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Cardiotocography

Cardiotocography (CTG) is a technique used to monitor the fetal heartbeat and uterine contractions during pregnancy and labour. The machine used to perform the monitoring is called a cardiotocograph. CTG 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.

To interpret a CTG, you need a structured method of assessing its various characteristics. The most popular structure can be remembered using the acronym DR C BRAVADO, which stands for define risk, contractions, baseline rate, variability, accelerations, decelerations and overall impression. Each of these elements can provide clues about the fetal condition and the progress of labour.

Some reasons a pregnancy may be considered high risk are maternal medical illness, obstetric complications, congenital malformations, oxytocin induction/augmentation of labour, pre-eclampsia and other risk factors such as absence of prenatal care, smoking and drug abuse. A high-risk pregnancy may require more frequent and longer CTG monitoring and a lower threshold for intervention.

Contractions are measured by the number, duration and intensity of uterine contractions in a 10-minute period. Contractions can affect the fetal heart rate and oxygen supply, so it is important to correlate them with the other features of the CTG.

Baseline rate is the average fetal heart rate over a 10-minute period, excluding accelerations and decelerations. The normal range is between 110 and 160 beats per minute (bpm). A baseline rate below 110 bpm is called bradycardia and above 160 bpm is called tachycardia. Both can indicate fetal distress or infection.

Variability is the fluctuation of the fetal heart rate around the baseline rate. It reflects the balance between the sympathetic and parasympathetic nervous systems and the fetal response to stimuli. The normal range is between 5 and 25 bpm. Reduced variability (less than 5 bpm) can indicate fetal hypoxia, acidosis, sleep or medication. Increased variability (greater than 25 bpm) can indicate fetal stimulation, infection or arrhythmia.

Accelerations are transient increases in the fetal heart rate above the baseline rate by at least 15 bpm for at least 15 seconds. They are a sign of fetal well-being and usually occur in response to fetal movement, uterine contractions or external stimuli. The presence of at least two accelerations in a 20-minute period is reassuring.

Decelerations are transient decreases in the fetal heart rate below the baseline rate by at least 15 bpm for at least 15 seconds. They can be classified into early, late, variable and prolonged decelerations. Early decelerations are symmetrical and mirror the contractions, indicating fetal head compression. Late decelerations are symmetrical and occur after the contractions, indicating uteroplacental insufficiency. Variable decelerations are asymmetrical and unpredictable, indicating umbilical cord compression. Prolonged decelerations last longer than 90 seconds, indicating severe fetal compromise.

Overall impression is the final step of CTG interpretation, where you integrate all the previous elements and assign a category of normal, suspicious or pathological. A normal CTG is reassuring and indicates a low risk of fetal hypoxia. A suspicious CTG is indeterminate and indicates a possible risk of fetal hypoxia. A pathological CTG is non-reassuring and indicates a high risk of fetal hypoxia. The management of the CTG depends on the category, the clinical context and the gestational age.