The document discusses the interpretation and management of CTG (cardiotocography). It describes the steps to interpret a CTG tracing, including evaluating the fetal heart rate baseline, variability, accelerations, decelerations and their correlation with uterine contractions. It provides a structured DR C BRA VADO method to categorize CTG tracings as normal, suspicious or pathological. The management strategies for each category are then outlined, such as continued monitoring, additional tests like fetal scalp blood pH, or expedited delivery depending on the severity of the CTG abnormalities. Specific situations like the second stage of labor, placental abruption or fetal abnormalities are also addressed.

1. CTG
Interpretation and management
Aboubakr Elnashar: Benha University Hospital, EgyptAboubakr Elnashar

2. INTERPRETATION
 Steps
1. Evaluate tracing.
Do you have enough of a continuous strip for
interpretation
2. Identify
 FHR baseline
 BBV
absent, minimal, moderate or marked
 Accelerations or
 Decelerations.
Aboubakr Elnashar

3. 3. Evaluate contractions
regularity, rate, intensity, duration of
contractions.
4. Correlate accelerations and decelerations with
uterine contractions and identify the pattern.
5. Determine whether the FHR recording is
reassuring, non reassuring or ominous.
6. Document interpretation of
FHR
clinical conclusion
plan of care.
Aboubakr Elnashar

4.  STRUCTURED METHOD
The most popular structure can be remembered using the
acronym:
DR C BRA VADO = 7 items
1. Demographics of the patient
2. indication of CTG
3. Any obvious abnormalities
DR - Define Risk ? PET, diabetes, IUGR, smoker
C - Contractions - Frequency, duration, intensity, resting
tone
BRA - Baseline rate - 110-160bpm
V - Variability - 5-25 beats
A - Accelerations - 2 in 20 minutes
D - Decelerations - abnormal
O - Overall risk assessmentAboubakr Elnashar

5.  Define Risk
• You first need to assess if this pregnancy is high or low risk
• This is important as it gives more context to the CTG
reading. e.g. If the pregnancy is high risk, your threshold for
intervening may be lowered
• Maternal medical illness
Gestational diabetes
Hypertension
Asthma.
• Obstetric complications
Multiple gestation
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of the membranes
Congenital malformations
Oxytocin induction/augmentation of labor
Pre-eclampsia. Aboubakr Elnashar

6. O – Overall assessment
Once you have assessed all aspects of the CTG
you need to give your overall impression
Aboubakr Elnashar

7. Categorization of FHR traces
Aboubakr Elnashar

8. Aboubakr Elnashar

9. Aboubakr Elnashar

10. Aboubakr Elnashar

11. II. MANAGEMENT
FIGO Fetal HR Pattern Classification
Normal means fetal health
• Suspicious means
- continue observation
- additional tests
• Pathological means
- additional test
- intervention
1. Normal/Reassuring
risk of fetal hypoxia in spontaneous labour is low:
Manage normally.
Aboubakr Elnashar

12. 2. Suspicious/Equivocal/ Non reassuring
 continue EFM
 Amniotomy should be performed
 +/- fetal scalp blood pH if meconium stained
liquor is present.
Aboubakr Elnashar

13. Initial Evaluation and Treatment of Nonreassuring
Fetal Heart Rate Patterns
Discontinuation of any labor stimulating agent
Cervical examination:
umbilical cord prolapse or
rapid cervical dilation or
descent of the fetal head
Changing maternal position
left or right lateral recumbent position:
reducing compression of the vena cava and improving
uteroplacental blood flow
Aboubakr Elnashar

14. Monitoring BP
for evidence of hypotension, especially in those with
regional anesthesia
if present: treatment with ephedrine or phenylephrine
may be warranted
Assessment of patient for uterine hyperstimulation
 by evaluating uterine contraction frequency and
duration
In the presence of abnormal FHR patterns and
uterine hypercontractility not secondary to oxytocin
infusion: tocolysis
 subcutaneous terbutaline 0.25 milligrams
Aboubakr Elnashar

15. In cases of suspected or confirmed acute fetal
compromise:
delivery should be accomplished as soon as
possible, accounting for the severity of the FHR
abnormality and relevant maternal factors
The accepted standard has been that ideally this
should be accomplished within 30 minutes.
Aboubakr Elnashar

16. Maternal facial oxygen therapy
Prolonged use of maternal facial oxygen therapy
may be harmful to the fetus and should be avoided.
There is no research evidence evaluating the
benefits or risks associated with the short-term use
of maternal facial oxygen therapy in cases of
suspected fetal compromise .•C
Aboubakr Elnashar

17. 3. Abnormal/Pathological
Amniotomy
Fetal scalp blood pH if meconium stained
liquor to determine subsequent management
or
Deliver if clinically indicated.
Deliver if fetal scalp pH required but not
obtainable i.e. if cervix not sufficiently dilated
or equipment not available.
Aboubakr Elnashar

18. III. SPECIAL SITUATIONS
Second Stage of Labour
Signs of hypoxia:
• Tachycardia
• ↓ variability between and during decelerations
• Late decelerations
• Failure to return to baseline (or > 100 bpm)
after decelerations
• Prolonged bradycardia
* Delay of 20 min → asphyxiated infant
Aboubakr Elnashar

19. Placental abruption
• Uterine irritability shown by frequent
contractions of low amplitude
• FHR trace:
initially tachycardia
± decelerations
no accelerations
↓ variability.
Bradycardia is a late and danger sign of
severe asphyxia
Aboubakr Elnashar

20. Fetal abnormality
• CNS abnormality: →
↓ baseline variability
low baseline rate
• Discrepancy between CTG (abnormal) and
biophysical profile (within normal) suggest
chromosomal abnormalities, especially if bony
measurements are reduced/slight IUGR
Aboubakr Elnashar

21. Heart block
• Persistent bradycardia / double counting
• No respond to stimulation
Dying fetus
• Acute/subacute insult : decelerations /
tachycardia / lack of accelerations → ↓
variability → bradycardia
Aboubakr Elnashar

22. Thank you
Aboubakr Elnashar

23. CTG
PATTERN
CAUSE CLINICAL MANAGEMENT
Declaration
Early
2nd Stage NONE
Late Uterine
hypercontractily
Stop oxytocin
Consider terbutaline sc
Oxygen @ 8-10 l/min
Left lateral decubitus
Variable Cord
compression
Consider amnioinfusion
(mild/mod v.d.)
Tachycardia Maternal fever,
tachycardia,
dehydration
Infection screen
Hydrate: crystalloids
Stop tocolysis if pulse>120
SUSPICIOUS CTG
Aboubakr Elnashar

24. PATHOLOGICAL
FETAL SCALP
BLOOD Ph
(If facilities available)
FETAL SCALP
STIMULATION TEST
FETAL VIBROACAUSTIC
STIMULATION TEST
Aboubakr Elnashar

25. PATHOLOGICAL
FETAL SCALP
BLOOD Ph
(If facilities available)
FETAL SCALP
STIMULATION TEST
FETAL VIBROACAUSTIC
STIMULATION TEST
Aboubakr Elnashar

26. Category Definition
Normal All four reassuring
Suspicious 1 non-reassuring
Rest reassuring
Pathological 2 or more non-reassuring
1 or more abnormal
Aboubakr Elnashar

27. b)Abnormal/Pathological Trace
- Baseline FHA> 150 bpm + silent pattern and/or repeated late or
variable decelerations
- Silent pattern for >90 minutes
- Complicated variable decelerations (depth >60 bpm for >60
seconds, changes in shape: over-shoot, decreased or
increased baseline FHR following the decelerations, or absence
of baseline variability in or between decelerations, slow
recovery)
- Combined/biphasic decelerations (variable followed by late)
- Prolonged bradycardia in a suspicious trace
- Prolonged bradycardia> 10 minutes with no signs of recovery
- Repeated late decelerations
- Pronounced loss of baseline variability regardless of baseline
FHR with shallow late decelerations
- Sinusoidal pattern with no accelerations
Aboubakr Elnashar

28. Aboubakr Elnashar

29. a)Normal/Reassuring Trace
- At least two accelerations (> 15 beats per minute
for >15 seconds) in 20 minutes
- Baseline heart rate: 110-150 bpm
- Baseline variability: 5-25 bpm
- Early decelerations (in late first stage of labour)
Aboubakr Elnashar

30. b)Suspicious/Equivocal Trace
- Absence of accelerations for >40 minutes
(non reactive)
- Baseline heart rate: 150-170 bpm or 100-110 bpm
(normal variability, no decelerations)
- Silent pattern (<5 bpm for >40 minutes) although
normal baseline (110-150 bpm), no
decelerations
- Baseline variability >25 bpm in the absence of
accelerations
- Variable decelerations (depth <60 bpm, duration
<60 seconds)
- Occasional transient prolonged bradycardia if
FHR drops to <80 bpm for >2 minutes or
<100 bpm For >3 minutes
Aboubakr Elnashar