Staff using electronic fetal monitoring should be aware of its limitations and artefacts, such as doubling maternal heart rate being displayed.

Transcription

1 CLINICAL GUIDELINE FOR THE USE OF ELECTRONIC FETAL MONITORING IN LABOUR, FETAL BLOOD SAMPLING AND PAIRED CORD SAMPLING 1. Aim/Purpose of this Guideline 1.1. This gives guidance to obstetricians and midwives in the use of electronic fetal monitoring in labour, when to perform fetal blood sampling and in what circumstances paired cord samples should be taken 2. The Guidance 2.1. Definition: Electronic fetal monitoring (EFM) is defined as the use of electronic fetal heart-rate monitoring for the evaluation of fetal wellbeing in Labour The basic principle of intrapartum monitoring is to detect developing fetal hypoxia with the aim of preventing subsequent acidaemia and cell damage. Staff using electronic fetal monitoring should be aware of its limitations and artefacts, such as doubling maternal heart rate being displayed. ² In chronic fetal hypoxia the initial response is to increase cardiac output by an increase in heart rate to redistribute blood to the brain and heart. This may be followed by a reduction in heart-rate variability due to brainstem hypoxia. Continued and worsening hypoxia will eventually produce myocardial damage and heart-rate decelerations. Acute fetal hypoxia in contrast, results in a decrease in the fetal heart rate (decelerations or bradycardia) Care of women: The assessment of fetal wellbeing is only one component of intrapartum care. It is an important area where due consideration must be given to maternal preference and priorities in the light of potential risk factors to both mother and baby. Women must be able to make informed choices regarding their care or treatment. Women should have the same level of care and support regardless of the mode of monitoring. Prior to any form of fetal monitoring, the maternal pulse should be palpated simultaneously with FHR auscultation in order to differentiate between maternal and fetal heart rates and this should be recorded on the CTG and in the maternal notes. If there is any clinical uncertainty the fetal heart rate should be confirmed by independent means, such as a pinard or ultrasound scan If fetal death is suspected despite the presence of an apparently recordable FHR, then fetal viability should be confirmed with real-time ultrasound assessment Documentation in relation to EFM: The indication for commencing continuous EFM should be recorded in the maternal records Page 1 of 16

2 the date and time clocks on the EFM machine should be checked and correctly set against the wall clock. At the commencement of the trace the following should be recorded, woman s name, date, time and hospital number and signed by the midwife. The maternal pulse should be recorded on the EFM trace at the start of the trace and whenever there is a sudden/significant change in the FHR. any intrapartum events that may affect the FHR should be noted contemporaneously on the EFM trace, signed and the date and time noted (e.g. vaginal examination, fetal blood sample, siting of an epidural) any member of staff who is asked to provide an opinion on a trace should note the classification of the FHR pattern on both the trace and maternal records, together with time and signature following the birth, the care-giver should sign and note the date, time and mode of birth on the EFM trace The EFM trace should be stored securely with the CTG secure-stor envelope in the maternal notes at the end of the monitoring process Fetal heart monitoring in an uncomplicated pregnancy: For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation is the preferred option. ³ Current evidence does not support the use of the admission CTG in low-risk pregnancy and it is therefore not recommended Indications for the use of continuous EFM: In an otherwise low-risk pregnancy when there is: Significant meconium-stained liquor. Abnormal FHR detected by intermittent auscultation (less than 110 beats per minute [bpm]; greater than 160 bpm; any decelerations after a contraction) maternal pyrexia (defined as 38.0 C once or 37.5 C on two occasions 2 hours apart) Fresh bleeding developing in labour Request for epidural where oxytocin is being used for induction or augmentation of labour Continuous EFM should be offered and recommended for high-risk pregnancies, such as: IUGR Women attempting vaginal birth after CS Multiple pregnancy Preterm labour Diabetic woman Pre-eclampsia Maternal request: EFM should be provided on maternal request, however, a full discussion should take place with the woman and she should be informed that this may increase the risk of intervention without any proven benefits and will restrict her mobility 1 Page 2 of 16

3 2.6. Interpretation of EFM: Settings on CTG machines should be standardised, so that: Paper speed is set to 1 cm/min Sensitivity displays are set to 20 bpm/cm FHR range displays of bpm are used. Categorisation of fetal heart rate patterns Category Normal Suspicious Pathological Definition A FHR trace in which all four features are classified as Reassuring. A FHR trace with one feature classified as non-reassuring and the remaining features classified as reassuring A FHR trace with two or more features classified as nonreassuring or one or more classified as abnormal 2.7. Classification of fetal heart rate (FHR) features (see appendix 1 for detailed definitions) Feature Baseline bpm Variability bpm Decelerations Reassuring None Early uniform decelerations (rare) Nonreassuring < 5 for 40- Typical variable min decelerations with over 50% of contractions, occurring over 90 minutes -Single prolonged deceleration for Abnormal < 100 > 180 Sinusoidal Pattern 10 minutes < 5 for > 90 min up to 3 minutes Either atypical variable decelerations with over 50% of contractions or late decelerations, both for over 30 minutes -Single prolonged deceleration for more than 3 minutes Accelerations Present The absence of accelerations with otherwise normal trace is of uncertain significance Page 3 of 16

4 2.8. Further information about classifying FHR traces: If repeated accelerations are present with reduced variability, the FHR trace should be regarded as normal. Most decelerations in labour are variable. If a bradycardia occurs in the baby for more than 3 minutes, urgent medical aid should be sought and preparations should be made to urgently expedite the birth of the baby, classified as a category 1 birth. This could include moving the woman to theatre if the fetal heart has not recovered by 9 minutes. If the fetal heart recovers within 9 minutes the decision to deliver should be reconsidered in conjunction with the woman. A tachycardia in the baby of bpm, where accelerations are present and no other adverse features appear, should not be regarded as suspicious. However, an increase in the baseline heart rate, even within the normal range, with other nonreassuring or abnormal features should increase concern FRESH EYES procedure The individual practitioner providing care to a woman who requires continuous EFM is responsible for it continual interpretation and appropriate action in the event of any concerns. In addition, a record of the FHR should be made on the partogram every 15 minutes. The contraction strength and frequency palpated for 10 minutes every 30 minutes and recorded on the partogram. Every hour the practitioner providing care to the woman must seek the assistance of a colleague (midwife or doctor) to systematically review the CTG trace with them. A Fresh eyes sticker must be completed, signed by both practitioners, and fixed in the woman s notes and the interpretation should be recorded on the EFM trace and signed. A EFM interpretation should be completed and documented in the woman s notes after any significant clinical event e.g. epidural insertion, vaginal examination, change of maternal position and must also be recorded on the CTG tracing and signed. After each CTG interpretation, an appropriate action plan should be made and followed depending on the classification (see below). The assessment, considerations, discussion and the plan should be documented in the woman s notes, as contemporaneously as possible Appropriate action in relation to classification Normal: If interpretation falls within normal category, and all other assessments are within normal range, the appropriate action is to continue with the plan of care and document this in the notes. Suspicious: If interpretation falls within the suspicious category, assessment should take place by the delivery suite co-ordinator. If, after conservative measures, such as changing position and rehydrating, the trace remains suspicious, assessment and plan should be made by a middle grade Obstetrician and documented in the notes. Pathological: If the interpretation remains within the pathological category, after appropriate conservative measures, fetal blood sampling or immediate delivery is indicated. Page 4 of 16

5 2.11. Points to consider in the presence of suspicious or pathological interpretation During episodes of abnormal FHR patterns when the woman is lying supine she should be advised to adopt the left-lateral position. Prolonged use of maternal facial oxygen therapy for abnormal EFM may be harmful to the baby and should be avoided. In the presence of abnormal FHR patterns stop Oxytocin infusion and consider tocolysis with subcutaneous Terbutaline 250 mcg. In cases of acute fetal compromise, delivery should be accomplished as soon as possible, accounting for the severity of the FHR abnormality and relevant maternal factors. Ideally this should be within 30 minutes Storage of EFM tracings: EFM traces should be kept for a minimum of 25 years. The trace should be placed in a secure-stor envelope. The envelope should be hole-punched and filed chronologically in the woman s medical notes. Tracer systems should be developed to ensure that the woman s health records, containing the CTG, can always be located. If a distant fetal monitoring trace is performed, a fresh eyes sticker should be placed in the women s hand held notes describing the tracing and the plan and the tracing sent to day assessment unit for filing in the woman s main medical notes Fetal Blood Sampling Where delivery is contemplated because of an abnormal fetal heart-rate pattern, in cases of suspected fetal acidosis, fetal blood sampling should be undertaken in the absence of technical difficulties or any contraindications. Contraindications to fetal blood sampling include: maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus) fetal bleeding disorders (e.g. haemophilia) prematurity (< 34 weeks). Where there is clear evidence of acute fetal compromise (e.g. prolonged deceleration greater than three minutes), fetal blood sampling should not be undertaken and the baby should be delivered urgently. Face presentation Immediately after a bradycardia. Full explanation should be given to the woman as to the reasons for the FBS, and the procedure and verbal consent obtained. This discussion should be recorded in the woman s notes and the results and ongoing plan should be documented chronologically in the women s intrapartum notes. Fetal blood sampling should be undertaken with the mother in the left-lateral position and an aseptic technique should be used Page 5 of 16

6 2.14. Classification of fetal blood sample results Fetal blood sample Subsequent action (FBS) result (ph)* 7.25 FBS should be repeated if the FHR abnormality persists Repeat FBS within 30 minutes or consider delivery if rapid fall since last sample 7.20 Delivery indicated *All scalp ph estimations should be interpreted taking into account the initial ph measurement, the rate of progress in labour and the clinical features of the mother and baby. After a normal FBS result, sampling should be repeated no more than 1 hour later if the FHR trace remains pathological or sooner if there are further abnormalities. After a borderline FBS result, sampling should be repeated no more than 30 minutes later if the FHR trace remains pathological or sooner if there are further abnormalities. The time taken to take a fetal blood sample needs to be considered when planning repeat samples. If the FHR trace remains unchanged and the FBS result is stable after the second test, a third/ further sample may be deferred unless additional abnormalities develop on the trace. Where a third FBS is considered necessary, consultant obstetric opinion should be sought. Fetal blood sampling results should be written, chronologically in the notes and printed reports filed in the secure-stor envelope. A paired cord sample should be taken following the birth of the baby Paired cord samples Paired cord samples should not be taken routinely on all births Paired cord samples should be taken on all births in which there has been concern regarding fetal wellbeing or admission to neonatal unit is expected It is the responsibility of the person conducting the delivery, to take the paired cord samples, unless this is not possible, then it may be delegated to another person The person conducting the delivery must ensure that paired cord samples are taken, and that an arterial and venous result are obtained All paired cord sample results should be hand written in the notes and printed reports filed in the secure-stor envelope Page 6 of 16

7 2.16. Staff training and updating will be completed as per the RCHT Maternity training needs analysis References: 1. NICE Intrapartum care Medical and Healthcare products regulation agency. 2010: Fetal monitoring/cardiotocograph, medical devices alert. 3. Cornwall maternity services (2009).Guideline for the intermittent auscultation of the fetal heart in labour 4. Medical Devices Agency: Guidance on Electronic Fetal Monitoring. 5. Joyce C: Fresh eyes CTG interpretation. PAMW, RCHT Page 7 of 16

8 3. Monitoring compliance and effectiveness Element to be monitored Lead The audit will take into account record keeping by obstetricians and midwives The results will be inputted onto an excel spreadsheet The audit will be registered with the Trust s audit department Maternity risk management midwife Tool for monitoring EFM Is the following data recorded in relation to the commencement of a CTG: Woman s name, Date, Time and Hospital number Is the following data recorded in relation to the continuing of a CTG: Intrapartum events are recorded on the CTG, Intrapartum events recorded on the CTG are signed, Any opinion on the trace is documented on the trace, Any opinion on the trace is signed Frequency of monitoring EFM Tool for monitoring fetal blood sampling Is the following data recorded in the health records in relation to the continuing of a CTG: If an opinion of the trace was sought is it documented in the health records Is there an hourly assessment of the trace? If the trace was assessed as being suspicious/pathological: Was the action taken documented and was a plan documented? On completion of the trace was the following documented: Date of birth, Time of Birth, Mode of delivery and Signature of midwife 1% or 10 sets, whichever is the greater, of all health records of women who have delivered will be audited over a 12 month period 1% or 10 sets, whichever the greater, of all health records of women who have delivered in whom the tracing was assessed as suspicious or pathological will be audited over a 12 month period Was the reason for the FBS documented in the notes were the results documented in the notes Was there a plan in the notes for the requirement and timing of the next FBS Was there a second FBS performed and were the results documented in the note Was there a plan in the notes for the requirement and timing of the next FBS Was there a third FBS considered and was a consultant obstetric opinion sought were all FBS results documented chronologically in the health records and filed in the secure store envelope In cases where FBS was performed was a paired cord Page 8 of 16

9 Frequency of monitoring fetal blood sampling Reporting arrangements Acting on recommendations and Lead(s) Change in practice and lessons to be shared sample taken following the birth of the baby If there were concerns about the baby in labour and no FBS was performed were paired cord samples taken. Were all paired cord sample results should hand written in the notes and printed reports filed in the secure-stor envelope 1% or 10 sets, whichever the greatest, of all health records of women who have delivered in whom fetal blood sampling and paired cord sampling have been undertaken, will be audited over a 12 month period 1% or 10 sets, whichever the greater, of all health records of women who have delivered in whom paired cord sampling only has been undertaken, where there has been concern about the baby in labour or immediately following birth, will be audited over a 12 month period Formal reports of the results will be received annually at the maternity risk management and clinical audit forum, as per the audit plan During the process of the audit if compliance is below 75% or other deficiencies identified, this will be highlighted at the next maternity risk management and clinical audit forum and an action plan agreed. Any deficiencies identified on the annual report will be discussed at the maternity risk management and clinical audit forum and an action plan developed Action leads will be identified and a time frame for the action to be completed by The action plan will be monitored by the maternity risk management and clinical audit forum until all actions complete Required changes to practice will be identified and actioned within a time frame agreed on the action plan A lead member of the forum will be identified to take each change forward where appropriate. The results of the audits will be distributed to all staff through the risk management newsletter/audit forum as per the action plan Page 9 of 16

10 4. Equality and Diversity 4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2. Page 10 of 16

11 Appendix 1 Definitions and descriptions of individual features of fetal heart-rate (FHR) traces Term Definition Baseline fetal heart-rate The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 or 10 minutes and expressed in bpm Preterm fetuses tend to have values towards the upper end of this range. A trend to a progressive rise in the baseline is important as well as the absolute values. Normal Baseline Moderate bradycardia* Moderate tachycardia* Abnormal bradycardia Abnormal tachycardia FHR bpm bpm bpm < 100 bpm > 180 bpm Baseline variability Normal variability The minor fluctuations in baseline FHR occurring at three to five cycles per minute. It is measured by estimating the difference in beats per minute between the highest peak and lowest trough of fluctuation in a one-minute segment of the trace Greater than or equal to 5 bpm between contractions. Non-reassuring Less than 5 bpm for 40 minutes or more but variability less than 90 minutes Abnormal variability Less than 5 bpm for 90 minutes or more. Accelerations Transient increases in FHR of 15 bpm or more and lasting 15 seconds or more. The significance of no accelerations on an otherwise normal CTG is unclear Decelerations -Early decelerations -Late decelerations -Variable decelerations -Atypical variable Transient episodes of slowing of FHR below the baseline level of more than 15 bpm and lasting 15 seconds or more Uniform, repetitive, periodic slowing of FHR with onset early in the contraction and return to baseline at the end of the contraction Uniform, repetitive, periodic slowing of FHR with onset mid to end of the contraction and nadir more than 20 seconds after the peak of the contraction and ending after the contraction. In the presence of a non-accelerative trace with baseline variability less than 5 bpm, the definition would include decelerations less than 15 bpm. Variable, intermittent periodic slowing of FHR with rapid onset and recovery. Time relationships with contraction cycle are variable and they may occur in isolation. Sometimes they resemble other types of deceleration patterns in timing and shape Variable decelerations with any of the following Page 11 of 16

12 decelerations -Prolonged deceleration -Sinusoidal pattern additional components: loss of primary or secondary rise in baseline rate slow return to baseline FHR after the end of the contraction prolonged secondary rise in baseline rate biphasic deceleration loss of variability during deceleration continuation of baseline rate at lower level An abrupt decrease in FHR to levels below the baseline that lasts at least seconds. These decelerations become pathological if they cross two contractions, i.e. greater than 3 minutes. a regular oscillation of the baseline long-term variability resembling a sine wave. This smooth, undulating pattern, lasting at least 10 minutes, has a relatively fixed period of 3 5 cycles per minute and amplitude of 5 15 bpm above and below the baseline. Baseline variability is absent *These ranges of baseline are not associated with hypoxia in the presence of accelerations, with normal baseline variability and no decelerations Page 12 of 16

13 Appendix 1. Governance Information Document Title Date Issued/Approved: 8 th October 2012 Clinical guideline for the use of electronic fetal monitoring in labour, fetal blood sampling and paired cord sampling Date Valid From: 8 th October 2012 Date for Review: 1 st October 2015 Directorate / Department responsible (author/owner): Dr Karen Watkins Consultant obstetrician Obs and gynae directorate Contact details: Brief summary of contents Suggested Keywords: Target Audience Executive Director responsible for Policy: This gives guidance to obstetricians and midwives in the use of electronic fetal monitoring in labour, when to perform fetal blood sampling and in what circumstances paired cord samples should be taken Monitoring in labour, CTG, EFM, FBS, cord blood gases RCHT PCT CFT Medical Director Date revised: September 2012 This document replaces (exact title of previous version): Guideline on the use of Electronic Fetal Monitoring, Fetal Blood Sampling and paired cord sampling Approval route (names of committees)/consultation: Maternity guidelines group Obs and gynae directorate meeting Divisional Manager confirming approval processes Name and Post Title of additional signatories Signature of Executive Director giving approval Publication Location (refer to Policy on Policies Approvals and Ratification): Internet & Intranet Intranet Only Page 13 of 16

14 Document Library Folder/Sub Folder Midwifery and obstetrics Links to key external standards CNST 2.3 & 2.4 Related Documents: Training Need Identified? Version Control Table RCHT: Intermittent auscultation Annual update as per training needs analysis Date January 2006 Septembe r 2009 December 2009 November 2010 Versio n No 1.0 Initial document Summary of Changes 1.1 Updated in line with NICE guidance 1.2 Compliance monitoring added 1.3 Updated to include NPSA alert statement Staff using electronic fetal monitoring should be aware of its limitations and artefacts, such as doubling maternal heart rate being displayed. ² Changes Made by (Name and Job Title) Jan Clarkson Maternity risk manager Jan Clarkson Maternity risk manager Jan Clarkson Maternity risk manager Jan Clarkson Maternity risk manager Septembe r Reviewed no changes made to clinical content, changes to compliance monitoring only Jan Clarkson Maternity risk manager All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager. Page 14 of 16

15 Appendix 2.Initial Equality Impact Assessment Screening Form Name of service, strategy, policy or project (hereafter referred to as policy) to be assessed: Clinical guideline for the use of electronic fetal monitoring in labour, fetal blood sampling and paired cord sampling Directorate and service area: Is this a new or existing Procedure? Obs and gynae directorate Exisiting Name of individual completing Telephone: assessment: Jan clarkson Policy Aim* This gives guidance to obstetricians and midwives in the use of electronic fetal monitoring in labour, when to perform fetal blood sampling and in what circumstances paired cord samples should be taken 2. Policy Objectives* To ensure appropriate monitoring in labour 3. Policy intended Outcomes* 5. How will you measure the outcome? 5. Who is intended to benefit from the Policy? Safe outcomes of labour Compliance monitoring tool Woman and their babies 6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure. *Please see Glossary 7. The Impact Please complete the following table using ticks. You should refer to the EA guidance notes for areas of possible impact and also the Glossary if needed. Where you think that the policy could have a positive impact on any of the equality group(s) like promoting equality and equal opportunities or improving relations within equality groups, tick the Positive impact box. Page 15 of 16

16 Where you think that the policy could have a negative impact on any of the equality group(s) i.e. it could disadvantage them, tick the Negative impact box. Where you think that the policy has no impact on any of the equality group(s) listed below i.e. it has no effect currently on equality groups, tick the No impact box. Equality Positive Negative No Reasons for decision Group Impact Impact Impact Age Yes All women in labour Disability Yes All women in labour Religion or belief Yes All women in labour Gender Yes All women in labour Transgender Yes All women in labour Pregnancy/ Yes All women in labour Maternity Race Yes All women in labour Sexual Orientation Marriage / Civil Partnership Yes Yes All women in labour All women in labour You will need to continue to a full Equality Impact Assessment if the following have been highlighted: A negative impact and No consultation (this excludes any policies which have been identified as not requiring consultation). 8. If there is no evidence that the policy promotes equality, equal opportunities or improved relations - could it be adapted so that it does? How? Full statement of commitment to policy of equal opportunities is included in the policy Please sign and date this form. Keep one copy and send a copy to Matron, Equality, Diversity and Human Rights, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Chyvean House, Penventinnie Lane, Truro, Cornwall, TR1 3LJ A summary of the results will be published on the Trust s web site. Signed Jan Clarkson Date 1 st September 2012 Page 16 of 16