How to read a CTG?

Dr Pradeep S
Dr Sabitha US
 Looking at the CTG paper
systematically
• Check the name, identity number
• Check the time and the date
• Define risk and the indication of CTG monitoring
• Check the maternal pulse, temperature
• Drugs if any- pethidine, betamethasone, MgSo4,
methyl dopa, betamimetics
• Epidural?

Intrapartum care: NICE guideline CG190

(December 2014).
 Overall care
• Do not make any decision about a woman's care in labour on the
basis of cardiotocography (CTG) findings alone.
• Take into account:

– any antenatal and intrapartum risk factors, the current wellbeing of

the woman and unborn baby, and the progress of labour when
interpreting the CTG trace. –

– Remain with the woman at all times in order to continue providing

one-to-one support.

– Ensure that the focus of care remains on the woman rather than the
CTG trace. Make a documented systematic assessment of the
condition of the woman and the unborn baby (including CTG findings)
hourly, or more frequently if there are concerns.

Intrapartum care: NICE guideline CG190

(December 2014).
 Check your paper speed first
• 1cm/minute
• 3cm/minute

Intrapartum care: NICE guideline CG190

(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Classification of CTG
• Normal
• Non Reassuring
• Abnormal

Intrapartum care: NICE guideline CG190

(December 2014).
Interpretation- 4 features

Baseline
Variability
Accelerations
Decelerations

Intrapartum care: NICE guideline CG190

(December 2014).
 Baseline FHR - Definition

• The mean level of the FHR when this is stable, excluding

accelerations and decelerations. It is determined over a time
period of 5 or 10 minutes and expressed in bpm.

• The normal baseline FHR varies between 100-160

bpm (slightly quicker for preterm).
• A baseline FHR of 100-109 bpm or 161-180 bpm
is non-reassuring.
• A baseline FHR of <100 or >180 bpm is classified
as an abnormal feature.
Intrapartum care: NICE guideline CG190
(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Baseline rate - Mean level of FHR
(excluding accelerations and decelerations)

Normal • Observed over 5-10

110-160bpm minutes
Non-reassuring
Borderline tachycardia 161-180bpm • Prematurity associated
Borderline bradycardia 100-109bpm with higher FHR
Abnormal
Tachycardia >180bpm • Trend in baseline and
Bradycardia <100bpm absolute value
important

Intrapartum care: NICE guideline CG190

(December 2014).
 Baseline fetal heart rate

• usually be between 110 and 160 beats/minute

• between 100 and 109 beats/minute with
normal baseline variability and no variable or
late decelerations is normal and should not
prompt further action
• between 90 and 99 beats/minute with normal
baseline variability may be a normal variation;
obtain a senior obstetric opinion if uncertain.
Intrapartum care: NICE guideline CG190
(December 2014).
• between 161 and 180 beats/minute with no
other non-reassuring or abnormal features on
the cardiotocograph:
– think about possible underlying causes (such as
infection) and
– appropriate investigation check the woman's
temperature and pulse
• if either are raised, offer fluids and paracetamol start
one or more conservative measures

Intrapartum care: NICE guideline CG190

(December 2014).
 Tachycardia>160BPM

Normal 110-160BPM

Bradycardia<100BPM

Intrapartum care: NICE guideline CG190

(December 2014).
Tachycardia

160/min

Intrapartum care: NICE guideline CG190

(December 2014).
 Causes
• Hypoxia
Chorioamnionitis
Maternal fever
B-Mimetic drugs
Fetal anaemia,sepsis
Heart failure, arrhythmias

Intrapartum care: NICE guideline CG190

(December 2014).
FETAL BRADYCARDIA
Bradycardia

100 bpm

Intrapartum care: NICE guideline CG190

(December 2014).
 Baseline variability

• The minor fluctuations in baseline FHR occuring

at three to five cycles per minute.
• It is measured by estimating the difference in
beats per minute between the highest peak and
lowest trough of fluctuation in a one-minute
segment of the trace
• Variability between 5 and 25 bpm is considered
‘reassuring’. Reduced variability of <5 bpm can be
physiological during periods of fetal sleep.
Intrapartum care: NICE guideline CG190
(December 2014).
 Variability
Normal
> or = 5 bpm between contractions
Non-reassuring
<5 bpm for 40 minutes or more
(but less than 90minutes)
Abnormal
<5 bpm for 90 minutes or more

Intrapartum care: NICE guideline CG190

(December 2014).
 5

Intrapartum care: NICE guideline CG190

(December 2014).
5 Beats above and 5 beats below

1 minute

Intrapartum care: NICE guideline CG190

(December 2014).
 Accelerations
• An acceleration is a transient increase in FHR
of at least 15 bpm above the baseline which
lasts for at least 15 seconds .
• Presence of FHR Accelerations have Good
outcome.

• Absence of accelerations on an otherwise

normal CTG remains unclear.

Intrapartum care: NICE guideline CG190

(December 2014).
 Accelerations

Normal

• 2 accelerations in a 20 minute trace

“reactive”

• Accelerations less frequent in active labour

Intrapartum care: NICE guideline CG190

(December 2014).
 15 seconds

15 beats

Intrapartum care: NICE guideline CG190

(December 2014).
 Decelerations
• A deceleration is a transient decrease in FHR
of at least 15 bpm below the baseline which
lasts for at least 15 seconds.

• The presence of decelerations is a non-

reassuring or abnormal feature in a CTG and is
classified according to the type, duration and
frequency of the decelerations.

Intrapartum care: NICE guideline CG190

(December 2014).
 Decelerations
• When describing decelerations in fetal heart rate,
specify:
– the depth and duration of the individual decelerations
– their timing in relation to the peaks of the
contractions
– whether or not the fetal heart rate returns to baseline
– how long they have been present for
– whether they occur with over 50% of contractions.

Intrapartum care: NICE guideline CG190

(December 2014).
 Decelerations
• Describe decelerations as 'early', 'variable' or
'late'. Do not use the terms 'typical' and
'atypical' because they can cause confusion.
[new 2014]

Intrapartum care: NICE guideline CG190

(December 2014).
 Decelerations

15 sec

15 beats

Intrapartum care: NICE guideline CG190

(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Early Vs Late Deceleration
• Early Deceleration

• Late Deceleration

Intrapartum care: NICE guideline CG190

(December 2014).
 Early deceleration
• Caused by head compression

Intrapartum care: NICE guideline CG190

(December 2014).
Late deceleration

Intrapartum care: NICE guideline CG190

(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Typical variable deceleration
• 'Shoulders' (primary and secondary
acceleratory phases)

Intrapartum care: NICE guideline CG190

(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Sinusoidal pattern
• A regular oscillation of the baseline long-term
variability resembling a sine wave. This smooth,
undulating pattern, lasting at least 10 minutes,
has a relatively fixed period of 3–5 cycles per
minute and an amplitude of 5–15 bpm above and
below the baseline. Baseline variability is absent

• Associated with -
Severe chronic fetal anaemia
Severe hypoxia & acidosis

Intrapartum care: NICE guideline CG190

(December 2014).
SINUSOIDAL

Intrapartum care: NICE guideline CG190

(December 2014).
PSEUDOSINUSOIDAL

Intrapartum care: NICE guideline CG190

(December 2014).
 SALTATORY PATTERN

Intrapartum care: NICE guideline CG190

(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
Intrapartum care: NICE guideline CG190
(December 2014).
 Definition of, normal, non reassuring and abnormal ctg

Normal
Non reassuring
Abnormal

Normal CTG: no non-reassuring or abnormal features, healthy fetus

Non reassuring: Combination of features that may be associated with increased risk of
fetal acidosis; if accelerations are present, acidosis is unlikely

Abnormal: likely to be associated with fetal acidosis

Intrapartum care: NICE guideline CG190

(December 2014).
2007 nice categorisation of ctg
 Latest Categorisation of ctg
Intrapartum care: NICE guideline CG190 (December 2014).
Description Baseline Baseline Decelerations
(beats/ minute) variability
(beats/ minute)

Non 161–180 less than 5 for Variable decelerations:

reassuring 30– 90 minutes -dropping from baseline by 60
beats/minute or less and
- taking 60 seconds or less to recover,
- present for over 90 minutes
- occurring with over 50% of contractions
OR
Variable decelerations:
-dropping from baseline by more than 60
beats/minute or taking over 60 seconds to
recover
- present for up to 30 minutes
– occurring with over 50% of contractions
OR
Late decelerations:
- present for up to 30 minutes
- occurring with over 50% of contractions

Intrapartum care: NICE guideline CG190 (December 2014).

Description Baseline Baseline Decelerations
(beats/ minute) variability
(beats/ minute)

Normal 100–160 5 or more None or early

Intrapartum care: NICE guideline CG190 (December 2014).

Abnormal Baseline Baseline Decelerations
(beats/ minute) variability
(beats/ minute)

Non Above 180 or Less than 5 for Non-reassuring variable decelerations (see
reassuring below 100 over 90 minutes row above):
- still observed 30 minutes after starting
conservative measures
- occurring with over 50% of contractions
OR
Late decelerations
- present for over 30 minutes
- do not improve with conservative
measures
- occurring with over 50% of contractions
OR
Bradycardia or a single prolonged
deceleration lasting 3 minutes or more

Intrapartum care: NICE guideline CG190 (December 2014).

 Record keeping
• Make sure that date and time clocks on the
cardiotocograph monitor are set correctly label
traces with the woman's name, date of birth and
hospital number or NHS number, the date and the
woman's pulse at the start of monitoring.
• Keep cardiotocograph traces for 25 years and, if
possible, store them electronically.
• In cases where there is concern that the baby may
experience developmental delay, photocopy
cardiotocograph traces and store them indefinitely
in case of possible adverse outcomes.
Intrapartum care: NICE guideline CG190 (December 2014).
Thank you

Intrapartum care: NICE guideline CG190

(December 2014).