Intrapartum Guidelines. No.10 The monitoring of fetal well-being during labour

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1 Intrapartum Guidelines No.10 The monitoring of fetal well-being during labour 1. Patient information and discussion Women must be afforded a documented discussion re: fetal monitoring and options available during the antenatal period and at the onset of labour. An information booklet should be provided in order to assist them in making the decision that is best for them, preferably in the antenatal period. Confirmation that an information leaflet has been provided must be documented within the Pregnancy Notes. Where there are communication or language support needs assistance can be obtained via patient advice and liaison service (PALS) and interpretation services. For women with no risk factors for fetal hypoxia in normal labour, intermittent auscultation is the method of choice because of the increased level of intervention associated with electronic fetal monitoring (Alfirevic et al. 2006; NICE 2007). Please note reason for choice of monitoring and equipment used in the patient health record. 2. Fetal monitoring An abdominal palpation should be performed to determine the optimal area for listening to the fetal heart. A pinard or fetal stethoscope should be used at initial assessment to establish the real sound of the fetal heart and to aid confirmation of presentation and position. The maternal pulse should be palpated at the initial assessment, hourly throughout labour and if an FHR abnormality is detected, to differentiate between the two heart rates (NICE 2007). On assessment of labour/pre-labour rupture of membranes: Palpate, and record maternal pulse as above Auscultate the fetal heart rate (between contractions) to determine an average rate (baseline rate), counting the rate over a period of one minute In the presence of contractions auscultate again immediately following a contraction to exclude decelerations for one minute Discuss the presence of fetal movements to ensure fetal wellbeing If possible auscultate the FH during a period of fetal movements to ensure acceleration in fetal heart rate Document all findings in yellow hand birth notes Ensure you document what equipment you are using for IA i.e. Pinnards/sonicaid Carry out a risk assessment to determine the choice of monitoring in labour CLI.MAT.GUI Fetal monitoring during labour 1

2 Minimum standards for monitoring in established labour The first stage of labour: the fetal heart rate should be listened to, as a minimum, every 15 minutes for a minimum of one minute after a contraction. The second stage of labour: the fetal heart rate should be auscultated after every contraction, or at least every 5 minutes. Hourly maternal pulse on the partogram to differentiate between fetal heart and maternal pulse 2.4. Transferring from intermittent auscultation to continuous electronic fetal monitoring. Amniotomy alone for suspected delay in the established first stage of labour is not an indication to commence continuous EFM If any of the following occur the woman should be advised to transfer to obstetric consultant care for continuous electronic fetal monitoring. Meconium stained liquor: if transferring in from a community setting consideration should be given to the woman s parity and stage of labour, volume of liquor and amount and type of meconium, and the fetal heart rate and transfer time. Fetal heart rate abnormality: Less than 110 beats per minute, greater than 160 beats per minute, any decelerations or any other abnormality or concern. Maternal pyrexia: A maternal temperature of 38 degrees centigrade, once, or 37.5 degrees centigrade on 2 occasions, 2 hours apart. Fresh vaginal bleeding developing in labour. Oxytocin used to augment labour. The woman s request. Women should be informed that continuous electronic fetal monitoring will restrict their mobility in labour. Epidural analgesia: refer to guideline for epidural analgesia in labour 4. Electronic fetal monitoring (EFM) and record keeping CTGs must be labelled with the mother s name, hospital no, date and time, gestation and maternal pulse. The date and time clocks on the EFM machine must be correctly set and signed to confirm this on the CTG paper. Any intrapartum events (that may affect the FHR) should be noted on the CTG together with time and signature. Any member of staff who is asked to provide an opinion on a CTG should note their findings on the CTG and in the hospital notes together with date, time and signature 5. Obstetric and medical indications for the use of Continuous Fetal Heart Rate Monitoring: High risk pregnancy as defined by At Risk Assessment Form in handheld notes Established maternal complications of pregnancy. e.g. diabetes mellitis, preeclampsia, cardiac disease Established fetal complications of pregnancy, e.g. intra-uterine growth retardation, Rhesus disease, oligohydramnios, prematurity, multiple pregnancy Epidural anaesthesia CLI.MAT.GUI Fetal monitoring during labour 2

3 Malpresentation, e.g. breech Multiple pregnancy Preterm pregnancy from 26 weeks unless clinicians requests earlier Previous caesarean section Antepartum haemorrhage Oxytocin Infusion Maternal pyrexia Fresh PV loss during labour Previous C/S PROM > 24 hours Pregnancy > 42 weeks Maternal request Continuous monitoring can be performed using an external Doppler or by applying a fetal scalp electrode (FSE). FSEs are commonly used where there is constant loss of contact and accurate interpretation of the CTG is hampered, where the fetal heart rate features become abnormal or for the 1 st twin. NB Do not use an FSE where an infective process is present, i.e. HIV, Hep B / C, group B strep face presentation or in the presence of any medical contraindication. They should be used with caution at gestations of < 34 weeks. NB: An FSE does not rule out the possibility of recording a maternal heart rate If there is any doubt with respect to the authenticity of the heart rate obstetric opinion should be sought and an USS performed. Please be aware of the limitations of CTG recordings of the fetal heart, i.e. artefact, double maternal heart rate. If there is any doubt with respect to origin of the CTG recording please confirm the presence of a fetal heart using other methods, i.e. Pinard, handheld Doppler. In addition, ensure the maternal pulse is recorded on the CTG. 6. Systematic CTG assessment 6.1 Throughout labour a formal CTG assessment should be made by the midwife at least every hour, in the yellow Birth notes, and based upon the criteria noted in table Fresh Eyes: An additional formal CTG assessment will be carried out hourly by the Labour Ward Coordinator or nominated person (for details of process see appendix 2).and countersigned if in agreement with the midwives assessment. Digital stimulation of the fetal scalp by a healthcare professional during a vaginal examination should be considered as an adjunct to continuous monitoring EFM. 7. Suspicious or pathological CTG Any suspicious or pathological features must be reported to a senior midwife or obstetrician. Immediate treatment: Place woman in left lateral position CLI.MAT.GUI Fetal monitoring during labour 3

4 Reduce syntocinon in presence of hypercontractility (contractions > 5:10 min) Consider tocolysis if hypercontractility not secondary to syntocinon use If CTG is pathological, discontinue syntocinon, if in use, and call for medical assistance Bradycardia of 3 min or longer must prompt immediate medical assistance together with preparations for category I delivery. If bradycardia persists for longer than 6 min, and vaginal delivery is not imminent, the woman must be transferred to theatre for possible LSCS. 8. Indications for the use of Continuous Fetal Heart Rate Monitoring: If one or more of the fetal heart features, recorded either by auscultation or electronic means, falls into the non-reassuring classification, see table 1. Non-reassuring and abnormal features should be reported to a senior member of staff i.e. CDS coordinator, SHO, Registrar Table 1. NICE guidelines (2007) for CTG interpretation and classification. FHR feature Reassuring Non-reassuring Abnormal Baseline FHR (bpm) Rate: Rate: Variability (bpm) 5 bpm or more <5 bpm for 40 to 90 min Accelerations Present None for 40 mins Decelerations Opinion Action None Typical variable decelerations with over 50% of contractions but for less than 90 min Typical or atypical variable decelerations with less than 50% of contractions True early decelerations Normal CTG (all four features reassuring) Date Time Signature Typical variable decelerations with over 50% of contractions occurring for over 90 min Atypical variable decelerations with more than 50% of contractions for less than 30 mins Late decelerations for less than 30 mins single prolonged deceleration lasting for up to 3 mins Suspicious CTG (one non-reassuring feature) <100 Rate: >180 Rate: Sinusoidal pattern 10 minutes <5 bpm for 90 min or more Comments: Atypical variable decelerations with more than 50% of contractions for more than 30 mins Late decelerations for more than 30 mins single prolonged deceleration lasting for more than 3 mins Pathological CTG (two or more non-reassuring or one abnormal feature) 1. Other fetal heart rate abnormalities: Decelerations to below 100 during 3 successive contractions Decelerations of more than 20 bpm following 3 successive contractions 2. Active second stage greater than 60 minutes 3. The liquor becomes meconium-stained. 9. Recording of maternal pulse CLI.MAT.GUI Fetal monitoring during labour 4

5 The maternal pulse should be recorded for both intermittent and continuous CTG monitoring. The maternal pulse must be recorded on the partogram or in the written labour record. Record maternal pulse rate at hourly intervals (more frequently if clinically indicated) Compare the maternal pulse rate with the CTG trace Compare the maternal pulse with the audible signal. 10. End of labour Following birth, the healthcare professional should sign and note the date, time and mode of birth on the CTG. 11. Support for parents in cases of actual or suspected fetal compromise and poor outcome of baby The cord ph is useful information to have when counselling parents of babies who encounter problems in the neonatal period. The neonatologists must be informed in cases of actual or suspected poor outcome for the baby. The Consultant neonatologist and Consultant Obstetrician will meet with the parents to discuss the labour, delivery and the possible prognosis for the baby and the details of what was discussed must be documented in the baby s notes or if the meetings have been performed separately then the obstetrician would document in the mother s notes. Provide parents with information for relevant support groups, if necessary. Where there are communication or language support needs assistance can be obtained via patient advice and liaison service (PALS) and interpretation services. 12. Storage of CTGs All CTGs should be stored in brown, sealed envelopes and attached securely to the obstetric notes. In addition, the CTG must have the mother s name and hospital number written on it together with the correct date and time throughout the labour and delivery. 12. Record keeping It is expected that every episode of care be recorded clearly, in chronological order and as contemporaneously as possible by all healthcare professionals as per Hospital Trust Policy. This is in keeping with standards set by professional colleges, i.e. NMC and RCOG. All entries must have the date and time together with signature and printed name. In addition: Documentation MUST include record keeping of: The equipment used to auscultate the fetal heart i.e. Sonicaid or Pinard together with reason for choice of equipment. Time and length of fetal heart auscultation i.e. before and after contraction Maternal pulse palpations - recorded on the partogram or written labour record Time and reason for transfer from intermittent auscultation to Continuous electronic fetal monitoring. CLI.MAT.GUI Fetal monitoring during labour 5

6 Continuous electronic fetal monitoring documentation MUST include a record of the above points AND: CTG traces should be labelled with the mother s name, date, hospital number, and include gestation and maternal pulse The date and time clocks on the EFM machine should be correctly set and the relevant member of staff s signature on the CTG paper is required to confirm. Any intrapartum events that may affect the FHR should be noted at the time on the FHR trace, which should be signed and the date and time noted (for example, vaginal examination, FBS or siting of an epidural). Full hourly CTG summary Hourly Fresh Eyes summary 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 medical records along with the date, time and signature and appropriate management plan in the event that the tracing is assessed as suspicious or pathological Following birth, the healthcare professional should sign and note the date, time and mode of birth on the FHR trace. The FHR trace should be stored securely with the woman s medical records at the end of the monitoring process. Fresh eyes documentation must be filed with the maternity record. Observations throughout labour must be recorded on the partogram or in the written labour records. All entries must have the date and time together with signature and printed name or an entry in the signature bank on each set of notes. CLI.MAT.GUI Fetal monitoring during labour 6

7 Appendix 1 Fresh Eyes Review FHR feature Reassuring Non-reassuring Abnormal Baseline FHR (bpm) Rate: Rate: Variability (bpm) 5 bpm or more <5 bpm for 40 to 90 min Accelerations Present None for 40 mins Decelerations Opinion Action None Typical variable decelerations with over 50% of contractions but for less than 90 min Typical or atypical variable decelerations with less than 50% of contractions True early decelerations Normal CTG (all four features reassuring) Date Time Signature Typical variable decelerations with over 50% of contractions occurring for over 90 min Atypical variable decelerations with more than 50% of contractions for less than 30 mins Late decelerations for less than 30 mins single prolonged deceleration lasting for up to 3 mins Suspicious CTG (one non-reassuring feature) <100 Rate: >180 Rate: Sinusoidal pattern 10 minutes <5 bpm for 90 min or more Comments: Atypical variable decelerations with more than 50% of contractions for more than 30 mins Late decelerations for more than 30 mins single prolonged deceleration lasting for more than 3 mins Pathological CTG (two or more non-reassuring or one abnormal feature) CLI.MAT.GUI Fetal monitoring during labour 7

8 Appendix 2 Fresh eyes Review Process: Continuous Electronic Fetal Monitoring in Labour Midwife to: 1. Generate Fresh Eyes Documentation Form with patient identifiers on both sides of the form 2. Documentation form to be placed in the Fresh Eyes Folder (by central surveillance monitor on labour ward) 3. Inform Labour Ward Co-ordinator of decision to use continuous electronic fetal monitoring 4. Perform routine hourly assessment on K2 5. Ensure Fresh Eyes Documentation form is filed with the maternal record following delivery Labour Ward Co-ordinator/designated other: 1. Systematic review of CTG Hourly using central surveillance 2. Document assessment on the woman s Fresh Eyes Documentation form 3. Identify actions arising from assessment 4. Date, time and Sign assessment Reassuring Repeat in one hour Suspicious/Pathological: Full assessment to be conducted at the woman s bedside, and recorded on K2 Medical opinion to be sought. CLI.MAT.GUI Fetal monitoring during labour 8

9 Monitoring and Audit Auditable standards: Documented discussion and patient information leaflet re: fetal monitoring and options available. Correct palpation of maternal pulse and documentation Correct auscultation of fetal heart rate and documentation Appropriate transfer from intermittent to continuous electronic fetal monitoring together with documented reason. CTG has mother s name, hospital no, date, time, intrapartum events (recorded at the time of the event with signature and time noted) If an opinion on CTG was sought was this recorded on CTG as well as in health records? Date at end of CTG Hourly systematic assessment of CTG Correct actions taken in event of suspicious or pathological CTG In cases of poor outcome documentation of discussions with parents and provision of information re: support groups. Documentation of all the above Please refer to audit tool, location: Maternity on cl2-file11, Guidelines Reports to: Clinical Effectiveness Committee responsible for action plan and implementation of recommendations from audit Clinical Governance & Risk Management Committee Frequency of audit: Annually Responsible person: CDS Manager Training requirements Audit of training needs compliance please refer to TNA policy Training needs analysis: Please refer to Training Needs Analysis guideline together with training attendance database for all staff Cross references Antenatal Guideline 31 - Maternity Hand Held Notes, Hospital Records and Record Keeping Antenatal Guideline 44 Guideline development within the maternity services References NICE 2001, The Use of Electronic Fetal Monitoring:The use and interpretation of cardiotocography in intrapartum fetal surveillance. Clinical effectiveness support group. Royal College of Obstetricians and Gynaecologists, London. NICE, Intrapartum care: Care of healthy women and their babies during childbirth. RCOG, London. Author Guideline Committee Work Address Maternity Unit, Derriford Hospital, Plymouth, Devon, PL6 8DH Version 7 Changes Fresh eyes on CDS Updated in line with Nice guidelines Date Ratified Sep 14 Valid Until Date Sep 17 CLI.MAT.GUI Fetal monitoring during labour 9

10 CLI.MAT.GUI Fetal monitoring during labour 10

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