This document provides guidance on cardiotocography (CTG), which assesses fetal well-being by monitoring the fetal heart rate and uterine contractions. It outlines the indications for CTG, how to perform and interpret a CTG, management based on CTG findings, and conservative measures that can be tried to improve abnormal tracings before expediting delivery. Key aspects of CTG include assessing the baseline heart rate, variability, accelerations, decelerations, and developing an overall impression of normal, suspicious, or pathological to guide management decisions.

1. CARDIOTOCOGRAPHY
Dr Shipra Kunwar
MD,FMAS,FICOG,MRCOG
Prof and head
Era’s lucknow medical college
lucknow

2. Assessment of fetal
well being
IA
EFM

5. INDICATIONS
CHORIOANIONITIS
MECONIUM
HYPERTENSION
OXYTOCIN
CONFIRMED DELAY IN LABOUR
PROLONGED RUPTURE OF MEMBRANES
FRESH VAGINAL BLEEDING IN LABOUR

6. NAME /AGE
TIME
DURATION
PAPER SPEED 1cm/min or 3 cm/min
PRESENCE OF FETAL BLOOD SAMPLING

7. Dr- define risk
C –contraction
B- Baseline
Ra-Rate
V-Variability
A-Accelerations
D-decelerations
O- overall impression

8. Define risk
contractions
Baseline rate
acelerationsvariabilty
declerations
Overall

9. DEFINE RISK
PREECLAMPSIA
GDM
FGR
PREVIOUS CAESAREAN
POSTDATES
PROM

10. BASELINE
110-160 beats/min
100- 109 nonreassuring
<100 abnormal
160-179 nonreassuring
> 180 abnormal

12. Bradycardia
Head compression
Congenital heart block
Maternal hypothermia
Severe pyelonephritis
Tachycardia
Materal hyperthermia
Chorioamnionitis
Maternal hypotension
Fetal compromise
Cardiac arrhythmias
Maternal administration of
parasympathetic blockers(
atropine) or
sympathomimetic drugs
(terbutaline)

13. ACCELERATIONS
INCREASE IN FETAL HEART RATE OF MORE THAN 15
BEATS PER MIN LASTING FOR MORE THAN 15
SECONDS
DENOTES A HEALTHY FETUS.

15. Variabilty
5-25 beats
Decreased variability is –parasympathetic stimulation
Seen in sleep , hypoxia, administration of many drugs
Increased variability is a sign of sympathetic
stimulation

16. NICE CLASSIFICATION
If variability reduced < 5 beats for < 50 min it is
referred to as non-reassuring feature.
If variability < 5 beats > 50 min then it is abnormal
feature
If variability > 25 for < 25 min then non-reassuring
If variabilty > 25 for >25 min then its an abnormal
feature

17. Decelerations
Decelerations are an abrupt decrease in
the baseline fetal heart rate of greater than 15 bpm fo
r greater than 15seconds.
There are a number of different types of
decelerations, each with varying significance.

18. Decelerations
Early Late Variable
Shoulder
pattern
Saltatory
pattern
Lambda
Pattern
Overshoot
Prolonged

19. Not to be used
Typical:
shoulders
Atypical :
Overshoot
Saltatory
Lambda
Slow return to baseline (late component)
Baseline returns to a lower level(after deceleration)
Biphasic(W shape)loss of variability during
deceleration

20. Early deceleration
Symmetrical Gradual decrease and return to baseline
associated with a contraction
The degree of deceleration is generally proportional
to the contaction strength and rarely falls below 100-
110 bpm or 20-30 bpm below baseline.
May be present physiologically in active labour
Not associated with tachycardia , loss of variability or
other foetal heart rate changes

21. Early decelerations

22. Pathophysiology
Head compression
Vagal nerve stimulation
Deceleration
Not associated with fetal hypoxia , acidemia or low apgar
scores .

23. Late deceleration
It is a smooth , gradual* and symmetrical decrease in
foetal heart rate , beginning at or after the contraction
peak and returning to baseline only after the contraction
has ended .
Not accompanied by accelerations .
Causes –
Maternal hypotension
Excessive uterine activity
Placental dysfunction
( Gradual - ≥ 30 sec from onset to nadir )

25. NICE CLASSIFICATION
Late decelerations for < 30 min is a non-reassuring
feature
however, if > 30 min it is an abnormal feature

26. Variable deceleration
Abrupt decrease in the foetal heart rate 15 bpm not
related to contractions.

27. Variable decelerations are usually caused by umbilical cord
compression:
The umbilical vein is often occluded first causing an acceleration in
response.
Then the umbilical artery is occluded causing a subsequent rapid
deceleration.
When pressure on the cord is reduced another acceleration occurs
and then the baseline rate returns.
Accelerations before and after a variable deceleration are known as
the “shoulders of deceleration”.
Their presence indicates the fetus is not yet hypoxic and is adapting
to the reduced blood flow.

31. Saltatory
Rapidly reccuring couplets of acceleration and
deceleration causing relatively large oscillations of
the baseline foetal heart rate .

32. Lambda
An acceleration followed by variable
decelerationwith no acceleration at the end of
deceleration.
Cause-
Mild cord compression or stretch

33. Overshoot
Variable deceleration followed by acceleration

34. Nice classification
Variable declerations if without concerning
characteristics and each of < 60 seconds for > 90 min
is non –reassuring.
And if concerning characteristics present and
variable declerations seen <50% contractions occur
for <30 min – nonreassuring
And if concerning characteristics present and
associated with > 50% contractions –abnormal.

35. Reading A CTG

36. OVERALL IMPRESSION
NORMAL SUSPICIOUS PATHOLOGICAL
All features
normal
1 non-
reassuring
feature
1 abnormal or 2
non-reassuring
features

38. FIGO NICE ACOG
Baseline Normal 110-150 110-160 110-160
Tachycardia - >180 bpm (161–180 bpm is
moderate tachycardia)
>160 bpm
Bradycardia <80 bpm <100 bpm (100–109 bpm is
moderate bradycardia)
<110 bpm
Variability Normal Between 5 and 25
bpm
≥5 bpm between
contractions
6–25 bpm
(moderate
variability)
Reduced <5 bpm for >40 min
(suspicious if
variability 5–10 bpm
for >40 min)
<5 bpm for 40–90 min
(nonreassuring)
>90 min
(abnormal)
≤5 bpm
(minimal
variability)
Increased >25 bpm - >25 bpm
(marked
variability)

39. FIGO NICE ACOG
Acceleration Transient
increase in
heart rate of
≥15 bpm and
lasting ≥15 s
Transient increases in FHR
of ≥15 bpm and lasting ≥15 s
abrupt increase
(onset to peak in <30
s) in the FHR ≥15 bpm
above the baseline,
with duration of ≥15 s
but <2 min
Decelerartion Early - Uniform, repetitive,
periodic slowing of FHR
with onset early in the
contraction and return to
baseline at the end of
the contraction
gradual decrease and
return of the FHR
associated with a
uterine contractions
The deceleration is
coincident with the
Contraction.
Late - Uniform, repetitive,
periodic slowing of FHR
ending after the
contraction.
associated with a
uterine contraction.
recovery of the
deceleration occur
ending of the
contraction
Variable - Variable, intermittent
periodic slowing of FHR
with rapid onset and
abrupt decrease in
FHR ≥15 bpm, lasting
≥15 s, and <2 min in

40. Management

41. Normal CTG
All features are reassuring
Management-
Continue CTG and usual care
Talk to the woman and her birth companion(s) about what is
happening

42. Suspicious CTG
1 non-reassuring feature AND 2 reassuring features
Management -
Correct any underlying causes, such as hypotension or
uterine hyperstimulation
Perform a full set of maternal observations
Start 1 or more conservative measures
Inform a senior obstetrician
Document a plan for reviewing the whole clinical picture
and the CTG findings
Talk to the woman and her birth companion(s) about what is
happening and take her preferences into account

43. Pathological CTG
1 abnormal feature OR 2 non-reassuring
features
Management-
Obtain a review by a senior obstetrician
Exclude acute events (for example, cord prolapse, suspected
placental abruption or suspected uterine rupture)
Correct any underlying causes, such as hypotension or
uterine hyperstimulation
Start 1 or more conservative measures
Talk to the woman and her birth companion(s) about what
is happening and take her preferences into account

44. If the cardiotocograph trace is still pathological after
implementing conservative measures:
– obtain a further review by a senior obstetrician
– offer digital fetal scalp stimulation and document the outcome
If the cardiotocograph trace is still pathological after fetal
scalp stimulation:
– consider fetal blood sampling
– consider expediting the birth
– take the woman's preferences into account

45. Conservative methods
NICE
mg).
Measures ACOG NICE
maternal oxygen
+ -
changing the mother's
position + +
treating maternal
hypotension. + +
discontinuing labor
stimulation + +
Tocolytics
- +

46. MATERNAL
POSITIONING

47. IV FLUIDS
MATERNAL HYDRATION IS IMPORTANT .
OVERLOAD SHOULD BE AVOIDED
DEXTROSE (5% AND 10%) ARE POTENTIALY
DANGEROUS AND SHOULD BE AVOIDED.

48. INTRAUTERINE
RESUSCITATION
S-STOP OXYTOCIN
P-POSITION
O-OXYGEN
I-IV FLUIDS
L-LOW BP – VASOPRESSORS
T-TOCOLYSIS

49. Need for urgent intervention is
required when-Acute bradycardia, or a single prolonged deceleration for 3 minutes
or more
Management –
Urgently seek obstetric help
If there has been an acute event (for example, cord prolapse,
suspected placental abruption or suspected uterine rupture), expedite
the birth
Correct any underlying causes, such as hypotension or uterine
hyperstimulation
Start 1 or more conservative measures*
Make preparations for an urgent birth
Talk to the woman and her birth companion(s) about what is
happening and take her preferences into account
Expedite the birth if the acute bradycardia persists for 9 minutes
If the fetal heart rate recovers at any time up to 9 minutes, reassess
any decision to expedite the birth, in discussion with the woman

50. Remember the 'Rule of 3' for fetal bradycardia:
3 minutes – call for help
6 minutes – move to theatre
9 minutes – prepare for assisted delivery
12 minutes – aim to deliver the baby.
The pH of the fetus has been shown to drop at the
rate of 0.01 every 2–3 minutes.

51. Foetal Scalp Blood
Sampling
Interpretation ph lactate
Normal ≥7.25 ≤4.1
Borderline 7.21–7.24 4.2–4.8
Abnormal ≤ 7.20 ≥ 4.9

52. STAN

53. Rise in ST segment reperesents a compensated
myocardial stress and a switch to anaerobic
metabolism
A progressive rise in T/QRS RATIO represents
continued anaerobic metabolism by adrenaline surge
due to stress caused by hypoxia
Biphasic and negative T wave indicate initial phases
of myocardial ischemia or hypoxia.
There may be conductance problems
STAN should not be used fetuses less than 36 weeks

55. Normal st segment BIPHASIC 1
BIPHASIC 2 BIPHASIC 3

56. Key messages
Being methodical and reporting all important aspects
in CTG is essential
-hourly reporting as trace changes
Remember the dr and spoilt the patient