How to read a CTG

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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
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DR Define Risk
C Contractions
BRa Baseline Rate
V Variability
A Accelerations
D Decelerations
O - Overall impression

Define risk (DR)

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You first need to assess if this pregnancy is high or low risk

1- Maternal medical illness

Gestational diabetes
Hypertension
Asthma

2- 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

3- Other risk factors

No prenatal care
Smoking
Drug abuse

Contractions (C)
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Record the number of contractions present in a 10 minute period - e.g. 3 in 10
Each big square is equal to 1 minute, so you look how many contractions occurred in
10 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?

Baseline rate of foetal heart (BRa)

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The baseline rate is the average heart rate of the foetus in a 10 minute window
Look at the CTG & assess what the average heart rate has been over the last 10
minutes
Ignore any Accelerations or Decelerations
A normal foetal heart rate is between 110-150 bpm
1- Foetal Tachycardia
Foetal tachycardia is defined as a baseline heart rate greater than 160 bpm

It can be caused by:

Foetal hypoxia
Chorioamnionitis if maternal fever also present
Hyperthyroidism
Foetal or Maternal Anaemia
Foetal tachyarrhythmia

2- Foetal Bradycardia
Foetal bradycardia is defined as a baseline heart rate less than 120 bpm.

Mild bradycardia of between 100-120bpm is common in the following situations:

Post-date gestation
Occiput posterior or transverse presentations

3- Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia

Causes of prolonged severe bradycardia are:

Prolonged cord compression
Cord prolapse
Epidural & Spinal Anaesthesia
Maternal seizures
Rapid foetal descent

If the cause cannot be identified and corrected, immediate delivery is recommended

Variability (V)
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Baseline variability refers to the variation of foetal heart rate from one beat to the
next
Variability occurs as a result of the interaction between the nervous system,
chemoreceptors, barorecptors & cardiac responsiveness.
Therefore it is a good indicator of how healthy the foetus is at that moment in time.
This is because a healthy foetus will constantly be adapting its heart rate to respond
to changes in its environment.

1- Normal variability is between 10-25 bpm

To calculate variability you look at how much the peaks & troughs of the heart rate
deviate from the baseline rate (in bpm)

Variability can be categorised as:

Reassuring 5 bpm
Non-reassuring < 5bpm for between 40-90 minutes
Abnormal < 5bpm for >90 minutes

2- Reduced variability can be caused by:

Foetus sleeping - this should last no longer than 40 minutes most common cause
Foetal acidosis (due to hypoxia) more likely if late decelerations also present
Foetal tachycardia
Drugs opiates, benzodiazipines, methyldopa, magnesium sulphate
Prematurity variability is reduced at earlier gestation (<28 weeks)
Congenital heart abnormalities

Accelerations (A)
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Accelerations are an abrupt increase in baseline heart rate of >15 bpm for >15
seconds
The presence of accelerations is reassuring
Antenatally there should be at least 2 accelerations every 15 minutes
Accelerations occurring alongside uterine contractions is a sign of a healthy foetus
However the absence of accelerations with an otherwise normal CTG is of uncertain
significance

Decelerations (D)
--------------------

Decelerations are an abrupt decrease in baseline heart rate of >15 bpm for >15
seconds

There are a number of different types of decelerations, each with varying significance

1- Early deceleration

Early decelerations start when uterine contraction begins & recover when uterine
contraction stops
This is due to increased foetal intracranial pressure causing increased vagal tone
It therefore quickly resolves once the uterine contraction ends & intracranial
pressure reduces

This type of deceleration is therefore considered to be physiological & not

pathological

2- Variable deceleration

Variable decelerations are seen as a rapid fall in baseline rate with a variable
recovery phase
They are variable in their duration & may not have any relationship to uterine
contractions
They are most often seen during labour & in patients with reduced amniotic fluid
volume

Variable decelerations are usually caused by umbilical cord compression

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 & then the
baseline rate returns
Accelerations before & after a variable deceleration are known as the shoulders of
deceleration
There presence indicates the foetus is not yet hypoxic & 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 is more worrying as it suggests the

foetus is hypoxic

3- Late deceleration

Late decelerations begin at the peak of uterine contraction & recover after the
contraction ends.
This type of deceleration indicates there is insufficient blood flow through the uterus
& placenta
As a result blood flow to the foetus is significantly reduced causing foetal hypoxia &
acidosis

Reduced utero-placental blood flow can be caused by:

Maternal hypotension
Pre-eclampsia
Uterine hyper-stimulation

The presence of late decelerations is taken seriously & foetal blood sampling for pH is
indicated

If foetal blood pH is acidotic it indicates significant foetal hypoxia & the need for
emergency C-section

4- Prolonged deceleration

A deceleration that last more than 2 minutes

If it lasts between 2-3 minutes it is classed as Non-Reasurring
If it lasts longer than 3 minutes it is immediately classed as Abnormal
Action must be taken quickly e.g. Foetal blood sampling / emergency C-section

5- Sinusoidal Pattern

This type of pattern is rare, however if present it is very serious

It is associated with high rates of foetal morbidity & mortality

It is described as:
A smooth, regular, wave-like pattern
Frequency of around 2-5 cycles a minute
Stable baseline rate around 120-160 bpm
No beat to beat variability

A sinusoidal pattern indicates:

Severe foetal hypoxia
Severe foetal anaemia
Foetal/Maternal Haemorrhage

Immediate C-section is indicated for this kind of pattern.

Outcome is usually poor

Once you have assessed all aspects of the CTG you need to give your overall
impression

Overall impression (O)

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The overall impression can be described as either: 4

Reassuring
Suspicious
Pathological