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How to Read a CTG

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What is cardiotocography?
Cardiotocography (CTG) is used during pregnancy to monitor fetal heart rate and uterine
contractions. It is most commonly used in the third trimester and its purpose is to monitor
fetal well-being and allow early detection of fetal distress. An abnormal CTG may indicate the
need for further investigations and potential intervention.
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knowledge to the test.

MEDICINE 

HowMedicine
CTG works PHYSIOLOGY
EMERGENCY
A comprehensive collection of medical revision notes that
MEDICINE
The device
coverused in cardiotocography
a broad is known as a cardiotocograph. It involves the placement
range of clinical topics. CARDIOLOGY
of two transducers onto the abdomen of a pregnant woman. One RESPIRATORY
transducer records the fetal
 
heart rate using ultrasound and the other transducer monitors theENDOCRINOLOGY
contractions of the
uterus by measuring the tension of the maternal abdominal wall GASTROENTEROLOGY
(providing an indirect
RENAL
indication of intrauterine pressure). The CTG is then assessed by a midwife and the obstetric
GERIATRICS
medical team. OBS & GYNAE
PAEDIATRICS
NEUROLOGY

How to read a CTG DERMATOLOGY

MENTAL HEALTH
OPHTHALMOLOGY
IMMUNOLOGY
HAEMATOLOGY
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HAEMATOLOGY
To interpret a CTG you need a structured method of assessing its various characteristics. The
SEXUAL HEALTH
most popular structure can be remembered using the acronym DRONCOLOGY
C BRAVADO:
RESEARCH
DR: De ne risk TOXICOLOGY
C: Contractions
BRa: Baseline rate
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V: Variability
A: Accelerations
D: Decelerations
O: Overall impression

De ne risk
When performing CTG interpretation, you rst need to determine 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
categorised as high-risk, the threshold for intervention may be lower). Some reasons a
pregnancy may be considered high risk are shown below.1

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Maternal medical illness

Gestational diabetes
Hypertension
Asthma

Obstetric complications

Multiple gestation
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Premature ruptureEvaluation of Haematuria
of membranes
Congenital malformations
Oxytocin induction/augmentation of labour
SURGERY 
Pre-eclampsia

Surgery DENTISTRY

OtherArisk factors
collection of surgery revision notes covering key surgical OPERATING THEATRE
SUTURING
topics
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topics. GENERAL SURGERY
Absence of prenatal care
  ORTHOPAEDIC
Smoking
SURGERY
Drug abuse PLASTIC SURGERY
NEUROSURGERY
GYNAECOLOGICAL

Contractions SURGERY
HEPATOBILIARY
SURGERY

Next, you need to record the number of contractions present in aENT SURGERYperiod.
10 minute
UROLOGY

Each big square on the example CTG chart below is equal to one VASCULAR SURGERY
minute, so look at how many
MAXILLOFACIAL
contractions occurred within 10 big squares.
SURGERY

Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity.

Assess contractions for the following:

Duration: How long do the contractions

Evaluation last?
of Haematuria
Intensity: How strong are the contractions (assessed using palpation)?
In the below example, there are 2 contractions in a 10 minute period (this is often referred to
as “2 in 10”).

A man with tight foreskin

Baseline rate of the fetal heart

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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,
ignoring any accelerations or decelerations.
Laryngeal Cancer
A normal fetal heart rate is between 110-160 bpm.

ANATOMY 

Anatomy ANATOMY
FUNDAMENTALS
A collection of anatomy notes covering the key anatomy
HEAD & NECK
concepts that medical students need to learn. UPPER LIMB

  BACK
THORAX
ABDOMEN
LOWER LIMB

Fetal tachycardia

Fetal tachycardia is de ned as a baseline heart rate greater than 160 bpm.
Muscles of the Foot
Causes of fetal tachycardia include:

Fetal hypoxia
Chorioamnionitis
Hyperthyroidism
Fetal or maternal anaemia
Fetal tachyarrhythmia

Fetal bradycardia

Fetal bradycardia is de ned 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:
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Postdate gestation
Small Intestine
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
Visual Pathway and Visual Field Defects
Baseline variability refers to the variation of fetal heart rate from one beat to the next.

CASES
Variability occurs as a result of the interaction between the nervous system, chemoreceptors,
baroreceptors and cardiac responsiveness.
Cases
A collection
It is, therefore, of interactive medical
a good indicator of how and surgical
healthy clinical
a fetus case
is at scenarios
that to put
particular moment in time, as
yourfetus
a healthy diagnostic and management
will constantly skillsits
be adapting to heart
the test.
rateEach clinical case
in response to scenario
changes in its
allows you to work through
environment. history taking, investigations, diagnosis and
management.
Normal variability indicates an intact neurological system in the fetus.
 
Normal variability is between 5-25 bpm. 3

To calculate variability you need to assess how much the peaks and troughs of the heart rate
deviate from the baseline rate (in bpm).

Variability categorisation
Variability can be categorised as either reassuring, non-reassuring or abnormal. 3

Reassuring: 5 – 25 bpm

Non-reassuring:

less than 5 bpm for between 30-50 minutes

more than 25 bpm for 15-25 minutes

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Abnormal:

less than 5 bpm for more than 50 minutes

more than 25 bpm for moreAthan
man25with tight
minutes foreskin
sinusoidal

CTG: Variability

A man with penile swelling

Reduced variability can be caused by any of the following:2

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

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QUIZ

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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.

PSA Question Bank

The absence of accelerations with an otherwise normal CTG is of uncertain signi cance.

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Medical Student Finals Question Bank

CTG: Accelerations

Decelerations
Decelerations are an abrupt decrease in the baseline fetal heart rate of greater than 15 bpm
for greater than 15 seconds. ABG Quiz
The fetal heart rate is controlled by the autonomic and somatic nervous system. In response to
hypoxic
APP 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
READING
in heart rate to reduce
 SHA Rmyocardial
E  T W EET demand is referred to as a deceleration.
HOW TO READ A CTG

There are a number of di erent types of decelerations, each with varying signi cance.

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

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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 uid 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. The mechanism is as
follows:1

1. The umbilical vein is often occluded rst causing an acceleration of the fetal heart rate in
response.

2. Then the umbilical artery is occluded causing a subsequent rapid deceleration.

3. When pressure on the cord is reduced another acceleration occurs and then the baseline
rate returns.

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The 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 ow. 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.

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 insu cient blood ow to the
uterus and placenta. As a result, blood ow to the fetus is signi cantly reduced causing fetal
hypoxia and acidosis.

Reduced uteroplacental blood ow can occur due to:1

Maternal hypotension
Pre-eclampsia
Uterine hyperstimulation

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Prolonged deceleration

A prolonged deceleration is de ned 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.

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Sinusoidal pattern

A sinusoidal CTG pattern is rare, however, if present it is very concerning as 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

Overall impression
Once you have assessed all aspects of the CTG you need to determine your overall impression.

The overall impression can be described as either reassuring, suspicious or abnormal.3

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Overall impression is determined by how many of the CTG features were either reassuring,
non-reassuring or abnormal. The NICE guidelines below demonstrate 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.

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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 signi cant meconium.

Abnormal

Baseline heart rate

Either of the below would be classed as abnormal:

Below 100 bpm

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
No shouldering

Reviewer

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Dr Venkatesh Subramanian
Obstetrics & Gynaecology Registrar in London

References
AMIR SWEHA, M.D. Interpretation of the Electronic Fetal Heart Rate During Labor. Am Fam
Physician. 1999 May 1;59(9):2487-2500. Available from: [LINK].
Clinical obstetrics and gynaecology. 2nd Edition. 2009. B.Magowan, Philip Owen, James Drife.
Intrapartum care: NICE guideline CG190 (February 2017). Available from: [LINK].

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