What is cardiotocography?

Cardiotocography (CTG) is used during pregnancy to monitor both the foetal heart and the
contractions of the uterus. It is usually only used in the 3rd trimester. Its purpose is to
monitor foetal well-being and allow early detection of foetal distress. An abnormal CTG
indicates the need for more invasive investigations and may lead to the need for emergency
caesarian section.

How it works

The device used in cardiotocography is known as a cardiotocograph.

It involves the placement of 2 transducers onto the abdomen of a pregnant

women.
One transducer records the fetal heart rate using ultrasound.

The other transducer monitors the contractions of the uterus.

It does this by measuring the tension of the maternal abdominal wall.

This provides an indirect indication of intrauterine pressure.

The CTG is then assessed by the midwife and obstetric medical team.

How to read a CTG

To interpret a CTG you need a structured method of assessing its various
characteristics.
The most popular structure can be remembered using the acronym DR C BRAVADO

DR Define Risk

C Contractions
BRa Baseline Rate

V Variability
A Accelerations

D Decelerations
O Overall impression

Define risk
You first need 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
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of membranes
Congenital malformations
Oxytocin induction/augmentation of labor
Pre-eclampsia

Other risk factors

Absence of 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 contractions occurred
within 10 squares.
Individual contractions are seen as peaks on the part of the CTG monitoring uterine
activity.
You should assess contractions for the following:
o

Duration how long do the contractions last?

Intensity how strong are the contractions? (assessed using palpation)

In this example there are 2-3 contractions in a 10 minute period e.g. 3 in 10

Baseline rate of the foetal heart

The baseline rate is the average heart rate of the foetus within a 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.

Foetal tachycardia
Foetal tachycardia is defined as a baseline heart rate greater than 160 bpm.
It can be caused by:
o

Foetal hypoxia

Chorioamnionitis if maternal fever also present

Hyperthyroidism

Foetal or maternal anaemia

Foetal tachyarrhythmia

Foetal bradycardia
Foetal bradycardia is defined as a baseline heart rate less than 120 bpm.
Mild bradycardia of between 100-120bpm is common in the following situations:
o

Post-date gestation

Occiput posterior or transverse presentations

Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia.
Causes of prolonged severe bradycardia are:
o

Prolonged cord compression

Cord prolapse

Epidural & spinal anaesthesia

Maternal seizures

Rapid foetal descent

If the cause cannot be identified and corrected, immediate delivery is recommended.

Variability
Baseline variability refers to the variation of foetal heart rate from one beat to the next.
Variability occurs as a result of the interaction between the nervous system,
chemoreceptors, baroreceptors and cardiac responsiveness.
Therefore it is a good indicator of how healthy the foetus is at that particular moment
in time.
This is because a healthy foetus will constantly be adapting its heart rate to respond
to changes in its environment.
Normal variability is between 10-25 bpm
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
o

Reassuring 5 bpm

Non-reassuring < 5bpm for between 40-90 minutes

Abnormal < 5bpm for >90 minutes

Reduced variability can be caused by:

o

Foetal sleeping this should last no longer than 40 minutes most common cause

Foetal acidosis (due to hypoxia) more likely if late decelerations are also present

Foetal tachycardia

Drugs opiates / benzodiazepines / methyldopa / magnesium sulphate

Prematurity variability is reduced at earlier gestation (<28 weeks)

Congenital heart abnormalities

Accelerations
Accelerations are an abrupt increase in baseline heart rate of >15 bpm for >15
seconds.

The presence of accelerations is reassuring.

Antenatally there should be at least 2 accelerations every 15 minutes.
Accelerations occurring alongside uterine contractions is a sign of a healthy foetus.
However the absence of accelerations with an otherwise normal CTG is of uncertain
significance.
Decelerations are an abrupt decrease in baseline heart rate of >15 bpm for >15
seconds.
There are a number of different types of decelerations, each with varying significance.

Accelerations

Early deceleration
Early decelerations start when uterine contraction begins and recover when uterine
contraction stops.
This is due to increased foetal 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.

Variable deceleration

Variable decelerations are observed as a rapid fall in baseline rate with a variable recovery
phase.
They are variable in their duration and may not have any relationship to uterine contractions.
They are most often seen during labour and in patients with reduced amniotic fluid volume.
Variable decelerations are usually caused by umbilical cord compression:
o

The umbilical vein is often occluded first causing an acceleration in response.

Then the umbilical artery is occluded causing a subsequent rapid deceleration.

When pressure on the cord is reduced another acceleration occurs and then the baseline rate
returns.
Accelerations before and after a variable deceleration are known as the shoulders of

deceleration.
Their presence indicates the foetus is not yet hypoxic and is adapting to the reduced blood

o
flow.

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 foetus is
hypoxic.

Variable deceleration

Late deceleration
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:
o

Maternal hypotension

Pre-eclampsia

Uterine hyper-stimulation

The presence of late decelerations is taken seriously and foetal blood sampling for pH is
indicated.
If foetal blood pH is acidotic it indicates significant foetal hypoxia and the need for
emergency C-section.

Late deceleration

Prolonged deceleration
A deceleration that last more than 2 minutes.
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as abnormal.
Action must be taken quickly e.g. foetal blood sampling / emergency C-section

Prolonged deceleration

Sinusoidal pattern
This type of pattern is rare, however if present it is very serious.
It is associated with high rates of foetal morbidity & mortality.
.
It is described as:
o

A smooth, regular, wave-like pattern

Frequency of around 2-5 cycles a minute

Stable baseline rate around 120-160 bpm

No beat to beat variability

A sinusoidal pattern indicates:

o

Severe foetal hypoxia

Severe foetal anaemia

Foetal/maternal haemorrhage

.
Immediate C-section is indicated for this kind of pattern.
Outcome is usually poor.

Overall impression
Once you have assessed all aspects of the CTG you need to give your overall
impression.
The overall impression can be described as either:
o

Reassuring

Suspicious

Pathological

The overall impression is determined by how many of the CTG features were either
reassuring, non-reassuring or abnormal. The NICE guideline below demonstrates how
to decide which category a CTG falls into.4