UNIT 2

FOETAL MONITORING
INSTRUMENTS
FOETAL MONITORING
INSTRUMENTS
Cardiotocograph
Methods of monitoring foetal heart rate
Monitoring labour activity
Recording system
 INTRODUCTION
The foetus in the uterus is mechanically shielded from the
outside world so that it can safely develop there
Information available are the electrical potential of the foetal
heart activity and the foetal heart sound signals
Signals when picked up are mixed up with the corresponding
maternal signals the condition of the foetus is assessed by
studying the blood flow in the foetal heart and its heart rate
The foetal heart rate (FHR) yields important information about
the status of the foetus
 CARDIOTOCOGRAPH
An assessment of the condition of the foetus can be
made during labour from the foetal heart action
Simultaneously, recording beat-to-beat foetal heart
rate and uterine activity provides basic information
for assessing the compensatory potential of the
foetal circulatory system
Monitoring and recording instrument is called
Cardiotocograph
In the undisturbed, healthy foetus, oscillation of
the FHR is normal whereas, absence of FHR
oscillation is considered a sign of potential foetal
distress
 CARDIOTOCOGRAPH
Uterine contraction may or may not cause a response in the FHR
To determine the prognostic significance of a response, the shape and time relationship of
the change in FHR, with respect to the contraction is usually studied
Cardiotocographs are designed to measure and record foetal heart rate on a beat-to-beat
basis rather than on an average basis
An accuracy of measurement may be 2–3% for classification of responses
Sensitivity of 20 bpm/cm of recording chart allows adequate reading of the recorded FHR
Labour activity and FHR traces are usually recorded simultaneously on the same time
scale
Chart speed of 1–2 cm/min is adequate to provide sufficient resolution of the stimulus -
response relationship
 Method Foetal Heart Rate Uterine Contraction

Indirect 1. Abdominal foetal 1. Tocodynamometry (using

(external) electrocardiogram
2. Foetal phonocardiogram
3. Ultrasound techniques (narrow
beam and wide-angle
transducer)
tocotonometer to sense changes in
uterine tension transmitted to the
abdominal skin surface)
2. Intrauterine pressure measurement
(using a fluid-filled intracervical
catheter with strain gauge
transducer)

Direct (internal) Foetal ECG with scalp electrode Intrauterine pressure measurement
(spiral, clip or suction electrode (using a fluid-filled intracervical
attached to the presenting part of catheter with strain gauge transducer)
the foetus)
 ABDOMINAL FOETAL
ELECTROCARDIOGRAM (AFECG)
Foetal electrocardiogram is recorded by suitably
placing the electrodes on the mother’s abdomen and
recording the combined maternal and foetal ECG
The maximum amplitude of FECG (R wave)
recorded during pregnancy is about 100 to 300 µV
This magnitude is much smaller than in the typical
adult ECG which is about 1 mV in the standard lead Abdominal recording of foetal
connection electrocardiogram.
Bandwidth
The amplitude is still lower in some stages of (a) 0.2 – 200 Hz
pregnancy and may not be even properly detected (b) 15-40 Hz
Low signal amplitude places very stringent requirements on the recording of the
FECG if the signal-to-noise ratio (SNR) is to be kept high
Hence, the usual precautions of obtaining good ECG records are more carefully
observed
They include low electrode skin contact impedance, proper electrode material with
low depolarization effects and placement of the electrodes at appropriate positions
The signals must be properly shielded, the equipment properly grounded and the
patient electrically isolated from the equipment
The best place for abdominal electrodes is when one electrode is near the umbilicus
and the other above the symphysis
The foetal heart rate is computed from the foetal ECG by appropriately shaping the
foetal QRS wave
The foetus heart rate is approximately twice that of the normal adult ranging
approximately from 110 to 180 bpm
ABDOMINAL FOETAL
ELECTROCARDIOGRAM
(AFECG)

Matonia, A., Jezewski, J., Kupka, T. et al. Fetal

electrocardiograms, direct and abdominal with
reference heartbeat annotations. Sci Data 7, 200
(2020). https://doi.org/10.1038/s41597-020-0538-
ELECTRODES
FECG
FECG
The major sources of noise in the foetal ECG signal recorded from the maternal
abdomen are
(i) amplifier input noise
(ii) maternal muscle noise (EMG)
(iii) fluctuations in electrode polarization potential
(iv) maternal ECG
The first three of these sources can be considered as random whereas the maternal
ECG is a periodic noise source
The frequency spectrum of each noise source partially overlaps that of the foetal
ECG and therefore, filtering alone is not sufficient to achieve adequate noise
reduction
Mains frequency noise pick-up, which is normally a problem in physiological
recordings, is usually eliminated by the use of a notch filter
 FECG
Signal averaging to improve the ratio of signal to random noise
The maternal ECG component is effectively removed from each lead recording by
creating an average maternal waveform at each of its occurrences in the recording
The maternal component can then either be subtracted directly from the foetal ECG
recording before averaging the foetal waveforms or
Corresponding portions of the separated maternal component can be averaged in
parallel with the selected foetal waveforms
The resulting residual maternal signal subtracted from the foetal waveform average
at the end of the process
The signal averaging often employed in stimulus-response work, there is no
external stimulus to trigger the start of the averaging procedure
The ECG signal itself must be used to provide that trigger.
BLOCK DIAGRAM OF THE
ABDOMINAL FOETAL ECG
PROCESSING CIRCUIT
Block diagram of the abdominal foetal ECG processing circuit
•Proper placement of the electrodes
•The signals are amplified in a preamplifier which provides
 a very high input impedance (100 MW)
 a high sensitivity and good common mode rejection ratio (up to 120 dB)
The input stage should preferably be kept isolated so that any earth leakage currents
that may develop under fault conditions comply with the safety requirements
•The preamplifier is a low-noise differential amplifier that has a wide dynamic range
A sizable common-mode signal manages to pass through the input amplifier, a
circumstance to be expected whenever electrodes spaced a few centimeters apart are
attached to the human body in a hospital environment
Power line hum is responsible for most of the common-mode interfering signal
This is suppressed by a notch filter following the input amplifier
The signal path then splits into two channels: the maternal ECG channel or M channel
and the foetal or F channel
Polarity recognition circuits in each channel accommodate signals of either polarity
After filtering, the M signal is assured of being the largest signal component in the M
channel, so it can be detected on the basis of peak amplitude
It is used to generate a blanking pulse for use in the F channel and in the pulse-insertion
logic circuits
The F channel has a 30 ms pulse generator that is triggered by the foetal ECG
It is inhibited, however, by the blanking pulse from the M channel, so it will not generate
a pulse in response to the maternal ECG signal feeding through to the F channel
The pulse train generated in the F channel is fed to logic circuits
These determine the rate at which the F channel pulses occur and if the timing indicates
that there should be an F pulse at a time when one is blanked or missing, a pulse is
inserted into the F channel output pulse stream
The logic circuits will not insert two pulses in a row, so there is no danger that the
instrument will continue to output normal pulses when no foetal ECG is present
The logic circuits also keep track of the maternal heart rate
If the M and F channels have exactly the same rate, they inhibit the F channel
output during the maternal P wave
The substitution logic requires a delay time to establish a missing foetal trigger
pulse delay has to be longer than the maximum permissible change in heart period
It is kept as 270 ms
The range of FHR measurement is limited to 40–240 bpm because of the
substitution logic. Thereafter, the output of logic circuits go to standard heart rate
computing circuits
 FOETAL PHONOCARDIOGRAM
Foetal heart sounds can be picked up from the
maternal abdomen by a sensitive microphone
The heart sounds are greatly disturbed by
maternal movements and external noise
A crystal microphone is used for picking up
phono signals
The phono transducer signals are amplified by
a low noise preamplifier and fed to a bandpass
filter which rejects all frequencies outside the
70 to 110 Hz range
The preamplifier is incorporated in the
transducer housing to minimize interference
signals being picked up.
Foetal phonocardiogram
From the normal foetal heart action, generally two sounds are produced corresponding to the
contraction and relaxation of the heart muscles
These two bursts of heart sounds are mixed up with unwanted signals which may succeed in passing
through the filters
Achieved by using the repetitive properties of the FHR considering the highest FHR to be 210 and the
lowest FHR as 50/min
A certain interval between the two heart beats, when computed, is stored into a memory for
comparison with the following interval
The latter is only accepted if it does not differ more than a certain number of beats (±7 bpm) from the
stored interval
A detected heart sound triggers a one-shot multi-vibrator that inhibits succeeding heart sounds from
reaching the following circuits for the duration of the one-shot
The circuit must be able to operate a 4-to-1 range (50 to 210 beats/min. or 1.2 to 0.285 s/period)
If the time between two triggers is less than 400 ms, the duration of the blanking pulse produced is
273 ms
If it is more than 400 ms, then the blanking pulse is extended to 346 ms
Block diagram of the arrangement used for obtaining a variable pulse duration to inhibit
triggering by the second heart sound
After peak detection, the processed pulses operate a one-shot circuit which gives a fixed
pulse width of 230 ms
The output of one-shot (2) triggers a variable pulse width multi-vibrator (3) which adds and
gives either 43 or 116 ms time depending on the heart rate
The pulse width at the output will be either 230 + 43 = 273 ms or 230 + 116 = 346 ms.
To detect the heart frequency, the 400 ms one-shot (4) is used
If the period duration is greater than 400 ms, the one-shot will deliver a pulse
The negative slope of this pulse is used to trigger the 20 ms one-shot (5)
These 20 ms pulses are integrated by the integrator (6) and the output of this
integrator is compared with a fixed voltage –V
If the output of the integrator is more negative than -V, the output of comparator (7)
will become positive
The reference level of the oneshot (3) is shifted to more a positive level and pulse
width of this one-shot increases from 43 ms to 116 ms, giving the total pulse width at
the output between 273 ms to 346 ms
The integrator (6) is used to delay the change in the time constant and to make sure
that a change of on-time takes place only if several (3 to 4) heart beats with the longer
period duration (below 150 bpm) are present
No output pulse will occur, if the period between two pulses is less than 400
ms
The 20 ms pulses are, therefore, not generated and the integrator discharges
slowly from the negative output voltage to a positive output voltage
If the output of the integrator (6) is less negative than-V, the output of
comparator (7) will become negative
Now the reference level of the one-shot changes in such a way that the time
varies from 116 to 43 ms, resulting in a pulse width of 273 ms
Phonocardiography provides a basically cleaner signal than does ultrasound,
thus allowing a greater chance of detecting a smooth baseline FHR
Phonocardiography is more susceptible to artefacts
Even with phonocardiography, the baseline FHR may have an apparent
increase in variability that may not be real
FHR MEASUREMENT USING
ULTRASOUND DOPPLER
FOETAL SIGNAL
The Doppler-shift based ultrasound foetal blood flow detectors use hand-held probes
which may be either pencil-shaped or flat and contain two piezo-electric crystals
The probe is coupled to the patient’s skin by means of an acoustic gel
This is done to exclude any air from the interface
The transmitting crystal emits ultrasound (2 – 2.5 MHz) and the back-scattered ultrasound
is detected by the receiving crystal
The back-scattered ultrasound frequency would be unchanged if the reflecting object is
stationary
FHR MEASUREMENT USING
ULTRASOUND DOPPLER
FOETAL SIGNAL
If the reflecting object is moving, as would be the foetal heart blood vessels, then the back-
scattered frequency is higher as the blood cell is approaching the probe, and lower if it is
moving away from the probe
The magnitude of the frequency shift (Df) varies according to the following formula:

where,
fo is the transmitted frequency
u is the blood velocity
cosine of the angle of the sound beam and the object’s direction
c is the velocity of the sound wave in the tissue.
FHR MEASUREMENT USING
ULTRASOUND DOPPLER
FOETAL
Two types of ultrasonic SIGNAL
transducers for FHR measurement: narrow beam and the wide-
angle beam types
NARROW BEAM TRANSDUCER: single ultrasound transmitter/receiver piezo-electric
crystal pair
The maximum ultrasound intensity is generally kept below 25 mW/cm2
The typical transducer diameter is 25 mm
The narrow beam transducer is very sensitive and produces a good trigger signal for
instantaneous heart rate determination
BROAD BEAM TRANSDUCERS: The transducers comprise a number of piezo-electric
crystals mounted in such a way as to be able to detect foetal heart movements over a wider
area
Different arrangements: the shape of a clover-leaf, an array transducer which has one
transmitter and six peripheral ceramic receiving crystals
PRINCIPLE OF ULTRASONIC DOPPLER-SHIFT BASED FHR
MEASURING CIRCUIT

Arrangement can be used both with a wide angle beam as well as a narrow beam transducer
Depending upon the transducer used, i.e. array or narrow beam, the filter circuits can be
selected to match the Doppler-shifted frequency components
The transmitted signal that leaks into the receiving path serves as a local-oscillator signal
for the mixing diodes in the demodulator
The output of the demodulator is dc except in the presence of a Doppler-shift frequency
The reflected signal is some 90 to 130 dB lower in amplitude than the transmitted signal.
The high overall gain in the receiving channel (+110 dB) requires special measures to
minimize the effects of interference
One measure used is a low noise, low distortion oscillator for the transmitter
This reduces interference caused by oscillator harmonics beating with radio and TV signals
Other measures involve filters in the transducer connected for attenuating high-intensity
high frequency radiation that could drive the amplifiers into a non-linear operating region
The high frequency section of the circuits is surrounded by both magnetic and electrical
shields
A bandpass filter centered on 265 Hz isolates the Doppler frequencies resulting from the
movement of the heart walls
 MONITORING LABOUR
ACTIVITY
During labour, the uterus muscle starts contractions of increasing intensity in a bid to expel out the
child.
The intrauterine pressure can reach values of 150 mmHg or more during the expulsion period.
However, a normal patient in spontaneous active labour will demonstrate uterine contractions
occurring at intervals of three to five minutes, with a duration of 30 to 70s and peak intensity of
50 to 75 mmHg.
Each uterine contraction diminishes placental perfusion and acts as a transient stress to the foetus,
which may be damaged by excessive contractility or by prolonged duration of labour.
Some patients will spontaneously exhibit much lower uterine activity, in terms of intensity and
frequency of contractions than others but will still show progressive cervical dilatation and an
otherwise normal progress of labour.
The labour activity can be recorded either in terms of the intra-uterine pressure
measured directly by means of a catheter or a relative indication of the labour
intensity measured through an external transducer
A plot of the tension of the uterine wall is obtained by means of a spring loaded
displacement transducer
The transducer performs a quasi-isometric measurement of the tension of the uterus
The transducer carries a protruding tip which is pressed to the mother’s abdomen
with a light force to ensure an effective coupling
The protruding surface of the transducer is displaced as the tension in the uterus
increases
This movement is converted into an electrical signal by a strain gauge in the
transducer housing
The abdominal transducer provides a reliable indication of the occurrence
frequency, duration and relative intensity of the contraction
The toco-transducers are location sensitive
They should be placed over the fundus where there is maximum motion with the
contractions
The toco-tonometer transducer cannot be used in the same place as the foetal heart
rate detector, thus the patient must have two transducers on her abdomen
To sense uterine contractions externally, it is necessary to press into the uterus
through the abdominal wall
Resistance to pressure is measured either by the motion of a spring or the force
needed to prevent a button from moving
External strain gauges are used to measure and record the bending of a spring. In
some instruments, a crystal which changes electrical characteristics with applied
pressure is used to measure force against a plunger
This method is automatic and provides pertinent information
BLOCK DIAGRAM OF LABOUR ACTIVITY MONITOR
(EXTERNAL METHOD):
The transducer output is amplified in an ac amplifier
The low frequency labour activity signal is obtained from the synchronous detector
and is further amplified by a dc amplifier
The activity can be either displayed on a meter or on a direct writing chart recorder
The labour-activity transducers are pressure transducers that drive circuits for
obtaining an electrical indication of pressure by conventional means
The pressure channel on the recorder is provided with a positioning control
This is done because the baseline is affected by the static pressure on the transducer
that results from the tension on the belt holding the transducer in place
The control permits the operator to position the baseline on the zero-level line of the
recording chart
In external toco-tonometry, movement of the foetus may be superimposed on the
labour activity curve
The internal method measures intra-uterine pressure (IUP) via a fluid-filled catheter
The catheter is inserted into the uterus through a guide after the rupture of the foetal membranes
After allowing free flow of amniotic fluid to ensure correct placement, the distal end of the catheter is
usually attached to a pressure transducer of the type used for cardiac studies
Changes in amnioticpressure are easily transmitted to the gauge by the incompressible fluid in the
catheter
The pressure transducer converts the catheter pressure into an electrical signal which can be displayed on
the strip chart recorder
Strain gauges, though very accurate, tend to drift up to several mmHg/h or drift with temperature
changes
Therefore, when continuous monitoring is employed, it is necessary to set zero and calibrate the
transducer frequently
The peak pressure may vary according to which catheter is placed in the uterus
It is necessary to flush the catheter system to avoid any blockage and to maintain the frequency response
The major applications of IUP measurement are accurate assessment of the pressure during contractions
and measurement of tonus, both impossible by indirect means
RECORDING SYSTEM
Instantaneous “beat-to-beat” rate is displayed on a calibrated linear scale or digitally
displayed with a range from 50 to 210 bpm
A two-channel chart recorder is incorporated in instruments used for monitoring labour
activity
One channel records FHR on a calibrated chart in beats per minute (50–210 bpm) while the
other channel is used for recording uterine contractions calibrated 0-100 mmHg
The standard chart speed is usually 1 or 2 cm/min. Both the contraction transducer and the
foetal heart transducer are held together in position using stretch belts or bandages
The recorder usually uses thermal writing and thus avoids the possibility of running out of ink
To make the operation quieter, contactless position feedback is provided by a capacitive
transducer on the galvanometer shaft
Recording system

This contactless feedback also enhances reliability by eliminating mechanical parts that could
wear out
The galvanometer, which needs a frequency response of only 3 Hz, is positioned by a servo
motor through a silent step-down belt drive. Recording sensitivity is 20 bpm/cm giving a basic
resolution of 1 bpm for seeing small changes in the heart rate.
The chart paper is advanced by a direct-drive stepper motor eliminating the usual gear train
Paper speed is changed simply by switching to a different motor drive frequency, rather than by
shifting gears
The paper magazine is designed to make loading the chart paper an extremely easy task
The ability to record large amounts of relatively artefact-free data, especially after the onset of
labour in the form of
 foetal electrocardiogram (FECG)
 foetal heart rate (FHR) and
 uterine contractions