Intrapartum CTG Workshop

Case # 1A 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

Sinus Tachycardia

ActionsHigh 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 tripleantibiotics were given. After 5 hours, the patient had normal vaginal delivery of a baby boy weighing 1.9 kg. Apgar score was5 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.

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.

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 OutcomeCesarean section was carried out. A baby girl weighing 3898 gmwas 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.

Case # 3

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

Rebound TachycardiaActionsFacial 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 OutcomeAfter recovery from prolonged deceleration, scalp PH were 7.28, 7.36 and 7.36.the patient had normal vaginaldelivery of baby girl weighing 2070gm(small for age). Apgar score was 9/10 at one and five minutes.

Case # 4A 24 years old patient, G 3 p1+1, 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

“Variable” Variable DecelerationActions: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 OutcomeVaginal examination showed fully dilated cervix with thehead at +1 station. Progressed to normal vaginal deliveryof baby girl weighing 2.7kg and Apgar score 9/10 at oneand five minutes. The position of the cord was not noted. The infant followed normal newborn course.

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.

No variability, flat line-unfavorable outcomeActionsUltrasound 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 OutcomeThe 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.

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

Increased variability with hypertonic labour

ActionsObserve 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 OutcomeSyntocinon 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 wasbaby 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.

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.

Sinusoidal Pattern

ActionsObserve 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 OutcomeCesarean 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.

Case # 8

Fifteen years old primigravid patient was admitted in

labour at approximately 40 weeks gestation.

She received epidural anesthesia

Increased variability with variable deceleration

ActionsObserve 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 OutcomeProgressed 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, whichaccounted for the initial low Apgar score. There was one nuchalcord and 10% placental abruption. The infant followed a normal

newborn course

Case # 9

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

Marked Accelerations

ActionsObserve for the development of other types of declarations (yes)Change maternal position (no)Prepare for cesarean section (no)Exclude maternal hypotention especially if > 50BPM

(yes)Fetal blood sampling for PH (no)

Course and ActionProgressed to normal vaginal delivery of male infant weighing 3374gmApgar score was 7/9 at one and five minutes and one nuchal cord was noted. The infant followed normal newborn course.

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.

Baseline obscured by acceleration with variable decelerations

ActionsAdjust tocodynamometer (yes)Give sedation to the mother (no)Start syntocinon (no)Fetal blood sampling for PH (no)Immediate cesarean section (no)

Course and OutcomeProgressed to the second stage of labour and had normal vaginal delivery. The outcome was female weighing 3218 gm. Apgar scorewas 9/9 at one and five minutes. The infant followed an uncomplicated newborn outcome.

Case # 11A 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.

Early decelerations

ActionsOxygen 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 outcomeProgressed 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.

Case # 12A 21 years old primigravid admitted in labour at 40 weeks‘

gestation.The vertex was in occipitoanterior position and liquor

was meconium stained.

Progression from Early to Variable Decelerations

ActionsCesarean 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 OutcomeNo other types of declarations developed. Progressed to normalvaginal delivery of male infant weighing 3374 gm. Apgar score was 7/9 at one and five minutes. The infant followed a normalnewborn course.

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.

Late decelerations

ActionsObserve 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 OutcomeCesarean 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.

Case # 14A 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.

Classic Variable Deceleration

ActionsObserve 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 OutcomeSyntocinon 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 cordaround the neck. Apgar score was 9/10 at one and five minutes. The infant had normal newborn course.

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.

Sinus bradycardia with deceleration: mixed pattern

ActionsCheck 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 outcomeProgressed 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.

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

Prolonged Deceleration

ActionsVaginal examination (yes)Check maternal vital signs (yes)Fetal blood sampling for PH (no)Cesarean section (yes)Oxygen by facial mask (no)

Course and outcomeRupture 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.

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

Absent Long Term, Present Short Term Variability

ActionsVaginal 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 OutcomeFetal 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.

Case # 18A 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

Dual channel monitoring: twins single scale

ActionsContinue 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 OutcomeCesarean section was done for arrest of cervical dilatation at 6 cm andfailure 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.

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.

Late Deceleration and Severe Variable Deceleration

ActionsChange 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 outcomeCesarean 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.

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.

Absent short term, present long term variability

ActionsReview 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 outcomeThe 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.

Case # 21 A19 years old G 2 p1 patient was admitted in active labour at

30weeks gestation

Decreased uterine activity produced by tocodynamometer placement:

artifactActionsAdjust 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 outcomeUterine 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 fiveminutes. The cord was wrapped around the arm of the baby who developed largeintraventricular haematoma . it was discharged from the hospital after 58 days.

Case # 22

A 25 years old primigravida admitted in labour at 40 weeks

gestation.The fetus was in occipitoanterior position

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 weighing3445 gm. Apgar score was 9/9 at one and five minutes. The infant followed a normal newborn course.