CTG
What is cardiotocography?
Cardiotocography (CTG) is used during pregnancy to monitor the fetal heart and contractions
of the uterus. It is most commonly used in the third trimester. Its purpose is to monitor fetal well-
being and allow early detection of fetal distress. An abnormal CTG indicates the need for more
invasive investigations and potentially emergency caesarian section. Check out our CTG quiz on
the new Geeky Medics quiz platform.
How CTG works
The device used in cardiotocography is known as a cardiotocograph. It involves the placement
of two transducers onto the abdomen of a pregnant woman. One transducer records the fetal
heart rate using ultrasound. The other transducer monitors the contractions of the uterus. It
does this by measuring the tension of the maternal abdominal wall. This provides an indirect
indication of intrauterine pressure. The CTG is then assessed by the midwife and obstetric
medical team.
How to read a CTG
To interpret a CTG you need a structured method of assessing its various characteristics.
The most popular structure can be remembered using the acronym DR C BRAVADO
DR – Define Risk
C – Contractions
BRa – Baseline Rate
V – Variability
A – Accelerations
D – Decelerations
O – Overall impression
Define risk
You first need to assess if the 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, the threshold for intervention will be lower.)
Some reasons a pregnancy may be considered high risk are shown below ¹
Maternal medical illness
Gestational diabetes
Hypertension
Asthma
Obstetric complications
Multiple gestation
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of membranes
Congenital malformations
Oxytocin induction/augmentation of labour
Pre-eclampsia
Other risk factors
Absence of prenatal care
Smoking
Drug abuse
Contractions
Next, you need to record the number of contractions present in a 10 minute period. Each big
square on the example CTG chart below is equal to one minute, so look at how many
contractions occurred within 10 big squares. Individual contractions are seen as peaks on the
part of the CTG monitoring uterine activity.
You should assess contractions for the following:
Duration – How long do the contractions last?
Intensity – How strong are the contractions? (assessed using palpation)
In this example, there are 2 contractions in a 10 minute period (this is often referred to as “2 in
10”)
Uterine contractions (CTG)
Baseline rate of the fetal heart
The baseline rate is the average heart rate of the fetus within a 10-minute window.
Look at the CTG and assess what the average heart rate has been over the last 10 minutes.
Ignore any accelerations or decelerations.
A normal fetal heart rate is between 110-160 bpm.
CTG – Baseline Heart Rate
Fetal tachycardia
Fetal tachycardia is defined as a baseline heart rate greater than 160 bpm.
Causes include:
Fetal hypoxia
Chorioamnionitis – if maternal fever also present
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia
Fetal bradycardia
Fetal bradycardia is defined as a baseline heart rate of less than 100 bpm. It is common to
have a baseline heart rate of between 100-120 bpm in the following situations:
Postdate gestation
Occiput posterior or transverse presentations
Severe prolonged bradycardia (less than 80 bpm for more than 3 minutes) indicates severe
hypoxia.
Causes of prolonged severe bradycardia include:
Prolonged cord compression
Cord prolapse
Epidural and spinal anaesthesia
Maternal seizures
Rapid fetal descent
Variability
Baseline variability refers to the variation of fetal heart rate from one beat to the next.
Variability occurs as a result of the interaction between the nervous system, chemoreceptors,
baroreceptors and cardiac responsiveness.
It is, therefore, a good indicator of how healthy a fetus is at that particular moment in time, as
a healthy fetus will constantly be adapting its heart rate in response to changes in its
environment. Normal variability indicates an intact neurological system in the fetus.
Normal variability is between 5-25 bpm. 3
To calculate variability you look at how much the peaks and troughs of the heart rate deviate
from the baseline rate (in bpm).
Variability can be categorised as follows: 3
Reassuring – 5 – 25bpm
Non-reassuring:
o less than 5bpm for between 30-50 minutes
o more than 25bpm for 15-25 minutes
Abnormal:
o less than 5bpm for more than 50 minutes
o more than 25bpm for more than 25 minutes
o sinusoidal
Reduced variability can be 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
CTG – Variability
..
CTG – Reduced Variability
Accelerations
Accelerations are an abrupt increase in the baseline fetal heart rate of greater than 15 bpm
for greater than 15 seconds. ¹ The presence of accelerations is reassuring. Accelerations
occurring alongside uterine contractions is a sign of a healthy fetus. The absence of accelerations
with an otherwise normal CTG is of uncertain significance.
CTG – Accelerations
Decelerations
Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm
for greater than 15 seconds. Fetal heart rate is controlled by the autonomic and somatic nervous
system. In response to hypoxic stress, the fetus reduces its heart rate to preserve myocardial
oxygenation and perfusion. Unlike an adult, a fetus cannot increase its respiration depth and rate.
This reduction in heart rate to reduce myocardial demand is referred to as a deceleration. There
are a number of different types of decelerations, each with varying significance.
Early deceleration
Early decelerations start when the uterine contraction begins and recover when uterine
contraction stops. This is due to increased fetal intracranial pressure causing increased vagal
tone. It therefore quickly resolves once the uterine contraction ends and intracranial pressure
reduces. This type of deceleration is therefore considered to be physiological and not
pathological. ³
CTG – Early Decelerations
Variable deceleration
Variable decelerations are observed as a rapid fall in baseline fetal heart rate with a variable
recovery phase. They are variable in their duration and may not have any relationship to uterine
contractions. They are most often seen during labour and in patients’ with reduced amniotic fluid
volume. All fetuses experience stress during the labour process, as a result of uterine contractions
reducing fetal perfusion. Whilst fetal stress is to be expected during labour, the challenge is to
pick up pathological fetal distress.
Variable decelerations are usually caused by umbilical cord compression: ¹
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.
Variable decelerations can sometimes resolve if the mother changes position. The presence of
persistent variable decelerations indicates the need for close monitoring. Variable decelerations
without the shoulders are more worrying, as it suggests the fetus is becoming hypoxic.
CTG – Variable Decelerations
Late deceleration
Late decelerations begin at the peak of the uterine contraction and recover after the contraction
ends. This type of deceleration indicates there is insufficient blood flow to the uterus and
placenta. As a result, blood flow to the fetus is significantly reduced causing fetal hypoxia and
acidosis.
Reduced uteroplacental blood flow can occur due to: ¹
Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation
. Prolonged deceleration
A prolonged deceleration is defined as a deceleration that lasts more than 3 minutes.
If it lasts between 2-3 minutes it is classed as non-reassuring.
If it lasts longer than 3 minutes it is immediately classed as abnormal.
CTG – Late Decelerations
CTG – Prolonged Deceleration
.
Sinusoidal pattern
This type of pattern is rare, however, if present it is very concerning.
It is associated with high rates of fetal morbidity and mortality. ¹
A sinusoidal CTG pattern has the following characteristics:
A smooth, regular, wave-like pattern
Frequency of around 2-5 cycles a minute
Stable baseline rate around 120-160bpm
No beat to beat variability
A sinusoidal pattern usually indicates one or more of the following:
Severe fetal hypoxia
Severe fetal anaemia
Fetal/maternal haemorrhage
Sinusoidal pattern
Overall impression
Once you have assessed all aspects of the CTG you need to give your overall impression.
The overall impression can be described as either: 3
Reassuring
Suspicious
Abnormal
The overall impression is determined by how many of the CTG features were either reassuring,
non-reassuring or abnormal. The NICE guideline below demonstrates how to decide which
category a CTG falls into.3
Reassuring
Baseline heart rate
110 to 160 bpm
Baseline variability
5 to 25 bpm
Decelerations
None or early
Variable decelerations with no concerning characteristics* for less than 90 minutes
Non-reassuring
Baseline heart rate
Either of the below would be classed as non-reassuring:
100 to 109 bpm
161 to 180 bpm
Baseline variability
Either of the below would be classed as non-reassuring:
Less than 5 for 30 to 50 minutes
More than 25 for 15 to 25 minutes
Decelerations
Any of the below would be classed as non-reassuring:
Variable decelerations with no concerning characteristics* for 90 minutes or more
Variable decelerations with any concerning characteristics* in up to 50% of contractions
for 30 minutes or more
Variable decelerations with any concerning characteristics* in over 50% of contractions
for less than 30 minutes
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
Abnormal
Baseline heart rate
Either of the below would be classed as abnormal:
Below 100bpm
Above 180 bpm
Baseline variability
Any of the below would be classed as abnormal:
Less than 5 for more than 50 minutes
More than 25 for more than 25 minutes
Sinusoidal
Decelerations
Any of the below would be classed as abnormal:
Variable decelerations with any concerning characteristics* in over 50% of contractions
for 30 minutes (or less if any maternal or fetal clinical risk factors [see above])
Late decelerations for 30 minutes (or less if any maternal or fetal clinical risk factors)
Acute bradycardia, or a single prolonged deceleration lasting 3 minutes or more
Regard the following as concerning characteristics of variable decelerations
Lasting more than 60 seconds
Reduced baseline variability within the deceleration
Failure to return to baseline
Biphasic (W) shape
