INRODUCTION:

Cardiotocography is the continuous electronic record of fetal heart rate and uterine activity, which
is obtained by two transducers placed on the abdomen of the mother and having a simultaneous
graphic representation of both on paper.

In 1969, Hammacher noted that the fetus can be regarded as safe, especially if reflex movements
are accompanied by an obious increase in the amplitude of oscillations in the basal fetal heart rate.
The hypothesis behind the use of CTG is that the integrity of the autonomic central nervous system
is pre requisite for a healthy fetus, the CNS being responsible for controlling the felt heart rate.
The exact mechanism is unknown, but it is proposed that hypoxemia and academia induce an
alteration of the brain stem centers, which are regulating the activity of the pacemaker cells of the
heart, thereby altering the CTG trace.

Four fetal states have been identified

 In third trimester fetus spend 20 % time in quite sleep and 60-80% in an active sleep state.
 During quite sleep the fetal heart rate slows and variability is reduced.
 There is no regular breathing movements and startled movements. This pattern of sleep
may last for 20 minutes in a term fetus. In REM sleep, on the other hand, is associated with
regular breathing movements and intermittent abrupt movements of head, limbs and trunk.
 The fetal heart shows increased variability and frequent accelerations with movements.
This pattern lasts for about 40 minutes in a term fetus.
 Some extrinsic factors like maternal activity, ingestion of drugs and nutrition are
responsible for activity.

TYPES OF CARDIOTOCOGRAPHY EXAMINATION

 Non stress test

 Contraction stress test

NON STRESS TEST

The non-stress test is most widely used and accepted method of antenatal fetal surveillance. It is
usually performed on outpatient basis and is readily interpreted. No particular stess is placed on
the fetus by performing such a test. A non-stress test involves attaching a belt with fetal heart rate
and uterine contractions monitors around the mother’s abdomen. The heart rate is recorded for
approximately 20-30 minutes, during which time the mother indicates whether she feels any fetal
movements.

The idea behind a non-stress test is that proper amounts of oxygen are required for the brain to
send signals that will be transmitted via nerves to the heart, signals to which the heart will respond
appropriately. When oxygen levels are low, the brain, nerves and heart may not respond normally,
and resulting fetal heart rate patterns will not reactive.

INDICATIONS OF NST

 Women with pre-existing medical conditions such as diabetes, hypertension

 Baby is less active than the normal
 Small for its age or not growing properly
 Amniotic fluid is either too much or too little
 Women have have lost previously their babies during the second trimester
 Women with pregnancies continuing after 40 week to basically check on well being of
baby
 Women who had a procedure of external cephalic version
 Amniocentesis

HOW TO PERFORM NST

 Usually done as outpatient care

 Time taken 20 minutes, rarely 40 minutes, in extended cases.
 Patient may be seated in semi fowler position or in a reclining chair
 Care taken to avoid supine hypotension syndrome, due to pressure on inferior vena cava
by producing a left lateral tilt by placing a pillow / wedge below the right hip of the patient.
 Patient’s blood pressure is to be recorded before starting the test and every 10 minutes
subsequently.
 Place the Doppler ultrasound transducer to the maternal abdomen for measuring fetal heart
rate. the tocodynamometer is applied to detest uterine contractions
 Fetal activity may be recorded by the patient using on event marker switch or noted by the
assistant performing the test

A reactive test: is considered when there are at least two accelerations of the fetal heart rate of 15
bpm amplitude and of 15 seconds duration observed over 20 minutes of monitoring. A reactive
non stress test is a good predictor of adequate fetal oxygenation and most reactive fetus do well
for atleast an other Week.

A non-reactive test (abnormal NST) a test is considered to be non-reactive when there is absence
of acceleration in fetal heart rate in relation to fetal movements. When the fetal heart acceleration
is less than 15 beats per minutes or lasts less than 15 seconds in relation with fetal movements, the
test is considered to be abnormal.

The NST is to analyse taking into consideration the following variables:

 Baseline fetal heart rate (FHR)

 Variability of the FHR
  Presence or absence of accelerations
 Presence or absence of decelerations

Baseline fetal heart rate (FHR): The normal baseline FHR frequency is between 110 and 160
bpm. There may be tachycardia (more than 160 bpm) or bradycardia(less than 110bpm) these
changes may occur due to maternal heart rate changes, body temperature and even in fetal hypoxia.

Variability of the FHR: the fetal variability depends upon the fetal sympathetic and
parasympathetic nervous system and is influenced by the gestational age, maternal medication
fetal congenital anomalies, fetal acidosis and fetal tachycardia. A non -reactive NST associated
with decreased or absent variability is mostly due to fetal hypoxia.

Presence or absence of accelerations and decelerations

The absence of acceleration may be indicated of fetal sleep. The absence of deceleration in the
NST is reassuring.

The presence of spontaneous severe variable or late decelerations is problematic and may indicate
fetal compromise. Variable decelerations may be seen often if these are mild and non-repetitive,
then they do not suggest fetal compromise. However repetitive variable decelerations, especially
in the absence of f etal movements or uterine activity, suggest fetal compromise.

Principle

The sympathetic and parasympathetic components of ANS control cardiac fetal behaviour

FHR accelerations in response to fetal movements is a sign of healthy featus.

ADVANTAGES:

 It is non- invasive test

 The test is simple , in expensive and takes less time
 There are no contraindications or complications of this test
 No special expertise is required in performance of the test
 This test provides an immediate answer

CONTRACTION STRESS TEST

The contraction stress test also known as the oxytocin challenge test, is yet another test available
for fetal surveillance in antenatal period, particularly testing for uteroplacental sufficiency. The
basic hypothesis behind the use of this test is that the increased myometrial pressures following
uterine contraction causes a decreased blood flow and oxygen exchange in the intervillous spaces
of the placental circulation. Foetuses with in adequate placental reserve would demonstrate late
decelerations in response to hypoxia. It helps to mimic the stress of labour.
Purpose: to evaluate the response of the fetal heart rate to a reduction of blood flow in the
intervillous space during induced contraction.
Indications: uteroplacental pathology e.g. diabetes, hypertension, intrauterine growth retardation
or post- dates.

HOW TO PERFORM THE CST

 CST has to be conducted in a labour or delivery suite

 The patient is placed in semi – flower’s position at a 30-450 angle with a slight left tilt to
avoid the supine hypotension syndrome.

The fetal heart rate is recorded by using Doppler ultrasound transducer , while the uterine
contractions are monitored with the tocodynamometer.

 Maternal blood pressure is recorded every 5-10 minutes

 Baseline fetal heart rate and uterine tone is to be recorded for a period of approximately
10-20 minutes.
 Oxytocin is administered by an infusion pump at 0.5 mU/min. for an adequate CST, uterine
contractions of moderate intensity lasting approximately 40-60 seconds with frequency of
three in 10 minutes, is required. This criterion is selected to approximate the stress
experienced by the fetus during the first stage of labour.
 Infusion rate may be doubled every 20 minutes until adequates uterine contractions have
been achived (not more than 10 Mu/ min is usually required).
 The time taken for the whole CST is around 1 -2 hours. At the completion of the test, the
patient is observed till the uterine activity returns to baseline level, if activity persists then
tocolysis may be given.

INTERPRETATIONS

Martin and Schifrin introduced the interpretation of CST in a ten minute window period. A positive
test would be the one in which any segment of 10 minutes duration tracing shows three
contractions, all showing late decelerations. Occasional late deceleration with at least one negative
window is also a negative test.

A contraction stress test checks to see if the fetus will stay healthy during the reduced oxygene
level that normally occur during contractions when woman is in labour.

Normal CST – Normal test results are called negative. In this the baby’s heart rate does not get
lower (decelerate) and stay low after the contraction (late decelerations).

Abnormal CST- abnormal test results are called positive. A slower heart rate( late decelerations)
that stay low after the contaction may mean that the baby will develop problems if delivery is
delayed.
Hyperstimulation – In this the contractions last for 90 seconds or more

Suspicious: intermittent late or variable decelerations

Unsatisfactory <3 contractions per 10 minutes

Risks:

The risks from having oxytocin include:

 May cause labour to start earlier than the expected delivery date
 Can result in prolonged contractions that may cause problems with the baby.
 The contractions usually stop when the oxytocin is stopped.

Contraindication to CST

 Premature rupture of membranes

 Cervical incompetence
 Multiple gestations
 Polyhydroamnios
 Placenta praevia
 Previous uterine surgeries like myomectomy or classical caesarean section.
 A contraction stress test is done to check :
 If the baby will stay healthy during the reduced oxygen levels that normally occur during
contractions during labour
 If the placenta is healthy and can support the baby
 Contraindications
 Women having placenta praevia
 Women having antepartum haemorrhage
 Previous classic caesarean section

Clients at high risk of preterm labour the limitation of this test is the incidence of false positivity
leading to unnecessary premature deliveries. The incidence of false – positive rate averages
approximately 30%, especially before 33 weeks of gestation. False positive rates are unusually
high due to misinterpretation of tracing, supine hypotension, uterine hyper stimulation or even an
improvement in fetal condition post performing a CST test.

IMPORTANCE:

A negative test is associated with good fetal outcome. Whereas a positive CST is associated with
increased incidence of IUD, fetal distress in labour and low Apgar score. But there is 50% chance
of false – positive results and as such positive test cases are subjected to others methods of
evaluation for the well-being of the fetus . Suspicious CST should have a repeat test in 24 hours.
Conclusion:

Cardiotocography is the continuous electronic record of fetal heart rate and uterine activity, it
inclues two test non stress test and contraction stress test. The non-stress and CST test is most
widely used and accepted method of antenatal fetal surveillance.

RESEARCH EVIDENCE
Diagnostic Value of Non Stress Test in Latent Phase of Labor and Maternal and Fetal
Outcomes
Purpose:
The Non stress test (NST) is one of the significant diagnostic fetal wellbeing tests. The purpose of
this study is to assess diagnostic value of NST during latent phase of labor by considering maternal
and neonatal outcomes.
Subjects:
This case control study was performed on 450 healthy pregnant women with gestational ages
between 38-42 weeks in AL-Zahra teaching hospital in Tabriz, Iran. All participants underwent
NST after being admitted to labor during their latent phase of delivery. Participants were divided
into two groups including the study group which included 150 participants with non-reactive NST
results whereas 300 subjects with reactive NST results assigned in the control group. Subjects in
both groups were hospitalized for pregnancy termination because of the delivery time. In order to
find out the importance of routine performance of NST during delivery, the relationship between
NST results and maternal and fetal outcomes was evaluated. Several criteria including type of
delivery, meconium defecation, descent arrest, bradycardia, Apgar score, and still birth were
compared between two groups.
Results:
Findings of this study showed that descent arrest occurred in 2.7% of the subjects in the study
group, whereas it occurred in 4.7% of the participants in the control group (p=0.44). Bradycardia
found in 28% of the participants in study group and 3.3% of the control group (p<0.001). The low
Apgar score was found in 2.7% of case group however; no the low Apgar score detected in the
control group. Meconium defecation observed in 11.3% of the subjects in the study group and
9.7% of the participants in control group (p=0.62). The amount of stillbirth was 2.7% in the study
group and no stillbirths were found in control group. There was a significant difference between
the results of both groups in terms of bradycardia, low Apgar score and cesarean section.
Conclusion:
Results of this study revealed that participants in study group with nonreactive NST results had
more fetal complications than those with reactive NST results. NST was found to be a valuable
diagnostic test for diagnosis of fetal distress during delivery in the latent phase. These findings of
this study suggest that NST should be performed routinely as a valuable diagnostic test during the
latent phase of delivery.
BOOK REFERENCES:

 Dutta’s D.C. Textbook of obstetrics. 9th edition. Published by jaypee brothers medical
publishers (P) ltd. Mohammadpur , Dhaka Bangladesh India.2018.

 Bhide Amarnath. Arias’ practical guide to high risk pregnancy and delivery. 4th edition.
Published by Elsevier (p) ltd IMT Manesar , Haryana India. 2015.

 Kumari Neelam . Textbook of midwifery and gynecological nursing 11th edition.

Published by s. Vikas and company ( medical publishers) (P) ltd. Jalandhar India 2012.

INTERNET REFERENCES

 https://www.slideshare.net/DebbieFritz/antepartum-testing

 https://www.webmd.com › Pregnancy ›

 http://www.ucsfcme.com
 M.M COLLEGE OF NURSING, MULLANA, AMBALA

CLINICAL DEMONSTRATION
ON
NST AND CST

SUBJECT: OBSTETRICS ANDGYNECOLOGICAL NURSING

SUBMITTED TO: SUBMITTED BY:

DR. POONAM SHEORAN NADIYA RASHID

H.O.D M.Sc. (N) IST YEAR

OBG DEPARTMENT ROLL NO. 1918721

SUBMITTED ON: 01-04-19