CTG INTERPRETATION

Supervisors: Dr Tanes/Dr Zaki

Presenter: Dr Nor Atiqah
 Cardiotocography
• Fetal heart beat
- Baseline fetal heart rate
- Baseline variability
- Acceleration
- Deceleration

• Maternal uterine contraction

 Baseline fetal heart rate
• Mean level of FHR when this is stable, excluding
accelerations and decelerations
• Determined over a period of 5 or 10 minutes
• Controlled mainly by autonomic nervous system
(sympathetic and para-sympathetic activity)
• Normal baseline: 110-160 bpm
• Abnormalities:
- Baseline tachycardia
- Baseline bradycardia
Baseline tachycardia

Moderate tachycardia: 161-180

Abnormal tachycardia: >180

Causes:
- Excessive fetal movement
- Maternal stress and anxiety
- Maternal pyrexia
- Fetal infection
- Chronic hypoxia
- Gestational age ≤32 weeks
- Fetal catecholamine
Baseline bradycardia

Moderate bradycardia: 100-

109
Abnormal bradycardia:
<100

Causes
- Gestational age> 40
weeks
- Cord compression
- Congenital heart
malformation
- Drug induced:
benzodiazepine
 Baseline variability
• Minor fluctuations in baseline FHR
• Measured by difference between the highest
peak and lowest trough of fluctuation in a
one-minute segment
• Occurs as a result of interaction between
nervous system, chemoreceptors and
baroreceptors with cardiac responsiveness
• Normal: ≥5 bpm between contractions
Baseline variability
 Reduced variability
• Non- reassuring: <5 for 30-50min
• Abnormal: <5 for >50 min
• Causes
- Fetal sleep
- Administration of drugs to mother
- Gestational age
- Severe hypoxia
 Acceleration
• Transient increases in FHR of 15 bpm or more lasting 15s or
more
• Indicates normal fetal oxygenation- interaction of nervous
system in response to increase in metabolic demands
• Reactive trace: ≥2 in 20 minutes
• Significance of no acceleration on an otherwise normal CTG
is unclear
 Deceleration
• Transient episodes of slowing of FHR below
the baseline level of more than 15bpm and
lasting 15s or more
Types
- Early deceleration
- Late deceleration
- Variable deceleration
- Prolonged deceleration
 Early deceleration

• Uniform, repetitive, periodic slowing of FHR

• Early onset in contraction
• Return to baseline at the end of contraction
 Early deceleration
• Caused by compression of fetal head during a
contraction
• Decrease in cerebral blood flow and
oxygenation
• Detected by cerebral chemoreceptors->
parasympathetic activity increased-> fall in
heart rate
• Management aimed at relieving pressure by
changing maternal posture
 Late deceleration

• Uniform, repetitive, periodic slowing of FHR

• Onset mid to the end of contraction
• Nadir more than 20s after the peak of contraction
and ends after the contraction
 Late deceleration
• Result of decrease in uterine blood flow during uterine
contraction
• Occur after contraction due to the time it takes for
circulating blood to reach aortic arch from the placenta
• Causes
- Reduction in placental blood flow: Abruptio placenta, maternal
hypotension, uterine hyperstimulation
- Placenta pathology: DM, PIH, renal disease
- Fetal compromise: IUGR, prematurity, TTTS, Rhesus isoimmunization
• Management aimed at increasing uterine blood flow
and oxygen transfer across the placenta
 Variable deceleration

• Variable, intermittent periodic slowing of FHR

• Rapid onset and recovery
• Relationships with contraction are variable, may occur in
isolation
 Variable deceleration
• Result of transient compression of the
umbilical cord during uterine contraction
1. Venous return obstructed->
cardiac output and arterial
pressure reduced-> sympathetic
activity-> FHR increased

2. Arterial flow obstructed-> fetal

hypertension-> parasympathetic
activity-> FHR decreased

3. Arterial obstruction removed->

fetal hypotension recurs-> FHR
increased till venous flow returns
to normal
 Variable deceleration
• Causes: cord around neck, true knot, cord
prolapse
• Management aimed at relieving the cord
compression
- Change maternal posture
- To exclude cord prolapse
- Stop oxytocin infusion
- Give oxygen
 Atypical variable deceleration
• Variable deceleration with any of the following
- Slow return to baseline FHR after the end of
contraction
- Prolonged secondary rise in baseline
- Biphasic deceleration
- Loss of variability during deceleration
- Continuation of baseline rate at lower level
 Prolonged deceleration
• Abrupt decrease in FHR to level below
baseline lasts at least 60-90 seconds
• Pathological if cross 2 contractions (ie 3
minutes)
 Prolonged deceleration
• Decrease in oxygen transfer across placenta to
fetus, usually result of decrease in uterine
blood flow
• Causes: total umbilical cord occlusion,
maternal hypotension, uterine
hyperstimulation
 Description
Baseline (bpm) Variability (bpm) Deceleration Acceleration

Reassuring 110-160 5-25 None or early Present

Non-reassuring 100-109 <5 for 30- Variable deceleration with no concerning

161-180 50minutes characteristic for ≥ 90𝑚𝑖𝑛𝑢𝑡𝑒𝑠
>25 for 15- Variable decelerations with any concerning
25minutes characteristics in up to 50% of contractions
for ≥ 30𝑚𝑖𝑛𝑢𝑡𝑒𝑠
Variable decelerations with any concerning
characteristics in over 50% of contractions
for<30𝑚𝑖𝑛𝑢𝑡𝑒𝑠
Late decelerations in over 50% of
contractions for <30minutes with no
maternal/fetal clinical risk factors

Abnormal <100 <5 for >50 min Variable deceleration with any concerning
>180 >25 for> 25 min characteristics in over 50% of contraction
Sinusoidal Sinusoidal for 30minutes
Late decelerations for 30minutes
Acute bradycardia/single prolonged
deceleration lasting 3 minutes or more
 Classification
Classification Definition

Normal All features reassuring

Suspicious 1 non reassuring & 2 reassuring features

Pathological 1 abnormal features

OR
2 non-reassuring features

Urgent intervention Acute bradycardia, or a single prolonged deceleration

for 3 minutes or more
 Management
Category Management

Normal • Continue CTG and usual care

Suspicious • Correct any underlying causes, such as hypotension or uterine hyperstimulation

• Perform a full set of maternal observations
• Start 1 or more conservative measures*
• Inform an obstetrician or a senior midwife
• Document a plan for reviewing the whole clinical picture and the CTG findings
• Talk to the woman and her birth companion(s) about what is happening and
take her preferences into account
Pathological • Obtain a review by an obstetrician and a senior midwife
• Exclude acute events (for example, cord prolapse, suspected placental abruption
or suspected uterine rupture)
• Correct any underlying causes, such as hypotension or uterine hyperstimulation
• Start 1 or more conservative measures*
• Talk to the woman and her birth companion(s) about what is happening and
take her preferences into account
• If the cardiotocograph trace is still pathological after implementing conservative
measures: – obtain a further review by an obstetrician and a senior midwife –
offer digital fetal scalp stimulation and document the outcome
• If the cardiotocograph trace is still pathological after fetal scalp stimulation: –
consider fetal blood sampling – consider expediting the birth – take the
woman's preferences into account
Need for urgent intervention • Urgently seek obstetric help
• If there has been an acute event (for example, cord prolapse,
suspected placental abruption or suspected uterine rupture),
expedite the birth
• Correct any underlying causes, such as hypotension or uterine
hyperstimulation
• Start 1 or more conservative measures*
• Make preparations for an urgent birth
• Talk to the woman and her birth companion(s) about what is
happening and take her preferences into account
• Expedite the birth if the acute bradycardia persists for 9
minutes
• If the fetal heart rate recovers at any time up to 9 minutes,
reassess any decision to expedite the birth, in discussion with
the woman
Clinical scenario- Case 1
28 years old G1P0 at 40
weeks + 7 days
ANC: uneventful

LPC: 2:10 moderate

SROM, clear liquor
Os 4cm

1. What do you notice in

the CTG?
2. What is the most
probable cause of FHR
abnormality shown?
3. What intervention would
you consider?
Clinical scenario- Case 2
Clinical scenario- Case 3
Clinical scenario- Case 4
 References
• Intrapartum care: NICE guideline CG190
(February 2017)