CTG: Interpretation and management
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The document discusses the interpretation and management of CTG (cardiotocography). It describes the steps to interpret a CTG tracing, including evaluating the fetal heart rate baseline, variability, accelerations, decelerations and their correlation with uterine contractions. It provides a structured DR C BRA VADO method to categorize CTG tracings as normal, suspicious or pathological. The management strategies for each category are then outlined, such as continued monitoring, additional tests like fetal scalp blood pH, or expedited delivery depending on the severity of the CTG abnormalities. Specific situations like the second stage of labor, placental abruption or fetal abnormalities are also addressed.
CTG: Interpretation and management
- 1. CTG Interpretation and management Aboubakr Elnashar: Benha University Hospital, EgyptAboubakr Elnashar
- 2. INTERPRETATION Steps 1. Evaluate tracing. Do you have enough of a continuous strip for interpretation 2. Identify FHR baseline BBV absent, minimal, moderate or marked Accelerations or Decelerations. Aboubakr Elnashar
- 3. 3. Evaluate contractions regularity, rate, intensity, duration of contractions. 4. Correlate accelerations and decelerations with uterine contractions and identify the pattern. 5. Determine whether the FHR recording is reassuring, non reassuring or ominous. 6. Document interpretation of FHR clinical conclusion plan of care. Aboubakr Elnashar
- 4. STRUCTURED METHOD The most popular structure can be remembered using the acronym: DR C BRA VADO = 7 items 1. Demographics of the patient 2. indication of CTG 3. Any obvious abnormalities DR - Define Risk ? PET, diabetes, IUGR, smoker C - Contractions - Frequency, duration, intensity, resting tone BRA - Baseline rate - 110-160bpm V - Variability - 5-25 beats A - Accelerations - 2 in 20 minutes D - Decelerations - abnormal O - Overall risk assessmentAboubakr Elnashar
- 5. Define Risk • You first need to assess if this pregnancy is high or low risk • This is important as it gives more context to the CTG reading. e.g. If the pregnancy is high risk, your threshold for intervening may be lowered • Maternal medical illness Gestational diabetes Hypertension Asthma. • Obstetric complications Multiple gestation Post-date gestation Previous cesarean section Intrauterine growth restriction Premature rupture of the membranes Congenital malformations Oxytocin induction/augmentation of labor Pre-eclampsia. Aboubakr Elnashar
- 6. O – Overall assessment Once you have assessed all aspects of the CTG you need to give your overall impression Aboubakr Elnashar
- 7. Categorization of FHR traces Aboubakr Elnashar
- 11. II. MANAGEMENT FIGO Fetal HR Pattern Classification Normal means fetal health • Suspicious means - continue observation - additional tests • Pathological means - additional test - intervention 1. Normal/Reassuring risk of fetal hypoxia in spontaneous labour is low: Manage normally. Aboubakr Elnashar
- 12. 2. Suspicious/Equivocal/ Non reassuring continue EFM Amniotomy should be performed +/- fetal scalp blood pH if meconium stained liquor is present. Aboubakr Elnashar
- 13. Initial Evaluation and Treatment of Nonreassuring Fetal Heart Rate Patterns Discontinuation of any labor stimulating agent Cervical examination: umbilical cord prolapse or rapid cervical dilation or descent of the fetal head Changing maternal position left or right lateral recumbent position: reducing compression of the vena cava and improving uteroplacental blood flow Aboubakr Elnashar
- 14. Monitoring BP for evidence of hypotension, especially in those with regional anesthesia if present: treatment with ephedrine or phenylephrine may be warranted Assessment of patient for uterine hyperstimulation by evaluating uterine contraction frequency and duration In the presence of abnormal FHR patterns and uterine hypercontractility not secondary to oxytocin infusion: tocolysis subcutaneous terbutaline 0.25 milligrams Aboubakr Elnashar
- 15. In cases of suspected or confirmed acute fetal compromise: delivery should be accomplished as soon as possible, accounting for the severity of the FHR abnormality and relevant maternal factors The accepted standard has been that ideally this should be accomplished within 30 minutes. Aboubakr Elnashar
- 16. Maternal facial oxygen therapy Prolonged use of maternal facial oxygen therapy may be harmful to the fetus and should be avoided. There is no research evidence evaluating the benefits or risks associated with the short-term use of maternal facial oxygen therapy in cases of suspected fetal compromise .•C Aboubakr Elnashar
- 17. 3. Abnormal/Pathological Amniotomy Fetal scalp blood pH if meconium stained liquor to determine subsequent management or Deliver if clinically indicated. Deliver if fetal scalp pH required but not obtainable i.e. if cervix not sufficiently dilated or equipment not available. Aboubakr Elnashar
- 18. III. SPECIAL SITUATIONS Second Stage of Labour Signs of hypoxia: • Tachycardia • ↓ variability between and during decelerations • Late decelerations • Failure to return to baseline (or > 100 bpm) after decelerations • Prolonged bradycardia * Delay of 20 min → asphyxiated infant Aboubakr Elnashar
- 19. Placental abruption • Uterine irritability shown by frequent contractions of low amplitude • FHR trace: initially tachycardia ± decelerations no accelerations ↓ variability. Bradycardia is a late and danger sign of severe asphyxia Aboubakr Elnashar
- 20. Fetal abnormality • CNS abnormality: → ↓ baseline variability low baseline rate • Discrepancy between CTG (abnormal) and biophysical profile (within normal) suggest chromosomal abnormalities, especially if bony measurements are reduced/slight IUGR Aboubakr Elnashar
- 21. Heart block • Persistent bradycardia / double counting • No respond to stimulation Dying fetus • Acute/subacute insult : decelerations / tachycardia / lack of accelerations → ↓ variability → bradycardia Aboubakr Elnashar
- 23. CTG PATTERN CAUSE CLINICAL MANAGEMENT Declaration Early 2nd Stage NONE Late Uterine hypercontractily Stop oxytocin Consider terbutaline sc Oxygen @ 8-10 l/min Left lateral decubitus Variable Cord compression Consider amnioinfusion (mild/mod v.d.) Tachycardia Maternal fever, tachycardia, dehydration Infection screen Hydrate: crystalloids Stop tocolysis if pulse>120 SUSPICIOUS CTG Aboubakr Elnashar
- 24. PATHOLOGICAL FETAL SCALP BLOOD Ph (If facilities available) FETAL SCALP STIMULATION TEST FETAL VIBROACAUSTIC STIMULATION TEST Aboubakr Elnashar
- 25. PATHOLOGICAL FETAL SCALP BLOOD Ph (If facilities available) FETAL SCALP STIMULATION TEST FETAL VIBROACAUSTIC STIMULATION TEST Aboubakr Elnashar
- 26. Category Definition Normal All four reassuring Suspicious 1 non-reassuring Rest reassuring Pathological 2 or more non-reassuring 1 or more abnormal Aboubakr Elnashar
- 27. b)Abnormal/Pathological Trace - Baseline FHA> 150 bpm + silent pattern and/or repeated late or variable decelerations - Silent pattern for >90 minutes - Complicated variable decelerations (depth >60 bpm for >60 seconds, changes in shape: over-shoot, decreased or increased baseline FHR following the decelerations, or absence of baseline variability in or between decelerations, slow recovery) - Combined/biphasic decelerations (variable followed by late) - Prolonged bradycardia in a suspicious trace - Prolonged bradycardia> 10 minutes with no signs of recovery - Repeated late decelerations - Pronounced loss of baseline variability regardless of baseline FHR with shallow late decelerations - Sinusoidal pattern with no accelerations Aboubakr Elnashar
- 29. a)Normal/Reassuring Trace - At least two accelerations (> 15 beats per minute for >15 seconds) in 20 minutes - Baseline heart rate: 110-150 bpm - Baseline variability: 5-25 bpm - Early decelerations (in late first stage of labour) Aboubakr Elnashar
- 30. b)Suspicious/Equivocal Trace - Absence of accelerations for >40 minutes (non reactive) - Baseline heart rate: 150-170 bpm or 100-110 bpm (normal variability, no decelerations) - Silent pattern (<5 bpm for >40 minutes) although normal baseline (110-150 bpm), no decelerations - Baseline variability >25 bpm in the absence of accelerations - Variable decelerations (depth <60 bpm, duration <60 seconds) - Occasional transient prolonged bradycardia if FHR drops to <80 bpm for >2 minutes or <100 bpm For >3 minutes Aboubakr Elnashar