CARDIOTOCOGRAPH (CTG)

FADZLINA BT AB JALAL BEKRI

YEAR 5,OBSTETRICS AND GYNAECOLOGY POSTING,26 FEB 2017
INTRODUCTION
Cardiotocograph (CTG) : recording (-
graphy) the fetal heartbeat (cardia) and the
uterine contractions (-toco) during pregnancy
Continuous tracing of fetal heart rate to
monitor fetal well-being and allow early
detection of fetal distress.

Doppler effect detect fetal heart motion.

It measure interval between successive beats.
 Fetal cardiac behaviour regulated through
autonomic nervous system by these mechanism
Vasomotor
Chemoceptor
Baroreceptor
pathological events (e.g: hypoxia)
Cardiac
response

variation in heart rate patterns

recorded in CTG
HOW IT WORKS?
o It involves the placement of 2
transducers onto the abdomen of a
pregnant women.

oOne transducer records the fetal

heart rate using ultrasound.

oThe other transducer monitors the

contractions of the uterus.
-measuring the tension of the
maternal abdominal wall.
- provides an indirect indication
of intrauterine pressure.
Precautionary steps before interpretation
1. Position - left lateral or semi-recumbent to avoid
compression of the maternal vena cava.

2. Fetal monitoring ultrasound transducer + tocodynometer

(stretch gauge)

3. Recordings at least 30 minutes

4. Graph produce two lines ( one fetal heart rate , another one
for uterine activity)
Pathological events
INTERPRETATION OF CTG
Accronym DR C BRaVADO
DR Define Risk
C Contractions

BRa Baseline Rate

V Variability
A Accelerations
D Decelerations
O Overall impression
Define risk
1st : to assess if this pregnancy is high or low risk.
This is important as it gives more context to the CTG reading e.g. If the
pregnancy is high risk, your threshold for intervening may be lowered.
Reasons a pregnancy may be considered high risk are shown below
Maternal medical illness
Gestational diabetes
Hypertension
Asthma
Obstetric complications
Multiple gestation
Postdategestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of membranes
Congenital malformations
Oxytocin induction/augmentation of labour
Pre-eclampsia
Other risk factors
Absenceof prenatal care
Smoking
Drug abuse
CONTRACTIONS
Record the number of contractions present in a 10 minute
period e.g. 3 in 10
*Each big square is equal to 1 minute, so look at how many

contractionsoccurred within10 squares.

Individual contractions are seen as peaks on the part of the

CTG monitoring uterine activity.
You should assess contractions for the following:
Duration how long do the contractions last?
Intensity how strong are the contractions? (assessed using
palpation)
BASELINE HEART RATE
The baseline rate is the average heart rate of the
fetus withina 10 minute window.

Look at the CTG and assess what the average

heart rate has been over the last 10 minutes.

Ignore any accelerations or decelerations.

A normal foetal heart rate is between 110-150

bpm.
Bradycardia
Baseline FHR persistently < 110 bpm
Causes:
Gestational age > 40w
Cord compression/ prolapsed
Congenital heart malformation
Drugs
Late fetal hypoxia
Unknown
Severe prolonged bradycardia (< 80 bpm for > 3 minutes)
indicates severe hypoxia.
Causes of prolonged severe bradycardia are:
Prolonged cord compression
Cord prolapse
Epidural & spinal anaesthesia
Maternal seizures
Rapid fetal descent
If the cause cannot be identified and corrected, immediate
delivery is recommended.
Tachycardia
Persistently baseline > 160 bpm (upper limit
of normal)
Causes:
Maternal pyrexia
Fetal infection
Chronic hypoxia
Hyperthyroidism or maternal stress
Gestational age < 32 weeks
Drugs
Excessive fetal movements
BASELINE VARIABILITY
Variability occurs as a result of the interaction between the nervous system,
chemoreceptors, baroreceptors and cardiac responsiveness.(Reflects a normal fetal
autonomic nervous system)
Therefore it is a good indicator of how healthy the foetus is at that particular moment
in time.
This is because a healthy fetus will constantly be adapting its heart rate to respond to
changes in its environment.
Normal variability is between 10-25 bpm
Abnormal when less than 10 beats per minute

To calculate variability you look at how much the peaks and troughs of the heart rate
deviate from the baseline rate (in bpm)
.
Variability can be categorised as:4
Reassuring 5 bpm
Non-reassuring < 5bpm for between 40-90 minutes
Abnormal < 5bpm for >90 minutes

Modified by;
fetal sleep states and activity
Hypoxia
Fetal infection
Drugs eg; opiods, hypnotics
ACCELERATION
A transient increase in baseline FHR of 15
bpm or more and lasting for 15 seconds or
more.

Presence of 2 or > accelerations on a 20-30

minute CTG defines reactive trace ; non
hypoxic fetus.
DECELERATION
Transient episode slowing FHR below the
baseline more than 15 bpm lasting for at
least15 seconds or more.

indicates :
Fetal hypoxia or umbilical cord compression
Early deceleration
Early decelerations start when uterine contraction
begins and recover when uterine contraction
stops.
This is due to increased fetal intracranial pressure
causing increased vagal tone.
It therefore quickly resolves once the uterine
contraction ends and intracranial pressure
reduces.
This type of deceleration is therefore considered
to be physiological and not pathological.
Late deceleration
Deceleration occur more than 15 seconds after
the peak of contraction
Late decelerations begin at the peak of uterine
contraction and recover after the contraction
ends.
This type of deceleration indicates there is
insufficient blood flow through the uterus and
placenta.
As a result blood flow to the foetus is significantly
reduced causing foetal hypoxia and acidosis.
Reduced utero-placental blood flow can be
caused by:
Maternal hypotension
Pre-eclampsia
 The presence of late decelerations is taken
seriously and fetal blood sampling for pH is
indicated.
If fetal blood pH is acidotic it indicates significant
fetal hypoxia and the need for emergency C-
section.
Causes;
Reduction in placental blood flow (abruptio,
hyperstimulation)
Maternal related disease (PIH)
Fetal compromise (IUGR, hypotension)
Supine hypotension
Variable deceleration
Deceleration that inconsistent in shape and in timing with
uterine contraction.
They are most often seen during labour and in patients with
reduced amniotic fluid volume.
Variable decelerations are usually caused by umbilical cord
compression:
 Variable decelerations can sometimes resolve if the mother
changes position.
The presence of persistent variable decelerations indicates
the need for close monitoring.
Variable decelerations without the shoulders is more
worrying as it suggests the fetus is hypoxic.
Causes:
Umbilical cord entanglement
Cord round neck
True knot
Cord prolapsed
Prolonged deceleration
A consistent drop in fetal heart rate > 30bpm,
lasting 2 minutes
Causes;
Total umbilical cord occlusion
Uterine hypertonic
Maternal hypotension
Cord compression

Action must be taken quickly e.g. fetal blood

sampling / emergency C-section
REACTIVE TRACE
Normal baseline heart rate, variability.
Presence of acceleration ( 2 in 20 mins trace)
Absence of deceleration
SINUSOIDAL
A smooth, wave like baseline, absent beat to
beat variability
Causes:
Severe hypoxia
Anaemic fetus
Idiopathic
Pathological
No accelerations and two or more of the following:
1. Abnormal BR
2. Abnormal variability
3. Repetitive late deceleration
4. Variable deceleration with ominous features
Duration > 60s
Late recovery baseline
Late deceleration component
Poor variability between / during deceleration

5. Others : Sinusoidal pattern

prolonged bradycardia
SUSPICIOUS
Absence of acceleration> 40 minutes
(important)
BHR 160-170 bpm or 100-110 bpm
Absence BV(<10bpm) for >40 min with
normal baseline deceleration
Variable deceleration <60 bpm for 60 sec
APPROACH TO CTG
DR C BRAVADO
Define risk : low/high
Contraction: freq/duration
Baseline rate : brady/tachy/normal
Variability : 5-10 bpm
Acceleration : present/absent
Deceleration : early/variable/late
Overall : comment/management
THANK YOU FOR PAYING ATTENTION