OBSTETRICS 2

CTG Reading
Dr. Candelario | OB clinics

I. FETAL CARDIOTOCOGRAPHY
 A technical means of recording (GRAPHY)
 Fetal Heart Rate (CARDIO) Fetal Heart Rate
 Uterine Contractions (TOCO)
 A test of fetal well-being (HEALTH)
 Done by use of ELECTRONIC FETAL MONITOR (EFM)
 Detect antepartum or intrapartum (LABOR) fetal hypoxia/asphyxia
Uterine contractions
II. WHAT REGULATES FETAL HEART RATE?
PRIMARY FACTORS SECONDARY FACTORS
- Autonomic NS (Sympathetic &  Central Nervous system: IV. WHAT IS WRITTEN IN THE EFM/PAPER?
Parasympathetic) - Cerebral cortex  Date; Time; Name; Age; OB score; Risk Factor; Diagnosis
- Baroreceptors - Hypothalamus  Internal Exam: Cervix; BOW; Amniotic Fluid
- Chemoreceptors - Medulla Oblongata  Vital signs
 Adrenals  Drugs

III. PARTS OF AN ELECTRONIC FETAL MONITOR V. POSITIONING OF ELECTRONIC FETAL MONITOR

 History taking (Risk assessment)
 Take vital signs every 5 minutes
 Auscultate FHR
 Apply transducers (Doppler/tocodynamometer)
o Apply gel on the Doppler tranducer (where FHR is best auscultated)
o DO NOT apply gel on the tocodynamometer (fundus)
 Position: Semi-fowler (avoid supine)
o Upright
o Half sitting
o Lateral recumbent

VI. TYPES OF FETAL CTG

EXTERNAL MONITORING INTERNAL MONITORING

 Transducers (externally)  Spiral electrode and internal pressure
 Antepartum/intrapartum catheter (internal)
 Requirement: Cervix dilated and
ruptured BOW
 Intrapartum ONLY

1. Doppler or ultrasound transducer

 Will detect FHR
 Placed on area where FHR is best auscultated
2. Tocodynamometer (Pressure sensing device)
 Placed at the uterine fundus to detect uterine contractions
3. Event marker
 pushed by the mother when she feels fetal movement
4. CTG Paper
 Paper speed: 1 cm/min or 3 cm/min

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VII. INDICATIONS OF FETAL CTG 2. FHR VARIABILITY
 Predominant indication of antenatal testing is a pregnancy at increased risk for fetal Normal 6-25 beats (FIGO 5-25)
hypoxia/asphyxia/death.
Reduced 3-5 beats
MATERNAL CONDITIONS FETAL CONDITIONS:
- Hypertension - IUGR Poor 0-2 beats
- Diabetes - Decreased fetal movement
Saltatory >25 beats
- Isoimmunization - Postdate pregnancy
- Chronic renal disease - Multiple pregnancy a. INCREASED VARIABILITY (SALTATORY)
- SLE - Prior history of unexplained  Causes:
- Cardiac disease fetal death o Excessive fetal movement
- Hemoglobinopathies o Transient hypoxia – cord compression during 2nd stage of labor
- hyperthyroidism
PLACENTA AMNIOTIC FLUID
- Placenta previa - Meconium staining
- Abruption placenta - oligohydramnios

VIII. BASIC COMPONENTS OF FETAL HEART PATTERN

1. Baseline FHR
2. FHR variability
3. Periodic changes: accelerations and decelerations
4. Change in trends over time

1. BASELINE FHR b. DECREASED/REDUCED VARIABILITY

 It is the estimated in the time period of 10 minutes and expressed in beats per minute (bpm)  Causes:
 Normal: 110-160 o Fetus is sleeping o Drugs – opiates, benzodiazepines,
o Fetal acidosis methyldopa, magnesium sulfate
o Fetal tachycardia o Prematurity
o Congenital heart abnormalities

Bradycardia (<110 bpm) Tachycardia (>160 bpm)

- Hypoxia - Maternal fever
- Cord prolapse - Hyperthyroidism c. SINUSOIDAL VARIABILITY
- Prolonged cord compression - Prematurity  seen in anemia, RH isoimmunization, and hypoxia
- Anxiety

Severe: <100 bpm Severe: >180 bpm

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3. DECELERATIONS

a. EARLY DECELERATION
 head compression

c. VARIABLE DECELERATION
 cord compression

b. LATE DECELERATION
 uteroplacental insufficiency

MEMORY TIP: VEAL CHOP

V – variable C – cord compression
E – early H – head compression
A – acceleration O – okay 
L – late P – placental insufficiency

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IX. UTERINE ACTIVITY - Absence: may suggest fetal distress
 Interval - Physiology: Intact cortical function where fetal movement is elicited will result to FHR acceleration
 Intensity - Loss of fetal reactivity may mean hypoxia and neurologic depression and acidosis
 Duration - Done at 32 weeks
 Resting tone
STEPS IN NON-STRESS TEST
A. Tachysystole 1. History/PE (auscultate FH tone)
- 5 uterine contractions in 10 minutes 2. Doppler Transducer (are FH tone)
- Risk for fetal hypoxia 3. Tocodynamometer (fundus of uterus)
- Interval (1-2 mins) 4. Position (semirecumbent position)
- Intensity: severe (80 mmHg/contraction) 5. Mother: push event marker (fetal movement)
- Duration (50-60 seconds) 6. Run paper (20 minutes)
- Resting tone (20 mmHg)
DEFINITION OF ACCELERATION
 ≥32 weeks (baseline rate 15 beats and duration of 15 seconds or more
 >32 weeks (10 bpm/10 seconds)

INTERPRETATION
Reactive 2 or more accelerations
Non reactive 1 or no acceleration
Interpretation Reactive NST (Good fetal health)
Reactive NST

B. MONTEVIDEO UNITS

Non-reactive NST

X. CLINICAL APPLICATIONS
 Nonstress Test (Antepartum)
 Contraction Stress test
 Intrapartum CTG

A. NONSTRESS TEST (ANTEPARTUM CTG)

- fetal heart rate accelerates with fetal movement
- Indicator: Good Fetal Health

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B. INTRAPARTUM CTG
- Admission test (Labor)
- Intrapartum monitoring
CATEGORY I
Reassuring pattern
CATEGORY II
Suspicious pattern
CATEGORY III
Nonreassuring pattern
I II
XI. CASES
A 28 y/o woman G2P0 (0010) 34 weeks AOG, Preterm rupture of membranes for 24 hours
- Normal rate
- Normal variability NST REPORT:
- No decelerations BFHR: 140 bpm
- (+/-) accelerations BFHR Variability: Normal
- Tachycardia Acceleration: Present (7)
- Reduced variability Deceleration: Absent
- Moderate variable Interpretation: Reactive NST
decelerations
- Abnormal FHR
- Late decelerations
- Severe variable decelerations
- Sinusoidal pattern
- Poor variability
An 18 y/o woman G1P0, 34 week with Preeclampsia, BP: 160/100mmHG. Ultrasound revealed small
baby and oligohydramnios.
III BFHR: 150 bpm
BFHR Variability: Poor or absent
Acceleration: Absent
Deceleration: Absent
Interpretation: Non-reactive NST

For more details: please read our transes from the lecture on Fetal Assessment last
semester: M.03 and M.04.

REPORT YOUR FINDINGS USING THE DR C BraVADO FORMAT

DR DEFINE RISK Low or high
C CONTRACTIONS Comment on frequency, etc. (intensity, duration)
Bra BASELINE RATE Bradycardia, normal, tachycardia
V VARIABILITY At least 10-15 bpm (persistent reduced variability is a
particularly ominous sign)

Increased (salutatory), reduced/poor, absent, sinusoidal or

normal
A ACCELERATIONS Present or absent
D DECELERATIONS Early, variable, or late
O OVERALL Assessment (category I/II/III) and plan of management

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