Cardiotocography (CTG) in India and UAE | Complete Patient Guide

• INDICATED PATIENTS (Antepartum CTG — Non-Stress Test / NST):

• Pregnant women at or beyond 28 weeks of gestation with high-risk obstetric conditions including pre-eclampsia, gestational hypertension, or chronic hypertension in pregnancy

• Fetal growth restriction (FGR) diagnosed on serial obstetric ultrasound with Doppler assessment

• Gestational diabetes mellitus (GDM) requiring insulin or with poor glycaemic control

• Reduced or absent fetal movements reported by the patient (kick count < 10 in 2 hours)

• Post-term pregnancy (≥ 41+0 weeks of gestation)

• Multiple gestation (twins or higher-order multiples), particularly monochorionic pregnancies

• Oligohydramnios (AFI < 5 cm) or polyhydramnios (AFI > 25 cm)

• Antepartum haemorrhage (placenta praevia, vasa praevia suspicion, placental abruption)

• Maternal medical conditions: systemic lupus erythematosus (SLE), renal disease, intrahepatic cholestasis of pregnancy (ICP), sickle cell disease, or hyperthyroidism

• Prior unexplained stillbirth or perinatal loss in a previous pregnancy

• INDICATED PATIENTS (Intrapartum CTG — Continuous EFM during Labour):

• All women with high-risk antenatal conditions transitioning to active labour

• Induced labour or augmented labour with oxytocin infusion

• Epidural analgesia in situ

• Previous uterine surgery including lower-segment caesarean section (LSCS) — trial of labour after caesarean (TOLAC) mandates continuous EFM

• Meconium-stained amniotic fluid (MSAF) — particularly thick meconium

• Preterm labour < 37 weeks of gestation

• Prolonged rupture of membranes (PROM > 18 hours)

• REQUIRED DIAGNOSTIC CONTEXT (prior to or concurrent with CTG):

• Dating ultrasound and anomaly scan (morphology scan) reports

• Recent obstetric growth scan with Doppler velocimetry (umbilical artery, MCA, ductus venosus)

• Biophysical profile (BPP) score if CTG is non-reactive

• Maternal blood pressure records, urine protein:creatinine ratio (PCR) for pre-eclampsia workup

• HbA1c and fasting glucose for diabetic mothers

• Full blood count (FBC), liver function tests (LFTs), and bile acids if ICP is suspected

• Group and screen / cross-match in haemorrhage scenarios

• CONTRAINDICATIONS / LIMITATIONS:

• CTG alone is insufficient for diagnosis of fetal anaemia (requires MCA Doppler peak systolic velocity — PSV)

• CTG is unreliable before 28 weeks due to immature fetal autonomic nervous system responses

• External CTG may be technically limited in morbidly obese patients (BMI > 40); fetal scalp electrode (FSE) or internal tocometry may be required

• Reactive NST does not guarantee absence of fetal compromise in the presence of acute cord events or abruption

• CTG should not replace urgent clinical assessment or operative delivery when obstetric emergency is clinically apparent

TYPES OF CTG MONITORING:

1. Non-Stress Test (NST) — External Antepartum CTG: The foundational outpatient or antenatal clinic-based test. Dual transducers (one Doppler ultrasound for FHR, one tocodynamometer for uterine activity) are secured to the maternal abdomen with elastic belts. The test typically runs for 20–40 minutes. A reactive NST requires ≥ 2 accelerations of ≥ 15 bpm above baseline lasting ≥ 15 seconds within a 20-minute window, indicating intact fetal autonomic function. A non-reactive NST warrants extended monitoring, vibroacoustic stimulation (VAS), or escalation to BPP/Doppler assessment.

2. Contraction Stress Test (CST) / Oxytocin Challenge Test (OCT): Performed in a controlled inpatient or day-assessment unit setting. Uterine contractions are induced either by nipple stimulation or low-dose intravenous oxytocin to achieve 3 contractions in 10 minutes, while the FHR response is observed for late decelerations. A negative CST (absence of late or significant variable decelerations) is strongly reassuring of adequate uteroplacental reserve. A positive CST raises concern for placental insufficiency and typically triggers expedited delivery planning.

3. Intrapartum Continuous Electronic Fetal Monitoring (CEFM): The standard of care in high-risk labour. Continuous dual-channel recording of FHR and uterine contractions throughout labour. Interpretation follows FIGO 2015 or ACOG three-tier classification. Category II (indeterminate) or Category III (abnormal) traces trigger structured escalation protocols including maternal repositioning, IV fluid bolus, cessation of oxytocin, oxygen administration, and emergency obstetric review.

4. Computerised CTG (cCTG) — Dawes-Redman Criteria: Advanced digital analysis using validated software (Oxford Sonicaid, Philips Avalon FM50, Monica AN24 Fetal Monitor). The Dawes-Redman algorithm computes short-term variation (STV) — a quantitative measure of beat-to-beat variability expressed in milliseconds — which is a more objective and reproducible predictor of fetal acidaemia than visual interpretation alone. STV < 3.0 ms is associated with significantly elevated risk of fetal acidosis and adverse outcome. This technology is routinely available in tertiary obstetric units in India (AIIMS, Apollo, Fortis) and the UAE (Medcare Women & Children Hospital, Cleveland Clinic Abu Dhabi, Mediclinic City Hospital Dubai).

5. Internal Fetal Monitoring (Fetal Scalp Electrode — FSE): In cases where external Doppler signal is technically inadequate (maternal obesity, polyhydramnios, active maternal movement), a spiral fetal scalp electrode is applied directly to the fetal presenting part following membrane rupture to provide a continuous, artefact-free fetal ECG-derived FHR signal. Combined with STAN (ST-Waveform Analysis), FSE-based monitoring can detect fetal myocardial hypoxia through ST-segment changes (T/QRS ratio elevation), providing an additional layer of intrapartum safety above conventional FHR pattern interpretation.

6. Wireless and Remote CTG Systems: Leading hospitals in both India and UAE now deploy wireless, Bluetooth-enabled CTG telemetry units (e.g., Philips Avalon CL, Monica AN24) that allow ambulatory monitoring — permitting the patient to mobilise during labour without loss of continuous fetal surveillance. The Monica AN24 applies abdominal ECG electrodes to derive both maternal and fetal ECG signals non-invasively, enabling monitoring from as early as 20 weeks gestation for high-risk antenatal surveillance.

7. CTG Combined with Biophysical Profile (Modified BPP): For outpatient antepartum surveillance in high-risk pregnancies, a modified BPP combining a 20-minute NST with amniotic fluid index (AFI) measurement by ultrasound provides a rapid, sensitive screen. A full BPP (Manning score: FHR reactivity, fetal breathing movements, gross body movements, fetal tone, AFI — score out of 10) is performed when the modified BPP is non-reassuring, with scores ≤ 6/10 typically prompting delivery assessment.

STEP 1 — INITIAL CLINICAL ASSESSMENT & TELECONSULTATION (Days 1–5 before arrival or at booking):

The patient submits obstetric records, including current gestational age, booking scan, anomaly scan, growth scan with Doppler, blood pressure diary, and current medications to GAF Healthcare's clinical coordination team. A board-certified obstetrician or maternal-fetal medicine (MFM) specialist reviews records remotely and determines the appropriate CTG protocol (outpatient NST series, inpatient monitoring, or intrapartum EFM plan). A personalised monitoring schedule is issued.

STEP 2 — PRE-ARRIVAL PREPARATION (3–7 Days Before First Session):

For antepartum outpatient CTG: no fasting required. Patient is advised to eat a light meal 30–60 minutes before the session (mild postprandial glucose rise can activate fetal movement and facilitate a reactive trace). Patients are asked to record a kick count log for 48 hours prior. Relevant blood test results (bile acids, HbA1c, FBC, LFTs, PCR) are collected locally or at arrival.

STEP 3 — OUTPATIENT CTG SESSION (Day 1 of Clinical Visit, Duration: 20–60 Minutes):

The patient is positioned in a comfortable left-lateral or semi-reclined position to optimise uteroplacental perfusion. Transducers are applied by an obstetric nurse or midwife. FHR and uterine activity are recorded for a minimum of 20 minutes. If the trace is non-reactive at 20 minutes, vibroacoustic stimulation (a 1–3 second pulse from a handheld device applied to the maternal abdomen) is employed and monitoring continues for a further 20 minutes. Results are interpreted immediately by the attending obstetrician using FIGO classification.

STEP 4 — RESULT INTERPRETATION & CLINICAL DECISION-MAKING (Immediately Post-Session):

• Reactive / Normal CTG: Patient is reassured. Repeat schedule determined by clinical risk (e.g., twice-weekly for FGR, weekly for GDM).

• Non-Reactive / Suspicious CTG: Biophysical profile ultrasound performed same-day. Doppler velocimetry (umbilical artery, MCA PSV) ordered. Maternal blood pressure and urinalysis reviewed.

• Pathological CTG or Abnormal BPP: Emergency escalation protocol activated. Patient admitted to antenatal ward. Corticosteroids administered if < 34 weeks. Delivery expedited via induction of labour or emergency caesarean section (LSCS) as clinically appropriate.

STEP 5 — INPATIENT MONITORING (If Admitted, Days 1–5+):

Continuous CTG commenced on the antenatal ward or labour suite. Neonatology team placed on standby for preterm or compromised deliveries. STAN or FSE applied in labour if external signal quality is inadequate. All trace interpretations are documented in structured electronic medical records per FIGO/ACOG guidelines.

STEP 6 — POST-DELIVERY OR POST-MONITORING REVIEW (24–48 Hours After Delivery or Final Session):

For patients who delivered: postnatal review by obstetrician and neonatologist. Cord blood gas results reviewed (umbilical artery pH, base excess). APGAR scores at 1 and 5 minutes documented. Neonatal examination completed.

For antepartum monitoring patients: written clinical summary issued, including CTG traces, Doppler findings, and recommended follow-up schedule for care continuation in home country.

STEP 7 — DISCHARGE & FIT-TO-FLY ASSESSMENT:

For routine antepartum monitoring patients without delivery: fit-to-fly clearance issued by the attending obstetrician after final review, typically within 1–2 weeks of the monitoring programme. Air travel beyond 36 weeks is medically contraindicated on most airlines without a specialist letter. GAF Healthcare provides a formal medical fitness-to-fly certificate for airline and travel insurance purposes.

STEP 8 — CONTINUITY OF CARE COORDINATION:

GAF Healthcare's clinical team prepares a comprehensive digital handover package — including all CTG trace data, scan reports, Doppler indices, blood results, and management summary — formatted to the patient's home country's medical records standards. Virtual follow-up consultation with the treating MFM specialist is offered at 2 and 4 weeks post-return.