CARDIOTOCOGRAPHY

INRODUCTION:

Cardiotocography is the continuous electronic record of fetal heart rate and uterine activity,
which is obtained by two transducers placed on the abdomen of the mother and having a
simultaneous graphic representation of both on paper.

In 1969, Hammacher noted that the fetus can be regarded as safe, especially if reflex movements
are accompanied by an obious increase in the amplitude of oscillations in the basal fetal heart
rate. The hypothesis behind the use of CTG is that the integrity of the autonomic central nervous
system is pre requisite for a healthy fetus, the CNS being responsible for controlling the felt heart
rate. The exact mechanism is unknown, but it is proposed that hypoxemia and academia induce
an alteration of the brain stem centers, which are regulating the activity of the pacemaker cells of
the heart, thereby altering the CTG trace.

Four fetal states have been identified

 In third trimester fetus spend 20 % time in quite sleep and 60-80% in an active sleep
state.
 During quite sleep the fetal heart rate slows and variability is reduced.
 There is no regular breathing movements and startled movements. This pattern of sleep
may last for 20 minutes in a term fetus. In REM sleep, on the other hand, is associated
with regular breathing movements and intermittent abrupt movements of head, limbs and
trunk.
 The fetal heart shows increased variability and frequent accelerations with movements.
This pattern lasts for about 40 minutes in a term fetus.
 Some extrinsic factors like maternal activity, ingestion of drugs and nutrition are
responsible for activity.

TYPES OF CARDIOTOCOGRAPHY EXAMINATION

 Non stress test

 Contraction stress test

NON STRESS TEST

The non-stress test is most widely used and accepted method of antenatal fetal surveillance. It is
usually performed on outpatient basis and is readily interpreted. No particular stess is placed on
the fetus by performing such a test. A non-stress test involves attaching a belt with fetal heart
rate and uterine contractions monitors around the mother’s abdomen. The heart rate is recorded
for approximately 20-30 minutes, during which time the mother indicates whether she feels any
fetal movements.

The idea behind a non-stress test is that proper amounts of oxygen are required for the brain to
send signals that will be transmitted via nerves to the heart, signals to which the heart will
respond appropriately. When oxygen levels are low, the brain, nerves and heart may not respond
normally, and resulting fetal heart rate patterns will not reactive.

INDICATIONS OF NST

 Women with pre-existing medical conditions such as diabetes, hypertension

 Baby is less active than the normal
 Small for its age or not growing properly
 Amniotic fluid is either too much or too little
 Women have have lost previously their babies during the second trimester
 Women with pregnancies continuing after 40 week to basically check on well being of
baby
 Women who had a procedure of external cephalic version
 Amniocentesis

HOW TO PERFORM NST

 Usually done as outpatient care

 Time taken 20 minutes, rarely 40 minutes, in extended cases.
 Patient may be seated in semi fowler position or in a reclining chair
 Care taken to avoid supine hypotension syndrome, due to pressure on inferior vena cava
by producing a left lateral tilt by placing a pillow / wedge below the right hip of the
patient.
 Patient’s blood pressure is to be recorded before starting the test and every 10 minutes
subsequently.
 Place the Doppler ultrasound transducer to the maternal abdomen for measuring fetal
heart rate. the tocodynamometer is applied to detest uterine contractions
 Fetal activity may be recorded by the patient using on event marker switch or noted by
the assistant performing the test

A reactive test: is considered when there are at least two accelerations of the fetal heart rate of
15 bpm amplitude and of 15 seconds duration observed over 20 minutes of monitoring. A
reactive non stress test is a good predictor of adequate fetal oxygenation and most reactive fetus
do well for atleast an other Week.

A non-reactive test (abnormal NST) a test is considered to be non-reactive when there is absence
of acceleration in fetal heart rate in relation to fetal movements. When the fetal heart acceleration
is less than 15 beats per minutes or lasts less than 15 seconds in relation with fetal movements,
the test is considered to be abnormal.

The NST is to analyse taking into consideration the following variables:

 Baseline fetal heart rate (FHR)

 Variability of the FHR
 Presence or absence of accelerations
 Presence or absence of decelerations

Baseline fetal heart rate (FHR): The normal baseline FHR frequency is between 110 and 160
bpm. There may be tachycardia (more than 160 bpm) or bradycardia(less than 110bpm) these
changes may occur due to maternal heart rate changes, body temperature and even in fetal
hypoxia.

Variability of the FHR: the fetal variability depends upon the fetal sympathetic and
parasympathetic nervous system and is influenced by the gestational age, maternal medication
fetal congenital anomalies, fetal acidosis and fetal tachycardia. A non -reactive NST associated
with decreased or absent variability is mostly due to fetal hypoxia.

Presence or absence of accelerations and decelerations

The absence of acceleration may be indicated of fetal sleep. The absence of deceleration in the
NST is reassuring.

The presence of spontaneous severe variable or late decelerations is problematic and may
indicate fetal compromise. Variable decelerations may be seen often if these are mild and non-
repetitive, then they do not suggest fetal compromise. However repetitive variable decelerations,
especially in the absence of f etal movements or uterine activity, suggest fetal compromise.

Principle

The sympathetic and parasympathetic components of ANS control cardiac fetal behaviour

FHR accelerations in response to fetal movements is a sign of healthy featus.

ADVANTAGES:

 It is non- invasive test

 The test is simple , in expensive and takes less time
 There are no contraindications or complications of this test
 No special expertise is required in performance of the test
 This test provides an immediate answer
CONTRACTION STRESS TEST

The contraction stress test also known as the oxytocin challenge test, is yet another test available
for fetal surveillance in antenatal period, particularly testing for uteroplacental sufficiency. The
basic hypothesis behind the use of this test is that the increased myometrial pressures following
uterine contraction causes a decreased blood flow and oxygen exchange in the intervillous spaces
of the placental circulation. Foetuses with in adequate placental reserve would demonstrate late
decelerations in response to hypoxia. It helps to mimic the stress of labour.

Purpose: to evaluate the response of the fetal heart rate to a reduction of blood flow in the
intervillous space during induced contraction.
Indications: uteroplacental pathology e.g. diabetes, hypertension, intrauterine growth
retardation or post- dates.

HOW TO PERFORM THE CST

 CST has to be conducted in a labour or delivery suite

 The patient is placed in semi – flower’s position at a 30-450 angle with a slight left tilt to
avoid the supine hypotension syndrome.

The fetal heart rate is recorded by using Doppler ultrasound transducer , while the uterine
contractions are monitored with the tocodynamometer.

 Maternal blood pressure is recorded every 5-10 minutes

 Baseline fetal heart rate and uterine tone is to be recorded for a period of approximately
10-20 minutes.
 Oxytocin is administered by an infusion pump at 0.5 mU/min. for an adequate CST,
uterine contractions of moderate intensity lasting approximately 40-60 seconds with
frequency of three in 10 minutes, is required. This criterion is selected to approximate the
stress experienced by the fetus during the first stage of labour.
 Infusion rate may be doubled every 20 minutes until adequates uterine contractions have
been achived (not more than 10 Mu/ min is usually required).
 The time taken for the whole CST is around 1 -2 hours. At the completion of the test, the
patient is observed till the uterine activity returns to baseline level, if activity persists then
tocolysis may be given.

INTERPRETATIONS

Martin and Schifrin introduced the interpretation of CST in a ten minute window period. A
positive test would be the one in which any segment of 10 minutes duration tracing shows three
contractions, all showing late decelerations. Occasional late deceleration with at least one
negative window is also a negative test.
A contraction stress test checks to see if the fetus will stay healthy during the reduced oxygene
level that normally occur during contractions when woman is in labour.

Normal CST – Normal test results are called negative. In this the baby’s heart rate does not get
lower (decelerate) and stay low after the contraction (late decelerations).

Abnormal CST- abnormal test results are called positive. A slower heart rate( late decelerations)
that stay low after the contaction may mean that the baby will develop problems if delivery is
delayed.

Hyperstimulation – In this the contractions last for 90 seconds or more

Suspicious: intermittent late or variable decelerations

Unsatisfactory <3 contractions per 10 minutes

Risks:

The risks from having oxytocin include:

 May cause labour to start earlier than the expected delivery date
 Can result in prolonged contractions that may cause problems with the baby.
 The contractions usually stop when the oxytocin is stopped.

Contraindication to CST

 Premature rupture of membranes

 Cervical incompetence
 Multiple gestations
 Polyhydroamnios
 Placenta praevia
 Previous uterine surgeries like myomectomy or classical caesarean section.
 A contraction stress test is done to check :
 If the baby will stay healthy during the reduced oxygen levels that normally occur during
contractions during labour
 If the placenta is healthy and can support the baby
 Contraindications
 Women having placenta praevia
 Women having antepartum haemorrhage
 Previous classic caesarean section

Clients at high risk of preterm labour the limitation of this test is the incidence of false positivity
leading to unnecessary premature deliveries. The incidence of false – positive rate averages
approximately 30%, especially before 33 weeks of gestation. False positive rates are unusually
high due to misinterpretation of tracing, supine hypotension, uterine hyper stimulation or even an
improvement in fetal condition post performing a CST test.

IMPORTANCE:

A negative test is associated with good fetal outcome. Whereas a positive CST is associated with
increased incidence of IUD, fetal distress in labour and low Apgar score. But there is 50%
chance of false – positive results and as such positive test cases are subjected to others methods
of evaluation for the well-being of the fetus . Suspicious CST should have a repeat test in 24
hours.

Conclusion:

Cardiotocography is the continuous electronic record of fetal heart rate and uterine activity, it
inclues two test non stress test and contraction stress test. The non-stress and CST test is most
widely used and accepted method of antenatal fetal surveillance.

BOOK REFERENCES:

 Dutta’s D.C. Textbook of obstetrics. 9th edition. Published by jaypee brothers medical
publishers (P) ltd. Mohammadpur , Dhaka Bangladesh India.2018.
 Bhide Amarnath. Arias’ practical guide to high risk pregnancy and delivery. 4 th edition.
Published by Elsevier (p) ltd IMT Manesar , Haryana India. 2015.
 Kumari Neelam . Textbook of midwifery and gynecological nursing 11 th edition.
Published by s. Vikas and company ( medical publishers) (P) ltd. Jalandhar India 2012.

INTERNET REFERENCES

 https://www.slideshare.net/DebbieFritz/antepartum-testing
 https://www.webmd.com › Pregnancy ›
 http://www.ucsfcme.com
Amniocentesis:

Amniocentesis is a diagnostic test that may be recommended by health care provider following
an abnormal triple test result. Inherited or genetic concerns lead some parents to choose
amniocentesis to determine if specific genetic disorders may be present in their baby.

Procedure
An ultrasound is used as a guide to determine a safe location for the needle to enter
the amniotic sac so the fluid may be safely removed.
A sample of amniotic fluid is collected through the needle. The procedure takes about 45
minutes, although the collection of fluid takes less than five minutes. The amniotic fluid, which
contains cells shed by the fetus, is sent to the laboratory for analysis. Results can take anywhere
from a few days to a couple weeks to be returned.

When Is Amniocentesis Performed?

Amniocentesis is usually performed between 14 and 20 weeks. Some medical
facilities may perform amniocentesis as early as 11 weeks.
Amniocentesis can be used later in the third trimester for a few reasons.
Healthcare provider may recommend the procedure if membranes have ruptured
prematurely to assess for uterine infections. Amniocentesis may also help determine
the severity of fetal anemia in babies with Rh disease and assist the physician
determine whether the fetus requires lifesaving blood transfusions.
Amniocentesis is sometimes done to assess lung maturity. If so, this is done shortly
before delivery.

Uses:
Amniocentesis detects chromosome abnormalities, neural tube defects and genetic
disorders.
Down syndrome or Trisomy 21 is the most common chromosome abnormality.
Genetic disorders include disorders like cystic fibrosis.
The most common neural tube defect is spina bifida .
Amniocentesis is occasionally used late in pregnancy to assess whether the baby’s
lungs are mature enough for the baby to breathe on his own.
Amniocentesis also provides access to DNA for paternity testing prior to delivery.
DNA is collected from the potential father and is compared to DNA obtained from
the baby during amniocentesis. The results are accurate (99%) for determining
paternity.

Amniocentesis Results findings:

Amniocentesis is a diagnostic test that detects chromosome abnormalities, neural
tube defects and genetic disorders with high levels of accuracy (98-99%). Although
the probabilities of identification are high, this test does not measure the severity of
these birth defects. Alpha-fetoprotein levels and advanced level ultrasounds may
assist in assessing the severity.

Risks And Side Effects To The Mother Or Baby

o Although amniocentesis is considered to be a safe procedure, it is recognized as an
invasive diagnostic test that does pose potential risks.
o Miscarriages can occur because of infection in the uterus, the water breaks or labor is
induced prematurely.
o Although extremely rare, it is possible for the needle to come in contact with the
baby. Great precautions are taken by using a sonogram to guide the needle away
from the baby.
o The mother may experience a sharp pain when the needle enters the skin and again
when it enters the uterus.
Following completion of the procedure, the mother may experience other side effects
that include:
Cramping
Leakage of fluid
Minor irritation around the puncture site
The Reasons To Test Or Not Test?
The reasons to test or not test vary from person to person and couple to
couple.
Performing the tests and confirming the diagnosis provides us with certain
opportunities:
Pursue potential interventions that may exist (i.e. fetal surgery for spina bifida)
Begin planning for a child with special needs
Start addressing anticipated lifestyle changes
Identify support groups and resources
Make a decision about carrying the child to term
Some individuals or couples may elect not to pursue testing or additional testing for
various reasons:
They are comfortable with the results no matter what the outcome is
Because of personal, moral, or religious reasons, making a decision about carrying the
child to term is not an option
Some parents choose not to allow any testing that poses any risk of harming the developing
baby
It is important to discuss the risks and benefits of testing thoroughly with healthcare provider.
KARYOTYPE ANALYSIS

Genetic counseling is a relatively new field that allows parents the opportunity to determine the
genetic odds that their offspring may carry a particular negative (or lethal) trait.
At first the counseling process was restricted to interviews, which helped create pedigree
analysis charts that revealed the expression of the trait in question among various family
members.
As technology improved, a process called karyotype analysis was developed. This procedure
provides information regarding the entire chromosomal complement of an individual, as viewed
during the process of mitosis.

Karyotypes were first performed using blood samples taken from youngsters and adults. Later, a
pre- birth process called amniocentesis was developed which allowed medical researchers to
obtain samples of cells from extraembryonic fluid located in the amniotic sac, which surrounds
an unborn child.

Still later a more refined version of the procedure, called chorionic villi sampling (CVS), was
developed that could be used earlier in the pregnancy than amniocentesis. CVS takes samples of
extraembryonic cells from extensions of the chorionic membrane called villi .
Karyotypes may be performed by taking (1) a blood, bone marrow, or skin sample from an adult;
or (2) a sample of amniotic fluid (which contains stray cells) or extra-embryonic cells (from the
chorionic villi) from an unborn child. Once the cells have been obtained for a karyotype, they are
mixed with plant-derived chemicals called lectins that stimulate mitosis.
After the required quantity of cells has been acquired, the cells are treated with a drug called
colchicine to stop the mitotic process at metaphase. Colchicine arrests the action of spindle fiber
microtubules; hence ceasing the mitotic process.
The cells are placed in a hypotonic solution (see: osmosis and diffusion lab) that causes them to
take on water, thereby increasing their overall size.
This provides room for chromosomes to be spread out. The cells are fixed to a microscope slide,
stained and then photographed.
After they are photographed, the photo is enlarged and the chromosomes are cut out and matched
up as pairs. Chromosomes may be distinguished from one another based upon several key
characteristics:

(1) The length of the arms of the chromosome; a pattern that is established by the position of the
Centromere along the arms,
(2) Shape and
(3) General appearance of the chromosome, such as size and placement of bands.
Karyotype analysis provides a mechanism to determine if non-disjunction diseases, such as
Down syndrome (Trisomy 21), are present in the fetus.
It also allows for detection of other non-disjunction diseases, such as Klinefelter’s syndrome (XXY) or
Turner’s syndrome (XO), which may otherwise go unnoticed until puberty (or even later).

It also provides a look at the chromosomes to see if there are any missing segments (deletions) or
translocations that may have occurred during crossing-over.
The Human Genome Project (HGP) is an ongoing worldwide effort to use new biotechnological advances
in the field of molecular biology (genetic engineering, recombinant DNA technology, etc.) to map all
nucleotides grouped as genes in human chromosomes. The human genome is contained in the 23 pairs
of chromosomes located in the nucleus of each somatic cell.
The project was originally coordinated by the National Institutes of Health (NIH) and the
Department of Energy (DOE). The director of the program was Dr. James Watson (of Watson andCrick).

The HGP used new techniques such as DNA extraction, gel electrophoresis, polymerase chain
reaction (PCR) and many others to accomplish much more than the karyotype procedure could. The HGP
has located just about every gene’s position on each of the human (46) chromosomes.
The project began in 1988 and is now, for all intents and purposes, completed. Chromosome #22 was
completely mapped by February 2000. It was the first human chromosome to be completed.
Approximately 100,000 gene segments are carried in our 23 pairs of chromosomes and the rest of the
DNA sequences are called fillers, spacers, RFLP’s, or nonsense codes (“junk DNA”). Research continues to
attempt to determine the value of the “non-gene” nucleotide sequences in the human genome.

There are so many nucleotides within a single set of 46 chromosomes (23 pairs) that scientists doing
karyotype/DNA analysis work always use the haploid cells (gametes) of the body whenever possible.
This restricts them to only a single set of 23 chromosomes, which contain +/- 3,000,000,000 (3 x 109)
nucleotides.
Amazingly enough, as little as 5% of our total DNA complement is used as genes. Recall from lecture
class that each chromosome contains the same linear sequences of DNA, (except for X/Y and
mutations). Mapping of the human genome will yield many benefits, especially in the field of health.
Samples of cells from unborn children will be taken and their analysis will reveal more than what the old
karyotype test did. That test merely showed if the cell had a full set of properly structured
chromosomes. It was limited to revealing only a few types of genetic problems, such as those caused by
nondisjunction.
The new, extended form of karyotype analysis will also be able to tell the researcher if the child has
gene mutations or if any sort of disease genes are present.
The maps of the human genome are of two varieties and provide these two types of information (1)
genetic maps = location of genes and their patterns of inheritance and (2) physical maps, such as
restriction maps, which describe the structural characteristics of the DNA molecule itself.
This is the outcome of the work that began in the classical and chromosomal eras of genetics!
MOTHER KRISHNA BAI COLLEGE OF NURSING, MUSHEERABAD

CASE PRESENTATION
ON
PREECLAMPSIA

SUBMITTED TO : SUBMITTED BY:

MRS. P. SUNEETHA SURABHI DAS

ASST. PROFESSOR FIRST YR MSC NSG