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Ali Sungkar Sub Bagian Fetomaternal Bagian Obstetri dan Ginekologi FKUI/RSUPN - CM
Track the baby¶s heart rate during labor. Safe procedure that has saved the lives of many babies in high-risk situations.
y Detect fetal hypoxia i.e reduce and avoid harm to the fetus and improve fetal and baby out-come. y Severe acidosis may result in FHR changes. y Could occur in Normal physiological response in labor. y Misunderstanding the physiological and pathphysiological CTGs will improve the Mx ( management).
EFM Problems and Realities
y Electronic Intra-partum FHR Monitoring is now considered mandatory for high-risk pregnancies. y Difficulties with interpretation include over confidence and not-only difference in opinion between practitioners but, also when the same practitioner examines the same CTG twice. y Increases CS rates 1.41%rr. y Increases operative vaginal delivery 1.20%rr. y And no change in incidence of C Palsy. y Reduction in Neonatal seizures rates 0.51% y No difference in APGAR scores. y ? About the efficacy.
6 .EFM. y PH Vs Lactate -39% Vs 2. 6% false positive.3(rr 16. y FBS 93% sensitivity.7). y False positive Dx reduces to 105 with FBS.Facts y Reliability of interpretation-50-75% are false positive .
Electronic Fetal MonitoringIndications Indications for the continuous EFM High risk pregnancies IOL and Augmentation of Labour. Reduced FM. Abdominal Trauma. DM.Multiple Gestation. Premature labour/TPL. 7 . Meconium Liq. Abnormal FHR detected. Previous CS. Malpresentation and in labour. APH/IPH Oligohydramnios Hypertension. Prolonged ROM.
EFM.? Induction labor Medications ? Direct or indirect monitoring 8 . Gestation. ? Malpresentation. Stage of labour.Interpretation Consider : Intrapartum / antepartum trace. Fetal presentation. Any augmentation.
EFM.4 Basic Features of FH Trace 9 .
EFM.Mean level of FHR when this is stable. 11 . 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.4 Basic Features. excluding Accelerations and Decelerations (110-160 bpm) -Tachycardia -Bradycardia y Baseline Variability-5 bpm or greater than or equal to 5bpm. Baseline FHR .
Uterine Contraction 12 .
Baseline variability CTG Baseline variability 15 .
FHR: Variability Definitions ± Short term ± Long term 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 .
Para-Sympathetic affects short term variability whilst Long Term is more Symp.Drugs reduce Variability High gestation increases variability Mild Hypoxia may cause both S and para S stimulation. 19 . CNS .Factors affecting Baseline variability.
reduced or less than 5 bpm for 40 min or more but less than 90 mins. NR CTGs. 21 . B-B or short Term V is varying intervals between successive heart beats .Non-reassuring Baseline variability. Normal is 5-25 bpm± this indicates N-CNS.. Long Term v is irregular waves on the CTG 3-5 bpm.
Presence of FHR Accelerations have Good outcome. Absence of accelerations on an otherwise normal CTG remains un clear. 22 .transient increase in FHR of 15 bpm or more lasting for 15 sec.EFM-Accelerations Accelerations.
23 . Or more.EFM Decelerations Decelerationstransient slowing of FHR below the baseline level of more than 15 bpm and lasting for 15 sec.
y Should not be disregarded if they appear early in labor or Antenatal. y Clinical situation should be r/v 24 .Electronic Fetal Monitoring a) Early Decelerations y Head compression y Begins on the onset of contraction and returns to baseline as the contraction ends.
Early Decelerations 25 .
Uniform periodic slowing of FHR with the on set of the contractions .Late Decelerations. 26 . Repetitive late decels increases risk of Umbilical artery acidosis and Apgar score of less than 7 at 5 mins and Increased risk of CP.
Electronic Fetal Monitoring b) Late Decelerations Due to acute and chronic feto-placental vascular insufficiency y Occurs after the peak and past the length of uterine contraction. 27 . IUGR or other form of placental insufficiency. y Are precipitated by hypoxemia y Associated with respiratory and metabolic acidosis y Common in patients with PIH. often with slow return to the baseline. DM.
Late Decelerations 28 .
30 .Late Decelerations Reduces Baseline variability together with Late Decelerations or Variable Decelerations is associated with increased risk of CP.
Variable Decelerations Variable intermittent periodic slowing of FHR with rapid onset recovery and isolation. Prolonged secondary rise in Base FHR Biphasic deceleration Loss of variability during deceleration Continuation of base line at a lower level. 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. 31 .EFM. They can resemble other types of deceleration in timing and shape.
Electronic Fetal Monitoring c) Variable Deceleration (Vagal activity) Inconsistent in configuration. are variable and occur in isolation. No uniform temporal r-ship to the onset of contraction. 32 . 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.
Variable Decelerations 33 .
References 35 .
Associated with poor neonatal outcome. Reduction in O2 transfer to placenta.e 3 mins. 37 .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.
Maternal hypertension Uterine Hypertonia Followed by a Vag Exam or ARM or SROM with High PP.EFM.Prolonged Decelerations CAUSES Cord prolapse. 38 .
Prolonged Deceleration 39 .
E to exclude cord prolapse Assess BP FBS if cx dilated and well applied PP Mx Depending on the clinical situation.EFM Mx Prolonged Deceleration Maternal position IV fluids V. 40 .
congenital H disease and Drugs). Causes. Postdates. Drugs. less than 100bpm (RANZCOG).(FBS.Baseline Bradycardia FH below 110bpm(FIGO ).Vag Exam. Idiopathic. Arrythmias. hypothermia(increased Vagal Tone) Cord Compression (Acute Hypoxia. Mx depends on the clinical situation. Observation or expedite delivery) 41 .
Tachycardia 161-180 bpm Abnormal Tachycardia more than 180 bpm Ranzcog Australian more than 170 bpm 42 .Types Moderate Bradycardia 100-109 bpm Abnormal bradycardia less than 100bpm.
43 .Baseline tachycardia and Bradycardia. Uncomplicated baseline tachycardia 161-180 bpm or bradycardia 101-109 do not appear to be associated with poor NN outcome.
Causes of B Tachycardia. Asphyxia Drugs Prematurity Maternal Fever Maternal thyrotoxicosis Maternal Anxiety Idiopathy Mx depends on the clinical situation 44 .
Vag Exam . (FBS.(Increased Vagal tone). and drugs) Mx depends on the clinical situation.Electronic Fetal Monitoring Baseline Bradycardia y y y y y y y FH Rate below 110bpm (FIGO Recommended) Postdates Drugs Idiopathic Arrhythmia's Hypothermia.Congenital H/disease. Cord compression(Acute Hypoxia. Observation or expedite Delivery). 45 .
Electronic Fetal Monitoring Baseline Tachycardia y Asphyxia y Drugs y Prematurity y Maternal fever y Maternal thyrotoxicosis y Maternal Anxiety y Idiopathy Mx depends on the clinical situation 46 .
Sinusoidal pattern Interpretation of the CTG 47 .
with amplitude of 5-15 bpm and above but not below the baseline.EFM-Sinusoidal Pattern Regular Oscillation of the Baseline long-term Variability resembling a Sine wave . Should be viewed with suspicion as poor outcome has been seen (eg Feto-maternal haemorrhage) 48 .with no Bb Variability Has fixed cycle of 3-5 p min.
3 % (Young 1980) cord compression hypovolemia ascites idiopathic(fetal thumb sucking) Analgesics Anaemia Abruption Mx r/v clinical situation 49 .distinctive smooth undulating Sine-wave baseline with no B-b variability 0.Electronic Fetal Monitoring Sinusoidal pattern.
Could be associated with Hypoxia. 50 .EFM.Saltatory pattern Seen During Fetal thumb sucking.
51 .leads to Increased rate of C Section. ?? To reduce CS«.NR CTGs Difficult to interpretation. 50% CTG in Labour have 1 abnormal feature 15-20% Nr CTGs (pathological).
EFM-Summary Normal . 52 .CTG with all 4 Features Suspicious -one non reassuring category and reminder are reassuring Pathological -2 or more non-reassuring categories or one or more abnormal categories.
Caring for the Mom. Not the Monitor! 53 .
Harvard Medical School 54 . by Niswander. University Of Queensland. MD Fetal Monitoring RCOG UK CTGs RANZCOG Literature review articles American Family Physician CTG Made Easy D. FRANZCOG.D. MD. Australia Charles Kawada. M.References Manual Obs and Gyn. Senior Lecturer. Lata Sharma.
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