Action Plan for Cardiotocography (CTG) 20-minute fetal assessment antepartum in the hospital wards.

  Introduction: The objective of this task is to assess the Cardiotocography (CTG) procedure done for 20 minutes mandatory for the patient in the Maternity  Ward. The author chose to create an ‘Action Plan for Cardiotocography (CTG) procedure at the hospital’ special ward at the Maternity Ward of Kinabatangan Sandakan Sabah, as an author’s learning environment.  As a midwife, Cardiotocography (CTG) procedure is a routine daily procedure. At the hospital, the labor room and maternity ward are combined and managed by 1 head nurse, 8 midwives ,and 16 community nurses. This ward consists of several disciplines, obstetrics (antenatal, postpartum), gynecological cases and neonate cases. Cardiotocography (CTG) procedure or also called the fetal monitor is one of the electronic devices is a form of fetal assessment that simultaneously records the rate of the fetus, fetal movement ,and uterine contractions to investigate hypoxia ( Pattison N, McCowan L 1999 ).  According to  Shahad Nidhal, M.

A.et al (2010), Cardiotocography (CTG) is a simultaneous recording of fetal heart rate (FHR) and uterine contractions and it is one of the most common diagnostic techniques to evaluate maternal and fetal well-being during pregnancy and before delivery. The researchers studying shows fetal heart rate ( FHR) patterns are observed manually by obstetricians during the process of CTG analyses.

For the last three decades, great interest has been paid to the fetal heart rate baseline and its frequency analysis, as a base for a more objective analysis of the CTG tracings. Changes in the fetal heart rate pattern relative to contractions provide an induction of fetal condition.       A study by Macones, G.

et al  (2008) showed,  fetal heart rate patterns are defined by the characteristics of baseline, variability, accelerations, and decelerations.  According to Susan et.al (2005), Electronic fetal monitoring (EFM) has been widely used for antepartum (the period before labor) and intrapartum (the period during labor and delivery) fetal surveillance.

The term EFM means the continuous recording and monitoring of fetal heart rate (FHR) and uterine contraction, also known as cardiotocogram (CTG) Susan et al (2005), shows CTG segment with the FHR at the upper part and uterine contraction at the lower part. Cardiotocogram (CTG) consists of two distinct signals, its continuous recording of instantaneous fetal heart rate (FHR) and uterine activity.   During stressful situations for the fetus, such as the uterine contractions at the time of delivery, the sympathetic nerves may act as a compensatory mechanism to improve the fetal heart pumping activity, which is reflected in the FHR signal variations (Parer, 1997).For the last three decades, many researchers have employed different methods to help the doctors to interpret the CTG trace pattern from the field of computer programming and signal processing. They have supported  and incorporated the doctors and interpretations inorder to reach a satisfactory level of reliability so as to act as a decision support system in obstetrics. The study by Shahad Nidhal, M. A.

et al (2010), the baseline fetal heart rate ( FHR) is determined by approximating the mean FHR rounded to increments of 5 beats per minute (bpm) during a 10-minute window, excluding accelerations and decelerations and periods of marked FHR variability (>25 bpm).  The abnormal baseline is termed bradycardia when the baseline FHR is<110 bpm; it is termed tachycardia when the baseline FHR is>160 bpm. Baseline FHR variability is determined in a 10-minute window, excluding accelerations and decelerations. Baseline FHR variability is defined as fluctuations in the baseline FHR that are irregular in amplitude and frequency.

The fluctuations are visually quantitated as the amplitude of the peak-to-trough in beats per minute. Variability is classified as follows: Absent FHR variability: amplitude range undetectable. Minimal FHR variability: amplitude range>undetectable and?5 bpm. Moderate FHR variability: amplitude range 6 bpm to 25 bpm. Marked FHR variability: amplitude range>25 bpm. An acceleration is a visuallyapparent abrupt increase in FHR.

An abrupt increase is defined as an increasefrom the onset of acceleration to the peak in<30 seconds. To be called anacceleration, the peak must be ?15 bpm, and the acceleration must last ?15seconds from the onset to return. A prolonged acceleration is ?2 minutes but<10 minutes in duration.

Finally, an acceleration lasting ?10 minutes is definedas a baseline change. Decelerations are an abrupt decrease inbaseline fetal heart rate of greater than 15 bpm for greater than 15 seconds.There are a number of different types of decelerations, each with varyingsignificance. Earlydecelerations start when the uterine contraction begins and recover whenuterine contraction stops. Late decelerationsbegin at the peak of the uterine contraction and recover after the contractionends.

 CTG screening  also is important for every pregnant woman at 28 weeks of age and over for monitoring the condition of the fetus especially in the following circumstances:a) Pregnancy with complications (high blood pressure, diabetes, thyroid, chronic infectious disease, etc.)b) Pregnancy with low fetal weight (Intra Uterine Growth Restriction)c) Oligohydramnios (amniotic fluid)d) Polihidramnios (excessive water)                The authors are staff in this hospital have realized that the inclusion of obstetric patients and the number of births is within 70 -100 cases per month. The authors are aware that the cardiotocography ( CTG )  procedure does not meet the required 20-minute requirement based on  Ministry of Health ( MOH ). Sometimes the CTG procedure is only 5 minutes – 10 minutes only as long as the CTG graph is acceptable. And sometimes, CTG procedure is more than 20 minutes, this is because the staff does not monitor about CTG procedure.According to Pattison N, McCowan L (1999), CTG procedure as an important assessment of the content was made to evaluate the effects of antenatal cardiotocography on perinatal morbidity and mortality and maternal morbidity. Action plans are a key step in achieving change in practice, according to (Bonner Network), action plans should  include seven steps: setting goals, assessing goals, identifying the actions needed to achieve goals, developing ways to evaluate procedures, approving the timeframe for action, identifying the source of the plan’s conclusions, and evaluating the results.