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NOMENCLATURE

A Review of the Proceedings

from the 2008 NICHD Workshop
on Standardized Nomenclature
for Cardiotocography
Update on Definitions, Interpretative Systems
With Management Strategies, and Research
Priorities in Relation to Intrapartum
Electronic Fetal Monitoring
Barrett Robinson, MD, MPH, Latasha Nelson, MD
Maternal Fetal Medicine, Northwestern Memorial Hospital, Chicago, IL

Despite evidence demonstrating no neonatal benefit, the medicolegal

climate in the United States requires obstetricians to integrate continuous
intrapartum surveillance into their care of the pregnant laboring patient.
The intent of this article is to familiarize the reader with the most recent,
standardized, quantitative nomenclature recommended to describe intrapartum CTG in order to reduce miscommunication among providers caring
for the laboring patient, propagate consistent, evidence-based responses
to CTG patterns, and systematize the terminology used by researchers
investigating intrapartum CTG.
[Rev Obstet Gynecol. 2008;1(4):186-192]
2008 MedReviews, LLC

Key words: Intrapartum cardiotocography Electronic fetal monitoring NICHD

nomenclature

n 2002, approximately 3.4 million fetuses (85% of approximately 4 million

live births) in the United States were assessed with continuous cardiotocography (CTG), making it the most commonly performed obstetric procedure.1
Although CTG, also known as electronic fetal monitoring, is widespread in developed nations, its ability to identify the fetus that may be becoming asphyxiated

This article provides an update for the review of NICHD nomenclature published in
Reviews in Obstetrics & Gynecology, Volume 1, Number 2, Spring 2008, on pages 56-60.

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Update: NICHD Standardized Nomenclature for Cardiotocography

and therefore may benefit from intervention is limited, and has failed to
lead to reduced rates of cerebral palsy
and neurologic injury. There are no
studies comparing CTG with an absence of intrapartum monitoring, but
trials comparing CTG with intermittent auscultation show no reduction
in the overall risk of perinatal death
(relative risk [RR] 0.85; 95% confidence interval [95% CI], 0.59-1.23) or
cerebral palsy (RR 1.74; 95% CI, 0.973.11).2 What studies have demonstrated is that CTG versus intermittent
auscultation leads to higher operative
delivery rates by cesarean or assisted
vaginal delivery (RR 1.66; 95% CI,

heart monitoring, with the ultimate

goal of producing a common language that would facilitate further investigational research examining the
predictive value of electronic fetal
monitoring and management strategies to recognize and reduce intrapartum fetal compromise.5 The American College of Obstetricians and
Gynecologists (ACOG); the Association of Womens Health, Obstetric and
Neonatal Nurses; the Royal College
of Obstetricians and Gynaecologists;
and the Society of Obstetricians and
Gynaecologists of Canada not only
endorsed the definitions, but recommended new interpretations, defini-

Despite compelling evidence demonstrating no neonatal benefit, the medicolegal climate in the United States requires obstetricians to integrate continuous
intrapartum surveillance into their care of the pregnant laboring patient.
1.30-2.13 and RR 1.16; 95% CI, 1.011.32, respectively).2
Despite
compelling
evidence
demonstrating no neonatal benefit,
the medicolegal climate in the United
States requires obstetricians to integrate continuous intrapartum surveillance into their care of the pregnant
laboring patient. Due to the setup of
labor and delivery units and the
team-oriented approach that exists in
most facilities, nurses, residents,
nurse midwives, and physicians may
all be regularly involved in assessing
the CTG. To communicate effectively
in the event that an abnormal CTG
exists and invoke an appropriate level
of concern, standardized terminology
is necessary.3,4
In 1997, the National Institutes of
Child Health and Human Development (NICHD) sponsored a Research
Planning Workshop that addressed
this issue. The workshops express
purpose was to develop a standardized and rigorously, unambiguously
described set of definitions that can
be quantitated for electronic fetal

tions, and particular intrapartum

management actions for some situations.
In April 2008, the NICHD, ACOG,
and the Society for Maternal-Fetal
Medicine (SMFM) jointly sponsored a
workshop on CTG, or fetal heart rate
(FHR) patterns. The goals of this
workshop6 were (1) to review and update the definitions for CTG pattern
categorization as compared with the
prior workshop, (2) to assess existing
classification systems for interpretation of particular CTG patterns and
make new recommendations for a
system to be employed in the United
States, and (3) to make recommendations for research priorities as they relate to CTG. The intent of this article
is to familiarize the reader with the
resulting standardized, quantitative
nomenclature that is recommended to
describe intrapartum CTG to reduce
miscommunication among providers
caring for the laboring patient, as well
as systematize the terminology used
by researchers investigating intrapartum CTG. A new emphasis on in-

VOL. 1 NO. 4 2008

terpretative systems and recommended management strategies, as set

forth by the recent 2008 joint workshop, is also included and reviewed in
detail.

Fundamental Principles When

Using NICHD Terminology6
A set of overarching operational
principles was outlined prior to presenting the actual definitions of terms
integral to the interpretation of cardiotocography. The most germane
principles are:
Although the development of computerized interpretation programs is
underway, the definitions are to be
used for visual interpretation of
CTG.
The definitions apply to patterns
produced from either an external
Doppler ultrasound device or a direct transcervical fetal electrode detecting the fetal electrocardiogram.
The documentation of both CTG
and tocodynamometry should be of
adequate quality for visual interpretation.
The chief emphasis is on intrapartum patterns, although the definitions are applicable to antepartum observations.
The patterns to be defined are categorized as either baseline, periodic,
or episodic. Periodic patterns are associated with contractions, whereas
episodic patterns are independent
of uterine contractions.
Periodic patterns are distinguished
based on waveform, with accelerations or decelerations defined as
abrupt versus gradual onset in relation to the adjacent baseline CTG.
No differentiation is made between
short-term variability (or beat-tobeat variability or R-R wave period
differences in the electrocardiogram) and long-term variability because in practice, they are visually
determined as a unit. The definition
of variability is based visually on

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the amplitude of the complexes,

with exclusion of the regular,
smooth sinusoidal pattern.
CTG patterns are gestational
agedependent and can differ based
on fetal physiologic status and maternal physiologic status, making
each of these critical interpretive
factors in the evaluation of a CTG
pattern. Maternal medical status,
prior fetal assessments, use of medications, and other factors also warrant consideration.
The individual components of CTG
that are defined do not occur in isolation and generally evolve over
time. A full description of a CTG requires a qualitative and quantitative description of uterine contractions, baseline fetal heart rate,

tions, (2) tachysystole can occur irrespective of whether labor is spontaneous or stimulated, although the
clinical responses may differ based on
whether contractions are spontaneous
or stimulated, and (3) the usage of
such terms as hyperstimulation and
hypercontractility are without meaning and should be abandoned.

Definitions of Fetal Heart

Rate Patterns6
Essential to the definitions of FHR
patterns are the characteristics of
baseline, variability, acceleration, and
deceleration.
Baseline fetal heart rate is the average fetal heart rate rounded to increments of 5 beats per minute during a
10-minute segment, excluding accel-

A full description of a cardiotocography (CTG) requires a qualitative and

quantitative description of uterine contractions, baseline fetal heart rate,
baseline CTG variability, presence of accelerations, periodic or episodic decelerations, and changes or trends of CTG patterns over time.
baseline CTG variability, presence
of accelerations, periodic or
episodic decelerations, and changes
or trends of CTG patterns over time.

Uterine Contractions6
The number of contractions present in
a 10-minute window, averaged over
30 minutes, is the manner by which
uterine contractions are quantified.
When assessing uterine activity, equal
importance should be given to contraction frequency, duration, intensity, and relaxation time between
contractions. Normal uterine contractions are 5 contractions or less in 10 minutes, averaged over a 30-minute
window. Tachysystole is defined as
more than 5 contractions in 10 minutes, averaged over a 30-minute window. When using the term tachysystole, several key points should be kept
in mind, including: (1) the presence or
absence of associated CTG decelera-

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erations and decelerations and periods of marked variability ( 25

beats/min).
In any given 10-minute window,
the minimum baseline duration must
be at least 2 minutes (not necessarily
contiguous), or else the baseline is
considered indeterminate. In cases
where the baseline is indeterminate,
the previous 10-minute window
should be reviewed and utilized to determine the baseline.
A normal FHR baseline rate ranges
from 110 to160 beats per minute. If
the baseline FHR is less than 110 beats
per minute, it is termed bradycardia. If
the baseline FHR is more than 160
beats per minute, it is termed tachycardia.
Baseline FHR variability is determined in a 10-minute window and
excludes accelerations and decelerations. A sinusoidal fetal heart rate
pattern is defined as a visually appar-

REVIEWS IN OBSTETRICS & GYNECOLOGY

ent, smooth, sine-wavelike undulating pattern in FHR baseline with a

cycle frequency of 3 to 5 per minute
that persists for 20 minutes or more.
A sinusoidal fetal heart rate pattern is
incompatible with the definition of
variability.
Variability is defined as fluctuations
in the FHR baseline with irregular amplitude and inconstant frequency.
These fluctuations are visually quantitated as the amplitude of the peak to
trough in beats per minute, shown in
Table 1.
Based on visual assessment, an acceleration is defined as an apparent
abrupt increase in FHR above baseline, with the time from the onset of
the acceleration to its acme less than
30 seconds. The increase is measured
from the most recently determined
portion of the baseline. The peak is
15 beats per minute or more above the
baseline, and the acceleration lasts
15 seconds or more, but less than
2 minutes from the onset to the return
to the previously determined baseline.
In pregnancies of fewer than 32 weeks
of gestation, accelerations are defined
as having a peak 10 beats per minute
or more above the baseline and duration of 10 seconds or longer.
Prolonged acceleration is 2 minutes
or longer and less than 10 minutes
in duration, with any acceleration

Table 1
Baseline Fetal Heart Rate Variability
Fluctuation Classification
Amplitude Range

Classification

Undetectable

Absent

Undetectable to
 5 beats/min

Minimal

6 to 25 beats/min

Moderate

More than
25 beats/min

Marked

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Update: NICHD Standardized Nomenclature for Cardiotocography

lasting 10 minutes or longer constituting a change in baseline.

FHR decelerations are classified as
late, early, or variable. The characteristics of each type of deceleration are
described in the following paragraphs.
Based on visual assessment, late
deceleration is defined as an apparent
gradual decrease and return to the
baseline FHR in association with a
uterine contraction, with the time
from onset of the deceleration to its
nadir as 30 seconds or longer. The decrease is typically symmetrical in
shape and is measured from the most
recently determined portion of the
baseline to the nadir of the deceleration. The decelerations timing is delayed, with the nadir of the deceleration occurring after the peak of the
uterine contraction. In general, the
onset, nadir, and recovery of a late
deceleration occur after the beginning, acme, and end of the associated
contraction, respectively.
Based on visual assessment, early
deceleration is defined as an apparent
gradual decrease and return to the
baseline FHR in association with a
uterine contraction, with the time
from onset of the deceleration to its
nadir as 30 seconds or longer. The decrease is typically symmetrical in
shape and is measured from the most
recently determined portion of the
baseline to the nadir of the deceleration. Early decelerations are coincident in timing with uterine contractions, with the nadir of the
deceleration occurring simultaneously
with the peak of the uterine contraction. In general, the onset, nadir, and
recovery of a late deceleration occur
in a coincident fashion with the beginning, acme, and end of the associated contraction, respectively.
Based on visual assessment, variable deceleration is defined as an apparent abrupt decrease in FHR below
the baseline, with the time from the
onset of the deceleration to the nadir

of the deceleration as fewer than

30 seconds. The decrease is measured
from the most recently determined
portion of the baseline to the nadir of
the deceleration. Variable decelerations may or may not be associated
with uterine contractions. The decrease from baseline is 15 beats per
minute or greater and lasts 15 seconds
or longer, but lasts less than 2 minutes from onset to return to baseline.
When variable decelerations occur in
conjunction with uterine contractions, their onset, depth, and duration
may vary with each successive uterine contraction. Variable decelerations may occur in conjunction with
other findings, the clinical significance of which requires further
investigational research. Some examples include a slow return of the FHR
after the end of the contraction,
biphasic decelerations, tachycardia
after variable deceleration(s), accelerations preceding and/or following
(often referred to as shoulders or
overshoots), and fluctuations in the
trough of the deceleration.
Based on visual assessment, prolonged deceleration is defined as an
apparent decrease in FHR below the
baseline, measured from the most recently determined portion of the
baseline. The decrease in the FHR is
15 beats per minute or more and
lasts at least 2 minutes but less than
10 minutes from onset to return to
baseline. A deceleration that is sustained for 10 minutes constitutes a
change in baseline.

Deceleration Quantification
Guidelines6
The quantification of deceleration
magnitude is based on the depth of
the decelerations nadir in beats per
minute below the baseline, excluding
any transient spikes or electronic artifact. The duration of the deceleration
is quantitated in minutes and seconds
from the start of the deceleration to

VOL. 1 NO. 4 2008

the deceleration end. Accelerations

are likewise quantitated.
Although some authors have suggested grading decelerations based on
such factors as the depth or absolute
nadir in beats per minutes and duration, the predictive value of these
grading systems has not been sufficiently established and requires further investigation.
Decelerations are classified as recurrent if they occur with 50% or
more of uterine contractions in any
20-minute segment. Decelerations occurring with less than 50% of uterine
contractions in any 20-minute segment are defined as intermittent.

Interpretative Systems for

Classification of Fetal Heart
Rate Patterns6
Although many interpretative systems
exist for FHR tracings, the selected
system must be evidence based, simple, and applicable to clinical practice. As the FHR response is a dynamic process that requires frequent
reassessment, categorization of a
tracing is limited to the time period
being assessed. Over time it is not uncommon for FHR tracings to migrate
from one category to another. FHR
tracing patterns provide information
on the current acid-base status of the
fetus and cannot predict the development of cerebral palsy.
Two FHR findings reliably predict
the absence of acidemia: (1) the
presence of FHR accelerations, either
spontaneous or stimulated, or (2)
moderate FHR variability. It must be
emphasized, however, that although
either fetal accelerations or moderate
FHR variability reliably predict the
absence of acidemia, the absence of
accelerations, the presence of minimal
variability, or the presence of absent
variability does not reliably predict
the presence of fetal hypoxemia or
metabolic acidemia. The significance

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of marked variability (formerly described as saltatory) remains unclear.

Although the entire associated clini-

cal circumstances must always be

taken into account, the 2008 NICHD
workshop has simplified categoriza-

tion and interpretation of FHR tracings into a 3-tier system, described in

Table 2.

Table 2
3-Tier Fetal Heart Rate Interpretation System6
Category I
Normal tracings, which are strongly predictive of normal fetal acid-base status at the time of observation and can be followed in a
routine manner without any specific action required, include all of the following:
Baseline rate: 110-160 beats/min
Moderate variability
Absence of any late or variable decelerations
Early decelerations may or may not be present
Accelerations may or may not be present
Category II
Indeterminate tracings, although not predictive of abnormal fetal acid-base status, cannot be classified as Category I or III and thus
require evaluation and continued surveillance and reevaluation. These tracings are not infrequently encountered in clinical care, and
include any of the following:
Baseline rate


Tachycardia

Bradycardia not accompanied by absent baseline variability

Baseline FHR variability



Minimal baseline variability

Absent baseline variability not accompanied by recurrent decelerations

Marked baseline variability

Absence of induced accelerations after fetal stimulation (eg, scalp stimulation, vibroacoustic stimulation, direct fetal scalp sampling, transabdominal halogen light)
Periodic or episodic decelerations


Recurrent variable decelerations accompanied by minimal or moderate baseline variability

Prolonged deceleration 2 min but 10 min

Recurrent late decelerations with moderate baseline variability

Variable decelerations with other characteristics, such as slow return to baseline, overshoots, or shoulders

Category III
Abnormal tracings, which are predictive of abnormal fetal acid-base status at the time of observation, require prompt evaluation and
initiation of expeditious attempts to resolve the abnormal FHR pattern, such as provision of maternal oxygen, change in maternal
position, discontinuation of labor stimulation, treatment of maternal hypotension, or additional efforts. These tracings include either:
Absent baseline FHR variability along with any of the following:


Recurrent late decelerations

Recurrent variable decelerations

Bradycardia

Sinusoidal pattern
FHR, fetal heart rate.

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Research Recommendations6
CTG is nearly ubiquitous in obstetric
practice in the United States, and welldesigned studies are needed to fill
gaps in knowledge. Areas of highest
priority include observational studies
focused on indeterminate CTG patterns, including descriptive epidemiology, frequency of specific patterns,
changes over time, relationships to
clinically relevant outcomes, and the
effect of the patterns durations (eg,
recurrent late decelerations with minimal variability) on clinical outcomes.
Additional areas with a paucity of research include the effect of uterine
contractile characteristics on clinical
outcomes, the effectiveness of CTG educational programs that include all
relevant stakeholders, potential comparisons between computerized interpretation and provider interpretation,
digitally addressable formatted comprehensive data sets that integrate
CTG outcomes, and techniques that
may serve to supplement CTG, such as
ST segment analysis.

Commentary and Conclusions

Cardiotocography has become an accepted component of most intrapartum monitoring in the United
States, despite the lack of demonstrated fetal or neonatal benefit in the
literature. In order to continue to
safely and consistently apply this
technology to the care of obstetrical
patients, agreed-upon guidelines for
description of CTG patterns, interpretation and categorization of CTG

patterns, and appropriate provider

responses to CTG patterns must be
systematically introduced into practice and adhered to by all members of
the obstetrical team. The recent joint
workshop on continuous fetal CTG
sponsored by the NICHD, ACOG, and
SMFM in April 2008 and the resulting
update published by Macones and
colleagues6 substantially advanced the
cause of clarifying the current, recommended nomenclature and establishing a simple, evidence-based, clinically
applicable interpretative system.
Standardization of terminology and
subsequent categorization into 1 of 3
tiers should aid providers who are deciding whether the patterns are suggestive of a lack of fetal acidemia or
alternately require intervention. Despite numerous studies demonstrating
that inter- and intraobserver variability is high when CTG tracings are reviewed,7,8 there is consensus that
normal tracings classified as Category
I indicate an absence of fetal
acidemia.6,9,10,11 On the other hand,
acidemia may be present in up to 1 of
4 fetuses with abnormal or Category
III CTG tracings.12 Although expeditious action is indicated to either resolve the concerning aspects of the
abnormal tracing or to move towards
delivery, due to the low prevalence of
intrapartum fetal asphyxia, even abnormal tracings have a well-recognized false-positive rate that in some
instances can be greater than 90%.13
Patients with indeterminate tracings, classified as Category II, may

ultimately be the most difficult to

manage in clinical practice. A mainstay of the recommended strategy is
close, continuous evaluation and
assessment. These tracings may ultimately fit criteria for normal, Category
I tracings as time passes or after subsequent evaluative strategies, at which
point confidence in the nonacidemic
status of the fetus may be gained. Alternately, indeterminate tracings may
ultimately meet the criteria for abnormal, Category III tracings, in which
case the imperative to resolve concerning aspects or move expeditiously towards delivery will become clear. Due
to the potential uncertainty inherent in
these nonpredictive tracings, a call has
been issued for investigational research
focusing on the relationship between
such tracings and clinical outcomes.
This document attempts to familiarize the reader with recently proposed NICHD language in an effort to
further advance the cause of utilizing
common terminology and employing
consistent, evidence-based, and simple interpretative systems among
providers who use continuous CTG in
their clinical practice. Personal review
of the original NICHD workshop document cited below, along with any or
all of the additional sources for this
article, is strongly encouraged.
References
1.

2.

Martin JA, Hamilton BE, Sutton PD, et al. Births:

final data for 2002. Natl Vital Stat Rep.
2003;52(10):1-113.
Alfirevic Z, Devane D, Gyte GM, et al. Continuous
tocography (CTG) as a form of electronic fetal

Main Points
Continuous cardiotocography (CTG) is the most commonly performed obstetric procedure in the United States.
Usage of the standardized terminology developed by the National Institute of Child Health and Human Development (NICHD) to
describe intrapartum CTG can help reduce miscommunication among providers caring for the laboring patient and systematize
the terminology used by researchers investigating intrapartum CTG.
Utilization of the recent interpretative systems and corresponding management strategies result in consistent, evidence-based
responses to CTG patterns that are normal (Category I), abnormal (Category III), or indeterminate (Category II).
Personal review of the original NICHD document is strongly encouraged.

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Update: NICHD Standardized Nomenclature for Cardiotocography continued

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