Ctg.kuliah Ppds

8/13/2019 Ctg.kuliah Ppds

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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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