Policy

Clinical Guideline
Antenatal Cardiotocography Clinical Guideline

Policy developed by: SA Maternal & Neonatal Clinical Network

Approved SA Health Safety & Quality Strategic Governance Committee on:
07 September 2015
Next review due: 30 September 2018

Summary Clinical practice guideline for the use of antenatal

cardiotocography.

Keywords antenatal, CTG, cardiotocography, reporting, storage of tracings,

fetal wellbeing, STAN, cycling, fetal heart rate, monitoring, external
fetal monitoring, Doppler, clinical guideline

Policy history Is this a new policy? N

Does this policy amend or update an existing policy? Y v3.0
Does this policy replace an existing policy? N

Applies to All SA Health Portfolio

All Department for Health and Ageing Divisions
All Health Networks
CALHN, SALHN, NALHN, CHSALHN, WCHN, SAAS

Staff impact All Staff, Management, Admin, Students, Volunteers

All Clinical, Medical, Nursing, Allied Health, Emergency, Dental,
Mental Health, Pathology

PDS reference CG222

Version control and change history

Version Date from Date to Amendment
1.0 17 Feb 2004 19 Oct 2006 Original version
2.0 19 Oct 2006 08 Nov 2010 Reviewed
3.0 08 Nov 2010 07 Sept 2015 Reviewed
4.0 07 Sept 2015 Current
© Department for Health and Ageing, Government of South Australia. All rights reserved.
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography © Department of Health, Government of South Australia. All rights reserved.

Note

This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of
published evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements
Explanation of the aboriginal artwork:
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in
unison.

Australian Aboriginal Culture is the oldest living culture in the world yet Aboriginal
people continue to experience the poorest health outcomes when compared to non-
Aboriginal Australians. In South Australia, Aboriginal women are 2-5 times more
likely to die in childbirth and their babies are 2-3 times more likely to be of low birth
weight. The accumulative effects of stress, low socio economic status, exposure to
violence, historical trauma, culturally unsafe and discriminatory health services and
health systems are all major contributors to the disparities in Aboriginal maternal
and birthing outcomes. Despite these unacceptable statistics the birth of an
Aboriginal baby is a celebration of life and an important cultural event bringing
family together in celebration, obligation and responsibility. The diversity between
Aboriginal cultures, language and practices differ greatly and so it is imperative that
perinatal services prepare to respectively manage Aboriginal protocol and provide a
culturally positive health care experience for Aboriginal people to ensure the best
maternal, neonatal and child health outcomes.

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines Workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 1 of 6
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography

Antenatal cardiotocography flow chart

Indications for antenatal CTG Procedure for CTG

 Reduced fetal movements  Explain procedure to woman
 Abdominal trauma  Position woman correctly
 Abnormal Doppler umbilical artery velocimetry  Record clinical observations
 Suspected intrauterine growth restriction  CTG should not be performed immediately after the
 Oligohydramnios woman has smoked, is / has fasted. Document
details on CTG report in these circumstances
 Prolonged pregnancy ≥ 42+0 weeks (twice weekly)
 Record maternal details on trace including
 Antepartum haemorrhage (in excess of a ‘show’ ≥ administration of drugs
50 mL)
 On trace indicate, fetal movements, loss of contact
 Prolonged rupture of membranes (> 24 hours) and audible decelerations
 Known fetal abnormality which requires monitoring
 If bradycardia note maternal pulse
 Threatened and actual preterm labour
 Operator to remain during trace
 Cervical ripening with vaginal prostaglandins or
cervical ripening balloon catheter (pre and post
CTG)
 Other medical conditions that constitute a
significant risk of fetal compromise

Reporting Storage of tracings Review of CTGs

 Operator to record result
 Refer tracings with abnormality
for medical review immediately
 Medical staff ordering trace to
review all tracings
 Senior medical staff to review all
traces of non-booked women
forwarded from
 CTG recordings to be filed
in case notes external facility
 If notes microfilmed, short  If faxed to hospital for
traces can be microfilmed advice, include patient details
 Electronic archiving of and condition
computer based programs  Case note record to be
created to archive advice
given

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 2 of 6
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography

Introduction
 The cardiotocograph (CTG) is an evaluation tool widely used in antenatal care for
assessment of fetal wellbeing. Antenatal CTG is commonly used in conjunction with
1
ultrasound assessment of fetal and placental Doppler in high risk pregnancy
 Antenatal fetal heart recordings only provide assessment of the immediate fetal condition
 Use of a CTG implies that a pregnancy risk has been identified and medical referral is
required

Literature review
 At present antenatal CTG is not thought to be useful as a method of routine fetal
assessment in low risk pregnancies
 The most recent systematic review of antenatal CTG for fetal assessment was only to
1
identify studies that included women with increased risk of complications
 The systematic review concluded that:
 The use of antenatal CTG has no effect on the risk of caesarean section for
1
women
 Antenatal CTG has no beneficial effect on rates of perinatal mortality or
1
morbidity

 However, a comparison between computerised interpretation of CTG and traditional CTG

(visual interpretation) showed a significant reduction in perinatal mortality with computerised
1
CTG but no difference in potentially preventable deaths
 There is no evidence that antenatal oral maternal glucose administration improves any
2
features of fetal well-being as assessed by reactivity on CTG
 10 % of CTGs may be uninterpretable due to:
 Gestational age

 Normal cycling (rest) phases (may be up to 90 minutes)

4
 The use of certain medications (e.g. central nervous system sedatives)

 Changes in heart rate patterns associated with circadian rhythms

Risk factors
 The following clinical situations may be an indication for antenatal CTG for fetal
assessment:
 Reduced fetal movements (for more information see in A to Z index at
www.sahealth.sa.gov/au/perinatal)

 Abdominal trauma (for more information, follow link to

www.sahealth.sa.gov.au/perinatal in the A to Z index under trauma in
pregnancy)
 Abnormal Doppler umbilical artery velocimetry

 Suspected intrauterine growth restriction

 Oligohydramnios
+0
 Prolonged pregnancy ≥ 42 weeks (twice weekly)

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 3 of 6
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography
 Antepartum haemorrhage (in excess of a ‘show’ ≥ 50 mL)

 Prolonged rupture of membranes (> 24 hours)

 Known fetal abnormality which requires monitoring

 Threatened and actual preterm labour

 Vaginal prostaglandins or cervical ripening balloon catheter (CTG pre and post
insertion)

 Other medical conditions that constitute a significant risk of fetal compromise

Use of antenatal CTGs

 Antenatal CTGs may be provided for women attending as an outpatient (emergency
department or day assessment unit) or as an antenatal inpatient
 As clinically indicated according to the presence of pregnancy risk factors
 The decision to perform EFM should be made following consultation with appropriate
clinicians and the woman with consideration of gestation

Antenatal CTG practice recommendations

(Link to CTG practice recommendations)
 If there is no centralised fetal monitoring the clinician should remain present throughout the
tracing. At all times a clinician must be assigned to observe the CTG
 The duration of the recording need only be 10 minutes if there are no decelerations and the
features are within the normal parameters described in CTG reporting by RANZCOG
 Document on the report when CTG is performed within 30 minutes of cigarette smoking and
administration of drugs
 The woman or her attending clinician should indicate fetal movements with the appropriate
marker (do not rely on the machine to document fetal movements)
 Document significant maternal events such as change of position to relieve aortocaval
compression
 Loss of contact and audible decelerations should be marked on the CTG by the attending
clinician
 Simultaneously palpate the maternal pulse to differentiate from FHR in the presence of a
fetal heart deceleration or bradycardia and document the maternal pulse on the CTG tracing

Responsibility for reporting

 The clinician who performs the CTG tracing should report the features of the tracing on the
individual hospital’s prescribed form
 Medical staff are responsible for the review of all CTGs they order
 The midwife should refer any CTG tracing with features of fetal compromise to a medical
officer for immediate review
 Outpatient CTGs of all non-booked women should be seen by senior medical staff. The
referring doctor should be telephoned and advised of the CTG findings

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 4 of 6
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography

References
1. Grivell RM, Alfirevic Z, Gyte GML, Devane D. Antenatal cardiotocography for fetal
assessment. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.:
CD007863. DOI: 10.1002/14651858.CD007863.pub3. (Level I). Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD007863/pdf_sta
ndard_fs.html
2. Tan KH, Sabapathy A. Maternal glucose administration for facilitating tests of fetal
wellbeing. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD003397.
DOI: 10.1002/14651858.CD003397.pub2. (Level I). Available from URL:
http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003397/pdf_sta
ndard_fs.html
3. Trimbos JB, Keirse MJNC. Significance of antepartum cardiotocography in normal
pregnancy. Br J Obstet Gynaecol 1978; 85: 907-913 (Level III-2).
4. Mohide P, Keirse MJNC. Biophysical assessment of fetal well-being. In: Chalmers I,
Enkin M, Keirse MJNC, eds. Effective Care in Pregnancy and Childbirth. Oxford: Oxford
University Press, 1989: 477-492.
5. Beard RW, Filshie GM, Knight CA, Roberts GM. The significance of the changes in the
continuous fetal heart rate in the first stage of labour. J Obstet Gynaecol of the British
Commonwealth 1971; 78(10): 865-81 (Level III-3).
6. Murray H. In: Allen T. Obstetrics and Gynaecology Grand Rounds: The neurologically
impaired infant. United Journal 2001; 3: 14-16.
7. Enkin M, Keirse MJNC, Neilson J, Crowther C, Duley L, Hodnett E, et al. A guide to
effective care in pregnancy and childbirth, 3rd ed. Oxford: Oxford University Press; 2000.
(Level I)
8. MacLennan A. A template for defining a causal relation between acute intrapartum
events and cerebral palsy: International consensus statement. Br Med J 1999; 319m:
1054-59 (Level IV).
9. Mires G, Williams F, Howie P. Randomised controlled trial of cardiotocography versus
Doppler auscultation of fetal heart at admission in labour in low risk obstetric
population. Br Med J 2001; 322: 1457-62 (Level I).
10. Royal College of Obstetricians and Gynaecologists (RCOG). The Use of Electronic Fetal
Monitoring, Evidence-based Clinical Guideline Number 8. RCOG Clinical Effectiveness
Support Unit, London: RCOG Press; 2001 (Level IV).
11. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG): Intrapartum Fetal Surveillance. Clinical Guidelines – Third Edition; 2014
(Level IV). Available at URL: http://www.ranzcog.edu.au

Useful reference
National Institute for Health and Clinical Excellence (NICE) Antenatal care
Available from URL http://www.nice.org.uk/guidance/index.jsp?action=download&o=40145

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 5 of 6
 South Australian Perinatal Practice Guidelines

antenatal cardiotocography

Abbreviations

cm Centimetre
CTG Cardiotocography
EFM External fetal monitoring
FHR Fetal heart rate
NICE National Institute for Clinical Excellence
RANZCOG Royal Australian and New Zealand College of Obstetricians and
Gynaecologists
RCOG Royal College of Obstetricians and Gynaecologists

Version control and change history

PDS reference: OCE use only

Version Date from Date to Amendment

1.0 17 Feb 04 19 Oct 06 Original version
2.0 19 Oct 06 08 Nov 10 Reviewed
3.0 08 Nov 10 07 Sept 15 Reviewed
4.0 07 Sept 15 Current

ISBN number: 978-1-74243-146-8

Endorsed by: South Australian Maternal & Neonatal Clinical Network
Last Revised: 07/09/15
Contact: South Australian Perinatal Practice Guidelines workgroup at:
HealthCYWHSPerinatalProtocol@sa.gov.au Page 6 of 6