Guidelines for Midwifery and Obstetric
Staff in the use and interpretation of
Cardio-Tocography in Antenatal and
Intrapartum Fetal Surveillance
Women and Children’s Services
Replaces (if appropriate):
Guidelines, Antepartum, Intrapartum Fetal Heart Rate Monitoring and the
interpretation of Continuous Electronic Fetal Monitoring (EFM) June 2007 (AAH)
NICE Fetal Monitoring Guidelines (2001) (Adapted by Causeway 2002)
Policy Author/Team: Type of document:
Dr Briege Lagan Departmental Guidelines
Clinical Midwife Specialist
Review Date: 31 October 2011
Approved by: Date Policy disseminated by
Margaret Gordon Equality Unit:
Assistant Director Obstetrics and
Gynaecology 12 January 2009
8 December 2008
NHSCT MISSION STATEMENT
To provide for all the quality of services we would expect for our families
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 1
GUIDELINES FOR MIDWIFERY AND OBSTETRIC STAFF IN THE USE AND
INTERPRETATION OF CARDIOTOCOGRAPHY IN ANTENATAL AND
INTRAPARTUM FETAL SURVEILLANCE
The aim of these guidelines is to educate and support best practice for
Midwifery and Obstetric Staff in the use and interpretation of cardiotocography
in antenatal and intrapartum fetal surveillance and avoid adverse outcome from
intrapartum acidotic/ hypoxic insult.
The objective of these guidelines is to encourage a consistent approach to the
use and interpretation of cardiotocography in antenatal and intrapartum fetal
surveillance by medical and midwifery staff across the Northern Health and
Social Care Trust.
There are very few properly randomized trials comparing different modalities of
fetal monitoring, apart from those comparing electronic fetal monitoring and
auscultation. The recommendations in this guideline therefore, are made on the
best evidence and information available to date.
These guidelines should be read in conjunction with the Northern Health and
Social Care Guidelines on Intrapartum Care and Guidelines on Induction of
The guidelines will be monitored through clinical midwifery supervision, issues
raised through training days, the Incident reporting system and risk
Antenatal Fetal Monitoring
• All women who attend the admission/day assessment units should be
individually assessed by the midwife and/or obstetric medical staff to
determine if cardiotograph (CTG) monitoring is indicated.
• Method (intermittent auscultation or continuous CTG monitoring) must be
decided in partnership with the woman according to her needs.
• The fetal heart should be auscultated whenever a woman attends the
maternity unit for assessment during the second and third trimester.
Below 24 weeks auscultate with a Pinard or hand-held doppler. Between
24-28 weeks CTG should only be performed on medical request or if
there is concern on auscultation.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 2
• CTGs performed before 30 weeks should be interpreted with caution
because of a physiologically higher baseline, lack of accelerations, lower
variability and the occurrence of sporadic decelerations.
• Current evidence does not support the use of the admission CTG in low-
risk pregnancy and it is therefore not recommended.
• All CTGs should be assessed utilising the CTG Assessment Label
(Appendix 1). The CTG must be classified (see Appendix 2) and signed
by the midwife when completed. Document action taken on the CTG and
on the CTG Assessment Label which must be inserted into the maternity
• Where indicated (see Table 1) a cardiotocograph (CTG) should be
performed for at least 20mins (Preferably using a monitor that would also
record fetal movements).
Indications for Antenatal Electronic Fetal Monitoring (RCOG 2001)
Maternal Conditions Fetal Conditions
• Hypertensive Disorders of • Small fetus
Pregnancy – Growth restriction
• Diabetes – Constitutionally small
• Antepartum haemorrhage • Prematurity
• Abdominal Pain • Oligohydramnios/Polyhydramnios
• Other maternal medical disease • Abnormal umbilical artery Doppler
– Cardiac Disease Velocimetry
– Severe Anaemia • Isoimmunisation
– Hyperthyroidism • Multiple Pregnancy
– Vascular disease • Breech Presentation
– Renal disease • Reduced Fetal Movement
• Abdominal trauma • Post-term pregnancy
Note: This list is not exhaustive.
• NORMAL CTG: this should be noted in the hand held records or case
notes by the midwife.
• SUSPICIOUS CTG: the CTG should be continued for a further 20
minutes. If then normal, discontinue and arrange a repeat if necessary
following medical review. If the CTG remains suspicious, continue
monitoring until the registrar (AAH) or Staff Grade (Causeway) has
reviewed the woman and the CTG. If bedside review within one hour is
not possible, the CTG may be taken to the doctor.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 3
• PATHOLOGICAL: the Registrar (AAH) / Staff Grade (Causeway) or
Consultant must be asked to see the CTG and woman without delay
• Only antenatal inpatients who are regarded as ‘high risk’ (see Table 1)
should have CTG monitoring performed for a minimum of 20 minutes
daily or more frequently if clinically indicated.
Intrapartum Fetal Monitoring
• Method (intermittent auscultation or continuous CTG monitoring) should
be decided in partnership with the woman according to her needs
• Intermittent auscultation is equally as effective as continuous CTG
monitoring for low risk women in labour
• Prior to any form of fetal monitoring, the maternal pulse should be
checked simultaneously with FHR auscultation in order to differentiate
between maternal and fetal heart rates.
• If fetal death is suspected despite the presence of a recordable FHR,
then fetal viability should be confirmed with real time ultrasound
• With regard to the conduct of intermittent auscultation:
The FHR should be auscultated at specified intervals
Any intrapartum events that may affect the FHR should be noted
contemporaneously in the maternity records, signed and the time
• For a woman who is healthy and has had an otherwise uncomplicated
pregnancy, intermittent auscultation should be offered and recommended
in labour to monitor fetal wellbeing.
• In the active stages of labour, intermittent auscultation should occur after
a contraction, for a minimum of 60 seconds, and at least:
Every 15 minutes in the first stage
Every 5 minutes in the second stage
• Continuous electronic fetal monitoring is recommended
- if there is evidence on auscultation of a baseline less than 110 bpm or
greater than 160 bpm
- if there is evidence on auscultation of any decelerations
- if any pregnancy/intrapartum risk factors are present (see Table 2).
• Where continuous EFM is required for the substantial part of labour, and
if the EFM to date is considered to be normal, monitoring may be
interrupted for short periods of up to 15 minutes to allow personal care
(e.g. shower, toilet). Such interruptions should be infrequent and not
occur immediately after any intervention that might be expected to alter
the FHR (e.g. amniotomy, epidural insertion, or top-up etc).
• If unable to obtain good quality CTG trace, record the reason and
consider use of a fetal scalp electrode
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 4
• Women who are to have a trial of instrumental delivery in theatre should
be continuously monitored as soon as possible after arrival in theatre.
Indications for Continuous Intrapartum Electronic Fetal Monitoring
Maternal Conditions Fetal Conditions
• Hypertensive Disorders of • Prematurity
Pregnancy • Meconium staining of the amniotic
• Diabetes fluid
• Antepartum haemorrhage • Suspicious fetal heart rate on
• Abdominal Pain auscultation
• Other maternal medical disease • Post-term pregnancy
– Cardiac Disease • Any evidence of/or suspected fetal
– Severe Anaemia
– Abnormal Doppler
– Vascular disease
– Renal disease
– Intrauterine growth retardation
• Vaginal bleeding in labour
• Intrauterine infection
• Regional analgesia
• Multiple Pregnancy
• Previous caesarean section
• Prolonged membrane rupture
• Induced/ Augmented labour
• Hypertonic uterus
Note: This list is not exhaustive
General Principles of EFM and Record- Keeping
In order to ensure accurate record-keeping regarding EFM:
• The date, time clock, and speed i.e. 1cm/min on the EFM machine
should be checked and if necessary correctly set prior to use.
• All EFM recordings should be labelled with the mother’s name, date of
birth, hospital number, parity, and gestation.
• The FHR must always be auscultated with a Pinard stethoscope or fetal
doppler and recorded with the mother’s pulse rate at the start of a CTG
• The trace must be dated, timed at commencement.
• Reason must be stated for commencement and discontinuation of CTG
must be recorded in the maternity record.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 5
• Any intrapartum procedures and/or events occurring whilst
cardiotocograph in progress that may affect the FHR should be should
be recorded on the graph, which should be signed and the date and time
noted (for example, vaginal examination, FBS or siting of an epidural).
• Any member of staff who is asked to provide an opinion on a trace
should note their findings on both the trace and the woman’s maternity
records along with the date, time and signature.
• Following birth, the healthcare professional should sign and note the
date, time and mode of birth on the FHR trace.
• Safe storage of CTGs is required for legal reasons, to fulfill Midwives
Rule no 9 (NMC, 2004) and to comply with Clinical Negligence Scheme
for Trusts (CNST) requirements. All CTGs should be stored securely
with the woman’s medical records at the end of the monitoring process.
Interpretation of FHR traces/Cardiotocographs
• CTGs must always be interpreted in the light of the clinical evidence and
each individual situation.
The recommended classifications and definitions of the FHR trace/
cardiotocograph produced during EFM are shown in tables 3 and 4.
Table 3 Classification of FHR trace features
Feature Baseline Variability Decelerations Accelerations
Reassuring 110–160 5 None Present
Non- 100–109 < 5 for Typical variable The absence of
reassuring 161–180 40– decelerations with over accelerations
90 minutes 50% of contractions, with otherwise
occurring for over normal trace is
90 minutes of uncertain
Single prolonged significance
deceleration for up to
Abnormal < 100 < 5 for Either atypical variable
> 180 90 minutes decelerations with over
Sinusoidal 50% of contractions or
pattern late decelerations, both
10 minutes for over 30 minutes
deceleration for more
than 3 minutes
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 6
Table 4 Definition of normal, suspicious and pathological FHR traces
Normal An FHR trace in which all four features are classified as
Suspicious An FHR trace with one feature classified as non-reassuring and
the remaining features classified as reassuring
Pathological An FHR trace with two or more features classified as non-
reassuring or one or more classified as abnormal
For women having continuous EFM, a documented systematic assessment
based on these definitions and classifications should be undertaken every
hour utilising the CTG Assessment Label (Appendix 1) which is inserted into
the maternity records.
• SUSPICIOUS CTG: consider possible causes and take appropriate
action (Appendix 3). If the CTG does not return to normal and has one
non-reassuring characteristic and delivery is not imminent, midwife must
inform registrar/staff grade. If CTG continues to be suspicious, the
registrar/staff grade must inform the consultant on call for delivery suite.
If the CTG has two or more non-reassuring characteristics for more than
30 minutes (i.e. pathological CTG), consider fetal blood sampling (FBS)
or expedite delivery. Reasons for any deviation from this standard must
be clearly documented
• PATHOLOGICAL CTG: Midwife must inform the registrar (AAH) / Staff
grade (Causeway) immediately (Appendix 4). This should be done prior
to any interventions. Prepare for delivery. The Co-coordinator/midwife in
charge may refer directly to the Consultant on call in the event of
suspected mismanagement. The “decision to deliver” to delivery time
interval should be as short as possible, but ideally within 30 minutes.
- Paired cord blood gases (arterial and venous) should always be
obtained when fetal blood sampling has been performed in labour,
or when delivery is expedited for an abnormal CTG. Obtaining
blood for cord gases is the responsibility of the person who
delivers the baby.
All midwifery and obstetric staff that use continuous fetal monitoring in their
clinical practice must:
Act within their scope of practice
Work within the NHSCT organisational guidelines
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 7
Be able to interpret the trace and act accordingly
Maintain knowledge and skills
Complete the K2 self-assessment tool in relation to CTG interpretation at
least once a year and 4 simulated cases within K2.
Attend at least four in-house CTG training seminar sessions per annum
Self-assessment of skills for all midwives and obstetric staff involved in
antenatal and intrapartum care will be assessed formally in the use and
interpretation of cardiotocography in antenatal and intrapartum fetal surveillance
at least once a year, in their annual appraisal. The training and education
required will be recorded in their personal development plan.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 8
1. Advanced Life Support in Obstetrics (ALSO) (2000) Provider Course
Syllabus, (4th Edition) American Academy of Family Physicians: Kansas.
2. Alfirevic Z, Devane D, Gyte GML. (2006) Continuous cardiotocography
(CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment
during labour. Cochrane Database of Systematic Reviews 2006, Issue 3.
Art. No.: CD006066. DOI: 10.1002/14651858.CD006066. Available at
/CD006066 /frame.html [Accessed August 11th 2008].
3. Mooney, S. E, Ogrinc, G., Steadman, W. (2007). Improving emergency
caesarean delivery response times at a rural community hospital. Qual Saf
Health Care 16: pp.60-66.
4. National Institute for Clinical Excellence (September 2007). Intrapartum
Care. Available at: http://www.nice.org.uk/nicemedia/pdf/word/IPCNICEv8.
7.doc [Accessed August 11th 2008].
5. Royal Australian and New Zealand College of Obstetricians and
Gynecologists (2006) Intrapartum fetal surveillance: clinical guidelines. 2nd
ed. Melbourne: The College. Available at: http://www.ranzcog.
6. Royal College of Midwives (2007) Safer Childbirth: Minimum Standards for
the Organisation and Delivery of Care in Labour. Available at:
http://www.rcm.org. [Accessed August 11th 2008].
7. Royal College of Obstetricians and Gynecologists (2001) The use of
electronic fetal monitoring: the use and interpretation of cardiotogography in
intrapartum fetal surveillance. [Evidence-based clinical guideline no 8].
8. Society of Obstetricians and Gynecologists of Canada (2007) Fetal Health
Surveillance: Antepartum and Intrapartum Consensus Guideline. Journal of
Obstetrics and Gynecology Canada, 29(9): Supplement 4.
9. Thomas J, Paranjothy S, James D (2004) National cross sectional survey to
determine whether the decision to delivery interval is critical in emergency
caesarean section.; British Medical Journal, 20;328(7441): 665.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 9
CTG ASSESSMENT LABEL
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ASSESSMENT OF NEED AND CLASSIFICATION OF ELECTRONIC FETAL MONITORING (EFM)
Consideration should be given to Maternal Preferences and Priorities
Admission Assessment Intermittent auscultation Abnormal Fetal Heart Rate (FHR) on
Any risk factors? Full minute after contraction with a
(List not exhaustive):
NO doppler or pinnard Baseline 110 bpm or 160 bpm
Maternal At least every: 15 minutes in 1 stage Any deceleration
Previous Caesarean 5 minutes in second stage
Post term (>42 wks gestation)
SROM >24 hrs CONTINUOUS ELECTRONIC FETAL MONITORING
Antepartum haemorrhage Cardiotocograph (CTG) Classification
Other maternal medical problem
NORMAL: All four features in reassuring category
Growth restriction SUSPICIOUS: One non-reassuring feature, remainder reassuring
Oligohydramnios PATHOLOGICAL: Two or more non-reassuring features, one or more abnormal features
Multiple pregnancy Fetal Heart-Rate Feature Classification
Breech presentation Baseline bpm Variability bpm Decelerations Accellerrattiions
Acce e a ons
Reassuring 110-160 bpm 5bpm None Present
Offer and recommend Early deceleration
continuous EFM Non- 100-109 bpm Less than 5 bpm for 40 - The absence
Reassuring 90mins (in the absence of Variable decelerations of
Intrapartum Risk Factors? accelerations) Single prolonged deceleration accelerations
up to 3 minutes with an other
Typical variable Atypical variable wise normal
Epidural analgesia Abnormal <100 bpm
Vaginal bleeding in labour CTG is of
decelerations with over decelerations
Maternal pyrexia >180 bpm uncertain
Fresh meconium-stained liquor 50% of contractions for Single prolonged deceleration significance
Maternal request Sinosodal pattern over 90mins over 3 minutes
If YES: Single prolonged
Offer and recommend deceleration up to 3mins
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 9
MANAGEMENT OF SUSPICIOUS CARDIOTOCOGRAPH (CTG)
Ensure adequate quality recording of both fetal heart rate and contraction pattern, and the
mother is informed of any concerns and included in the management plan
INADEQUATE QUALITY CTG? UTERINE HYPERCONTRACTILITY
Check maternal pulse Is the mother receiving oxytocin?
- Reduce/stop infusion
Poor contact from external transducer?
- check position of transducer Has the mother recently received vaginal
- consider applying fetal scalp electrode prostaglandins?
(FSE) - Consider tocolysis:
Terbutaline 0.25mg subcutaneously
FSE not working?
- Check position of FSE/reapplying FSE
- Confirm FH with Pinard
stethoscope/fetal doppler and/or
MATERNAL TACHYCARDIA/PYREXIA OTHER MATERNAL FACTORS
Is there a maternal infection? Check:
- Check temperature. If 37.5 C on two
What is the maternal position?
occasions two hours apart or 38 C or
higher, consider screening and - Ensure woman not supine
treatment. - Ensure left lateral position
Is mother dehydrated?
- Check blood pressure and given The mother is not hypotensive?
500mls crystalloid (IV) if appropriate Has she just:
- Had a vaginal examination
Has the woman had a tocolysis?
- Been vomiting or vasovagal?
- If pulse 140bpm do not give any
further tocolysis - Had an epidural sited/topped up?
Give 500mls crystalloid if appropriate
The midwife who has direct care for the woman must inform a senior obstetrician of any suspicious
If CTG remains suspicious continue to observe for further non-reassuring or abnormal features and
always consider in context of overall clinical picture of mother and fetus. If CTG becomes pathological,
see action for pathological CTG (Appendix 4).
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 10
MANAGEMENT OF PATHOLOGICAL CARDIOTOCOGRAPH (CTG)
Inform Senior Obstetrician
Fetal Blood Sampling (FBS) Possible and/or Appropriate?
• Encourage mother to adopt left lateral position.
• Check B/P and give 500mls crystalloid (IV) if appropriate.
FBS Result (pH) Interpretation Recommended Action
7.25 Normal - FBS should be repeated in one hour if FHR
abnormality persist, or sooner if there are further
- If results remains stable after 2nd test, then a
third/further sample may be deferred unless there are
further abnormalities of the CTG
7.21 – 7.24 Borderline - Repeat FBS within 30 minutes if the FHR remains
pathological, or sooner if there are further
abnormalities. (Consideration should be given to the
time taken to perform FBS when planning repeat
- If a third sample is indicated, a consultant obstetric
opinion should be sought.
7.20 Abnormal Consultant obstetric advice must be sought
All FBS results should be interpreted taking into account the previous pH measurement,
progress of labour and the clinical features of the mother and fetus.
Fetal Blood Sampling (FBS) Not Possible and/or Inappropriate?
• Encourage mother to adopt left lateral position
• Check B/P and give 500mls crystalloid (IV) if appropriate
- The urgency and mode of delivery should take into account the severity of the FHR and
- The accepted standard is that delivery should be accomplished within 30 minutes from
decision to deliver
Following delivery, take paired umbilical cord samples and calculate apgar scores. Document all
results in the mother’s maternity notes and on the CTG tracing.
NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008 11