Fetal assessment (1)

-CTG-

Adrian Goenawan, M.D.

References

Cunningham, F. Gary, et al. Williams

Obstetrics, 24th Edition. McGraw Hill
Education, 2014.
 Goal

Prevent fetal death

Assess the risk of fetal death in
pregnancies complicated by preexisting
maternal conditions as well as those in
which complications have developed
 Indications (ACOG)
Maternal conditions:
Hyperthyroidism
Hemoglobinopathies
Cyanotic heart disease
Chronic renal disease
DM type I
 Indications (ACOG)
Pregnancy-related conditions:
Pregnancy-induced hypertension
Intrauterine growth restriction
Amniotic fluid abnormalities
APAS
SLE
Isoimmunization
Decreased fetal movement
Post-term pregnancy
Previous fetal demise
Multiple gestation
Test with Stillbirth rate Negative
normal results predictive value
NST 1.9/1000 99.8 %
CST 0.3/1000 > 99.9 %
BPP 0.8/1000 > 99.9 %
Modified BPP 0.8/1000 > 99.9 %
 When
Non high risk: 32-34 weeks
High risk: 26-28 weeks
Frequency: every 7 days, can be done earlier if
needed
 Fetal Movement Counting
Fetus begin to move 7 weeks AOG
Movement perceive by the mother:
Primigravida 20 weeks AOG
Multigravida 16-18 weeks AOG
Method: 10 fetal movement in 2 hours
 CTG
Basic term:
Baseline
Variability
Acceleration
Deceleration
 CTG
Pattern Workshop Interpretation
Baseline The mean FHR rounded to increments of 5 bpm during a 10-min
segment, excluding:
Periodic or episodic changes
Periods of marked FHR variability
Segments of baseline that differ > 25 bpm
Bradycardia Baseline FHR < 110 bpm
Tachycardia Baseline FHR > 160 bpm
 CTG
Pattern Workshop Interpretation
Variability The baseline must be for a minimum of 2 min in any 10-min
segment
Fluctuations in the FHR of two cycles per min or greater
Variability is visually quantified as the amplitude of peak-to-trough
in bpm
Absent: amplitude range undetectable Minimal: amplitude
range detectable but 5 bpm Moderate (normal): amplitude
range 625 bpm Marked: amplitude range > 25 bpm
 CTG
Pattern Workshop Interpretation
Acceleration A visually apparent increaseonset to peak in less than 30 secin
the FHR from the most recently calculated baseline
The duration of an acceleration is defined as the time from the
initial change in FHR from the baseline to the return of the FHR to
the baseline
At 32 weeks and beyond, an acceleration has an acme of 15 bpm
above baseline, with a duration of 15 sec but < 2 min
Before 32 weeks, an acceleration has an acme 10 bpm above
baseline, with a duration of 10 sec but < 2 min
Prolonged acceleration lasts 2 min, but < 10 min
If an acceleration lasts 10 min, it is baseline change
 CTG
Pattern Workshop Interpretation
Early In association with a uterine contraction, a visually apparent,
Deceleration usually symmetrical, gradualonset to nadir 30 secdecrease in
FHR with return to baseline
Nadir of the deceleration occurs at the same time as the peak of
the contraction
Late In association with a uterine contraction, a visually apparent,
Deceleration gradualonset to nadir 30 sec decrease in FHR with return to
baseline
Onset, nadir, and recovery of the deceleration occur after the
beginning, peak, and end of the contraction, respectively
Variable An abrupt onset to nadir < 30 sec, visually apparent decrease in
Deceleration the FHR below the baseline
The decrease in FHR is 15 bpm, with a duration of 15 sec but < 2
min
 CTG
Pattern Workshop Interpretation
Prolonged Visually apparent decrease in the FHR below the baseline
Deceleration Deceleration is 15 bpm, lasting 2 min but < 10 min from onset to
return to baseline
The National Institute of Child Health and Human Development Research Planning Workshop
Sinusoidal pattern
 Sinusoidal pattern
Criteria:
1. Stable baseline heart rate of 120 to 160 bpm with
regular oscillations
2. Amplitude of 5 to 15 bpm (rarely greater)
3. Long-term variability frequency of 2 to 5 cycles per
minute
4. Fixed or flat short-term variability
5. Oscillation of the sinusoidal waveform above or
below a baseline
6. Absent accelerations.
 Sinusoidal pattern
Fetal intracranial hemorrhage
Severe fetal asphyxia
Severe fetal anemia with Rh alloimmunization
Fetomaternal hemorrhage
Twin to twin transfusion syndrome
Vasa previa with bleeding
FACTORS AFFECTING FETAL HEART RATE

Gross body movement

Breathing movements
Pain
Temperature
Vibroacoustic stimulation
Sleep/wake cycles
Drugs
 Gross body movements
Associated with increase in FHR, starting
at 20-26 weeks AOG
Large, combined limb and trunk
movements versus isolated limb or rolling
trunk movement
Passive fetal movements produced by
palpation DOES NOT elicit increase in
FHR
 Fetal breathing movements
Variability may be increased with breathing
movements
Increased variability and breathing
movements during REM sleep
 Pain
Early 2nd trimester: FHR deceleration
22 weeks onwards: increase in FHR
 Temperature
Increase in maternal temperature (I.e.
infection): gradual increase in FHR
Lowering of maternal temperature: fetal
bradycardia
 Vibroacoustic stimulation
< 30 weeks: single sustained increase in
FHR
> 33 weeks: increase in FHR may take > 10
minutes from stimulation
Term: elevation of FHR may persist up to 1
hour
 Sleep/awake cycles
Affects mainly variability rather than FHR
Variability organized into episodes of high
and low variability (lasting about 20
minutes each)
REM sleep: increased variability
Quiet sleep: reduced to absent variability
 Drugs

In general, drugs affect the baseline fetal

heart rate and has less effect on the fetal
reflex responses
 Drugs
Primary mechanisms Examples

Increased heart Beta-adrenergic stimulation Ritodrine, isoxsuprine,

rate terbutaline
Alpha-adrenergic blockade Phentolamine
CNS stimulants/dysarrhythmics Cocaine, ketamine
(general)
Parathecol stimulants Ephedrine
Catechol release Nicotine
Increased metabolic rate Caffeine, thyroxine
Vagal blockade Atropine

Decreased Vagal stimulation/SA depression Digoxin

heart rate Beta-sympathetic blockade Propranolol
Alpha-sympathetic stimulation Dopamine
CNS depressant General anesthetics
Myocardial depressant Lidocaine
 Early Deceleration
usually associated with head compression
generally seen in active labor between 4
and 7 cm dilatation
not associated with fetal hypoxia, acidemia
or low Apgar scores
 Late Deceleration
smooth, gradual symmetrical decrease in
FHR beginning at or after the peak of the
contraction
return to baseline after the contraction has
ended
usually but not invariably pathological
 Late Deceleration
magnitude not more than 30-40 bpm
in milder cases, can be a reflex to CNS
hypoxia
in more severe cases, may be the result of
direct myocardial depression
 Late Deceleration
any process that causes maternal
hypotension, excessive uterine activity or
placental dysfunction
epidural anesthesia
oxytocin stimulation
 Variable Deceleration
Onset of deceleration varies with
successive contractions
Due to umbilical cord compression
Reflex that reflects BP changes due to
interruption of umbilical blood flow or
changes in oxygenation
 Variable Deceleration
appearance of the dip is variable in
duration, depth and shape from
contraction to contraction
usually abrupt in onset and cessation
described as severe when the
decelerations are below 70 bpm and
longer than 60 seconds in duration
 Non Stress Test (NST)
Fetal heart acceleration in response to fetal
movement as a sign of fetal health
Fetal heart rate of a fetus that is not acidotic
or neurologically depressed will temporarily
accelerate with fetal movement
 Non Stress Test (NST)
Reactive:
At least 2 fetal movements within a a 20 minute strip,
acceleration at least 15 bpm, lasting for 15 seconds
Nonreactive:
No fetal movement, no acceleration with movement or
stimulation, poor or absent long-term variability
Baseline heart rate within or outside the normal range
Non Stress Test (NST)
 Contraction Stress Test (CST)
Oxytocin challenge test
Test to check for uteroplacental function
90 minutes test
Require 3 contractions of 40 seconds or
more in 10 minutes tracing
 Contraction Stress Test (CST)
As uterine contractions increases,
myometrial pressure exceeds collapsing
pressure for vessels coursing through
uterine muscle decreases blood flow to
the intervillous space
Fetus with reduced placental reserve will
develop transient fetal hypoxemia in
association with the interruption of
uteroplacental blood flow
 Contraction Stress Test (CST)
Induction of contraction
Manual nipple stimulation
Not to exceed 2 minutes in duration, not less than 5 minutes
apart
Intravenous oxytocin
Start with 0.5 mU/min then doubled every 20 minutes until
satisfactory contractions perceive
Contraction Stress Test (CST)
Contraction Stress Test (CST)
Contraction Stress Test (CST)
 Contraction Stress Test (CST)
Contraindication
 Admission Test
A short, continuous electronic FHR recording
made immediately on admission
Better impression of the fetal condition than
traditional assessment
A screening test
 Admission Test
Use of admission electronic fetal monitoring
did not improve infant outcome
Its use resulted in increased interventions,
including operative delivery
Parameter Normal Tracing Atypical Tracing Abnormal Tracing
(Previously (Previously non- (Previously non-
reassuring reassuring) reassuring)
Baseline 110 160 bpm Bradycardia 100 Bradycardia < 100
110 bpm bpm
Tachycardia > 160 Tachycardia > 160
bpm for > 30 min to bpm for > 80 min
< 80 min Erratic baseline
Rising baseline
Variability 6 25 bpm 5 (absent or minimal) 5 for 80 min
5 (absent or for 40 - 80 min 25 bpm for 10 min
minimal) for < 40 Sinusoidal
min
Parameter Normal Tracing Atypical Tracing Abnormal Tracing
(Previously (Previously non- (Previously non-
reassuring reassuring) reassuring)
Deceleration None or occasional Repetitive ( 3) Repetitive ( 3)
uncomplicated variable uncomplicated uncomplicated variable
or early deceleration variable decelerations decelerations
Occasional late o Deceleration to <
decelerations 70 bpm for > 60 sec
Single prolonged o Loss in variability in
deceleration > 2 min trough or in
but < 3 min baseline
o Biphasic
decelerations
o Overshoots
o Slow return to
baseline
o Baseline lower after
deceleration
o Baseline
tachycardia
Late decelerations > 50
% of contractions
Single prolonged
deceleration > 3 min
but < 10 min
Parameter Normal Tracing Atypical Tracing Abnormal Tracing
(Previously (Previously non- (Previously non-
reassuring reassuring) reassuring)
Acceleration Spontaneous Absence of acceleration Usually absent (but
accelerations present: with fetal scalp presence of acceleration
FHR increases > 15 stimulation does not change the
bpm for > 15 sec classification of tracing)
For < 32 weeks
gestation, increase
in the FHR > 10
bpm for > 10 sec
Acceleration present
with fetal scalp
stimulation
Action EFM may be Further vigilant ACTION REQUIRED
interrupted for periods assessment required, Review overall clinical
up to 30 min if especially when situation, obtain scalp pH
maternal fetal combined features are if appropriate / prepare
conditions are stable present for delivery
and/or oxytocin
infusion rate stable

NICHHD (2008)