The Cardiotocogram

Dana Wynsze P. Lim | RLE D3.1 | Delivery Room Rotation

WHAT IS A CARDIOTOCOGRAPHY?

Cardiotocography (CTG) measures a baby's

heart rate. At the same time it also monitors
the contractions in the womb (uterus). CTG is
used both before birth (antenatally) and during
labour, to monitor the baby for any signs of
distress.
TYPES OF CTG
PURPOSE

1. EXTERNAL MONITORING
The purpose of CTG recordings is to identify when
there is concern about fetal well-being to allow
interventions to be carried out before the fetus is Non-invasive; transducers are placed on the
harmed. The focus is on identifying fetal heart rate mother’s abdomen to record FHR and UC (Uterine
(FHR) patterns associated with inadequate oxygen Contractions)
supply to the fetus.

COMPONENTS

1. Ultrasound Transducer:
● It is for continuous or intermittent
Used to measure the fetal heart rate via sound
monitoring. The fetal heart rate and activity
waves.
of the uterine muscle are detected by two
2. Tocotransducer (Tocodynamometer): transducers placed on the mother's
Measures uterine contractions by sensing abdomen(one above the fetal heart and
abdominal pressure changes. other at the fundus).

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Dana Wynsze P. Lim | RLE D3.1 | Delivery Room Rotation

● Doppler ultrasound provides the information

WHAT IS IT USED FOR?
which is recorded on a paper strip known as
Cardiotocograph(CTG).
CTG is used in high-risk pregnancies, during labor,
or in specific situations where fetal well-being may
2. INTERNAL MONITORING be at risk. Indications include:

For high-precision readings when needed; requires ● Decreased fetal movements

ruptured membranes and uses a fetal scalp ● High-risk factors, such as maternal
electrode to measure FHR directly hypertension, diabetes, or pre-eclampsia
● Labor induction or augmentation
● Suspected intrauterine growth restriction
(IUGR)
\\\ ● Abnormal Doppler findings
● Meconium-stained amniotic fluid
● Fetal abnormalities detected in ultrasound
(Saccone et al., 2020)

KEY PARAMETERS AND CTG INTERPRETATION

Interpreting CTG involves assessing several

parameters of fetal heart rate patterns and uterine
contractions. As outlined by Devane et al. (2020)
and Ayres-de-Campos et al. (2021), the following
are the main parameters for CTG interpretation:
● This method can be useful if the membrane
has ruptured either spontaneously or BASELINE FETAL HEART RATE
artificially.
● Uses an electronic transducer connected
● Normal range: 110–160 beats per minute
directly to the fetal scalp through the
(bpm).
cervical opening and is connected to the
● Baseline FHR is the average FHR over a
monitor. This type of electrode is sometimes
10-minute period, excluding accelerations,
called a spiral or scalp electrode.
decelerations, and periods of marked
● Internal monitoring provides a more
variability
accurate and consistent transmission of the
fetal heart rate than external monitoring
Each big square on the example CTG chart
because factors such as movement do not below is equal to one minute, so look at how
affect it. many contractions occurred within 10 big
● Internal monitoring may be used when squares.
external monitoring of the fetal heart rate is
inadequate, or closer surveillance is
needed.

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Dana Wynsze P. Lim | RLE D3.1 | Delivery Room Rotation

ACCELERATIONS

● Brief increases in FHR above the baseline

by 15 bpm for at least 15 seconds.
● Accelerations are a positive sign,
indicating fetal health and reactivity (Yli &
Kjelland, 2021).

VARIABILITY

● Reflects the fluctuations in FHR around

the baseline and indicates fetal nervous
system health.
● Normal variability: 6–25 bpm.
● Reduced variability: ≤5 bpm, may
indicate fetal hypoxia, sleep cycles, or
medication effects.
● Increased variability: >25 bpm, often
due to fetal movement or mild hypoxia. DECELERATIONS

Temporary decreases in FHR, classified based

on timing and relation to contractions:

● Early Decelerations: Typically benign,

mirror contractions, and associated with
head compression.

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Dana Wynsze P. Lim | RLE D3.1 | Delivery Room Rotation

● Analyzed for frequency, duration, and

intensity. Excessively frequent or intense
contractions may cause fetal hypoxia.

CTG INTERPRETATION POINTS

● Baseline FHR: Normal range is 110–160

bpm.
● Variable Decelerations: Abrupt ● Variability: Normal range is 6–25 bpm;
decreases in FHR, often due to umbilical reduced variability ≤5 bpm; increased
cord compression. variability >25 bpm.
● Accelerations: Presence is reassuring.
● Decelerations: Evaluate timing, depth, and
relation to contractions.
● Contractions: Ensure that frequency and
intensity are not excessive.

CTG CLASSIFICATION SYSTEMS

● Late Decelerations: Begin after the The FIGO guidelines classify CTG findings to
contraction peak and suggest provide a standardized approach for interpreting
uteroplacental insufficiency, which can and responding to results (Ayres-de-Campos et al.,
indicate fetal hypoxia (Mangesi et al., 2021):
2021).
1. NORMAL CTG

Baseline FHR of 110–160 bpm, moderate

variability, no decelerations, and presence of
accelerations.

2. SUSPICIOUS CTG

Slight deviations from normal (e.g., reduced

variability or occasional variable decelerations),
warranting close observation.
CONTRACTIONS
2. ABNORMAL CTG

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Dana Wynsze P. Lim | RLE D3.1 | Delivery Room Rotation

Persistent deviations such as minimal variability, References

repetitive late decelerations, or abnormal baseline
FHR, indicating the need for immediate Ayres-de-Campos, D., Spong, C. Y., &
intervention. Chandraharan, E. (2021). FIGO consensus
guidelines on intrapartum fetal monitoring:
Cardiotocography. International Journal of
NURSING RESPONSIBILITIES
Gynecology & Obstetrics, 151(1), 13–24.
[Link]
Nurses play a critical role in CTG monitoring during
labor, ensuring appropriate interventions if any Devane, D., Lalor, J. G., Daly, S., McGuire, W., &
abnormalities are detected (Ayres-de-Campos et Smith, V. (2020). Cardiotocography versus
al., 2021; Mangesi et al., 2021). Key nursing intermittent auscultation of fetal heart on
responsibilities include: admission to labour ward for assessment of
fetal wellbeing. Cochrane Database of
Systematic Reviews, 2020(1), Article
CD005122.
[Link]
● Preparation and Setup: Verify that the
2.pub5
transducers are correctly placed on the
mother’s abdomen and that equipment is Mangesi, L., Hofmeyr, G. J., Smith, V., Smyth, R.
calibrated. M., & Cochrane Pregnancy and Childbirth
● Baseline Assessment: Record baseline Group. (2021). Continuous
FHR, variability, accelerations, cardiotocography (CTG) as a form of
decelerations, and contraction patterns. electronic fetal monitoring (EFM) for fetal
● Continuous Monitoring: Regularly assessment during labour. Cochrane
observe and document FHR and Database of Systematic Reviews, 2021(5),
contraction data, taking immediate action if Article CD006066.
abnormalities appear. [Link]
● Patient Positioning: Position the mother, 6.pub5
usually on her left side, to optimize fetal
oxygenation by reducing vena cava Saccone, G., Khalifeh, A., & Berghella, V. (2020).
compression. Fetal heart rate monitoring technologies for
● Documentation: Record observations intrapartum surveillance: A systematic
accurately, including the time and details of review and meta-analysis. Obstetrics &
any notable FHR or contraction changes. Gynecology, 136(4), 715–723.
● Interventions: Implement actions for [Link]
abnormal CTG patterns, such as 4019
administering oxygen, increasing IV fluids,
and notifying the healthcare provider. Yli, B. M., & Kjelland, E. K. (2021). Fetal heart rate
● Education: Inform the patient and her assessment during labor: A comparison of
family about CTG’s purpose, explaining different monitoring techniques. European
findings and answering questions to help Journal of Obstetrics & Gynecology and
reduce anxiety. Reproductive Biology, 256, 320–327.
[Link]