How to read a CTG

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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
-----------------DR Define Risk
C Contractions
BRa Baseline Rate
V Variability
A Accelerations
D Decelerations
O - Overall impression
Define risk (DR)
----------------You first need to assess if this pregnancy is high or low risk
1- Maternal medical illness
Gestational diabetes
Hypertension
Asthma
2- Obstetric complications
Multiple gestation
Post-date gestation
Previous cesarean section
Intrauterine growth restriction
Premature rupture of the membranes
Congenital malformations
Oxytocin induction/augmentation of labor
Pre-eclampsia
3- Other risk factors
No prenatal care
Smoking
Drug abuse
Contractions (C)
-----------------Record the number of contractions present in a 10 minute period - e.g. 3 in 10
Each big square is equal to 1 minute, so you look how many contractions occurred in 10 squares
Individual contractions are seen as peaks on the part of the CTG monitoring uterine activity
You should assess contractions for the following:
Dur ation how long do the contractions last?
Intensity how strong are the contractions?
Baseline rate of foetal heart (BRa)
-----------------------------------The baseline rate is the average heart rate of the foetus in a 10 minute window
Look at the CTG & assess what the average heart rate has been over the last 10 minutes
Ignore any Accelerations or Decelerations
A normal foetal heart rate is between 110-150 bpm
1- Foetal Tachycardia
Foetal tachycardia is defined as a baseline heart rate greater than 160 bpm

It can be caused by:

Foetal hypoxia
Chor ioamnionitis if maternal fever also present
Hyper thyr oidism
Foetal or Mater nal Anaemia
Foetal tachyar r hythmia
2- Foetal Bradycardia
Foetal bradycardia is defined as a baseline heart rate less than 120 bpm.
Mild bradycardia of between 100-120bpm is common in the following situations:
Post-date gestation
Occiput poster ior or tr ansver se pr esentations
3- Severe prolonged bradycardia (< 80 bpm for > 3 minutes) indicates severe hypoxia
Causes of prolonged severe bradycardia are:
Prolonged cord compression
Cor d pr olapse
Epidur al & Spinal Anaesthesia
Mater nal seizur es
Rapid foetal descent
If the cause cannot be identified and corrected, immediate delivery is recommended
Variability (V)
----------------Baseline variability refers to the variation of foetal heart rate from one beat to the next
Variability occurs as a result of the interaction between the nervous system, chemoreceptors,
barorecptors & cardiac responsiveness.
Therefore it is a good indicator of how healthy the foetus is at that moment in time.
This is because a healthy foetus will constantly be adapting its heart rate to respond to changes
in its environment.
1- Normal variability is between 10-25 bpm
To calculate variability you look at how much the peaks & troughs of the heart rate deviate from
the baseline rate (in bpm)
Variability can be categorised as:
Reassur ing 5 bpm
Non-reassuring < 5bpm for between 40-90 minutes
Abnor mal < 5bpm for >90 minutes
2- Reduced variability can be caused by:
Foetus sleeping - this should last no longer than 40 minutes most common cause
Foetal acidosis (due to hypoxia) more likely if late decelerations also present
Foetal tachycar dia
Dr ugs opiates, benzodiazipines, methyldopa, magnesium sulphate
Pr ematurity variability is reduced at earlier gestation (<28 weeks)
Congenital hear t abnor malities
Accelerations (A)
-------------------Accelerations are an abrupt increase in baseline heart rate of >15 bpm for >15 seconds
The presence of accelerations is reassuring
Antenatally there should be at least 2 accelerations every 15 minutes
Accelerations occurring alongside uterine contractions is a sign of a healthy foetus
However the absence of accelerations with an otherwise normal CTG is of uncertain significance

Decelerations (D)
-------------------Decelerations are an abrupt decrease in baseline heart rate of >15 bpm for >15 seconds
There are a number of different types of decelerations, each with varying significance
1- Early deceleration
Early decelerations start when uterine contraction begins & recover when uterine contraction
stops
This is due to increased foetal intracranial pressure causing increased vagal tone
It therefore quickly resolves once the uterine contraction ends & intracranial pressure reduces
This type of deceleration is therefore considered to be physiological & not pathological
2- Variable deceleration
Variable decelerations are seen as a rapid fall in baseline rate with a variable recovery phase
They are variable in their duration & may not have any relationship to uterine contractions
They are most often seen during labour & in patients with reduced amniotic fluid volume
Variable decelerations are usually caused by umbilical cord compression
The umbilical vein is often occluded first causing an acceleration in response
Then the umbilical ar ter y is occluded causing a subsequent r apid deceler ation
When pr essur e on the cor d is r educed another acceler ation occur s & then the baseline r ate
returns
Acceler ations befor e & after a variable deceleration are known as the shoulders of
deceleration
Ther e pr esence indicates the foetus is not yet hypoxic & is adapting to the r educed blood flow.
Variable decelerations can sometimes resolve if the mother changes position
The presence of persistent variable decelerations indicates the need for close monitoring
Variable decelerations without the shoulders is more worrying as it suggests the foetus is hypoxic
3- Late deceleration
Late decelerations begin at the peak of uterine contraction & recover after the contraction ends.
This type of deceleration indicates there is insufficient blood flow through the uterus & placenta
As a result blood flow to the foetus is significantly reduced causing foetal hypoxia & acidosis
Reduced utero-placental blood flow can be caused by:
Mater nal hypotension
Pr e-eclampsia
Uter ine hyper -stimulation
The presence of late decelerations is taken seriously & foetal blood sampling for pH is indicated
If foetal blood pH is acidotic it indicates significant foetal hypoxia & the need for emergency Csection
4- Prolonged deceleration
A deceleration that last more than 2 minutes
If it lasts between 2-3 minutes it is classed as Non-Reasurring
If it lasts longer than 3 minutes it is immediately classed as Abnormal
Action must be taken quickly e.g. Foetal blood sampling / emergency C-section

5- Sinusoidal Pattern
This type of pattern is rare, however if present it is very serious
It is associated with high rates of foetal morbidity & mortality
It is described as:
A smooth, r egular , wave-like pattern
Fr equency of ar ound 2-5 cycles a minute
Stable baseline r ate ar ound 120-160 bpm
No beat to beat var iability
A sinusoidal pattern indicates:
Sever e foetal hypoxia
Sever e foetal anaemia
Foetal/Mater nal Haemor r hage
Immediate C-section is indicated for this kind of pattern.
Outcome is usually poor
Once you have assessed all aspects of the CTG you need to give your overall impression
Overall impression (O)
-------------------------The overall impression can be described as either: 4
Reassur ing
Suspicious
Pathological