Intrapartum CTG Workshop

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Intrapartum CTG Workshop
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Case 1

• A 26 years old, G 3 p 3 with H/O twin delivery in
  the first pregnancy,
• admitted to the hospital at 31 weeksgestation
  with labour pains and
• preterm premature rupture of membranes for 4
  weeks.
• Her temperature was 39º C, the cervix cm
  dilated, clear liquor draining.
• The WBCs were 25 x 109

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Sinus Tachycardia

• Actions
• High vaginal swab for bacterial culture and
  sensitivity test (yes)
• Parentral antibiotics (yes)
• Antipyretics and review after 2 hours (no)
• Adjust tocodynamometer and review (yes)
• Cesarean section immediately (no)
• Fetal blood sampling for PH (no)
• Course and Outcome
• Labour was augmented with syntocinon, and
  intravenous triple
• antibiotics were given. After 5 hours, the
  patient had normal
• vaginal delivery of a baby boy weighing 1.9 kg.
  Apgar score was
• 5 at one minute and 8 at five minutes. Cord blood
  PH was 7.061,
• PO2 11.3, PCO2 61 , base excess 13.9, and O2
  saturation 6.4.
• The baby died after 10 hours due to septicemia.

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Case 2

• A 31 years old patient G 2 p 1 was admitted at 41
  weeks of gestation
• in active labour. Received pethidine and Phenrgan
  earlier.
• The cervix is 9 cm dilated and meconium stained
  liquor is draining.

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Sinus Tachycardia With Deceleration And No
Variability Mixed Pattern

• Actions
• Wait and review after 30 minutes (no)
• Change the position of the patient (yes)
• Fetal scalp blood sampling (no)
• Immediate cesarean section (yes)
• Give naloxone (no)
• Explain and reassure the patient (yes)
• Course and Outcome
• Cesarean section was carried out. A baby girl
  weighing 3898 gm
• was delivered from vertex presentation. Apgar
  score was 1/5
• at one and five minutes. The position of the cord
  was not noted.
• The baby had meconium aspiration pneumonitis and
  was
• discharged after 10 days.

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Case 3

• A 25 years old patient admitted at 36 weeks of
  gestation in labour. No sedation is given yet

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Rebound Tachycardia

• Actions
• Facial oxygen (no)
• Give sedation (no)
• Fetal scalp blood sampling for PH
  (yes)
• Augmentation of labour with syntocinon (no)
• Cesarean section (no)
• Maternal hydration (no)
• Course and Outcome
• After recovery from prolonged deceleration, scalp
  PH
• were 7.28, 7.36 and 7.36.the patient had normal
  vaginal
• delivery of baby girl weighing 2070gm(small for
  age).
• Apgar score was 9/10 at one and five minutes.

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Case 4

• A 24 years old patient, G 3 p11, with H/O
  cesarean section in the last
• pregnancy due to breech presentation. Currently
  admitted in active
• labour at 39 weeks of pregnancy. The cervix was
  6cm dilated and the
• head was at 0 station 2hours prior to this trace

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Variable Variable Deceleration

• Actions
• Vaginal examination and deliver if fully (yes)
• Immediate cesarean section (no)
• Fetal blood sampling for PH (yes)
• Facial oxygen (no)
• Change maternal position (yes)
• Review after 1 hour (no)
• Course and Outcome
• Vaginal examination showed fully dilated cervix
  with the
• head at 1 station. Progressed to normal vaginal
  delivery
• of baby girl weighing 2.7kg and Apgar score 9/10
  at one
• and five minutes. The position of the cord was
  not noted.
• The infant followed normal newborn course.

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Case 5

• A 19 years old primigravid patient admitted in
  labour at 34 weeks.
• She had pyelonephritis and chorioamnionitis.
• Pethidene was given 90 minutes prior to this
  trace.

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No variability, flat line-unfavorable outcome

• Actions
• Ultrasound to exclude anomalies
  (yes)
• Fetal vibroacuastic stimulation (yes)
• Fetal blood sampling for acid base status (yes)
• Observe and review after one hours (no)
• Immediate cesarean section (no)
• Stop fetal monitoring (no)
• Course and Outcome
• The mean of serial fetal blood sampling four
  times were showing
• nonacidotic intrapartum capillary PH of 7.2, so
  she was allowed to
• progress in labour.had Normal vaginal delivery
  of female weighing
• 2381 gm. Apgar score was 2/3 at one and five
  minutes. The newborn
• required intubation. It survived and was
  discharged after 9 days.

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Case 6

• A 21 years old primigravid patient complaining of
  reduced fetal
• movement at 42 weeks of gestation was admitted
  for induction of
• labour. Received prostin and started labouring.
  The cervix was 3cm
• dilated, so amniotomy was done and liquor was
  clear. Syntocinon
• infusion was started 30 minutes ago

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Increased variability with hypertonic labour

• Actions
• Observe and review after 30 minutes (no)
• Vaginal examination to asses progress
  (no)
• Reduce syntocinon infusion rate
  (yes)
• Immediate cesarean section (no)
• Oxygen by facial mask (yes)
• Fetal blood sampling for PH (no)
• Course and Outcome
• Syntocinon infusion was reduced and fetal heart
  returned to normal.
• 3 hours later CTG started to show late and late
  variable decelerations,
• so cesarean section was performed for fetal
  distress. Outcome was
• baby girl weighing 3 kg with 3 tight loops of the
  cord around the neck.
• Apgar score was 9/10 at one and five minutes.
• The infant had normal newborn course.

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Case 7

• A 28 years old patient G 5 p 4 0 was admitted in
  labour at 39½ weeks
• gestation. Her blood group was O positive,
  without antibodies.
• She received pethidine and phenrgan for sedation.

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Sinusoidal Pattern

• Actions
• Observe and review after 1 hour (no)
• Fetal blood sampling if feasible for PH
  (yes)
• Fetal blood sampling if feasible for haematocrit
  Hg (yes)
• Maternal Kleihaure-Betke test (yes)
• Immediate cesarean section (yes)
• U/S scan for fetal hydrops and abruptio placenta
  (yes)
• Course and Outcome
• Cesarean section was performed due to fetal
  distress.
• Outcome was baby girl weighing 960 gm with Apgar
  1/6 at
• one and five minutes with intrauterine growth
  restriction.
• Umbilical arterial PH was 7.37 and venous 7.41.
• The infant had intracrebral hemorrhage and died
  after
• 5days.

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Case 8

• Fifteen years old primigravid patient was
  admitted in
• labour at approximately 40 weeks gestation.
• She received epidural anesthesia

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Increased variability with variable deceleration

• Actions
• Observe and review after 30 minutes
  (no)
• Reduce the rate of syntocinon infusion if it is
  in us (yes)
• Vaginal examination to determine if delivery
  isimminent (yes)
• Cesarean section even if delivery is imminent
  (no)
• Fetal blood sampling
  (no)
• Course and Outcome
• Progressed to normal vaginal delivery of a female
  fetus weighing
• 3076 gm and Apgar score 3/9 at one and five
  minutes.
• Meconium was present requiring tracheal
  suctioning, which
• accounted for the initial low Apgar score. There
  was one nuchal
• cord and 10 placental abruption. The infant
  followed a normal
• newborn course

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Case 9

• A 21 years old primigravid patient admitted in
  labour at 40 weeks gestation

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Marked Accelerations

• Actions
• Observe for the development of other types of
  declarations (yes)
• Change maternal position
  (no)
• Prepare for cesarean section
  (no)
• Exclude maternal hypotention especially if gt
  50BPM (yes)
• Fetal blood sampling for PH
  (no)
• Course and Action
• Progressed to normal vaginal delivery of male
  infant weighing 3374gm
• Apgar score was 7/9 at one and five minutes and
  one nuchal cord was
• noted. The infant followed normal newborn course.

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Case 10

• A 23 years old primigravid patient was
  admitted in labour at 40 weeks gestation. The
  cervix was 4 cm dilated. Amniotomy was done and
  excessive clear liquor drained.

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Baseline obscured by acceleration with variable
decelerations

• Actions
• Adjust tocodynamometer (yes)
• Give sedation to the mother (no)
• Start syntocinon (no)
• Fetal blood sampling for PH (no)
• Immediate cesarean section (no)
• Course and Outcome
• Progressed to the second stage of labour and had
  normal vaginal
• delivery. The outcome was female weighing 3218
  gm. Apgar score
• was 9/9 at one and five minutes.
• The infant followed an uncomplicated newborn
  outcome.

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Case 11

• A 27 years old G 4 p 3 0 was admitted in labour
  at 41 ½ weeks
• gestation. 15 minutes prior to this recording the
  cervix was 4cm
• dilated with the head at 1 station. Artificial
  rupture of membranes
• was performed and clear liquor drained.

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Early decelerations

• Actions
• Oxygen by facial mask (no)
• Change maternal position (no)
• Cesarean section (no)
• Observe for the development of other types of
  declarations (yes)
• Vaginal examination for progress assessment
  (no)
• Fetal blood sampling (no)
• Course and outcome
• Progressed to normal vaginal delivery of female
  infant
• weighing 3969 gm. Apgar score was 8/9 at one and
  five
• minutes. The infant followed a normal newborn
  course.

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Case 12

• A 21 years old primigravid admitted in labour at
  40 weeks
• gestation.The vertex was in occipitoanterior
  position and liquor
• was meconium stained.

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Progression from Early to Variable Decelerations

• Actions
• Cesarean section (no)
• Syntocinon infusion (no)
• Observe for the development of other types of
  declarations (yes)
• Fetal blood sampling for PH
  (no)
• Oxygen by facial mask
  (no)
• Course and Outcome
• No other types of declarations developed.
  Progressed to normal
• vaginal delivery of male infant weighing 3374 gm.
  Apgar score
• was 7/9 at one and five minutes. The infant
  followed a normal
• newborn course.

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Case 13

• A 35 years old patient G 7 p 6 admitted at 42
  weeks gestation in
• labour. The cervix was 6 cm dilated with the head
  at - 2 station,
• liquor was stained with meconium.

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Late decelerations

• Actions
• Observe and review after1 hour
  (no)
• Cesarean section unless the fetus is about to be
  delivered (yes)
• Correct maternal hypotention if present
  (yes)
• Fetal scalp blood for PH (no)
• Maternal Kleihaure-Betke test
  (yes)
• Course and Outcome
• Cesarean section was done. The outcome was male
  baby weighing
• 3100 gm. Apgar score was 2/8 at one and five
  minutes.
• The infant had meconium aspiration.

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Case 14

• A 21 years old primigravid patient complaining of
  reduced fetal
• movement at 42 weeks of gestation was admitted
  for induction of
• labour. Received prostin and started labouring.
  The cervix was
• 3cm dilated, so amniotomy was done and liquor was
  clear.
• Syntocinon infusion was started 30 minutes ago.

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Classic Variable Deceleration

• Actions
• Observe for development of other abnormal forms
  (no)
• Cesarean section (yes)
• Fetal blood sampling for PH (no)
• Oxygen by facial mask (no)
• Amnioinfusion (no)
• Course and Outcome
• Syntocinon infusion was reduced and fetal heart
  returned to normal.
• 3 hours later CTG started to show late and late
  variable decelerations,
• so cesarean section was performed for fetal
  distress.
• Outcome was baby girl weighing 3 kg with 3 tight
  loops of the cord
• around the neck. Apgar score was 9/10 at one and
  five minutes.
• The infant had normal newborn course.

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Case 15

• A 29 years old G 4 p 2 1 patient admitted at 40
  weeks gestation
• in labour. The head of the fetus was in
  occipitoposterior position.

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Sinus bradycardia with deceleration mixed pattern

• Actions
• Check maternal pulse (yes)
• Change maternal position (yes)
• Cesarean section (no)
• Fetal blood sampling for PH (yes)
• Oxygen by facial mask (no)
• Reduce syntocinon infusion rate if it is in use
  (yes)
• Course and outcome
• Progressed to normal vaginal delivery of male
  baby weighing
• 2665 gm. Apgar score was 9/9 at one and five
  minutes.
• The infant followed normal course.

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Case 16

• A 30 years old G 4 p 3 patient was admitted in
  labour at 36 weeks
• gestation. She had H/O cesarean section in her
  second delivery.
• One hour prior to this trace, the cervix was 8cm
  dilated and clear
• liquor was draining

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Prolonged Deceleration

• Actions
• Vaginal examination (yes)
• Check maternal vital signs
  (yes)
• Fetal blood sampling for PH
  (no)
• Cesarean section (yes)
• Oxygen by facial mask
  (no)
• Course and outcome
• Rupture uterus was suspected and laparatomy was
  performed.
• There was complete scar dehiscence and the infant
  was in the
• peritoneal cavity. It was male 3.1 00 gmand fresh
  stillbirth.
• The uterus was repaired.

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Case 17

• A 29 years G 3 p 1 1 was admitted at her first
  antenatal care visit at
• 38 weeks gestation for blood sugar control, as
  blood sugar was
• found high. Polyhydraminous and big baby were
  diagnosed.
• She started to complain of labour pains

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Absent Long Term, Present Short Term Variability

• Actions
• Vaginal examination
  (yes)
• Vibroa-acouastic stimulation
  (no)
• Oxygen by facial mask
  (no)
• Maternal blood sugar
  (yes)
• Immediate cesarean section
  (no)
• Wait for another 10 minutes
  (yes)
• Course and Outcome
• Fetal heart returned to normal with good
  variability and accelerations.
• Cesarean section was done as planned.
• The outcome was baby boy weighing 4100gm. Apgar
  score was
• 9/9 at one and five minutes.

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Case 18

• A 23 years old primigravid patient, twin
  pregnancy was admitted in
• labour at 40 weeks gestation. The first twin was
  in cephalic
• presentation and second twin was in breech
  presentation. The cervix
• was 3 cm dilated with intact membranes one hour
  earlier

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Dual channel monitoring twins single scale

• Actions
• Continue observation as for uncomplicated
  twin (yes)
• Amniotomy and fetal scalp electrode (no)
• Cesarean section (no)
• Oxygen by facial mask (no)
• Change maternal position (no)
• Course and Outcome
• Cesarean section was done for arrest of cervical
  dilatation at 6 cm and
• failure to descent of fetal head. First twin was
  male with deflexed head
• weighing 3000 gm. Apgar score was 5/8 at one and
  five minutes.
• Second twin was breech, male weighing 2150 gm.
  Apgar score 6/8 at
• one and five minutes. There was one placenta.
  Both twins had normal
• newborn course.

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Case 19

• A 25 years old primigravid patient, diabetic
  on diet control with mild pregnancy induced
  hypertension.Labour was induced at 38 weeks
  gestation with vaginal prostin. She had
  spontaneous rupture of membranes 24 hours before
  this trace and clear liquor drained.

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Late Deceleration and Severe Variable
Deceleration

• Actions
• Change maternal position (yes)
• Fetal blood sampling (no)
• Immediate cesarean section (no)
• Exclude cord prolapse (yes)
• Wait and review as normal patient (no)
• Administration of tocolytics if the pattern
  continues (yes)
• Course and outcome
• Cesarean section was performed for failed
  induction of labour.
• Outcome was female infant weighing 3200 gm. Apgar
  score was
• 9/10 at one and five minutes.
• The infant followed normal newborn outcome.

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Case 20

• A 35 years old G 3p 1 1 had induction of labour
  at 39 weeks for
• premature rupture of membranes. She had received
  pethidine 90
• minutes prior to this segment. The fetus was in
  vertex
• presentation in occipetoanteror position at that
  time.

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Absent short term, present long term variability

• Actions
• Review previous segments of the trace to compare
  (yes)
• Fetal blood sampling for PH (yes)
• Change maternal position (no)
• Immediate cesarean section (no)
• Observe and review vaginally after 30
  minutes (yes)
• Course and outcome
• The tracing improved and the patient had normal
  vaginal delivery of
• female baby weighing 3600 gm. Apgar score was
  8/9 at one and five
• minutes. The infant had normal newborn course.

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Case 21

• A19 years old G 2 p1 patient was admitted in
  active labour at 30weeks gestation

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Decreased uterine activity produced by
tocodynamometer placement artifact

• Actions
• Adjust tocodynamometer belt (yes)
• Observe for development of other forms of
  decelerations (yes)
• Administration of tocolytics (no)
• Start augmentation with syntocinon (no)
• Immediate cesarean section (no)
• Course and outcome
• Uterine contractions were properly recorded after
  adjustment of the
• tocodynamometer belt. The patient had normal
  vaginal delivery of a
• Male baby weighing 1304 gm. Apgar score was 7/7
  at one and five
• minutes. The cord was wrapped around the arm of
  the baby who
• developed largeintraventricular haematoma . it
  was discharged from
• the hospital after 58 days.

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Case 22

• A 25 years old primigravida admitted in
  labour at 40 weeks
• gestation.The fetus was in
  occipitoanterior position

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W shaped Variable deceleration with maternal
straining

• Actions
• Observe and allow labour to progress (yes)
• Cesarean section (no)
• Syntocinon infusion for augmentation of
  labour (no)
• Adjust tocodynamometer belt (no)
• Oxygen by facial mask (no)
• Course and outcome
• Progressed and had normal vaginal delivery of a
  female weighing
• 3445 gm. Apgar score was 9/9 at one and five
  minutes.
• The infant followed a normal newborn course.

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