South Australian Perinatal Practice Guideline

Fetal Surveillance
(Cardiotocography)
© Department for Health and Wellbeing, Government of South Australia. All rights reserved.

Note:
This guideline provides advice of a general nature. This statewide guideline has been prepared to promote and facilitate
standardisation and consistency of practice, using a multidisciplinary approach. The guideline is based on a review of published
evidence and expert opinion.
Information in this statewide guideline is current at the time of publication.
SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not
sponsor, approve or endorse materials on such links.
Health practitioners in the South Australian public health sector are expected to review specific details of each patient and
professionally assess the applicability of the relevant guideline to that clinical situation.
If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the
patient’s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline.
This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful
confidential discussion. This includes:
• The use of interpreter services where necessary,
• Advising consumers of their choice and ensuring informed consent is obtained,
• Providing care within scope of practice, meeting all legislative requirements and maintaining standards of
professional conduct, and
• Documenting all care in accordance with mandatory and local requirements

Explanation of the aboriginal artwork:

The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape design
shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this instance
represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in unison.

Australian Aboriginal Culture is the oldest living culture in the world yet
Aboriginal people continue to experience the poorest health outcomes when
compared to non-Aboriginal Australians. In South Australia, Aboriginal women are
2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to
be of low birth weight. The accumulative effects of stress, low socio economic
status, exposure to violence, historical trauma, culturally unsafe and discriminatory
health services and health systems are all major contributors to the disparities in
Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics
the birth of an Aboriginal baby is a celebration of life and an important cultural
event bringing family together in celebration, obligation and responsibility. The
diversity between Aboriginal cultures, language and practices differ greatly and so
it is imperative that perinatal services prepare to respectively manage Aboriginal
protocol and provide a culturally positive health care experience for Aboriginal
people to ensure the best maternal, neonatal and child health outcomes.

Purpose and Scope of Perinatal Practice Guideline (PPG)

The purpose of this guideline is to provide clinicians with information on the rationale for and use of
cardiotocography (CTG) to monitor fetal heart rate (FHR) in both antenatal and intrapartum
environments. It also provides clinicians with information on the interpretation of FHR patterns and
associated management in the context of abnormal FHR recordings, including referral for advice.

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Table 1: Indications for performing a CTG in the Antenatal Period

Indications for CTG

Abdominal trauma
Abnormal Doppler umbilical artery velocimetry
Abnormal Doppler studies
Antepartum haemorrhage (in excess of a ‘show’ ≥ 50mL)
Diabetes requiring stabilisation
Intrauterine Growth Restriction (suspected or confirmed)
Known fetal abnormality that requires monitoring
Maternal medical condition that constitutes a significant risk of fetal compromise
Maternal Obstetric condition (e.g. cholestasis)
Oligohydramnios (Amniotic fluid index (AFI) <5cm)
Polyhydramnios (Amniotic fluid index (AFI) > 25 cm)
PPRoM (>24 hours)
Prolonged pregnancy ≥ 42 weeks
Previously abnormal antenatal CTG
Prior to and following attempted external cephalic version (ECV)
Reduced fetal movements
Rhesus isoimmunisation
Severe hypertension or preeclampsia

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Table 2: Indications for Intrapartum CTG Monitoring3

Antenatal Indications for Intrapartum CTG

Abnormal antenatal CTG
1
Abnormal cerebroplacental ratio ** (recommended by RANZCOG but remains experimental)
Abnormal Doppler umbilical artery velocimetry
Abnormal maternal serum screening results associated with an increased risk of poor perinatal
outcome (e.g. PAPP-A <0.37 MoM) **
Abnormal placental cord insertion (e.g. velamentous cord insertion) **
Antepartum Haemorrhage
Diabetes (on medication, or poorly controlled or fetal macrosomia)
Hypertension / preeclampsia (current pregnancy)
Intrauterine growth restriction (suspected or confirmed)
Known fetal anomaly which requires monitoring
Maternal age ≥ 42 years **
Maternal medical conditions that constitute a significant risk of fetal compromise (e.g. severe
anaemia, cardiac disease, cholestasis, hyperthyroidism, renal disease, iso-immunisation,
substance abuse, vascular disease)
Morbid obesity (BMI ≥40)
Multiple pregnancy
Oligohydramnios or polyhydramnios
Reduced fetal movements (within preceding week unless investigated and FM now normal)
Uterine scar / previous caesarean section
Indications at the Onset of Labour
Breech presentation
Post-term pregnancy (≥ 42 weeks)
+0

Preterm labour
Prolonged rupture of membranes (≥ 24 hours)
Labour Indications for Intrapartum CTG
Absent liquor following amniotomy
Chorioamnionitis
FHR abnormalities on auscultation (bradycardia, tachycardia, decelerations)
Maternal pyrexia ≥ 38 ˚C
Meconium-stained or blood-stained liquor
Prolonged active first stage labour (> 12 hours regular uterine contractions with cervical
dilatation > 3 cm)
Prolonged second stage of labour (> 1 hour active pushing)
Regional anaesthetic (epidural or spinal) (including just before insertion)
Uterine tachysystole, hypertonus or hyperstimulation
Vaginal bleeding in labour (in excess of a “show” ≥ 50 mL)
Indications associated with the use of interventions
Before and for at least 20 minutes after administration of prostaglandin or cervical-ripening
balloon catheter
Use of oxytocin for either induction or augmentation of labour
Regional anaesthesia: epidural, spinal (including prior to and at the time of insertion)
1
** RANZCOG include these indications, however if appropriate antenatal investigation / serial
ultrasound / maternal investigation has been undertaken and is reassuring, then the woman and
her unborn baby should not be inappropriately pathologised, and should be managed as ‘normal’
without the need for continuous CTG unless other indications are present or arise.

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Table 3: RANZCOG definition and classification of fetal heart rate
(FHR) using cardiotocography (CTG)3
Term Definition
The mean of the stable FHR determined in the absence of uterine activity,
fetal movements (accelerations) or decelerations over 5 to 10 minutes.
Baseline FHR Expressed in beats per minute (bpm)
Calculated on resting heart rate, NOT sleeping heart rate
It is expected that the FHR of preterm fetuses may be in the upper range
Normal baseline FHR 110-160 bpm
Baseline bradycardia FHR less than 110 bpm
Baseline tachycardia FHR more than 160 bpm
The minor baseline FHR fluctuations measured by estimating the
Baseline variability difference in bpm between the highest peak and lowest trough of
fluctuation in 1 minute segments of the CTG trace between contractions
Normal baseline FHR fluctuates 6-25 bpm between contractions
variability
Reduced baseline FHR fluctuates 3-5 bpm for > 30 minutes
variability
Absent baseline FHR fluctuates less than 3 bpm
variability
Increased baseline FHR fluctuates > 25 bpm
variability
FHR amplitude changes > 25 bpm with an oscillatory frequency > 6 per
Saltatory Pattern
minute for a minimum of one minute in duration
A regular oscillation of the baseline FHR resembling a sine wave.
Persistent, smooth and undulating pattern with relatively fixed period of 2-
Sinusoidal 5 cycles per minute and amplitude of 5-15 bpm above and below the
baseline.
Baseline variability and FHR accelerations are absent
Transient increases in FHR of 15 bpm or more above the baseline and
lasting 15 seconds
Accelerations
Accelerations in the preterm fetus may be of lesser amplitude and shorter
duration
Transient episodes of decrease of FHR below the baseline lasting at least
Decelerations
15 seconds and conforming to one of the patterns below:
Uniform, repetitive decrease of FHR where there is a slow onset early in
Early decelerations contraction with a slow return to baseline prior to the end of the
contraction
Repetitive or intermittent decrease in FHR with rapid descent and rapid
Variable decelerations recovery. Timing may be variable but usually simultaneous with
contractions
Slow return to baseline FHR after the end of the contraction
Complicated variable Large amplitude of > 60 bpm and/or long duration > 60 seconds
decelerations Presence of smooth post deceleration overshoots (temporary smooth
increase in FHR above baseline)
Uniform, repetitive decreasing of FHR usually with slow onset mid to end
Late decelerations of the contraction with nadir > 20 seconds after the peak of the contraction
and ending after the contraction
Prolonged decelerations Decrease of FHR below the baseline for > 90 seconds but < 5 minutes
Bradycardia Decrease of FHR below the baseline for ≥ 5 minutes

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Table 4: Definition and classification of fetal heart rate (FHR) using
STan Guidelines2

Table 5: Descriptors for documentation of CTG traces7

Baseline Baseline rate and presence of any change
Variability of Language includes
baseline Normal, increased, reduced or absent
Accelerations State:
Present or absent
Decelerations Four components:
Type: early, late, prolonged or variable
Duration: describe in time (seconds or minutes), include shortest
and longest deceleration. Describe in detail.
Depth: describe in bpm the depth of deceleration, compare shallowest
to deepest
Frequency: use terms regular or frequent, persistent or isolated
Uterine activity Four components:
• Strength
• Duration
• Frequency (per 10 minutes)
• Any period of rest, hypertonia

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Table of Contents
Purpose and Scope of Perinatal Practice Guideline (PPG) ............................................................... 1
Table 1: Indications for performing a CTG in the Antenatal Period.................................................... 2
Table 2: Indications for Intrapartum CTG Monitoring ......................................................................... 3
Table 3: Definition and classification of fetal heart rate (FHR) using cardiotocography (CTG) ......... 4
Table 4: Definition and classification of fetal heart rate (FHR) using STan Guidelines ..................... 5
Table 5: Descriptors for documentation of CTG traces ...................................................................... 5
Table of Contents ............................................................................................................................... 6
Summary of Practice Recommendations ........................................................................................... 7
Abbreviations ...................................................................................................................................... 7
Cardiotocography (CTG) .................................................................................................................... 8
Background Physiology .................................................................................................................. 8
Antenatal Use of CTG ........................................................................................................................ 8
Intrapartum fetal surveillance ............................................................................................................. 9
Indications for continuous CTG intrapartum ................................................................................. 10
Interruptions to fetal heart rate monitoring ................................................................................... 10
3
Consider intrapartum cardiotocography if several of the following conditions are present ......... 10
Indications associated with the use of interventions .................................................................... 10
Performing a CTG ............................................................................................................................ 10
CTG setting recommendations ..................................................................................................... 10
General recommendations when performing a CTG.................................................................... 11
Fetal Heart Rate Monitoring Modes ............................................................................................. 11
Documentation of CTG ..................................................................................................................... 12
Description of fetal heart rate patterns using CTG ....................................................................... 12
Classification of the CTG .................................................................................................................. 13
Normal CTG.................................................................................................................................. 13
Fetal Compromise (Abnormal CTG) ............................................................................................. 13
Action in the context of an abnormal CTG ....................................................................................... 14
Conservative measures ................................................................................................................ 14
Maternal Oxygenation .................................................................................................................. 14
Fetal blood sampling (FBS) .......................................................................................................... 14
Communication and consultation ................................................................................................. 14
Review and management advice for abnormal CTGs (Wider SA) ................................................... 15
Storage of CTG tracings ................................................................................................................... 15
CTG competency assessment ......................................................................................................... 16
References ....................................................................................................................................... 17
Acknowledgements .......................................................................................................................... 19
Document Ownership & History ....................................................................................................... 20

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Summary of Practice Recommendations
CTG competency training is recommended for all practitioners and is mandated in SA.
Analysis of the CTG must be made using a combination of pattern recognition, review of the
individual’s woman’s antenatal/intrapartum history, identification of any risk factors and
consideration of fetal physiology.
Antenatal CTG implies that a pregnancy risk has been identified and medical referral is required.
Fetuses less than 32 weeks will not demonstrate a mature reactive pattern.
Intermittent auscultation is equally as effective as continuous CTG monitoring for low risk women in
labour.
Continuous CTG is recommended when risk factors for fetal compromise are detected during
pregnancy, at the onset of labour, or at any time during labour.
Continuous cardiotocography should not be used as a substitute for a midwife.
Maternal heart rate should be checked and recorded at the commencement of monitoring the fetus
to ensure the CTG is monitoring FHR.
At all times a clinician must be assigned to observe the CTG whether in the room or via a
centralised monitoring system.
Any abnormalities or non-reassuring/abnormal signs should be reported, and appropriate
management initiated.

Abbreviations
ACOG American College of Obstetricians and Gynaecologists
BMI Body mass index
bpm Beats per minute
cm Centimetre
CTG Cardiotocography
cCTG Computerised cardiotocography
EFM External fetal monitoring
ECG Electrocardiogram
e.g. For example
FBS Fetal blood sampling
FHR Fetal heart rate
FSE Fetal scalp electrode
HIV Human immunodeficiency virus
IP Intrapartum
min Minute
mL Millilitre(s)
MoM Multiples of the median
NICE National Institute for Clinical Excellence
PAPP-A Pregnancy associated plasma protein A
PPROM Preterm prelabour rupture of membranes
RANZCOG Royal Australian and New Zealand College of Obstetricians and
Gynaecologists
RCOG Royal College of Obstetricians and Gynaecologists
RCT Randomised controlled trial
SA South Australia
STAN ST analysis

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Cardiotocography (CTG)
Background Physiology
Cardiotocography (CTG) Is an electronic method of simultaneously recording fetal heart
rate (FHR), fetal movements and uterine contractions as a method of assessing fetal well-
1,2,3
being, predominantly in pregnancies with increased risk of complications . The aim of
the CTG is to identify the fetus(s) who may be hypoxic, to guide potential assessments of
1
fetal wellbeing and mode of birth .
To accurately interpret a CTG a sound foundational knowledge of fetal physiology including
4,5
fetal oxygenation is essential . Key points to remember when interpreting a CTG are:
• A fetus is unable to increase its own oxygen supply. To prevent myocardial
5, 6
hypoxia and /or mechanical stress the fetus will decrease its heart rate which is
heard as a deceleration.
• Fetal oxygenation is dependent on adequate utero-placental circulation and
6
placental reserve .
• A fetus is able to protect itself from hypoxia in normal situations by:
1. increasing O2 delivery by stimulating the sympathetic nervous system
to increase its heart rate and therefore flow through the placenta and
7,8
increase O2 uptake
2. increasing O2 delivery to target organs, heart, brain and adrenal
glands, by increasing sympathetic stimulation to redistribute blood
7,8
flow
7,8
3. reducing O2 consumption by decreasing movements
• Fetal heart rate is controlled by both autonomic and somatic components of the
central nervous system. Understanding the parasympathetic and sympathetic
involvement in fetal heart rate control facilitates the practitioner to identify normal
8
and abnormal features in the fetal heart rate pattern in the CTG recording
• Chemoreceptors and baroreceptors within the carotid artery, aortic arch and brain
stem also actively play a role in controlling the fetal heart by stimulating the
sympathetic and parasympathetic nervous systems to help control fetal heart rate,
cardiac output and blood pressure to maintain an environment that is optimal for
7,8
the fetus to maintain functionality and oxygenation
• A fetus generates energy from glucose, in the form of adenosine triphosphate
9
(ATP) .
• A well oxygenated fetus has the following metabolism: Glucose →pyruvate →CO2
9
+ H2O + 38 ATP
• A poorly oxygenated fetus has the following metabolism: glucose →pyruvate
→lactic acid + H+ + 2 ATP
9

Antenatal Use of CTG

2,3,5,7
The CTG is an evaluation tool widely used in antenatal care for assessment of fetal wellbeing .
Tests of fetal wellbeing have to be interpreted in the context of risk assessment and fetal
physiology.
A Cochrane systematic review of 1636 high risk women concluded:
10
1. The use of antenatal CTG has no effect on the risk of caesarean section for women
10
2. Antenatal CTG has no beneficial effect on rates of perinatal mortality or morbidity
Currently there is not a single best-performing test of fetal wellbeing. It is thought that CTG has
limited value for the assessment of antenatal fetal wellbeing as it is good at identifying well fetuses,
11
but poor at identifying unwell fetuses . It is therefore commonly used in conjunction with
2,12
ultrasound assessment of fetal and placental Dopplers in high risk pregnancy .
Use of an antenatal CTG implies that a pregnancy risk has been identified and medical referral is
required. See Table 1 for indications to perform antenatal CTG.
Antenatal CTG only provides assessment of the immediate fetal condition.

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Antenatal CTG should not be conducted if the result will not be acted upon; for example a pre-
viable fetus.
Antenatal CTGs on fetuses < 32 weeks need to be interpreted with the understanding that the fetus
2,13
will not demonstrate a mature reactive pattern . The TRUFFLE Study compared computerised
CTG (cCTG) and abnormal ductus venosus (DV) measurement in use with preterm foetuses 26-32
weeks that had fetal growth restriction (FGR) as a trigger for preterm birth. Conclusions stated an
abnormal DV was associated with adverse outcome; fetal decelerations were not present on 6 of
the 7 fetuses that died. Recommendations are that cCTG changes should not be used in isolation
14
to determine birth timing with preterm fetuses .
The duration of the recording need only be 10 minutes and discontinued if the CTG trace meets
3
the criteria for a normal CTG .

Intrapartum fetal surveillance

Intermittent auscultation is equally as effective as continuous CTG monitoring for low risk women
1 1,5
in labour . In low risk women, the incidence of intrapartum fetal compromise is low .
16
CTG is thought to have a 30% positive predictive value for intrapartum fetal hypoxia . A good
17
knowledge of fetal physiology is essential in the interpretation and management of a CTG .
The strength of intrapartum (IP) CTG is the reliability of its ability to predict the absence of hypoxic
18,19
neurologic injury and absence of metabolic fetal acidaemia .
3,5
Aims of IP CTG are to avoid adverse outcome from intrapartum acidotic / hypoxic insult .
Continuous CTG provides a record of change over a period of time.
Analysis of the CTG must be made within the context of the clinical picture and consideration of all
risk factors. It is suggested that the isolated classification of a CTG on pattern recognition alone
16
may lead to fetal and maternal damage .

1
A Cochrane Review of the literature found no new trials had been conducted on IP CTG. The
results were:
1. Compared with intermittent auscultation of the FHR, continuous CTG had no significant
improvement in perinatal mortality. It was associated with a higher caesarean section
rate and instrumental birth. There was little difference in the incidence of cord blood
acidosis.
2. There was no significant difference between intermittent and continuous CTG and the
caesarean section rate.
3. CTG use in labour is linked to a reduction in neonatal seizures, but no clear difference in
1,20,21
the incidence of cerebral palsy or infant mortality .

22
Two large multisite RCTs were conducted in the USA evaluating fetal ECG ST analysis (STan)
and fetal pulse oximetry. The trials did not show any clear benefit in reducing caesarean section
23
rate or neonatal outcomes .

Use of computerised decision making systems to interpret FHR patterns on CTG during labour
remains controversial, with some concluding that an electronic decision making tool does not
24,25
improve outcomes or detect abnormal traces effectively . Human factors in the interpretation
and response to the alerts on computerised programs may result in poor outcomes, however
multiple trials have suggested that the benefit of computerised programs to assist in the decision
1,3,11,25
making process of assessing abnormal trace findings of clinical benefit .

Similarly, a comparison between computerised interpretation of CTG and traditional CTG (visual
interpretation) showed a significant reduction in perinatal mortality with computerised CTG but no
1
difference in potentially preventable deaths . Computerised CTGs augmented by fetal ECG ST
26
segment analysis (STAN) during labour have been introduced at the Women’s and Children’s
Hospital in South Australia as part of an ongoing trial. For further information on STAN see
www.neoventa.com. ST segment analysis (STan) classification is available in Table 4.

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Indications for continuous CTG intrapartum
Continuous CTG is recommended when risk factors for fetal compromise are detected during
16
pregnancy, at the onset of labour, or at any time during labour (see Table 2) . However, if
antenatal risk factors have been appropriately investigated via antenatal investigation, serial
ultrasound and/or maternal investigation and are reassuring, then the woman and her unborn baby
should not be inappropriately pathologised, and should be managed as normal.
If there is difficulty obtaining an adequate fetal heart rate tracing at any time in labour, consider the
5
fetal heart rate being monitored via a fetal scalp electrode .
When possible, CTG monitoring should also be commenced prior to the insertion of a regional
anaesthetic to establish baseline fetal heart rate characteristics.

Interruptions to fetal heart rate monitoring

Where continuous CTG is required for labour, and if the CTG 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 could impact on the wellbeing of the fetus (e.g. amniotomy, epidural insertion, or
epidural top-up).
Intermittent auscultation during unavoidable interruptions to continuous CTG monitoring or at times
of potential fetal vulnerability is recommended (e.g. epidural insertion, transfer to operating theatre
and birth of the fetus).
Interruptions to fetal heart rate monitoring should be minimised whenever possible.

Consider intrapartum cardiotocography if several of the following conditions

are present3
• Pregnancy gestation 41+0 to 41+6 weeks gestation
• Gestational hypertension
• Gestational diabetes mellitus without complicating factors
• Obesity (BMI 30-40)
• Maternal age 40 – 41 years
• Maternal pyrexia ≥ 37.8 and < 38 °C
• Borderline AFI (5-8cm)

Indications associated with the use of interventions

• Any use of oxytocin whether for induction or for augmentation of labour
• Before and for at least 20 minutes after administration of prostaglandin or cervical ripening
balloon catheter
• Epidural analgesia (including at the time of inserting an epidural block)

Performing a CTG
CTG setting recommendations
13 3
There are no internationally agreed practice recommendations . In SA we recommend :
• CTG paper speed at 1cm/minute
• Sensitivity displays at 20 beats per minute/cm
• Set FHR range display at 50 – 210 bpm
• Date and time settings on CTG tracings are validated whenever used
Health professionals should be aware that machines from different manufacturers use different
vertical axis scales, and this can change the perception of fetal heart rate variability.

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General recommendations when performing a CTG
For antenatal CTG, the woman should be in an upright position, reclining at 45° or lying on her side
11
to prevent postural hypertension .
With the use of telemetry, women can labour with minimal restriction on their activity.
The woman should indicate fetal movements with the appropriate marker (do not rely on the CTG
machine to accurately record fetal movements).
Maternal heart rate should be checked and recorded at the commencement of monitoring the fetus
2,3
to ensure the CTG is monitoring FHR .
Maternal heart rate should be checked with ‘loss of contact’, when the CTG is reapplied and
2,3,5
checked 15 – 30 minutely in labour .
CTG traces should be observed for the first 5 minutes to ensure transducers are correctly situated
and monitoring the fetus prior to the woman being left if centralised monitoring is available.
If there is no centralised fetal monitoring the clinician should remain present throughout the tracing.
At all times a clinician must be assigned to observe the CTG.
Any abnormalities or non-reassuring/abnormal signs should be reported, and appropriate
3,7
management initiated .
Monitoring should continue if the indication for monitoring is maternal pain, bleeding or contractions
or if the trace is non-reassuring or abnormal.
Twins should be monitored simultaneously, where possible a monitor ‘twin offset function’ should
27
be used .
On commencement of CTG monitoring, women should be advised, in general terms, the elements
of their CTG trace.

Fetal Heart Rate Monitoring Modes

A CTG is achieved via three different modes in SA: external, internal – via a fetal scalp electrode
2,3,25,26,28
(FSE) or via (STan) .

External CTG
The transducer is located externally on the maternal abdomen, ideally placed over the anterior
3,5
shoulder of the fetus . The toco-transducer, which is pressure-sensitive, is placed over the top of
the fundus, as this is the most contractile segment of the uterus. It is important to note that the
toco-transducer will inform the length (time) of the uterine contraction (if positioned correctly), but
3,5,7
not interpret the strength of the uterine contraction .
External CTG monitoring can be less reliable than internal monitoring due to loss of signal,
detection and recording of maternal heart rate. It can also pick up signal artefact, particularly in the
3,5,7
second stage of labour .

Internal CTG
An internal fetal scalp electrode (FSE) is applied to the presenting part of the fetus. It can be
5
applied to the scalp (preference) but also the buttock . The FSE has an electrode which when
5
applied to the fetus detects the fetal ECG and calculates a FHR . The FSE can only be applied
when the cervix is sufficiently dilated and the membranes have been ruptured. In most situations
the cervix needs to be 2 – 3 cm dilated to allow for correct attachment. FSE should be applied over
7,19
fetal bone and not over a suture lines or fontanelles .
3,5,19
The toco-transducer remains on the maternal abdomen, as with external CTG monitoring .
Internal FSE monitors can be inadvertently applied to the maternal cervix or other tissue and
therefore detect the maternal heart rate. Additionally, when there has been a fetal death, the
5
maternal heart rate can be conducted through the fetus and be recorded .
FSE should not be used when contraindicated. Contraindications include the presence of infection
5,
(e.g. HIV, Hepatitis B, Hepatitis C, active genital herpes) or sepsis to prevent vertical transmission
6,9,13
. Internal CTG should also be avoided in situations where there are fetal bleeding disorders,
3, 5, 7
malpresentation or an unstable lie of the fetus or intact membranes .

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ST-segment analysis (STan)
STan is an internal CTG, using a specialised gold tip FSE. This electrode is able to detect and
record a fetal ECG. This computerised technology assesses the fetal oxygenation of the fetus by
1,17,26,28
monitoring the T/QRS ratio .

Additional monitoring techniques

Intrauterine pressure catheters inserted into the intrauterine cavity. They can detect pressure
strength and timing unlike the toco-transducer. They require the membranes to be ruptured so that
3,7,16
the catheter can be inserted into the uterine cavity .
3,7 3
Fetal pulse oximetry : RANZCOG reviewed the RCT’s of STan monitoring, intrauterine pressure
catheters and fetal pulse oximetry and found there to be no benefit to traditional external or internal
CTG monitoring. Currently they do not recommend their use for routine intrapartum fetal
3
surveillance .

Documentation of CTG
The clinician who performs the CTG tracing should record the features of the tracing in the
woman’s hospital record.
Documentation of the CTG should be recorded 30 minutely to hourly within the woman’s case
3
notes as required. Documentation on the CTG recording itself includes :
• The mother’s name, date, time commenced, hospital record number and maternal
observations
• Intrapartum events that may affect the FHR (e.g. starting or changing oxytocin regimen,
vaginal examination, obtaining fetal blood sample or insertion of an epidural) should be
noted contemporaneously both on the CTG and in the maternal case notes, including date,
time and signature
• Document on the report when CTG is performed within 30 minutes of cigarette smoking,
self-medication of illicit substances or administration of any prescribed medications.
• Document significant maternal events such as change of position to relieve aortocaval
26
compression .
• Loss of contact and audible decelerations should be marked on the CTG by the attending
clinician and actions taken to ensure that the CTG recording has good contact and uterine
activity is clearly recorded.

3,7
Documentation of ANY abnormal features should be described in detail as per Table 5 . Where
the features indicate fetal compromise, continual CTG monitoring and recording is recommended.
3,7
Medical review should also be sought .

Description of fetal heart rate patterns using CTG

The CTG should be interpreted using a combination of pattern recognition, review of the
individual’s woman’s antenatal/intrapartum history, identification of any risk factors and
2,3,5,11,16
consideration of fetal physiology .
Each hospital will have its own documentation policy; practitioners must ensure they are familiar
with their own policy.
10 % of CTGs may be uninterpretable due to:
• Gestational age
• Normal cycling (rest) phases (may be up to 90 minutes)
•
3
The use of certain medications (e.g. central nervous system sedatives)
• Changes in heart rate patterns associated with circadian rhythms

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Classification of the CTG
29
A systematic approach to interpreting the CTG trace is recommended (see classification of CTG) .
The CTG should be classified and analysed on the following criteria. This is the same terminology
3, 7
used to document and describe the CTG
• Baseline Fetal Heart Rate
• Accelerations
• Variability: normal, reduced, absent, salutatory pattern
• Decelerations: early, late, variable – complicated or uncomplicated, prolonged
Definitions of the terms are listed in Table 3. A list of descriptors to help explain the elements of the
CTG are provided in Table 5.

Physiologically based assessments of antenatal CTG traces support the following classification of
antenatal traces:
1. Reactive: 2 accelerations in 10 minutes within a recording period of 120 min
2. Unreactive: no accelerations seen in 120 minutes of tracing
3. Decelerative: presence of repetitive decelerations on an otherwise unreactive trace

2
Above classification reduces high rate of false-positive traces for recordings of 40 minutes or less .
Review of language and consistent definitions and implementation of ‘normal’ and ‘abnormal’ has
2
reduced false positive rate for fetal compromise .

Normal CTG
A reassuring (normal) CTG is associated with a low probability of fetal compromise
3, 5
and has the following features :
• Baseline FHR 110-160 bpm
• Baseline FH variability of 6-25 bpm
• FH accelerations
• No decelerations
All other CTGs are by this definition abnormal and require further evaluation in the context of the
full clinical picture.

Fetal Compromise (Abnormal CTG)

The following features are unlikely to be associated with fetal compromise when
3,5,7
occurring in isolation
• Baseline rate 100-109 bpm
• Absence of accelerations
• Early decelerations
• Variable decelerations without complicating features

The following features may be associated with significant fetal compromise and
3,5,7
require further action
• Baseline fetal tachycardia > 160 bpm
• Reduced or reducing baseline variability (3-5 bpm)
• Rising baseline fetal heart rate
• Complicated variable decelerations
• Late decelerations
• Prolonged decelerations

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The following features are likely to be associated with significant fetal compromise
3,5,7
and require immediate management, which may include urgent birth
• Prolonged bradycardia (<100 bpm for > 5 minutes)
• Absent baseline variability (< 3 bpm)
• Sinusoidal pattern
• Complicated variable decelerations with reduced or absent baseline variability
• Late decelerations with reduced or absent baseline variability

Action in the context of an abnormal CTG

Conservative measures4
If there are any concerns about fetal wellbeing, think about possible underlying causes (e.g.
infection) and start one or more of the following conservative measures, based on the most likely
cause/s:
• Encourage the woman to mobilise or adopt a left lateral position, and in particular avoid
being supine
• Give intravenous fluids
• Offer paracetamol if the woman’s temperature is raised
• Assess contraction frequency / reduce oxytocin (if being used) if uterine hyperstimulation
• Inform midwife coordinator and obstetrician
• Do not use maternal facial oxygen for intrauterine fetal resuscitation, only administer
38
supplementary oxygen to safely manage maternal signs and symptoms of hypoxia .

Maternal Oxygenation
Cochrane reviewed the literature on maternal oxygenation in labour and second stage. No
30
conclusive benefit to the fetus was determined based on current evidence . In review of
supplemental maternal oxygenation at caesarean section, there was statistically a higher umbilical
and artery and vein partial pressure of oxygen, but no clinical significance or benefit to the woman
or fetus. Cochrane have stated that there is no evidence to suggest supplemental maternal
31
oxygenation as either beneficial or harmful to either mother or baby . In 2018, a RCT of
hyperoxygenation in second stage for fetal distress was conducted. Recommendations of this trial
are to not use maternal hyperoxygenation to treat fetal distress. Further studies in neonatal
outcomes are recommended to determine the risk or benefit to the fetus in using maternal
32
oxygenation .

Fetal blood sampling (FBS)

33
Fetal blood sampling is a peripheral test of fetal wellbeing . The fetal scalp is accessed to collect
a sample of fetal blood. This allows for the fetal scalp lactate analysis to determine the presence of
3,33
fetal academia . RANZCOG recommends that centres using electronic fetal monitoring should
have access to fetal blood sampling and that a lactate measurement should be obtained in
3
preference to a pH measurement .
It is possible that the availability of fetal blood sampling in labour lessens the increase in caesarean
section rate associated with continuous CTG; however it should not be instituted in cases where it
3
may delay birth and thereby worsen outcomes . For further information on fetal blood sampling see
the Fetal Acid Base Balance Assessment PPG at www.sahealth.sa.gov.au/perinatal.
Introduction of STan monitoring has seen as reduction in fetal blood sampling by 48% in some
23
centres globally .

Communication and consultation3

Medical staff are responsible for the review of all CTGs they order.
The midwife should refer women with CTG tracing with features of fetal compromise to a medical
3,5,7
officer for immediate review .

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Local facilities should establish clear communication channels that enable midwives / medical
officers to inform or seek advice from an obstetrician. This may include consultation with an
obstetrician at another facility if required.
Details of the CTG transmitted to the obstetrician must be documented in the woman’s case notes,
including the date and time, and a description of the features of the CTG.
Outpatient CTGs of all non-booked women should be sighted and reviewed by senior medical staff.
The referring doctor should be telephoned and advised of the CTG findings.

Review and management advice for abnormal CTGs (Wider SA)

Clinical advice is available via the SA Perinatal Advice Line. An obstetrician and neonatologist are
on roster 24 hours a day. Refer to Perinatal advice and emergency transport PPG available at
www.sahealth.sa.gov.au/perinatal for further information.
Medical officers from country hospitals may directly contact referral hospitals for a second
opinion / review of CTG tracings.
When CTGs are forwarded to a referral hospital for review by specialist staff, the following
information should be included:
• Indications for referral
• Clinical details
• Demographic details
• Contact details of the referring doctor
• Verbal communication must be made with the Obstetrician by the referring staff within a
short timeframe. i.e. 10 minutes to ensure review and management advice are received
Case notes specific to the information and advice given by the obstetric medical officer on- call
should be created so that a permanent record exists
Referring medical officers must document in the woman’s case notes, details of the CTG
transmitted to the obstetric medical officer at the referring hospital, including the date and time, a
description of the features of the CTG, name of the obstetric medical officer on-call they liaised with
and management plan.
The referring medical officer will be notified via phone of the review and suggested management
plan as soon as possible. If no communication has occurred within 30 minutes, the referring
medical officer should contact the referral hospital and discuss with the on-call registrar (obstetric
medical officer)

Storage of CTG tracings3

File all CTG tracings in the woman’s case record with the appropriate hospital report or archive,
including details that link with the woman’s case record.
If notes are to be microfilmed, provision should be made for the storage of CTG traces. For
example, short traces may need to be microfilmed whilst long traces may need to be stored in their
original format in heat protected envelopes (not plastic sleeves). Consider electronic storage of
traces. e.g. optical disc.
CTG recordings should be stored for the same period of time as medical records (33 years).
CTGs from centrally monitored systems (e.g. Tracevue) may be initially stored on the hard disc of
the server and subsequently archived to a permanent medium.

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CTG competency assessment
CTG competency training is mandated for all practitioners using and interpreting CTGs in SA
38
Health facilities . Evidence suggests that a physiological based training rather than pattern
11,34
recognition is beneficial .
3,7
RANZCOG recommend that all clinicians using and interpreting CTGs should have current
knowledge of:
• Fetal physiological responses to hypoxia
• Good pattern recognition skills
• The ability to integrate the theory of fetal physiology to each clinical situation

Continuing professional development in the application and interpretation of fetal monitoring

7,11,35
should be completed by all clinicians using and interpreting CTG’s : For example:
•
35
RANZCOG Online Fetal Surveillance Education Program (OFSEP) .
Available at www.fsep.edu.au
•
37
K2
Available at:
http://www.sahealth.sa.gov.au/wps/wcm/connect/11bdf1804c210b85af28ffb3172da4a1/16
012.3-
K2+Fetal+MonitoringFS%28V1%29.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPAC
E-11bdf1804c210b85af28ffb3172da4a1-m08lEny

Regular case review of individual CTGs with corresponding outcomes at local unit level is
recommended.
Governance of competency for CTG application and interpretation is described in the SA Health
38
Perinatal Emergency Education Strategy Policy Directive, 2018 .

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References
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12. Everett, T. R., & Peebles, D. M. (2015). Antenatal tests of fetal wellbeing. Seminars in Fetal and
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13. Johnson,. R. & Taylor,. W. (2016).Skills for Midwifery Practice, 4th Edition. Elsevier. Edinburgh.
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C. M., TRUFFLE Group. (2017). How to monitor pregnancies complicated by fetal growth
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F., Arabin, B., Bilardo, C. M., … TRUFFLE Group. (2017). How to monitor pregnancies
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Intensive Care Medicine, 17(8), 395–399. doi:10.1016/j.mpaic.2016.05.008
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classification and management. Best Practice and Research: Clinical Obstetrics and
Gynaecology, 30(2016), 33–47. doi:10.1016/j.bpobgyn.2015.03.022
17. Pinas Carrillo,. A & Chandraharan,. E. (2017a). Chapter 22: ST-Analyser (STAN) in
Chandraharan,. E. Handbook of CTG Interpretation: From Patterns to Physiology. Cambridge
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limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia.
American Journal of Obstetrics and Gynecology, 216(2), 163.e1–163.e6.
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patient safety. American Journal of Obstetrics and Gynecology, 206(4), 278–283.
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Summary of findings for the main comparison. Cochrane Database Syst Rev, (12).
https://doi.org/10.1002/14651858.CD000116.pub5.www.cochranelibrary.com
21. Lees, C. (2017). Most cases of cerebral palsy are associated with antenatal events. BMJ
(Online), 356(February). doi:10.1136/bmj.j834
22. Belfort, M. A., Saade, G. R., Thom, E., Blackwell, S. C., Reddy, U. M., Thorp, J. M., …
Vandorsten, J. P. (2015). A Randomized Trial of Intrapartum Fetal ECG ST-Segment Analysis.
Obstetrical and Gynecological Survey, 70(12), 735–737. doi:10.1097/OGX.0000000000000276
23. Bloom, S. L., Belfort, M., & Saade, G. (2016). What we have learned about intrapartum fetal
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doi:10.1053/j.semperi.2016.03.008
24. Belfort, M. A., & Clark, S. L. (2017). Computerised cardiotocography—study design hampers
findings. The Lancet, 389(10080), 1674–1676. doi:10.1016/S0140-6736(17)30762-6
25. Brocklehurst, P., Field, D. J., Juszczak, E., Kenyon, S., Linsell, L., Newburn, M., … Steer, P.
(2017). The INFANT trial. The Lancet, 390(10089), 28. doi:10.1016/S0140-6736(17)31594-5
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Practice and Research: Clinical Obstetrics and Gynaecology, 38, 59–70.
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28. Ayres-de-Campos, D. (2016). Best Practice & Research Clinical Obstetrics and Gynaecology
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Acknowledgements
The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of
clinicians and other stakeholders who participated throughout the guideline development process
particularly:

Write Group Lead

Vanessa Tilbrook

Write Group Members

Rebecca Smith
Dr Feisal Chenia
John Coomblas
Dr Anupam Parange

Contributors to original PPGs

Allison Rogers
A/Prof Rosalie Grivell
E/Prof Jeffrey Robinson
Dr David Morris

SAPPG Management Group Members

Sonia Angus
Lyn Bastian
Dr Elizabeth Beare
Elizabeth Bennett
Corey Borg
Dr Feisal Chenia
John Coomblas
Dr Vanessa Ellison
A/Prof Rosalie Grivell
Dr Sue Kennedy-Andrews
Jackie Kitschke
Dr Kritesh Kumar
Dr Anupam Parange
Rebecca Smith

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Document Ownership & History

Developed by: SA Maternal, Neonatal & Gynaecology Community of Practice
Contact: HealthCYWHSPerinatalProtocol@sa.gov.au
Endorsed by: SA Health Safety and Quality Strategic Governance Committee
Next review due: 17/10/2024
ISBN number: 978-1-76083-203-2
PDS reference: CG326
Policy history: Is this a new policy (V1)? N
Does this policy amend or update and existing policy? Y
If so, which version? 1
Does this policy replace another policy with a different title? N
If so, which policy (title)?

Approval Who approved New/Revised

Version Reason for Change
Date Version
Chair, SA Maternal, Neonatal & Minor changes to indications in line
07/04/2020 V1.1 Gynaecology Community of with updated RANZCOG Intrapartum
Practice Fetal Surveillance guideline
Original SA Health Safety and Quality
SA Health Safety and Quality
17/10/2019 V1 Strategic Governance Committee
Strategic Governance Committee
approved version.

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