Skip to main content
Log in

Cardiotocography and the evolution into computerised cardiotocography in the management of intrauterine growth restriction

  • Review
  • Published:
Archives of Gynecology and Obstetrics Aims and scope Submit manuscript

Abstract

Timely recognition and appropriate management of high-risk pregnancies, such as intrauterine growth restriction (IUGR), are of paramount importance for every obstetrician. After the initial screening of IUGR fetuses through sonographic fetometry and Doppler, the focus is shifted to the appropriate monitoring and timing of delivery. This can, especially in cases of early IUGR, become a very difficult task. At this point, cardiotocography (CTG) is introduced as a major tool in the day-to-day monitoring of the antenatal well-being of the IUGR fetus. Since the first introduction of CTG up to the nowadays widely spreading implementation of computerised CTG in the clinical practice, there has been great progress in the recording of the fetal heart rate, as well as its interpretation. Focus of this review is to offer an understanding of the evolution of CTG from its early development to modern computerised methods and to provide an insight as to where the future of CTG is leading, especially in the monitoring of IUGR.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Soothill PW, Bobrow CS, Holmes R (1999) Small for gestational age is not a diagnosis. Ultrasound Obstet Gynecol 13(4):225–228

    Article  CAS  PubMed  Google Scholar 

  2. Illanes S, Soothill P (2004) Management of fetal growth restriction. Semin Fetal Neonatal Med 9(5):395–401

    Article  PubMed  Google Scholar 

  3. Cnattingius S, Haglund B, Kramer MS (1998) Differences in late fetal death rates in association with determinants of small for gestational age fetuses: population based cohort study. Br Med J 316:1483e7

    Article  Google Scholar 

  4. McIntire DD, Bloom SL, Casey BM, Leveno KJ (1999) Birth weight in relation to morbidity and mortality among newborn infants. N Engl J Med 340:1234e8

    Article  Google Scholar 

  5. Bernstein IM, Horbar JD, Badger GJ, Ohlsson A, Golan A (2000) Morbidity and mortality among very-low-birth-weight neonates with intrauterine growth restriction. The Vermont Oxford Network. Am J Obstet Gynecol 182:198e206

    Article  Google Scholar 

  6. Kok JH, den Ouden AL, Verloove-Vanhorick SP, Brand R (1998) Outcome of very preterm small for gestational age infants: the first nine years of life. Br J Obstet Gynaecol 105:162e8

    Article  Google Scholar 

  7. Roth S, Chang TC, Robson S, Spencer JA, Wyatt JS, Stewart AL (1999) The neurodevelopmental outcome of term infants with different intrauterine growth characteristics. Early Hum Dev 55:39e50

    Article  Google Scholar 

  8. Lackland DT, Egan BM, Ferguson PL (2003) Low birth weight as a risk factor for hypertension. J Clin Hypertens (Greenwich) 5:133e6

    Article  Google Scholar 

  9. Hales CN, Ozanne SE (2003) For debate: fetal and early postnatal growth restriction lead to diabetes, the metabolic syndrome and renal failure. Diabetologia 46:1013e9

    Google Scholar 

  10. Baschat AA, Gembruch U, Harman CR (2001) The sequence of changes in Doppler and biophysical parameters as severe fetal growth restriction worsens. Ultrasound Obstet Gynecol 18(6):571–577

    Article  CAS  PubMed  Google Scholar 

  11. Figueras F, Gardosi J (2011) Intrauterine growth restriction: new concepts in antenatal surveillance, diagnosis, and management. Am J Obstet Gynecol 204(4):288–300. doi:10.1016/j.ajog.2010.08.055

    Article  PubMed  Google Scholar 

  12. Visser GH, Huisjes HJ (1977) Diagnostic value of the unstressed antepartum cardiotocogram. Br J Obstet Gynaecol 84(5):321–326

    Article  CAS  PubMed  Google Scholar 

  13. Grivell RM, Alfirevic Z, Gyte GM, Devane D (2015) Antenatal cardiotocography for fetal assessment. Cochrane Database Syst Rev 12(9):CD007863. doi:10.1002/14651858.CD007863.pub4

    Google Scholar 

  14. Roederer JG (1766) Elementa artis obstetriciae. Neu herausgegeben und mit annotationes versehen von H. A. WRISBERG, med. anatomes atque artis obstetr. Prof., Göttingen, Comment No. 63, p 69

  15. Caldeyro-Barcia R, Alvarez H, Reynolds SMR (1959) A better understanding of uterine contractility through simultaneous recording with an internal and seven channel external method. Surg Gynecol Obstet 91:641–650

    Google Scholar 

  16. Alvarez H, Caldeyro-Barcia R (1954) The normal and abnormal contractile waves of the uterus during labour. Gynaecologia 138(2):190–212

  17. Hon EH (1958) The electronic evaluation of the fetal heart rate. Am J Obstet Gynecol 75:1215

    Article  CAS  PubMed  Google Scholar 

  18. Hon EH (1966) A fetal electrocardiographic electrode. Yale J Biol Med 39(1):54–58

    CAS  PubMed  PubMed Central  Google Scholar 

  19. Hammacher K (1962) [New method for the selective registration of the fetal heart beat]. [Article in German]. Geburtshilfe Frauenheilkd 22:1542–1543

    CAS  PubMed  Google Scholar 

  20. Hammacher K (1967) Die kontinuierliche elektronische Überwachung der fetalen Herztätigkeit vor und während der Geburt. In: Käser O, Friedberg V, Ober KG, Thomsen K, Zander J (eds) Gynäkologie und Geburtshilfe, Bd. II (Hrsg.), S. 793. Thieme, Stuttgart

    Google Scholar 

  21. Hammacher K (1969) The clinical significance of cardiotocography. In: Huntingford PJ, Hüter KA, Saling E (eds) Perinatal medicine, 1st European Congress, Berlin. Thieme, Stuttgart

    Google Scholar 

  22. Hopp H, Heinrich J (1979) [External cardiotocography utilizing the US-Doppler principle developed by VEB Ultraschalltechnik Halle]. [Article in German]. Zentralbl Gynakol 101(6):409–416

    CAS  PubMed  Google Scholar 

  23. Alfirevic Z, Devane D, Gyte GM (2013) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 31(5):CD006066. doi:10.1002/14651858.CD006066.pub2

    Google Scholar 

  24. Fischer WM, Stude I, Brandt H (1976) [A suggestion for the evaluation of the antepartal cardiotocogram]. [Article in German]. Z Geburtshilfe Perinatal 180(2):117–123

    CAS  Google Scholar 

  25. Ayres-de-Campos D, Spong CY, Chandraharan E, FIGO Intrapartum Fetal Monitoring Expert Consensus Panel (2015) FIGO consensus guidelines on intrapartum fetal monitoring: cardiotocography. Int J Gynaecol Obstet 131(1):13–24. doi:10.1016/j.ijgo.2015.06.020

    Article  PubMed  Google Scholar 

  26. Royal College of Obstetricians and Gynaecologists (2001) The use of electronic fetal monitoring—the use and interpretation of cardiotocography in intrapartum fetal surveillance, Evidence-based Clinical Guideline Number 8. RCOG, London

    Google Scholar 

  27. Kamath MV, Fallen EL (1993) Power spectral analysis of heart rate variability: a noninvasive signature of cardiac autonomic function. Crit Rev Biomed Eng 21(3):245–311

    CAS  PubMed  Google Scholar 

  28. ACOG practice bulletin. Antepartum fetal surveillance. Number 9, October 1999 (replaces Technical Bulletin Number 188, January 1994) (2000) Clinical management guidelines for obstetrician-gynecologists. Int J Gynaecol Obstet 68(2):175–185

    Article  Google Scholar 

  29. Spencer JA (1993) Clinical overview of cardiotocography. Br J Obstet Gynaecol 100(Suppl 9):4–7

    Article  PubMed  Google Scholar 

  30. Bernardes J, Costa-Pereira A, Ayres-de-Campos D, van Geijn HP, Pereira-Leite L (1997) Evaluation of interobserver agreement of cardiotocograms. Int J Gynaecol Obstet 57(1):33–37

    Article  CAS  PubMed  Google Scholar 

  31. Devane D, Lalor J (2005) Midwives’ visual interpretation of intrapartum cardiotocographs: intra- and inter-observer agreement. J Adv Nurs 52(2):133–141

    Article  PubMed  Google Scholar 

  32. Hruban L, Spilka J, Chudáček V, Janků P, Huptych M, Burša M, Hudec A, Kacerovský M, Koucký M, Procházka M, Korečko V, Seget’a J, Šimetka O, Měchurová A, Lhotská L (2015) Agreement on intrapartum cardiotocogram recordings between expert obstetricians. J Eval Clin Pract 21(4):694–702. doi:10.1111/jep.12368

    Article  PubMed  Google Scholar 

  33. Ayres-de-Campos D, Bernardes J, Costa-Pereira A, Pereira-Leite L (1999) Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision. Br J Obstet Gynaecol 106(12):1307–1310

    Article  CAS  PubMed  Google Scholar 

  34. Reif P, Schott S, Boyon C, Richter J, Kavšek G, Timoh KN, Haas J, Pateisky P, Griesbacher A, Lang U, Ayres-de-Campos D (2016) Does knowledge of fetal outcome influence the interpretation of intrapartum cardiotocography and subsequent clinical management? A multicentre European study. BJOG ​123(13):2208–2217

    PubMed  Google Scholar 

  35. Brown VA, Sawers RS, Parsons RJ, Duncan SL, Cooke ID (1982) The value of antenatal cardiotocography in the management of high-risk pregnancy: a randomized controlled trial. Br J Obstet Gynaecol 89(9):716–722

    Article  CAS  PubMed  Google Scholar 

  36. Kidd LC, Patel NB, Smith R (1985) Non-stress antenatal cardiotocography–a prospective randomized clinical trial. Br J Obstet Gynaecol 92(11):1156–1159

    Article  CAS  PubMed  Google Scholar 

  37. Lumley J, Lester A, Anderson I, Renou P, Wood C (1983) A randomized trial of weekly cardiotocography in high-risk obstetric patients. Br J Obstet Gynaecol 90(11):1018–1026

    Article  CAS  PubMed  Google Scholar 

  38. Hamed HO (2013) Intrapartum fetal asphyxia: study of umbilical cord blood lactate in relation to fetal heart rate patterns. Arch Gynecol Obstet 287(6):1067–1073

    Article  CAS  PubMed  Google Scholar 

  39. Berlit S, Welzel G, Tuschy B, Nickol J, Hornemann A, Sütterlin M, Kehl S (2013) Emergency caesarean section: risk factors for adverse neonatal outcome. Arch Gynecol Obstet 287(5):901–905

    Article  PubMed  Google Scholar 

  40. Flynn AM, Kelly J, Mansfield H, Needham P, O’Conor M, Viegas O (1982) A randomized controlled trial of non-stress antepartum cardiotocography. Br J Obstet Gynaecol 89(6):427–433

    Article  CAS  PubMed  Google Scholar 

  41. Dawes GS, Moulden M, Redman CW (1991) System 8000: computerized antenatal FHR analysis. J Perinat Med 19(1–2):47–51

    Article  CAS  PubMed  Google Scholar 

  42. Dawes GS, Moulden M, Redman CW (1991) The advantages of computerized fetal heart rate analysis. J Perinat Med 19(1–2):39–45

    Article  CAS  PubMed  Google Scholar 

  43. Pardey J, Moulden M, Redman CW (2002) A computer system for the numerical analysis of nonstress tests. Am J Obstet Gynecol 186(5):1095–1103

    Article  PubMed  Google Scholar 

  44. Dawes GS, Moulden M, Redman CW (1996) Improvements in computerized fetal heart rate analysis antepartum. J Perinat Med 24(1):25–36

    Article  CAS  PubMed  Google Scholar 

  45. Galazios G, Tripsianis G, Tsikouras P, Koutlaki N, Liberis V (2010) Fetal distress evaluation using and analyzing the variables of antepartum computerized cardiotocography. Arch Gynecol Obstet 281(2):229–233. doi:10.1007/s00404-009-1119-8

    Article  PubMed  Google Scholar 

  46. Chen CY, Yu C, Chang CC, Lin CW (2014) Comparison of a novel computerized analysis program and visual interpretation of cardiotocography. PLoS One 9(12):e112296. doi:10.1371/journal.pone.0112296

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bracero LA, Morgan S, Byrne DW (1999) Comparison of visual and computerized interpretation of nonstress test results in a randomized controlled trial. Am J Obstet Gynecol 181(5 Pt 1):1254–1258

    Article  CAS  PubMed  Google Scholar 

  48. Steyn DW, Odenaal HJ (1997) Routine or computerized cardiotocography in severe preeclampsia? A randomized controlled trial. Journal of Maternal Fetal Investigation 7:166–171

    Google Scholar 

  49. Snijders RJ, Ribbert LS, Visser GH, Mulder EJ (1992) Numeric analysis of heart rate variation in intrauterine growth-retarded fetuses: a longitudinal study. Am J Obstet Gynecol 166(1 Pt 1):22–27

    Article  CAS  PubMed  Google Scholar 

  50. Sonicaid Fetalcare Clinical Application Guide. http://www.huntleigh-diagnostics.com. Accessed 25 May 2015

  51. Rotmensch S, Lev S, Kovo M, Efrat Z, Zahavi Z, Lev N, Celentano C, Ben-Rafael Z (2005) Effect of betamethasone administration on fetal heart rate tracing: a blinded longitudinal study. Fetal Diagn Ther 20(5):371–376

    Article  PubMed  Google Scholar 

  52. Street P, Dawes GS, Moulden M, Redman CW (1991) Short-term variation in abnormal antenatal fetal heart rate records. Am J Obstet Gynecol 165(3):515–523

    Article  CAS  PubMed  Google Scholar 

  53. Dawes GS, Moulden M, Redman CW (1992) Short-term fetal heart rate variation, decelerations, and umbilical flow velocity waveforms before labor. Obstet Gynecol 80(4):673–678

    CAS  PubMed  Google Scholar 

  54. Guzman ER, Vintzileos AM, Martins M, Benito C, Houlihan C, Hanley M (1996) The efficacy of individual computer heart rate indices in detecting acidemia at birth in growth-restricted fetuses. Obstet Gynecol 87(6):969–974

    Article  CAS  PubMed  Google Scholar 

  55. Hecher K, Bilardo CM, Stigter RH, Ville Y, Hackelöer BJ, Kok HJ, Senat MV, Visser GH (2001) Monitoring of fetuses with intrauterine growth restriction: a longitudinal study. Ultrasound Obstet Gynecol 18(6):564–570

    Article  CAS  PubMed  Google Scholar 

  56. Anceschi MM, Ruozi-Berretta A, Piazze JJ, Cosmi E, Cerekja A, Meloni P, Cosmi EV (2004) Computerized cardiotocography in the management of intrauterine growth restriction associated with Doppler velocimetry alterations. Int J Gynaecol Obstet 86(3):365–370

    Article  CAS  PubMed  Google Scholar 

  57. Serra V, Moulden M, Bellver J, Redman CW (2008) The value of the short-term fetal heart rate variation for timing the delivery of growth-retarded fetuses. BJOG 115(9):1101–1107. doi:10.1111/j.1471-0528.2008.01774.x

    Article  CAS  PubMed  Google Scholar 

  58. Lees CC, Marlow N, van Wassenaer-Leemhuis A, Arabin B, Bilardo CM, Brezinka C, Calvert S, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Ganzevoort W, Hecher K, Martinelli P, Ostermayer E, Papageorghiou AT, Schlembach D, Schneider KT, Thilaganathan B, Todros T, Valcamonico A, Visser GH, Wolf H; TRUFFLE study group (2015) 2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial. Lancet 385(9983):2162–2172

    Article  PubMed  Google Scholar 

  59. Wolf H, Arabin B, Lees CC, Oepkes D, Prefumo F, Thilaganathan B, Todros T, Visser GH, Bilardo CM, Derks JB, Diemert A, Duvekot JJ, Ferrazzi E, Frusca T, Hecher K, Marlow N, Martinelli P, Ostermayer E, Papageorghiou AT, Scheepers HC, Schlembach D, Schneider KT, Valcamonico A, van Wassenaer-Leemhuis A, Ganzevoort W (2016) A longitudinal study of computerised cardiotocography in early fetal growth restriction. Ultrasound Obstet Gynecol. doi:10.1002/uog.17215 (Epub ahead of print)

    PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Christina Kouskouti.

Ethics declarations

Funding

None.

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

This review article does not contain any studies with human participants or animals performed by any of the authors.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kouskouti, C., Regner, K., Knabl, J. et al. Cardiotocography and the evolution into computerised cardiotocography in the management of intrauterine growth restriction. Arch Gynecol Obstet 295, 811–816 (2017). https://doi.org/10.1007/s00404-016-4282-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00404-016-4282-8

Keywords

Navigation