Aust N Z J Obstet Gynaecol 2023; 63: 278–289

DOI: 10.1111/ajo.13667

SYSTEMATIC REVIEW

Clinical practice guidelines for intrapartum

cardiotocography interpretation: A systematic review

James Brown1,2 , Dhusyanthy Kanagaretnam1 and Monica Zen1

1
Obstetrics and
Gynaecology, Westmead Hospital,
Sydney, New South Wales, Australia
2
University of Sydney, Sydney, New
South Wales, Australia
Correspondence: Dr. James
Brown, Obstetrics and
Gynaecology, Westmead Hospital,
Westmead, NSW 215, Australia.
Email: j.h.w.brown@gmail.com
Conflict of Interest: The authors report
no conflict of interest.
Received: 18 November 2022;
Accepted: 20 February 2023
Background: Clinical practice guidelines on intrapartum cardiotocography (CTG)
interpretation provide structured tools to detect fetal hypoxia. Despite frequent
use of different guidelines, little is known about their comparable consistency. We
sought to appraise guidelines relevant to intrapartum CTG interpretation and sum-
marise consensus and non-­consensus recommendations.
Aims: To compare existing intrapartum CTG interpretation guidelines.
Materials and methods: We searched PubMed, CINAHL, Cochrane, Embase,
guideline databases and websites of guideline development institutions using
terms ‘cardiotocography’, ‘electronic fetal/foetal monitoring’, and ‘guideline’ or
equivalent term. The search was restricted to English-­language articles published
between January 1980 and January 2023 and excluded animal studies. The initial
search yielded 2128 articles with 1253 unique citations. Guidelines were included if
they: used English as the reporting language; included CTG interpretation criteria or
guidelines as a primary objective; were published or updated since 1980; and were
the most recently updated publications when multiple versions were identified.
Results: Nineteen studies were considered for full review, and 13 met inclusion
criteria. Two reviewers independently assessed guideline quality using the AGREE
II instrument, and synthesised consensus and non-­consensus recommendations
using the content analysis approach. Most guidelines employed a three-­tier inter-
pretation framework. There were significant differences between the guidelines
for relative importance of key CTG features such as accelerations, decelerations
and variability, with respect to the outcome of fetal hypoxia.
Conclusions: There are significant differences between key intrapartum CTG in-
terpretation guidelines currently being used. Greater consistency is needed across
CTG interpretation guidelines to improve the quality of data, clinical governance,
monitoring of outcomes, and to support future developments.

KEYWORDS
cardiotocography, practice guidelines, systematic review, intrapartum, electronic
fetal monitoring

INTRODUCTION high income countries.1 Through interpretation of the fetal heart

rate and uterine contractions, clinicians can potentially detect
Cardiotocography (CTG) or electronic fetal monitoring (EFM) is the early signs of fetal hypoxia2 and act accordingly. However, large
most used technique for assessing intrapartum fetal wellbeing in studies of CTG effectiveness are inconclusive—­hampered by high

278wileyonlinelibrary.com/journal/anzjog
© 2023 Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

J. Brown et al.
false-­positive rates, increased surgical births, and underpowered
3,4
perinatal morbidity analyses.
Standardised interpretation of CTG patterns is critical to clin-
ical decision making.3,5 Poor interobserver consistency has been
highlighted as a critical limitation of the technology.6 In an effort
to improve the efficacy of CTG, a number of national and college
guidelines have been developed and refined to provide a frame-
work for more accurately interpreting CTG features.7
In 1986, the International Federation of Gynaecology and
Obstetrics (FIGO) developed the first general interpretation crite-
ria based on key fetal heart rate pattern morphologies and their
relationship to the contraction.8 Since then, criteria have been
refined and differentiated, but with no significant change to the
4,9–­12 4
interobserver variability. In turn, the FIGO-­15 interpretation
template, created by an international consensus panel, resulted
in being more prescriptive in aligning features with grades of fetal
hypoxia,7 and therefore, more likely to induce clinical action. This
represented a shift in how CTG patterns were interpreted, offer-
ing a practical escalation that has been merged, extrapolated and/
or integrated with local and international guidelines for intrapar-
tum monitoring.2 Countries have chosen to adopt or adapt the
7
FIGO-­15 guidelines based on local preference and evidence.
The fractured and staggered adoption of standardised CTG
interpretation criteria has important ramifications. First, it means
that women giving birth are treated differently based on location
and local consensus. Second, the tendency for local adaptation
means that with each minor permutation, the criteria may have
migrated further away from where the current evidence lies.
Third, varied interpretation and consequent management makes
even retrospective analysis of intrapartum CTG patterns and in-
terpretation criteria impossible at the scale required to answer
some of the historically unanswered concerns about the utility
and safety of the technology.13
To address the inconsistency, we used systematic review
methods to identify, summarise and compare available intrapar-
tum CTG interpretation guidance. Through this we aim to map
the current state of CTG interpretation guidelines worldwide and
move toward greater consistency and strategically aligned re-
search in this clinical area.
MATERIALS AND METHODS
A systematic literature search was performed to identify
intrapartum cardiotocography interpretation guidelines via
guideline databases, websites of guideline development
organisations in midwifery or obstetrics and gynaecology,
government websites, as well as electronic databases including
PubMed, CINAHL, Cochrane, and Embase. Clini​calTr​ials.gov
was not included in the search as the review is examining
clinical practice guidelines and not clinical trial or effectiveness
data. The search was restricted to English-­
language articles
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279
published between January 1980 and January 2023 and excluded
animal studies.
Search terms used were ‘cardiotocography’, ‘electronic fetal/
foetal monitoring’ for guideline databases and websites of guide-
line development institutions, combined with terms of ‘guideline*’,
‘guidance*’, ‘recommendation*’, ‘consensus*’, ‘best practice*’,
‘statement*’, ‘standard*’, ‘practice parameter*’, ‘position paper’
and ‘position stand’ for electronic databases. A full list of guide-
line databases and websites of guideline development institutions
that were searched, along with detailed search strategies, are pro-
vided (Appendix S1 and S2). Reference lists of relevant articles and
reviews were manually searched for additional reports.
This systematic review is reported in accordance with the
Preferred Reporting Items for Systematic Reviews and Meta-­
Analyses (PRISMA) criteria. The protocol for this systematic review
was prospectively registered on PROSPERO (CRD42018085085).
Eligibility criteria were predetermined. Guidelines were in-
cluded if they: (i) used English as the reporting language; (ii)
were a labelled guideline, or recommendation, or consensus, or
practice parameter, or position paper/stand; (iii) included intra-
partum CTG interpretation criteria or guidelines as a primary ob-
jective; (iv) were published or updated since 1980; and (vi) were
the most recently updated iteration when multiple serial versions
were identified.
Literature search, screening of search outputs, identification
of eligible guidelines and data extraction were performed by inde-
pendently two reviewers. A third reviewer checked data for errors
and resolved discrepancies or disagreements through discussions
or consultations.
Two review authors independently extracted the following
data from all included guidelines: title, published year, last up-
dated year, guideline group, country or region, evidence bases,
and method of access.
Two review authors extracted all the relevant content on CTG
interpretation from each guideline into predetermined data col-
lection forms. Recommendations were organised in accordance
with accepted interpretation algorithms; significant deviations
from this scaffold are highlighted in the text. On completion, unan-
imous and discrepant recommendations were categorised, sum-
marised and analysed, respectively. During the whole process, a
third reviewer checked the data for errors and resolved discrep-
ancies or disagreements through discussions or consultations.
The AGREE II (Appraisal of Guidelines for Research and
Evaluation II) instrument was used to critically appraise the meth-
odological rigour and to report the quality of included guidelines.14
The AGREE II consists of 23 items organised into the following six
domains: scope and purpose (three items), stakeholder involve-
ment (three items), rigour of development (eight items), clarity of
presentation (three items), applicability (four items) and editorial
independence (two items). Each of the 23 items was scored on a
seven-­point Likert scale ranging from one (strongly disagree) to
seven (strongly agree).

280
As recommended by the AGREE II instrument,14 each of the
six-­domain scores were calculated independently by summing up
all the scores of the individual items in a domain, as well as by
scaling the total as a percentage of the maximum possible score
for that domain. Domain scores were calculated as conducted in
similar studies: (obtained score –­minimum possible score)/(max-
imum possible score –­minimum possible score). The minimum
possible score was calculated as 1 × (number of items) × (num-
ber of appraisers). The maximum possible score was calculated
as 7 × (number of items) × (number of appraisers). We defined a
cut-­off of 50%, and scores above this were considered acceptable.
The quality assessment of all included clinical practice guidelines
was independently performed by two appraisers.
RESULTS
Systematic search results
Our initial search on 31 January 2023 retrieved 2128 records. After
removal of duplicate records (n = 875), we screened the titles
and/or abstracts of 1253 references, of which 19 articles were
subsequently reviewed in full text. Among them, six articles were
excluded (see Appendix S3) and the final selection yielded a total
of 13 clinical practice guidelines (Fig. 1).
FIGURE 1 Flow diagram illustrating the selection of guidelines.
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Review of CTG guidelines
Characteristics of included guidelines
Table 1 presents the characteristics of the guidelines included.
The majority (69%) of the guidelines were published or updated
within the last ten years.
The guidelines originated from the USA (three guidelines), the
UK (three guidelines), Oceania (one guideline), Sweden (one guide-
line), Canada (one guideline), Ireland (one guideline), Japan (one
guideline), Germany (one guideline) and Sri Lanka (one guideline).
All included guidelines were at least partially evidence-­based
(ie references to peer-­reviewed research as foundation for pol-
icy recommendation) with consensus recommendations (ie policy
recommendations based on the conclusions of a recognised pro-
fessional body in the relevant field), primarily carried over from
previous published criteria or workshops. All were available as
electronic copies.
AGREE II assessment
Overall scores and domain scores of the included 13 guidelines
are shown in Appendices S4 and S5, respectively.
All but one of the 13 guidelines scored >50% for total scores
(59.42–­77.54%). Of the 13 guidelines, the NICE, ACOG and SWE-­
17 guidelines scored >50% across all six domains—­and gener-
ally outperformed all the other guidelines in each domain. The
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J. Brown et al. 281

TABLE 1 Characteristics of included guidelines

Abbreviation Guideline group or authors First published Last updated Country/region

15
ACOG American College of Obstetricians and 2009 2009 USA
Gynaecologists
DGGG16 German Society of Gynaecology and Obstetrics 2014 2014 Germany
FIGO4 The International Federation of Gynaecology and 1986 2015 United Kingdom
Obstetrics
IRELAND17 National Women and Infants Health Programme 2019 2019 Ireland
Ireland
NICE18a National Institute for Health and Care Excellence 2014 2022 United Kingdom
(NICE)
NICHD19 National Institute of Child Health and Human 2008 2008 USA
Development (NICHD)
PARER20 Parer et al.b 2007 2007 USA
21
PCJSOG The Perinatology Committee of the Japan Society of 2010 2010 Japan
Obstetrics and Gynaecology (PCJSOG)
RANZCOG22 Royal Australian and New Zealand College of 2002 2019 Australia
Obstetricians and Gynaecologists (RANZCOG)
SLCOG23 Sri Lanka College of Obstetricians & Gynaecologists 2013 2013 Sri Lanka
(SLCOG)c
SOGC24 Society of Obstetricians and Gynaecologists of 2007 2018 Canada
Canada (SOGC)
SWE-­177 Ekengård et al.b 2009 2017 Sweden
25 d
WALES Wales Maternity Network 2018 2018 Wales (UK)
a
Previously RCOG Electronic Fetal Monitoring guideline.
b
Downloaded from journal.
c
Evidence base not stated.
d
Consensus-­based only.

highest average domain score of all guidelines was ‘Scope and
Purpose’ (88.46%), followed by ‘Clarity of Presentation’ (86.32%),
‘Stakeholder Involvement’ (62.39%), ‘Rigour of Development’
(57.21%), ‘Applicability’ (53.21%), and ‘Editorial Independence’
(44.87%). All 13 guidelines obtained scores >50% in the domain of
‘Clarity of Presentation’.
Summary of interpretation criteria
Categorisation
All but three of the 13 guidelines grouped CTG patterns into
three distinct risk categories (Tables 2–­4), with one using four
22 20,21
categories and the other two using five categories.
Of those guidelines with three categories, the lowest risk cat-
egory was labelled either ‘Category I', ‘Normal’ or ‘Reassuring’
(Normal); the middle risk category was labelled ‘Category II',
‘Atypical’, ‘Non-­reassuring’ or ‘Suspicious’ (Suspicious); the highest
risk category was labelled ‘Category III', ‘Pathological’ or ‘Abnormal’
(Abnormal). There was no consistent relationship between the
labelling used for categories and the features of that category.
Despite inconsistency in labelling most guidelines stratified the re-
quired action for each category similarly: no intervention needed
(Normal), increased vigilance recommended (Suspicious), and ur-
gent medical review needed (Abnormal).
The RANZCOG guideline22 used a four-­category system. The
first three categories were similar to the three-­category guidelines
described above, with an additional fourth category of CTG fea-
tures of severe fetal compromise that require immediate man-
agement, which included: bradycardia, absent baseline variability,
sinusoidal pattern, complicated variable decelerations with re-
duced or absent variability, and late decelerations with reduced
or absent variability. Many of these features are included in the
Abnormal category of the three-­category guidelines, such as: sinu-
soidal pattern, complicated variable decelerations with reduced
or absent baseline variability, or bradycardia.
PCJSOG21 and Parer et al.20 outlined a five-­category system
that describes escalating concerns depending on the character
of decelerations and their relationship to other features and are
described further below.
Features considered
All guidelines include consideration of baseline fetal heart rate,
fetal heart rate variability, and decelerations.
Fetal baseline heart rate
All guidelines consider a fetal baseline heart rate between 110
and 160 beats per minute (BPM) to be Normal. All guidelines
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282 Review of CTG guidelines

TABLE 2 CTG three-­tier interpretation criteria—­low probability of fetal acidosis category (Normal)

Baseline
Guideline Label rate (bpm) Variability (bpm) Decelerations Accelerations

ACOG15 Category I 110–­160 6–­25 Absent late or variable Present or absent

decelerations, OR
Absent or present early
decelerations.
DGGG16 Normal 110–­160 >5 (during the interval when No decelerations. Two accelerations in
no contractions occur) 20 min
FIGO4 Reassuring 110–­160 5–­25 No repetitive decelerations Present or absent
(>50% of contractions).
IRELAND17 Normal 110–­160 5–­25 No repetitive—­>50% Present or absent
contractions
NICE18 White 110 to 160 5–­25 No decelerations, OR Present or absent
Early, OR
Variable decelerations with no
concerning characteristics for
less than 90 min.
NICHD19 Category I 110–­160 6–­25 Absent late or variable Present or absent
decelerations, OR
Absent or present early
decelerations.
SLCOG23 Reassuring 110–­160 ≥5 None Present
24
SOGC Normal 110–­160 6–­25, OR None, OR ≥2 accelerations with
≤5 (absent or minimal) for Occasional variable <30 sec. acme of ≥15 bpm, lasting
<40 min. 15 sec <40 min of testing
SWE-­177 Normal 110–­160 5–­25 No repetitive (>50%) Not included.
decelerations, OR
Uniform early decelerations,
OR
Variable decelerations lasting
<1 min
WALES25 Reassuring 110–­160 5–­25 True early decelerations, OR Present or absent
V-­shaped variable
decelerations with <50% of
contractions, OR
V-­shaped variable
decelerations with >50% of
contractions for less than
90 min, OR
U-­shaped variable
decelerations with <50%
of contractions (if all other
features NAD)

considered a fetal heart rate below 100 BPM to be abnormal and
a feature of the highest possible risk category. Four guidelines
(DGGG, NICE, SLCOG, WALES) considered fetal tachycardia above
180 BPM to also meet criteria for the highest risk category.16,18,23,25
Most guidelines noted a baseline between 100–­110 BPM and 160–­
180 BPM to be a Suspicious feature. Only two guidelines (NICE,
SOGC) included a rise in baseline (without breaching the above
18,24
limits) as a Suspicious feature.
Variability
All guidelines considered a baseline variability of 5–­25 BPM
to be Normal. The SOGC guideline24 was the only guideline to
consider variability of ≤5 BPM to be a Normal feature if present
for less than 40 min. There was marked variation in Suspicious
variability criteria, with most guidelines indicating that vari-
ability below 5 BPM for between 30 to 90 min indicates mod-
erate risk of fetal hypoxia. Five guidelines (ACOG, DGGG, NICE,
NICHD, WALES) indicated increased variability above 25 BPM as
a Suspicious feature.15,16,18,19,25 All guidelines agreed on absent
variability as an Abnormal feature. Decreased variability was
considered prolonged and abnormal if continuing beyond 50 to
90 min depending on the guideline. A sinusoidal pattern was
identified in all guidelines as a grossly abnormal pattern, but
three allowed for up to 30 min of this pattern before meeting
Abnormal criteria.7,17,25
 TABLE 3 CTG three-­tier interpretation criteria –­moderate probability of fetal acidosis category (Suspicious)

Guideline Label Advice Baseline rate (bpm) Variability (bpm) Decelerations Accelerations
15
ACOG Category II • <110 not accompanied by absent • Minimal baseline variability, • Recurrent variable decelerations Absence of induced
J. Brown et al.

baseline variability, OR • >160 OR accompanied by minimal or moderate accelerations after

• Absent baseline variability baseline variability, OR fetal stimulation
with no recurrent • Prolonged deceleration more than
decelerations, OR 2 min but less than10 min, OR
• >25 baseline variability • Variable decelerations with other
characteristics, such as slow return to
baseline, ‘overshoots’, or ‘shoulders’
DGGG16 Suspicious At least one criteria • 100–­109, OR • <5 and >40 min but <90 min, • Early decelerations, OR Periodical occurrence
but all others Normal • 161–­180 without simultaneous OR • Variable decelerations, OR with every contraction
accelerations • >25 • Prolonged decelerations (abrupt drop
below baseline for at least 60–­90 sec
but <3 min).
FIGO4 Suspicious Lacking at least one
characteristic of
normality, but with no
pathological features
IRELAND17 Suspicious Lacking at least one
characteristic of
normality, but with no
pathological features
NICE18 Amber Only one non-­ • 100–­109, OR • Less than five for 30–­50 min, • Variable decelerations with no
reassuring feature • 161–­180 OR concerning characteristics for ≥90 min,
AND two reassuring OR • More than 25 for 15–­25 min OR
features • an increase in baseline fetal heart • Variable decelerations with any
rate of 20 bpm or more from the concerning characteristics in ≤50% of
start of labour or since the last contractions for ≥30 min, OR
review an hour ago • Variable decelerations with any
concerning characteristics in >50% of
contractions for <30 min, OR
• Late decelerations in >50% of
contractions for <30 min, with no
maternal or fetal clinical risk factors
such as vaginal bleeding or significant
meconium.
NICHD19 Category II • <110 not accompanied by absent • Minimal baseline variability, • Recurrent variable decelerations Absence of induced
baseline variability, OR • >160 OR accompanied by minimal or moderate accelerations after
• Absent baseline variability baseline variability, OR fetal stimulation
with no recurrent • Prolonged deceleration more than
decelerations, OR 2 min but less than10 min, OR
• >25 baseline variability • Variable decelerations with other
characteristics, such as slow return to
baseline, ‘overshoots’ or ‘shoulders’
283

(Continued)

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284 Review of CTG guidelines

Accelerations

• ≤2 accelerations with
Uncertain significance

15 sec in 40–­80 min.

acme of ≥15, lasting
There was considerable variation in the role of fetal heart rate ac-
Accelerations

celerations in intrapartum CTG interpretation. Three guidelines

(DGGG, SLCOG, SOGC) describe accelerations as a necessary fea-
ture of a Normal CTG,16,23,24 whereas the other guidelines deem
that accelerations can be present or absent and/or have an uncer-
tain significance in the interpretation of fetal compromise. This is

shaped late decelerations for <30 min,

• V-­shaped variable decelerations with

• Repetitive (>50% of contractions) U-­

>50% of contractions for >90 min, OR
carried over into the Suspicious and Abnormal categories where

• Single deceleration lasting 3–­5 min.

• Variable decelerations of 30–­60 sec

variable decelerations with >50% of

only the SOGC guideline describe absent accelerations as a fea-
• Repetitive variable >1 min with
normal baseline and variability.
• Typical variable with >50% of

ture of an Abnormal CTG.24

contractions for <30 min, OR

• Non V-­shaped (U-­shaped)
contractions for >90 min.

Decelerations
Decelerations

Both the description and relative risk stratification of decelera-

tions varied dramatically between guidelines. All guidelines agree
duration.

that absence of decelerations was a Normal CTG feature—­and

two (DGGG, SLCOG) indicated that presence of any decelerations
OR

was a Suspicious or Abnormal finding.16,23 That is, only a CTG with

no decelerations could be considered in the Normal category.
• ≤5 (absent or minimal) for

Two guidelines (FIGO, IRELAND) permitted no repetitive decelera-

tions (<50% of contractions).4,17 Five (ACOG, NICE, NICHD, SWE-­17,
• <5 for 30–­50 min, OR
• ≥25 for 15–­25 min.

WALES) confirmed typical early decelerations also in the Normal

• <5 for 40–­90 min
Variability (bpm)

category,7,15,18,19,25 while one (DGGG) placed early decelerations in

the Suspicious category.16 However, other (NICE, SWE-­17, WALES),
40–­80 min.

guidelines also permitted limited typical variable decelerations

as Normal.7,18,25
Note: Grey cells indicate that this feature was not considered in the guideline for this risk category.

Decelerations qualifying as Suspicious were discrepant be-

tween the guidelines. Some guidelines (NICE, SWE-­17, WALES)
considered recurrent typical variable decelerations Normal if
present for less than 90 min and up to 60 sec in duration,7,18,25
• 100–­109 for >10 min, OR

while others (ACOG, SWE-­17) made explicit that all other features
• >160 for <30 min, OR

(such as variability and baseline) must be in the range expected

Baseline rate (bpm)

• >160 for >10 min.

of the Normal category.7,15 There was more consistency in the

• Rising baseline
• 100–­109, OR

• 100–­110, OR

• 100–­109, OR

Abnormal criteria for decelerations, with unanimous classification

of late decelerations and bradycardia (>5 min) as convincing evi-
• 161–­180

• >160

dence of fetal compromise.

Importantly, despite impacting which risk category the CTG
would be interpreted as, the description of deceleration mor-
phology was inconsistent across guidelines. For example, the
presence of recurrent variable decelerations are considered
Abnormal in ACOG15 and NICHD19 guidelines, but the SOGC
guideline24 classifies variable decelerations on their length
Advice

(>60 sec) rather than their frequency. The Wales PROMPT25

guideline is the most descriptive of deceleration morphology,
classifying decelerations as ‘V-­shaped’ or ‘U-­shaped’ and using
Suspicious
reassuring

reassuring

frequency, recurrence and variability to further clarify which

TABLE 3 (Continued)

Atypical

risk category to classify the CTG.

Label

Non-­

Non-­

Five-­category guidelines
Guideline

SLCOG23

WALES25
SWE-­177
SOGC24

Although the vast majority of guidelines stratify CTG patterns into

one of three categories as described above, two guidelines differ
 TABLE 4 CTG three-­tier interpretation criteria—­high probability of fetal acidosis category (Abnormal)

Guideline Label Advice Baseline rate (bpm) Variability (bpm) Decelerations Accelerations
15
ACOG Category III Absent baseline • Bradycardia • Absent baseline variability, OR • Recurrent variable
J. Brown et al.

variability and any • Sinusoidal pattern decelerations, OR

of the following • Recurrent late decelerations
features.
DGGG16 Pathological At least one feature • <100, OR • <5 for >90 min, OR • Atypical variable decelerations, • Absent for >40 min—­
present. • >180 • Sinusoidal pattern OR unclear significance
• Late decelerations, OR
• Isolated prolonged deceleration
for >3 min
FIGO4 Pathological • <100 • Reduced variability, OR • Repetitive late or prolonged
• Increased variability, OR (>3 min) decelerations for
• Sinusoidal pattern >30 min or > 20 min if reduced
variability, OR
• Single prolonged deceleration
with >5 min
IRELAND17 Pathological • <100 for >10 min • Reduced variability <5 for >50 min, • Repetitive late or prolonged
OR (>3 min) decelerations for
• Increased variability >25 for >30 min or >20 min if reduced
>50 min, OR variability, OR
• Sinusoidal pattern for >30 min. • Single prolonged deceleration
with >5 min
NICE18 Red • <100, OR • Reduced variability <5 for >50 min, • Variable decelerations with any
• >180 OR concerning characteristics in
• Increased variability >25 for >50% of contractions for >30 min
>50 min, OR (or less if any maternal or fetal
• Sinusoidal pattern clinical risk factors), OR
• Late decelerations for >30 min
(or less if any maternal or fetal
clinical risk factors), OR
• Acute bradycardia, OR
• Single prolonged deceleration
lasting 3 min or more
NICHD19 Category III Absent baseline • Bradycardia • Absent baseline variability, OR • Recurrent variable
variability and any • Sinusoidal pattern decelerations, OR
of the following • Recurrent late decelerations
features.
SLCOG23 Abnormal • <100, OR • <5 >90 min, OR • Repetitive late or atypical
• >180 • Sinusoidal pattern decelerations for >3 min
SOGC24 Atypical • <100, OR • ≤5 for ≥80 min, OR • Variable decelerations of • ≤2 accelerations with
• >160 for >30 min, OR • ≥25 for >10 min, OR >60 sec duration OR acme of ≥15, lasting
• Erratic baseline • Sinusoidal pattern • Late decelerations 15 sec in >80 min.

(Continued)
285

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 286

TABLE 4 (Continued)

Guideline Label Advice Baseline rate (bpm) Variability (bpm) Decelerations Accelerations
7
SWE-­17 Pathological • <100 • <2, OR • Repetitive late decelerations for
• <5 for >60 min, OR >30 min, OR
• >25 for >30 min, OR • Repetitive late decelerations for
• Sinusoidal pattern for >30 min >20 min with tachycardia and/or
decreased variability, OR
• Repetitive variable
decelerations lasting >1 min with
tachycardia and/or decreased
variability for >20 min, OR
• Repetitive prolonged
decelerations lasting >3 min, OR
• Single prolonged deceleration
lasting >5 min
WALES25 Pathological • <100, OR • <5 for >50 min, OR • Non V-­shaped (U-­shaped)
• >180 • >25 for >25 min, OR variable decelerations with >50%
• Sinusoidal pattern for >30 min of contractions for >30 min, OR
• Repetitive (>50% of
contractions) U-­shaped late
decelerations for >30 min, OR
• Repetitive (>50% of
contractions) U-­shaped late
decelerations and reduced
variability for >20 min, OR
• Single deceleration lasting
>5 min.

Note: Grey cells indicate that this feature was not considered in the guideline for this risk category.
Review of CTG guidelines

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J. Brown et al.
from the rest and use a distinct five-­table, five-­category classifi-
20,21
cation system. PCJSOG and Parer et al. describe five discrete
cross-­tables with the deceleration types on the x-­axis and fetal
heart rate baseline on the y-­axis. Clinicians choose which of the
five tables to use depending on the baseline heart rate variability
of the CTG for interpretation.
Decelerations are classified as early, variable (mild), variable
(severe), late (mild), late (severe), prolonged (mild), prolonged
(severe). The guideline defines the severe category of the three
relevant decelerations as below, and if it does not meet this, it is
considered mild.
• Late—­decline in heart rate of more than 15 bpm from the
baseline to the lowest point.
• Variable—­when the lowest point is less than 70 bpm and con-
tinues for more than 30 sec, or when the lowest point is more
than 70 bpm and less than 80 bpm and continues for more
than 60 sec.
• Prolonged—­Prolonged deceleration is when the lowest point is
less than 80 bpm.
Once all three variables are considered and cross-­tabulated,
the CTG will be classified as one of five colour-­coded ‘variant
patterns’ (Normal, Benign, Mild, Moderate, Severe). Each variant
pattern aligns with a recommended set of actions depending
on the severity. For example, the expected action for a category
five CTG is ‘conduct caesarean section or operative vaginal de-
livery, prepare for resuscitation of newborn’, with no alternative
option described.
DISCUSSION
This work gives a comprehensive overview of clinical practice
guidelines for the interpretation of intrapartum cardiotocography
and highlights their similarities and inconsistencies. Overall, the
guidelines were high quality as assessed by the AGREE II tool.
Despite difference in labelling, most guidelines were struc-
tured into a three-­tier risk stratification of Normal (low), Suspicious
(moderate) and Pathological (high). However, significant variation
in risk stratification of key CTG features was identified, suggest-
ing critical differences in directing clinical practice depending on
which guideline a facility or practitioner chooses to use.
Difference in clinical importance of specific features occurred
across all risk categories, including in the Normal category. For ex-
ample, some guidelines required accelerations to be present for a
CTG to be considered Normal, whereas most guidelines thought
accelerations were a positive feature if present but of unclear clin-
ical significance if absent.
The Suspicious category was the most heterogenous across
the guidelines, with major differences in expectations for variabil-
ity and deceleration patterns. Deceleration morphology itself was
varied across guidelines, with some guidelines prescriptive about
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287
shape, while others highlighted depth and duration as important
features. Signs of immediate and profound fetal hypoxia, like bra-
dycardia and sinusoidal patterns, were much more likely to be
consistent across guidelines.
Inter-­guideline variability has crucial ramifications on ac-
curacy, safety and feasibility of CTG interpretation. Guidelines,
although superficially may be seen as inert documents, they influ-
ence a myriad of consequential actions in delivery wards around
the world, on a daily basis. With such disparity in CTG interpreta-
tion, women are being treated differently depending on location
of birth, rather than what the best evidence dictates.
With limited data supporting the included guidelines, the vari-
ation stems from permutations of consensus that have evolved
over time to improve specificity and/or sensitivity. The permissi-
bility of such disparity reveals an underlying inaccuracy in all CTG
interpretations, despite the gravity of decisions it informs. There
are few studies comparing inter-­guideline accuracy,7 and with or-
ganic evolution of guidelines, we need such research to under-
stand what constitutes actual best practice.
In a broader context, guideline inconsistency has significant
medico-­legal ramifications. The high false-­positive rate of CTG in-
terpretation allows attribution of intrapartum decisions to grave
adverse outcomes, when a similar CTG pattern may not have re-
sulted in a similar management decision or outcome at another
location, including within the same city or country. Guideline vari-
ation codifies otherwise subjective interpretation and may permit
a legal argument that a specific pattern was considered more
severe under the rules of a different guideline, even if not used
in that unit. This may not even be with sinister intentions, with
expert witnesses practising in different locations accustomed to
different guidelines and CTG interpretation. It is feasible to as-
sume that CTG interpretation guideline inconsistency has been in-
strumental in court decisions that had grave consequences to an
obstetrician's livelihood and wellbeing—­while those practitioners
were behaving in accordance with their preferred interpretation
algorithm and consequent clinical management.
The ultimate challenge is balancing sensitivity and specific-
ity, where over-­reaction to a false-­positive may itself result in
unnecessary adverse outcome. CTG interpretation guidelines
are caught between two opposing forces that seem to sustain
and inform the differences. On one hand, more CTG features
can be defined as Suspicious or Abnormal to improve the sen-
sitivity of the guideline—­while on the other hand, including too
many will result in unnecessary intervention and possibly inflate
the number of unnecessary surgical births, both of which are
not without ramifications. Conversely, considering too few fea-
tures as Suspicious or Abnormal will miss instances of critical
fetal acidosis.26 Efforts to therefore introduce more nuance to
guidelines impair the effectiveness of the interpretation tool it-
self. While there is some evidence that the five-­tier system is
more sensitive than a three-­tier system,27 the intricacy of such
guidelines may make CTG interpretation a laborious, analyti-
cal task that is likely to be unwelcome and impractical in busy

288
birth units. Some guidelines19 now recommend stimulation to
induce fetal acceleration to further clarify fetal reserves, which
acknowledges normally functioning homeostatic mechanisms
that may temporarily meet abnormal CTG criteria. Beyond
this, diversity in CTG interpretation, and subsequent decision-­
making, undermine reproducibility of obstetric research, accu-
racy of perinatal epidemiology, and staff skill transition between
units. In essence, it appears we are all speaking the same lan-
guage, when we are not.
In practice, these findings position CTG interpretation guide-
lines in a new context. Over time, such guidelines have shifted
from descriptive tools to assist clinician triage, into prescriptive
action plans based on rigid stratifications—­often mandating
immediate delivery by quickest mode. However, while there
are universally accepted features of Normal, Suspicious and
Pathological CTG features, the differences between the guide-
lines allow for the return of clinician interpretation of CTG pat-
terns in the specific context of their patient. In other words, it
is difficult to justify mandatory action on a CTG pattern that
is considered less severe by an equally reputable guideline.
Applicability is further hampered by differences in risk toler-
ance between countries and institutions. For example, expecta-
tion of maximal sensitivity (at the risk of more false positives) in
a certain context will produce a different pattern of behaviour
in response to an identical CTG pattern in an institution with
a higher risk tolerance. It must always be acknowledged that
CTG interpretation remains a subjective science, at least for the
time being.
The consequences of this inter-­interpretation inconsistency
cannot be overstated. There are few other areas of widely prac-
tised, high-­stakes, clinical care where there are well-­documented
differences in key decision-­making tools. Consider the ramifica-
tions of 13 accepted guidelines defining different parameters to
diagnose sepsis. Some hospitals would miss fatal cases, while oth-
ers would over-­prescribe antibiotics and contribute to antimicro-
bial resistance. This review demonstrates that something similar
is happening in the interpretation of CTGs—­in some centres criti-
cal fetal distress might be missed, while others routinely perform
unnecessary caesarean sections. Efforts toward evidence-­based
guideline uniformity are critical for future safety.
The strengths of this systematic review include its large num-
ber of included guidelines, quality of the guidelines, and rigorous
analysis. Limitations include language and availability. This study
only includes guidelines in the English language, and it is likely
there are guidelines available in non-­English languages that have
not been included. As practical tools foremost, guidelines are
more likely to be in native languages than typical peer-­reviewed
research. With regard to availability, it can be anticipated that
many guidelines are used locally at a district or facility-­level and
are not uploaded for public availability on the internet. Therefore,
it is possible that this study underestimates the number of avail-
able guidelines; however, it is likely that these guidelines are
based on the foundational ones included in this study.
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Review of CTG guidelines
All the included guidelines are an attempt to make the best
use of the available evidence for the best outcomes; however,
the lack of evidence remains the rate-­limiting step for improve-
ment. The widespread use of CTG criteria is a paradoxically self-­
defeating cycle. To improve criteria, we must first understand the
efficacy of the CTG itself for detecting fetal acidosis. To use the
CTG for this purpose, we need guidelines for interpretation of the
patterns. However, the guidelines themselves are varied and lack
robust evidence. Therefore, it becomes impossible to separate
the efficacy of a guideline from the technology. Even comparison
between criteria is skewed by the denominator of the technolo-
gy's limitations. Moreover, the technology is now so entrenched
that it is ethically irresponsible to withhold or modify its use for
research. With these key limitations in mind, the first goal toward
improvement is comparable consistency. That is, we must agree
to play from the same rulebook. There are not enough good data
to justify so many different guidelines being used. This can be
achieved two ways. First, disassemble existing guidelines into the
specific patterns they describe and analyse those patterns against
neonatal outcomes—­after which, the patterns are recombined ac-
cording to the findings. Or second, a single consensus guideline is
created that can be tested and improved by adding, subtracting
or modifying key patterns described in research or smaller guide-
lines. Until consistency is improved, innovation in CTG interpreta-
tion will be hamstrung by subjective variety.
CONCLUSION
This is the first study to identify and evaluate clinical practice
guidelines relevant to intrapartum CTG interpretation. The meth-
odological quality of guidelines was consistent and generally
good; however, most recommendations were based on consen-
sus. There were significant differences in the features nominated
as Normal, Suspicious and Abnormal. This inconsistency is likely
to have ramifications on sensitivity and specify in detecting fetal
acidosis, and almost certainly results in unnecessary or delayed
intervention. Improving consistency across guidelines is an impor-
tant step toward establishing a global gold standard and better
research data in this field, which is necessary to further improve
the efficacy of intrapartum CTG monitoring.
A U T H O R C O NT R IB U T IO NS
JB and MZ conceived and designed the study. JB and DK per-
formed the literature search, data extraction and guideline
quality appraisal. JB, DK and MZ synthesised the guideline rec-
ommendations. All authors contributed to drafting and editing
the manuscript.
F U ND ING INF O R M A T IO N
No funding was received for this systematic review.
 1479828x, 2023, 3, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/ajo.13667 by Universitat Autonoma De Barcelona, Wiley Online Library on [18/07/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
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