SDMS ID: P2010/0486-001 2.

3/09WACS Title: Replaces: Description: Target Audience: Key Words: Policy Supported: P2010/0495-001 Fetal Scalp Electrode Application P2010/0494-001 Fetal Blood Sampling P2010/0528-001 Uterine Hyperstimulation Purpose: The aim of intrapartum fetal surveillance is to prevent adverse perinatal outcomes arising from fetal metabolic acidosis/cerebral hypoxia related to labour. Surveillance during labour is expected to detect fetuses at risk of compromise, allowing appropriate intervention and thereby increasing the likelihood of improved perinatal outcomes. Background: All women presenting in labour will undergo fetal monitoring. The type and frequency of monitoring is dependent upon clinical presentation and history. During their pregnancy women should be offered information on intrapartum fetal monitoring to facilitate informed decision making based on accurate information and their particular risk factors. Monitoring in a Low Risk Pregnancy For a women who is healthy and has had an otherwise uncomplicated pregnancy at term, intermittent fetal heart auscultation should be offered and recommended in labour to monitor fetal well being. Intermittent auscultation should be performed using a Doppler ultrasound on speaker mode. Prior to any form of fetal monitoring, the maternal pulse should be palpated simultaneously with the FHR auscultation in order to differentiate between maternal and fetal heart rate. In the active stage of labour, intermittent auscultation should commence toward the end of a contraction and continue for a least 30 seconds after the contraction has finished, and at least: every 30 minutes in the first stage every 5 minutes in the second stage after every contraction during active pushing. Intrapartum Fetal Monitoring Intrapartum Fetal Monitoring WACSClinProc2.3/06 Fetal Monitoring in Labour Midwifery and Medical Staff, Queen Victoria Maternity Unit Fetal Monitoring / Fetal Surveillance

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Continuous electronic fetal monitoring (EFM) should be offered: if there is evidence on auscultation of a baseline rate of less than 110 beats per minute (bpm) or greater than 160 bpm. if there is evidence on auscultation of any decelerations if any intrapartum risk factors develop. Current evidence does not support the use of the admission CTG in low risk pregnancy.

Indications for Continuous Electronic Fetal Monitoring Continuous EFM should be recommended when either risk factors for fetal compromise have been detected antenatally, are detected at the onset of labour or develop during labour. Antenatal risk factors for increased risk of fetal compromise include: abnormal antenatal CTG abnormal Doppler umbilical artery velocity suspected or confirmed intrauterine growth restriction oligohydramnios or polyhydramnios prolonged pregnancy > 42 weeks multiple pregnancy breech presentation antepartum haemorrhage prolonged rupture of membranes (>24 hours) known fetal abnormality which requires monitoring prior uterine scar/caesarean section pre-eclampsia diabetes (on insulin or poorly controlled or with fetal macrosomia) other current or previous obstetric or medical conditions which constitute a significant risk of fetal compromise Intrapartum risk factors: induction or augmentation of labour with oxytocin abnormal auscultation or CTG epidural analgesia abnormal vaginal bleeding in labour maternal pyrexia 38 C meconium or blood stained liquor absent liquor following amniotomy active first stage of labour >12 hours (ie regular uterine activity, cervix 4cm dilated) active second stage of labour (ie pushing) > 1 hour where delivery is not imminent pre-term labour less than 37 completed weeks Where continuous EFM is required for the substantial part of labour, and if the EFM to date is considered to be normal, monitoring may be interrupted for short periods of up to 15 minutes to allow personal care. Such interruptions should be infrequent and not occur immediately after any intervention that might be expected to alter the FHR (eg amniotomy, epidural top up). Continuous monitoring should not be removed if the previous monitoring has shown abnormal features.
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Procedure 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 rate. Settings on the CTG machine should be standardised, so that: Paper speed is set to 1cm/min Sensitivity displays are set to 20 bpm/cm FHR range displays of 50 210 bpm CTG: The date and time settings should be validated whenever used. The trace should be labelled with the mothers name and unit record number. Any intrapartum events that may affect the FHR should be noted contemporaneously on the EFM trace, signed, with the date and time noted (eg vaginal examination, fetal blood sampling, siting of epidural) Any member of staff who is asked to provide an opinion on a trace should note their findings on both the trace and maternal case notes, together with the date, time and their signature. Following the birth the midwife should sign, noting the date, time and mode of birth on the EFM trace. The CTG should be stored in the womans medical record. The normal CTG is associated with a low probability of fetal compromise and has the following features: Baseline rate of 110 160 Baseline variability of 5 25 bpm. Accelerations 15 bpm for 15 seconds. No decelerations. All other CTGs are by this definition abnormal and the midwife in charge, registrar or consultant must be informed. The following features are unlikely to be associated with significant fetal compromise when occurring in isolation: Baseline rate 100-109 Absence of accelerations Early decelerations Variable decelerations without complicating features The following features may be associated with significant fetal compromise and require further action: Fetal tachycardia Reduced baseline variability Complicated variable decelerations Late decelerations Prolonged decelerations The following features are very likely to be associated with significant fetal compromise and require immediate management, which may include urgent delivery: Prolonged bradycardia (<100 bpm for > 5 minutes)
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Absent baseline variability Sinusoidal pattern Complicated variable decelerations with reduced baseline variability Late decelerations with reduced variability Abnormal Fetal Heart Rate In clinical situations where the FHR pattern is considered abnormal, immediate management includes: Maternal repositioning which may alleviate maternal hypotension or cord compression Stop oxytocic infusion if in progress. Commence oxygen via Hudson mask at 6 litres per minute. Initiation or maintenance of continuous EFM. Monitor and document fetal and maternal observations. Call for assistance do not leave the woman unattended. Perform vaginal examination to exclude cord prolapse and ascertain cervical dilation. Consider application of a fetal scalp electrode. Consideration of further fetal evaluation or delivery if a significant abnormality persists as per Fetal Blood Sampling WACSClinProc2.21 Consider tocolysis: Terbutaline 250 micrograms administered subcutaneously Delivery should be expedited where: Significant fetal acidosis is suspected There is clear evidence of serious fetal compromise (FBS should not be undertaken). CTG abnormalities are of a degree requiring further assessment, but FBS is contraindicated, clinically inappropriate or not feasible. Competency Case reviews have indicated that adverse perinatal outcomes are more likely to occur where there is a lack of clear communication between clinicians caring for the individual women and failure to use clear and consistent terminology. Midwifery and obstetric staff working within the QVMU are required undertake the online K2 Fetal Monitoring Training Program or to provide evidence of completion of an accredited fetal surveillance program. Completion of the K2 training package is required within six months of commencement. The training package must be undertaken every two years.

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Attachments
Attachment 1 Attachment 2 Attachment 3 Attachment 4 Abbreviations Description of Fetal Heart Rate Patterns Intrapartum Fetal Surveillance Algorithm References

Performance Indicators: Evaluation of compliance with guideline to be achieved through medical record audit annually by clinical Quality improvement Midwife WACS Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Date: 3 August 2009

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ATTACHMENT 1 Abbreviations:bpm CTG EFM FBS FHR IA VE Beats per minute Cardiotocography Electronic fetal monitoring Fetal blood sampling Fetal heart rate Intermittent auscultation Vaginal examination

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APPENDIX 2 Descriptions of fetal heart rate (FHR) patterns Term

Baseline fetal heart rate:

Definition
The mean level of the FHR when this is stable, excluding accelerations and decelerations. It is determined over a time period of 5 to 10 minutes and expressed in bpm. Preterm fetuses tend to have values towards the upper end of this range. A trend to progressive rise in the baseline is important as well as the absolute values. FHR 110 160 bpm <110bpm >160 bpm The minor fluctuations in baseline FHR. It is assessed by estimating the difference in beats per minute between the highest peak and the lowest trough of fluctuation in one minute segments of the trace 5 25 bpm 3 5 bpm < 3 bpm > 25 bpm A regular oscillation of the baseline FHR resembling a sine wave. This smooth, undulation pattern in persistent, has a relatively fixed period of 2 5 cycles per minute and an amplitude of 5 15 bpm above and below the baseline. Baseline variability is present and there are no accelerations. Transient increases in the FHR of 15 bpm or more above the baseline and lasting 15 seconds. Accelerations in the preterm fetus may be of lesser amplitude and shorter duration. The significance of no accelerations on an otherwise normal CTG is unclear. Transient episodes of decrease of FHR below the baseline of more than 15 bpm lasting at least 15 seconds, conforming to one of the patterns below: Uniform, repetitive decrease of FHR with slow onset early in the contraction and slow return to baseline by the end of the contraction. Repetitive or intermittent decreasing of FHR with rapid onset and recovery. Time relationships with contraction cycle may be variable but most commonly occur simultaneously with contractions. The following additional features increase the likelihood of fetal hypoxia: Rising baseline rate or fetal tachycardia Reducing baseline variability Slow return to baseline FHR after the end of the contraction. Large amplitude (by 60 bpm or to 60 bpm) and/or long duration (60 secs). Loss of pre and post deceleration shouldering (abrupt brief increases in FHR baseline). Presence of post deceleration smooth overshoots (temporary increase in FHR above baseline). Decrease of FHR below the baseline of more than 15 bpm for longer than 90 seconds but less than 5 minutes. Uniform, repetitive decreasing of FHR with, usually, slow onset mid to end of the contraction and nadir more than 20 seconds after the peak of contraction and ending after the contraction. In the presence of a nonaccelerative trace with baseline variability <5 bpm, the definition would include decelerations < 15 bpm.

Normal Baseline: Bradycardia Tachycardia: Baseline Variability:

Normal baseline variability: Reduced baseline variability: Absent baseline variability: Increased baseline variability: Sinusoidal:

Accelerations:

Decelerations:

Early decelerations: Variable decelerations:

Complicated variable decelerations:

Prolonged decelerations: Late decelerations:

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APPENDIX 3 Intrapartum Fetal Surveillance Algorithm

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APPENDIX 4 REFERENCES Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 2006, Intrapartum Fetal Surveillance. Clinical Guidelines Second Edition Royal College of Obstetricians and Gynaecologist 2001 The use of electronic fetal monitoring: The use and interpretation of cardiotocograhy in intrapartum fetal surveillance . Evidence-based Clinical Guideline Number 8. Enkin, M., Keirse, M.J.C., Neilson, J., Crowther, C., Duley, L., Hodnett, E. & Hofmeyr, J. A Guide to Effective Care in Pregnancy and Childbirth, Oxford University Press, 2000.

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