CTG INTERPRETATION
Supervisor: Dr Alifah, Dr Tanes
Cardiotocography
• Fetal heart beat
- Baseline fetal heart rate
- Beat to beat variability
- Acceleration
- Deceleration
• Maternal uterine contraction
Baseline fetal heart rate
• Mean level of FHR when this is stable, excluding accelerations and
decelerations
• Determined over a period of 5 or 10 minutes
• Controlled mainly by autonomic nervous system (sympathetic and
para-sympathetic activity)
• Normal baseline: 110-160 bpm
• Abnormalities:
- Baseline tachycardia
- Baseline bradycardia
Baseline tachycardia
Moderate tachycardia: 161-180
Abnormal tachycardia: >180
Causes:
- Excessive fetal movement
- Maternal stress and anxiety
- Maternal pyrexia
- Fetal infection
- Chronic hypoxia
- Gestational age ≤32 weeks
- Fetal catecholamine
Baseline bradycardia
Moderate bradycardia: 100-109
Abnormal bradycardia: <100
Causes
- Gestational age> 40 weeks
- Cord compression
- Congenital heart malformation
- Drug induced: benzodiazepine
Baseline variability
• Minor fluctuations in baseline FHR
• Measured by difference between the highest peak and lowest trough
of fluctuation in a one-minute segment
• Occurs as a result of interaction between nervous system,
chemoreceptors and baroreceptors with cardiac responsiveness
• Normal: ≥5 bpm between contractions
Baseline variability
Reduced variability
• Non- reassuring: <5 for ≥40 but <90min
• Abnormal: <5 for ≥90 min
• Causes
- Fetal sleep
- Administration of drugs to mother
- Gestational age
- Severe hypoxia
Acceleration
• Transient increases in FHR of 15 bpm or more lasting 15s or more
• Indicates normal fetal oxygenation- interaction of nervous system in response to
increase in metabolic demands
• Reactive trace: ≥2 in 20 minutes
• Significance of no acceleration on an otherwise normal CTG is unclear
Deceleration
• Transient episodes of slowing of FHR below the baseline level of more
than 15bpm and lasting 15s or more
Types
- Early deceleration
- Late deceleration
- Variable deceleration
- Prolonged deceleration
Early deceleration
• Uniform, repetitive, periodic slowing of FHR
• Early onset in contraction
• Return to baseline at the end of contraction
Early deceleration
• Caused by compression of fetal head during a contraction
• Decrease in cerebral blood flow and oxygenation
• Detected by cerebral chemoreceptors-> parasympathetic activity
increased-> fall in heart rate
• Management aimed at relieving pressure by changing maternal
posture
Late deceleration
• Uniform, repetitive, periodic slowing of FHR
• Onset mid to the end of contraction
• Nadir more than 20s after the peak of contraction and ends after
the contraction
Late deceleration
• Result of decrease in uterine blood flow during uterine contraction
• Occur after contraction due to the time it takes for circulating blood to
reach aortic arch from the placenta
• Causes
- Reduction in placental blood flow: Abruptio placenta, maternal hypotension,
uterine hyperstimulation
- Placenta pathology: DM, PIH, renal disease
- Fetal compromise: IUGR, prematurity, TTTS, Rhesus isoimmunization
• Management aimed at increasing uterine blood flow and oxygen
transfer across the placenta
Variable deceleration
• Variable, intermittent periodic slowing of FHR
• Rapid onset and recovery
• Relationships with contraction are variable, may occur in isolation
Variable deceleration
• Result of transient compression of the umbilical cord during uterine
contraction
1. Venous return obstructed-> cardiac
output and arterial pressure reduced->
sympathetic activity-> FHR increased
2. Arterial flow obstructed-> fetal
hypertension-> parasympathetic
activity-> FHR decreased
3. Arterial obstruction removed-> fetal
hypotension recurs-> FHR increased till
venous flow returns to normal
Variable deceleration
• Causes: cord around neck, true knot, cord prolapse
• Management aimed at relieving the cord compression
- Change maternal posture
- To exclude cord prolapse
- Stop oxytocin infusion
- Give oxygen
Atypical variable deceleration
• Variable deceleration with any of the following
- Loss of primary or secondary rise in baseline
- Slow return to baseline FHR after the end of contraction
- Prolonged secondary rise in baseline
- Biphasic deceleration
- Loss of variability during deceleration
- Continuation of baseline rate at lower level
Prolonged deceleration
• Abrupt decrease in FHR to level below baseline lasts at least 60-90
seconds
• Pathological if cross 2 contractions (ie 3 minutes)
Prolonged deceleration
• Decrease in oxygen transfer across placenta to fetus, usually result of
decrease in uterine blood flow
• Causes: total umbilical cord occlusion, maternal hypotension, uterine
hyperstimulation
Baseline (bpm) Variability Deceleration Acceleration
(bpm)
Reassuring 110-160 ≥5 None Present
Non-reassuring 100-109 <5 for ≥40 but Early deceleration
161-180 <90min Variable deceleration
Single prolonged deceleration up to 3 min
Abnormal <100 <5 for ≥90 min Atypical variable deceleration
>180 Late deceleration
Sinusoidal Single prolonged deceleration greater than
3 min
Classification
Classification Definition
Normal All four features fall into category
Suspicious Feature fall into one of the non-reassuring categories
and the remainder of the features reassuring
Pathological Features fall into ≥2 non-reassuring categories or ≥1
abnormal categories
Clinical scenario- Case 1
28 years old G1P0 at 40 weeks + 7 days
ANC: uneventful
LPC: 2:10 moderate
SROM, clear liquor
Os 4cm
1. What do you notice in the CTG?
2. What is the most probable cause of
FHR abnormality shown?
3. What intervention would you
consider?
Clinical scenario- Case 2
Clinical scenario- Case 3
Clinical scenario- Case 4
References
• Keith Edmonds. Dewhurst's Textbook of Obstetrics and Gynaecology
for Postgraduates. 8th edition. Wiley, 2011; 259-273.
• Susan Gauge, Christine Henderson. CTG Made Easy. Chruchill
Livingstone, 1992.
