Cardiotocography as a Test of

Fetal Well Being

Max Brinsmead PhD FRANZCOG

December 2014
The objective of CTG screening:

x = Healthy
0 = Hypoxic

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An ideal screening test:
x = Healthy
0 = Hypoxic

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CTG as a screening test
x = Healthy
0 = Hypoxic

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 CTG as a Screening Test
Positive predictive value = the chance that
a screen positive individual will have the
disease
For CTG this is never more than 50%
i.e. at least 50% of the time it will be
unnnecessarily alarming
A screening test is more likely to
be a true positive if
A screening test is more likely to
be a true positive if
It is positive in a high risk
group
So always consider the
clinical context
And be prepared to back up
with a diagnostic test
Which, for the diagnosis of fetal
hypoxia, is Scalp Blood pH or
lactate
 Problems with Screening:

FALSE POSITIVES
And the resources required to deal with them
UNREALISTIC EXPECATATIONS
i.e. misunderstanding about the sensitivity of
the test
 Meta analysis of RCTs of
Intrapartum CTG monitoring
12 Trials
In 10 centres in the US, Australia, Europe
and Africa
58,855 women and 59,324 babies
Both high and low risk pregnancies
Compared routine EFM with intermittent
auscultation
 Meta analysis Results

A significant decrease in:

rate of 1 minute Apgar scores less than 4 (RR =
0.82 and CI 0.65 - 0.98)

Neonatal seizures (RR=0.50 and CI 0.32 - 0.82)

 Meta analysis Results

A significant increase in:

The rate of intervention by Caesarean section

and operative delivery (RR=1.23 and CI
1.15 - 1.31)
 Meta analysis Results

No effect on:
rate of 1 min Apgar scores <7

rate of admissions to NICU

Perinatal death rate

5 min Apgar scores

rate of Cerebral palsy

But let us not throw out the baby
with
The CTGs dirty bathwater!
Because, as a screening test for
hypoxia,
IT IS CURRENTLY THE BEST
TEST WE HAVE
Who should have Intrapartum CTG?

Patients who have increased risk for fetal

hypoxia or acidosis
Identified by antenatal factors
Intrinsic fetal problems
Develop intrapartum problems
Antenatal Risks
 Intrapartum indications for CTG?

Suspected chorioamnionitis or temp >380 C

BP >160 systolic or 110 diastolic
Oxytocin in use
Significant meconium
Fresh vaginal bleeding
Non reassuring intermittent auscultation
But remove after 20 min if normal
 Intrapartum indications for CTG?

Consider continuous CTG if 2 or more of

the following occur
BP >150 systolic or 100 diastolic
Delay in the 1st or 2nd stage
Light meconium staining
An Examination of CTG
Abnormalities
What is Important
 CTG Features

Baseline heart rate

Decelerations - early, late and variable
Short term variability
Accelerations
 Reassuring CTG

Baseline 110 160 bpm

>5 bpm variability
No decelerations
Accelerations present
(The absence of accelerations in an otherwise
normal CTG is of uncertain significance)
 Non Reassuring CTG

Baseline 100 - 109 or 161 - 180 bpm

Variability <5 bpm for <40 but <90 min
Variable decelerations <30 min
Single prolonged deceleration up to 3 min
Decelerations in <50% contractions
 Abnormal CTG

Baseline <100 or >180 bpm

Variability <5 bpm for >90 min
Decelerations with >50% of contractions
Variable decelerations for >30 min
Late decelerations for >30 min
Prolonged deceleration >3min or recurs
Sinusoidal for >10 min
Decelerations
 Atypical Variable Deceleration

Slow return to baseline

Secondary rise in baseline
Biphasic
Loss of variability during deceleration
Continution baseline at a lower level
NB The 2014 NICE guidelines have
dispensed with atypical and typical
 RCOG Recommendations

Settings on CTG machines should be

standardised, so that:
Paper speed is set to 1 cm/min
Sensitivity displays are set to 20
bpm/cm
FHR range displays of 50210 bpm
are used.
 Categorisation of CTGs

Normal =A CTG where all four features

fall into the reassuring category
Suspicious =a CTG with one non
reassuring feature
Pathological =a CTG with two or more
nonreassuring features or one or more
abnormal features
RCOG and NICE
RCOG and NICE