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Cardiotocography
This document discusses cardiotocography (CTG), which is a method for electronic fetal monitoring. It outlines the basic patterns seen on a CTG including baseline heart rate, variability, accelerations, and decelerations. It then describes how to interpret each component of a CTG reading based on whether findings are reassuring, non-reassuring, or abnormal. Management recommendations are provided depending on the CTG category of normal, suspicious, pathological, or need for urgent intervention. Conservative measures that can be tried include changing the mother's position, giving intravenous fluids, and reducing uterine contractions.
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- 1.
- 2. Features of theCTG Basic patterns: 1. Baseline heart Rate 2. Variability Periodic Changes 1.Accelerations 4.Decelerations
- 3. APPROACH TO CTG DR >determine risk (Pre Eclampsia, Chorio, Meconium) C > Contractions >Tachysystole,HyperStimulation B > Baseline heart Rate V > Variability A > Accelerations D > Decelerations O > Overall Impression
- 4. BRA> Baseline fetal heartrate Reassuring: 110 to 160 b/m Non-Reassuring: 100 to 109 b/m or 161 to 180 b/m Abnormal: <100 b/m or >180 b/m
- 5. V > Baselinevariability reassuring: 5 to 25 b/min non-reassuring: <5 b/min for 30 to 50 minutes more than 25b/min for 15 to 25 minutes abnormal: less than 5 b/min for more than 50 minutes more than 25 b/min for more than 25 minutes sinusoidal. Normal Variability represents an intact nervous pathway
- 6. Reduced variability canbe caused by any of the following: ² •Fetal sleeping – this should last no longer than 40 minutes (most common cause) •Fetal acidosis (due to hypoxia) – more likely if late decelerations are also present •Fetal tachycardia •Drugs – opiates / benzodiazepines / methyldopa / magnesium sulphate •Prematurity – variability is reduced at earlier gestation (<28 weeks) •Congenital heart abnormalities
- 7. A >>Accelerations Incin FHR of 15bpm or more,lasting for atleast 15sec the presence of FHR accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy absence of accelerations on an otherwise normal cardiotocograph trace does not indicate fetal acidosis. If digital fetal scalp stimulation (during vaginal examination) leads to an acceleration in fetal heart rate, regard this as a sign that the baby is healthy. Take this into account when reviewing the whole clinical picture.
- 8. D>>Decelerations Slowing ofFHR of 15bpm for atleast 15sec EARLY DECELERATIONS: Early decelerations tend to be uniform in shape & occur with each contraction Mirror image of contraction caused by compression of the fetal head during a contraction Inc in ICP > dec blood flow & oxygenation > Inc parasympathetic activity > Dec FHR
- 9. Late Decelerations areusually uniform in shape & depth and occur after each contraction Lowest point occurs >15sec after the peak of contraction Aetiology: Dec in uterine bood flow & therefore oxygen transfer during a uterine contraction
- 10. Variable Decelerations Inconsistentin shape & frequency and in their relationship to uterine contractions Most decelerations that occur in labor are variable Typical variable decelerations have shoulders-accelerations on either side of deceleration this demonstrates a normal physiological response to cord compression & is a reassuring feature
- 12. DECELERATIONS Reassuring: None orearly Variable decelerations with no concerning characteristics for less than 90 minutes Nonreassuring: Variable decelerations with no concerning characteristics for 90min or more OR Variable decelerations with any concerning characteristics in up to 50% of contractions for 30 minutes or more OR Variable decelerations with any concerning characteristics in over 50% of contractions for less than 30 minutes OR Late decelerations in over 50% of contractions for less than 30 minutes, with no maternal or fetal clinical risk factors such as vaginal bleeding or significant meconium
- 13. DECELERATIONS Abnormal: Variable decelerationswith any concerning characteristics in over 50% of contractions for 30 minutes (or less if any maternal or fetal clinical risk factors OR Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors) OR Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more Concerning characteristics: lasting more than 60 seconds; reduced baseline variability within the deceleration; failure to return to baseline; biphasic (W) shape; no shouldering
- 14. Category Definition Management NormalAll features are reassuring Continue cardiotocography (unless it was started because of concerns arising from intermittent auscultation and there are no ongoing risk factors) and usual care Talk to the woman and her birth companion(s) about what is happening Suspicious 1 non-reassuring feature AND 2 normal/reassuring features Correct any underlying causes, such as hypotension or uterine hyperstimulation Perform a full set of maternal observations Start 1 or more conservative measures Inform an obstetrician or the senior midwife 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
- 15. Pathological 1 abnormalfeature OR 2 non-reassuring features • Obtain a review by an obstetrician and a senior midwife • 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 • If the cardiotocograph trace is still pathological after implementing conservative measures obtain a further review by an obstetrician and a senior midwife offer digital 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.
- 16. Category Definition Management Needfor urgent intervention Acute bradycardia, or a single prolonged deceleration for 3 minutes or more • 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
- 17. Conservative Measures basedon an assessment of the most likely cause(s): encourage the woman to mobilise or adopt an alternative position (and to avoid being supine) offer intravenous fluids if the woman is hypotensive reduce contraction frequency by reducing or stopping oxytocin if it is being used and/or offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg)
Editor's Notes
- #5 Estimated over a 5 to 10 min period of ctg excluding accelerations or decelerations although a baseline fetal heart rate between 100 and 109 beats/minute is a non-reassuring feature, continue usual care if there is normal baseline variability and no variable or late decelerations
- #6 intermittent periods of reduced baseline variability are normal, especially during periods of quiescence ('sleep').