NHS Borders clinical guidelines
IA Intermittent Auscultation
CTG Cardiotocograph
EFM Electronic Fetal Monitoring
FHR Fetal Heart Rate
ARM Artificial Rupture of Membranes
PROM Prolonged Rupture of Membranes
Fetal Monitoring Guideline
Warning
Scope
The purpose of this policy is to give guidance to staff on the monitoring of the fetal heart in the antenatal and intrapartum period.
The most appropriate form of monitoring should be discussed with the woman to enable the woman to make informed choices regarding the method of monitoring the fetal heart. Due consideration must be given to maternal preference in addition to risk factors for both mother and baby. If a woman declines the recommended method of fetal monitoring the discussion and outcome should be documented in the clinical record.
Introduction
Electronic Fetal Monitoring (EFM) with a cardiotocograph (CTG) should be the preferred and recommended method of monitoring of the fetal heart in labour for high-risk women. Intermittent Auscultation (IA) with a Doppler device or Pinard stethoscope should be the preferred and recommended method of monitoring of the fetal heart in labour for low risk women. This document is based on the recommendations of the National Institute for Health and Care Excellence guideline NG229 (published Dec 2022).
Qualified professionals should receive annual training on the interpretation and documentation relating to fetal monitoring.
The on call Consultant Obstetrician holds overall responsibility of the high risk woman. The on call Obstetric Registrar is responsible for the clinical management of the high risk woman, escalating any concerns to the Consultant Obstetrician for an opinion or consultation. The Consultant Obstetrician is required to attend in person if requested by the Registrar or Senior Midwife.
The Senior Midwife in charge of labour ward is responsible for having an awareness or the management and progress of all women on labour ward, prioritising concerns identified by midwives and escalating appropriately to the on-call Registrar or Consultant Obstetrician.
The midwife is responsible for the care of the antenatal or labouring woman, escalating any concerns to the Senior Midwife or Registrar where appropriate.
A CTG can be reviewed remotely on Badgernet only on an NHS Borders computer but must not be shared on any social media platform or by mobile device. An image of the CTG, even if no identifiable information is present, must also never be shared on a social media platform or by mobile device.
Face to face review by consultant Obstetrician is indicated if
- Requested by the Obstetric registrar
- Requested by the senior midwife in charge of labour ward
- For all preterm women with a pathological CTG
Complete a CTG label and attach at commencement of the CTG. Link CTG on Badgernet. When the CTG is discontinued complete a CTG review on Badgernet and have a CTG peer review completed by a colleague.
The appropriate method of fetal monitoring will be dictated by the maternal and fetal risk factors identified and a thorough assessment of the woman’s medical and obstetric history should be taken. The NICE guidelines (NICE Dec 2022) should be used to aid assessment of risk factors which necessitate continuous monitoring
The Intrapartum Risk Assessment on Badgernet indicates the appropriate method of fetal monitoring. Complete a CTG label upon commencement of the CTG.
1 Admission of Low Risk woman in Labour
For women categorised as ‘Low Risk’ with an uncomplicated pregnancy, current evidence does not support the use of an admission CTG or EFM and it is therefore not recommended (NICE 2022). However, risk assessment is a continual process, and women should be advised that the method of fetal heart rate monitoring may change throughout the course of labour.
During the initial assessment the fetal heart should be auscultated for a minimum of one minute immediately after a contraction and recorded as a single rate. The maternal pulse must be palpated to differentiate between maternal and fetal heart rate and recorded as part of a full set of maternal observations.
If a CTG had been commenced due to concerns from intermittent auscultation but there are no abnormal or non-reassuring features on the CTG, then the CTG can be discontinued after 30 minutes and return to intermittent auscultation.
In the 1st stage of labour the fetal heart should be auscultated after a contraction for at least a minute, every 15 minutes and documented in a labour assessment on Badgernet.
In the 2nd stage of labour the fetal heart should be auscultated after a contraction for at least a minute every 5 minutes and documented in a labour assessment on Badgernet or on paper records.
The maternal pulse should be palpated hourly throughout labour and documented in a labour assessment on Badgernet. If a fetal heart rate abnormality is detected, the maternal pulse should be palpated to differentiate the maternal and fetal heart rates.
2 Intrapartum indications to transfer from intermittent auscultation to continuous EFM
Base any decisions about moving to EFM from IA on clinical findings and discuss your recommendations with the woman and her birth partner.
Be aware intrapartum risk factors may increase the risk of fetal compromise, and that intrapartum risk factors that develop as labour progresses are particularly concerning. Staff should use the fetal monitoring risk assessment on Badgernet
Indications to offer transfer from IA to continuous fetal monitoring:
- Contractions that last longer than 2 minutes, or 5 or more contractions in 10 minutes
- Maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart
- Severe hypertension (a single reading systolic of 160mmHg or more or diastolic of 110mmHg or more, measured between contractions.
- Hypertension – either systolic of 140mmHg or more or diastolic 90mmHg or more on 2 consecutive readings taken 30 minutes apart.
- A reading of 2+ of protein on urinalysis and a single reading of BP systolic greater than 140mmHg or diastolic greater than 90mmHg, temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
- suspected chorioamnionitis or sepsis
- Pain reported by the woman that differs from the pain normally associated with contractions
- Meconium stained liquor
- Fresh vaginal bleeding
- Blood stained liquor not associated with vaginal examination
- Use of oxytocin
- Epidural analgesia
- Confirmed delay in first or second stage of labour
- Consider continuous fetal monitoring if based on clinical assessment and multidisciplinary review, there are concerns about other intrapartum factors not listed above that may lead to fetal compromise
3 Antenatal indications for continuous fetal monitoring in labour
The NICE guidelines recommend continuous EFM for high risk women when in active labour;
Maternal Risk Factors
- If it is in their personalised care plan to have continuous fetal monitoring
- Previous Caesarean section or other full thickness uterine scar
- Any hypertensive disorder needing medication
- Prolonged rupture of membranes >24hrs
- Antepartum haemorrhage
- Type 1 or 2 Diabetes or GDM requiring medication
Fetal Risk Factors
- Non cephalic presentation ( breech, transverse, oblique and cord)
- EFW < 3rd centile)
- SGA (EFW <10th centile) other risk factors eg. Abnormal doppler, reduced LV or reduced growth velocity.
- > 42 weeks at onset of labour
- Oligohydramnious or polyhydramnious
- Reduced fetal movements in the 24 hours before onset of labour
- < 37 weeks
Attach a CTG label at commencement of the CTG. Record the maternal pulse at commencement of EFM and hourly during labour.
Link the CTG to the record on BadgerNet.
Complete a CTG review hourly on BadgerNet and have a peer review completed by a colleague.
If there are concerning features on a CTG escalate to the labour ward co-ordinator without delay.
Mark significant intrapartum events on the CTG using the ‘CTG comments’ note on BadgerNet or by marking the CTG paper e.g;
- Analgesia
- Augmentation
- Pyrexia
- Position change
- FSE application
- Epidural
If the quality of the CTG recording is unsatisfactory adjust the tocograph or transducer. If necessary apply a FSE with maternal consent to ensure accurate recording of the fetal heart. Please note that use of a FSE is contraindicated in the following circumstances;
- < 34+0 weeks gestation
- Malpresentation
- Placenta Praevia
- Excessive vaginal bleeding
- Genital infection (Herpes, gonorrhoea)
- Blood borne virus (Hep B, HIV, Hep C)
4 Interpretation of the CTG
Make a documented systematic assessment of the condition of the woman and unborn baby (including cardiotocography [CTG] findings) every hour, or more frequently if there are concerns.
Do not make any decision about a woman's care in labour based on CTG findings alone.
Take into account the woman's preferences, any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby and the progress of labour. Ensure that the focus of care remains on the woman rather than the CTG trace.
Remain with the woman in order to continue providing one-to-one support.
Talk to the woman and her birth companion(s) about what is happening and take her preferences into account.
Principles for intrapartum CTG trace interpretation
When reviewing the CTG trace, categorise the 4 features of the CTG trace (contractions, baseline fetal heart rate; variability and decelerations) as WHITE, AMBER or RED – indicating levels of concern.
Categorise CTG traces as –
- NORMAL – no amber or red features (all 4 features are white)
- SUSPICIOUS – any 1 feature is amber
- PATHOLOGICAL – any 1 feature is red or 2 or more features are amber.
If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low. If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician.
Accelerations
The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy
| White | Amber | Red | |
| Contractions | < 5 | 5 or more in 10 mins Hypertonus | |
| Baseline compare with earlier traces |
Stable 110-160bpm Lower rate expected with post term and higher rate in preterm pregnancies |
Increase of 20 or more 100-109bpm (continue usual care if this has been stable throughout labour and there is normal variability and no variable or late decels) Unable to determine |
< 100bpm >160bpm Increase of 20 beats in 2nd Stage |
| Variability | 5 to 25bpm | <5 for 30-50mins >25 for up to 10 mins |
<5 for 50mins >25 for 10mins or more Sinusoidal |
| Decelerations | No decels Early Decels Variable with no concerning features |
Repetitive variable with concerning features <30 mins Late Decels <30mins |
Repetitive variable * with concerning features >30mins Late decels >30mins Bradycardia |
Regard the following as concerning characteristics of variable decelerations:
- lasting more than 60 seconds
- reduced baseline variability within the deceleration
- failure to return to baseline
- Loss of previously present shouldering
5 Management based on interpretation of CTG
| Category | Definition | Management |
Normal |
No amber or red features (all 4 features are white) |
|
|
Suspicious |
1 amber feature |
If no other concerning features –
If there are additional intrapartum risk factors such as slow progress, sepsis or meconium;
|
|
Pathological |
1 abnormal feature OR 2 non-reassuring features |
|
|
Need for urgent intervention |
Acute bradycardia, or a single prolonged deceleration for 3 minutes or more |
|
|
* If there are any concerns about the baby's wellbeing, be aware of the possible underlying causes and start one or more of the following conservative measures based on an assessment of the most likely cause(s):
|
||
6 Fetal scalp stimulation
If the cardiotocograph trace is suspicious, offer digital fetal scalp stimulation. If this leads to an acceleration in fetal heart rate and a sustained improvement in the CTG trace, continue to monitor the fetal heart rate and clinical picture. Absence of an acceleration in response to fetal scalp stimulation is a worrying sign that fetal compromise may be present, and plan to expedite delivery should be considered. Fetal blood sampling is not currently recommended.
NICE guidelines recommend that paired cord blood samples are taken (arterial and venous). Cord blood gas analysis should be performed after every delivery and the results must be recorded on BadgerNet. The cord must be double clamped and analysed within 30 minutes. Document the length of time of deferred cord clamping (DCC) as this does affect the pH.
Antenatal CTGs should be filed on the standard mount sheet in the maternity case notes. Intrapartum CTGs should be stored in the CTG envelope in the maternity case notes. CTG traces are kept for a minimum of 25 years. The CTG forms part of the BadgerNet maternity record.