Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode Fetal monitoring in labour, including: fetal blood sampling fetal scalp electrode (V1) (Supersedes - Fetal Monitoring: Intermittent Auscultation and Electronic Fetal Monitoring in antenatal period and in labour. Storage of Cardiotocographs. Normal Birth guidelines) Guideline Readership This guideline applies to all women booking within the Heart of England Foundation Trust, attending clinicians; obstetricians, midwives and specialist midwives. All care is tailored to individual patient needs alongside trust guidelines, incorporating the most up-to-date evidence for best practice. All information provided to the woman and her partner, should include an indepth discussion of the intended risks and benefits of either undergoing the procedure or declining intervention. Guideline Objectives This guideline aims to aid fetal heart auscultation and cardiotocography (CTG) interpretation. It is imperative that all midwives and obstetricians are able to recognise normal and abnormal features of the fetal heart rate (FHR) pattern, take timely appropriate action, including escalate to senior team members. The monitoring of the fetal heart rate (FHR) in labour aims to identify fetal hypoxia in adequate time to allow either: removal/amelioration of the hypoxic insult or delivery of the fetus, before hypoxic damage is sufficient to lead to long-term poor neurological outcome for the baby (NICE, 2007 & 2014). Other Guidance This guideline incorporates the National Institute for Clinical Excellence (NICE) Intrapartum Care guidelines (October 2007 and December 2014); the full 2014 guideline is available from: http://www.nice.org.uk/guidance/cg190/evidence/cg190-intrapartum-care-full-guideline3 RCOG and RCM recommendations are incorporated Please refer to full reference listing at end of guideline. Compliant with NICE 2014 Intrapartum Care. Ratified Date: 14 th October 2015 Effective from: 19 th November 2015 Review Date: 19 th November 2018 Guideline Author(s)/Reviewer(s): M. Umbers Clinical Guideline Midwife, Clinical Governance Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Contents and page numbers: 1. Flowcharts Flowchart 1 Indications for continuous CTG in labour 3 Flowchart 2 Continuous CTG classifications 4 Flowchart 3 Fetal Blood Sampling (FBS) 5 2. Executive summary and overview 6 3. Body of the Guideline Indications for continuous fetal monitoring 6 Low risk women 6 High risk women 6 Preterm labour 6 Epidural 7 Multiple pregnancies 7 Maternal information for continuous CTG 7 Methods of obtaining a continuous CTG in labour 7 Telemetry monitoring 7 Inadvertent recording of the maternal heart rate 7 Actions 8 Fetal scalp electrodes (FSE) 8 Consent for procedure 8 Contraindications for use of FSE 8 Risk to fetus 8 Description and classification of CTG traces (including classification sticker) 9 Ryle of 3 fetal bradycardia 10 CTG interpretation sticker for hourly assessment (example) DrCBraVADO 11 Assessment of CTG monitoring 11 Fresh eyes 11 Interpretation conflict 11 Management based on interpretation of CTG traces (Conservative management) 12 Conservative measures 13 Fetal scalp stimulation 13 Fetal blood sampling (FBS) 13 Cautions with maternal bleeding disorders 13 Absolute contraindications 13 Relative contraindications 14 Sources of error 14 Results classification 14 Expediting birth 14 Paired cord blood gases 14 Normal values for cord blood at delivery 15 Technique for collecting cord blood 15 Record keeping and risk management 15 Record keeping 15 Risk management 16 Retention and disposal of medical documentation 16 Live patient records 16 Deceased patient records 16 4. Reason for development of the Guideline 16 5. Methodology 16 6. Implementation in HEFT and community 16 Training 17 7. Monitoring and suggested quality standards 17 8. References 19 Appendices Appendix 1 Monitoring twins and triplets 20 Appendix 2 Definitions and descriptions of FHR traces 23 Appendix 3 Procedure for application of FSE 25 Appendix 4 Obtaining an FBS 26 Meta Data and Revision history 27 Page 2 of 27
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode 1. Flowcharts Flowchart 1- Indications for continuous cardiotocograph (CTG) in labour Indications for continuous CTG in labour Indications for continuous CTG from the onset of labour include the following: Intrapartum indications for changing from intermittent to continuous CTG monitoring Maternal risk factors: Previous caesarean section Induction or augmentation of labour Hypertension including chronic hypertension, pregnancy induced hypertension and pre-eclampsia Diabetes Type1, Type 2 and Gestational Obesity (BMI 35) Other maternal medical disease (Note: HIV per se is not an indication for CTG) Fetal risk factors: SGA or suspected IUGR (growth <10 th centile and/or slowing growth velocity) Abnormal liquor or Doppler's Decreased fetal movements within previous 24 hours and/or recurrent decreased movements Multiple pregnancy Prolonged rupture of membranes >24 hours before the onset of established labour Prematurity (<37+0 weeks gestation) Post maturity (>41+6 weeks gestation) Recurrent antepartum haemorrhage Abnormal lie or presentation This list is not exhaustive, if there is any doubt about method of monitoring, please discuss with a senior obstetrician. Any one of the following risk factors: Abnormal maternal observations temperature 38 C or 37.5 C on two occasions one hour apart, suspected sepsis or chorioamnionitis pulse >120 on two occasions 30 min apart Hypertension Systolic 160 and/or diastolic 110 mmhg on a single episode Systolic 140 and/or diastolic 90 on two consecutive readings 30 min apart ++ proteinuria with BP 140/90 on one occasion Bleeding fresh vaginal bleeding that develops in labour Oxytocin for induction or augmentation Significant meconium Abnormal Heart Rate heard on intermittent auscultation (baseline >160 bpm or <110 bpm, audible deceleration) Epidural analgesia Instrumental delivery Any two of the following risk factors (or any one plus any other risk factor): Ruptured membranes for 24 hours Moderate hypertension (150/100 to 159/109 mmhg) without proteinuria Delay in the first or second stage of labour (amniotomy alone is not an indication for CTG) Insignificant Meconium Pain reported by the woman that differs from the pain normally associated with contractions NB. If the only reason for consultant-led care is not one that increases the risk of fetal acidosis in labour (e.g. the risk of third stage or postnatal complications), a senior obstetrician may document that a woman is suitable for intermittent auscultation. For babies with a known fetal abnormality a plan regarding monitoring in labour should be documented by a consultant obstetrician. Adapted from NICE 2007 & 2014 Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode Flowchart 2 Continuous cardiotocograph (CTG) classifications Continuous CTG classifications Refer to full guideline for conservative measures Inform the woman that mobility will be restricted. If available, offer telemetry monitoring Hourly assessment of CTG required & fresh eyes minimum 2 hourly Consider using an FSE if a satisfactory trace cannot be achieved with an abdominal transducer Normal/Reassuring All 3 features reassuring: Baseline rate Variability Decelerations Normal/Reassuring CTG with oxytocin Continue with oxytocin until 4-5 contractions every 10 mins Reduce oxytocin if more than 5:10 Non-reassuring CTG 1 non-reassuring feature and 2 normal/reassuring and suggests need for conservative measures Non-reassuring CTG with oxytocin Continue with oxytocin until 4-5 contractions every 10 mins Abnormal CTG indicates need for conservative measures AND further testing (1 abnormal feature OR 2 nonreassuring features). Abnormal CTG with oxytocin Stop oxytocin. Full assessment by obstetrician before recommencing oxytocin. If hypercontractility consider 0.25mg terbutaline SC Continue CTG and normal care If CTG was started because of concerns arising from intermittent auscultation, remove CTG after 20 minutes if there are no non-reassuring or abnormal features and no on-going risk factors Offer to take an FBS (for lactate or ph) after implementing conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as a result of scalp stimulation Refer to flowchart 3 for interpretation of FBS Suspected fetal death with recordable trace assessment with real time ultrasound Adapted from NICE 2007 & 2014 Urgent intervention Abnormal CTG indicating need for further intervention Bradycardia or a single prolonged deceleration with baseline below 100bpm persisting for 3 minutes or more Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Flowchart 3 Fetal blood sampling (FBS), management of: Fetal Blood Sampling (FBS) FBS required Woman ideally in left lateral position Normal ph 7.25 Lactate 4.1 Repeat FBS within 1 hour if trace remains Abnormal / non-reassuring, or sooner if additional non-reassuring / abnormal features Action: conservative measures Borderline ph 7.21 7.24 Lactate 4.2 4.8 Repeat FBS within 30 minutes if trace remains Abnormal (if urgent intervention not required) Action: conservative measures Abnormal ph 7.20 Lactate 4.9 Inform Consultant and plan to expedite delivery (assisted delivery / CS) In the event that an FBS cannot be obtained discuss events with a consultant obstetrician. If the scalp stimulation results in accelerations, a decision should be made to continue with labour or expedite delivery in light of all clinical circumstances. If there is NO improvement in the CTG trace the birth should be expedited. Second FBS Normal ph 7.25 Borderline ph 7.21 7.24 CTG unchanged and FBS result stable; defer 3 rd / further FBS unless additional abnormalities on trace develop If 3 rd FBS considered Consultant opinion is required Additional considerations when to offering / undertaking an FBS: Inform the woman of ALL clinical decisions made and the rationale All FBS results should be interpreted against any previous lactate or ph measurement, the rate of progress in labour and any other maternal or fetal clinical features. Document the requirement and timing for repeat FBS, all results, and all discussions with consultant obstetrician and the mother clearly in maternal notes. Adapted from NICE 2007 & 2014 Page 5 of 27
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode 2. Executive Summary & Overview This guideline is a local adaptation of the National Institute for Health and Clinical Excellence (NICE) clinical guideline no 55 Intrapartum Care: Care of healthy women and their babies during childbirth. (NICE, 2007); and the most recent publication on Intrapartum care from NICE, Intrapartum care: care of healthy women and their babies during childbirth, CG190, issued December 2014. This guideline also incorporates guidelines from the: Royal College of Obstetricians and Gynaecologists (RCOG) and Royal College of Midwives (RCM). 3. Body of Guideline Indications for continuous fetal monitoring (refer to flowchart 1) Low risk women (refer to MLU guideline for further management):do not perform a CTG on admission for low risk women in suspected or established first stage of labour in any birth setting as part of the initial assessment. Auscultate the fetal heart (FH) at first contact, and at each further assessment using a Pinard or hand-held Doppler/Sonic Aid. Listen to the FH rate for a minimum of 1 minute immediately after a contraction, at least every 15 minutes in the first stage of labour and every 5 minutes during the second stage, recorded as a single rate. Record accelerations and decelerations if heard. During intermittent monitoring palpate the woman s pulse every 15 minutes to differentiate between the two heart rates. Offer CTG if intermittent auscultation indicates possible fetal heart rate abnormalities, and explain to the woman why this is necessary. Remove the CTG and return to intermittent auscultation if the trace is normal after 20 minutes, with no non-reassuring or abnormal features and no on-going risk factors. High risk women: All high-risk women should be offered continuous CTG monitoring in labour. Individual cases should be discussed with delivery suite co-ordinator and Registrar or Consultant and a management plan initiated. The woman s wishes should be taken into consideration and intended benefits of continuous CTG discussed with her. (NB. Refer to midwifery led care guidelines for reasons why transfer to Obstetric unit (OU) might be necessary). Preterm labour (spontaneous onset of labour before 37+0 weeks gestation) The normal fetal heart rate varies with vagal and sympathetic tone adjustments and therefore varies with gestational age due to maturation of fetal nervous system. CTG performed before 30 weeks should be interpreted with caution because of a physiologically higher baseline, lack of accelerations, lower variability and occurrence of sporadic deceleration. (Nicolaides et al 1989). Undertaking a CTG at earlier gestation prior to 28 weeks needs to be a Consultant decision. For women confirmed to be in established preterm labour care during Intrapartum fetal monitoring requires: The Consultant obstetrician for delivery suite should always be informed of any women admitted in preterm labour and a clear management plan documented relevant to the gestational age and consideration given to neonatal input. continuous CTG a low threshold for intervention some limitations to care i.e. the use of Fetal scalp electrodes/fetal blood sampling additional considerations as to choice of mode of delivery Also refer to the preterm guidelines on spontaneous rupture of membranes, antenatal fetal monitoring, preterm labour and magnesium sulphate for fetal neuroprotection. Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Epidural is accompanied by a more intensive level of monitoring and intravenous (IV) access, and so mobility may be reduced. NICE, 2007 & 2014, recommends continuous CTG for 30 minutes during establishment of regional analgesia and following a bolus of 10ml or more. If the choice of FHR monitoring prior to an epidural was intermittent, continuous monitoring should commence once the epidural is established, and continue throughout labour and delivery. During the epidural siting while the woman is in a flexed position there is a likelihood of picking up maternal pulse from the femoral artery. Therefore, if continuous FHR monitoring is already in progress and there are concerns regarding the FHR on the CTG trace prior to the epidural siting, as an alternative, the epidural may be able to be sited in a left-lateral position, this can be discussed with the anaesthetist prior to siting the epidural. Multiple pregnancies refer to appendix 1 Consider the use of USS to identify the two individual fetal hearts prior to commencing CTG. Maternal information for continuous CTG: Explain that continuous CTG is used to monitor the baby s heartbeat and the labour contractions Give details of the type of findings that may occur. Explain that a normal trace is reassuring and indicates that the baby is coping well with labour, but if the trace is not normal there is less certainty about the condition of the baby and further continuous monitoring will be advised. Explain the decisions about whether to take any further action will be based on an assessment of individual factors, including the findings from CTG. Methods of obtaining a continuous CTG in labour: (refer to appendix 2 for Definition and description of FHR traces) Every effort must be made to obtain a high-quality CTG trace, so that appropriate interpretation is possible. The FHR should always be auscultated with a Pinard or hand-held Doppler/Sonic Aid or visualised with an USS prior to commencing a CTG. Maternal heart rate (HR) should be recorded at the start of a CTG to avoid recording maternal HR in the case of intrauterine death (IUD). Two-lead ECGs linked to CTGs can be utilised, if available, to assist distinguishing between fetal and maternal HR's. An initial assessment of the CTG should be undertaken by the caring midwife within 15-20 minutes of commencement. Telemetry monitoring: - If available, offer telemetry monitoring to any woman who needs continuous CTG (NICE 2007 & 2014). Inadvertent recording of the maternal heart rate should be suspected in the following situations (example top of page 8): 1. Sudden shift in the baseline rate 2. Sudden improvement of a previously abnormal trace 3. Accelerations that coincide with the contractions especially in the second stage of labour 4. The CTG monitor identifies the possibility of maternal heart rate with a question mark on the FHR numeric display and printed on the CTG (see example below). Page 7 of 27
Actions: Check maternal pulse and pulse oximetery if available, or two lead ECG Attempt to locate the FH with sonic aid, pinard or USS Once fetal viability has been confirmed the quality of the CTG trace can be improved by repositioning the transducer or applying an FSE. Any concerns should be escalated immediately to the delivery suite co-ordinator and a senior obstetrician, SpR or Consultant level. Fetal scalp electrodes (FSE, refer to appendix 3 for procedure) Consent for procedure. Verbal consent must be obtained from the patient prior to applying an FSE; this should be recorded in the patient s healthcare records as this is a medical legal requirement. An FSE is used to provide a continuous CTG when a satisfactory trace cannot be obtained by an abdominal transducer. An internal fetal electrode is not definitive, as a fetus that is recently dead can conduct the maternal cardiac signals through its body to the electrode (RCOG, 2013). Contra-indications for use of Fetal Scalp Electrode: Maternal infection (e.g. HIV - FSE to be avoided if possible but not absolutely contraindicated. Potential increased risk of mother-to child transmission, more likely with detectable viraemia, refer to HIV guideline, hepatitis B & C infection). Fetal bleeding disorders (e.g. haemophilia, maternal Idiopathic thrombocytopenic purpura [ITP]) Malpresentation (e.g. face or shoulder) Gestational age less than 34+0 Risks to Fetus includes: infection (or rarely) penetrating injury could lead to meningitis, osteomyelitis or intracranial haemorrhage due to vascular injury. Page 8 of 27
Description & classification of CTG traces (adapted from NICE 2014): Do not make any decision about a woman s care in labour on the basis of CTG findings alone Take into account any antenatal and Intrapartum risk factors, the current wellbeing of the woman and unborn baby, and the progress of labour when interpreting the CTG trace NICE 2014 recommends that the midwife should remain with the woman at all times in order to continue providing one-to-one support during established labour. This trust aims to provide one-to-one midwifery care to all high risk women during established labour as a minimum standard. Ensure that the focus of care remains on the woman rather than the CTG trace Make a documented assessment of the condition of the woman and the unborn baby (including CTG findings) hourly, or more frequently with concerns. It is not possible to categorise or interpret every CTG trace; senior input in these cases is important. Decisions regarding a woman s care should not be based on CTG findings alone (NICE, 2014). (refer to flowchart 2 & appendix 1) A stable baseline value of 90-99 bpm with normal baseline variability (having confirmed that this is not the maternal heart rate) may be a normal variation; refer to senior obstetrician for opinion if uncertain (NICE, 2014). Describe any decelerations as early, variable or late. Page 9 of 27
Normal - all features to be classified as normal/reassuring. Non-reassuring - 1 non-reassuring feature and 2 normal/reassuring, suggests need for conservative measures. Combination of features that may be associated with increased risk of fetal acidosis; if accelerations are present, acidosis is unlikely. Record accelerations if heard. Refer to management based on interpretation of CTG traces. Abnormal and indicates need for conservative measures AND further testing 1 abnormal feature OR 2 non-reassuring features. Combination of features that is more likely to be associated with fetal acidosis. Refer to management based on interpretation of CTG traces. Abnormal and indicates need for URGENT INTERVENTION Bradycardia or a single prolonged deceleration with baseline below 100 beats/minute (bpm) persisting for 3 minutes or more*. An abnormal feature that is very likely to be associated with current fetal acidosis or imminent rapid development of fetal acidosis. Refer to management based on interpretation of CTG traces. *A stable baseline value of 90-99 bpm with normal baseline variability (having confirmed that it is not maternal heart rate) may be a normal variation. A significant shift in baseline rate and/or CTG pattern, consider potential causes with referral to registrar/consultant as appropriate. The following should be considered: uterine rupture, abruption, fetal haemorrhage, cord presentation/prolapse or maternal issues such as pyrexia or dehydration. NB. If a CTG cannot be categorised as normal at any time, a second opinion must be sought within 30 minutes and escalated for senior obstetric review. Rule of 3 fetal bradycardia: o 3 minutes call for help o 6 minutes move to theatre o 9 minutes - prepare for assisted delivery o 12 minutes aim to delivery the baby NB. The ph of the fetus has been shown to drop at the rate of 0.01 every 2-3 minutes (RCOG, 2013). Early decelerations: If early decelerations have persisted for above or equal to 90 minutes, seek a second opinion from a senior obstetrician. Page 10 of 27
CTG interpretation sticker for hourly assessment - Dr C Bravado mnemonic (example): (DrCBraVADO adapted from Advanced Life Support in Obstetrics [ALSO]) Assessment of CTG monitoring: to be undertaken hourly and a plan of care documented in the maternal notes, including any conservative measures and any increase in frequency of assessment. CTG interpretation stickers are available to aid documentation/description and classification of CTG findings. Fresh eyes - A fresh eyes approach involves a review of the CTG trace irrespective of hourly CTG classification. Fresh eyes aims to minimise human oversight in misinterpretation or questionable classification of CTG traces; therefore a fresh eyes review of the CTG trace is to be undertaken regularly by a midwife/obstetrician (someone other than the caring midwife) within a minimum period of 2 hours from the previous fresh eyes interpretation, or sooner if there are other indications. Interpretation conflict: in the event of a disagreement regarding CTG classification, the Consultant on for Delivery suite or on call should be requested to review the CTG trace and their decision/classification is final. Escalating to a Consultant can be undertaken by any staff member at any time. NB. Junior doctors MUST NOT be requested to review a CTG. ONLY ST3 or above. Page 11 of 27
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode Management based on interpretation of CTG traces (NICE, 2014) Management of non-reassuring or abnormal CTGs may include conservative measures, further testing or delivery. Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode Conservative measures: (refer to management table) if concerns are raised about fetal wellbeing, consider the possible underlying causes and starts 1 or more conservative measures based on an assessment of the most likely cause(s), and inform the midwifery coordinator and an obstetrician when these measures have been implemented. Do not use maternal facial oxygen therapy for intrauterine fetal resuscitation, because it may harm the baby (but it can be used where it is administered for maternal indications such as hypoxia or as part of pre-oxygenation before a potential anaesthetic). Also, amnioinfusion should not be offered for fetal resuscitation. Fetal scalp stimulation: if the FHR responds to scalp stimulation (accelerates) regard this as a reassuring feature. This response can elicit information about fetal wellbeing if FBS is unsuccessful or contraindicated (see below for contraindications to FBS). Take this into account when reviewing the whole clinical picture. Fetal blood sampling (FBS) (refer to Flowchart 3 & appendix 4 for procedure) If a CTG is classified as abnormal but urgent intervention is not required, confirmation of fetal well-being should be obtained through an FBS where possible. Electronic fetal monitoring without supporting FBS in suspected fetal distress in labour is associated with significant increase in caesarean delivery with no apparent improvement in neonatal outcome. If the FBS result is normal, labour may be allowed to continue with an appropriate management plan in place for subsequent testing. Timing the commencement of any subsequent test should take into account the time required to obtain the sample (on average 18 minutes). If an FBS cannot be obtained due to technical difficulties or contraindications, consider delivery; this must be discussed with a consultant obstetrician. Urgency to deliver should take into account the severity of the CTG abnormality and relevant maternal factors. If there is clear evidence of acute fetal or maternal compromise an FBS should not be undertaken and urgent preparations to expedite birth should be made. FBS, cautions with maternal bleeding disorders: Type 1 Von Willebrand disease (VWD) sampling is acceptable Idiopathic Thrombocytopenia Purpura (ITP) sampling is acceptable providing previous children did not have low platelet counts immediately following birth For other cases of VWD or ITP in first pregnancy or previous children born with thrombocytopenia, do not undertake FBS without discussion with Consultant obstetrician and Consultant haematologist. Absolute contraindications to FBS include: Where there is clear evidence of acute fetal compromise (e.g. prolonged deceleration) FBS should not be taken and baby should be delivered urgently. Maternal infection with Human Immunodeficiency virus (HIV), Hepatitis C, Hepatitis B (as FBS increases transmission to the baby). Fetal bleeding disorders (e.g. haemophilia) Prematurity (less than 34+0 weeks) Face presentation or uncertain presenting part Absolute contraindications continued Paper Copies of this Document If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
If a fetus is in a breech presentation during labour and is exhibiting signs of fetal compromise that are not readily remediable, it would be more appropriate to deliver that baby by caesarean section than to undertake fetal blood sampling (RANZCOG, 2014, Good practice note) *Group B Streptococcus carrier status does not preclude FBS (RANZCOG, 2014. Good practice note & RCOG query bank) Relative contraindications (discuss with Consultant Obstetrician) Gestation range 34 weeks to 36 weeks and 6 days Maternal pyrexia above 38 0 C Suspected or confirmed intrauterine sepsis (to discuss with Consultant if concerns are raised) Sources of Error Contamination with amniotic fluid (error in ph value) Contamination with meconium ( or ph value) Presence of air bubbles ( ph value) Fetal scalp oedema or caput ( ph value) Delay in processing ( ph value) Classify results as per tables below: Lactate (mmol/l) ph Interpretation 4.1 7.25 Normal 4.2 4.8 7.21 7.24 Borderline Pre-acidotic range 4.9 7.20 Abnormal Acidotic range NB. If blood gas analysis machines available to undertake lactate then this action must be undertaken. If the result seems completely out of keeping with the full clinical picture (lactate/ph either lower or higher than expected) this needs to be discussed with the Consultant Obstetrician. All FBS results should be interpreted against any previous lactate or ph measurement, the rate of progress in labour and any other maternal or fetal clinical features. Document the requirement and timing for repeat FBS, all results, and all discussions with consultant obstetrician and the mother clearly in maternal notes. Expediting birth, assessment of baby and woman to include: Degree of urgency (inform the team) Abdominal & VE findings Location (transfer as necessary) Anaesthetic requirements Women s preferences and options Choice of mode of delivery, anticipating any difficulties Record the time at which the decision is made to expedite birth and the management plan. Refer to assisted delivery or caesarean section guideline for further information. Paired cord blood gases: (arterial and venous) are not taken routinely but should always be obtained when there has been concern about the baby either in the Intrapartum period or immediately following birth. This includes: ALL assisted deliveries (ventouse/forceps) ALL caesarean sections In the presence of significant/particular meconium stained liquor When fetal blood sampling (FBS) has been performed during labour Following an abnormal CTG trace Page 14 of 27
Babies delivered at less than 36 weeks gestation Complex delivery i.e. shoulder dystocia, breech Prolonged second stage (greater than 1 hour in multip and 2 hours in a primip) When a baby requires more than basic resuscitation, resulting in a low Apgar When a baby is admitted to neonatal unit soon after birth The person delivering the baby is responsible for ensuring that paired umbilical cord samples for cord gases are obtained, analysed and clearly documented. Cord gases should be analysed within 60 minutes of obtaining, if any delays in analysis occur this must be noted in the delivery records. Normal values for cord blood at delivery ph P02 pco 2 Base Deficit Mean Arterial ± ISD 7.26 ± 0.1 (7.16 7.36) 21 ± 8 (13 29) 53 ± 13 (40 66) 4.5 ± 3.6 (0.9 8.1) Mean Venous ± ISD 7.31 ± 0.06 (7.25 7.37) 30 ± 7.5 (22.5 37.5) 42 ± 9 (33 51) 4.0 ± 2.7 (1.3 6.7) Assessment of the acid-base status of umbilical cord blood at birth provides an objective and reliable measure of the fetal response to labour. The Apgar score which is subjective usually assigned retrospectively and is influenced by many factors other than hypoxia during labour. The presence of an arterial metabolic acidosis will identify those babies who have experienced significant oxygen deficit prior to delivery, and who therefore may be at risk of neonatal problems such as hypoglycaemia. It is also useful information to have when counselling parents of babies who encounter problems in the neonatal period. It provides an objective tool for the audit of intrapartum care and for risk management. Technique for collecting cord blood: Clamp a minimum 20cm segment of cord using 2 pairs of forceps. Apply the clamp nearest the baby first and allow blood from the placenta to fill the cord vessels before applying further clamps. (This will ensure that an adequate amount of blood is trapped in the clamped section of cord.) Collect blood into pre-heparinised syringe and analyse as soon as possible. Use 21G (green) needles to extract sample, slowly withdrawing the hypodermic needle. Blood from the artery should be taken first. The umbilical vein is a single bulging thin walled vessel while the arteries are narrow and more tortuous. Cord ph are to be printed and documented in the hospital notes/maternity information system (MIS) NB: The sample should be obtained and analysed within 60 minutes of delivery. Record keeping and risk management Record Keeping To ensure accurate record keeping for cardiotocography: make sure that date and time clocks on the cardiotocograph monitor are set correctly Document the mother s name, date, time, hospital number and maternal pulse at the start of monitoring enter this information either electronically or document on the actual CTG paper. Page 15 of 27
Intrapartum events that may affect a CTG should be recorded on the CTG paper and in the medical records e.g. vaginal examination, fetal blood sample, epidural siting. Sign, date and time these entries. Staff providing an opinion on the CTG should complete a CTG interpretation sticker in the medical records, and sign the CTG paper including the date and time that they reviewed. Following birth, sign the CTG and record the date, time and mode of delivery, or if the trace discontinued at any time prior to delivery. Storage of traces: all CTGs should be folded in sequence and securely stored in date order in an identifiable CTG envelope, and placed within the medical files. Ensure that the patient s name and hospital number (or personal ID label) is on the envelope. Risk Management CTG traces should be retained for 25 years; where possible store electronically If the baby is at risk of suffering developmental delay, photocopy/scan the CTG and the medical records and store indefinitely in case of possible adverse outcomes Use tracer systems if CTG traces are stored separately from women s records; ensure system can locate traces removed e.g. for teaching. Safe storage of CTGs is a legal requirement. Retention and disposal of medical documentation Retention periods are calculated from the end of the calendar year and from the date of the patient s last attendance to the trust. Live patient records Obstetric retained for a period of 25 years from date of last obstetric attendance Children and young people until the patients 25 th birthday, or 26 th birthday if the young person was aged 17 years at conclusion of treatment Deceased patient records Stillbirth 25 years Children and young people under 18 years (exc. Stillbirth) 8 years from date of death Obstetric records 8 years from date of death 4. Reason for Development of the Guideline The guideline provides information to all clinicians as to the recommendations for fetal monitoring during when labour is considered established, during the intrapartum period. 5. Methodology Development of all guidelines adheres to a process of examining the best available evidence relevant to the topic, incorporating guidance and recommendations from national and international reports. Finalised guidelines will ultimately be approved and ratified by the Obstetrics and Gynaecology Guideline Group and minuted at clinical Directorate as ratified. 6. Implementation in HEFT & Community Following approval the guideline will be disseminated and available for reference to all members of the multidisciplinary team via the Trust and Obstetric intranet site; also paper copies will be stored in a marked folder within a designated clinical area. Page 16 of 27
Training Relevant and on-going training to ensure competence in auscultation and interpretation of CTGs will be multidisciplinary and defined in the Training Needs Analysis (TNA). Midwives and obstetric medical staff caring for women are to attend six-monthly mandatory in-house training as a minimal requirement. This will be supplemented by CTG case discussions presented at clinical risk review meetings, individual teaching, SHO teaching, labour ward meetings, audit and perinatal mortality meetings. Actual anonymised CTG s from cases are used for training so that lessons can be learnt 7. Monitoring & Suggested Quality Standards Adherence to the clinical guideline will be monitored through regular clinical audit. Auditing of a clinical guideline will be multidisciplinary, allocated and overseen by the Clinical Audit Lead. Element to be monitored Tool Frequency Minimum requirements: Low-risk women transferring to OU/high-risk care, rationale for change of pathway Auscultation Documentation of: Equipment used Palpation and documentation of the maternal pulse When to auscultate the fetal heart in the first and second stage of labour and length of auscultation When to transfer from intermittent to continuous CTG monitoring Continuous (CTG) Date and time checked on CTG machines When to monitor in labour Hourly systematic assessment of trace to include: o Baseline rate o Baseline rate variability o Accelerations o Decelerations Actions taken in the event of abnormal/non-reassuring CTG, conservative management +/- expediting delivery or CS Intrapartum notes and/or maternity information system CTGs Training Database and Training Reports Proforma Auscultation Annual review of 1% or 10 sets (whichever the greater) of all health records of women who have delivered and needed to be transferred from intermittent to continuous fetal monitoring during labour. Continuous (CTG) Annual review of 1% or 10 sets of all health records (whichever the greater) of women who have delivered. Annual review of 1% or 10 sets of all health records (whichever the greater) of women who have delivered in whom the tracing was assessed as abnormal/nonreassuring FBS Annual review of 1% or 10 sets of all health records (whichever the greater) of women who have delivered in whom fetal blood sampling and paired cord sampling has been undertaken. Page 17 of 27
Documentation on CTG Woman s name, date, time and hospital number Maternal pulse Any intrapartum event (recorded at the time of event) signed and time noted Any opinion to be recorded on trace and health records including time and signature On completion of trace to include: time, date, name & signature of person and reason trace ended Annual review of 1% or 10 sets of all health records (whichever the greater) of women who have delivered in whom paired cord sampling only has been undertaken, when there has been concern about the baby either in labour or immediately following birth. Fetal blood sampling (FBS) Details of when FBS to be undertaken and documentation in health records Timings and requirement for repeated FBS & documentation Referral to the consultant where a 3 rd FBS is considered When paired cord samples should be taken & documentation in maternity records Reporting arrangements The completed reports will go to the clinical governance group and be presented at the departmental audit meetings. Action plans will be documented in minutes. Acting on recommendations and lead(s) The clinical audit leads will use the electronic tracker system for audit to track action plans, which will have stated time frames Change in practice and lessons to be shared Required changes to practice will be identified and actioned within a specific time frame. A lead member of the team will be identified to take each change forward where appropriate. Lessons will be shared with all the relevant stakeholders Non-compliance to actions from audit will be escalated to the Directorate governance meetings; further noncompliance will be finally escalated to the Women s and Children s Quality and Safety for resolution. Interpretation of CTG s that have been highlighted as cases of interest will be monitored through regular clinical discussion at specific meetings. Relevant action plans in response to lessons learnt from past cases will be implemented as necessary. Professional updates in CTG interpretation will take place during mandatory training for obstetric staff. A quarterly training report is presented at the Obstetric and Gynaecology Governance meeting. Following clinical audit of a guideline an addendum to change in clinical practice may be necessary. Any change to a clinical guideline requires that it must be ratified by the directorate locally. Review dates for guidelines will be set at a period of three years; however this set period can be overridden in light of new clinical evidence. All unused/previous guidelines will be logged and archived electronically, and in paper format within the Trust. Page 18 of 27
8. References Additional Information Regarding Ultrasound Fetal Monitoring English. This addendum provides additional information for all Avalon FM20/FM30/FM40/FM50 Fetal Monitor Instructions for Use, regarding Ultrasound Fetal Monitoring Available from: https://www.swissmedic.ch/recalllists_dl/02848/vk_20091223_05-e2.pdf Confidential Enquiry into Stillbirths and Deaths in Infancy 7 th Annual Report (2000). Maternal and Child Health Research Consortium: London Cross Health Care Boundaries Maternity Clinical Guideline, Methods and interpretation of Antenatal fetal heart rate monitoring (Nottingham University Hospitals NHS trust). Available from: clinicalguidelines@nuh.nhs.uk Daly N, Brennan D, Foley M, O Herlihy C. (2011) Cardiotocography as a predictor of fetal outcome in women presenting with reduced fetal movements. Eur J Obstet Gynecol Reprod Biol. 2011 Nov; 159(1):57-61. Firzpatrick, T., Holt, L. (2008) A Buddy approach to CTG. The Royal College of Midwives Journal. Oct/Nov p40-41 Freeman, R. K. (Editor), Garite, T. J. (Editor), Nageotte, M. P. (Editor), Miller, L. A. (2012) Fetal heart rate monitoring. Journal of Obstetrics and Gynaecology Canada (JOGC) (2007) Fetal heart surveillance: Antepartum and Intrapartum consensus Guideline No 197, September 2007 K2 Medical fetal monitoring training system (2014): mandatory training. National Health Service (NHS) Quality Improvement Scotland. (2009) Pathways for maternity care. Available from: www.healthcareimprovementscotland.org/programmes/reproductive,_maternal child/programme_resource s/keeping_childbirth_natural.aspx National Institute for Clinical Excellence (NICE) (2003) Antenatal Care. Routine Antenatal care for the healthy pregnant woman. Clinical Guideline number: 6 [Online]. Available from: http://www.nice.org.uk Accessed 20 th September 2007 National Institute for Clinical Excellence (NICE) (2007) Intrapartum Care. Care of healthy women and their babies during childbirth [Online]. Available from: http://www.nice.org.uk Accessed October 2007 National Institute for health and care excellence (NICE) (2014) Intrapartum care: care of healthy women and their babies during childbirth, CG190, issued December 2014. Available from: www.nice.org.uk/cg190 National Perinatal Epidemiology Unit (NPEU) (2014) Saving lives, improving mothers care. Lessons learned to inform future maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009-2012. Available from: www.npeu.ox.acuk/mbrrace-uk Nicolaides, K.H.; Sadovsky, G. and Visser, G.H. (1989) Heart rate patterns in normoxaemic, hypoxaemic and anemic second-trimester fetuses. Am J Obstet Gynecol. May; 160 (5 Pt 1): p.1034-7 Nursing & Midwifery council (NMC) (2004) Midwives Rules and Standards. NMC: London Nursing & Midwifery council (NMC) (2015) The Code. Professional standards of practice and behaviour for nurses and midwives. NMC: London Royal College of Anaesthetists, Royal College of Midwives, Royal College of Obstetricians and Gynaecologists, Royal College of Paediatrics and Child Health. (2007). Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. London: RCOG Press. Available at: www.rcog.org.uk Royal College of Midwives. (2008). Midwifery Practice Guideline Fetal Heart Rate Monitoring. London: RCM. Available at: www.rcm.org.uk Royal College of Obstetricians and Gynaecologists (RCOG) (2001) The use of electronic fetal monitoring. Inherited Clinical Guideline. National Institute for Clinical Excellence. RCOG Press: London Royal College of Obstetricians and Gynaecologists (RCOG) (2001) The use of Electronic Fetal monitoring. Evidence Based Guideline Number 8. Clinical Effectiveness Support Unit. RCOG press RCOG (2013) StratOG is an educational resource developed by the Royal College of Obstetricians and Gynaecologists (RCOG). https://stratog.rcog.org.uk/tutorial/obstetrics/ctg-interpretation-and-furthermanagement-6354 Symon AG, McStea B, Murphy-Black T. (2006) An exploratory mixed-methods study of Scottish midwives understandings and perceptions of clinical near misses in maternity care. Midwifery 22(2): 125-36. The Royal Australian and New Zealand College of Obsetricians and Gynaecologists (RANZCOG) (2014) Intrapartum fetal surveillance. Clinical Guideline Third Edition 2014. Approved 21 st March 2014. www.ranzcog.ed.au Page 19 of 27
Clinical Guideline for the Management of fetal monitoring in labour, including: fetal blood sampling & fetal scalp electrode Paper Copies of this Document Appendices Appendix 1 - Monitoring twins & triplets: Monitoring twins (multiple pregnancies, for further detailed information refer to relevant monitor manual) NB. 2 separate CTG interpretation stickers are required to record each fetus, clearly marked stating relevant fetus. It is also advised to mark the abdominal transducers with each fetus. You can monitor twin FHRs externally using two ultrasound transducers. It is not possible to monitor twins eternally using cordless ultrasound transducers. Following rupture of membranes (ROM) one twin (cephalic presentation ONLY) can be monitored internally via direct ECG (DECG) and the other externally using ultrasound. The procedures and any contraindications that apply for twins monitoring also apply for monitoring triplets. In addition, when monitoring triplets: Be aware that monitoring three (3) FHRs is inherently more difficult than monitoring single or twin FHRs. The nature of the application increases the likelihood that a FHR is monitored by more than one transducer. Ensure three (3) different heart rates are being recorded. Pay attention to any coincidence of heart rates detected by the monitors CCV feature. If two or more heart rates coincide check the trace, and if necessary, reposition the ultrasound transducers as appropriate to detect all the FHRs correctly. If necessary, identify the FHRs using independent means, such as a fetoscope, stethoscope, or Pinard stethoscope. Important considerations: FHR measurements are labelled in the order in which the transducers are plugged in, regardless of which fetal sensor socket is used i.e. the first transducer you connect is automatically allocated to a channel, and the measurement is labelled FHR1, the second is FHR2, and so on. If the transducers are disconnected temporarily reconnection should be in the same order as originally connected to make sure the measurement labels remain consistent. The blue transducer finder LED identifies which transducer is monitoring which heart rate channel. The trace recorded for FHR1 is thicker (darker) than FHR2. Remember that only one (1) fetal heartbeat can be heard from the loudspeaker at any time. The audio symbol shows which fetus you are listening to. Separating the traces: Separated by an offset of 20bpm by switching trace separation on. Switching trace separation ON and OFF Connect transducers to the monitor to measure FHR Enter the Main Setup menu by pressing the Main Setup Select Fetal Recorder Select Trace Separation to toggle between ON and OFF Exit the Main Setup menu Determining the separation order (when trace separation is ON): Enter the Main Setup menu by pressing the Main Setup Smartkey If you are reading a printed copy of this document you should check the Trust s Guideline website to ensure that you are using the most current version.
Select Fetal Recorder Select Separation Order to toggle between Standard and Classic o Standard: the FHR2 trace is shifted up by 20 bpm (it is recorded 20 bpm higher than it really is). No offset is ever applied to the FHR1 trace it stays where it is. (In the case of a third FHR, this is shifted down by 20 bpm). o Classic: the FHR1 trace is shifted up by 20 bpm when there is more than one FHR measurement. No offset is ever applied to the FHR2 trace it stays where it is. (In the case of a third FHR, this is shifted down by 20 bpm). Exit the Main Setup menu When the trace separation is ON, the recorder prints a dotted line labelled with the FHRs at the top and ± 20 at the bottom. When the trace separation is OFF, a dotted line labelled +0 prints across the FHR scale. Examples when the maternal heart rate can be misidentified as the FHR - When using an ultrasound transducer: Possible to pick up maternal signal sources, such as the aorta or other large vessels Misidentification can occur if maternal heart rate higher than normal When using an FSE: Electrical impulses from the maternal heart rate can sometimes be transmitted to the monitor through a recently deceased fetus via the spiral FSE cable, appearing to be a fetal signal source The recorded maternal heart rate (or any artefact) can be misinterpreted as a FHR (especially when over 100 bpm) Monitoring triplets: If the monitor is equipped with the triplet option it carries the label. Procedures and any contra-indications that apply for twins monitoring also apply for monitoring triplets, including: Monitoring three (3) FHRs is inherently more difficult than monitoring single or twin FHRs. The nature of the application increases the likelihood that a FHR is monitored by more than one transducer The CCV feature alerts if two or more heart rates coincide (if two or more transducers are recording the same FHR or maternal heart rate). The trace recorded for the FHR3 is thicker (darker) than for FHR1, which is thicker than that for FHR2. Thickness of recording can be changed in configuration mode. Only one (1) fetal heartbeat can be heard at any one time. The audio symbol indicates the fetus being listened too. Refer to signal quality indicators for best recording, and reposition transducers as necessary. Separating the traces: the trace for FHR2 is offset by +20 bpm, and the trace for FHR3 is offset by -20 bpm. In other words the trace for FHR2 is recorded 20 bpm higher than it really is, while the trace for FHR3 is recorded 20 bpm lower than it really is. FHR1 is never shifted. The recorder is annotated and prints a dotted line labelled +20 across the FHR scale to identify FHR2 The recorder is annotated and prints a dotted line labelled -20 across the FHR scale for FHR3 Page 21 of 27