Proceedings oflhe 25'" Annual lnlemational Conference of the IEEE EMBS
Cancun, Mexico * September 17-21.2003
On-line fetal heart rate monitor by Phonocardiography
M. Godinez, A. JimCnez, R.Ortiz, M. Pefia
Department of Electrical Engineering, Universidad Autonoma Metropolitana, Iztapalapa, MCxico
Abstract-The beat-to-beat fetal heart rate variability can
he evaluated using the fetal Phonocardiogram (PCG) as a part
of a well-being evaluation procedure. In previous works, we
have developed and tested an off-line algorithm to generate
Cardiotachograms (CTGs) by processing WCGs. This method
has showed its confidence to generate reliable CTGs, especially
when maximums of cardiac sounds (S1 and SZ) are used. Now
we are interested to change our off-line processing scheme into
a first on-line fetal heart rate monitor version. This monitor
was developed with a LabView-Matlah program, it acquires
and processes the WCGs displaying, almost on-line, the CTGs
generated by S1 and S2. It also storages information and
provides the possibility to manually correct CTGs. For testing
the monitor, off-line time references from five testing signals
were calculated, and compared against monitor time
references. This comparison showed good results on detecting
on-line time references and intervals. The system really works
as a monitor, it acquires and processes signals during 20
minutes at least, and its CTGs do not differ from the ON-line
CTGs for more than 2 ms. The system is now ready to include
an adaptive filter that improves its performance with WCGs.
Keywordsxardiac sounds, fetal electronic monitoring,
fetal well-being
I. INTRODUCTION
For a long time, obstetricians have looked for
mechanisms to evaluate fetal well-being and identify, as
soon as possible, problems related to fetal condition. If some
of these problems, like fetal distress and fetal hypoxia, could
he detected on time, then it would be possible to start
procedures in order to reduce the risk of fetal morbidity
and/or mortality.
The study of fetal heart rate variability (MKV) has
shown to be a very useful mechanism to evaluate fetal well-
being, before and during labour. For this reason, the
electronic monitoring of the MRV has become one of the
most common methods used for this purpose [l]. The
Doppler ultrasound is frequently used to measure the fHRV,
but it is not possible to detect the variability beat tn heat
with this technique [2]. On the other hand, by processing
some signals like the abdominal Electrocardiogram (aECG),
and the fetal Phonocardiogram (PCG), it is possible to
quantify the beat-to-heat intervals, and then getting
information about short-time and long-time MRV. In order
to process the aECG it is necessary to eliminate its main
interference signal, the maternal Electrocardiogram, prior to
get a reliable detection of each cardiac beat by using the
fetal K wave, and it is not an easy task. In the P C G case, the
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processing method has to generate one reliable peak related
to each cardiac sound (SI andlor S2), and then,calculate the
heat-to-beat intervals [3]. The main advantage of the P C G
is that it also has information about fetal behavior [4]. For
this reason, we have developed and evaluated an off-line
method to generate Cardiotachograms (CTGs) by processing
the P C G . This method first improves the signal to noise
ratio (SNR) of the P C G ; second, generates an envelope of
the filtered P C G , and finally detects time references of each
cardiac sound that are used for calculating the CTG [ 5 ] .
Results showed that maximum of S2 and SI (mS1, mS2)
were good to generate CTGs [3], and we are now interested
to evaluate the capability of the method to work on-line. The
goal of this work is to generate a first version of an on-line
fetal heart rate monitor, able to acquire and simultaneously
process P C G s during twenty minutes in order to detect fetal
cardiac sounds, and generate the CTGs corresponding to
intervals mS1-mS1 and mS2-mS2; a monitor which also
offers the possibility to see each CTG almost on-line, save,
and manually correct the CTGs once the time acquisition
has finished.
11. MATERIALS
Five twenty minutes signals were used to test the
monitor performance. Three signals were generated by using
a Grass stimulator, they simulated phonocardiographic
cardiac cycles at 60, 120 and 180 heatdminute
(physiological ranges for adults and fetus). Two adults
signals (from the carotid artery and the cardiac sounds) were
acquired by using a TK701T microphone and a
phonocardiographic amplifier from Nihon Kohden.
The signals were acquired and processed on-line with a
virtual instrument composed by an AT-MIO-16E-1 data
acquisition card, which was programmed using Labview
(both from National Instruments), and some Matlab
processing algorithms installed in a Pentium IV computer.
111. METHODS
As was mentioned before, this paper presents the
methodology followed to implement our first on-line
monitor version by P C G . It takes the main part of our off-
line algorithm, and creates a Labview-Matlab program. This
program lets us evaluate the possibility to change the present
programming platform (Matlab) to a new one (Labview)
that looks more appropriate for on-line programming. It was
3141
 evaluated in order to qualify and quantify the program
performance as an on-line fetal heart rate monitor.
A . Monitor development
In order to develop the monitor, two operation modes
were considered: acquisition-processing and manual
correction.
1) Acquisition-processing mode: The main monitor
characteristic is its capability to acquire and simultaneously
process the P C G using one acquisition channel. The
programming process was as follows:
fPCG acquisition: To make the monitor able to work
on-line, it was necessary to use the buffered acquisition
option that LabView offers. This option makes the system
capable to acquire a finite data block, and also offers the
possibility to temporaly storage data, avoiding losing
information. This is important because each data block is
going to he processed as soon as the buffer is full,
meanwhile, buffer starts again reading new data. The
acquisition process continues fulfilling the buffer, and
transferring data blocks towards displaying and processing
stages until user stops the acquisition (Fig. I). User can also
adjust the buffer length and sampling frequency, in this
work signals were acquiring during twenty minutes at 1000
Hz by using 5000 samples buffer length.
fPCG processing: Once a data block arrives to the
processing stage, it is processed using a MATLAB Script
before getting back the control to LabView. This Script
filters and generates an envelope related to each cardiac
sound (S1 and S2) [6]. The process considers six steps:
STEP 1 (Matlab Script): Present data block is filtered using
a FIR band-pass filter with a bandwidth from 10 to 50 Hz,
and order 60.
STEP 2 (Matlab Script): An envelope of the filtered signal is
generated by using the Hilbert Transform.
STEP 3 (Matlab Script): The envelope is smoothed to ensure
just one peak associated to each cardiac sound, it needs a
FIR band-pass filter with a bandwidth from 1 to 5 Hz, and
order 80.
STEP 4: Maximums of the peaks associated to cardiac
sounds are detected, to do it, the program uses a threshold
that the user defines during acquisition. The program allows
the user to change the threshold on-line in accordance to the
input signal characteristics.
STEP 5: Once the peaks have been detected, it is necessary
to identify each cardiac sound, S1 and S2. The program
considers time intervals among three consecutive peaks to
define SI and S2. First, calculates the distance from peak
one to peak two, and the distance from peak two to peak
three. If first distance is shorter than second one, it means
that a systolic-diastolic period it is been analyzed, peak one
is S1 and peak two is S2. On the other hand, if first distance
is longer than second one, it means that a diastolic-systolic
period it is been analyzed, peak one is S2 and peak two is
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S1. Process continues u.ntil all present peaks have been
identified.
STEP 6: After each peak has been identified as SI or S2, the
program begins to calculate the intervals mS1-mS1 and
mS2-mS2. Then, when the present block has been
processed, each CTG (IETGSl, CTGS2) is displayed at
independent graphics (Fig. I).
Data storage: After user stops acquisition, the monitor
storages a text file containing the envelope, time references
(mS1, mS2), CTGSI, CTGS2, and the acquisition
information: sampling frequency and buffer length.
2 ) Manual correction mode: After data has been
storage, the user can m,anually correct the errors of the
CTGs. Working in this mode, the program shows two
windows, first one contains the envelope and time
references of S1 and S 2 , and the second one displays the
CTG of SI or S2, depending on what user choices. This
process activates a cursor to mark the CTG section where an
error exists, then the program shows the envelope that
generated this CTG se:gment, finally, the user has the
possibility to correct the wrong time reference by using the
mouse. Each time the w e r corrects one peak, the present
CTG (CTGSI or CTGS2:) is refreshed (Fig. 2).
B. Monitor tests
To test the monitor performance, off-line time
references were also detected by using our off-line method
to generate CTGs [3]. These off-line references were
extracted from the sam.e signals the monitor processed
because they were simultaneously acquired by the monitor
and a 16 bits acquisition system from Biopac Systems.
Once the off-line time references were detected, the
monitor was evaluate'd in order to quantify two
characteristics: its capability to get a reliable detection of
mS1 and mS2, and its performance as an on-line monitor:
1) Selectiviry (Se) and positive predictiviry (P+): these
parameters were calculated using ( I ) and (2) [6]:
TP
S,?= >
TP + NF
~
TP
P, =- (2)
TP+PF'
where:
TP: means the total number of SI and S2 peaks in the
envelope.
N E means the number of negative fakes.
PF: means the number ofpositive fakes..
2) Precision for detecting rime references: The
correlation coefficient ( r ) , the mean, and the standard
deviation values of the differences among off-line time
references and monitor time references were calculated.
 3 ) Perfnrmance as an on-line monitor: To evaluate
this characteristic, the monitor heat-to-heat intervals, of each
CTG, which were different to the off-line beat-to-beat
intervals, were compared. After that, the percentage of
intervals different from of-line intervals (e%), mean and
standard deviation values of these differences were
calculated. The number of cardiac sounds misclassified (SI
as S2 or S2 as SI) was also calculated.
monitor. Table also shows that the mean value is different
from zero for the five signals studied.
Table 11 shows the results for performance evaluation as
an on-line monitor. It can be noted that although the amount
of monitor intervals that were different to the off-line
intervals was higher than 50 % (for four signals), their mean
values are not higher than 2 ms, for both SI and S2.

IV. RESULTS

Fig. 1 shows the on-line monitor screen at acquisition-

processing mode. The user can select which operation mode
wants to use: acquisition-processing mode or manual
correction one. In acquisition mode, the user defines the
active channel, the sampling frequency, and the buffer
length, prior to start signal acquisition and processing. The
screen shows four windows containing: the P C G , its
envelope, the CTGS1, and the CTGS2. The envelope
window also shows the time references detected and the
threshold that user chose. The SNR of the P C G is high,
more than 15 dB.

TABLEI
PRECISION FORDETECTMG SI AND SZ MAXIMUMS’

Signal TP NF PF P. Se mta(ms) r
Simulatedl 2401 38 0 1 0.98 7 . 4 6 f 4 . 1 8 1.00
Simulated2 4594 68 0 I 0.99 8 . 5 4 i 4 . 1 5 1.00
Simulated3 7040 101 0 I 0.99 8 . 1 9 i 4 . 1 1 1.00
Pulse 2519 39 4 1 0.99 9 . 5 0 f 4 . 3 8 1.00
PCG 2519 28 8 I 0.99 6.91 + 4 . 9 3 1.00
. ..
TP: totll number of oeaks SI and S2 in the envelooe. NF: neeative falses.
I

PF: positive falses, P,: positive predictivity, Se: selectivity, m: mean, a:

standard deviation, r: correlation coefficient.

TABLE11
PRECISION FOR DETECTINGMSI-MSI A N 0 MSZ-MSZ MONITOR
Fig. I . Monitor screen st acquisition-pracPssing mode. From Ietl to right INTERVALS’
and up to down: WCG, envelope and time references detected, CTGSI and
CTGS2. mSI-mS1 mS2-mS2
Signal N
e(%) Mfa(ms) e(%) Mia(ms)
Fig. 2 shows the monitor screen at manual correction Simulated1 1199 61 1.25t0.48 59 1.24+0.48.
mode. The user can select which CTG does heishe want to Simulated2 2296 50 1.04fO.19 50 1.01tO.10
correct, CTGSI or CTGSZ, then marks the CTG segment to Simulated3 3518 16 1.01to.10, IS 1.01to.08
correct, and its corresponding envelope is shown. Finally, Pulse 1258 74 2.01+2.92 55 1.18+0.73
user can correct the wrong time reference, this action refresh PCG 1255 49 2.13+6.27 56 1.22k0.48
the present CTG. This figure also shows a helping window N: total number of beat-to-beat intervals, e (%): percentage of off-line
intervals different from the on-line intervals, M i a. mean f- standard
that guides the user about how to correct the CTG. deviation ofdifferences among mSI-mSI and mS2-mS2 intervals.

Table I shows monitor performance for detecting S1 and Respect to misclassified sounds, the highest value was
S2. It can be noted that higher Se, P+, and r values were obtained when the monitor processed a Phonocardiographic
obtained for the time references (S 1 and S2) detected by the signal (7 SI as S2, and 8 S2 as Sl). Just first simulated

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 signal presented one SI as S2 and one S2 a SI, whereas the
pulse signal presented one SI as S2 and two S2 as SI.
Nevertheless the CTGs generated by this way, were not very
different from the right ones, and can be considered as
reliable CTGs as can be seen in table II.
V. DISCUSSION
Even the system was design using a buffered acquisition
method in order to guarantee not to miss data, mean and
standard deviation values in table I show delays among the
on-line time references and the off line time references. Our
observations have shown that this delay increases depending
on time acquisition, probably because of buffer parameters
configuration. Other possible reason is that the stage
processing takes much time and avoids the buffer works
efficiently. We consider, the main problem is to improve the
buffered acquisition, and it requires finding the best
parameters for the acquisition-processing process. The
buffer not necessarily must be processed in one block; it
could be split for the processing stage in order to reduce
time processing and improves system performance. Respect
to negative fakes, most of them were generated when a
cardiac sound peak matched with the end of the buffer
window, and we presume that it can be reduced by adding
some extra criteria to the peak detect algorithm, or by
improving the buffered acquisition performance. The
number or positive falses, on the other hand, was not
important because of the high SNR of the signals.
Fortunately, although the system has presented this
buffer problems, results in table I also show very high
values of selectivity, positive predictivity, and correlation
coefficient, these results make evident the good performance
of the monitor to contend with negative and positive falses.
It demonstrates the system now has the capability to process
these kinds of signals with very good results.
Results in table I1 show the system performance as an
on-line monitor, as we supposed, the delay produced during
acquisition was not important when intervals were
calculated. Other positive result is the number of intervals
different among on-line and off-line methods, it is
interesting because four signals showed that more than fifty
percent are different to the off-line data, but they also
showed that the difference is not higher than 2 ms. It means
that our monitor can generate some wrong intervals, but
they will not be far from the correct values. The percentage
of misclassified cardiac sounds is very low, they usually
appear when the system produces a negative or positive
false, but now it is not a problem, because if we improve the
monitor performance to reduce positive and negative falses,
and if we add temporary criteria, these values can be
reduced.
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Finally, results obtained have shown the monitor
capability to work efficiently by acquiring and processing
Phonocardiograms in order to generate CTGs. As a first
version, it does not have included the complete off-line
processing algorithm, and was evaluated using signals with
high SNR. We presume that if the buffer problem is
eliminated, the monitor is going to be ready to include the
most important part of our off-line algorithm, an adaptive
filter [SI. This filter will make the monitor capable to
contend with low SNR levels, like the SNR of the fetal
Phonocardiograms.
VI. CONCLUSION
The on-line fetal heart rate monitor by
phonocardiography presented here is a system that can be
easily used. It displays the: Phonocardiogram, generates and
displays the CTGSl and CTGS2 and they can be manually
corrected. We can say that the monitor generates reliable
CTGs because of our good results about precision,
selectivity, and positive predictivity. It is now possible to
integrate new stages that give the monitor the possibility to
process signals with lower SNR like the fetal
Phonocardiograms.
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