CARDIOTOCOGRAPHY [C.T.G.

INTRODUCTION

- Cardiotocography is the monitoring of the foetal heart and uterine contraction

during pregnancy, after the age of viability, either before labour (antepartum
CTG) or during labour (intrapartum CTG)
- The device used in cardiotocography is a Cardiotocograph
- One transducer records the Foetal heart rate using ultrasound. The other
transducer monitors uterine contraction by measuring the tension of the maternal
abdominal wall.

The CTG sheet

- X-axis on the CTG

o represents time
o one big box represents 1minute (60sec); one small box represents (60÷5 =
12sec)
- Y-axis on the CTG
o represents FHR
o one big box is …
o one small box is 5bpm

HOW TO READ THE CTG

Mnemonics = DR C. BRAVADO

- DR = define the risk i.e. indications for CTG

- C = contractions
- BRa = Basal rate i.e. Basa foetal heart rate
- V = Variability
- A = Acceleration
- D = Deceleration
- O = Overall assessment
DR = Defining the Risk i.e. INDICATIONS FOR CTG

- Maternal indications
o GDM
o P.I.H., Pre-eclampsia, Eclampsia
o Asthma
- Obstetric indications
o Decreased foetal movt; a sign of foetal distress
o IUGR (intrauterine growth restriction)
o Premature rupture of membrane
o Intrapartum haemorrhage
o AOL (Augmentation of labour)
o IOL (Induction of labour)
o If you want to attempt VBAC
o Multiple Gestation
o Post-date gestation
- Other Risk factors
o Absence of prenatal care
o Smoking
o Drug abuse

C = CONTRACTIONS

NOTE =

- The transducer for uterine contraction is put in place (on the most protruding
part of the fundus) if the patient C/O LAP or labour pain. As such the CTG
sheet will show readings for both Foetal heart activity and Uterine contraction.
If patient is not C/O of LAP or labour pain, there is no need to place the “TOCO”
transducer; in which case the CTG will show only Foetal heart readings
- A CTG done during Labour is said to be an Intrapartum CTG; & the CTG
done b4 labour is said to an Antepartum CTG

Contractions are assessed by the following:

- How many contractions (Peaks) in 10 minutes?

o On big box on the X-axis is 1 minute; 10 big boxes = 10 minutes
- How long does each peak/contraction last?
 - How strong are the contractions? (assessed using palpation)

BRa = BASAL OR BASELINE FOETAL HEART RATE (BFHR)

- Normal BFHR = 110 to 160 bpm

o A Reassuring Feature
- BFHR around 100 to 109 bpm or 161 to 180 bpm are non-reassuring features
of CTG
- BFHR <100bpm for ≥ 3 minutes is termed foetal Bradycardia & BFHR of
>180bpm is termed Foetal Tachycardia. Both are Abnormal Features of CTG
- Causes of Foetal Tachycardia
o Foetal hypoxia’
o Foetal Tachyarrhythmia
o Foetal or maternal Anaemia
o Chorioamnionitis – if maternal fever also present
o Hyperthyroidism
- Severe prolonged Bradycardia - - is defined as BFHR of <80bpm for >3minutes
o Indicates Hypoxia
o Causes include
▪ Prolonged cord compression
▪ Cord prolapse
▪ Epidural and spinal anaesthesia
▪ Maternal seizures
▪ Rapid foetal descent
o If the cause cannot be identified and corrected, immediate delivery is
recommended

V = Baseline Variability

- Refers to the variation of Foetal Heart Rate from one beat to the next
- Variability in Baseline FHR occurs as a result of interaction btw the nervous
system, chemoreceptors, baroreceptors and cardiac responsiveness.
- A healthy foetus will constantly adapt its HR in response to changes in its
environment (touch, mother’s movt, drugs, temp change, uterine contractions, …)
- & A Normal Baseline variability indicates an intact neurological system of the
foetus & its btw 5 to 25 bpm
 o Variability > 25bpm = Increased variability
o Variability < 5bpm = Reduced variability
o Variability < 3bpm said to be Absent variability
- To measure the variability, you look at how much the peaks and troughs of the
heart rate deviate from the baseline FHR (in bpm)
- Areas of the FHR reading where accelerations and deceleration are present are
NOT used to measure variability.
- Categories of variability
o Reassuring variability - -
▪ variability is normal i.e. btw 5-25bpm
o Non-Reassuring variability
▪ variability is < 5bpm for btw 30-50 minutes OR when variability is
> 25bpm for btw 15-25 minutes
o Abnormal variability
▪ < 5bpm for > 50minutes OR >25bpm for >25min
- NOTE = Causes of Reduced B. variability (< 5 bpm)
o Foetal sleeping (most common cause)
o Foetal acidosis
o Drugs – opiates, benzodiazepines, methyldopa, MgSO4
o Prematurity – variability is reduced in earlier gestation (< 28 weeks)
o Congenital heart abnormalities

A = Acceleration

- Is defined as transient increase in Baseline FHR by ≥ 15 bpm lasting for ≥ 15

seconds
- Acceleration occurring alongside uterine contraction is a sign of a healthy foetus

D = Decelerations

- Transient decrease in BFHR by ≥ 15 bpm lasting for ≥ 15 seconds

- Types
o Early deceleration
▪ A physiological deceleration
 ▪ Start when uterine contraction occurs and recovers when the uterine
contraction stops
▪ Due to increase in foetal intracranial pressure (when uterine contraction
occurs) causing increased vagal tone
o Late deceleration
▪ Starts at the peak of uterine contraction and recovers after the
contraction ends
▪ An indication of Uteroplacental insufficiency (i.e. blood flow to the foetus
is significantly reduced causing foetal hypoxia and acidosis)
• Causes of Uteroplacental insuff. include
o Maternal hypotension
o Pre-eclampsia
o Uterine hyperstimulation
▪ If there is late deceleration, foetal blood sampling for pH is indicated. If
there is acidosis, emergency C/S is needed
o Variable decelerations
▪ Occur irrespective of uterine contraction i.e. they can occur during
contractions and even when there is no contraction
▪ An indication of umbilical cord compression for which Urgent CS (within 30
minutes) must be done to save the child’s life
▪ It’s also seen during labour and in patient’s with reduced amniotic volume
▪ Sometimes it resolve when mother changes position
o Prolonged deceleration
▪ Deceleration that last > 3 minutes (or 90 sec)
▪ If deceleration last btw 2-3 minutes, it is classed as non-reassuring
▪ If it lasts > 3 minutes it is said to be Abnormal
NB: INTEPRETATIONS OF THE FEATURES OF CTG

FEATURES BFHR (BPM) VARIABILITY ACCELERATION DECELERATION

REASSURING 110-160 > 5 (or 5-25) Present None
NON-REASSURING 100-109 < 5bpm for btw Absence of Early dec
161-180 30-50 minutes unknown &/or
OR significance Lasting btw 2-
> 25bpm for 3 minutes
btw 15-25
minutes
ABNORMAL < 100 < 5bpm for >50 Absence of Late dec
> 180 min unknown &/or
OR significance Lasting > 3
> 25bpm for minutes
>25min (prolonged)

OVERALL IMPRESSION & PLAN OF ACTION

CATEGORY DEFINITIOIN ACTION

Normal CTG BFHR, variability & None
decelerations are all
reassuring
Suspicious CTG 1 non-reassuring feature Conservative measures
Pathological CTG 2 or more non-reassuring Foetal scalp sampling or
features just go ahead and deliver
OR the baby
1 abnormal feature