CARDIOTOCOGRAPHY

Cardiotocography(CTG) is a technical means of recording (-graphy) the fetal heartbeat (cardio-)

and the uterine contractions (-toco-) during pregnancy, typically in the third trimester.
 The machine used to perform the monitoring is called aCardiotocograph, more commonly
known as an Electronic Fetal Monitor (EFM).

METHOD
 Recordings are performed by TWO separate transducers;
 One for the measurement of the fetal heart rate and a second one for the uterine
contractions.
 Each of the transducers may be either external or internal.
 External measurement means taping or strapping the two sensors to the abdominal wall.
This is called an indirect measure
 Internal measurement (direct) requires a certain degree of cervical dilatation,
 As it involves inserting a pressure catheter into the uterine cavity, as well as attaching a
scalp electrode to the child's head to adequately measure the electric activity of the fetal
heart.
 Internal measurement is more precise, and might be preferable when a complicated
childbirth is expected.
INTERPRETATION
 Includes description of:.
 Uterine activity (contractions)
 Baseline fetal heart rate
 Baseline FHR variability
 Presence of accelerations
 Periodic or episodic decelerations
 UTERINE CONTRACTIONS
There are several factors used in assessing uterine activity :
 Frequency: the amount of time between the start of one contraction to the start of the
next contraction.
  Duration: the amount of time from the start of a contraction to the end of the same
contraction. (e.g. 15 secs)
 Intensity: a measure of how strong a contraction is. (mild, moderate, strong)
 Uterine Activity
 May be defined as:
 Normal less than or equal to 5 contractions in 10 minutes.
 Tachysystole more than 5 contractions in 10 minutes.
 Baseline Fetal Heart Rate
 The baseline fetal heart rate is the heart rate range that occurs between uterine
contractions.
 The normal baseline heart rate can be any where between 110 and 160 beats per
minute.
How Do Uterine Contractions Affect Fetal Heart Rate?
 Uterine contractions can affect fetal heart rate by increasing or decreasing that rate in
association with any given contraction
 The THREE primary mechanisms by which uterine contractions can cause a decrease in
fetal heart rate are compression of:
o Fetal head
o Umbilical cord
o Uterine myometrial vessels
What are Causes of Fetal Heart Rate Bradycardia?
 Fetal bradycardia is defined as a decrease in the baseline FHR to less than 100 beats per
minute
 Fetal Hypoxia: Bradycardia is a late sign of fetal hypoxia (a continual lack of oxygen).
 rate slows in response to a depression of heart muscle (myocardial) activity
caused by this continued decrease in needed oxygen.
Medications:
 Medications such as narcotics cause
o Bradycardia by preventing receptor sites in the fetal
o Heart muscle from accepting epinephrine, which works to increase heart
rate.
 Synthetic Oxytocin (Pitocin) may produce bradycardia by causing a
hyperstimulation of the uterine muscle (myometrium), resulting in hypoxia.
 Maternal Hypotension: Supine hypotension syndrome caused by pressure
of the uterus and its contents on the inferior vena cava, when you lay on your
back, results in decreased maternal blood pressure.
What Are Causes Of Fetal Heart Rate Tachycardia?
 Tachycardia: Suspicious tachycardia is defined as being between 150 and
170 whereas a pathological pattern is above 170.
 Fetal Hypoxia-Tachycardia may be an early sign of hypoxia (fetal lack
of adequate oxygen).
 Medications-Medications used to prevent/stop premature labor such as
terbutaline (sympathomimetic), have a stimulating effect on the fetal
heart, which increases the rate.
 Prematurity-A premature baby has an immature nervous system resulting
in an increased heart rate.
 Baseline FHR Variability
o Fetal heart rate variability has become one of the most important
indicators in the clinical assessment of fetal well-being.
o Variability is indicative of a mature fetal neurologic system
Fetal Heart Rate Variability
• The baseline rate variability should vary by at least 10-15 beats over a
period of one minute.
• A decrease in variability can be noted during
Fetal sleep.
• Variability can be divided into the following categories:
• Decreased: minimal variability (0-5 bpm).
• Moderate: normal variability (6-25 bpm).
• Marked: saltatory variability (>25bpm).
• A normal, healthy fetal heart rate should possess average or moderate
variability.
Decreased Variability May Occur in The Following Situations:
• Hypoxia
 • All central nervous system depressant medications, Prematurity.
• Fetal sleep.
• Accelerations
o The fetal heart rate will normally remain steady or accelerate
during uterine contractions.
o Accelerations are defined as a transient increase in heart rate of
greater than 15 bpm for at least 15 seconds (the 15x15 rule).
o Two accelerations in 20 minutes is considered a reactive trace.
• Periodic or Episodic Decelerations
o Periodic refers to decelerations that are associated with contractions;
o Episodic refers to those not associated with contractions.
o Deceleration-decrease in baseline FHR.
 THREE Types of Decelerations:
A- Early Decelerations:
o The early deceleration begins at the onset of the contraction and ends
with the end of the contraction.
o Early deceleration is caused by vagal stimulation from head
compression.
o Early decelerations are not a sign of fetal problems.
B - Late Deceleration:
o Late decelerations are transitory decreases in heart rate caused by
uteroplacental insufficiency, a compromised blood flow to the baby
that does not deliver the amount of oxygen needed to withstand the stress
of labor.
o The late deceleration begins after the onset of the peak or middle of the
contraction and ends a, after the contraction.
C - Variable Deceleration:
 Variable decelerations are transitory decreases in fetal heart rate caused by
umbilical cord S. compression.
Normal/Reactive FHR Pattern
o Baseline rate 110-160 bpm
o Moderate variability (>5 bpm)
 Absence of late, or variable decelerations
 Early decelerations and accelerations may or may not be
present.
If any problem has been found Intrauterine Resuscitation
o Has the mother lie on her left side (remember, lying on her back
invites hypotension which affects baby's oxygen supply) or in a
knee chest position. To alleviate possible cord
compression.
o Reduce or stop any oxytocin she may be receiving.
o Initiate tocolytics - to decrease uterine activity and increase
placental blood flow. Increase IV fluid - to increase
maternal blood flow volume
o Give her oxygen by mask - to promote oxygenation across the
placenta
Apply an internal monitor - to verify the accuracy of external
monitor readings.
o Administer amnioinfusion - to decrease pressure on cord.
o If the heart rate is not restored to normal within 30
minutes, prompt delivery is needed.
o Cesarean section may then become necessary.

EFFECT ON MANAGEMENT:
It has been shown that use of CTG reduces the rate of seizures
in the newborn,
 But there is no clear benefit in the prevention of cerebral palsy,
perinatal death and other complications of labor.