Cardiotocography

The cardiotocograph (CTG) is a continuous electronic record of the fetal heart rate obtained via an ultrasound transducer placed on the mothers abdomen (external or indirect CTG). a second transducer is placed on the mothers abdomen over the uterine fundus to record simultaneously the presence of any uterine activity

 It is sometimes referred to as electronic fetal monitoring (EFM). but is considered to be a less precise term because (1) CTG monitoring also includes monitoring the mothers contractions and (2) other forms of fetal monitoring might also be classed as electronic, e.g. ECG, fetal pulse oximetry.

 Cardiotocography is used widely in maternity care, both in the antepartum and intrapartum periods Antenatal Cochrane: Antenatal CTG has no significant effect on perinatal outcome or interventions such as early elective delivery NICE: Evidence does not support the routine use of antenatal electronic fetal heart rate monitoring for fetal assessment in women with an uncomplicated pregnancy and therefore it should not be offered

 But further studies focusing on the use of computerised CTG in specific populations of women with increased risk of complications are warranted commonly performed in the third trimester of pregnancy (after 28 weeks) Frequency of testing varies widely in practice, depending on the indication for the CTG and gestational age, and ranges from weekly to three times a day

concept for the use of CTG in pregnancy screening test for the identification of babies with acute or chronic fetal hypoxia or at risk of developing such hypoxia. Intrapartum monitoring fetal heart rate changes during labour to identify those babies who are becoming short of oxygen (hypoxic) who may benefit from caesarean section or instrumental vaginal birth.

 Fetal hypoxia pathophysiological adaptations cause changes in the pattern of the fetal heart rate parameters. Normal parameter (Gribbin 2006; RCOG 2001) : Baseline fetal heart rate of 110 to 160 beats per minute. Baseline variability should be greater than five beats per minute. Presence of two or more accelerations of the fetal heart rate exceeding 15 beats per minute, sustained for at least 15 seconds in a 20-minute period (Devoe 1990) - this pattern is termed reactive. Absence of decelerations.

 There was no difference in the number of babies who died during or shortly after labour (about 1 in 300) Fits (neonatal seizures) in babies were rare (about 1 in 500 births), but they occurred significantly less often when continuous CTG was used to monitor fetal heart rate. There was no difference in the incidence of cerebral palsy.

Reliability of cardiotocography in predicting baby's condition at birth

The sensitivity of an abnormal tracing was 35.2% for babies who needed intermittent positive pressure ventilation and 20.0% for babies who did not but who had Apgar scores of less than 7 The sensitivity of an abnormal tracing for all babies with an Apgar score of less than 7 was 23.2%. The positive predictive value of an abnormal tracing was 8-7% for babies who needed intermittent positive pressure ventilation and 18 7% for babies who did not but who had an Apgar score of less than 7.

 The positive predictive value of an abnormal tracing was 27-4% for all babies with an Apgar score of less than 7. The specificity of the tracing was 93 4% for babies with an Apgar score of 7 or over. The relatively high incidence of false positive predictions might be explained on the grounds that abnormalities in the cardiotocograph tracing are a more sensitive indicator of hypoxia than the Apgar score. False negative predictions might have been due to adverse factors other than hypoxia-for example, fetal trauma, compression of the head, infection, and analgesia in labour.

Reference Grivell RM, Alfirevic Z, Gyte GM, Devane D. Antenatal cardiotocography for fetal assessment. The Cochrane database of systematic reviews. 2010 (1):CD007863. PubMed PMID: 20091654 Grivell RM, Alfirevic Z, Gyte GM, Devane D. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour (Review). The Cochrane database of systematic reviews. 2007. Curzen P, Bekir Js, Mclintock DG, PATEL M. Reliability of cardiotocography in predicting baby's condition at birth. BRITISH MEDICAL JOURNAL. 1984;289.