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H A N D B O O K O F C T G I N T E R P R E TAT I O N H ANDB OOK OF CTG I NT ER P R ETAT I ON From Patterns to Physiology Edited by Edwin Chandraharan St George’s University Hospitals NHS Foundation Trust, London, and St George’s University of London, UK University Printing House, Cambridge CB2 8BS, United Kingdom Cambridge University Press is part of the University of Cambridge It furthers the University’s mission by disseminating knowledge in the pursuit of education, learning and research at the highest international levels of excellence www.cambridge.org Information on this title: www.cambridge.org/9781107485501 © Cambridge University Press 2017 This publication is in copyright Subject to statutory exception and to the provisions of relevant collective licensing agreements, no reproduction of any part may take place without the written permission of Cambridge University Press First published 2017 Printed in the United Kingdom by TJ International Ltd Padstow Cornwall A catalogue record for this publication is available from the British Library Library of Congress Cataloging-in-Publication data Names: Chandraharan, Edwin, editor Title: Handbook of CTG interpretation: from patterns to physiology / edited by Edwin Chandraharan Description: Cambridge, United Kingdom; New York: Cambridge University Press, [2017] | Includes bibliographical references and index Identifiers: LCCN 2016047896 | ISBN 9781107485501 (pbk.) Subjects: | MESH: Cardiotocography | Fetal Hypoxia – prevention & control | Fetal Heart – physiology | Uterine Monitoring – methods Classification: LCC RG618 | NLM WQ 209 | DDC 618.3261–dc23 LC record available at https://lccn.loc.gov/2016047896 ISBN 978-1-107-48550-1 Paperback Cambridge University Press has no responsibility for the persistence or accuracy of URLs for external or third-party internet websites referred to in this publication, and does not guarantee that any content on such websites is, or will remain, accurate or appropriate Every effort has been made in preparing this book to provide accurate and up-to-date information which is in accord with accepted standards and practice at the time of publication Although case histories are drawn from actual cases, every effort has been made to disguise the identities of the individuals involved Nevertheless, the authors, editors and publishers can make no warranties that the information contained herein is totally free from error, not least because clinical standards are constantly changing through research and regulation The authors, editors and publishers therefore disclaim all liability for direct or consequential damages resulting from the use of material contained in this book Readers are strongly advised to pay careful attention to information provided by the manufacturer of any drugs or equipment that they plan to use Dedicated to all babies who have sustained intrapartum hypoxic injuries and to all healthcare providers who are focussed on reflective practice and To my teachers who inspired me to develop an interest in human physiology and intrapartum care Contents List of Contributors Preface Acknowledgements Glossary ‘An Eye Opener’: Perils of CTG Misinterpretation: Lessons from Confidential Enquiries and Medico-legal Cases Edwin Chandraharan Fetal Oxygenation Anna Gracia-Perez-Bonfils and Edwin Chandraharan Physiology of Fetal Heart Rate Control and Types of Intrapartum Hypoxia Anna Gracia-Perez-Bonfils and Edwin Chandraharan Understanding the CTG: Technical Aspects Harriet Stevenson and Edwin Chandraharan Applying Fetal Physiology to Interpret CTG Traces: Predicting the NEXT Change Edwin Chandraharan Avoiding Errors: Maternal Heart Rate Sophie Eleanor Kay and Edwin Chandraharan Antenatal Cardiotocography Francesco D’Antonio and Amar Bhide Intermittent (Intelligent) Auscultation in the Low-Risk Setting Virginia Lowe and Abigail Archer Current Scientific Evidence on CTG Ana Piñas Carrillo and Edwin Chandraharan 10 Role of Uterine Contractions and Intrapartum Reoxygenation Ratio Sadia Muhammad and Edwin Chandraharan 11 Intrapartum Monitoring of a Preterm Fetus Ana Piñas Carrillo and Edwin Chandraharan 12 Role of Chorioamnionitis and Infection Jessica Moore and Edwin Chandraharan 13 Meconium: Why Is It Harmful? Nirmala Chandrasekaran and Leonie Penna 14 Intrapartum Bleeding Edwin Chandraharan 15 Labour with a Uterine Scar: The Role of CTG Ana Piñas Carrillo and Edwin Chandraharan 16 Impact of Maternal Environment on Fetal Heart Rate Ayona Wijemanne and Edwin Chandraharan 17 Use of CTG with Induction and Augmentation of Labour Ana Piñas Carrillo and Edwin Chandraharan 18 Recognition of Chronic Hypoxia and the Preterminal Cardiotocograph Austin Ugwumadu 19 Unusual Fetal Heart Rate Patterns: Sinusoidal and Saltatory Patterns Madhusree Ghosh and Edwin Chandraharan 20 Intrauterine Resuscitation Abigail Spring and Edwin Chandraharan 21 Management of Prolonged Decelerations and Bradycardia Rosemary Townsend and Edwin Chandraharan 22 ST-Analyser (STAN): Principles and Physiology Ana Piñas Carrillo and Edwin Chandraharan 23 ST-Analyser: Case Examples and Pitfalls Ana Piñas Carrillo and Edwin Chandraharan 24 Role of a Computerized CTG Sabrina Kuah and Geoff Matthews 25 Peripheral Tests of Fetal Well-being Charis Mills and Edwin Chandraharan 26 Operative Interventions for Fetal Compromise Mary Catherine Tolcher and Kyle D Traynor 27 Nonhypoxic Causes of CTG Changes Dovilé Kalvinskaité and Edwin Chandraharan 28 Neonatal Implications of Intrapartum Fetal Hypoxia Justin Richards 29 Role of the Anaesthetist in the Management of Fetal Compromise during Labour Anuji Amarasekara and Anthony Addei 30 Medico-legal Issues with CTG K Muhunthan and Sabaratnam Arulkumaran 31 Ensuring Competency in Intrapartum Fetal Monitoring: The Role of GIMS Virginia Lowe and Edwin Chandraharan 32 Physiology-Based CTG Training: Does It Really Matter? Sara Ledger and Edwin Chandraharan Appendix: Rational Use of FIGO Guidelines in Clinical Practice Answers to Exercises Index C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an induction of labour and, 97 intrapartum bleeding, 82–84 prolonged decelerations, 118, 119–120 variable decelerations and, 18–19 ‘upside down’ CTG trace, false ‘reduced baseline variability,’ 29–30 uterine contractions chemoreceptor decelerations, 34–36 contraction stress test, 48–51 CTG measurement of, 27–28 cumulative uterine activity, 36–38 fetal oxygenation and, 9–10 intermittent (intelligent) auscultation following, 55–56 internal pressure transducer monitoring, 28 intrapartum re-oxygenation ratio, 62–65 maternal heart rate monitoring and, 41–44 uterine hyperstimulation, 62 acute hypoxia, 19–20 CTG interpretation guidelines, 97, 114–115 induction of labour and risk of, 96 key features, 63–64 management guidelines, 122 pathophysiology of, 63–64 prolonged decelerations, 118 recommended management, 64 saltatory FHR patterns, 109, 111 suspected fetal compromise, 114 tachysystole, 120–122 tocolytics, 18 uterine rupture management and outcome optimization, 88–89 prolonged decelerations, 118, 119–120 uterine scar acute hypoxia with rupture of, 19–20 diagnosis and management, 87–89 pitfalls and consequences of rupture, 89 utero-placental circulation Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an diabetic pregnancy, 9–10 intrauterine resuscitation, 114 normal placentation and, 6–8 uterine hyperstimulation and, 62 utero-placental insufficiency baseline fetal heart rate, 16 chemoreceptor decelerations, 34–36, 114–115 chorioamnionitis and, 74 contraction stress test, 48–51 deceleration patterns, 17–19 effects of, 63–64 uterotonic use, intrapartum re-oxygenation ratio and, 62 utrine rupture, intrapartum bleeding, 82–85 vacuum-assisted delivery CTG changes during instrument application, 151–152 failure of, 152–153 fetal compromise and, 151–154 indications for, 151 vagal innervation to myocardium, baseline fetal heart rate variability, 101–102 vagotomy, baseline fetal heart rate variability, 101–102 variability in CTG patterns See baseline variability fetal heart rate, 101–102 maternal environment and reduction in, 92–93 predicted prolonged deceleration recovery, CTG interpretations, 122 uterine scar rupture and reduction in, 87–88 variable decelerations abnormal CTG, significant STAN events, 140–141 CTG patterns and, xii–xiii, 3–4, 18–19 fetal compromise and, 169 fetal hypertension, 114–115 intrapartum bleeding, 82–84 uterine hyperstimulation and, 63–64 uterine scar rupture, 87–88 vasa praevia, 82–85 vertical transmission risk, fetal scalp electrode monitoring and, 27–28 Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an vibro-acoustic stimulation (VAS), 45 *Vincent and Ennis, Wharton’s jelly in umbilical cord, in preterm fetuses, 68 zona pellucida, normal placentation and, 6–8 Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Table of Contents Half title Title page Imprints page Dedication Contents Contributors Preface Acknowledgements Glossary ‘An Eye Opener’: Perils of CTG Misinterpretation Introduction Effects of CTG Misinterpretation CTG Interpretation: What Is the Problem? Further Reading Fetal Oxygenation Introduction Placentation: Impact on Fetal Oxygenation Normal Placentation Impact of Placental Reserve on Fetal Growth and Well-being Fetal Adaptation to Hypoxic Intrauterine Environment Abnormal Placentation Fetal Response to Hypoxic Stress Summary Further Reading Physiology of Fetal Heart Rate Control and Types of Intrapartum Hypoxia Physiology of Fetal Heart Rate Control Parasympathetic Nervous System Baroreceptors Chemoreceptors Role of Sympathetic System and the Fetal Adrenal Glands The Somatic Nervous System Features of a Normal CTG Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 11 14 19 20 23 23 24 26 28 30 30 30 31 34 35 36 36 38 38 40 40 41 42 42 43 44 45 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Baseline FHR Variability Accelerations Decelerations Types of Intrapartum Hypoxia Acute Hypoxia Subacute Hypoxia Gradually Evolving Hypoxia Long-Standing (Chronic) Hypoxia Preterminal CTG Exercises Further Reading Understanding the CTG 45 46 46 47 50 50 52 52 53 54 55 56 57 Introduction Parts of the Machine CARDIOtocograph – Records the Features of the FHR Transabdominal Monitoring – Noninvasive Monitoring Fetal Scalp Electrode - Invasive Monitoring CardioTOCOgraph – Measurement of Uterine Activity Internal Pressure Transducers - Invasive Monitoring CardiotocoGRAPH– Display of the CTG Trace Paper Printout Electronic Display and Storage Pitfalls Doubling of FHR Halving of FHR Erroneous Monitoring of Maternal Heart Rate as FHR Loss of Contact or Poor Signal Quality Interference Incorrect Placement of Thermosensitive Paper Further Reading 57 58 58 58 59 60 61 61 62 62 62 62 62 63 63 63 63 64 Applying Fetal Physiology to Interpret CTG Traces 65 Adult Physiological Response to Hypoxic Stress Fetal Physiological Response to Hypoxic Stress Physiological Approach to CTG Interpretation: ‘8Cs’ Approach to Management Key Messages on Physiology-Based CTG Interpretation Exercises Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 65 67 71 74 75 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an CTG Exercise A CTG Exercise B Avoiding Errors 75 76 77 Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on CTG Trace Recommended Management Key Tips to Optimize Outcome Common Pitfalls Consequences of Mismanagement References Antenatal Cardiotocography Key Facts Indications for Antenatal Fetal Testing Role of Antenatal Cardiotocography Pathophysiology behind CTG Features Interpretation of a CTG Trace Baseline Heart Rate Fetal Tachycardia Fetal Bradycardia Variability Accelerations Decelerations Sinusoidal Pattern Types of CTG Examinations Contraction Stress Test Non-Stress Test Computerized CTG Pearls: CTG in Clinical Practice Pitfalls Consequence of Mismanagement Possible Future Developments Conclusions References Intermittent (Intelligent) Auscultation in the Low-Risk Setting Key Facts Recommended Method Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 77 78 79 80 80 81 81 81 83 83 83 84 84 85 85 86 86 86 87 87 88 88 88 89 91 92 93 94 94 94 94 99 99 100 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Physiology behind IA 101 Pitfalls Exercises Further Reading 102 103 104 Current Scientific Evidence on CTG Key Facts Current Evidence Interpretation of Current Evidence Future Developments Further Reading 10 Role of Uterine Contractions and Intrapartum Reoxygenation Ratio Key Facts Key Features (Increased Uterine Activity) An Acute Increase in Uterine Activity (e.g Immediately after Increasing Oxytocin Infusion) Effects of Continuing Increase in Uterine Activity over Time Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Pearls Pitfalls Consequences of Mismanagement Exercises References 11 Intrapartum Monitoring of a Preterm Fetus Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercises Further Reading 12 Role of Chorioamnionitis and Infection Key Facts Key Pathophysiology of Infection and CTG Stt.010.Mssv.BKD002ac.email.ninhd 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131 133 Key Facts Recommended Management Common Pitfalls Consequences of Meconium Further Reading 133 134 138 138 139 14 Intrapartum Bleeding 140 Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercise Further Reading 15 Labour with a Uterine Scar Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercise Further Reading 16 Impact of Maternal Environment on Fetal Heart Rate Introduction Key Facts Conditions Causing Maternal Metabolic Acidosis Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 140 140 141 143 143 144 144 145 146 147 147 148 148 149 150 150 151 151 152 153 153 153 154 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Conditions Causing Chronic Maternal Hypoxia Conditions Reducing Placental Perfusion 154 154 Maternal Autoantibodies Drugs Maternal Temperature Key Changes on the CTG Trace Raised Baseline Fetal Heart Rate (FHR) Reduced Baseline FHR Reduced Variability Chemoreceptor-Stimulated Decelerations Prolonged Decelerations Key Pathophysiology behind the Features Observed on the CTG Trace Raised Baseline FHR Reduced Baseline FHR Reduced Variability Chemoreceptor-Simulated Decelerations Prolonged Decelerations Management Key Tips for Optimizing the Outcome Common Pitfalls Consequences of Mismanagement Exercise Further Reading 154 155 155 155 155 155 155 156 156 156 156 156 157 157 157 157 158 158 159 159 160 17 Use of CTG with Induction and Augmentation of Labour 161 Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercise Further Reading 18 Recognition of Chronic Hypoxia and the Preterminal Cardiotocograph The Fetal Neurologic State Physiology of FHR Regulation and Variability Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 161 162 163 164 165 166 166 167 167 169 169 170 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Fetal Response to Hypoxia-Ischaemia FHR Characteristics of a Chronically Hypoxic Fetus Other Markers of Chronic Hypoxia in the Fetus The Preterminal CTG Conclusions References 19 Unusual Fetal Heart Rate Patterns Key Facts Key Features on the CTG Trace Key Pathophysiology of Sinusoidal and Saltatory FHR Patterns Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercise References 20 Intrauterine Resuscitation Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Pitfalls Consequences of Mismanagement Exercise Further Reading 21 Management of Prolonged Decelerations and Bradycardia Key Facts Management of Prolonged Decelerations Causes of Prolonged Decelerations Nonreversible Causes of Prolonged Decelerations Reversible Causes of Prolonged Decelerations Maternal Hypotension Management of Hypotension Excessive Uterine Activity (Tachysystole) Management of Uterine Hyperstimulation CTG Parameters That Predict Recovery of Prolonged Decelerations Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 171 172 176 177 178 178 181 181 182 183 184 185 185 186 186 187 189 189 190 190 191 192 193 193 193 194 195 195 196 198 198 199 199 200 200 201 202 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Assessment of CTG Parameters When Should Delivery Occur? After the Prolonged Deceleration Has Resolved 202 203 205 When Is It Safe to Restart Oxytocin? Suggested Approach to Management of Prolonged Decelerations Management of Prolonged Decelerations Management of Fetal Bradycardia Common Pitfalls Exercise References 205 206 206 207 207 208 211 22 ST-Analyser (STAN) Key Facts Key Features on the STAN Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Outcome Common Pitfalls Consequences of Mismanagement Recent Developments Further Reading 23 ST-Analyser 213 213 214 215 216 217 217 218 219 219 221 Key Principles Case Commencement of STAN Case STAN Events on a Normal CTG Trace Case Nonsignificant ‘Episodic’ STAN Events Case Abnormal CTG without Significant ST Events Case Abnormal CTG with a Significant STAN Events Pitfalls with the Use of STAN Conclusions Further Reading 24 Role of a Computerized CTG Introduction Cardiotocography Adjuncts to CTG Fetal Blood Sampling Fetal ECG (STAN) Training and Reducing Human Error Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 221 224 225 226 227 229 230 230 231 232 232 233 233 234 234 234 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Computerized Decision Support Conclusion References 25 Peripheral Tests of Fetal Well-being Key Facts Fetal Scalp Blood Sampling Fetal Scalp Lactate Analysis Fetal Pulse Oximetry Recommended Management Consequences of Mismanagement References 26 Operative Interventions for Fetal Compromise Key Facts Operative Vaginal Delivery Anticipated CTG Changes Following Instrument Application Failed Operative Vaginal Delivery Decision to Delivery Interval Pitfalls Consequences of Mismanagement References 27 Nonhypoxic Causes of CTG Changes 235 237 237 239 239 240 241 242 242 243 243 245 245 245 246 247 248 249 249 250 252 Key Facts Key Features on the CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key tips to Optimize the Outcome Pitfalls Consequences of Mismanagement References 253 254 256 258 258 259 259 260 28 Neonatal Implications of Intrapartum Fetal Hypoxia 262 Introduction When Does Fetal Hypoxia Pose a Risk for the Fetus? Mechanisms of Hypoxic Brain Injury Clinical Features of Hypoxic-Ischaemic Encephalopathy Management of HIE Outcomes References Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 262 262 264 265 266 267 268 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an 29 Role of the Anaesthetist in the Management of Fetal Compromise during Labour Key Facts Key Pathophysiology Recommended Management Key Issues Key Tips to Optimize Outcome Pitfalls References 30 Medico-legal Issues with CTG Background Key Facts Key Features on the CTG Trace Acute Hypoxia Subacute Hypoxia Gradually Developing Hypoxia Long-standing or Preexisting Hypoxia Anaemia and Sinusoidal CTG Trace Key Pathophysiology behind Patterns Seen on the CTG Trace Recommended Management Key Tips to Optimize Management Pitfalls Fetus at Risk Fetus at Possible Risk Due to Injudicious Management Consequences of Mismanagement Exercise References 31 Ensuring Competency in Intrapartum Fetal Monitoring Background Objectives Strategies Intense Physiology-Based CTG Training Use of Fetal ECG (STAN) Competency Testing Training and Assessment Outcomes Discussion Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 269 269 270 271 272 273 274 274 276 276 276 277 277 278 279 280 281 282 283 284 285 285 286 286 287 288 290 290 291 291 291 292 292 292 293 294 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Conclusion Further Reading 295 295 32 Physiology-Based CTG Training 297 Key Facts 297 Baby Lifeline’s Role in CTG Training Centres and Delegates Structure and Aim of Masterclass Key Outcomes Delegate Feedback Impact of Training: Pre- and Post-Tests Key Challenges to Multiprofessional Training in Physiology-Based CTG Interpretation Conclusion References 297 298 298 298 298 301 Appendix Rational Use of FIGO Guidelines in Clinical Practice 306 Clinical Decision Implementation of FIGO Guidelines in Clinical Practice Answers to Exercises Chapter Physiology of Fetal Heart Rate Control and Types of Intrapartum Hypoxia Answer Chapter Applying Fetal Physiology to Interpret CTG Traces: Predicting the NEXT Change CTG Exercise A Answers CTG Exercise B Answers Chapter Intermittent (Intelligent) Auscultation in the Low-Risk Setting Answers Chapter 10 Role of Uterine Contractions and Intrapartum Reoxygenation Ratio Answers Chapter 11 Intrapartum Monitoring of a Preterm Fetus Answers Chapter 12 Role of Chorioamnionitis and Infection Answers Chapter 14 Intrapartum Bleeding Answers Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn 301 304 304 307 308 310 310 311 312 312 314 317 318 320 321 322 323 324 324 325 326 328 329 C.33.44.55.54.78.65.5.43.22.2.4 22.Tai lieu Luan 66.55.77.99 van Luan an.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.C.33.44.55.54.78.655.43.22.2.4.55.22 Do an.Tai lieu Luan van Luan an Do an.Tai lieu Luan van Luan an Do an Stt.010.Mssv.BKD002ac.email.ninhd 77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77.77.99.44.45.67.22.55.77.C.37.99.44.45.67.22.55.77t@edu.gmail.com.vn.bkc19134.hmu.edu.vn.Stt.010.Mssv.BKD002ac.email.ninhddtt@edu.gmail.com.vn.bkc19134.hmu.edu.vn
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