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Yuyun Lisnawati
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A continuous recording of thefetal heart rate obtained via
an ultrasound transducerplaced on the mothersabdomen.
CTG is widely used inpregnancy as a method ofassessing fetal well-being.
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EFM was introduced with an aim of
reducing perinatal mortality and cerebral
palsy.
Fetal wellbeing could monitor antenatally
and during labor to save babies from the
potentially catastrophic effects of hypoxiaduring labor.
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RCOG- NICE 2001
Categorisation of Fetal Heart Rate (FHR) Features
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The NICHD workgroup proposed terminology of a three-tiered system to replace the
older undefined terms "reassuring" and "nonreassuring:
Category I (Normal) :
strongly predictive of normal fetal acid-base status at the time of observation :
Baseline rate 110-160 bpm,
Moderate variability,
Absence of late, or variable decelerations, Early decelerations and accelerations may or may not be present.
Category II (Indeterminate) :
Tracing is not predictive of abnormal fetal acid-base status, but evaluation andcontinued surveillance and reevaluations are indicated.
Category III (Abnormal) :predictive of abnormal fetal acid-base status at the time of observation :
Absence of baseline variability with recurrent late or variable decelerations orbradycardia; or
Sinusoidal fetal heart rate.
Macones GA, Hankins GD, et al. NICHD. Obstet Gynecol (2008) 112
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Initial observational studies showed a strong
correlation between an abnormal CTG and
poor fetal outcome.
(Freeman 1982a; Freeman 1982b; Phelan 1981).
In high-risk pregnancies in particular, non-
reactiveCTGs were associated with increasedmorbidity and mortality for the baby.
(Boehm 1986; Flynn 1977).
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An evaluation of antenatal CTG in Nigeria (2008)
found a non-reactive non-stress test were :
significantly more likely to deliver by CS
experience high perinatal mortality, and
have small-for-gestational-age infants
Fawole et alconcluded, that the non-reactive
non-stress test was a valuable tool for early
detection of fetal compromise.
Fawole Ao, et al. Antenatal cardiotocography: experience in a Nigerian tertiary hospital. Nigerian Postgraduate Med Jou 2008;15.
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There was no improvement in neonatal
outcome when low risk women were
continuously monitoried.
MacDonald D, Grant A, Sheridan-Pereira M et al. The Dublin randomized controlled trial of intrapartum
fetal heart rate monitoring.Am J Obstet Gynecol 1985;152:524-39.
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Nelson et al, reviewed women with a highly
abnormal CTG in labor i.e. fetal tachycardia
with reduced variability and late
decelerations :- Only 58% of these fetuses with a highly
abnormal CTG were acidotic at birth as
judged by umbilical artery pH.
- Only 0.2% went on to develop CP.
Nelson KB, Dambrosia JM, et al. N Engl J Med. 1996;334:613-8.
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The false-positive rate of CTG for cerebral
palsy is given as high as 99%, meaning that
only 1-2 of one hundred babies with non-reassuring patterns will develop cerebral
palsy.
Cochrane Database of Systematic Reviews 2006
ACOG Practice Bulletin, 2005
RCOG-NICE 2001
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CTG has a lack of specificity and high false
positive rates when using it to detect fetal
compromise.
(Sadovsky 1981; Trimbos 1978a).
Intra-observer variability when a subjective
visual assessment was used was as low as 57%.(Trimbos 1978b).
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Poor agreement of both visual interpretation and
classification or scoring of antenatal CTGs.
(Ayres-de-Campos1999; Bernades 1997;Devane 2005).
Inter- and intra-observer variability affect the
reliability and reproducibility of the test.
(Borgotta 1988; Lotgering 1982).
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Six studies (involving 2105 women)
Comparison of traditional CTG versus no CTG showed :
- no significant difference identified in perinatalmortality (risk ratio (RR) 2.05, 95% (CI) 0.95 to 4.42,
2.3% versus 1.1%, four studies, N = 1627)
-no significant difference identified in potentiallypreventable deaths(RR 2.46, 95% CI 0.96 to 6.30,
four studies, N = 1627, though the meta-analysis was
underpowered to assess this outcome.
RHL WHO Laboratory 2010Cochrane Review2010
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There were no eligible studies that comparedcomputerised CTG with no CTG.
Comparison of computerised CTG versus traditionalCTG showed :
- a significant reduction in perinatal mortality withcomputerised CTG(RR 0.20, 95% CI 0.04 to
0.88, two studies, 0.9% versus 4.2%, 469 women).
- no significant difference identified in potentiallypreventable deaths (RR 0.23, 95% CI 0.04 to
1.29, two studies, N = 469), though the meta-
analysis was underpowered to assess this outcome.
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In contrast, labour monitored by CTG isslightly more likely to result in instrumentaldelivery (forceps or vacuum extraction) orCesarean section.
The relative risk was 1.41 (95% CI 1.23-1.61),compared to that with intermittentauscultation of the fetal heart.
Cochrane Database of Systematic Reviews 2006
ACOG Practice Bulletin, 2005
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The RCOG and the NICE reviewed the whole issue of FHR monitoring (2001)
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Five trials involving 2974 women with
pregnancies with a high risk of poorer fetal
outcome were found.
The data are insufficient to reach a
conclusion about the benefit or otherwise of
the BPP as a test of fetal wellbeing.
The Cochrane Database of Systematic Reviews 2011
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SKOR PENILAIAN 2 0
Reaktifitas DJJ > 2 < 2
Akselerasi stimulasi > 2 < 2
Rasio SDAU 3
Gerak napas
stimulasi
>= 2 episode < 2 episode
Indeks Cairan Amnion >= 10 cm < 10 cm
Wiknjosastro G. Tesis, 1992
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Sensitivity 80% 13% and spesifisity 89%, in
predicting fetal acidosis in cases of
preeclampsia and eclampsia.
FDJP score < 5, the fetal is likely to suffer
acidosis , so it is recommended to be
delivered with caesarea.
FDJP score > 5 it is recommended to be
delivered normally.
Wiknjosastro G. Tesis, 1992
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Test scores FDJP < 5 in cases of high risk
pregnancy related meaning with medium to
heavy asphyxiation incident on neonatal, with
RR 6.35 and 8.4 times for events the minute
Apgar score 1st and 5th of less than 7.
Test scores FDJP < 5 statistically increases therisk of 8.8 times with care needs neonatal in
NICU
Purnawan. Tesis, 2009
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Lahir bayi SC 3100 gr/45 cm AS 9/10
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Lahir bayi SC 3300 gr, AS 8/9. Air ketuban hijau encer, jumlah
sedikit. Ibu dan bayi baik di ruangan rawat gabung
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Lahir bayi laki-laki 3400g/49 cm AS 7/8, air
ketuban keruh , jumlah sedikit
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The FHR is only an indirect measure of fetal
wellbeing and fetal hypoxia.
CTG has a lack of specificity, high false positive
rates and intra-observer variability.
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More valuable information would be gained :
blood pressure and cerebral flow or cerebral
oxygen saturation.
Such measurements are technically difficult
at the moment, at least in human fetuses,
and hence all we have to rely on is the FHR.
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