Dip Obs

1. Fetal monitoring
Themba Hospital DipObs Tutorials
By Dr N.E Manana

2. Intro
• The aim of fetal monitoring is to assess fetal wellbeing during the
pregnancy – antenatally and during labour – once the fetus has reached
viability.
• This presentation provides guidelines for clinicians in CTG interpretation
and response to the CTG pattern by defining a standardized process of
interpretation, documentation and management.
• CTGs should be interpreted in the context of the entire clinical situation,
including the gestational age, fetal growth, fetal movements, and clinical
conditions which may compromise fetal wellbeing.

3. Antenatal screening
Fetal movements
• Auscultation alone cannot confirm whether the baby is well.
• Every pregnant woman should be properly educated about deliberate
daily awareness of fetal movements from 26 weeks’ gestation.
• All women be given clear information on completing the fetal kick chart
in the Maternity Case Record (MCR) as well as what to do if movements
are thought to be reduced – to take some food or drink and rest for 30
minutes and repeat assessment.
• It must be emphasised to the woman that urgent (same day)
attendance at a health facility is required if reduced movements of less
than 4 kicks in 1 hour persist for 2 consecutive hours

4. Antenatal screening
Symphysis fundal height
• This measurement should be carefully plotted on the graph in the
antenatal section of the MCR.
• Abnormalities which should prompt referral for a further, more detailed
assessment including ultrasound include:
• Lack of increase in symphysis-fundus measurements between antenatal
visits at least 4 weeks apart
• Any SFH measurement below the 10th centile
• Any abnormalities found on ultrasound should prompt antenatal
cardiotocography (CTG) and referral for Doppler.

5. Antenatal diagnosis
Antenatal cardiotocography
• CTGs done prior to labour onset and therefore in the absence of contractions
are sometimes called “non-stress tests” (NST).
• For simplicity, the term antenatal CTG can be used.
• Antepartum CTG assesses the current state of the fetus and does not predict
the condition of the fetus as the pregnancy progresses
• Low-risk antenatal women do not need CTG monitoring
• The antenatal CTG helps practitioners evaluate current fetal condition in
pregnancies where maternal or fetal complications may impact placental
function.
• If the antenatal CTG has 2 accelerations in 30 min, this is reassuring.
• If no acceleration after 40 minutes, try changing maternal position or
administer acoustic stimulation.

6. …Cont
• Acoustic stimulation can be applied using a special instrument which creates a
standardised ‘buzz’, or an empty soft drink can.
• Place the base of the can against the mother’s abdomen over the baby’s head.
• Support the upper rim with your thumb and third finger.
• Depress the ring opener with your second finger and allow it to snap back giving
a ‘twanging’ noise.
• Continue to count the baby’s heart rate over several 30 second periods.
• If the heart rate increases by at least 8 beats over 30 seconds, or if you or the
mother feel a distinct movement in response to the stimulation, the baby is
responsive and very unlikely to be dangerously compromised.
• The significance of absence of accelerations in an otherwise normal antenatal
CTG is not clear.
• It does not indicate fetal distress

7. Indications for antenatal CTG
Maternal diabetes, especially when poorly controlled, or known fetal macrosomia
Hypertensive disorders of pregnancy
Prolonged pregnancy (41 weeks gestation and above)
Fetal growth restriction (IUGR)
Decreased fetal movements
Oligohydramnios or polyhydramnios
Abnormal umbilical artery resistance index on doppler
Antepartum haemorrhage without contractions
Preterm prelabour rupture of membranes

8. Umbilical artery resistance index (Doppler)
• Abnormal umbilical artery waveforms are associated with histological evidence of reduced
numbers of small placental blood vessels and therefore reflect "placental insufficiency".
• In pregnancies with reduced, absent or reversed end-diastolic velocity, there is an increased
risk of stillbirth, asphyxia, chromosomal and congenital abnormality.
Indications for Doppler are:
• Fetal growth restriction
• Hypertensive disorders of pregnancy
• Low amniotic fluid volume (<5cm)
• Measuring the “resistance index” allows one to compare against expected readings for
gestational age. A resistance index > 95th centile needs careful follow up:
• Repeat the Doppler after 1 week at High Risk Clinic
• Arrange twice weekly CTGs once baby viable
• Absent or reversed end diastolic flow suggests fetal acidosis.
• If <32 weeks or <1kg, CTG at least daily. Deliver if >34 weeks or variability decreases and
movements reduced.

9. Intrapartum diagnosis
• Inadequate intrapartum diagnosis of fetal compromise (hypoxia) is the major
avoidable factor relating to medical personnel in perinatal deaths caused by
intrapartum asphyxia in South Africa.
• It is essential that midwives and doctors are familiar with the indications for
monitoring, what is expected, how to analyse a CTG trace and what to do in the case
of abnormalities.
Intrapartum fetal heart monitoring
• Low risk women should be monitored with fetal heart auscultation after
contractions
• Pinard (fetal) stethoscope and conventional stethoscope are acceptable
• Handheld ultrasound (doptone) preferred as woman, her companion and midwife
can hear sound and be reassured
• CTG machines should be used for high-risk labour only
• They are not recommended for intrapartum use in Community Health Centres
(CHCs).

10. Some Indications for intrapartum CTG
The frequency of CTG monitoring required in labour may vary according to the risk factor and the stage of labour. Where CTG
monitoring is intermittent, then auscultation should be used in between the periods of CTG monitoring
Breech presentation
Vaginal bleeding in labour
Oxytocin augmentation
Fresh meconium-stained liquor
Maternal pyrexia >38°C
Epidural anaesthesia
Labour after Caesarean section in a previous pregnancy
Induction of labour – woman now in labour
Suspected sepsis or chorioamnionitis
Impaired fetal growth
Concern about FHR on auscultation or previous suspicious trace
Tachysystole (>5 contractions in 10min, FHR normal) / uterine hypertonus (contractions lasting >2min)
Maternal diabetes
Hypertensive disorders of pregnancy
Multiple pregnancy
Post-term pregnancy (≥42 weeks)
Prolonged rupture of membranes >24 hours
Stillbirth or labour-related neonatal death in previous pregnancy
Oligohydramnios prior to labour
Preterm labour <37 weeks (On admission to exclude fetal distress prior to tocolysis, then as indicated)
Poor progress in labour
Other maternal or fetal disorders

11. Intrapartum cardiotocography
• CTG machines should ideally be available in all hospitals managing
women in labour,
• But in the South African setting, there may be inadequate numbers of
CTG machines at many hospitals
Monitoring at such hospitals may need to rely on the methods used for
low-risk pregnancies:
• Intermittent auscultation of the fetal heart (by stethoscope or
doptone)
• With clinical palpation of contractions

12. Fetal physiology as it relates to CTG
• CTGs are an indirect measure of several aspects of fetal health, including central nervous system function, fetal oxygenation,
autonomic control of heart rate, fetal movements and sleep-wake cycles.
• These are all influenced by the condition of the baby and its in-utero environment.
• FHR is estimated by detecting movements of the heart valves and interventricular septum, using Doppler ultrasound and
autocorrelation
• Without input from the central nervous system, the baby’s heart would beat at a very consistent ‘intrinsic heart rate’ of about 150
beats per minute at term.
• The sympathetic system increases the heart rate by on average 10 beats per minute, parasympathetic system reduces the heart rate by
on average 20 beats per minute.
• The parasympathetic tone (via the vagus nerve) is continuously changing to be exactly appropriate for the baby from moment to
moment, thus imparting short-term variability.
• During uterine contractions, the pressure inside the uterus and the intervillous space increases.
• During most of the contraction, no maternal blood flows to the placenta. A healthy baby and placenta have sufficient reserve
• When the baby has limited reserve, he or she may become hypoxic during uterine contractions.
• When oxygen deprivation occurs temporarily during labour contractions, this mechanism may cause repetitive slowing of the heart
rate (decelerations).
• Because it takes some time after the end of the contraction for oxygen to reach the baby again, in a more compromised baby, recovery
of the heart rate after the end of the contraction takes more than 30 seconds (a ‘late’ deceleration).
• Decelerations can also be due to cord compression or compression of the baby’s head.

13. Fetal behavioural states
• Periods of quiet sleep (no eye movements), alternating with periods of active sleep
(rapid eye movements - REM).
• The unborn baby alternates quite abruptly every 20 to 40 minutes between the two
distinct sleep states
• During quiet sleep the heart rate is less variable and there are no breathing
movements or accelerations
• During active (REM) sleep, the baby is more active, the heart rate more variable, with
accelerations in response to fetal movements, and episodes of breathing movements.
• Transitions between these periods become clear after 32–34 weeks, because of fetal
nervous system maturation.
• Vibroacoustic stimulation can be used to stimulate a switch from a state of quiet sleep
with reduced variability, however maintaining monitoring for longer time periods is a
more physiological alternative.
• During labour, when the cervix is dilated, digital fetal scalp stimulation can be done.

14. CTG Analysis
• CTG interpretation can be challenging and inter-observer variation even among specialists familiar
with international guidelines is a well-documented phenomenon.
• Additionally, CTGs have a high degree of sensitivity but low specificity.
Important principles
• Always talk to the woman and her birth companion(s) about what is happening and take her
preferences into account.
• Explain what the CTG does and what your findings are.
• The CTG should never be interpreted in isolation from the patient-take into account any antenatal and
intrapartum risk factors, the current wellbeing of the woman and unborn baby and, intrapartum, the
progress of labour.
• The CTG is never a substitute for good clinical observation and judgement.
• Ensure that the focus of care remains on the woman rather than the cardiotocography trace.
• A running CTG is never a reason to leave the woman unattended during labour. Continue observations
and support.
• Remember, a CTG trace can be extremely difficult to interpret during the second stage of labour.

15. Assess the CTG trace
Principles for intrapartum cardiotocography trace interpretation
• Check the paper speed. Most South African clinicians are used to interpreting patterns on CTGs
running at 1cm/min
• If your machine is running at a faster speed, adjust the paper speed to 1cm/min speed.
• When reviewing the cardiotocography trace, assess and document contractions and all 4 features
of fetal heart rate: baseline rate; baseline variability; presence or absence of decelerations;
presence of accelerations.
• Use these four features to then categorise the trace
• Analysing the tocography (contractions) helps understand the context of the fetus and FHR
• If it is difficult to categorise or interpret a cardiotocography trace, obtain a review by a senior
midwife or a medical officer.
• If there is doubt about the significance of a finding it is often helpful to review the previous
tracings.
• When in doubt, continue the tracing until it becomes clear whether there is cause for concern or
not.

16. Elements of the trace to be assessed
The interpretation of CTGs is dealt with in detail in guidelines produced by FIGO and NICE and others.
A summary of the core aspects is included here.
• Contractions: Duration, frequency, form and relationship to the FHR can all be determined from the tocography trace,
strength of the contraction cannot be determined from the trace
• Uterine action should be considered excessive if there are more than 5 contractions in a 10 minutes period (tachysystole)
or contractions last more than 2 minutes (uterine hypertonus)
• Baseline fetal heart rate, differentiate between fetal and maternal heartbeats, Baseline fetal heart rate will usually be
between 110 and 160 beats/minute, preterm fetuses tend to have higher heart rates, while prolonged pregnancies lower
• If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual
care as the risk of fetal acidosis is low
• Tachycardia refers to a baseline value above 160 bpm lasting more than 10 minutes.
• Maternal pyrexia is the most frequent cause, and it may be of extrauterine origin or associated with intrauterine
infection.
• In the initial stages of a non-acute fetal hypoxemia,
• Maternal dehydration and uterine rupture (especially in patient with previous CS) and obstructed labour may result in
fetal tachycardia.
• Other less frequent causes are the administration of beta-agonists, parasympathetic blockers, and fetal arrhythmias
• Bradycardia is a baseline value below 110 bpm lasting more than 10 minutes.
• Values between 100 and 110 bpm may occur in normal fetuses, especially in post-term pregnancies.
• Maternal hypothermia, administration of beta-blockers, and fetal arrhythmias.

17. Elements of the trace to be assessed
Baseline variability
• Baseline variability is the minor fluctuation in baseline FHR.
• It is assessed by estimating the difference in bpm between the highest peak and lowest trough of fluctuation in
one-minute segments of the trace.
• Normal variability 5-25 beats per minute
• Reduced variability <5 beats per minute
• Absent variability <3 beats per minute
• Intermittent periods of reduced baseline variability are normal, especially during periods of quiescence ('quiet
sleep') which last 20-40 minutes, or after drugs such as MgSO4, opioids and betamethasone.
• Preterm fetuses may also have lower variability.
Accelerations
• The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the
baby is healthy.
• The absence of accelerations on an otherwise normal cardiotocograph trace during labour, does not indicate fetal
acidosis.
• A normal antenatal trace will have at least 2 accelerations in 20 minutes.

18. Elements of the trace to be assessed
• Decelerations are transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least
15 seconds.
• The specific features of the deceleration inform the classification.
• When describing decelerations specify: their timing in relation to the peaks of the contractions, the duration of the
individual decelerations, whether or not the fetal heart rate returns to baseline, how long they have been present
for, whether they occur with over 50% of contractions
• The presence or absence of shouldering, the presence or absence of reduced variability within the deceleration.,
depth of deceleration – especially if FHR drops to or by 60 bpm ,
• Describe decelerations as 'early', 'variable' or 'late'. Do not use the terms 'typical' and 'atypical' because they can
cause confusion.
• Early decelerations are usually benign and often associated with head compression. If there are no non-reassuring
or abnormal features they should not prompt further action.
• Variable decelerations are a repetitive or intermittent decreasing of FHR with rapid onset and recovery.
• Time relationships with contraction cycle may be variable but most commonly occur simultaneously with
contractions.
• If variable decelerations with no concerning characteristics are observed: be aware that these are very common,
can be a normal feature in an otherwise uncomplicated labour and birth, and are usually a result of cord
compression ask the woman to change position or mobilise.
• Complicated variable decelerations are defined by their features as well as the other features of the CTG.

19. Elements of the trace to be assessed
These additional non-reassuring features indicate the likelihood of fetal hypoxia and the
definition includes one or more of the following:
• Rising baseline rate or, fetal tachycardia, Reduced or absent baseline variability ,
• Slow return to baseline FHR after the end of the contraction , Onset of the nadir after the peak
of the contraction
• Large amplitude (by 60bpm or to 60bpm) and /or long duration (60 seconds) , Loss of pre and
post deceleration shouldering (abrupt brief increases in FHR baseline)
Late decelerations (U-shaped or with reduced variability) have a gradual onset, gradual return to
the baseline (>30 seconds), or reduced variability within the deceleration.
• When contractions are adequately monitored, late decelerations start more than 20 seconds
after the onset of a contraction, the nadir is after the acme, and return to the baseline occurs
after the end of the contraction.
• Prolonged decelerations last more than 3 minutes and are likely to include a chemoreceptor-
mediated component and thus to indicate hypoxemia. Isolated prolonged decelerations are
commonly due to supine position.

20. Sinusoidal pattern
• Regular, smooth, undulating signal, resembling a sine wave, with an amplitude of 5–15 bpm, and a
frequency of 3–5 cycles per minute. This pattern lasts more than 30 minutes.
• The pathophysiological basis for the sinusoidal pattern is incompletely understood, but it usually
occurs in association with severe fetal anemia, as is found in:
• Anti-D alloimmunization,
• fetal–maternal hemorrhage, ruptured vasa previa
• Twin-to-twin transfusion syndrome
• Less frequently, it has been described in cases of acute fetal hypoxia, infection, cardiac
malformations, hydrocephalus and gastroschisis.
• The pseudo-sinusoidal pattern resembles the sinusoidal pattern but has a more jagged “saw-tooth”
appearance, rather than the smooth sine-wave form.
• The duration seldom exceeds 30 minutes and is characterized by normal patterns before and after.
• This pattern has been described after analgesic administration to the mother, and during periods of
fetal sucking and other mouth movements.

21. Categorise the CTG trace
DESCRIPTION
OF FEATURE
REASSURING NON-REASSURING ABNORMAL
Baseline 110-160 100-109 or
161-180
Less than 100 > 5min
Greater than 180
Sinusoidal pattern
Variability 5-25bpm Reduced <5 bpm for 30
to 50 min
Reduced <5 bpm for >50
min
Deceleration
s
None Typical variable
decelerations
Complicated variable or
Late decelerations or
Prolonged deceleration
Accelerations 2 present in 20 minutes

22. Categorise the CTG trace
TRACE
CATEGORY
NORMAL SUSPICIOUS PATHOLOGICAL
CTG features All CTG features normal 1 Non-Reassuring feature,
others normal
2 Non-Reassuring features
or
1 abnormal feature
Hypoxic
chance
Normal features Features UNLIKELY to be
associated with fetal
compromise when occurring
in isolation
Features LIKELY to be
associated with fetal
compromise
Action
required
NO further action OBSERVE if only 1 feature
[NB: 2 OR MORE Non-
Reassuring features makes
trace PATHOLOGICAL and
REQUIRES FURTHER ACTION]
IMMEDIATE
MANAGEMENT OR
URGENT DELIVERY

23. Management plan
1.Call for help if you’re unsure. A second opinion, from medical officer or senior midwife is helpful to obtain and document.
2.For a normal trace - Keep watching. If normal after 20 minutes, return to intermittent auscultation or CTG tracing.
3.For a suspicious trace - Conservative measures.. Be aware of the possible underlying causes and start one or more of the following
conservative measures based on an assessment of the most likely cause(s):
a. Encourage the woman to mobilise or adopt an alternative position (and to avoid being supine)
b. Offer intravenous fluids if the woman is hypotensive or dehydrated
i. Avoid intravenous infusions with dextrose unless otherwise indicated, ii. Do not use sodium bicarbonate for resuscitation
4. For a pathological trace - further interventions. Implement the conservative measures as for suspicious traces. However, additional
steps are necessary for pathological traces:
a. Exclude an acute event (cord prolapse, suspected placental abruption or suspected uterine rupture) b. Reduce contraction frequency
by:
i. Reducing or stopping oxytocin if it is being used and/or ii. Offering a tocolytic drug
d. Prepare for an urgent birth if not improving on conservative measures. Expedite the birth if the acute bradycardia persists for 9 min.
5 “Intrauterine fetal resuscitation” Do not use maternal facial oxygen therapy for intrauterine fetal resuscitation,

24. CTG feature Clinical questions Action to be taken
Early or variable decelerations 1. How is the progress of labour?
2. Is there excessive uterine action (e.g. 6 or more contractions in
ten minutes)?
3. What is the woman's position?
4. Is the woman hypotensive?
5. Has the woman had a vasovagal episode?
6. Have the membranes ruptured? If so, is liquor clear?
1. Change maternal position
2. Check the blood pressure
3. Give 500ml bolus of fluid
4. Stop any oxytocin augmentation
5. Consider tocolysis if excessive uterine action
6. Consider vaginal examination to exclude cord prolapse or cord
presentation
7. If labour progressing well, aim for vaginal delivery
“Flat” CTG / variability reduced
(less than 5bpm bandwidth)
1. Is there any evidence of congenital infection (e.g. has syphilis
serology been checked recently)?
2. Any evidence of a congenital anomaly on ultrasound scan?
3. Was there oligohydramnios or polyhydramnios?
4. Has the woman had an opioid?
5. Is the woman sedated / drug dependent?
6. Has the woman received drugs which suppress the fetal CNS (e.g.
MgSO4 or betamethasone)?
7. Have the membranes ruptured? If so, is liquor clear?
8. How is the progress of labour?
1. In the absence of any other worrying features, continue the trace for at
least 50 minutes, to see if variability returns to normal (over 5bpm
bandwidth)
2. If decreased variability persists beyond 50 minutes, try fetal scalp
stimulation or acoustic stimulation, change maternal position and continue
CTG
3. If variability remains persistently under 5bpm for 50 minutes and vaginal
delivery is not anticipated within the next hour, then consider CS
4. If there are other non-reassuring CTG features, such as fetal tachycardia or
decelerations, (as well as reduced variability), then earlier intervention may
be indicated
Late decelerations (occurring with
over half of contractions; not
isolated late deceleration)
1. How is the progress of labour?
2. Is there excessive uterine action (e.g.,6 or more contractions in
ten minutes)?
3. What is the woman's position?
4. Is the woman hypotensive?
5. Has the woman had a vasovagal episode?
Have the membranes ruptured? If so, is liquor clear?
1. Address any reversible cause (e.g. stop oxytocin augmentation, change
maternal position)
2. Consider tocolysis with salbutamol 100-250mcg IVI (dilute in 10ml WFI)
[contraindications: cardiac disease; maternal pulse >110bpm]
3. Consider assisted delivery if fully dilated and spontaneous delivery not
imminent
Prepare for CS if vaginal delivery is not anticipated within the next hour

25. Persistent fetal bradycardia,
including single prolonged
deceleration (>9min)
1. Has the heart rate been bradycardic from the start of
the CTG trace, or was the heart rate previously
normal (i.e. now prolonged deceleration?)
2. Is the CTG picking up the maternal pulse or fetal heart
rate?
3. Is the variability of the baseline reduced or normal?
4. Is the cervix fully dilated?
5. Is the woman lying supine?
6. Is the uterus overstimulated with oxytocin?
7. Is the woman hypotensive?
8. Are there signs of placental abruption or ruptured
uterus?
9. Is there a cord prolapse?
Are there good fetal movements?
1. Confirm baby is alive and that the CTG trace is picking up fetal
rather than maternal pulse (Ultrasound scan may help)
2. Address any reversible cause (e.g., stop oxytocin augmentation,
change maternal position, maternal fluid resuscitation)
3. Consider a fetal heart block if baby is moving well and baseline
variability is good. In this case refer to a centre with specialist
neonatal services if possible. Emergency delivery is not indicated.
4. Consider assisted delivery if fully dilated and spontaneous delivery
not imminent.
5. If delivery not imminent, consider emergency caesarean section.
However, note that with a persistent bradycardia and reduced
baseline variability, prognosis for the baby may not be good, and
the presence of the fetal heartbeat should be re-checked in theatre
before starting the CS. Only proceed with the CS if the fetal
heartbeat is still present.
Fetal tachycardia 1. Is the variability of the baseline reduced or normal?
2. Are there fetal heart rate accelerations?
3. Are there fetal heart rate decelerations?
4. How is the progress of labour?
5. Is there maternal infection / pyrexia?
6. Is the mother dehydrated?
7. Has the mother taken or been administered drugs
that can increase the heart rate (e.g. salbutamol?)
8. Are there signs of obstructed labour?
9. Is there uterine rupture?
1. Exclude CPD / ruptured uterus
2. If temperature >38C investigate and treat
3. Check blood pressure
4. Give 500ml bolus of fluid if dehydrated
5. If baseline variability is good, an isolated fetal tachycardia is not an
indication for caesarean section. Allow labour to progress and
repeat CTG within an hour.

26. Excessive uterine action 1. Is the woman receiving oxytocin?
2. Has the woman recently received prostaglandins /
misoprostol / umchamo wemfene / isihlambezo /
other herbal oxytocic?
1. Stop or reduce the oxytocin infusion
2. Consider the possibility of placental abruption
3. Consider tocolysis with salbutamol 100-250mcg IVI (dilute in 10ml
WFI) [contraindications: cardiac disease; maternal pulse >120bpm]
Inadequate quality CTG (loss of
contact)
1. What is the lie, presentation of the fetus and the
position and level of the presenting part of the fetus?
2. Can you identify through auscultation a place where
the fetal heart is clearly heard?
3. Does the mother feel active feta movements?
1. Do not make any conclusions about the fetal condition based on a
CTG tracing with frequent episodes of loss of contact
2. Check maternal pulse rate
3. Reposition ultrasound transducer to a location where the fetal
heart can be clearly heard, making sure that the transducer is not
picking up the maternal pulse
4. A change of maternal position may assist in getting a clearer CTG
signal. However, avoid the supine maternal position
5. Ultrasound scan may be helpful in locating the fetal heart location
and confirming that it is beating.

27. Action to be taken following birth if Apgar <5.
• In settings where it is possible, it aids clinical understanding and documentation to perform
umbilical cord blood gas analysis and send the placenta for histology.
Cord blood gas
• Isolate a 10cm segment of cord immediately after delivery and perform blood gas analysis
within one hour of delivery.
• Inform paediatrician, or institute appropriate management if:
• Arterial pH < 7.15 (5th centile for term infants)
• Arterial Base excess >-10
Placental histology
• Place whole placenta into bucket supplied by laboratory.
• Pour formalin over placenta until it is completely covered.
• Ensure lid is tightly closed and bucket correctly labelled.
• Send specimen to laboratory with properly completed histology form, ideally within 24
hours.

28. Reassuring antepartum CTG with no abnormal features. Also demonstrates quiet/active sleep cycle of the fetus
Pathological CTG – reduced variability and prolonged shallow late decelerations

29. Classic early decelerations during labour – usually pressure on the head or cord
Classic variable decelerations during labour

30. Classic late decelerations – recover long after end of the contraction, then improve after reducing oxytocin
Severe hypoxia during labour: Baseline tachycardia, absent baseline variability, late decelerations

31. typical pattern of placental abruption. In the second half of the trace only maternal heart rate seen (fetal
death)

32. THANK YOU