Understanding Cardiotocography

– “CTGs”

Max Brinsmead MB BS PhD

May 2015
A Normal Antenatal CTG
 Features of a CTG
• Baseline
• Short term variability
• Accelerations
• Decelerations
• Response to stimuli
• Contractions
• Fetal movements
• Other
 Baseline Fetal Heart Rate
• 110 to 150 bpm at term
• Faster in early pregnancy
• Below 100 = baseline bradycardia
• Below 80 = severe bradycardia
• Tachycardia common with maternal fever
• Tachycardia with reduced STV = early
hypoxia
 Accelerations
• Must be >15 bpm and >15 sec above baseline
• Should be >2 per 15 min period
• Always reassuring when present
• May not occur when fetus is “sleeping”
• Should occur in response to fetal movements or
fetal stimulation
• Non reactive periods usually do not exceed 45 min
• (>90 min and no accelerations is worrying)
 Short Term Variability
(or Beat to Beat Variability with a Scalp Clip)

• Should be >5 bpm

• The most important feature of any CTG
• Is a reflection of competing acceleratory and
decelerating CNS influences on the fetal heart
• And therefore represents the best measure of CNS
oxygenation
• Will be affected by drugs
• Will be reduced in the pre term fetus
 Decelerations
• Early: mirrors the contraction
• Typically occurs as the head enters the pelvis and is
compressed, i.e. it is a vagal response
• Late: Follows every contraction and exhibits a
slow return to baseline
• Is quite rare but is the response of a hypoxic myocardium
• Variable: Show no relationship to contractions
• Mild
• Moderate
• Severe
• In practice many “decels” or “dips” are MIXED
An Abnormal Antenatal CTG
An Abnormal Antenatal CTG cont’d
Abnormal CTG Features

• Reduced STV
• No accelerations
• Decelerations after
most contractions with
a slow return to
baseline
In Practice a CTG is best regarded as a
screening tool:

• High negative predictive value

• >98% of fetuses with a normal CTG will be OK
• Poor positive predictive value
• Up to 50% of fetuses with an abnormal CTG will be
hypoxic and acidotic but 50% will be OK
• Therefore the CTG should always be
interpreted in its clinical context
• And backed by fetal blood sampling PRN
 A Classification of CTGs

• Normal = all 4 features are reassuring

• Suspicious = One non reassuring feature

• Pathological = Two or more non reassuring

features or a abnormal pattern
 Non Reassuring Features of a CTG

• Baseline <110>100 or >160<180

• STV <5 for >40 min but <90 min
• Early decelerations
• Variable decelerations
• A single prolonged deceleration up to 3 min
 A CTG is abnormal when:
• Baseline is <100 or >180 bpm
• STV is <5 for >90 min
• Late decelerations are repeated
• Atypical variable decelerations occur
• Two prolonged decelerations for >3 min
occur
• Sinusoidal pattern >10 min
It is best to regard CTG as screening
for fetal hypoxia:
x = Healthy
0 = Hypoxic

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An ideal screening test:
x = Healthy
0 = Hypoxic

xxx0xxx0xxx0
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xxxxxxxxx 000
xxxxxxxxx 000
xxxxxxxxx 000
xxxxxxxxx 000
CTG as a screening test
x = Healthy
0 = Hypoxic

xxx0xxx0xxx0
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xxx0xxx0xxx0
xxx0xxx0xxx0

xxx000 xxxxxx
xxx000 xxxOxx
xxx000 xxxxxx
xxx000 xxxxxx
 CTG as a Screening Test
• Positive predictive value = the chance that
a screen positive individual will have the
disease
• For CTG this is never more than 50%
• i.e. at least 50% of the time it will be
unnnecessarily alarming
A screening test is more likely to
be a true positive if
A screening test is more likely to
be a true positive if
It is positive in a high risk
group
So always consider the
clinical context
And be prepared to back up
with a diagnostic test
Which, for the diagnosis of fetal
hypoxia, is Scalp Blood pH or
lactate
 Problems with Screening:
• FALSE POSITIVES
– And the resources required to deal with them
• UNREALISTIC EXPECATATIONS
– i.e. misunderstanding about the sensitivity of
the test
 Meta analysis of RCTs of
Intrapartum CTG monitoring
• 12 Trials (as of 2008)
• In 10 centres in the US, Australia, Europe
and Africa
• 58,855 women and 59,324 babies
• Both high and low risk pregnancies
• Compared routine EFM with intermittent
auscultation
 Meta analysis Results
• A significant decrease in:
– rate of 1 minute Apgar scores less than 4 (RR =
0.82 and CI 0.65 - 0.98)

– Neonatal seizures (RR=0.50 and CI 0.32 - 0.82)

 Meta analysis Results
• A significant increase in:

The rate of intervention by Caesarean section

and operative delivery (RR=1.23 and CI
1.15 - 1.31)
 Meta analysis Results
• No effect on:
– rate of 1 min Apgar scores <7

– rate of admissions to NICU

– Perinatal death rate

– 5 min Apgar scores

– rate of Cerebral palsy

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