis. fetal monitoring:
When hypoxia occurs, cellular energy production can still be main-
tained for a limitedIf an
time accompanying
by anaerobic metabolism, but this tachysystole
process pro- is Int J Gynecol Obstet 2015;131(1):5–8 (in
Adjunctive technologies
detected,
All human cells require oxygen and glucose ☆,★to maintain aerobic should
consideration duces 19 times beless given
energy and to acute
results tocolysis
in the accumulation of lacticwith
acid beta-
metabolism, their main source of energy production. Glucose can usual- inside the cell, and its dispersion to the extracellular fluid and fetal cir-
ly be stored and mobilized when needed, but total lack of oxygen b supply culation. The increased concentration of hydrogen ions of intracellular
Gerard
for just a few Visseris aenough
H.minutes , Diogo Ayres-de-Campos
to place the cells at risk. During;fetalforlife,
the FIGO Intrapartum Fetal Monitoring Expert Consensus Panel 1
origin in the fetal circulation is called metabolic acidemia, but it closely
oxygen
a supply
Department is entirely
of Obstetrics, dependent
University onCenter,
Medical maternal respiration
Utrecht, and circu-
The Netherlands parallels hydrogen ion concentration in the tissues, so the term meta-
lation,
b placental
Medical perfusion,
School, Institute gas exchange
of Biomedical across
Engineering, the Hospital,
S. Joao placenta, and umbil-
University bolic acidosis is frequently used as a synonym. The hydrogen ions of
of Porto, Portugal
ical and fetal circulations. Complications occurring at any of these levels lactic acid are transferred very slowly across the placenta, but they are
buffered by circulating bases, comprised mainly of bicarbonate, hemo-
☆ Developed by the FIGO Safe Motherhood and Newborn Health Committee; globin, and plasma proteins. The depletion of these buffering agents
1. Introduction
coordinated by Diogo Ayres-de-Campos. comparing CTG + fetal pulse oximetry with isolated CTG showed no dif-
(increasing base deficit, or base excess in negative numbers) indicates
★ The views expressed in this document reflect the opinion of the individuals and not ference in the overall cesarean delivery rate (relative risk [RR] 0.99; 95%
the growing inability to neutralize hydrogen ions, and their continued
necessarily those of the institutions that they represent.
1 Cardiotocography (CTG) has a high sensitivity but only
a limited CI, 0.86–1.13),
production while
will ultimately adverse
lead fetal outcomes
to the disruption were
of cellular rare insys-
enzyme both groups
specificity
Jacquemyn in predicting
(Belgium⁎), Susana Santofetal hypoxia/acidosis
(Portugal⁎), Lennart Nordström[1]. (Sweden⁎),
In other Tullia [4]. to
words, atems and The present
tissue chapter focuses on the adjunctive technologies current-
injury.
normal
Todros CTGBranka
(Italy⁎), is reassuring regarding
Yli (Norway⁎), the state(Greece⁎),
George Farmakidis of fetal Sandor
oxygenation
Valent as ly available for intrapartum fetal monitoring.
hypoxia/acidosis is generally restricted to cases with suspicious or
Joscha Reinhard (Germany⁎), Anneke Kwee (Netherlands⁎), Ehigha Enabudoso 3. Documentation of fetal hypoxia
pathological
(Nigeria⁎), patterns
Fadi Mirza (see Tak
(Lebanon⁎), theYeung
definitions
Leung (Hong given in the
Kong⁎), CTG
Ramon chapter
Reyles 2. Fetal blood sampling for pH and lactate measurements
[1]). However,
(Philippines⁎), Park ainlarge
Yang number of fetuses
(South Korea⁎), Henry with
Murray the latter patterns
(Australia and New will
As oxygen concentration in the tissues cannot in practice be quanti-
Zealand⁎),
not haveYuen Tannirandorn
clinically (Thailand⁎),
important Krishna Kumar (Malaysia⁎),
hypoxia/acidosis Taghreed such
[2,3]. To reduce FBS duringoflabor
fied, the occurrence fetalwas described
first can
hypoxia only beinassessed
1962 [5]byand theisdocu-
currently used
Alhaidari (Iraq⁎), Tomoaki Ikeda (Japan⁎), Ferdousi Begum (Bangladesh⁎), Jorge Carvajal
false positive
(Chile⁎), José Teppacases and unnecessary
(Venezuela⁎), medical
Renato Sá (Brazil⁎), Lawrenceinterventions,
Devoe (USA⁎⁎), adjunctive
Gerard for assessment
mentation of metabolic of acidosis.
fetal blood gases and/or
Metabolic lactate.
acidosis can beStudies
evaluatedin fetal mon-
technologies
Visser have Richard
(Netherlands⁎⁎), been proposed toBarry
Paul (USA⁎⁎), further assess
Schifrin fetalJulian
(USA⁎⁎), oxygenation.
Parer keys showed
by sampling arterial aand
good correlation
venous blood fromof acid–base parameters
the umbilical cord immedi-between scalp
32
(USA⁎⁎),
These Philip Steer (UK⁎⁎), Vincenzo
technologies should Berghella
indicate (USA⁎⁎), Isis Amer-Wahlin
intervention at an(Sweden⁎⁎),
early stageately after
and carotid blood
birth (see [6], and
Appendix human
1 for datadescription
a detailed have shown similar
of the meth-correlations
Susanna Timonen (Finland⁎⁎), Austin Ugwumadu (UK⁎⁎), João Bernardes (Portugal⁎⁎),
of evolving fetal hypoxia/acidosis to prevent rather than to predictod), measuring
Justo Alonso (Uruguay⁎⁎), Catherine Spong (USA⁎⁎), Edwin Chandraharan (UK⁎⁎). between pH pH and
andpartial
lactatepressure
values of carbon dioxide
obtained in scalp(pCO
blood2), and those re-
⁎poor newborn
Nominated by FIGOoutcome. Several
associated national adjunctive
society; ⁎⁎ Invited bytechnologies have beenthe derived
FIGO based on literature corded bicarbonate (HCO3-)
shortly after birth and base
in the deficit (BD)
umbilical values.
artery and Base
veindef-
[7–11]. How-
developed over the last decades, including fetal blood samplingicit in ever,
search. the extracellular
correlation fluid (BDvalues
of these ecf), as with
calculated fromoutcome
newborn umbilicaldepends
cord on the
(FBS), continuous pH and lactate monitoring, fetal stimulation, pulse time interval between scalp sampling and birth [12]. It has been argued
oximetry, and ST waveform analysis, and some of these have been suc-
http://dx.doi.org/10.1016/j.ijgo.2015.06.018 that fetal capillary blood is likely to be affected by the redistribution of
cessfully established.
0020-7292/© circulation
2015 Published by Elsevier Ireland Ltd. on behalf of International Federation of Gynecology occurring during fetal hypoxemia, and therefore it may not
and Obstetrics.
Caring for the Mom,
Not the Monitor!
65
References
• Manual Obs and Gyn. by Niswander, MD
• Fetal Monitoring RCOG UK

• CTGs RANZCOG
• Literature review articles American Family Physician
• CTG Made Easy
• D. Lata Sharma, MD, FRANZCOG, Senior Lecturer, University Of

Queensland, Australia
• Charles Kawada, M.D,Harvard Medical School

• S Arulkumaran,St.George’s Hospital Medical School, University of
London. Introducing Fetal ECG waveform analysis for Intrapartum Care
66
33

Interpretsi Cardiotocography (CTG) Electronic Fetal Monitoring

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Interpretsi Cardiotocography (CTG) Electronic Fetal Monitoring

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Interpretsi Cardiotocography ( CTG )

Electronic Fetal Monitoring

• Safe procedure that has

Fetal response to hypoxemia

Decrease in growth rate

Hypoxemia Maintained energy balance

Surge of stress hormones

Redistribution of blood flow

Fetal response to asphyxia

Hypoxia from reduced cord blood flow

Oxygen reduces and CO2 increases

If cord flow is not improved then base

Major fetal organ damage 8

• Detect fetal hypoxia i.e reduce and avoid

EFM Problems and Realities

• And no change in incidence of C Palsy.

• Reliability of interpretation-50-75% are

• Intrapartum / antepartum trace.

EFM- 4 Basic Features.

• The minor fluctuations on baseline FHR at

• Examine imin segment and estimate

• Normal is more than or equal to 5 bpm.

Hypoxia Drugs Extreme prematurity

• Para-Sympathetic affects short term

• CNS ,Drugs reduce Variability

• High gestation increases variability

• Mild Hypoxia may cause both S and para S

Non-reassuring Baseline variability.

• NR CTGs- reduced or less than 5 bpm for 40

min or more but less than 90 mins..

• B-B or short Term V is varying intervals

• Long Term v is irregular waves on the CTG

• Normal is 5-25 bpm– this indicates N-CNS. 24

• Accelerations- transient increase in FHR of

15 bpm or more lasting for 15 sec.

• Absence of accelerations on an otherwise

normal CTG remains un clear.

• Presence of FHR Accelerations have Good

• EARLY : Head compression

• LATE : U-P Insufficiency

• VARIABLE : Cord compression

• Uniform periodic slowing of FHR with the on

Electronic Fetal Monitoring

• Reduces Baseline variability together

Decelerations is associated with

EFM Prolonged deceleration

• Followed by a Vag Exam or ARM or

SROM with High PP.

• V.E to exclude cord prolapse

• FBS if cx dilated and well applied PP

Mx depends on the clinical situation.(FBS,Vag Exam,

• Moderate Bradycardia 100-109 bpm

Baseline tachycardia and

• Uncomplicated baseline tachycardia

161-180 bpm or bradycardia 101-109

Electronic Fetal Monitoring

Electronic Fetal Monitoring

• Seen During Fetal thumb sucking.

• Could be associated with Hypoxia.

Normal All four reassuring

International Journal of Gynecology and Obstetrics 131 (2015) 13–24

Contents lists available at ScienceDirect

International Journal of Gynecology and Obstetrics