Download Fetal Monitoring 1844

Guidelines in relation to Fetal Monitoring
Section
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Appendix 1
Appendix 2
Appendix 3
Appendix 4
Heading
Background
Aims
Antenatal fetal monitoring
3.1 low risk women
3.2 Indications for antenatal EFM
3.2.1 Interpretation of Antenatal CTG
3.3 Monitoring in latent phase of labour
Intrapartum fetal monitoring
4.1 Assessment prior to monitoring
4.2 Admission CTGs
4.3 Low risk women (ongoing Intelligent Auscultation)
4.3.1 Documentation
4.4 Continuous Electronic Fetal Monitoring
4.4.1Transfer to continuous EFM
4.4.2 Indications for continuous EFM
4.4.3 prolonged SROM at term
4.4.4Documentation of maternal pulse
4.5 Documentation for electronic fetal monitoring
Procedure for management of Electronic Fetal
Monitoring
5.1 Interpretation of EFM
5.1.1 Suspicious CTG
5.1.2 Pathological CTG
5.2 EFM with use of oxytocin
Guidance for CTG Categorization - the “Buddy” System
6.1 The role of the CTG Buddy
6.2 Non agreement on categorisation
Fetal blood sampling
7.1 Indications for undertaking fetal blood sampling
7.2 Contraindications to fetal blood sampling
7.3 Procedure
7.4 Classification and interpretation of fetal blood
sampling results
7.4 Paired cord sample
7.6 Follow up
Education and training
Monitoring Compliance & Risk management
Evidence base
Definitions & descriptions of FHR characteristics
Fetal blood sampling proforma
Algorithm for management of suspicious or pathological CTG
Intrapartum monitoring using ST analysis (STAN)
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1.0 BACKGROUND
Fetal monitoring is an essential part of the assessment of fetal wellbeing in
pregnancies where there are either fetal or maternal complications. However, the role
of routine auscultation of the fetal heart in low risk pregnancies is less clear. All forms
of fetal monitoring can lead to increased intervention and there should be clear
pathways in place for further investigation/assessment if the monitoring is not
reassuring. These should include measures such as ultrasound assessment and fetal
blood sampling.
Electronic Fetal Monitoring (EFM) is carried out using a cardiotocograph (CTG)
machine which records the fetal heart rate (FHR) via a transducer on the abdomen or
a probe on the fetal scalp. In addition to the fetal heart rate another transducer
measures the uterine contractions over the fundus.
This guideline is intended for the use of all health care professionals involved in the
care of women delivering within the Leeds Teaching Hospitals Trust and includes
staff providing care for women delivering in all care settings. Guidelines are not rigid
constraints upon decision making and should not negate from using professional
judgment when required.
2.0 AIMS
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To define the role of auscultation of the fetal heart in low risk pregnancies
To ensure that appropriate monitoring of the fetal heart occurs in women with
maternal complications
To ensure that appropriate monitoring of the fetal heart occurs in pregnancies
with fetal complications
To increase awareness of the role of electronic fetal monitoring among health
care professionals
To ensure all women have appropriate intrapartum fetal monitoring
To standardize the terminology used in electronic fetal monitoring
TO ENSURE THERE IS CLEAR AND ADEQUATE DOCUMENTATION OF
INTERPRETATION OF THE MONITORING
TO ENSURE THERE ARE EFFECTIVE METHODS IN PLACE FOR
FURTHER ASSESSMENT OR INTERVENTION WHERE THE MONITORING
IS ABNORMAL
TO PROMOTE GOOD COMMUNICATION AMONG PROFESSIONALS
3.0 ANTENATAL FETAL MONITORING
3.1 LOW RISK WOMEN
If no risk factors are present, there is no indication to auscultate the fetal heart as
part of an antenatal assessment. Whilst it confirms viability, it does not add to our
assessment of fetal well-being and it has no predictive value. However, it may
improve maternal satisfaction and aid bonding with the unborn child. If requested by
the mother, the fetal heart should be auscultated using a hand held Doppler or
Pinard. Fetal heart rate should be documented in the Hand held records.
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3.2 INDICATIONS FOR ANTENATAL ELECTRONIC FETAL
MONITORING
(EFM)
Antenatal EFM should not be performed prior to 26 weeks gestation as reliability is
less certain due to the immaturity of the central nervous system. In addition, the
information gained at the limits of viability may make decision making more difficult. If
complications arise in the antenatal period prior to 26 weeks then the fetal heart
should be auscultated as part of the overall assessment but a CTG should not be
performed.
If after 26 weeks, maternal or fetal complications arise, EFM may be recommended.
This is not an exhaustive list and should not negate from individual risk assessment
in order to assess the need for further assessment of fetal well-being.
Maternal Problems
 Hypertension in pregnancy
- At each visit for blood pressure monitoring on Antenatal Day Unit
(ANDU) / Maternity Assessment Centre (MAC)
- daily for in-patients on antenatal ward
 Obstetric cholestasis
 Pregnancy over 42 weeks – at each visit to ANDU
 Premature Pre labour Rupture of Membranes (PPROM)
- At each visit (usually twice weekly) to ANDU
- Twice daily for in-patients
 Prior to induction of labour
 Antepartum haemorrhage after 26 weeks – on admission. Thereafter as
determined by clinical condition
 admission in woman with medical disorders e.g. diabetes, Systemic Lupus
Erythematosis (SLE)
 Abdominal pain of unknown cause
Fetal Problems
 Self presentation with reduced fetal movements.
 Fetal growth restriction
 Oligohydramnios or abnormal fetal Doppler’s – as part of the biophysical
profile or as laid out in the management plan.
 Prematurity – in-patients with suspected pre-term labour.
 Breech presentation – prior to and after attempts at external cephalic version.
3.2.1 Interpretation of Antenatal CTG
The aim of an antenatal CTG is to confirm fetal wellbeing. Each feature of the CTG
should be assessed in turn:
 Baseline rate
 Variability
 Presence of accelerations
 Presence/absence of decelerations.
All 4 features must be normal after a maximum of 40 minutes for the CTG to be
categorised as normal.
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The categories for a CTG in a non-labouring woman are therefore:
 normal
 abnormal
Where available, a pre-printed antenatal CTG sticker should be placed in the notes,
the CTG categorised and the sticker signed and dated. If a sticker is not available,
documentation should include a comment on each feature of the CTG identified
above and a categorisation. The place of documentation will depend on where the
woman access care.
If the CTG is classified as abnormal this should be referred to the obstetrician for
review within 30 minutes and the coordinator on delivery suite informed. In some
circumstances it may be appropriate to request additional tests of fetal well being
such as an ultrasound scan or biophysical profile. Further management will be
individualised depending on the indication for monitoring and the gestation but should
be discussed with a senior doctor (ST5 or above).
In all cases a plan of care must be made, discussed with the woman and
documented in the maternity records. The CTG must be properly labelled and stored
in the designated folder in the maternity records. All finding must be documented in
the Hand Held records. .
3.3 FETAL MONITORING IN THE LATENT PHASE OF LABOUR
The definition for the Latent phase of labour is:
A period of time, not necessarily continuous, when:
there are painful contractions, and
there is some cervical change, including cervical effacement and
dilatation of up to 3cm
lesser changes may be more significant in a primigravida.
Low risk women not in established labour but remaining in hospital should continue
to have the fetal heart monitored by intermittent auscultation. The frequency of
monitoring should be decided on an individual basis and documented in the plan of
care. However, as a minimum there should be documented auscultation at least
every 2 hours, plus prior to administration of analgesia, after vaginal examination and
after rupture of the membranes. Women who have received intramuscular opiates
should have an hourly review of contractions, maternal pulse and fetal heart rate for
4 hours following administration.
High risk women not in established labour should have a CTG on admission and this
should be repeated as a minimum every 6 hours. The fetal hearts should also be
auscultated every hour along with contractions and maternal pulse. In addition the
fetal heart should be auscultated after rupture of the membranes, after vaginal
examination and it should also be considered prior to administration of analgesia.
Those women planning a homebirth, who have been assessed at home, are deemed
to be in the latent phase of labour and the midwife leaves alone to establish in labour,
do not need repeat auscultation until in established labour. Obviously, the fetal heart
should be auscultated and documented in the birth record at every patient contact.
Women should be informed that fetal movements continue even in labour and be
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advised to contact the midwife if fetal movements reduce or the situation changes in
any way e.g. SROM, any bleeding etc.
4.0 INTRAPARTUM FETAL MONITORING
These guidelines are based on those produced by the RCOG and adopted by NICE.
For this guideline, electronic fetal monitoring (EFM) is defined as “the use of
electronic fetal heart rate monitoring for the evaluation of fetal well-being in labour”.
Assessment of fetal wellbeing in labour needs to take into account a number of
factors and is not based on electronic fetal monitoring alone. Other factors to
consider include antenatal risk factors, gestation, stage and progress in labour and
the development of risk factors during labour. As such the assessment and care
planning can be complex. These guidelines aim to give some general principles for
management, particularly of suspicious and pathological CTGs, that cover commonly
occurring abnormalities. However, junior staff should discuss any uncertainties
regarding interpretation of CTG or plan of care with a more senior member of staff.
For those at ST2 level or below, all pathological and suspicious CTGs should be
discussed a more senior obstetrician. Those at ST3 and above should be familiar
with the management of a suspicious of pathological CTG. However, if in doubt, the
case should be discussed with and/or reviewed by, a more senior person, particularly
if there is concern about fetal wellbeing:
 In preterm labour
 In early labour/latent phase of labour
 If there is disagreement about the categorisation between CTG buddies or 2
caregivers
 There are persistent or repeated non-reassuring features which are not
sufficient to prompt intervention e.g. lack of accelerations, occasional atypical
or prolonged decelerations
All discussions should be documented in the birth record along with a plan of care.
4.1 ASSESSMENT PRIOR TO FETAL MONITORING
 Women should be able to make informed choice regarding their care, and
specifically for the purposes of this guideline, fetal monitoring in labour and
due consideration should be given to maternal preference and priorities in the
light of potential risk factors to both mother and baby.
 Women should have the same level of care and support regardless of the
mode of intrapartum fetal monitoring.
 There should be clear lines of communication between carers and consistent
terminology should be used to convey urgency or concern regarding fetal
wellbeing.
 Palpation of maternal pulse. Prior to the start of fetal monitoring, the
maternal pulse should be palpated simultaneously with the fetal heart-rate
auscultation in order to differentiate between the maternal and fetal heart
rates. This should be documented on the MOEWS chart, and the birth record.
Where irregularities of the fetal heart are heard with intermittent auscultation,
the maternal pulse should be palpated in order to differentiate between
maternal and fetal heart rate.
 If fetal death is suspected despite the presence of an apparently recorded
fetal heart rate (FHR), then fetal viability should be confirmed with real-time
ultrasound.
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4.2 ADMISSION CTG’S
The RCOG states that “current evidence does not support the use of the admission
cardiotocograph (CTG) in low-risk pregnancy and it is therefore not recommended”.
Thus an admission CTG will not be performed in low risk women. However, if a
woman would like a CTG to be performed on admission we will, of course
accommodate her wishes. It should be stressed that this applies to Low Risk women
only; any women with risk factors should have a CTG performed on admission in
labour
4.3 LOW RISK WOMEN (ONGOING INTELLIGENT AUSCULTATION)
For low risk women with no identified risk factors the fetal heart rate may be
monitored using ongoing intelligent auscultation. The fetal heart should be
auscultated as follows using a hand held Doppler or pinard stethoscope (not the
transducer from an electronic machine):
For one full minute immediately after a contraction at least every:
 15 minutes in the first stage of labour
 5 minutes in the second stage of labour (This must be undertaken from
confirmation of full dilation and not just for active second stage)
The baseline fetal heart rate should be documented as a single figure on the
partogram every 15 minutes. Once the woman enters the second stage of labour,
the fetal heart should be auscultated every 5 minutes and documented every 5
minutes in the birth record and recorded every 15 minutes on the partogram.
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During the auscultation signs of developing hypoxia should be listened for i.e.
lack of accelerations, presence of decelerations and a rising baseline as seen
on the partogram.
There should be heightened suspicion if accelerations are regularly heard
immediately following a contraction as these may indicate overshoot, which is
an abnormal feature
Maternal pulse should be recorded hourly and simultaneously with
auscultation if an abnormal fetal heart rate is heard to confirm the two
different rate
Ongoing risk assessment should be undertaken. Continuous Electronic fetal
monitoring (EFM) is recommended if risk factors develop. The following
mnemonic (A MOTHER) may be useful (adapted from a tool by Edwin
Chandraharan using NICE criteria).
APH – any fresh bleeding in labour
Meconium – old thin meconium is of doubtful significance and suggests good
liquor volume; thick fresh meconium may suggest fetal compromise and
reduced liquor volume
Oxytocin usage – hyperstimulation
Temperature – 38˚C once or 37.5˚C on two occasions two hours apart
Heart rate abnormal pattern – less than 110bpm, greater than 160bpm, any
deceleration following a contraction
Epidural analgesia – this may cause a degree of instability of maternal
vascular system, which can affect the fetus.
Request by the mother – following a discussion about the risk of further
intervention when EFM is used inappropriately.
Immediate action is necessary if:
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► Risk factors develop
► There is difficulty in hearing the fetal heart
► The heart rate is abnormal or decelerations are heard i.e. baseline on
auscultation is less than 110bpm or more than 160 bpm / any decelerations
are heard / Any other irregularities
► There is an increasing baseline.
Actions should include:
► Listening more frequently initially to confirm suspicion
► Thinking about the whole picture and looking for a correctable cause such
as maternal position, strength and frequency of contractions, hydration
► Summoning help
► Recommending continuous EFM.
In a community setting, additional risk factors should be re-assessed, and a decision
made about transfer to hospital based on this information. It may be appropriate to
auscultate at 5-minute intervals in order to determine whether it is a true tachycardia
or a temporary phenomenon e.g. secondary to fetal movements.
4.3.1 Documentation
► The initial assessment should be documented within the clinical notes and include
reference to a discussion with the mother and recommendations for intelligent
auscultation
► Records should reflect:
 What equipment was used for auscultation
 When auscultation was carried out in relation to contractions
 Palpation of maternal pulse (document on partogram and MOEWS chart)
 Duration of auscultation
 Fetal heart rate
► Ongoing documentation should include the baseline plotted as a single number on
the partogram and comments within the clinical notes about the presence/absence of
decelerations and accelerations and a recognition of developing risk factors
► If an abnormal heart rate is heard, the maternal pulse should be simultaneously
palpated and recorded to confirm the presence of two heart rates
► If a decision is made to recommend continuous EFM the reasons should be
documented clearly.
If a decision is made to recommend continuous EFM the reasons should be
documented clearly
► Where any actions are taken and in particular, if there was escalation to the
coordinator or the obstetrician this should be clearly documented in the birth record
Due to the frequency of auscultation, it may be useful to document at the start of any
episode of care, the equipment used, when and for how long the auscultation will
occur. For example: “unless otherwise stated, auscultation of the fetal heart will be
carried out for 1 full minute following a contraction using a hand held Doppler” or
similar wording.
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4.4 CONTINUOUS ELECTRONIC FETAL MONITORING
4.4.1 Transfer to Continuous EFM
Changing from intermittent auscultation to continuous EFM in low risk women should
be advised for the following reasons:
 Significant meconium stained liquor and this change should be considered for
light meconium stained liquor
 Maternal pyrexia – defined as 38.0oC on one occasion or 37.5oC on two
occasions 2 hours apart
 Fresh bleeding in labour
 OXYTOCIN USE FOR AUGMENTATION
 ABNORMAL FHR DETECTED BY INTERMITTENT AUSCULTATION (LESS
THAN 110 BEATS PER MINUTE [BPM]; GREATER THAN 160 BPM; ANY
DECELERATIONS AFTER A CONTRACTION)
4.4.2 Indications for the use of continuous EFM
If any of the following risk factors are present, continuous EFM should be offered and
recommended. However, this is not an exhaustive list and there may be other risk
factors identified or that arise during labour.
Maternal Risk factors
Previous caesarean section
Pre-eclampsia
Fetal Risk Factors
Fetal growth restriction
Prematurity
Pregnancy >42 weeks
Oligohydramnios
Intrapartum risk factors
Meconium stained liquor
Abnormal FHR on
auscultation
Maternal pyrexia (38.0oC on
one occasion or 37.5oC on 2)
Fresh bleeding in labour
Oxytocin augmentation
Woman’s request
PROM (>24 hours)
Abnormal fetal doppler’s
Induced labour
Multiple pregnancy
Diabetes Mellitus
Breech presentation
Antepartum haemorrhage
Other maternal medical disease
Term history of reduced fetal
movements
Term history of pyrexia requiring
inpatient admission
NB Maternal obesity, group B strep colonization and pregnancies between 40 and 42
weeks and epidural anaesthesia alone are not indications for continuous EFM
4.4.3 Monitoring after Prolonged PROM at term
Women who labour spontaneously after term prelabour of the membranes (PROM)
do not need continuous fetal monitoring and can be managed with intermittent
auscultation providing there are no other risk factors and labour progresses normally.
This applies provided labour is deemed to be established within 24 hours of PROM.
However, there is potentially an increased risk of infection and women should have
regular maternal observations performed and continuous EFM if they develop a
pyrexia.
If labour does not establish for more than 24 hours, electronic fetal monitoring should
be offered although there is little evidence prolonged ROM is associated with an
increased risk of hypoxia.
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4.4.4 Documentation of Maternal Pulse
Maternal pulse should be palpated and documented on the partogram every hour as
a minimum during established labour. If a fetal heart rate abnormality is detected
then the maternal pulse should be palpated to differentiate between the two heart
rates and documented in the birth record.
4.5 DOCUMENTATION FOR ELECTRONIC FETAL MONITORING (EFM)
Documentation in relation to the use of electronic fetal monitoring via CTG recordings
should follow NICE Guidance. In particular:
 At the commencement of a CTG trace, the mother’s name & hospital number,
date & time and the reason for commencing a CTG should be recorded on
the CTG, using a sticker where possible. The indication for EFM should also
be documented in the birth record
 The date and time clocks on the CTG machine should be checked as being
correctly set at the commencement of a recording and the relevant box ticked
on the CTG sticker to confirm the check has been completed or a note made
on the CTG.
 Any intrapartum events that may affect the FHR should be noted at the time
on the CTG trace(e.g. vaginal examination, fetal blood sampling, siting of an
epidural) which should be signed and the date and time noted ( this is done
either by writing the date and time on the CTG or drawing a line down the
CTG to confirm date/time)
 Any member of staff who is asked to provide an opinion on the trace should
note their findings on both the trace and in the birth record along with the
date, time and signature.
 Following the birth, the care-giver should sign the trace and note the date,
time and mode of delivery on the CTG trace
 The CTG trace should be stored securely within the CTG envelope in the
Hospital records at the end of the monitoring process.
 The settings on the CTG machine should be standardized so that,
Paper speed is set to 1cm/min
o Sensitivity displays are set to 20bpm
 FHR range displays of 50-210 bpm are used
5.0 PROCEDURE FOR THE MANAGEMENT OF ELECTRONIC
FETAL MONITORING
5.1 INTERPRETATION OF EFM AND ACTION TO BE TAKEN
A documented systematic assessment of the CTG should be undertaken every hour
as a minimum. If there is a delay in categorisation, for whatever reason e.g. siting of
epidural, the reason for delay should be documented in the birth record.
The assessment criteria used should be those described by NICE and involve
independent assessment of each of 4 features of the CTG (see table 1) and each
feature described as reassuring, non-reassuring or abnormal
When all the features have been assessed, the CTG can be assigned a
categorisation as either
1) Normal – all 4 features are reassuring
Continue monitoring and reassess in 30 minutes
2) Suspicious – 1 feature is non-reassuring but all others reassuring
Consider correctable causes (table 2). If the trace remains suspicious for a
further 30 minutes, despite the actions taken, the Coordinator and an
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obstetrician (ST2 or above) should be informed and a plan of care
documented in the birth record
3) Pathological– 2 or more features non-reassuring or one or more features
abnormal. The case should be referred to the Coordinator and an
experienced obstetrician (ST3 or above) and a review requested
immediately following which a plan of care can be made and documented in
the birth record
A CTG sticker can be used provided it is signed and dated. If a sticker is not
available, documentation should include a comment on each feature of the CTG
identified below and a categorisation.
Following assessment a plan of management should be documented in the
Intrapartum records.
Table 1: Categorization of fetal heart rate (FHR) features
Feature
Reassuring
Nonreassuring
Abnormal
Baseline
(bpm)
110–160
100–109
161–180
Less than 100
More than 180
Sinusoidal
Pattern 10
Minutes
Variability
(beats)
more than 5
Less than 5 for
between 40-90
minutes
Less than 5 for
90 minutes or
more
Decelerations
Accelerations
None
Typical variable
decelerations with over
50% of contractions
occurring for over 90
minutes
Single prolonged
deceleration up to 3
minutes
Atypical variable
decelerations with over
50% of contractions for
30 minutes OR late
decelerations for 30
minutes
Single prolonged
deceleration for more
than 3 minutes
Present
The absence of
accelerations with
an otherwise
normal CTG are
of uncertain
Significance
Additional points to bear in mind during CTG interpretation are:
 If repeated accelerations are present with reduced variability, the FHR trace
should be regarded as reassuring.
 True early uniform decelerations are rare and benign, and therefore they are
not significant.
 Most decelerations in labour are variable
 Accelerations in the late first stage and second stage of labour are unusual
and should be viewed with suspicion. In some cases the maternal pulse has
been recorded in this situation.
 a change over time can be as significant as a particular feature e.g. rising
baseline, reduced variability, reduced response to stimulation
If a bradycardia lasts for more than 3 minutes, urgent medical aid must be sought
(within 6 minutes) and preparations made to expedite delivery (Category 1 caesarean
section). This could include transfer to theatre if the fetal heart has not recovered by
9 minutes with a view to starting delivery by 12 minutes if the bradycardia persists. If
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the fetal heart recovers within 9 minutes, the decision to deliver should be
reconsidered in conjunction with the woman.
Where assisted birth is considered because of an abnormal FHR pattern and
suspected acidosis, a fetal blood sample should be undertaken unless there are
contraindications.
In the presence of maternal pyrexia, the CTG may be more difficult to interpret
although there is likely to be a fetal tachycardia. EFM and fetal blood sampling are
used for the diagnosis of fetal hypoxia and will not give information about fetal
infection. As such, they may be falsely reassuring. In addition, an infected fetus is
more susceptible to the effects of hypoxia and may be more at risk. Therefore, if
maternal pyrexia fails to respond to routine measures the case should be discussed
with a senior obstetrician (ST5 or above).
5.1.1 Suspicious CTG
If the CTG is categorised as suspicious, correctable causes should be considered
(table 2) as simple measures may return the CTG to normal. If the trace remains
suspicious for a further 30 minutes, despite the actions taken, the Coordinator and/or
the STR should be informed and a plan of care documented in the birth record
In the meantime the following corrective measures should be commenced (see
algorithm):
 Position woman in left lateral position
 Give 500mls crystalloid unless contra-indicated (e.g., hypertensive)
 Consider stopping or reducing oxytocin infusion
 Vaginal examination to assess progress and response to scalp stimulation
The prolonged use of maternal facial oxygen therapy may be harmful to the baby and
should be avoided. There is no evidence on the benefits or risks from the use of short
term maternal facial oxygen therapy for suspected fetal compromise and as such it
should not be used.
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Table2: Factors to consider and actions to be taken in the presence of a nonreassuring CTG
Contributing Factor
Maternal position
Maternal tachycardia (may
represent dehydration or
infection)
Likely CTG Abnormalities
Reduced variability
Lack of accelerations
Variable or late decelerations
Tachycardia
Reduced variability
Epidural/spinal
anaesthesia
Variable decelerations or
prolonged bradycardia
Maternal pyrexia
Tachycardia
Reduced variability
Maternal position, opiates,
maternal exhaustion
Uterine hypercontractility
on syntocinon
Uterine hypercontractility
(not on syntocinon)
Maternal obesity
Vasovagal episode e.g.
using bedpan, vomiting
No accelerations or reduced
variability
Corrective Measure
Change to left lateral position
Intravenous fluids therapy- 500mls
0.9% sodium chloride or Hartman’s
solution
If maternal pulse over 140bpm stop
oxytocin infusion
Check blood pressure
Change maternal position to left
lateral
Give iv fluid bolus
Anaesthetic review
Intravenous fluids therapy- 500mls
0.9% sodium chloride or Hartman’s
solution
Paracetamol 1g (oral, rectal or IV)
Digital fetal scalp stimulation (stroke
fetal head at VE)
Stop infusion
Consider tocolysis with terbutaline
0.25mg by subcutaneous injection
Consider FSE
Left lateral position
Intravenous fluids therapy- 500mls
0.9% sodium chloride or Hartman’s
solution
Loss of contact
Bradycardia
Whilst a suspicious CTG per se is not an indication for fetal blood sampling or
delivery, a full assessment should be carried out by the obstetrician after 90 minutes
if the CTG remains suspicious. This should take into account prior risk, the progress
and stage of labour and the CTG features which are none reassuring. In many cases
a persistent abnormality will change a CTG from suspicious to pathological or
another feature will become non-reassuring. However, if there is a persistently
suspicious CTG for more than 90 minutes and delivery is still not likely within a
known time frame, there should be consideration of a fetal blood sample.
5.5.2 Pathological CTG
If the CTG is classified as pathological, the coordinator and obstetrician (ST 3 or
above) should be asked to review with a view to fetal blood sampling or delivery. In
the meantime the following corrective measures should be commenced (see
algorithm):
 Position woman in left lateral position
 Give 500mls crystalloid unless contra-indicated (e.g., hypertensive)
 Stop oxytocin infusion
 Vaginal examination to assess progress and suitability for FBS or delivery
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5.2 CONTINUOUS EFM WITH THE USE OF OXYTOCIN
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All women where labour is being induced or augmented with oxytocin must
have EFM.
If the FHR is normal, oxytocin may be continued until the woman is
experiencing 4 or 5 contractions every 10 minutes. Oxytocin should be
reduced if contractions occur more frequently than 5 contractions in 10
minutes.
If the CTG is classed as suspicious, the coordinator should be informed,
corrective measures should be commenced and the woman reviewed by an
obstetrician. The oxytocin infusion should not be increased further until this is
complete and a continuing plan of care made and documented in the birth
record. This should include consideration of the need for fetal blood sampling.
If the CTG is pathological, the coordinator should be informed, the oxytocin
infusion stopped and corrective measures commenced. The woman should
be reviewed by an obstetrician within 30 minutes and a plan of care made
and documented in the birth record. This should include a decision regarding
the continuation of oxytocin and the need for fetal blood sampling.
6.0 PEER REVIEW OF CTG CATEGORISATION
- THE “BUDDY” SYSTEM
The 2006/07 annual report of the LSA for Yorkshire and Humber highlighted that
misclassification of CTG’s, poor documentation and failure to refer to a doctor were
key trends in cases investigated. As a result of this some trusts in the region have
implemented a “fresh eyes” approach to CTG interpretation. This “fresh eyes”
initiative is also supported by Symon et al 2006 who noted that what often prevents
an adverse outcome is intervention by another practitioner. Within LTHT this is
referred to as the CTG Categorization Buddy System
Each midwife caring for a woman having continuous EFM is assigned a “buddy” .
These pairs are then asked to make an independent assessment of each other’s
CTG traces as a minimum every 2 hours but hourly where possible. If a sticker is
used the midwife should categorize the CTG and then countersign, date and time. If
a sticker is not available, documentation should include a comment on each feature
of the CTG (see table 1) and a categorisation as well as the time, date and a
signature and a clear indication that they were peer reviewing the CTG. .
It is recognized that with a buddy system it is the same two colleagues who makes
an assessment of the CTG trace each time and that the margin for error may be
greater than with a true “fresh eyes” approach. However, “buddying” does have
advantages over random peer review including:
 a named buddy is more likely to remind and motivate midwives to peer review
the categorisation of their CTG tracings.
 With a named buddy continuity of carer and the privacy of the woman is
maintained where possible.
 The nature of the workload on Delivery Suite is such that it is unlikely that the
midwife’s named buddy will always be available and therefore review by a
third person is likely to occur. Review by a third person will also inevitably
occur if the CTG categorisation is found to be anything other than Normal.
Midwives should have their buddy assigned at the start of each shift by the
coordinator who should should ensure that staff are clear as to their role and who
they are paired with.
13
6.1 THE ROLE OF A CTG BUDDY
Women who are being continuously monitored in labour should have the previous 30
minutes of CTG monitoring assessed and categorised
If the 2 professionals are in agreement, no further action needs to be taken.
6.2 Non-agreement on categorization
If there is disagreement about the categorization, this should be documented in the
birth record and referred immediately to a senior person for further clarification. This
can be the coordinator, another Band 7 or an experienced obstetrician (ST3 or
above) If agreement still cannot be reached, the case should be referred to the
Consultant. The final categorization and the subsequent plan of care agreed should
be documented in the birth record and the CTG signed.
7.0 FETAL BLOOD SAMPLING
7.1 INDICATIONS FOR UNDERTAKING FETAL BLOOD SAMPLING
 Pathological CTG where delivery is not imminent
 Prior to assisted delivery where the CTG is suspicious or pathological
 Prior to Caesarean section for suspected “fetal distress” unless there is a
prolonged bradycardia
NB fetal blood sampling may be of less value in the presence of pyrexia as it screens
for acidaemia/hypoxia and not sepsis
7.2 CONTRAINDICATIONS TO FETAL BLOOD SAMPLING

Maternal infection (e.g. HIV, hepatitis virus’, herpes simplex virus)

Fetal bleeding disorders (e.g. haemophilia, thrombocytopenia)

Prematurity (<34 weeks gestation)

prolonged bradycardia as this requires urgent delivery not further
assessment of fetal wellbeing
7.3 PROCEDURE
 The indication for performing a fetal blood sample and the possible outcomes
should be discussed with the parents. These discussions and their consent
should be documented in the birth record. A fetal blood sampling proforma
should be commenced
 left lateral position
 clean vulva, VE to assess cervical dilatation and position/station of fetal head
 insert amnioscope to visualize fetal scalp
 clean head with small gauze pledget and apply a thin layer of paraffin
 prick fetal head firmly with blade, wait for blood to collect in large drop, allow
to run into capillary tube (need 4cm to avoid split sample). Small samples
prone to error and not reliable
 give samples (take at least 2, preferably 3) to assistant for analysis
 apply pressure to bleeding point with pledget to secure haemostasis
 The capillary tube should be gently rocked to encourage movement and good
mixing and avoid clotting in the tube
 Only staff trained in the use of the blood-gas analyzer should introduce
samples in order to avoid unnecessary problems and breakdowns in
equipment
14

The results should be discussed with the parents and a clear plan
documented in the birth record including the potential need for repeated
samples
7.4 DOCUMENTATION OF RESULTS
 The event should be noted on the CTG, and the trace signed and timed
 The results should be recorded on the FBS proforma which is placed in the
birth record.
 The blood gas analyzer print out should be numbered and placed in the
brown fetal monitoring folder in the same way as CTGs are secured.
 A plan of care should be documented in the birth record along with a
summary of what was discussed with the woman including the need for and
timing of repeat samples
7.5 CLASSIFICATION AND INTERPRETATION OF FETAL BLOOD SAMPLING
RESULTS
Table 4: Classification of fetal blood sampling results
Fetal blood
sample
result (pH)
≥7.25
Interpretation
Subsequent action
Normal
FBS should be repeated within no more than 1
hour if the FHR abnormality persists
7.21-7.24
Borderline
≤7.20
Abnormal
Repeat FBS within 30 minutes or consider delivery
if rapid fall since last sample
Inform Consultant and agree plan for delivery
All scalp pH estimations should be interpreted taking into account the previous pH
measurement, the rate of progress in labour and the clinical features of the woman
and her baby. A plan of care should be documented in the birth record and explained
to the parents which should include if and when the test will be repeated.
If the FHR trace remains unchanged and the FBS result is stable after the second
test, a further sample should be deferred unless additional abnormalities develop on
the trace.


If a third test is considered necessary, it must be discussed with the
Consultant prior to taking the sample and this discussion documented in the
birth record.
The results should be recorded on the FBS proforma and the print out from
the blood gas analyser numbered and placed in the brown fetal monitoring
folder in the same way as CTG’s are secured.
7.6 PAIRED CORD SAMPLES
Paired cord blood gases do not need to be taken routinely but should be
obtained where there has been concern about the baby either during labour or
immediately following birth
Umbilical artery acid-base status should be performed as a minimum after:
 Emergency caesarean section is performed
 Instrumental vaginal delivery is performed
 A fetal blood sample has been performed in labour
 Birth, if the baby’s condition is poor
15
The results should be documented on the FBS proforma and in the birth record and
the results securely stored as detailed above.
7.7 FOLLOW UP
If there is a poor outcome e.g. baby admitted to neonatal unit, the Consultant on call
as well as the woman’s own Consultant should be informed so that arrangements
can be made for on-going review. Senior involvement with the parents is important to
provide them with information about intrapartum events and support during the
postnatal period. Any discussions undertaken with the parents should be
documented in the maternal hospital records and/or neonatal records where
appropriate.
8.0 EDUCATION AND TRAINING
The role specific requirements for undertaking fetal monitoring updates are identified
in the Maternity Services Training Needs Analysis.
9.0 MONITORING COMPLIANCE AND RISK MANAGEMENT
9.1 Risk Management
A clinical incident report should be completed for: All babies born with evidence of hypoxia (arterial cord pH <7.05; venous
<7.10)
 All unexpected admissions to the neonatal unit
EFM traces should be kept for a minimum of 25 years
Tracer systems should be developed to ensure that CTG’s removed from case notes
can always be located
9.2 Audit
A multidisciplinary annual audit will be carried out in accordance with the Maternity
Services Audit Plan including review of intermittent auscultation, continuous
electronic fetal monitoring and fetal blood sampling.
Audit criteria include:








Method of fetal heart rate monitoring in different clinical settings
when to transfer from intermittent to continuous electronic fetal monitoring
documentation requirements for fetal heart rate monitoring
systematic assessment of CTG interpretation and peer review
actions taken if CTG categorised as suspicious or pathological
Need for FBS and documentation of FBS results in the birth record
Need for paired cord samples and documentation of results in birth record
Compliance with Staff training as identified in the Training Needs Analysis
Audit results will be presented at the Women’s Services Clinical Governance and
Audit meeting and an action plan developed as necessary. A lead will be appointed
for monitoring of the action plan, including re-audit, and the status of the action plan
reported to the Women’s Services Clinical Governance and Risk management Forum
(WSCG&RMF) quarterly. Audit results will be included in the Maternity risk
management report issued quarterly and any resulting changes disseminated via the
Maternity Services Forum, Team Leaders Forum, Supervisors Forum.
16
10.0 EVIDENCE BASE
1. Pattison N, McCowan L. Cardiotocography for antepartum fetal assessment.
Cochrane database of Systematic Reviews 2001 ;( 2).
2. NICE guidance. Antenatal Care. October 2007.
3. The use of electronic fetal monitoring. The Royal College of Obstetricians &
Gynaecologists. London 2001
4. Bix E, Reiner LM, Kloving A, Oian P. Prognostic value of the labour admission
test and its effectiveness compared to auscultation only: a systematic review.
BJOG. 2005 Dec; 112(12):1595-604.
5. Neilsen JP. Fetal electrocardiogram for fetal monitoring during labour. Update of
Cochrane Database Syst Rev. 2003 ;( 2):CD000116.
6. Noren H, Amer-Wahlin I, Hagberg H, Herbst A et al. Fetal electrocardiography in
labour and neonatal outcome: data from the Swedish randomised controlled trial
on intrapartum fetal monitoring. Am J Obstet Gynecol. 2003 Jan; 188(1):183-92.
7. Westgate j, Harris M, Curnow JS, Greene KR. Plymouth randomized trail of CTG
only versus ST waveform plus CTG for intrapartum monitoring in 2400 cases. Am
J Obstet Gynecol. 1993Nov; 169(5):1151-60.
8. LSA, 2007. Annual report of the Local Supervising Authority and the NMC Pilot
review of Yorkshire and Humber LSA. Yorkshire and Humber Strategic Health
Authority. Accessed 9/4/2008. http://www.yorksandhumber.nhs.uk
9. NICE (2007), Intrapartum Care: Care of Healthy Women and Babies during
Childbirth Clinical Guideline 55, London National Institute for Clinical Excellence
10. National Institute for Clinical Excellence (NICE) 2007.The Use of Electronic Fetal
Monitoring: The use and Interpretation of Cardiotocography in Intrapartum Fetal
Surveillance. (Guideline C).
11. Symon et al 2006. An exploratory mixed methods study of Scottish midwives
understandings and perceptions of clinical near misses in maternity care.
Midwifery. 22 (2): pp 125-136.
12. Amer-Wahlin et al 2007. Fetal ECG: ST waveform analysis in intrapartum
surveillance. BJOG. 2007;114:1191-1193.
13. Westerhuis et al 2007. BJOG 2007;114:1194-1201
14. LSA. 2007. Annual report of the Local Supervising Authority and the NMC Pilot
review of Yorkshire and Humber LSA. Yorkshire and Humber Strategic Health
Authority. [online] Accessed 9th April 2008. Available from World Wide Web:
http://www.yorksandhumber.nhs.uk
15. Symon et al. 2006. An exploratory mixed methods study of Scottish midwives
understandings and perceptions of clinical near misses in maternity care. Midwifery.
22 (2), pp 125-136.
17
Appendix 1
Definitions and descriptions of individual features of fetal heart-rate (FHR)
traces
Term
Baseline fetal heart rate
Normal Baseline FHR
Baseline variability
Normal baseline variability
Accelerations
Decelerations
Early decelerations
Late decelerations
Variable decelerations
Prolonged deceleration
Definition
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
110 –160 bpm
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
If repeated accelerations are present with reduced
variability the FHR trace should be regarded as
reassuring.
Greater or equal to 5 bpm between contractions
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
Transient episodes of slowing of FHR below the baseline
level of more than 15 bpm and lasting 15 seconds or more
Most decelerations in labour are variable
True early decelerations are rare and benign and should
not be regarded as significant
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 <5 bpm, the definition would
include decelerations <15 bpm
Intermittent periodic slowing of FHR with rapid onset and
recovery. Time relationships with contraction cycle are
variable and they may occur in isolation. In addition,
atypical variable decelerations have the following
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 60 –90 seconds. These decelerations
become abnormal if they last longer than 3 minutes
18
Atypical variable
decelerations
Sinusoidal pattern
Variable decelerations with any of the following additional
components:
i. loss of primary or secondary rise in baseline rate
ii. slow return to baseline FHR after the end of the
contraction
iii. prolonged secondary rise in baseline rate,
iv. biphasic deceleration
v. loss of variability during deceleration
vi. continuation of baseline rate at lower level.
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 an amplitude of 5 –15 bpm
above and below the baseline. Baseline variability is
absent
19
Appendix 2
FETAL BLOOD SAMPLING (FBS) RECORD KEEPING PROFORMA
To be completed for all cases when FBS has been undertaken
Name of woman:……………………………………………………
Hospital No: …………………………………………………………
Fix addressograph here
Date:………………………………………………………………….
First Time for FBS:
Time:
Full explanation of FBS procedure and informed consent gained Yes □ No □
Reason for undertaking FBS
………………………………………………………………………………………………
First set of results (pH/Base Excess/Time)
Management plan (to include the requirement and timing of repeat FBS):
Observe……………………………………………………………………………………………
Repeat FBS (As per Guideline)…………………………………………………………………
Emergency C/S……………………………………………………………………………………
If abnormal, time Consultant was informed ………………………………………………...
Signature ………………………………………… Printed name ………………………………
Grade:………………………………………
Second Time for FBS:
Time:
Full explanation of FBS procedure and informed consent gained Yes □ No □
Reason for undertaking FBS
………………………………………………………………………………………………
Second set of results (pH/Base Excess/Time)
Management plan (to include the requirement and timing of repeat FBS):
Observe……………………………………………………………………………………………
Repeat FBS (As per Guideline)…………………………………………………………………
Emergency C/S……………………………………………………………………………………
If abnormal time Consultant was informed…………………………………………………
Signature …………………………………………Printed name ………………………………
Grade:………………………………………
Third time for FBS:
Time:
Consultant on-call informed - Time:………………………………………………………….
Full explanation of FBS procedure and informed consent gained Yes □ No □
Reason for undertaking FBS
………………………………………………………………………………………………
Third set of results (pH/Base Excess/Time)
20
Management plan (to include the requirement and timing of repeat FBS):
Observe……………………………………………………………………………………………
Repeat FBS (As per Guideline)………………………………………………………………… Emergency
C/S……………………………………………………………………………………
If abnormal time Consultant was informed ………………………………………………….
Signature:…………………………………………Printed name:……………......................
Grade:…………………………………….
Fourth time for FBS:
Time:
Consultant on-call informed - Time:………………………………………………………….
Full explanation of FBS procedure and informed consent gained Yes □ No □
Reason for undertaking FBS
………………………………………………………………………………………………
Fourth set of results (pH/Base Excess/Time)
Management plan (to include the requirement and timing of repeat FBS):
Observe……………………………………………………………………………………………
Repeat FBS (As per Guideline)………………………………………………………………… Emergency
C/S……………………………………………………………………………………
If abnormal time Consultant was informed ………………………………………………….
Signature:…………………………………………Printed name:……………......................
Grade:…………………………………….
PLEASE FILL THIS IN BELOW AFTER DELIVERY
PAIRED CORD SAMPLE RESULTS Venous pH: …………….................
Venous Base Excess:……………...
Arterial pH:…………………………..
Arterial Base Excess:……………….
21
Normal
If typical variable decelerations occur, measures
should be taken to improve uteroplacental
circulation eg changing maternal position &
hydration.
If typical variable decelerations occur with >50%
of contractions for > 90 minutes  SUSPICIOUS
CTG.
If early decelerations occur, remember these are
rare & seen in the late first stage/second stage with
head compression.
Suspicious
Measures should be taken to improve
uteroplacental circulation eg changing maternal
position & hydration.
If typical variable decelerations occur with >50%
of contractions for > 90 minutes an obstetric
review is necessary.
If oxytocin is being used there should be a review
by an obstetrician (ST3 or above) and the dose
should only continue to increase to achieve 4 or 5
contraction in 10.
t
Pathological
Measures should be taken to improve
uteroplacental circulation eg changing maternal
position & hydration and Fetal Blood Sampling or
Delivery carried out.
If either atypical decelerations occur with >50% of
contractions or late decelerations occur for >30
minutes an obstetric review is required and Fetal
Blood Sampling or delivery carried out.
If oxytocin is being used it should be stopped and a
full assessment of the fetal condition undertaken by
an obstetrician (ST3 or above) before being
recommenced.
If oxytocin is being used it should be reduced if
contractions occur more frequently than 5 in 10.
WARNING FEATURES - consider possible causes and corrective measures
INCREASED BASELINE – even within the normal range with other non-reassuring or abnormal features should increase
concern.
ABSENCE OF ACCELERATIONS- with an otherwise NORMAL trace is of uncertain significance (intrapartum only).
TYPICAL VARIABLE DECELERATIONS - if occur for over 60 mins consider corrective measures
A warning feature plus a nonreassuring feature should prompt
an obstetric review
Prolonged Deceleration >3 mins help should be called and interventions initiated (positioning/IV fluids/stop syntocinon/tocolysis). If no recovery by 6mins expedite
delivery. If necessary move to theatre by 9 mins, surgery by 12 mins and delivery by 15 mins.
22
Appendix 4
FETAL MONITORING IN LABOUR USING ST-ANALYSIS - STAN®
ST-Analysis is the analysis of changes occurring in the ST-segment of the fetal ECG during labour.
The STAN Fetal Monitor detects these changes in the fetal ECG in addition to recording the CTG.
The combined analysis of the CTG and the fetal ECG helps to detect a fetus that is exposed to
hypoxia and which needs remedial action or delivery and provides reassurance when no
intervention is required. These guidelines are based on the available research and Swedish /
British clinical experience of ST- analysis of fetal electrocardiogram in intrapartum fetal monitoring.
The combination of CTG and automatic ST-analysis increases the ability of the obstetric team to
identify intrapartum fetal hypoxia and to intervene appropriately, resulting in an improved perinatal
outcome.
As a result we should have

Significantly less babies born with umbilical artery metabolic acidosis

Reduction in number of fetal blood samplings

Reduction in assisted deliveries

INCLUSION CRITERIA
Singleton, Cephalic presentation
Over 36+0 weeks
Requiring CTG monitoring & willing to accept fetal scalp electrode
Ruptured membranes (Spontaneous Rupture Membranes (SROM) or Artificial Rupture
Membranes (ARM))
First stage of labour









EXCLUSION CRITERIA
Contra-indication to fetal scalp electrode
Congenital fetal malformation
Known Intrauterine Growth Retardation (IUGR <5th centile)
Rhesus disease
Maternal temperature above 37.5C on admission
Obstetric cholestasis
Moderate to large antepartum haemorrhage
Full dilatation
Pre-terminal CTG




In the presence of several peripartum risk factors i.e. meconium liquor, poor progress in labour,
abnormal CTG etc. the decision to put the woman on STAN should be discussed with a senior
member of the obstetric team (ST5 or above)
DECISION TO COMMENCE ST-MONITORING
STAN monitoring is predominantly used in women at risk of intrapartum complications who may
then need urgent delivery. Its use requires excellent communication and teamwork skills. Whilst it
appears to reduce the need for intervention, it does place additional demands on staff particularly
when urgent delivery is indicated (aim for delivery within 20 minutes). Therefore, before monitoring
is commenced, each case must be discussed and agreed to be appropriate by the obstetric,
midwifery and anaesthetic staff.

Senior midwife
o Ensure safe staffing
o Midwife caring for woman appropriately trained
23

Senior Obstetrician – Consultant or ST5 and above
o Appropriate case
o woman fully informed about possible consequences
o potential need for FBS prior to start
o appropriate training/supervision of junior staff

Senior Anaesthetist – ST4 and above
o No predictable problems if emergency anaesthesia required e.g. obesity, problems
with IV access
o Review and advise on current analgesia
o Fully informed of possible events if emergency delivery indicated
PATIENT CONSENT
The woman must be willing to accept a fetal scalp electrode and be fully counselled about the
procedure and its aims e.g. reduction in intervention, reduction in acidosis at delivery. She should
be aware that there may be frequent discussions with other members of the team and that if
delivery is indicated it should be within 20 min.
PREPARATION
Fetal blood sampling (FBS)
Where the indication to use STAN is a suspicious or pathological CTG it is preferable to obtain a
fetal blood sample prior to commencing STAN. This will provide an assessment of the current
acid/base status of the baby and allow the 20 minutes of monitoring that may be required until
automatic analysis can begin.
Setting up the monitor
There are 3 electrodes: fetal scalp electrode; leg electrode; inguinal electrode
1. FETAL SCALP ELECTRODE (FSE)
2. Leg Electrode
3. INGUINAL ELECTRODE
Use sandpaper to scour the area where you will apply the electrode
Apply the electrode and attach the fetal ECG
Ensure good quality recording
Good signal quality is essential for ST-analysis. In the event of a report of poor signal quality
the CTG and the ST trace should be reviewed and appropriate changes made depending on if
the fault lies with the CTG or the fetal ECG (see appendix 3). If adequate recording cannot be
established after 30 minutes, the team should revert to conventional EFM.
INTERPRETATION OF STAN
ST events can be only be interpreted in the light of the CTG classification. The CTG is classified
according to the manufacturer’s guidelines as either:
 Normal
 Intermediate
 Abnormal
 Pre-terminal
24
These criteria differ from the NICE guidelines. The CTG should be reviewed continually and the
classification documented in the notes every 30 minutes. In cases of uncertainty the worst category
should be used e.g. if uncertain whether CTG is intermediate or abnormal, it should be classified
as abnormal.
If at any point the CTG is deemed to be pre-terminal delivery should be immediate
irrespective of the ST analysis.
Table 5: CTG Interpretation for STAN
CTG
classification
Normal CTG
Baseline heart frequency

110 – 150 bpm
Intermediary
CTG



100 – 110 bpm
150 - 170 bpm
short bradycardia (<3
mins)
Variability
Reactivity
 5 – 25 bpm
 accelerations
Decelerations



>25bpm
<5bpm for >40mins


Early decelerations
Uncomplicated variable decels
with a duration of <60sec and
a loss of <60 beats
Uncomplicated variable decels
with duration <60sec and loss
of >60beats
A combination of 2 or more intermediary features will result in an abnormal CTG
Abnormal
CTG
Preterminal
CTG

150 – 170 bpm &
 <5bpm for >60mins  Complicated variable decals
reduced variability
with a duration of >60 sec
 sinusoidal pattern
 >170 bpm
 Repeated late uniform
decelerations
 persistent bradycardia
(>3mins)
Total lack of variability (<2 bpm)and reactivity with or without decelerations or bradycardia
If an ST event occurs, the CTG should be assessed, discussed with the team involved and the
action taken clearly documented in the birth record. Alleviation of the cause of fetal distress e.g.
overstimulation, maternal hypotension, may be sufficient but delivery is often indicated.
Where the CTG is abnormal for more than 30 minutes, but the ST is normal, a further fetal blood
sample will be required to assess for deterioration of the fetal state. This should occur sooner if
there is a rapid change in the fetal heart rate pattern.
The STAN clinical guidelines for delivery are summarised below depending on
 The STAN event
 The CTG classification
 The stage of labour
 The cause of fetal compromise
In the presence of pyrexia (maternal temp greater than 37.5oC on 2 occasions or greater than 38oC
on 1 occasion), an intermediary CTG and an ST event would be an indication for intervention.
25
Poor quality recording or gaps on the monitoring of over 4 mins may result in missed ST events
and management should be reviewed depending on the CTG pattern and the clinical situation. A
further FBS may be required.
During the second stage of labour with active pushing, intervention means that immediate
operative delivery should be offered unless spontaneous delivery is anticipated within the next 5-10
minutes.
Midwives whose woman is being monitored with STAN should have their CTG categorisation
“buddied” in the same way. The midwife and his/her buddy should also note and ensure good
signal quality and continuous T/QRS ratio recording.
The Delivery Suite Coordinator, Registrar and Anaesthetist should be informed if the CTG is found
to be intermediary or abnormal. If a preterminal CTG is noted the Coordinator and an
experienced obstetricician (ST5 or above) should be informed and immediate delivery
carried out
Table 6: Interpretation of ST events
ST event
Normal CTG
Intermediary
CTG
Episodic T/QRS
rise
Baseline T/QRS
rise
Biphasic ST
event
>0.15

Expectant
management

Continued
observation
Abnormal CTG
Preterminal CTG
>0.10
Immediate delivery
>0.10
3 biphasic log
messages
>0.05
2 biphasic log
messages
Situations in which intervention is required
* Alleviation of the cause of fetal distress e.g. overstimulation, maternal hypotension, may be
sufficient but delivery is often indicated.
DELIVERY
When a significant ST event occurs, delivery should be within 20 minutes. This will highlight again
the need for good communication between the different teams.
In order to shorten the decision to delivery interval some preparations can be made in women on
STAN monitoring
 Urinary catheter in-situ
 Anaesthetic review to assess and discuss epidural top-up/spinal/GA
 the woman should read +/- sign the consent form for emergency caesarean section
 discussion of instrumental delivery in women in second stage
The woman should be assessed by an experienced obstetrician (ST5 or above) as to the most
appropriate mode and place of delivery. A trial of forceps in theatre or a rotational delivery is not
recommended at this stage as it is likely to lead to undue delay especially if unsuccessful.
Where delivery is to be by Caesarean section the obstetrician should clearly communicate this as
being a category 1 section so that appropriate care can be delivered.
26
POST-PARTUM
Paired cord samples should be obtained in all women monitored with STAN irrespective of the
mode of delivery or the indication. The data should be saved to the hard disc but also printed out
and the hard copy filed in the case notes. There will be on-going audit into the outcome of those
monitored with STAN and an audit form should be completed and returned to the Delivery Suite
Coordinator at the LGI
27
ACTIONS TO BE TAKEN IN EVENT OF SUBOPTIMAL CTG OR FETAL ECG RECORDING
WHEN USING STAN
Poor quality recording
Reposition patient
and wait 5 minutes
Good quality signal
Continue
Poor quality signal
Poor fECG
Poor CTG
Poor fECG
Normal CTG
Reapply inguinal
electrode
Reapply FSE
Quality remains poor after 20 minutes
Revert to conventional monitoring
Consider repeat Fetal Blood sampling
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Fetal Monitoring - Guidelines and Protocols
Author(s)
Colette Sparey (Consultant Obstetrician)
Amended by Jayne Shillito (Consultant Obstetrician)
Contact name
Jayne Shillito ([email protected])
Approval process Maternity Services Forum (previously Maternity Services Clinical Governance
for amendments
and Risk Management Forum)
June 2004.
First Issue Date
Version no:
Version 3.2
Review Date:
July 2015
Approval
Ratified by: Clinical Guidelines Committee: September 2008
(LHP version 1.0)
Amendments approved by MSF (25/01/13 version 3.2)
Consultation Process
Maternity Services Guideline Group / Maternity Services Forum, Maternity Services Governance and
Risk Forum / Obstetricians / Team Leaders / Supervisors of Midwives
Scope of guidance
P
ALL WOMEN RECEIVING ANTENATAL AND INTRAPARTUM CARE WITHIN
Clinical condition
THE LEEDS
TEACHING HOSPITALS NHS TRUST
All pregnant women booked to deliver within the Leeds teaching Hospitals NHS
Patient Group
Trust
All Health Care Professionals involved in the provision of antenatal and
Professional
intrapartum care within the Leeds Teaching Hospitals NHS Trust
Group
All Obstetricians within the Women and Children's Division.
Distribution List
Lead Clinician (Midwifery and Neonates)
Head of Midwifery
Matrons (midwifery and neonatal)
Clinical Midwifery Team Leaders (for distribution to midwives within their areas)
Dissemination
Via Risk Management Midwife
Audit and
Monitoring
Will be carried out in accordance with Maternity Services Audit Plan
Broad Recommendations
All women should be offered fetal monitoring appropriate to needs and based on best clinical evidence
Equity and Diversity
Leeds Teaching Hospitals NHS Trust believes in fairness, equity and above all values diversity in all
dealings, both as providers of health services and employers of people. The Trust is committed to
eliminating discrimination on the basis of gender, age, disability, race, religion, sexuality or social
class. We aim to provide accessible services, delivered in a way that respects the needs of each
individual and does not exclude anyone. By demonstrating these beliefs the Trust aims to ensure that
it develops a healthcare workforce that is diverse, non-discriminatory and appropriate to deliver
modern healthcare.
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