The Cardiotocograph (CTG)

3 W s
Why do we need CTG?
What is CTG?
When to use CTG?

Why Do We Need CTG?
Used to monitor the foetal well
being in utero
to identify the already
compromised or likely to become
compromised fetus of an
apparently normal / low-risk
pregnancy upon admission
* Any one with a suspicious
Admission Test (AT) should have
continuous CTG from early in
labour
What Is It?

Measures Foetal
Heart Tracings and
Contractions
Interpretation is KEY
Cardiotocograph
Pressure Transducer




US Probe
When to Use it?
Not ALL women need it
Restricts MOBILITY
Only in High Risk
Pregnancies
Diam diam
Tak boleh Makan,
Minum
Tak Boleh Kencing
Sendiri, Masuk Tiub,
Tak Boleh Jalan,
Sebab Pasang CTG
NICE Recommendation
Criteria of normal CTG
Normal -

(1) Baseline 110-160 bpm
(2) Baseline variability 5-25 bpm
(3) No decelerations / sporadic mild
deceleration of short duration
(4) 2 accelerations during a 10
minutes period
B. Suspicious -
(1) Baseline 160-170 or 110-100 bpm
(2) Variability 5-10 bpm for > 40 min
(3) Variability > 25 bpm
(4) No accelerations > 40 min
(5) Sporadic mild decelerations of any type (6)
Variable deceleratopms
Antepartum - (1) - (5) any one / combination
Intrapartum - (1) - (4) & (6) any one /
combination
C. Pathological :
Antepartum
(1) Baseline < 100 or > 170 bpm
(2) Variability < 5 bpm for > 40 min
(3) Recurring and repeated decelerations of
any type
(4) Sporadic noncurrent severe variable,
prolonged or late decelerations
(5) Sinusoidal pattern Any one or in
combination
Abnormal Pattern
The following alone and in combination
signify developing hypoxia and acidosis
Absence of accelerations
baseline FHR
baseline variability
Late decelerations
Variable decelerations with abnormal
features
Early decelerations with abnormal
features
Talking in TALK
We need to talk in
the same language
to avoid confusion
DR C BRAVADO
DR Define Risk
C Contractions
BR Baseline Rate
A - Accelerations
Va - Variability
D - Decelerations
O - Others
Breaks up the
reading of the CTG
Reminds us to look
at the cases as a
whole!!

Part 1 CTG: Foetal Heart Trace

BASELINE RATE
Part 1 CTG: Foetal Heart Trace

VARIABILITY
Variation in Baseline
Part 1 CTG: Foetal Heart Trace

ACCELERATIONS
Increase in Baseline by 15 bpm for 15 seconds
Part 1 CTG: Foetal Heart Trace

DECELERATIONS
Reduction in Baseline by 15bpm for 15 seconds
FHR Features
Described as
Reassuring
Non Reassuring
Abnormal
FHR Features
Feature Baseline
(bpm)
Variabilitity
(bpm)
Decelerations Accelerations
Reassuring 110-160 >5 None

Non
Reassuring
100-109
161-180
<5 for
40-90mins
Typical Variable
Decelerations
Early
Decelerations
Single Prolonged
Decelerations <
3mins
Absence of
Accelerations
in an
otherwise
normal CTG
is of
uncertain
significances
Abnormal <100
>180
Sinusoidal
pattern
>10 min
<5 for 90mins
Atypical Variable
Decelerations
>30mins
Late Decelerations
>30 mins
Single prolonged
Deceleration >3mins
CTG Description

NORMAL

SUSPICIOUS

PATHOLOGICAL


NORMAL CTG
Feature
Baseline Variability Decelerations Accelerations
Reassuring 110-160 >5 None


Non
Reassuring
Abnormal
DR C BRAVADO
DR Define Risk
C Contractions
BR Baseline
Rate
A - Accelerations
Va - Variability
D - Decelerations
O - Others

DR Define Risks
C - Contractions: 1 in 10 mins
BR - Baseline Rate: 140 bpm
A - Accelerations: 3
Va - Variability: >5 bpm
D Decelerations: NIL
O - Others
NORMAL CTG
Suspicious CTG
Feature
Baseline Variability Decelerations Accelerations
Reassuring
<5 for 40-90
mins
None

Non
Reassuring
100 - 109
161 - 180
Abnormal
REMEMBER:
The Absence of an Acceleration in an OTHERWISE
normal CTG is of unknown significance
Pathological CTG
Feature
Baseline Variability Decelerations Accelerations
Reassuring
None

Non
Reassuring
100-109
161-180
<5 for 40-90
mins
Abnormal
Feature
Baseline Variability Decelerations Accelerations
Reassuring
>5 None

Non Reassuring
Abnormal
<100
>180
Sinusoidal
pattern
>10 minutes
DR C BRAVADO
DR Define Risk
C Contractions
BR Baseline
Rate
A - Accelerations
Va - Variability
D - Decelerations
O - Others

DR Define Risks

C - Contractions: 1 in 10 mins

BR - Baseline Rate: 160 bpm

A - Accelerations: NIL

Va - Variability: >5 bpm (10-20 bpm)

D Decelerations: (+)

O Others

PATHOLOGICAL CTG

Management of Suspicious CTG
Correctable Factors:
Hydration
Left Lateral Position
Hyperstimulation?
Others (i.e. fever)

Repeat CTG tracing after correction
The Management of
a Suspicious CTG is
NOT repeat till CTG
normal.
Management of Pathological CTG
Can we wait?
Additional Testing Required
Foetal Blood Sampling
Thank you very much.

Q1?

A1
DR Define Risks

C - Contractions: NIL

BR - Baseline Rate: 160 bpm

A - Accelerations: NIL

Va - Variability: <5 bpm

D Decelerations: (+) (<15bpm from baseline)

O Others: decelerations last 1min and probably due to
contractions although the toco tracing has not picked up the
mild contractions

PATHOLOGICAL CTG
Q2?
A2
DR Define Risks

C - Contractions: 1 in 10 mins

BR - Baseline Rate: 140 bpm

A - Accelerations: 3

Va - Variability: (+) (5-10 bpm)

D Decelerations: NIL

O Others

NORMAL CTG
Q3?
A3
DR Define Risks

C - Contractions: NIL

BR - Baseline Rate: 150 bpm

A - Accelerations: NIL

Va - Variability: reduced variability 5-10
bpm

D Decelerations: NIL >40mins

O Others

SUSPICIOUS CTG
Q4?
A4
DR Define Risks: fetus with severe anemia

C - Contractions: NIL

BR - Baseline Rate: 180 bpm

A - Accelerations: NIL

Va - Variability: NIL

D Decelerations: NIL

O Others: tracing showing tachycardia & sinusoidal fetal heart rate with
absent of short-term variability

PATHOLOGICAL CTG
Q5?
A5
DR Define Risks

C - Contractions: 4 in 10

BR - Baseline Rate: 135-140 bpm

A - Accelerations: NIL

Va - Variability: 5-10 bpm

D Decelerations: Variable suggesting cord compression

O Others: Fetal scalp blood pH may be necessary if baseline rate rises
and/or the variability becoming <5bpm

SUSPICIOUS CTG
Q6?
A6
DR Define Risks

C - Contractions: 3 in 10

BR - Baseline Rate: 150 bpm

A - Accelerations: NIL

Va - Variability: 10-25 bpm

D Decelerations: Variable with ominous features late
recovery and combined or biphasic decelerations (i.e.
variable and late)

O Others

PATHOLOGICAL CTG
Q7?
A7
DR Define Risks: augmentation of labour with oxytocin infusion

C - Contractions: 5 in 10

BR - Baseline Rate: 140 - 150 bpm

A - Accelerations: (+)

Va - Variability: 10-25 bpm

D Decelerations: Hyperstimulation, with increased basal tone, resulted in a
prolonged bradycardia

O Others

PATHOLOGICAL CTG
Q8?
A8
DR Define Risks

C - Contractions: 3 in 10

BR - Baseline Rate: 138 bpm

A - Accelerations: (+)

Va - Variability: 10-25 bpm

D Decelerations: Variable with sudden bradycardia to 70 bpm

O Others: Cessation of pushing should be advised and arrangements for
assisted vaginal delivery made unless spontaneous delivery is imminent

PATHOLOGICAL CTG
Q9?
A9
DR Define Risks

C - Contractions: 4 in 10

BR - Baseline Rate: 165 bpm

A - Accelerations: NIL

Va - Variability: 5-10 bpm

D Decelerations: Repetitive late decelerations

O Others

PATHOLOGICAL CTG
Q10?
A10
DR Define Risks

C - Contractions: 1 in 10

BR - Baseline Rate: 165 bpm

A - Accelerations: (+)

Va - Variability: 10-25 bpm

D Decelerations: NIL

O Others: Twin FHR signals offset by 20 bpm

NORMAL CTG
Some Interesting Facts
Even the most PATHOLOGICAL of
CTGs is associated with acidosis in
50% cases
Use of EFM in low risk pregnancies:
Increase in intervention
Reduce incidence of neonatal seizures
No difference in long term handicap or
mortality
Take Home Messages
CTG is not for everyone
Treat the WOMAN not
the CTG
Interpretation is the KEY
CTG is only a screening
test

For More Information
www.nice.org.uk/CG055fullguideline
Thank You