Fetal Monitoring

Cardiotocography (CTG)
Cardiotocograph (CTG)
Continuous tracing of the fetal heart rate used to assess fetal well
being.

Doppler effect detects fetal heart motion and allows the interval
between successive beats to be measured, thus, allowing a
continuous assessment of the fetal heart rate.

Types: External, Internal CTG

Types
External cardiotocography
For continuous or intermittent monitoring.
The fetal heart rate and the activity of the uterine muscle are detected by
two transducers placed on the mothers abdomen (one above the fetal
heart, to monitor heart rate and the other at the fundus of the uterus to
measure frequency of contractions).
Doppler ultrasound provides the information which is recorded on a paper
strip known as a cardiotocograph (CTG).
External tocometry is useful in showing the beginning and end of
contractions, as well as frequency, but not the strength of contractions.
The absolute values of pressure readings on an external tocometer are
dependent on position, and are not sensitive in people who are obese.
In cases where information on the strength, or precise timing, of
contractions is needed, an internal tocometer is more appropriate.[
Internal cardiotocography
An electronic transducer connected directly to the fetal scalp.
A wire electrode is attached to the fetal scalp through the cervical opening and is
connected to the monitor. This type of electrode is sometimes called a spiral or
scalp electrode.
Internal monitoring provides a more accurate and consistent transmission of the
fetal heart rate than external monitoring because factors such as movement do
not affect it.
Internal monitoring may be used when external monitoring of the fetal heart rate
is inadequate, or closer surveillance is needed.
Internal tocometry can only be used if membranes have ruptured either
spontaneously or artificially, and the cervix is open.
To gauge the strength of contractions, a small catheter (Intrauterine pressure
catheter or IUPC) is passed into the uterus, past the fetus. Combined with an
internal fetal monitor, an IUPC may give a more precise reading of the baby's
heart rate and the strength of contractions
 CTG

Baseline
Baseline Rate Accelerations Decelerations
Variability
Baseline Fetal Heart Rate
Normal: 110-150 bpm (prior to term, upper limit of normal is 160bpm)
> 150 bpm : Fetal Tachycardia
< 110 bpm : Fetal Bradycardia
Baseline fetal heart rate falls with advancing gestational age (due to
maturing fetal parasympathetic tones)
Best determined over 5-10 minutes
Causes of Fetal Tachycardia:
Maternal/Fetal Infection
Acute fetal hypoxia
Fetal anaemia
Drugs (adrenoceptor agonists, e.g. Ritodrine)
Baseline Variability
It reflects a normal fetal autonomic nervous system
Abnormal when it is < 10 bpm.
Reduced during:
Fetal sleep states (deep sleep cycle of 20-30 minutes at a time)
Hypoxia
Fetal infection
Drugs suppressing the fetal central nervous system (opioids, hypnotics)
Fetal Heart Rate Accelerations
Increase in baseline fetal heart rate of
At least 15 bpm
At least 15 seconds
Presence of 2 or more accelerations on a 20-30 minutes CTG defines a
reactive trace (indicative of a non-hypoxics fetus; there are a positive
sign of fetal health)
Fetal Heart Rate Decelerations
Transient reduction in fetal heart rate of
15 bpm or more
15 seconds or more
Indication of:
Fetal hypoxia
Umbilical cord compression
4 Types of Decelerations (NICHD)
Early decelerations
Late decelerations
Variable decelerations
Prolonged decelerations
Early Deceleration
A result of increased vagal tone due to compression of the fetal head
during contractions.
Monitoring usually shows a symmetrical, gradual decrease and return
to baseline of FHR which is associated with a uterine contraction
(onset to nadir: 30 seconds or more).
Early decelerations begin and end at approximately the same time as
contractions, and the low point of the fetal heart rate occurs at the
peak of the contraction.
Late Decelerations
A result of placental insufficiency, which can result in fetal distress.
Monitoring usually shows symmetrical gradual decrease and return to
baseline of the fetal heart rate in association with a uterine
contraction (30 seconds or more)
In contrast to early deceleration, the low point of fetal heart rate
occurs after the peak of the contraction, and returns to baseline after
the contraction is complete.
Variable Deceleration
Variable decelerations are variable in onset, duration and depth. They
may occur with contractions or between contractions.
Typically, they have an abrupt onset and rapid recovery (in contrast to
the rest).
Generally a result of vagal tones respond to umbilical cord
compression, and contractions may further compress a cord when it
is trapped around the neck or under the shoulder of the fetus.
Prolonged Decelerations
Prolonged decelerations last at least 2 minutes but not as long as 10
minutes. (If the deceleration lasts 10 minutes or more, it is considered
a baseline change).
Causes can include:
maternal supine hypotension (repositioning)
epidural anesthesia (self-limiting)
paracervical block (self-limiting)
umbilical cord prolapse (prompt intervention needed)
Summary
Normal Antepartum CTG
Fetal Heart Rate: 110-150 bpm
Baseline variability: >10 bpm
Fetal Heart Rate Acceleration: >1 in 20-30 minutes tracing

Suspicious if:
Reduced baseline variability
Absence of acceleration
Presence of deceleration
General Management
Suspicious CTG

Antenatal Risk
No Risk Factor
Factor

May warrant Repeated

delivery of the investigation
baby later in the day
Biophysical Profile (BPP)
Long (30min) ultrasound scan which observes fetal behaviour,
measures amniotic fluid volume and include a CTG.
Performed after 32 weeks of gestation

Biophysical
Profile

Non-Stress Ultrasound
Test Evaluation
Non-Stress Test
Also known as Non-Stress CTG, Reactive Fetal Heart Rate
Basic concept: well-oxygenated, non-acidemic fetus will spontaneously
have temporary increases in the fetal heart rate (FHR) / accelerations.
Reactive (normal): presence of two or more fetal heart rate accelerations
within a 20-minute period, with or without fetal movement discernible by
the pregnant woman. (Accelerations:15 bpm above baselines for at least
15 seconds if beyond 32 weeks gestation, or 10 bpm for at least 10 seconds
if at or below 32 weeks).
Nonreactive: the presence of less than two fetal heart rate accelerations
within a 20-minute period over a 40-minute testing period
Lack of implementation
Time consuming (30% of time fetal is sleeping, require longer
duration of scan to exclude physiological cause of poor score)
Late detection of fetal distress (by the time the fetus develops an
abnormal score prompting delivery, it is likely to already be severely
hypoxic)
No significant benefits (reduce perinatal death, but may not increase
long term survival rate or survival without significant mental/physical
impairment)
Insufficient evidence to support the use of BPP in high risk
pregnancies.