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1 Document Classification Document Title Document Type Unique Identifier Function(s) (see table) Scope (see table) Target Audience Key words Author(s) Owner (see table) Date first published 2004 Date this version published 30 April 2010 Next scheduled review date April 2013 CONTENTS 1. Introduction 2. One to one care 3. Intermittent auscultation 4. Admission CTG 5. Electronic fetal monitoring 6. Fetal blood sampling a. Indications for FBS b. Contraindications for FBS c. Scalp Lactate Values d. Indications for cord sampling (ideally lactate) 7. Documentation 8. Interpretation a. Normal b. Suspicious c. Abnormal 9. Management of abnormalities 10. Supporting Evidence 11. Associated Documents 12. Disclaimer Fetal Heart Rate - Intrapartum - Surveillance Guideline NMP200/SSM/005 Clinical Service Delivery Single service: Women s health Obstetricians, midwives, and all LMCs Fetal monitoring, Electronic fetal surveillance, Intrapartum fetal monitoring Midwifery Educator, Women s Health Clinical Director, Women s Health (Obstetrics) Page 1 of 10

2 1. Introduction The purpose of this Guideline is to ensure Fetal Heart Rate Surveillance is carried out appropriately and correctly, and that the woman understands the procedures and their implications, enabling her to make an informed choice about monitoring the baby in labour. Two percent of labours will be complicated by significant hypoxic fetal distress requiring emergency intervention; half of these cannot be predicted. Cardiotocography (CTG) is a screening test for fetal hypoxia and has a high sensitivity but low specificity. This means that it is very good at picking up hypoxia, but has a high false positive rate (about 50%). So an abnormal CTG is not diagnostic of fetal hypoxia, but indicates that further measures should be taken. The Fetal heart recording either intermittent or Electronic fetal trace should always be interpreted in the light of the clinical details or risk factors, in a timely manner and by an appropriately qualified health practitioner. Following explanation of recommended means of fetal monitoring verbal consent is obtained from the woman. Document using CTG sticker (see below) for electronic monitoring and recommended terminology. Initial Risk factors Intra partum risk factors Dilation Contractions 10 minutes Normal Suspicious Abnormal Baseline rate <100 >160 Variability (bpm) 5bpm or more <5 for 40 mins - 90mins <5 for 90mins or more Accelerations present none none Decelerations none Early decelerations, OR Single variable or deceleration up to 3 minutes Opinion Actions all four features normal =Normal CTG one suspicious feature = Suspicious CTG Repeated variables or late decelerations OR prolonged decelerations more than 3 minutes two or more suspicious OR One or more abnormal features = Abnormal CTG Date Time.... Signature status Page 2 of 10

3 2. One to one care Guideline 1: Women in labour require one to one care and Intrapartum Fetal Surveillance Intensive fetal surveillance by intermittent auscultation or electronic fetal monitoring requires continuous presence of midwifery staff. One- to-one care of the woman is recommended, recognizing that the midwife is really caring for two people, the woman and her unborn child. 3. Intermittent auscultation Guideline 2: Intermittent Auscultation of the fetal heart in labour of the low risk woman This is an auditory or listening technique for sampling and counting fetal heart beats at specified intervals and should not be viewed as electronic fetal monitoring. The fetal heart is auscultated following abdominal palpation and by placing the pinards or Doppler over the anterior shoulder of the fetus. The maternal pulse should be checked during auscultation to differentiate maternal and fetal heart rates. Baseline fetal heart rate is assessed by listening and counting between uterine contractions for 60 seconds. Auscultate in active labour every 15-30mins partway through and for 60 seconds after contraction has finished. Second stage Auscultate every five minutes or when pushing after each contraction. If there are any audible concerns commence electronic fetal monitoring. The type of monitoring and how the fetal heart is auscultated must be indicated in the notes at commencement of care and the fetal heart and maternal pulse are recorded on the partogram in established labour, otherwise in the clinical notes. Do not use CTG machine for intermittent Auscultation Use. If risk factors occur at any stage during active labour commence electronic fetal monitoring. If you are at any stage unsure as to the appropriate monitoring method, click here for RANZCOG Algorithm. Page 3 of 10

4 4. Admission CTG Guideline 3: Admission Electronic Fetal monitoring Trace Not recommended for healthy women at term in labour in the absence of risk factors for adverse perinatal outcome, as there is no evident benefit. Admission electronic fetal heart tracings are recommended for women with risk factors for adverse perinatal outcome. On admission do a risk assessment and discuss with the woman to decide on mode of fetal monitoring. Informed consent is required. 5. Electronic fetal monitoring Guideline 4: Intrapartum fetal surveillance for women with risk factors for adverse perinatal outcome Click here for RANZCOG algorithm Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome to identify hypoxia before it is sufficient to lead to damaging acidosis and long term neurological adverse outcome. Normal CTG tracings during the first stage of labour When a normal trace is identified, it may be appropriate to interrupt the CTG tracing for up to 30mins to facilitate periods of ambulation, showering or position change, providing that auscultation is carried out at 15mins, and that: the maternal-fetal condition is stable if Oxytocin is being administered, the infusion rate is not increased Discuss monitoring options with woman and inform her of the need for continuous electronic fetal monitoring and that it will restrict her mobility. A discussion on fetal blood sampling should be included. If appropriate use telemetry. Always listen to fetal heart with pinards or sonicaid and ensure it is present and distinguished from maternal pulse prior to initiating EFM. If not heard confirm urgently with ultra sound (not with fetal scalp electrode since false readings can occur). Tocograph is essential when using EFM to allow description of contraction pattern and classification of decelerations and uterine tachysystole. Page 4 of 10

5 A Fetal Scalp Electrode should be applied when it is difficult to record a good quality CTG with external tracing, due to: Obesity A poor abdominal trace due to women moving a lot Unable to establish good monitoring of high risk fetus during insertion of epidural In second stage if unable to distinguish between FH or maternal pulse 6. Fetal blood sampling Guideline 5: Fetal scalp stimulation or Fetal Blood Sampling (FBS) avoids some instrumental births and Caesarean Sections a. Indications for FBS Fetal scalp stimulation is recommended in women with suspicious or abnormal fetal heart rate trace as per the definitions above. Digital scalp stimulation is performed by gently stroking the fetal scalp and a reassuring response is defined as acceleration in the heart rate. However the absence is not always associated with fetal acidosis. This should be considered as an adjunct to EFM Fetal scalp blood sampling is recommended for women with abnormal fetal heart tracings at gestation >34 weeks when delivery is not imminent, or if digital fetal scalp stimulation does not result in an acceleratory fetal heart rate response. When a FHR trace is abnormal a fetal scalp lactate is advised unless there is clear evidence of acute compromise. Where delivery is contemplated because of an abnormal FHR pattern at full dilatation, FBS should be considered especially if assisted vaginal birth would be difficult or contraindicated. FBS should be undertaken in the absence of any contraindications as follows. b. Contraindications for FBS Clinical signs of acute fetal compromise. (E.g. a prolonged bradycardia > 5 minutes without recovery) Technical difficulties Maternal Infection (e.g. HIV, Hep B, Herpes simplex virus) Fetal bleeding disorders (e.g. haemophilia) Maternal bleeding disorders (e.g. Thrombocytopenia) Prematurity (less than 34 weeks) Second twin Abnormal presentation (breech, face) Page 5 of 10

6 c. Scalp Lactate Values Normal <4 no need to repeat if trace improves. If abnormality continues repeat in 1-2 hrs Pre acidotic Repeat in 30minutes Acidotic >4.8 Deliver. If over 5.7 category 1 Comparisons between ph and lactate ph Lactate For all babies that have had a scalp lactate during labour it should be followed up with cord lactate at birth both Arterial and Venous samples. If baby is to be delivered in the operating room, then a lactate kit should go with the woman. Cord lactate must be taken within 10 minutes of cord clamping. Results must be documented and signed for in the clinical notes and on the lactate record sheet where they will be entered into Concerto by the point of care staff. d. Indications for cord sampling ( ideally lactate) All babies that have had a lactate during labour All babies born unexpectedly flat Following all instrumental births All babies being admitted to NICU where opportunity exists to sample the cord. If lactate cannot be done because of the time frame then cord gases may be possible. Babies with fetal abnormalities IUGR babies Preterm babies All caesarean sections Any case where there has been concern about fetal condition. This is important to document the acid-base status of the baby at birth and gives objective information which can be useful for management and audit Page 6 of 10

7 7. Documentation Ensure correct paper in machine Check date and time and speed (1cm per minute) is correct on CTG machine Label trace with ID label or mothers name and NHI and date Maternal pulse must be documented at commencement of CTG and hourly thereafter Name of person providing an opinion should be noted on the trace at the time and in the clinical notes Any intrapartum event should be documented e.g. vaginal examination, change of position Epidural insertion, syntocinon infusion commenced or altered Following birth note time of delivery and mode of birth Trace must be stored securely in woman s notes following the birth. (This is a legal document) When electronically monitoring twins each fetal heart must be labeled appropriately on the trace: twin 1 twin 2. It must also be documented in the clinical notes if the traces have been separated by 20+ for monitoring purposes and which twin has had the increase 8. Interpretation Terminology The correct terminology must be used when analyzing and describing a trace to ensure accurate clear communication between clinicians. Initial assessment commences with: Assessment of antenatal and ongoing intrapartum risk factors. Assessment of contractions. (Hyperstimulation is 6 or more contractions in 10 minutes or less than seconds relaxation between contractions) Baseline Variability ( assess between contractions ) Accelerations Decelerations Definition of normal, suspicious and abnormal FHR traces Category Definition Page 7 of 10

8 a. Normal A FHR trace in which all features are classified as reassuring Contractions not more than 5 in 10 minutes Baseline rate Baseline variability of 5-25bpm Accelerations ( increase of 15bpm for 15 seconds above baseline) No decelerations (decrease of 15bpm for 15 seconds below baseline) All other CTGs are by this definition not normal and require further evaluation taking into account the full clinical picture b. Suspicious A FHR trace with one feature classified as not normal Contractions >5 in 10 minutes Baseline rate of Variability < 5 bpm for minutes Absence of Accelerations Early decelerations Variable decelerations without complicating features Unlikely to be associated with significant fetal compromise when occurring in isolation c. Abnormal A FHR trace with two or more features classified as suspicious or one or more classified as abnormal: Fetal tachycardia > 160/min Reduced baseline variability <5 bpm for > 90 minutes Complicated variable decelerations Late Decelerations Prolonged decelerations > 3 min May be associated with significant fetal compromise and require further action The following features are very likely to be associated with significant fetal compromise and require immediate management, which may include urgent delivery Prolonged bradycardia (<100bpm for > 5 minutes) Page 8 of 10

9 Absent baseline variability Sinusoidal pattern Complicated variable decelerations with reduced baseline variability Late decelerations with reduced variability Rapidly rising baseline Consultation is mandatory for suspicious or abnormal traces to CCM or Registrar. CTG sticky must be used and adhered to clinical notes by any person interpreting the trace at least hourly. Fresh Eyes In recognition that fatigue and familiarity may make CTG interpretation challenging, each practitioner caring for a woman must seek the opinion of a colleague (midwife or doctor) to systematically review the trace with them at a minimum 2 hourly. The findings must be documented on a sticky label and adhered to clinical notes. 9. Management of abnormalities For a suspicious or abnormal CTG trace, the attending midwife must: Alert the Clinical Charge Midwife Alert the obstetric team (registrar) Try to identify a cause for the abnormality and correct it: o Maternal supine hypotension corrected by turning woman to a left lateral position o Epidural hypotension: give bolus of IV. Plasmalyte. If the BP fails to respond, consult an Anaesthetist urgently. o Uterine hypercontractility: stop Oxytocin. Consider emergency halting of contractions o Click here for emergency halting of contractions. o Antipyretics, cultures and antibiotics if maternal pyrexia. If tachycardia does not respond there should be further review and a low threshold for delivery. If the trace remains suspicious or abnormal, consider fetal scalp blood sampling if appropriate. If FBS is not appropriate or possible, delivery should be expedited. If staff availability allows it would be valuable to commence paper work required for caesarean section e.g. check list. There must be no delay in summoning help with an abnormal trace and no delay in transferring to operating room in the event of a caesarean section being needed. Click here for Acute Caesarean Section policy flowchart. Page 9 of 10

10 If a bradycardia occurs in the baby for more than 3 minutes, call for urgent assistance and preparations should be made to urgently expedite the birth of the baby, classified as a Category 1. This could include moving the woman to OR if the fetal heart has not recovered by 9 minutes. If the fetal heart recovers within 9 minutes the decision should be reconsidered in conjunction with the woman if reasonable. For women having continuous EFM a documented systematic assessment based on these definitions and classifications should be undertaken every hour. 10. Supporting Evidence JOGC Sept.2007 Volume 29, number 9 RANZCOG fetal surveillance guidelines edition 2 Nice guidelines 2007 Intrapartum fetal heart rate Monitoring research Robyn Maude, Maralyn Foureur Evidenced based care for normal labour and birth a guide for midwives Denis Walsh Ingemarsson,I; Arulkumaran,S; Ingemarasson, E; Tambyraja. R L; & Ratnam, S S (1986) Admission test: a screening for fetal distress in labour. Obstetrics Gynecology,68, East Kent Hospitals University Assessment and interpretation of the Fetal Heart Feb Associated Documents Intrapartum Care Caesarean section - access to, preparation for, & care in operating room Emergency Caesarean section part of above document Normal birth Pathway yet to come 12. Disclaimer No set of guidelines can cover all variations required for specific circumstances. It is the responsibility of the health care practitioners using these guidelines to adapt them for safe use within their institutions and for the individual needs of patients. See example disclaimer here. Back to Contents Page 10 of 10