MIDP371

CTG
INTERPRETATION
Mrs. J Neethling
 CARDIOTOCOGRAPH
CARDIO – FHR
TOCO – UTERINE CONTRACTIONS
GRAPH – RECORDING/PICTURE

WHY….?
• Monitor the fetal condition (FHR) in the company of contractions (stressor)
• Fetal distress / Fetal compromise / Fetal hypoxia
• Uterine activity
 INFORMATION

• NAME

• HOSPITAL NO.

• DATE AND TIME OF CTG

• VITAL SIGNS
• URINE ANALYSIS
• VAGINAL EXAMINATION
• SCALE - ?1CM/1MIN – CTG
 CONSIDERATIONS

• GESTATION IN WEEKS
• GRAVITY AND PARITY
• PREVIOUS TYPE OF DELIVERY
• ADEQUACY OF PELVIS
• COMPLICATIONS E.G. PET, DM, PREMATURE LABOUR ETC.
• CURRENT VAGINAL EXAMINATION
• CURRENT URINE ANALYSIS
• CURRENT VITAL SIGNS
 INDICATIONS FOR CTG
(FETAL)

• IUGR
• PREMATURE LABOUR
• OLIGOHYDRAMNIOS
• MULTIPLE PREGNANCY
• BREECH PRESENTATION
INDICATIONS FOR CTG
(MATERNAL)

• PREVIOUS C/S
• PET
• > 42 WEEKS GESTATION
• ROM > 24 HOURS
• DIABETES
• APH
• MEDICAL CONDITIONS
 INDICATIONS FOR CTG
(LOW RISK)

• MECONIUM STAINED LIQUOR

• ABNORMAL FH
• BASELINE < 110 BPM AND > 160 BPM
• LATE DECELERATIONS
• MATERNAL PYREXIA
• 38° X 1
• 37,5° X 2 FOR 2 HOURS
• FRESH BLEEDING IN LABOUR
• AUGMENTATION
• MATERNAL REQUEST
 • Calibration
• Scale
• Maternal part
• Fetal part
• Timeline
• Measurements
• Contractions
INTERPRETATION • FHR
Calibration

Scale
 Maternal part

Fetal part

Fetal part

Maternal part
Timeline (horizontal axe)
• 1cm = 1 min
 Measurements (vertical axe)
• Contractions – mmHg
• FHR - bpm

Fetal part
bpm

Maternal part mmHg

 CTG INTERPRETATION

REMEMBER……..!!!!!
Interpretation every 10 minutes…
To diagnose an abnormality on a CTG, 2 or more of the same abnormality should be present in 10 min
 CTG INTERPRETATION ACRONYM

Dr.
Define risks

C.
Contractions
BR
Dr. C. BRAVADO Baseline rate

A
Accelerations

VA
Variability

D
Decelerations

O
Overall impression
CTG INTERPRETATION ACRONYM

Dr.
Define risks
 MATERNAL PART
10 min
mmHg

UTERINE ACTIVITY PRESENT/NOT?

BASAL TONE
AMPLITUDE
C.
CONTRACTIONS INTENSITY
DURATION
FREQUENCY
COUPLE CONTRACTIONS
 CTG INTERPRETATION & DIAGNOSIS

CONTRACTIONS
Uterine activity present/not?

Intensity (strength)
Basal tone (resting)
• Amplitude (highest peak) – basal tone
• Normally between 10 – 15 mmHg
• Normally = 40 – 80 mmHg
10 min

mmHg
 CTG INTERPRETATION & DIAGNOSIS

CONTRACTIONS

Frequency (amount)

Duration (length) • ?:10

• Normally = 20 sec, 20 – 40 sec, > 40 sec • Normally = 2-3:10 / 3-4:10

• Sufficient / insufficient
10 min

mmHg
 CTG INTERPRETATION & DIAGNOSIS

Couple contractions

CONTRACTIONS • No return to basal tone

• Abnormal – hyperstimulation of uterus
 INTERPRETATION OF CONTRACTIONS…

• Uterine activity: Present / not present

• Basal tone: ? mmHg (normal = ?)
• Amplitude: ? mmHg
• Intensity: Basal tone – Amplitude = ? mmHg (normal is ?)
• Frequency: ?:10 min (normal is ?)
always give rationale
• Duration: (normal is ?)
• < 20 seconds (mild)
• > 20 – 40 seconds (moderate)
• > 40 seconds (strong)
• Couple contractions: yes / no (normal / abnormal)
• Effective / Ineffective according to phase of labour + Mx
 WHAT IS CONSIDERED NORMAL CONTRACTIONS…

Active phase (4 (5) – 10cm):

Latent phase (0 – 3 (4)cm): • Basal tone: 5 – 15 mmHg
• Basal tone: 5 – 10 mmHg • Frequency: 3 – 4:10
• Frequency: 2-3:10 • Duration: >40 sec
• Duration: <20sec / 20 – 40 sec • Intensity: 60 – 80 mmHg
• Intensity: 40 – 60 mmHg • No couple contractions
• No couple contractions
Sufficient uterine activity

Never!!!!
• >4:10 – hyperstimulation
• Couple contractions - hyperstimulation
 NURSING DIAGNOSIS

• Reassuring – no abnormalities
• Non-reassuring
• Hypotonic / Hypertonic uterine activity
• Due to whatever abnormalities identified on the CTG ( couple contractions / etc…….)
 Interpret the CONTRACTIONS

Insufficient uterine activity due to Uterine activity: present

hyperstimulation evidenced by Basal tone: 0 mmHg
• Frequency of 6 - 7:10 Amplitude: 100 mmHg
• Intensity of 100mmHg Intensity: 100 mmHg
Frequency: 6 -7:10
Duration: >40 sec
Couple contractions: No
10 min 10 min

Active phase
 Interpret the CONTRACTIONS

Insufficient uterine activity due to hypo Uterine activity: present

stimulation evidenced by
CONTRACTIONS
Basal tone: 0 mmHg
• Frequency of 2:10 Amplitude: 50 mmHg
• Intensity of 50mmHg Intensity: 50 mmHg
Frequency: 2:10
Duration: >40 sec
Couple contractions: No
10 min

Active phase
 Interpret the CONTRACTIONS

Insufficient uterine activity due to Uterine activity: present

CONTRACTIONS
hyperstimulation evidenced by Basal tone: 0 mmHg
• Intensity of 90 mmHg Amplitude: 90 mmHg
• Frequency of 4:10 Intensity: 90 mmHg
• Duration: > 40 sec. Frequency: 4:10
• Couple contractions Duration: > 40 sec.
Couple contractions: Yes

10 min

Latent phase
 FETAL PART
10 min 1cm = 1 min

BR – BASELINE rate (TACHYCARDIA / BRADYCARDIA)

Bpm

A - ACCELERATIONS
VA – VARIABILITY
SHORT TERM VARIABILITY (BEAT-TO-BEAT)
LONG TERM VARIABILITY
D - DECELERATIONS
SINUSOIDAL RHYTHM
O – OVERALL IMPRESSION (Diagnose & Mx)
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

Baseline (BR)
• Average heart rate
TACHYCARDIA • 110 – 160 b/min BRADYCARDIA

10 min
Bpm
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART
10 min

BRADYCARDIA

Bpm
10 min

Bpm
TACHYCARDIA
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

10 min

Accelerations (A)
• ≥ 15 b/min for ≥ 15 seconds

Bpm
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART
Accelerations

10 min
Bpm
 CTG INTERPRETATION & DIAGNOSIS
FETAL HEART
VARIABILITY (VA)
Short term variability (beat-to-beat)
• > 5 bpm = reactive
• < 5 bpm = reduced / non-reactive
• Reactive / Non-reactive
 CTG INTERPRETATION & DIAGNOSIS
FETAL HEART
VARIABILITY (VA)

Poor short term variability

Non-reactive
 CTG INTERPRETATION & DIAGNOSIS
FETAL HEART
VARIABILITY (VA)

Long term variability (waves)

• Short term + accelerations
• “Waves”
• Reactive / Non-reactive
 CTG INTERPRETATION & DIAGNOSIS

• Short term variability absent FETAL HEART

VARIABILITY (VA)
• Accelerations present
Poor long term variability
Non-reactive
 CTG INTERPRETATION & DIAGNOSIS
Decelerations (D) FETAL HEART
≥ 15 bpm last for ≥ 15 sec Early
• Uniform - Shape & depth Late
• Relation with contraction Variable
• Accelerations before / end
10 min

Bpm
CTG INTERPRETATION & DIAGNOSIS

Decelerations

https://www.youtube.com/watch?v=rti7WusyIpY
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

Early decelerations
• Uniform in shape
• Mirror image of contraction
• Same time as contraction (begin & end)
• Back to baseline immediately
(seldom below 110 bpm)
• Normal reaction of fetus to contraction
• HEAD COMPRESSION – PELVIS / CERVIX
CTG INTERPRETATION & DIAGNOSIS

Early decelerations

10 min
CTG INTERPRETATION & DIAGNOSIS

Early decelerations

10 min
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

Late decelerations
• Uniform in shape
• FHR return to baseline after the contraction end
• Delayed (15 sec)
• UTEROPLACENTAL INFUFFICIENCY - HYPOXIA
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

Late decelerations

10 min
 CTG INTERPRETATION & DIAGNOSIS
Variable decelerations
• Inconsistent FETAL HEART

• Shape
• Relation to contractions
• “Shoulders” – accelerations
• CORD COMPRESSION 10 min

Bpm
CTG INTERPRETATION & DIAGNOSIS

Variable decelerations

10 min
 CTG INTERPRETATION & DIAGNOSIS

FETAL HEART

Sinusoidal rhythm

10 min
 What kind of decelerations are present?

Uniform?
Relation to contractions?

Early…
 What kind of decelerations are present?

Uniform?
Relation to contractions?

Late…
 What kind of decelerations are present?

Uniform?
Relation to contractions?
Distinguishing factor present?

Variable…
 INTERPRETATION OF FETAL HEART…

• Baseline: ? Bpm (normal: 110 – 120)

• Tachycardia / Bradycardia (why ?)
• Accelerations (definition)
• Short term variability (definition)
always give rationale
• Long term variability (definition)
• Decelerations: early, late, variable (definition)
• Fetal compromise / fetal distress / re-assuring / non – reassuring / Reactive
/ Non-reactive & Mx
 NURSING DIAGNOSIS

• Reassuring – no abnormalities
• Non-reassuring
• Fetal compromise / distress / Non-reactive…
• Due to whatever abnormalities identified on the CTG ( couple contractions,
decelerations, poor variablitiy, etc…….)
 Fetal compromise
Presence of bradycardia or tachycardia on the fetal heart baseline, poor variabilities >30 minutes,
presence of decelerations and the absence of accelerations and the presence of MSL
 CAUSES OF FETAL COMPROMISE

PLACENTAL FACTORS
• Placental • Cord prolapse • Congenital

FETAL FACTORS
UMBILICAL CORD FACTORS
• Medical
MATERNAL FACTORS

conditions insufficiency abnormalities

• Cord
• Placental compression
• Epidural block separation
• True knots
• Infections
 SIGNS OF FOETAL COMPROMISE

• Foetal Tachycardia
Warning •
•
Decelerations
Poor variability
signs • Meconium stained liquor

• Bradycardia
Danger • Progressive late
decelerations
signs • Loss of variability
 MANAGEMENT OF HYPER/HYPO UTERINE ACTIVITY

• Hypertonic contractions
• Pain relief – according to phase of labour
• Salbutamol 250 μg (½ of a 500 μg ampoule diluted in 20 mL saline) IV slowly
• Hypotonic contractions
• Augmentation – Oxytocin regime
• Continuous CTG
• Maternal vital signs – treat accordingly
• Vaginal examination
• Inform RN / Dr
• Transfer to hospital – emergency c/section
 MANAGEMENT OF FETAL COMPROMISE

• Internal resuscitation of fetus

• Change maternal position – Left lateral (Sims)
• Oxygen – 6L/min per nasal cannule
• IV – Ringers @ 240ml/hour – hypertensive/cardiac problems
• Continuous CTG
• Stop augmentation
• Maternal vital signs – treat accordingly
• Vaginal examination
• Inform RN / Dr
• Transfer to hospital – emergency c/section
 PRACTISE TIME……………

• HISTORY:
• P2G3 2X NVD
• GESTATION: 39/52

• MATERNAL VITAL SIGNS:

• PULSE - 94 BPM
• BP – 134/74 MMHG
• TEMP. – 36.7ºC

• URINE ANALYSIS:
• SG 1030
• PH 6
• BLOOD 3+

• VAGINAL EXAMINATION:
• CX 9 CM DILATED
• 90% / 0.5CM EFFACEMENT
• SROM – CLEAR LIQUOR (2 HOURS AGO)
• ROA POSITION

• STATION 0
PRACTISE TIME……………
QUESTIONS…….?????