REGION 2 TRAUMA AND MEDICAL CENTER

CARDIOTOCOGRAPHY
PGI ALIMBOYOGUEN, REXOR
 OBJECTIVES
• TO BE ABLE TO KNOW AND UNDERSTAND THE
FUNCTION AND MECHANISM OF THE
CARDIOTOCOGRAM

• TO BE ABLE TO INTERPRET RESULTS

• TO GAIN SKILLS AND KNOWLEDGE ABOUT CTG

THAT WE CAN USE IN OUR CLINICAL PRACTICE
 WHAT IS CTG?
CARDIOTOCOGRAPHY (CTG) IS A CONTINUOUS ELECTRONIC RECORD
THAT USES AN ULTRASOUND TRANSDUCER PLACED ON THE
MOTHER’S ABDOMEN TO:
1. MONITOR FETAL HEART RATE
2. MONITOR UTERINE CONTRACTIONS
INTRAPARTUM FETAL HEART
RATE MONITORING
INTERMITTENT:
• DOPPLER
• STETHOSCOPE

CONTINUOUS:
• ELECTRONIC FETAL MONITORING
⚬ DIRECT INTERNAL MONITORING
⚬ INDIRECT EXTERNAL MONITORING
 CONTINUOUS INDIRECT
CONTINUOUS EXTERNAL
DIRECT INTERNAL MONITORING
MONITORING

Transducer that records fetal

heart rate using ultrasound

Transducer (Tocometer) that

monitors contractions of the uterus
CTG BASICS
 FETAL BEHAVIORAL STATES
STATE 1F (QUIESCENT) – quiet sleep, has
a NARROW oscillatory bandwidth of the
fetal heart rate (FHR). Increased bladder
volume:
STATE 3F – continuous eye movements in
the absence of body movements and no
FHR accelerations.

STATE 2F (ACTIVE SLEEP) – same as REM STATE 4F (AWAKE) –vigorous body

in adults, frequent gross body movement with continuous eye
movements, continuous eye movements, movement and erratic FHR accelerations.
wider oscillation of the FHR. Reduced
renal blood flow and diminished bladder
volume.
 INDICATIONS:
FETAL HYPOXIA/ACIDOSIS
MATERNAL HEALTH CONDITIONS
ABNORMAL FETAL GROWTH
DURING PREGNANCY

EPIDURAL ANALGESIA
ABNORMALITIES DURING
INTERMITTENT FETAL
AUSCULTATION
INDUCED OR AUGMENTED LABOR
 TRACING ACQUISITIONS
• MATERNAL POSITION FOR CTG
• PAPER SCALES FOR CTG MONITORING AND VIEWING
• EXTERNAL VERSUS INTERNAL FHR MONITORING
• EXTERNAL VERSUS INTERNAL MONITORING OF UTERINE CONTRACTIONS
• SIMULTANEOUS MONITORING OF THE MATERNAL HEART RATE
• MONITORING OF TWINS
• STORAGE OF TRACINGS
ANALYSIS OF TRACINGS:
FEATURES OF CTG TRACING
• BASELINE FETAL HEART RATE
• VARIABILITY
• ACCELERATIONS
• DECELERATIONS
• CONTRACTIONS
 BASELINE FETAL HEART RATE
Mean Fetal Heart Rate is rounded to
Baseline must be for a minimum of 2
increments of 5 bpm during a 10 minute
minutes in any 10 minute segment
segment excluding segments that differ
by >25 bpm

NORMAL FHR BASELINE IS 110-160

BPM
 BASELINE FETAL HEART RATE
FETAL TACHYCARDIA: FETAL BRADYCARDIA:
FHR BASELINE OF >160 BPM FHR BASELINE OF <110 BPM

Head compression
MATERNAL FEVER (MOST COMMON) Congenital heart block
Fetal compromise Fetal hypoxia
Cardiac arrhythmias Maternal hypothermia
Maternal administration of
parasympathetic inhibiting
(Atropine) or sympathomimetic
(Terbutaline) drugs
 BASELINE FETAL HEART RATE

BASELINE FHR

CONTRACTIONS
BASELINE FETAL HEART RATE
 VARIABILITY
• Important index of cardiovascular function
• Reflects a sympathetic and parasympathetic push
and pull mediated by fetal SA node
• Fluctuations with irregular amplitude and
inconstant frequency
• Normal variability shows oscillations that change to
6 to 25 bpm for >2 cycles/min
 VARIABILITY
CAUSES OF DECREASED OR ABSENT VARIABILITY:
- Fetal acidemia (baby is hypoxic), maternal acidemia
- Fetal asleep
- Prematurity
- Drugs (MgSO4 – for patients with pre eclampsia and
eclampsia; diazepam; meperidine)
- Vagal blockade (atropine)
- Defective cardiac conduction system
 CRITERIA FOR QUANTIFICATION OF VARIABILITY

Undetectable, absent variability

 CRITERIA FOR QUANTIFICATION OF VARIABILITY

Minimal variability, <5 bpm

 CRITERIA FOR QUANTIFICATION OF VARIABILITY

Moderate (Normal)variability, 6-25 bpm

 CRITERIA FOR QUANTIFICATION OF VARIABILITY

Marked variability, >25 bpm

 CRITERIA FOR QUANTIFICATION OF VARIABILITY
Sinusoidal pattern

• Fetal intracranial
hemorrhage
• Severe fetal asphyxia
• Severe fetal anemia
• Chorioamnionitis
• Fetal distress
• Umbilical cord occlusion
 ACCELERATIONS
>32 weeks AOG:
• Acceleration is ≥15 bpm above the baseline
and the acceleration lasts ≥15 seconds or
longer but less than 2 minutes
Abrupt FHR increase above the baseline with the
time from onset of the acceleration to its peak within
30 secs

Prolonged acceleration lasts ≥2 minutes but <10

<32
<32 weeks
weeksAOG:
AOG: minutes in duration
•• Acceleration
Accelerationisis ≥10
≥10 bpm above the
bpm above the baseline
baseline
and
and the acceleration lasts
the acceleration lasts ≥10 seconds or
≥10 seconds or Change in baseline if the acceleration lasts >10
longer but less than 2 minutes minutes
longer but less than 2 minutes
 ACCELERATIONS
Mechanisms for intrapartum accelerations:
- Fetal movement
- Stimulation by uterine contractions
- Environment (noise)
- Fetal stimulation during pelvic examination especially
if mother is at active phase of labor, and the cervix is
open; we can gently push the scalp and the baby will
be awaken
ACCELERATIONS
 DECELERATIONS
>32 weeks AOG:
• Deceleration is ≥15 bpm below baseline
and the deceleration lasts ≥15 seconds or
longer but less than 2 minutes
Visually apparent abrupt decrease in FHR below
baseline, with the time from the onset of the
deceleration to its peak <30 secs
Prolonged deceleration lasts ≥2 minutes but <10
minutes in duration

<32
<32 weeks
weeksAOG:
AOG: Change in baseline if the acceleration lasts >10
•• Acceleration
Decelerationis ≥10 bpm above
is ≥10 bpm the baseline
below the minutes
and the acceleration
baseline lasts ≥10 seconds
and the deceleration or
lasts ≥10
longer but less than 2 minutes EARLY, LATE, VARIABLE AND PROLONGED
seconds or longer but less than 2 minutes
DECELERATIONS
DECELERATIONS
 EARLY DECELERATION
Seen in active labor Not associated with
between 4 and 7 cm tachycardia, loss of variability
cervical dilation or other FHR changes

Benign, not associated with

Proportional to the
fetal hypoxia, acidemia or
contraction strength, rarely
low apgar score but is
falls below 100 to 110 bpm believed to be associated
or 20 to 30 bpm below with fetal head compression
baseline
EARLY DECELERATION
 LATE DECELERATION

Smooth, gradual symmetrical

decline in the FHR that begins at
or after the contraction peak and
Reflects poor uterine
returns to baseline only after the
perfusion or placental
contraction has ended
dysfunction, first FHR
consequence of
uteroplacental-induced
Reaches its nadir within 30 hypoxia
seconds of its onset depth <10
to 20 bpm below
 LATE DECELERATION - Pathophysiology

The lag between contraction onset

and late deceleration onset was
directly related to basal fetal
oxygenation Uterine contraction constricting blood
vessels -> decrease blood flow into the
placenta -> reducing fetal oxygen into
fetal capillaries -> decreased fetal
The lower the fetal PO2 oxygen
before contractions, the
shorter the lag to the late
deceleration onset
LATE DECELERATION
 VARIABLE DECELERATION

Most frequent deceleration

Apparent abrupt decrease in
pattern encountered during
FHR; An abrupt decrease
labor
is defined as from the onset to
the FHR nadir is <30 secs

Last between 15 sec and 2
min, depth is >15 bpm in
amplitude onset varies with
successive contractions
C O R D C O M P R E S S I O N PAT T E R N S 🡪
occlusion of vein
🡪 reduced fetal blood return 🡪
deceleration
VARIABLE DECELERATION
VARIABLE DECELERATION
 PROLONGED DECELERATION

Isolated deceleration with a depth

of >15 bpm and length >2
minutes but <10 minutes from
the onset to return to baseline
PROLONGED DECELERATION
 INTERPRETATION
include all of the FF:
include all of the FF:
• B a s e l i n e ra t e : 1 1 0 - 1 6 0 b p m • Baseline rate: 110-160 bpm
• Baseline FHR variability • Va r i a b i l i t y o f 5 - 2 5 b p m
• M o d e ra t e • Decelerations:
• L a t e o r Va r i a b l e d e c e l e ra t i o n s • No repetitive deceleration
• Absent • Interpretation:
• E a r l y d e c e l e ra t i o n s : • Fetus with no hypoxia/acidosis
• Present or absent • Clinical management
• A c c e l e ra t i o n : • No intervention necessary to
i m p r o v e fe t a l o x y g e n a t i o n s t a t e
• Present or Absent

ACOG CATEGORY I FIGO: NORMAL

CATEGORY I
CATEGORY I
 INTERPRETATION
I n c l u d e s a l l t ra c i n g n o t c a t e g o r i ze d a s • Lacking atleast one characteristic of
Category I or 3
n o r m a l i t y, b u t w i t h n o p a t h o l o g i c a l
• Baseline
⚬ Bradycardia not accompanied by absent
fe a t u r e s
variability • Interpretations
⚬ Ta c h y c a r d i a ⚬ Fetus with a low probability of
• B a s e l i n e F H R va r i a b i l i t y having hypoxia/acidosis
⚬ Minimal baseline
• Management:
⚬ Absent baseline with no recurrent
decelerations ⚬ Action to correct reversible cause
⚬ M a r ke d b a s e l i n e if identified
• Accelerations ⚬ C l o s e m o n i t o r i n g t o e v a l u a t e fe t a l
⚬ Absence of induced accelerations after fetal
oxygenation
stimulation

ACOG CATEGORY II FIGO: SUSPICIOUS

CATEGORY II
CATEGORY II
 INTERPRETATION
Absent baseline FHR variability and
any of the following:
• Recurrent late deceleration
• Recurrent variable deceleration
• Bradycardia
Sinusoidal pattern
ACOG CATEGORY III
• Baseline of <100 bpm
• Va r i a b i l i t y :
⚬ Increased/reduced variability
⚬ Sinusoidal pattern
• Deceleration
⚬ repetitive, late or prolonged
• Interpretations
⚬ Fetus with hypoxia/acidosis
• Management
⚬ Immediate action to correct
reversible causes
FIGO: Pathological
CATEGORY III
CATEGORY III
 CONTRACTION STRESS TEST
- Intravenous oxytocin or ni pple
stimulation (rub through clothing for
2 minutes) is both used to stimulate
contractions

- It is a test of uteroplacental
insufficiency

- Requires 90 minutes

- 3 spontane ous uterine contractions

in a 10 mi nute trace (no uterine
stimulation necessary) – if we
already see this result, stop IV
oxytocin and nipple stimulation
 NON-STRESS TEST
• REACTIVE:
⚬ > 2 A C C E L E R AT I O N W I T H I N 2 0 - 4 0
MINUTES
• >32 weeks:
⚬ Acceleration of >15 bpm from
b a s e l i n e a n d l a s t s fo r > 1 5 s e c b u t < 2
minutes
• <32 weeks:
⚬ Acceleration of >10bpm from
b a s e l i n e , l a s t fo r > 1 5 s e c b u t < 2 m i n

• NON REACTIVE:
⚬ < 2 A C C E L E R AT I O N S
⚬ N o fe t a l m o v e m e n t , n o a c c e l e r a t i o n
with movement or
⚬ Stimulation, poor or absent long
term variability in a 20 min period
 NON STRESS TEST
MATERNAL POSITIONING

• L AT E R A L R E C U M B E N T
POSITION

• SEMI SITTING POSITION

• UPRIGHT POSITION

• Tr a d i t i o n a l s u p i n e r e c u m b e n t c a n l e a d t o a o r t o c a v a l c o m p r e s s i o n ,
d e c r e a s e d p l a c e n t a l p e r f u s i o n a n d fe t a l o x y g e n a t i o n
 REFERENCES:
• C u n n i n g h a m , F. , e t . a l ( 2 0 2 2 ) . W i l l i a m s O b s t e t r i c s ( 2 6 t h e d . ) . U S A : M c G r a w - H i l l
• FIGO Consensus Guidelines on Intrapartum Fetal Monitoring
• A G R E E M E N T A N D A C C U R A C Y U S I N G F I G O , A C O G A N D N I C E C A R D I OTO C O G R A P H Y
I N T E R P R E TAT I O N G U I D E L I N E S
• P O C K E T G U I D E TO F E TA L M O N I TO R I N G : A M U LT I D I S C I P L I N A R Y A P P R O A C H , 7 T H E D I T I O N

THANK
YOU!