INTRAPARTUM

ASSESSMENT
(CARDIOTOCOGR
OB Clinical Clerk Faigani

APHY-CTG)
OBJECTIVES
 Learn how to evaluate fetal status
 Enumerate and define different methods of
evaluating fetal status
 Discuss briefly the categories of FHR CTG traces
 Compare Non stress Test and Contraction Stress
Test
 ELECTRONIC FETAL
MONITORING
 Direct / Internal electronic fetal
monitoring

 Indirect / External electronic fetal

monitoring
DIRECT / INTERNAL ELECTRONIC
FETAL MONITORING
 Direct fetal heart measurement is accomplished by
attaching a bipolar spiral electrode directly to the fetus
 EXTERNAL (INDIRECT)
ELECTRONIC MONITORING
 The fetal heart rate is detected through the
maternal abdominal wall using the ultrasound
Doppler principle.
 EXTERNAL (INDIRECT)
ELECTRONIC MONITORING
Consists of:

 Transducer
 Sensor
 Coupling gel
 Belt
Reflected ultrasound signals
from moving fetal heart
valves are analyzed through a
process, called
autocorrelation.
RECOMMENDATIONS FOR
INTRAPARTUM FHR
MONITORING
WHEN?
 FACTORS THAT INDICATE USE OF
CONTINUOUS ELECTRONIC FETAL
MONITORING

Fetal Factors:

 Abnormal fetal heart rate on

auscultation or admission tracing (20-
minute strip)*
 Meconium-stained amniotic fluid

Liston R, Sawchuck D, Young D, for the Society of Obstetrics and Gynaecologists of Canada, and the British Columbia Perinatal Health Program. Fetal health surveillance: antepartum and
intrapartum consensus guideline. No. 197 (replaces No. 90 and No. 112) [published correction appears in  J Obstet Gynaecol Can. 2007;29(11):909]. J Obstet Gynaecol Can. 2007;29(9 suppl
4):S33.
 FACTORS THAT INDICATE USE OF
CONTINUOUS ELECTRONIC FETAL
MONITORING

Maternal Factors:
 Hypertonic uterus
 Induced or augmented labor
 Intrauterine infection or
chorioamnionitis
 Post-term pregnancy (> 42 weeks'
gestation)
 Preterm labor (< 32 weeks' gestation)

Liston R, Sawchuck D, Young D, for the Society of Obstetrics and Gynaecologists of Canada, and the British Columbia Perinatal Health Program. Fetal health surveillance: antepartum and
intrapartum consensus guideline. No. 197 (replaces No. 90 and No. 112) [published correction appears in  J Obstet Gynaecol Can. 2007;29(11):909]. J Obstet Gynaecol Can. 2007;29(9 suppl
4):S33.
 FACTORS THAT INDICATE USE OF
CONTINUOUS ELECTRONIC FETAL
MONITORING
 Maternal Factors:

 Previous cesarean delivery

 Prolonged membrane rupture > 24 hours at
term
 Regional analgesia, particularly after initial
bolus and after top-ups (continuous electronic
fetal monitoring is not required with mobile or
continuous-infusion epidurals)
 Vaginal bleeding in labor

Liston R, Sawchuck D, Young D, for the Society of Obstetrics and Gynaecologists of Canada, and the British Columbia Perinatal Health Program. Fetal health surveillance: antepartum and
intrapartum consensus guideline. No. 197 (replaces No. 90 and No. 112) [published correction appears in  J Obstet Gynaecol Can. 2007;29(11):909]. J Obstet Gynaecol Can. 2007;29(9 suppl
4):S33.
HOW?
 NATIONAL INSTITUTE OF
CHILD HEALTH AND HUMAN
DEVELOPMENT (2008)
 DR C BRAVADO
DR - Determine risk
C - Contractions
BRA - Baseline rate
V - Variability
A - Accelerations
D - Decelerations
O - Overall assessment and written plan
 DETERMINE RISK

High
Moderate
Low risk
 CONTRACTIONS
Frequency – time between start of
contraction to start of next contraction

Duration – time from the start of

contraction to end of same contraction

Interval – amount of time between end of

one contraction to start of another
 CONTRACTIONS
Intensity – measure of how strong a
contraction

Resting tone – measure of how relaxed

the uterus is between contractions
 CONTRACTIONS

Normal - no more than (<5) five

contractions in a 10-minute
period.
Tachysystole
>5 contractions in a 10-minute
period, averaged over a 30-
minute window
TACHYSYSTOLE
 CONTRACTIONS
 Montevideo units
 Uterine performance is the product of the
intensity – increased uterine pressure above
the baseline tone
 An MVU of >200 predicts normally
progressive labor 90% of the time
 An MVU < 200 suggest protraction of labor
or frank arrest of labor
 CONTRACTIONS
 calculated by obtaining the peak uterine pressure
amplitude and subtracting the resting tone. Then
multiply the difference is multiplied to the # of
contractions within a 10-minute window.

 Example
 A patient has baseline of 15 mmHg with 4
contractions, each of which has a peak pressure of
70 mmHg.

 70-15=55
 MVU- 55x4= 220
 CONTRACTIONS

 Contractions
 Clinically palpable after intensity
exceeds 10 mmHg
 Associated with pain if it exceeds 15
mmHg
 CONTRACTIONS
First 30 weeks of pregnancy
 Quiescent
 Contractions seldom > 20 mmHg

After 30 weeks of pregnancy

 Increase in intensity and frequency
 CONTRACTIONS
Last weeks of pregnancy
Further increase in uterine pregnancy –
prelabor

Clinical labor
- 80 to 12o montevideo units
 DEFINITION OF
TERMS
 Baseline
 Baseline Variability
 Acceleration
 Early Deceleration
 Late Deceleration
 Variable Deceleration
 Prolonged Deceleration
 Sinusoidal Pattern
 BASELINE
 The mean FHR rounded to increments of
5 bpm during a 10-min segment,
excluding:

 Periodic or episodic changes

 Segments of baseline that differ by >25bpm
 BASELINE

 The baseline must be for a minimum of 2

min in any 10-min segment or the
baseline for that time period is
indeterminate
 BASELINE
 With increasing fetal maturation, heart
rate decreases
 Corresponds to the maturation of the
parasympathetic (vagal) heart control

 Baseline decreased an average of 24 bpm

between 16 weeks and term (1 bpm/week)
Average FHR
 tonic balance between the
accelerator (sympathetic) and
decelerator (parasympathetic)
influences on pacemaker cells

 Control of arterial chemoreceptors

 BASELINE
Normal FHR: 110-160 bpm

Tachycardia: >160 bpm

Bradycardia: <110 bpm

 NORMAL BASELINE

 Normal baseline fetal heart rate (FHR), shown at 135 beats per minute (bpm). Normal baseline rate ranges
from 110 to 160 bpm for a 10-minute segment and duration ≥ 2 minutes. Excludes periodic and episodic
changes, marked variability, and segments differing by ≥ 25 bpm.
BRADYCARDIA
 BRADYCARDIA
 Causes:
• Congenital heart block
• Serious fetal compromise
• Maternal hypothermia
• Severe pyelonephritis
 TACHYCARDIA

 Tachycardia of fetal heart rate (FHR), shown at 170 beats per minute (bpm). Baseline rate with tachycardia is > 160 bpm.
 TACHYCARDIA
 Causes:
• Maternal fever from chorioamnionitis
• Fetal compromise
• Cardiac arrhythmias
• Maternal administration of parasympathetic
(atropine) or sympathomimetic (terbutaline)
drugs
 BASELINE VARIABILITY
An important index of
cardiovascular function and is
regulated by autonomic nervous
system

Fluctuations in the baseline FHR

that are irregular in amplitude and
frequency
 BASELINE VARIABILITY
Quantified as the amplitude of
peak-to-trough in bpm

Absent – undetectable
Minimal - <5 bpm
Moderate - 6-25 bpm
Marked - >25 bpm
 ABSENT

 Amplitude range of FHR tracing is undetectable.

 MINIMAL

Amplitude range of FHR tracing ≤ 5 beats per minute.

 MODERATE

 Amplitude range of FHR tracing is 6 to 25 beats per minute.

 MARKED

 Amplitude range of FHR tracing > 25 beats per minute.

 SHORT TERM VARIABILITY

instantaneous change in fetal heart

rate from one beat – or R wave – to the
next
 LONG TERM VARIABILITY

oscillatory changes during 1 minute and

results in the waviness of baseline
 INCREASED
VARIABILITY
Factors that causes increased
variability:
 Fetal breathing
 Fetal body movements
 Advancing gestational age
 DECREASED
VARIABILITY

Factors that causes decreased variability:

 Hypoxemia
 A result of metabolic acidemia that
causes depression of the fetal
brainstem or the heart itself.
 analgesic drugs
 It is generally believed that reduced
baseline heart rate variability is
the single most reliable sign of fetal
compromise.
 ACCELERATION
Visually apparent abrupt increase
(onset to peak in <30s) in the FHR

Prolonged acceleration was defined

as 2 minutes or more but less than
10 minutes.
Proposed mechanisms for
intrapartum accelerations
include:
- fetal movement
- stimulation by uterine
contractions
- umbilical cord occlusion
- fetal stimulation during pelvic
examination
 DECELERATION
A decrease below the baseline
rate

Early
Late
Variable
 Early decelerations are termed head
compression

 Late decelerations are termed

uteroplacental insufficiency

 Variable decelerations become cord

compression patterns.
 EARLY DECELERATION

This consists of a gradual

decrease and return to baseline
associated with a contraction.
 Head
compression

Dural
stimulation

Vagal nerve
activation

Heart rate
deceleration
 LATE DECELERATION

 A late deceleration is a smooth,

gradual, symmetrical decrease in
fetal heart rate beginning at or after
the contraction peak and returning to
baseline only after the contraction
has ended.
A gradual decrease is defined as
30 seconds or more from the
onset of the deceleration to the
nadir.

In most cases, the onset, nadir,

and recovery of the deceleration
occur after the beginning, peak,
and ending of the contraction,
respectively
 VARIABLE DECELERATION

 Variable deceleration is defined as an

abrupt decrease in the fetal heart
rate beginning with the onset of the
contraction and reaching a nadir in less
than 30 seconds.
The decrease must last between
≥ 15 seconds and 2 minutes
and must be ≥ 15 bpm in
amplitude.
 Partial or complete cord
occlusion

Increase in afterload (baroreceptor) and a

decrease in fetal arterial oxygen content
(chemoreceptor)

Vagal activity

DECELERATION
Variable decelerations represent
fetal heart rate reflexes that
reflect either blood pressure
changes due to interruption of
umbilical flow or changes in
oxygenation
American College of Obstetricians
and Gynecologists (2013)
 recurrent variable decelerations
with minimal to moderate
variability are indeterminate,
whereas those with absent
variability are abnormal.
 PROLONGED DECELERATION

 An isolated deceleration greater than 15 bpm lasting 2 minutes

or longer but < 10 minutes from onset to return to baseline.

Common causes include:

 cervical examination
 uterine hyperactivity
 cord entanglement
 maternal supine hypotension
 Placental abruption
 Umbilical cord knots or prolapse
 Maternal seizures
 SINUSOIDAL PATTERN
 Visually apparent, smooth, sine wave-line
undulating pattern in FHR baseline with a cycle
frequency of 3-5 per minute which persists for 20 min
or more
 NATIONAL INSTITUTES OF HEALTH
WORKSHOPS
THREE-TIER CLASSIFICATION SYSTEM

Category I – Normal
Category II – Indeterminate
Category III – Abnormal
CATEGORY I—NORMAL

Include all of the following:

• Baseline rate: 110–160 bpm
• Baseline FHR variability: moderate
• Late or variable decelerations: absent
• Early decelerations: present or
absent
• Accelerations: present or absent
 CATEGORY II –
INDETERMINATE
 Include all FHR tracings not categorized
as Category I or III
 Baseline rate:
 Bradycardia not accompanied by absent
baseline variability
 Tachycardia

 Baseline FHR variability:

 minimal, absent, marked
 CATEGORY II –
INDETERMINATE
 Accelerations:
 absence of induced accelerations after fetal
stimulation
 Periodic or episodic decelerations
 Recurrent variable decelerations accompanied by
minimal or moderate baseline variability
 Prolonged decelerations >2min but <10 min
 Recurrent late decelerations with moderate
baseline variability
 Variable decelerations with other characteristics,
such as slow return to baseline, “overshoots” or
“shoulders”
CATEGORY III – ABNORMAL

 Include either
 Absent baseline FHR variability and
any of the following:
 Recurrent late decelerations
 Recurrent variable decelerations
 Bradycardia

 Sinusoidal pattern
 Category I – Normal; strongly
predictive of normal fetal acid-base
status.
 Category II – Indeterminate; Not
predictive of abnormal fetal acid-
base status, but evaluation and
continued surveillance and
reevaluations are indicated.
 Category III – Abnormal; predictive
of abnormal fetal acid-base status &
requires prompt evaluation and
mamangement
 NON STRESS
TEST
VS
CONTRACTION
STRESS TEST
 NON STRESS TEST
 Evaluates the response of FHR to fetal
movement
 Based on the premise that the heart rate
of the fetus that is not acidotic or
neurologically depressed and will
temporarily accelerate with fetal
movement
 NON STRESS TEST
 REACTIVE:
 At least 2 FHR acceleration occur for at least 15 bpm
from baseline lasting for 15s within 20 min observation
time
 NON STRESS TEST
 NON REACTIVE:
 <2 accelerations
 Loss of reactivity associated with fetal sleep
cycle, acidosis or CNS depression
 CONTRACTION STRESS
TEST
 Goal: to identify a fetus at risk for
compromise by observing the fetus in
the presence of stress
 Evaluates the reaction of the FHR to
contraction induced by either nipple
stimulation or oxytocin administration
 Testing is stopped once 3 contraction/10
minutes has been established
 CONTRACTION STRESS
TEST
 POSITIVE:
 Presence of late deceleration with at least
50% of the contraction
 CONTRACTION STRESS
TEST
 NEGATIVE:
 No late or significant variable decelerations,
with at least 3 uterine contraction in 10
minutes
 CONTRACTION STRESS
TEST
 EQUIVOCAL SUSPICIOUS
 Late deceleration with fewer than 50% of
contraction or significant variable
decelerations
 CONTRACTION STRESS
TEST
 EQUIVOCAL UNSATISFACTORY
 <3 contractions occur within 10 minutes or
a tracing quality that cannot be interpreted
 CONTRACTION STRESS
TEST
EQUIVOCAL TACHYSYSTOLE
 Contractions that occur more
frequently than every 2 minutes
or longer than 90s in the
presence of late decelerations
OTHER
INTRAPARTUM
ASSESSMENT
TECHNIQUE
 OTHER INTRAPARTUM
ASSESSMENT TECHNIQUES
 Fetal Scalp Blood Sampling
 Scalp Stimulation
 Vibroacoustic Stimulation
 Fetal Pulse Oximetry
 Fetal Electrocardiography
 Intrapartum Doppler Velocimetry