CTG Interpretation: Dr. Areen Alnasan

CTG Interpretation
Dr. Areen Alnasan

CTG
 Cardiotocography (CTG) is a continuous electronic record of the fetal’s heart

rate obtained via a transducer placed on the mother’s abdomen .
 It is sometimes referred to as ‘electronic fetal monitoring.
Methods
 External Cardiotocography:
 For continuous or intermittent monitoring of the fetal heart rate and the
activity of the uterine muscle .
 Two transducers on the mother's abdomen(one above the fetal heart and the
other at the fundus).
 The tocodynamometer (“toco”) is placed over the uterine fundus. It provides
information that can be used to monitor uterine contractions.
 The second tranducer is placed over the area of the fetal back. This device
transmits information about the FHR.
 Internal Cardiotocography:
 Uses an electronic transducer connected directly to the fetal scalp through
the cervical opening and is connected to the monitor.
 Amniotic membranes must be ruptured
 Cervix dilated 2 cm.
 Presentation must be cephalic
 Presenting part down against the cervix.
Intrapartum CTG Interpretation
 Baseline fetal heart rate (FHR)

 Baseline FHR variability
 Presence of accelerations
 Decelerations
 Uterine activity (contractions)
 Fetal heart bseline
 differentiate between fetal and maternal heartbeats
 baseline fetal heart rate will usually be between 110 and
160 beats/minute.
 Fetal Tachycardia :Baseline FHR greater than 160 beats per min
 Fetal bradycardia : Sustained fetal heart rate less than 110 beats per
minute
 causes of fetal tachycardia :
 Maternal fever
 Chorioamnionitis
 Fetal sepsis
 Drugs (Atropine, Phenothiazines, Beta-sympathomimetics)
 Tachyarrhythmias
 Fetal heart failure
 Severe fetal anemia, fetal hydrops
 Maternal hyperthyroidism
Variability
 Variability:
 variability will usually be between 5 and 25 beats/minute
 intermittent periods of reduced baseline variability are normal, especially
during periods of quiescence ('sleep').
 Causes of decreased variability include:
 Hypoxemia/acidosis
 Fetal sleep cycles
 Drugs (Analgesics, barbiturates, phenothiazines, anesthetics)
 Prematurity
 Arrhythmias
 Pre-existing neurological abnormality
 Congenital anomalies
 Accelerations:
 Increase in FHR greater than or equal to 15 bpm, for greater than or equal to
15 seconds from the onset to return to baseline.
 The presence of accelerations, even with reduced baseline variability, is
generally a sign that the baby is healthy.
 The absence of accelerations on an otherwise normal cardiotocograph trace
does not indicate fetal acidosis.
 If digital fetal scalp stimulation (during vaginal examination) leads to an
acceleration in fetal heart rate, regard this as a sign that the baby is healthy
 Decelerations:
 Decreases in fetal heart rate from the base line by at least 15b/m, lasting
for at least 15 seconds
Types of decelerations
 Early decelerations:
 Begins at the start of uterine contraction and end with conclusion of
contraction.
 In most cases the onset, nadir(lowest point), and recovery of the deceleration
are coincident with the beginning, peak, and ending of the contraction,
respectively
 Its related to Head compression.
 Early decelerations are a benign( kind/ gentle) finding caused by a vasovagal
response as a result of fetal head compression by the contraction.
 No intervention necessary. Just continue to watch for any changes.
Early decelerations
 Variable decelerations:
 Variable decelerations are variable in duration, intensity, and timing .
 Variable decelerations Abrupt(sudden) decrease in FHR of > 15 beats per
minute measured from the most recently determined baseline rate.
 The onset of deceleration to nadir is less than 30 seconds. The deceleration
lasts > 15 seconds and less than 2 minutes .
 Related to cord compression.
Variable decelerations
Variable decelerations
 Late Decelerations:
 Gradual decrease in FHR with onset of deceleration to nadir >30

seconds.
 Onset of the decleration occurs after the beginning of the
contraction, and the nadir of the deceleration occurs after the peak
of the contraction.
 Related to decreased uteroplacental perfusion
Late Decelerations
Late Decelerations
 It is important to remember the following learning points regarding EFM:
 It is used to identify intrapartum hypoxia – a significant cause of fetal
death and disability; fetal hypoxia can lead on to fetal asphyxia and death.
 It should not be used unless indicated as it increases the rates of

caesarean section and instrumental delivery in low-risk women.
 It has become an integral component of labour management in high-risk

women.
 Intermittent auscultation of the fetal heart rate to women at low risk of
complications in established first stage of labour:
 Intermittent auscultation immediately after a contraction for at least 1 minute,
at least every 15 minutes in the first stage of labour and and at least every 5
minutes in the second stage and record it as a single rate.
 Palpate the maternal pulse hourly, or more often if there are any concerns, to
differentiate between the maternal and fetal heartbeats.
 High-Risk pregnancies need continuous FHM :
 Maternal medical illness ,Gestational diabetes, Hypertension ,Asthma.
 Obstetric complications : Multiple gestation ,Post-date
gestation ,Previous cesarean section ,Intrauterine growth
restriction ,Oligohydramnios ,Premature rupture of the membranes,
Congenital malformations ,Third-trimester bleeding.
 Oxytocin induction/augmentation of labor, Preeclampsia ,Meconium
stained liquor.
 Continuous cardiotocography if any of the following risk factors :
 Maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
 Temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
 Suspected chorioamnionitis or sepsis
 Pain reported by the woman that differs from the pain normally associated with contractions
 The presence of significant meconium
 Fresh vaginal bleeding that develops in labour
 Severe hypertension: a single reading of either systolic blood pressure of 160 mmHg or more or diastolic blood
pressure of 110 mmHg or more, measured between contractions
 Hypertension: either systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90 mmHg or
more on 2 consecutive readings taken 30 minutes apart, measured between contractions
 A reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure (140 mmHg
or more) or raised diastolic blood pressure (90 mmHg or more)
 Confirmed delay in the first or second stage of labour
 Contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes
(tachysystole)
 Oxytocin use.
 Concerning characteristics of variable decelerations:
 Lasting more than 60 seconds
 Reduced baseline variability within the deceleration
 Failure to return to baseline
 Biphasic (W) shape
 No shouldering.
 Categorise Cardiotocography traces as follows:
 normal: all features are reassuring
 suspicious: 1 non-reassuring feature and 2 reassuring features (but
note that if accelerations are present, fetal acidosis is unlikely)
 pathological: 1 abnormal feature or 2 non-reassuring features
CTG interpretation and further management
 If CTG is normal: continue CTG or if it was started because of concerns arising from intermittent
auscultation, remove CTG after 20 minutes if there are no non-reassuring/abnormal features and no
ongoing risk factors.
 If suspicious: commence conservative measures – left lateral position, oral/intravenous fluids, stop
oxytocin, consider tocolysis.
 If the CTG is abnormal: Offer to take fetal blood sample (FBS; for lactate or pH) after implementing
conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as
a result of scalp stimulation.
 The pH of the fetus has been shown to drop at the rate of 0.01 every 2–3 minutes.
Fetal blood sampling interpretation
 Normal(PH:>=7.25): and there are no accelerations in response to fetal scalp

stimulation, consider taking a second fetal blood sample no more than 1
hour later if this is still indicated by the cardiotocograph trace.
 Borderline (PH 7.24-7.21): and there are no accelerations in response to fetal

scalp stimulation, consider taking a second fetal blood sample no more than 30
minutes later if this is still indicated by the cardiotocograph trace.
 Abnormal (PH<7.2) : Delivery.

CTG Interpretation: Dr. Areen Alnasan

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CTG Interpretation

Dr. Areen Alnasan

 Cardiotocography (CTG) is a continuous electronic record of the fetal’s heart

 Baseline fetal heart rate (FHR)

 Gradual decrease in FHR with onset of deceleration to nadir >30

 It should not be used unless indicated as it increases the rates of

 It has become an integral component of labour management in high-risk

 Normal(PH:>=7.25): and there are no accelerations in response to fetal scalp

 Borderline (PH 7.24-7.21): and there are no accelerations in response to fetal

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