Clinical Teaching

on Cardiotocography
(CTG)
Presented By
Saraswata Neupane
MN 2nd year
Women Health and Development
Group
CMC-SON
Objectives

General objective
At the end of the teaching session, the
participants will be able to interpret CTG
Contd…

Specific objectives

The participants will be able to;

• introduce the CTG

• list out the indications of CTG

• explain the preparation of CTG

Contd…

• enlist the method of application of transducers

• interpret the CTG

• explain the advantages and disadvantages of

CTG
• summarize topic
 Introduction of CTG

CTG is used during pregnancy to monitor the fetal

heart and contractions of the uterus. It is most
commonly used in the third trimester when fetal neural
reflexes are present. Its purpose is to monitor fetal
well-being and allow early detection of fetal distress in
antepartum and intrapartum.
Indications of CTG

Maternal indications
1 Maternal medical disorder
• Pregnancy induced hypertension
• Diabetes mellitus
• Chronic hypertension
• Cardiac disease
• Collagen disease
• Renal disease
2 Bad obstetric history
3 Post-date pregnancy
Contd…

Fetal indications
• Decrease fetal movement
• Suspected IUGR
• Abnormal FHR by auscultation
• Multiple pregnancy
• Rhesus iso-immunization
• Before induction of labor
Preparation of CTG

• Determine indication of fetal monitoring

• Discuss fetal monitoring with the women and obtain
permission to commence
• Give women the opportunity to empty the bladder
• Perform abdominal examination to determine lie and
presentation
• secure transducer over the loudest spot - remember
position of fetal heart descends with descent of fetal
head
Contd…

• The women should be in an upright or lateral

position (not supine)
• Check the accurate date and time has been set on the
CTG machine
• Maternal heart rate must be recorded on the C TG at
commencement of the CTG in order to differentiate
between maternal and fetal heart rate
• fetal stimulation should be considered if no
reactivity is seen within 30 minutes
• Label CTGs with the mother’s name, date, time,
commenced and hospital record number
 Method of Application of Transducers

External fetal monitor

• It involves the placement of 2 transducers on the
abdomen of pregnant women: one transducer records fetal
heart rate using ultrasound beam the other transducer
record uterine contraction by measuring the tension of the
maternal abdominal wall.
Internal fetal monitor
• It involves the placement of 2 transducers:
• A fetal scalp electrode (FSE): an internal fetal heart rate
monitor, and intrauterine pressure
• Intrauterine pressure could be simultaneously measured
by passing a catheter inside the uterine cavity.
CTG Interpretation

The most popular structure can be remembered

using the acronym DR C BRa V A D O

DR – Define Risk
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression
Contd…

Define risk
First need to assess if the pregnancy is high or
low risk. This is important as it gives more
context to the CTG reading some reasons a
pregnancy may be considered high risk.
Contd…

Contractions
Need to record the number of contractions present in
a 10 minute period. Each big square on the example
CTG chart below is equal to one minute, so how
many contractions occurred within 10 big squares.
Individual contractions are seen as peaks on the part
of the CTG monitoring uterine activity. Should assess
contractions for the following:
• Duration 
• Intensity 
 
Contd…

Baseline rate of the fetal heart

 
The baseline rate is the average heart rate of the fetus
within a 10-minute window. CTG and assess what the
average heart rate has been over the last 10 minutes.
Ignore any accelerations or decelerations.
A normal fetal heart rate is between 110-160 bpm. 
Contd…

Fetal tachycardia
Fetal tachycardia is defined as
a baseline heart rate greater than 160 bpm.
Causes include:
• Fetal hypoxia
• Chorioamnionitis – if maternal fever also present
• Hyperthyroidism
• Fetal or maternal anemia
• Fetal tachyarrhythmia
 
Contd…

Fetal bradycardia
Fetal bradycardia is defined as
a baseline heart rate less than 100 bpm for 3
minutes or more. It is common to have a
baseline heart rate of between 100-120 bpm in
the following situations:
• Postdate gestation
• Occiput posterior or transverse presentations
Contd…

Severe prolonged bradycardia (less than 80 bpm

for more than 3 minutes) indicates severe hypoxia.
• Causes :
• Prolonged cord compression
• Cord prolapses
• Epidural and spinal anesthesia
• Maternal seizures
• Rapid fetal descent
• If the cause cannot be identified and corrected,
immediate delivery is recommended.
 Contd…
Baseline variability 
It refers to
the variation of fetal 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.
Normal variability is between 5-25 bpm. To calculate
variability, how much the peaks and troughs of the heart rate
deviate from the baseline rate (in bpm).
 Contd…
Variability can be categorized as follows: 
Reassuring – 5 – 25bpm
Non-reassuring:
• less than 5bpm for between 30-50 minutes
• more than 25bpm for 15-25 minutes
Abnormal:
• less than 5bpm for more than 50 minutes
• more than 25bpm for more than 25 minutes
Sinusoidal
 Contd…

Reduced variability can be caused by any of the

following: 
• Fetal sleeping – this should last no longer than 40
minutes (most common cause)
• Fetal acidosis (due to hypoxia) – more likely if late
decelerations are also present
• Fetal tachycardia
• Drugs – opiates / benzodiazepines / methyldopa /
magnesium sulphate
• Prematurity – variability is reduced at earlier gestation
(<28 weeks)
• Congenital heart abnormalities
Contd…

Acceleration:
Transient increase in FHR by 15 bpm or more
lasting for at least 15 seconds. Prolonged
acceleration lasts > 2 min but < 10 min and
when it is > 10 min it is a baseline change.
Acceleration denotes an intact neurohormonal
and cardiovascular activity and therefore a
healthy fetus
Contd…

Deceleration:
Transient decrease in FHR below the baseline by 15
bpm or more and lasting ≥ 15 seconds. Three basic
types of deceleration are observed and are called
early, late and variable
• Early deceleration (Type I Dips): uniform,
repetitive periodic slowing of FHR and in most
cases the onset, nadir and recovery of deceleration
coincides with the beginning, peak and ending of
uterine contraction respectively. It is due to head
compression
Contd…

Variable deceleration
• Variable decelerations are observed as a rapid
fall in baseline fetal heart 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 labor and in
patients with reduced amniotic fluid volume.
• It is due to cord compression.
Contd…

Late deceleration
• Late decelerations begin at the peak of the uterine
contraction and recover after the contraction
ends.
• This type of deceleration indicates there is
insufficient blood flow to the uterus and placenta.
• As a result, blood flow to the fetus is
significantly reduced causing fetal hypoxia and
acidosis.
Contd…

Prolonged deceleration
• A prolonged deceleration is defined as a
deceleration that lasts more than 3 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.
 Contd…

Sinusoidal pattern
• This type of pattern is rare, however, if present it
is very concerning.
• It is associated with high rates
of fetal morbidity and mortality.
A sinusoidal CTG pattern has the following
characteristics:
• A smooth, regular, wave-like pattern
• Frequency of around 2-5 cycles a minute
• Stable baseline rate around 120-160bpm
• No beat to beat variability
Contd…

 A sinusoidal pattern usually indicates one

or more of the following:
• Severe fetal hypoxia
• Severe fetal anemia
• Fetal/maternal hemorrhage
• Immediate C-section is indicated for this kind
of pattern.
• The outcome is usually poor.
 Contd…

Overall impression
• Once assessed all aspects of the CTG need to give
overall impression. The overall impression can be
described as either: 
• Reassuring
• Suspicious
• Abnormal
The overall impression is determined by how many of the
CTG features were either reassuring, non-reassuring or
abnormal.
Categorization of CTG Traces

Based on 4 features (Baseline FHR,

Variability, Decelerations, Accelerations)
• NORMAL: all 4 features are reassuring
• SUSPICIOUS: One non - reassuring and the
rest are reassuring
• PATHOLOGICAL: Two or more features
non- reassuring OR one or more abnormal
categories
Advantages of CTG

• Accurate monitoring of uterine contractions.

• Significant improvement of perinatal
mortality.
• Can detect hypoxia early and can explain the
mechanism of hypoxia and its specific
treatment.
• Improvement of intrapartum fetal death by
three fold.
• It is an important record for medicolegal
purpose
Disadvantages of CTG

• Interpretation is affected by observer

error
• Due to error of interpretation, cesarean
section rate may be high
• Instruments are expensive and trained
personnel are required to interpret a trace
• Mother has to be confined in bed.
References

• Konar, H. (2018).DC Dutta’s Textbook of Obstetrics.9th Ed. Jaypee.

• https://www.babycenter.in/x1045384/what-is-cardiotocography-ctg-
and-why-do-i-need-it
• https://geekymedics.com/how-to-read-a-ctg/
• https://parenting.firstcry.com/articles/cardiotocography-ctg-what-it-i
s-and-why-do-you-need-it/
• https://patient.info/health/cardiotocography