Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.

Outcomes of Labour based on Cardiotocography Categories:

Donabedian Model Approach
Dr. Nahid Khalil Elfaki1, Dr. Hassan Yahya Guzailan2, Dr. Amna Mohammed Idris3, Dr.
Sawsan Ahmed Osman4, Dr. Nahla Elradhi Abdulrahman1, Dr. Wargaa Hashim Taha5, Dr.
Yahya Hussein Abdalla1, Dr. Abdalla Mohammed Osman1, Dr. Mohammed Ateeg Ahmed1,
Dr. Elwaleed Idris Sagrion1, Dr. Abdelelah Ahmed Hamed3, Mrs. Hanan Saad Alwadei1,
Mrs. Reem Ali Assiry6, Dr. Elsadig Eltaher Abdulrahman3, Dr. Sharafeldin Mohammed
Shuib3, Dr. Samah Ramadan Elrefaey7
1Department of Community and Mental Health Nursing, College of Nursing, Najran University, Saudi Arabia
2Consultant Radiologist MD, JBR, EDiR, King Khalid Hospital; Najran, Saudi Arabia
3Department of Medical-Surgical Nursing, College of Nursing, Najran University, Saudi Arabia
4Radiology department, College of applied medical sciences- Najran University, Saudi Arabia
5Department of Obstetrics & gynecology, College of Nursing, Najran University, Saudi Arabia
6Department of Nursing administration, College of Nursing, Najran University, Saudi Arabia
7Department of Community and Mental Health Nursing, College of Nursing, Najran University, Saudi Arabia&
Assistant professor of Psychiatric and Mental Health Nursing, Faculty of Nursing, Benha University, Egypt .

Abstract
Background: Many factors are crucial to be considered when determining labor outcomes
and mode of giving births for pregnant women. The aim of the study: The current study aimed to
investigate the correlation between cardiovascular imaging categories and determining the labor
outcome based on Donabedian model approach.. Methodology: A correlational and descriptive
study design was adopted in the labor room at maternal and children hospital (MCH) in Najran-
Saudi Arabia. A purposive sampling technique was utilized for recruiting a total of 390 full term
pregnant ladies at labor stag with specific inclusion criteria. A self- reported questionnaire, besides
check-list was used for collecting data. Results: The age of the participants ranged between 18 and
41 years, with a mean of 26.2 ±6.1 years. Gravidity ranged between 1 and 7, with a mean of 2.7
±3.1. Moreover, parity ranged between 1 and 8, with a mean of 1.9 ±1.8. The observed delivery
mode was spontaneous normal vaginal delivery for 43.1%, followed by emergency cesarean section
for 26.7%, while the least reported mode was vacuum-assisted (instrumental) vaginal birth for 9.2%
of the participants. CTG was determined to be 86% for category I, 9% for category II, while
category III was estimated for 5% respectively. Most of the newborns 362 (92.8%) had 7-10 Apgar
scores in 1st minute, and almost 96% of them had 7-10 Apgar scores in the 5th minute. Only 7.2%
(n=28) of newborns had been admitted to the neonatal intensive care unit (NICU). Mode of
delivery, Apgar score at first minute, and admission to NICU were significantly associated with the
CTG categories (P= 0.001, 0.045 & 0.012). Conclusion & recommendation: CTG categories were
significantly related to labour outcomes in terms of mode of delivery, Apgar score at first minute,
and thus NICU admission. For increasing CTG efficiency, continuous training is crucial for
obstetricians and midwives on how to interpret CTGs and to escalate when there are concerns.
Keywords: Cardiotocography; Donabedian model; Labor outcome
Introduction which are unique to the individual life
Both mothers and their fetuses are experiences of pregnant women (Humenick &
subjected to significant metabolic stress during Howell, 2003) and (Bang & Lee, 2009) and
labor and delivery process. Nonetheless, most (Kim & Lee, 2008).
women are able to cope with these stressors
without adverse effects on their labor results1. On the other hand, fetuses too might
Multiple factors should be considered when expose to stressful periods for instance
determining labor outcomes as well as mode of disrupting oxygenation which may result in a
giving births for pregnant ladies. These factors degree of acidosis and even death (Walton &
had been grouped into psychological, Peaceman, 2012). Accordingly, intermittent
psychosocial as well as psychosexual factors and or continuous fetal monitoring is a crucial

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

intervention for detecting fetal compromise categories: “structure,” “process,” and

during labor. Therefore, monitoring fetal heart “outcomes." (Donabedian, 1988). Structure
rates is crucial during the laboring process describes the context in which care is delivered,
(Omidvar, et al., 2018) Thus, obstetricians or including hospital buildings, staff, financing,
midwives must accurately keep the records of and equipment. Process denotes the transactions
any changes that may occur to fetal heart rates between patients and providers throughout the
(FHR) during labor. delivery of healthcare (McDonald, et al.,
For determining the fetal heart rates, the 2007). While there are other quality of care
most popular monitoring method that widely frameworks, including the World Health
used in healthcare institutions is Organization (WHO)-Recommended Quality of
Cardiotocography (CTG) which is also named Care Framework and the Bamako Initiative, the
Electronic fetal monitoring that utilized for Donabedian Model continues to be the
recording the fetal heart rate via ultrasound dominant paradigm for assessing the quality of
transducer which used for fetal assessment health care (Frenk &2000).
during labor (Singh, et al., 2022) In this regard,
the National Institute of Child Health and Despite the fact that fetal heart rate
Human Development (NICHD) developed 3- monitoring and CTG interpretation are common
category system that helps obstetricians and practices in healthcare institutions, they have
midwives for CTG trace interpretation some drawbacks such as falsely interpretation.
accurately (Robinson, Nelson, 2008). It was documented that poor or falsely CTG
Accordingly, healthcare providers can interpretation is considered one of the leading
make their decision for determining the suitable causes of stillbirth and brain injury. When the
mode and outcome of labor in which category 1 CTG is abnormal, further investigations should
denotes a normal trace, indeterminate trace be undertaken to decide whether delivery of the
represented by category II, while category III baby should be brought forward dependent on
indicates abnormal trace respectively. In this the diagnosis of the fetal and maternal
line, numerous of obstetricians and midwives condition. Therefore, it should not be the only
believe that the practice of continuous CTG diagnostic tool for fetal distress and further
monitoring and relying on it to decide on the measurements such as fetal scalp pH need be
mode of delivery and predict labor outcomes employed to distinguish hypoxic from non-
should be reconsidered (Grivell, et al., 2015) hypoxic fetuses with abnormal CTG and reduce
and (Rimsza , et al., 2023). Moreover, some the rate of unnecessary cesarean sections
researchers concluded that there is a significant (Ikram, et al., 2018) and (Joshi et al., 2019).
association between CTG categories, and the The immediate care of the neonates at
status of the newborns evaluated by 1st and 5th the golden minutes include APGAR scoring
minutes Apgar score, umbilical cord artery system that had been defined as a quick
blood pH, and NICU admission rate among assessment was done to babies at the first and
women with abnormal test results (Alfirevic, et the fifth minutes after birth (Abd El-Moniem,
al., 2017) Furthermore, (Amsumang, et al., et al, 2018). A baby's first-minute score
2017) documented that CTG categories had indicates how well the neonate tolerates birth,
been significantly associated with early labor while the five minute scores show how well the
outcomes as mothers with category II CTG baby is doing outside of the mother's womb,
were more likely to undertake operative and also can help in measuring how well the
delivery and cesarean delivery, compared to baby responds when resuscitation is needed
those with category I CTG (51.4% vs. 25.3%, p after birthing process (Salustiano, et al. 2012)
= 0.005) (Ayrapetyan etal., 2019) and and (Nair, et al, 2018) .
(Rahman et al., 2012). It has been documented that APGAR
The Donabedian model is a conceptual score could be influenced by many factors, such
model that provides a framework for examining as fetus neurological condition, gestational age,
health services and evaluating quality of health some maternal medications, resuscitation, as
care. According to the model, information about well as cardio-respiratory conditions (Devane,
quality of care can be drawn from three et al., 2007) and (Ayrapetyan, et al., 2019).

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Significance of the study The inclusion criteria were:

The current study examined the  Active or transition phases of the first
association between CTG categories and labor stage
outcomes in terms of delivery mode, Apgar  Single fetus
score at first and fifth minutes, and NICU  Cephalic presentation,
admission. In addition to examining quality  Full-term pregnancy (38 to 40+6
within a healthcare delivery unit, the weeks)
Donabedian model is applicable to the structure The exclusion criteria were:
and process for treating certain diseases and  High-risk pregnancy (Pre-Eclampsia
conditions with the aim to improve the quality Toxemia (PET), gestational diabetes
of chronic disease management. mellitus (GDM), cardiac disease,
However, minimal studies were found in placenta previa or abruption placenta),
Saudi Arabia, assessing the relationship  Elective cesarean section,
between CTG categories and labor outcomes.  Malposition or non-cephalic
Also, the application of Donabedian model in presentations.
such area was not focuses on labour so that the  Ladies with twins
researchers need to study this Donabedian
approach at the labour and assess the model Sample size
outcomes, finally, outcomes of this research  The following formula was used to
refer to the effects of healthcare on the health determine the sample size (Mani et al, 2015).
status of patients and populations will reflect on Wherever: n= size of sample, N= size of
our community in Saudi Arabia population, e=Margin of errors which is±0.05
𝑛 = / 1+𝑁(𝑒)2
Aim of the Study
This study aimed to investigate the Data Collection Tools
correlation between cardiovascular imaging The following tools were used to gather data:
categories and determining the labor outcome
based on Donabedian model approach. Tool I: A structured Interviewing
Questionnaire: It was written by the researchers
Research questions after reading and reviewing relevant literature. It
Is there a relation between was divided into two parts:
cardiovascular imaging categories and
determining the labor outcome based on Part (1): Personal characteristics of studied
Donabedian model approach? women (3 items) such as (age, level of
What is the outcome of using education and Employment status)
Donabedian model approach on cardiovascular
imaging categories and labor ? Part (2): Obstetrical History (Previous
Infertility, Number of pregnancies and Previous
Methodology Mode of Childbirth)
Study Design, Setting and Population
A correlational and descriptive study Tool II: Observational Checklist
design was utilized in the current study. This
study was carried out at Najran Maternal and The second used tool was that composed
children hospital (MCH) among full-term of two main parts:
pregnant ladies. Part one used when observing laboring
Sample type: ladies starting from the 1st stage of labour till
Purposive sample was utilized to the first 24 hours after giving birth included the
conduct this study under the following inclusion participants' previous and current labour history
and exclusion criteria which includes status of liquor, CTG
characteristics in terms of uterine contractions,
fetal heart rate (FHR) variability, acceleration,
deceleration, categories, who interpreted it and

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

mode of delivery. The researcher observed the structure, process, and outcome. In
CTG for 40 minutes during the active or Donabedian's view, health care systems are
transition phase of the first stage of labor. Then, shaped by their structures, which in turn affect
the researcher asked an experienced midwife or processes and outcomes21. For the current study,
the obstetrician to interpret the CTG according the setting's policy and procedure regarding
to NICHD 2008 criteria system which was continuous fetal monitoring, staff training
already used in the current study setting17. If regarding CTG, and the application of
any changes occurred in the CTG pattern, the continuous fetal monitoring in routine care are
midwife or the obstetrician was asked to all considered care structures. Moreover,
reinterpret the CTG. The researcher considered examining the relationship between
and recorded the last interpretation category interpretation of CTG categories based on
before women's delivery. NICDH is considered as a process of care.
Part two: a. Neonatal Outcomes While the outcomes denote the mode of
Immediate Assessment in terms of birth weight, delivery, 1st and 5th minute Apgar score, and
Apgar score at 1st and 5th minutes, and NICU admission rate in NICU (Figure 1).
admission status. Health care structure in form of physical
b. Cord Assessment After delivery, cord and organizational aspects of care, is
blood was collected in heparinized containers represented in the current study as applying
and analyzed within 5-10 minutes. Normal cord continuous CTG monitoring to all laboring
blood pH was defined as 7.25 or above while women. While the care processes that showed
neonatal acidosis was defined as cord blood pH in the middle of the diagram (figure 1) in the
of 7.20 or less (NICE, 2020). current study, the process of care is denoted as
Tool III: Donabedian model interpretation of CTG categories which based
The Donabedian model provides a on NICHD and health outcomes that specified
framework for evaluating and improving the as labor outcomes.
quality of healthcare. The Donabedian domains
of structures and processes were the focus of the
elements influencing the infant outcome. This
model based on three main constructs namely,
Figure 1: Donabedian Model

Donabedian Model

Structure of Processes of Health outcome

Continuous fetal monitoring Based on NICHD, CTG Delivery mode, APGAR

policy & procedure Interpretation score at (first & fifth minute)
regarding CTG staff training & NICU admission rate

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

Validity and Reliability 43.1%, followed by emergency cesarean section

The checklist and the questionnaire were for 26.7%, while the least reported mode was
reviewed translated into Arabic language and vacuum-assisted (instrumental) vaginal birth for
tested for content validity by a jury of 5 experts 9.2% of the participants (Table 1).
in obstetrics and gynecology field for relevancy As displayed in figure (2), CTG was
and appropriateness to the current study aim. determined to be 86% for category I, 9% for
While the internal consistency was tested by category II, while category III was estimated for
Cronbach's alpha test which was 0.79 that 5% respectively.
showed acceptable internal consistency. As shown in table (2), the most noticed
Data Analysis indications for CTG was abnormal presentation
Obtained data were entered, coded, and / fetal position (19.5%), followed by post-
analyzed using the statistical package for social maturity (13.8%), while the least one was blood
sciences (SPSS) version 25. Data were stained liquor (4.9%). Additionally, it had been
described using frequencies and percentages noticed that most indications for CTG were
and presented in tables and graphs. Mean ±SD noticed to be higher among primigravida (PG)
were utilized for continuous variables. except the indication due to decreased fetuses'
Inferential statistics as Chi-square and ANOVA movements was observed to be among
tests were used to test the relationship between multigravida (MG). Moreover, 87.2% have
variables. The level of statistical significance clear liquor.
was considered at p-value <0.05 throughout the Table (3) illustrates more than half of the
study. neonates (54.1%) was normal vaginal birth.
Pilot Study It had been noticed that the mode of delivery
Furthermore, a pilot study was was significantly associated with the CTG
performed on 10 participants who were categories. Almost half of the participants with
excluded from the main sample for ascertain the CTG category I had spontaneous vaginal birth
instrument's clarity and applicability and who represented 49.2%, while only 4.4% of
accordingly the necessary changes were them had vacuum-assisted vaginal birth. In
undertaken. regard to participants with CTG category II,
3.3% of them had spontaneous vaginal birth
Ethical Consideration followed by 2.6% who had vacuum-assisted
vaginal birth. In terms of the participants with
An official permission and ethical CTG category III, 2.6% of them had an
approval was obtained from the deanship of
emergency caesarean section, while only 1.5%
scientific research at Najran University.
of them had spontaneous vaginal birth (Table
Additionally, an official permission was
4).
obtained too from maternal and children
Moreover, a significant relationship was
hospital's officials. A verbal consent indicated identified between CTG categories and the
that the participant has the right to decline or mode of giving birth (P- value =0.001). Apgar
withdraw at any point during the course of the
score at 1st minute was noticed too to be
study was obtained from all participants.
significantly correlated with CTG categories
Furthermore, confidentiality was assured to
with P-value = 0.045 respectively. The majority
each participant.
of new-born babies (83.1%) with CTG category
Results I, had a reassuring Apgar score (7-10), while
only 2.8% of them had moderate asphyxia.
Description of the Participants and Further, this study showed a significant
CTG Characteristics association between the CTG categories and
The age of the participants ranged admission to NICU (P-value = 0.012). Almost
between 18 and 41 years, with a mean of 26.2 all new-born babies who had CTG category I
±6.1 years. Gravidity ranged between 1 and 7 were not admitted to NICU except one baby
with a mean of 2.7 ±3.1. Moreover, parity respectively. In contrast, most of new-born
ranged between 1 and 8, with a mean of 1.9 babies with CTG category III were admitted to
±1.8. The observed delivery mode was
spontaneous normal vaginal delivery for

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

NICU except one baby (0.3%) who was not admitted to NICU (Table 4).

Table (1): Demographic characteristics of the studied sample (n=390)

Variable N (%) P
Age 0.61
≤25 112 (28.7%)
26-35 207 (53.1%)
≥36 71 (18.2%)
Educational level 0.33
Elementary/intermediate/secondary 280 (71.8%)
College/University 110 (28.2%)
Employment status 0.17
Employee 138 (35.4%) 0.09
Not employee (House wife) 252 (64.4%)
Previous Infertility >1 year prior pregnancy 78 (20%) 0.11
Number of pregnancies 0.045*
Primiparas 106 (27.2%) 0.001*
Multiparas 284 (72.8%)
Previous Mode of Childbirth
Normal Vaginal Birth (one or more) 168 (43.1%) 0.16
Instrumental (vacuumed) Vaginal (one or more) 36 (9.2%) 0.037*
Elective caesarean section (one or more) 82 (21%) 0.002*
Emergency caesarean section (one or more) 104 (26.7%) 0.101
Gravidity Mean ± SD Range
2.7 ±3.1 1-7
Parity 1.9 ±1.8 1-8

Figure (2): Categories of Cardiotocography (CTG) among participants (n=390)

CTG categories (n=390)

Category III Category II Category I

86%

9% 5%

Category I Category II Category III

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Table (2): Comparison between Gravidity Groups and indication for Categories of
Cardiotocography (CTG) (n=390)

Indications for CTG PG MG Total Frequency %

Pre-maturity 26 15 41 10.5%
Post-maturity 30 24 54 13.8%
A decreased fetuses movements 19 27 46 11.8%
Abnormal presentation/position 42 34 76 19.5%
Induction of labour 29 12 41 10.5%
Clear liquor 155 185 340 87.2%
Meconium stained liquor 18 13 31 7.9%
Blood stained liquor 12 7 19 4.9%
Syntocinon 17 10 27 6.9%
Ante-partum hemorrhage 20 10 30 7.7%
Abnormal fetal heart rates 14 11 25 6.4%
CTG = cardiotocography; PG = Primigravida; MG = Multigravida

Table 3. Current labor outcomes of the participants (n=390)

Variable Frequency %
Mode of Childbirth
Normal Vaginal Birth 211 54.1%
Instrumental (vacuumed) Vaginal Birth 31 7.9%
Elective caesarean section 73 18.7%
Emergency caesarean section 75 19.2%
The fetus weight
>2.5 kg 26 6.7%
2.5-4kg 303 77.7%
< 4 kg 61 15.6%
Admission to NICU
Yes 28 7.2%
No 362 92.8%
Umbilical Cord Arterial Blood pH
Cord arterial blood acidosis (≤ 7.0) 11 2.8%
Normal cord arterial blood pH (≥7.10) 379 97.2%
APGAR score at the first minute
≤3 0 0%
4 -6 28 7.2%
7-10 362 92.8%
APGAR score at the fifth minute
≤3 0 0%
4 -6 16 4.1%
7-10 374 95.9%
*NICU = Neonatal Intensive Care Unit

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

Table 4. Association between labour outcomes and CTG categories (n=390)

Variable Frequency (%) Cardiotocography (CTG ) Categories P-value
I II III
335(86%) 35 (9%) 20 (5%)
Mode of Childbirth
Normal Vaginal Birth 211 (54.1%) 192 (49.2%) 13 (3.3%) 6 (1.5%)
Instrumental (vacuumed) 31 (7.9%) 17 (4.4%) 10 (2.6%) 4 (1%) 0.001*
Vaginal Birth
Elective caesarean section 73 (18.7%) 66 (16.9%) 7 (1.8%) 0 (0%)
Emergency caesarean section 75 (19.2%) 60 (15.4%) 5 (1.3%) 10 (2.6%)
The fetus weight 0.056
>2.5kg 26 (6.7%) 14 (3.6%) 9 (2.3%) 3 (0.8%)
2.5-4kg 303 (77.7%) 279 (71.5%) 17 (4.4%) 7 (1.8%)
< 4 kg 61 (15.6%) 42 (10.8%) 9 (2.3%) 10 (2.6%)
Admission to NICU 0.012*
Yes 28 (7.2%) 1 (0.3%) 8 (2.1%) 19 (4.9%)
No 362 (92.8%) 334 (85.6%) 27 (6.9%) 1 (0.3%)
Umbilical Cord Arterial Blood 0.111
pH
Cord blood acidosis (≤ 7.0) 11 (2.8%) 2 (0.5%) 3 (0.8%) 6 (1.5%)
Normal cord blood pH(≥7.10) 379 (97.2%) 333 (85.4%) 32 (8.2%) 14 (3.6%)
APGAR score at the first 0.045*
minute
≤3 0 (0%) 0 (0%) 0 (0%) 0 (0%)
4 -6 28 (7.2%) 11 (2.8%) 8 (2.1%) 9 (2.3%)
7-10 (normal) 362 (92.8%) 324 (83.1%) 27 (6.9%) 11 (2.8%)
Cord pH < 7.10 as a cut of for acidosis
P-value ≥ 0.05* is considered statistically significant
NICU = Neonatal Intensive Care Unit

Discussion Obstetrics German Society of Gynecology and

Globally, CTG has been considered as a Obstetrics {DGGG}, 2014)
central tool for risk identification to babies The important point to consider in this
during the course of giving birth. According to regard is the staff training. In order to maintain
Donabedian Model, the main three pillars on this important clinical skill, clinical staff
which this model based are: 1- structure of care engages in fetal well-being assessments are
(Continuous fetal monitoring by CTG + staff expected to keep up to date through professional
training). 2-Processes of care (CTG development activities on regular basis. The
interpretation based on NICHD,). 3- Health same idea had been raised by numerous studies.
outcomes (Delivery mode, APGAR score at (Santos, 2016) and (Domingues et al., 2013)
(first & fifth minute) & NICU admission rate)
For the second pillar of Donabedian
(Guta, 2022)
model which is about the CTG interpretation.
The structure of care that highlighted in Robinson et al believe that the success of CTG
the current study was utilizing CTG assessment usage depends on how correct when healthcare
tool to assess fetal wellbeing for preventing any professionals interpret CTG records
adverse fetal outcomes. The current study meaningfully for allowing evidence-based
showed that the most reported indication for clinical decisions. It was documented that poor
performing CTG among participants was post- or falsely CTG interpretation is considered one
mature babies (pregnancies >42 weeks) which of the leading causes of stillbirth and brain
is considered as high risk pregnancy. The same injury. In this regard, CTG performing and
indication had been recommended and reported interpretation in the current study were done by
by German Society of Gynecology and expert staff as mentioned earlier. The
interpretation was performed by general

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Original Article Egyptian Journal of Health Care, March 2024 EJHC Vol 15. No.1

practitioner for 66 cases (16.9%), expert delivered vaginally, and only 13.4% of them
midwives for 178 lady (45.6%), and specialists had cesarean section. While mode of delivery
for 146 (37.4%) respectively (Yan Jia, et al., for the participants having abnormal CTG was
2021) cesarean section for 66.7%, assisted vaginal
In regard to CTG categories that can be birth for 10%, and spontaneous vaginal delivery
determined by this tool, most identified for 23% of them (Amsumang et al., 2017)
category was category I. In the same line, In regard to the neonatal outcomes, the
numerous studies showed that, more than two current study revealed a significant statistical
third of the participants had CTG category I. relationship between CTG categories and 1st
(Ayrapetyan etal., 2019) and (Rahman et al., minute Apgar score (P = 0.045). In the same
2012). line, a previous study revealed that all newborns
with CTG category I had reassuring at 1st
In terms of the third Donabedian model's minute Apgar score (Joshi et al., 2019).
component was the health outcomes that Different results were found in another study
represented in form of delivery mode, APGAR where 86.7% of the new-borns with CTG
score at (first & fifth minute) & NICU category I had a reassuring 1st minute Apgar
admission rate. In the light of this point, our score and 90% of them had a reassuring 5th
study revealed that there was a statistically minute Apgar score. While 63.4% of the
significant relationship between CTG categories newborns with CTG category II and III, had a
and mode of delivery where majority of the reassuring 1st minute Apgar score (Amsumang
participants with CTG category I (49.2%), had et al., 2017). This difference may be
normal vaginal birth. Only 1.5% of the attributed to the small sample size (n=60)
participated ladies with category III gave birth compared to ours in addition to different
normally. These findings agreed with previous population and study area respectively
studies (Nabukera etr al., 2006) and (Garite Additionally, another study revealed that, two-
& Simpson , 2011). thirds of the newborns who had moderate
This study showed a significant asphyxia at the 5th minute after delivery were
statistical association between CTG categories with CTG category III while, the vast majority
and mode of delivery (P = 0.001). These of the new-borns who had reassuring 5th minute
findings agreed with another study which Apgar score were with CTG category I (Ikram,
showed that, two thirds of the participants 2018)
delivered by vaginal delivery, followed by This study showed no statistically
cesarean delivery and the least mode was significant relationship between CTG categories
forceps extraction respectively Devane, et al., and cord pH (P-value = 0.111). Coincided, other
2007) and (Ayrapetyan, et al., 2019). studies reported a statistically significant
association between CTG categories and
Additionally, participants with CTG umbilical cord pH where newborns with CTG
category III were more likely to undertake category II were more likely to develop
emergency cesarean delivery. Whereas, more neonatal acidosis than those with category I
than half of the participants with CTG category (Furthermore, it was found that, only 0.5% of
II had either normal or instrumental vaginal the participants with CTG category I had acidic
delivery. In the same line, it was reported that, umbilical cord blood pH, 0.8% with CTG
vaginal delivery was the mode of delivery for category II had acidic umbilical cord blood pH
99.7% of the participants with CTG category I, and, 1.5% with CTG category III had acidic
while cesarean sections was the mode of umbilical cord blood pH. These results were
delivery for most of the participants with CTG much lower than another study in which the
category III with a statistical significant acidic pH of the umbilical cord blood were
relationship as reported by Joshi et al documented to be 2% of the participants with
respectively (Ikram, 2018). Moreover, another CTG category I had acidic umbilical cord blood
study used only two classification system of pH, 22% with CTG category II had acidic
CTG categories, normal for category I and umbilical cord blood pH and, 44% with CTG
abnormal for category II and III identified that, category III had acidic umbilical cord blood pH
83.3% of the participants who had normal CTG,

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respectively (Devane, et al., 2007) and at 10 Minutes and Outcomes in Term and Late
(Ayrapetyan, et al., 2019). Preterm Neonates with Hypoxic-Ischemic
The current study showed a statistically Encephalopathy in the Cooling Era. Am J
significant relationship between CTG categories Perinatol. 2019 Apr;36(5):545-554.
Ayrapetyan M, Talekar K, Schwabenbauer K,
and NICU admission (P-value = 0.012). These
Carola D, Solarin K, McElwee D, Adeniyi-
findings were consistent with numerous studies, Jones S, Greenspan J, Aghai ZH. Apgar Scores
which showed that, most of the newborns at 10 Minutes and Outcomes in Term and Late
admitted to NICU, had CTG category III Preterm Neonates with Hypoxic-Ischemic
(Ikram, 2018), (Devane, et al., 2007) and Encephalopathy in the Cooling Era. Am J
(Ayrapetyan, et al., 2019). Perinatol. 2019; 36(5):545-554.
Bang SW, Lee SS. The factors affecting pregnancy
Conclusion and recommendation outcomes in the second trimester pregnant
women. Nutr Res Pract. 2009; 3(2):134-40. doi:
In summary, CTG categories have a 10.4162/nrp.2009.3.2.134.
significant relationship with labor outcomes in Devane D, Lalor J, Bonnar J. The use of
terms of mode of delivery, Apgar score at the intrapartum electronic fetal heart rate monitoring:
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CTG pattern during intrapartum CTG has high Domingues RMSM, Leal MC, Hartz ZMA, Dias
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system.

Acknowledgment Donabedian(2003). An introduction to quality

assurance in health care. (1st ed., Vol. 1).
Our sincere thanks and acknowledgment New York, NY: Oxford University Press.
to the maternity & children hospital (MCH)
obstetricians, midwives and nurses for their
tireless effort to make this study successful Donabedian, A. (1988). "The quality of care:
How can it be assessed?". JAMA. 260 (12):
1743–
Conflict of interest statement
8. doi:10.1001/jama.1988.0341012008903
There are no conflicts of interest to be declared. 3. PMID 3045356.

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