Download IWK - 7070 - Intrapartum Fetal Health Surveillance

Policy/Procedure
TITLE: Intrapartum Fetal Health Surveillance
NUMBER: 7070
Effective Date:
Page: (1 of 18)
October, 2014
Applies To: Birth Unit RNs, Midwives, Physicians
THIS IS A BEYOND ENTRY LEVEL COMPETENCY (BELC)
FOR REGISTERED NURSES AT THE IWK HEALTH CENTRE
POLICY
All labouring patients with viable unborn babies will receive ongoing fetal health surveillance
(FHS) during active labour. Fetal monitoring is an integrated part of, not a substitute for,
continuous one to one support and care provision from a trained health professional throughout
active labour. This policy will provide clinical staff with guidance to support and ensure the
provision of consistent, safe, ethical, and competent care in FHS to women during active labour.
Fetal health surveillance includes intermittent auscultation and continuous electronic fetal
monitoring.
Fetal Health Surveillance (FHS) Guidelines discussed in the following policy are based on the
Society of Obstetricians and Gynaecologists of Canada (SOGC) (2007), Fetal Health
Surveillance: Antepartum and Intrapartum Consensus Guideline.
The provision of FHS by Registered Nurses (RNs) employed in the Birth Unit at the IWK Health
Centre is a Beyond Entry Level Competency (BELC) and requires initial certification, online
eSource tracking, and recertification every two years. This is achieved by successful completion
of the Fetal Monitoring course approved by the IWK Health Centre Childbirth Care Team and
demonstration of competency in FHS. The expectation is that all RNs practicing in the Birth Unit
will successfully complete the approved Fetal Monitoring course within 6 - 12 months of hire.
The course will be offered as needed throughout the year.
For pregnancies less than 24 weeks gestation, auscultation of the fetal heart rate (FHR) is the
recommended method of fetal surveillance.
Electronic fetal monitoring (EFM) is not performed unless by order of physician/midwife. EFM
tracings must have adequate signal strength of both uterine activity and the FHR to ensure
appropriate interpretation of the tracing.
IWK Community Midwives are employed in the Women’s and Newborn Health Program and
provide care for low risk women and their babies in the health centre, community and home
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setting. The guidelines within this document will be adhered to in accordance with midwifery
practice, labour and delivery setting, and clinical situation as appropriate.
DEFINITIONS
Stages of Labour – Labour and birth have been divided into four stages with clinical
parameters and maternal and fetal assessments associated with each one. Cervical changes
are used to assess the progression through each stage. Periodic review and assessment of the
fetal heart status is based on clinical status and underlying risk factors as outlined in this
document.(Simpson & Creelman, 2014).
First Stage of Labor – divided into three phases: latent, active and transition.
 Latent phase - 0 – 3 cm cervical dilation
 Active phase - 4 to 7cm cervical dilation
 Transition – 8 to 10 cm cervical dilation
Second Stage of labor – this stage begins at complete cervical dilation (or 10 cm) and ends
with the birth of the baby.
Leopold’s Maneuvers- a series of maneuvers used to provide a systematic assessment of fetal
position and presentation performed prior to application of the external monitor as part of the
admission assessment. These maneuvers also can provide information that can support
assessments during vaginal examinations and assists in determining the best location to locate
the fetal heart rate(Simpson & Creelman, 2014).
Periodic changes - changes in the FHR associated with contractions and may be either
accelerations or decelerations
Episodic changes - changes in the FHR not associated with contractions and can occur at any
time.
Bradycardia- a fetal heart rate below 110 beats per minutes for greater than 10minutes.
Tachycardia- a fetal heart rate above 160 beats per minute for greater than 10 minutes.
GUIDING PRINCIPLES AND VALUES
The guidelines for Fetal Health Surveillance (FHS) will be provided according to the mode of
monitoring available which include: intermittent auscultation (IA) and continuous electronic fetal
monitoring (EFM). Fetal risk status will be assessed on an ongoing basis following an
established protocol of surveillance and response (SOGC, 2007).
It is important to consider the overall clinical picture including gestational age, presence of risk
factors, stage of labour, and other physiological factors that may influence the tracing.FHR
response is a dynamic process and evolves over time. FHR patterns are dynamic and transient
and require frequent reassessment. It is common for FHR tracings to move from one
classification to another over time.
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Intermittent auscultation (IA) is the recommended fetal surveillance method during labour for
healthy women without risk factors for adverse perinatal outcomes (SOGC, 2007).
Continuous Electronic Fetal Monitoring (EFM) is recommended for high risk pregnancies
where the fetus is at an increased risk of death, cerebral palsy or neonatal encephalopathy and
includes both external and internal methods of monitoring. Examples of patients who require
EFM with are those undergoing induction of labour with Oxytocin and Augmentation of Labour.
Internal methods are not discussed in depth in this policy. Refer to Birth Unit Policies # 7050
Electronic Fetal Heart Rate Monitoring (Internal) and #7095 Intrauterine Pressure Catheter
(IUPC)/Amnioinfusion.
With the increased incidence of multiple gestation pregnancies, there is a challenge to
electronically monitor multiple fetuses. Use of electronic fetal monitoring will attempt to
discriminate between multiple fetal heart rates. Designation of “Twin A” is usually for the fetus in
the lowest position in the pelvis. Dual channeled fetal monitors allow simultaneous heart rate
recordings which display each FHR in a different colour and/or one in a bold line and the other in
a faint line. Each FHR should be clearly labeled to correlate with the monitoring method (Chez &
Baird, 2011).
PROTOCOL
Auscultation of Fetal Heart Rate (FHR) Guidelines (See Appendix C)
1. Fetoscope or hand held doppler device are appropriate tools for auscultation. (Feinstein,
Sprague & Trepanier, 2008).
Important Note: Use of the external ultrasound transducer of the fetal monitor should not be
used as a device for IA. In the computerized OBTV system the data obtained is archived
automatically whether a paper copy of the graph is generated or not. These intermittent brief
segments of graph are too short in duration to be interpretable. It is best to use a hand held
doppler or fetoscope for the purposes of IA for fetal surveillance. (Feinstein et al, 2008).
2. Frequency of Auscultation:
a. For the latent phase of labour, there is limited data on which to base a
recommendation for IA (SOGC, 2007). If, in low risk women, during the latent
phase, a change in the woman’s condition should occur example rupture of the
membranes, bleeding or other significant clinical events, the fetal heart should
be documented on a regular basis. Assess and document every hour if
hospitalized.
b. The active phase of labour is established when a patient has regular
contractions and the cervix has reached 3-4 cm dilation and 80-90%
effacement in a nullipara, and 4-5 cm dilation and 70-80% effacement in a
multipara.
c. Every 15-30 minutes, for one full minute immediately after contraction, during
the active phase of the first stage of labour
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d. Every 15 minutes, for one full minute after contraction, during the second stage
of labour when the woman is not pushing
e. Every 5 minutes or following every second contraction, for one full minute, in the
second stage of labour once the woman has began pushing
f. The FHR should be assessed regularly to ensure it is in the same range after the
contraction as it was in the previous assessments. If not assess for possible
reasons for the change (SOGC, 2007). If change is noted auscultate again
after next contraction and institute intrauterine resuscitation measures (see
appendix E). If FHR changes continue then initiate EFM.
3. Assess fetal heart rate before:
a. Initiation of labour enhancing procedures (example amniotomy)
b. Administration of medications
c. Administration or initiation of analgesia/anaesthesia
d. Transfer or discharge of patient
4. Assess fetal heart rate after:
a. Admission of the patient
b. Artificial or Spontaneous Rupture of Membranes
c. Vaginal examinations
d. Fetal stimulation
e. Abnormal uterine activity patterns (example increased basal tone or tetany)
f. Evaluation of oxytocin (maintenance, increases or decreases of the drug
dosage)
g. Evaluation of analgesia/anaesthesia (maintenance, increases or decreases of
the drug dosage)
h. Administration of medications (at peak time of actions)
i. Following any labour event which has potential influence on fetal oxygenation
(example hypotension, bleeding)
5. Procedure:
a. Palpate the maternal abdomen to identify fetal presentation and position
(Leopold’s Maneuvers).
b. Place the doppler/fetoscope over the area of maximum intensity of fetal heart
sounds (usually over the fetal back).
c. Place a finger on the mother’s radial pulse to differentiate maternal from fetal
heart rate.
d. Uterine contractions will be palpated during a period of fetal heart rate
auscultation in order to clarify the relationship between the fetal heart rate and
the uterine contraction. Contractions will be assessed for frequency, duration,
intensity and resting tone
e. The fetal heart rate will be counted between uterine contractions for at least 60
seconds in order to identify an average baseline rate, the rhythm (regular or
irregular) and the presence or absence of gradual/abrupt changes (increases
or decreases) in the FHR between contractions.
f. Baseline variability is a characteristic which is assessed on EFM and cannot be
reliably identified with IA. Although some practitioners believe that counting the
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FHR for shorter intervals provides information about variability there is no
research to support this practice. (SOGC, 2007).
g. With auscultation there is no data to indicate the practitioner can distinguish the
type of deceleration. Therefore the deceleration patterns classified visually with
EFM cannot be classified with auscultation (SOGC, 2007)
h. The fetal heart rate will be counted after a contraction for at least 60 seconds to
identify the fetal response to contractions/active labour.
i. If distinct differences are noted between counts, recounts for longer periods are
appropriate to clarify the presence and possible nature of periodic fetal heart
rate changes (such as abrupt vs. gradual changes). To clarify fetal heart rate
increases and decreases, consecutive counts for 6 second intervals (multiply
by 10 may be helpful. The FHR may be counted in 15, 30, or 60 second time
blocks; however, the total time the heart rate is counted to determine baseline
must be 60 seconds or more.
j. If unable to obtain fetal heart rate by IA, use a second device (EFM or
ultrasound) to assess for FHR. If continue to have difficulty assessing fetal
heart rate, please call for assistance and notify physician/midwife
6. Interpretation of fetal heart rate as follows (see appendix C):
a. Normal
i. Normal baseline rate (Normal range is 110 to 160 bpm)
ii. Regular rhythm
iii. Presence of increases
iv. Absence of decreases
b. Abnormal
i. Abnormal baseline rate
ii. Irregular rhythm
iii. Tachycardia (FHR greater than 160 bpm)
iv. Bradycardia (FHR less than 110 bpm)
v. Presence of decreases
vi. Changing fetal heart rate
7. Interventions for abnormal fetal heart rate should include (see appendix F)
a. Tachycardia
i. Reposition patient to increase/improve uteroplacental perfusion or
alleviate cord compression.
ii. Rule out fever, dehydration, drug effect and prematurity.
iii. Improve hydration with IV fluid bolus, unless contraindicated.
iv. Consider oxygen at 8 - 10 L/min by non-rebreather face mask.
v. Assess and record maternal pulse and blood pressure.
vi. Oxytocin infusion will be decreased or discontinued.
vii. Continue auscultation of fetal heart rate after next contraction or
consider initiation of electronic fetal monitoring to clarify and document
components of fetal heart rate.
viii. Notify physician/midwife (who may consider fetal scalp sampling) or, if
abnormal findings persist despite corrective measures, consider prompt
delivery.
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b. Bradycardia
i. Reposition patient to increase/improve uteroplacental perfusion or
alleviate cord compression
ii. Perform vaginal exam to assess for prolapsed cord or relieve cord
compression
iii. Assess and confirm maternal pulse.
iv. Administer oxygen at 8-10 L/min by non-rebreather face mask
v. Assess and record blood pressure.
vi. Improve hydration with IV fluid bolus, unless contraindicated.
vii. Discontinue Oxytocin infusion.
viii. Auscultate after next contraction and if pattern persists consider
initiation of electronic fetal monitoring to clarify and document
components of the fetal heart rate (example accelerations or
decelerations).
ix. Notify physician/midwife or, if abnormal findings persist despite
corrective measures, consider prompt delivery (see appendix D).
c. Technically inaccessible fetal heart rate
i. Initiate electronic fetal monitoring
ii. Notify physician/midwife and request assessment of patient.
iii. Obtain ultrasound.
8. Documentation of fetal heart assessment using auscultation should include FHR data,
uterine activity characteristics and classification of normal or abnormal (CPPC, 2008,
p.342):
 Hourly in latent labour (if hospitalized)
 Every 15-30 minutes in active labour
 Every 5 minutes in active second stage of labour
a. Fetal heart rate data
i. Numerical baseline rate (in BPM)
ii. Rhythm if auscultation (regular or irregular – document with initial
assessment and when changes occur)
iii. Nature of changes (gradual or abrupt increases and decreases)
iv. Interpretation of normal/abnormal
b. Uterine activity characteristics obtained by palpation:
i. Frequency (in minutes)
ii. Duration (in seconds)
iii. Intensity (mild, moderate or strong)
iv. Resting tone
c. Interventions appropriate for interpretation of heart rate changes
i. Position changes
ii. Continue with auscultation
iii. Increase frequency of auscultation
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iv. Consider EFM if changes persist
v. Other observations and assessments of maternal/fetal status (example
fetal movements, progress of labour).
vi. Maternal/fetal responses to interventions.
vii. Any subsequent return to normal findings.
viii. Physician/midwife notification and/or presence.
Continuous Electronic Fetal Monitoring
1. Patients will be admitted to the Obstetrical Trace Vue (OBTV) System as outlined in the
OBTV policies and fetal graph managed as outlined in Policy 7118 Quality Practices for
Fetal tracings.
2. The standard graph paper speed for fetal monitors in the IWK Health Centre will be set at
3cm/minute (6 blocks = 1 minute of time) which spreads the data out more facilitating the
interpretation of the tracing. (CPPC, 2008, p.93).
3. The fetal monitor clock will display the correct time (and corresponds to the computer
clock and the wall clock in the birth room).
4. Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal
outcomes (SOGC, 2007). See Appendix A.
5. Procedure:
a. Leopold’s maneuvers are performed to identify fetal position.
b. Fetal heart rate is auscultated over an area of maximum intensity (usually over
the fetal back).
c. A finger is placed on the mother’s radial pulse (to differentiate maternal from
fetal heart rate).
d. During downtime procedures or when using graph paper, the beginning of each
separate tracing is labeled with the woman’s name, unit number, date and time,
room number and nurse’s signature and status.
e. The woman is assisted to a position that allows for maternal comfort and
technical reliability. NOTE: Lateral position is preferred. Avoid supine position
f. Gel is applied to the ultrasound transducer and placed over an area of maximum
fetal heart rate intensity and secured
g. The green indicator light is observed for flashing (denoting optimum fetal heart
rate signal).
h. The woman’s abdomen is palpated to locate the fundus. The toco is placed over
the fundus and secured. Always apply a toco when doing EFM.
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i. Between contractions, the control for the toco is adjusted to read 20mm/Hg.
(normal resting tone of the uterus).
j. The frequency and duration of contractions are noted. The uterus is palpated to
determine intensity of contractions and resting tone of uterus.
6. Systematic interpretation of EFM includes (see appendix C for National Institute for Child
Health & Development (NICHD) ) definitions in more detail):
a. Baseline rate
b. Presence of variability
c. Presence of periodic and/or episodic changes:
i. Accelerations
ii. Decelerations
iii. Periodic changes
iv. Episodic changes
d. Uterine activity:
i. method (i.e. palpation, external toco of IUPC)
ii. Frequency (example, Q4-5 minutes)
iii. Duration (example, 45-60 seconds)
iv. Intensity (example, mild, moderate, strong)
v. Resting Tone
Note: accurate intensity and resting tone are determined by palpation and IUPC
(intrauterine pressure catheter) if in place.
e. Classification (see appendix E)
i. Normal
ii. Atypical
iii. Abnormal
7. Interventions for abnormal/atypical fetal heart pattern should include the following
intrauterine resuscitation measures to improve uterine blood flow, umbilical circulation,
and maternal oxygenation (see appendix F):
a. Maternal position change
b. Oxygen at 8-10L/min by non-rebreather face mask
c. Improve hydration with IV fluid bolus, unless contraindicated.
d. Decrease or discontinue oxytocin infusion
e. Perform vaginal exam to relieve pressure off presenting part
f. Notify physician of fetal heart rate pattern and interventions
8. Documentation for electronic fetal monitoring is to include:
a. Rationale for continuous electronic fetal monitoring. If risk factors are present
and continuous electronic fetal monitoring is not used, the reason will be
documented.
b. During electronic fetal monitoring, the graph will be inspected and findings
(including fetal heart rate and uterine activity) documented:
 at least hourly in latent labour (every 15 minutes if Oxytocin is infusing)
 every 15-30 minutes in the active phase of labour
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
at least every 5 minutes in the active second stage of labour. (SOGC,
2007)
c. Initiation and completion time of electronic fetal monitoring
d. Fetal heart rate data will be documented on the electronic patient health record
including:
i. Numerical baseline rate (example, FHR 125 with CEFM)
ii. Rhythm (regular or irregular – documented with initial assessment when
changes occur).
iii. Nature of the changes (gradual or abrupt, presence of accelerations or
decelerations, type of decelerations – with CEFM).
iv. Variability (example, absent, minimal, moderate, or marked).
v. Note classification (normal/abnormal/atypical) will be documented in the
same frequency as identified in #b of this section. If frequency is every 5
minutes due to pushing classification will occur at 15 minutes intervals
due to the lack of information to perform the classification in 5 minute
increments.
vi. If a tracing is abnormal/atypical the actions taken in response to the
action, and the subsequent return to normal findings (see appendix F).
e. Uterine Activity Characteristics:
i. Frequency (example, Q4-5 minutes)
ii. Duration (example, 45-60 seconds)
iii. Intensity (example, mild, moderate, strong)
iv. Resting Tone -accurate intensity and resting tone are determined by
palpation or IUPC (intrauterine pressure catheter).
f. Fetal responses to procedures (example rupture of membranes)
g. Interventions (example, maternal position change)
h. Changes in maternal status (example, change in vital signs) that may influence
the fetal health will be documented.
i. If the tracing has been shown for inspection, time and name of person who
viewed the graph will be documented.
j. Any mechanical problems affecting the quality of the tracing and action taken will
be documented, (example, “scalp electrode not working, new electrode
applied”).
9. Artifact is an irregular variation or intermittent tracing of the FHR on the fetal monitoring
tracing that is due to mechanical limitations or electrical interference from the monitoring
system.
a. Artifact is usually due to an improper placement of the ultrasound transducer or
internal fetal scalp electrode
b. It is important to distinguish between artifact and cardiac dysrhythmias which
appear as an organized pattern.
c. To troubleshoot suspected artifact:
i. Confirm the presence of FHR sounds by auscultation and note the rate and
rhythm.
ii. Reposition the tocotransducer to obtain a clear continuous signal
iii. Anticipate the need for placement of a fetal scalp electrode if unable to
obtain a technically adequate external tracing
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iv. If an internal fetal scalp electrode is in place, check for disconnection from
the fetus or equipment
v. Obtain the assistance of a second RN
vi. Notify the physician if unable to obtain a technically adequate tracing
vii. Document all interventions, notification of physician and the plan and
implementation of care to obtain an adequate FHR tracing.
10. To check an ambiguous FHR pattern, the RN will auscultate with a doppler and compare
to the maternal pulse. Document the FHR, maternal pulse findings, interventions,
maternal/fetal response and physician notification.
11. Upon completion of the fetal monitoring for the patient’s admission if electronic save and
close episode as per OBTV policy # 7116 or if paper graph refer to OBTV policy: Down
Time Procedures # 7117.
12. Document fetal heart rate assessment parameters on health record.
SPECIAL CONSIDERATIONS:
Scheduled Same day Admissions (Cesarean Sections) where fetal heart rates are often
assessed using the Doppler, please ensure that fetal heart rate is assessed following the
placement of a spinal/epidural analgesia every 5 minutes x 3 then every 15 minutes following
the implementation of analgesia if case is delayed.
Telemetry
Ambulatory electronic fetal monitoring (telemetry) may be used when continuous monitoring is
required for healthy patients in labour at term or for low risk induction of labour.
Telemetry can be used for continuous, cordless fetal heart monitoring in the antepartum period
and during labour and delivery. It provides an opportunity for the laboring patient to ambulate
while satisfying the requirement for continuous monitoring in labour during induction of labour..
This is a valid option for surveillance if able to maintain a good quality tracing for interpretation
and fetal well being is maintained.
In the presence of an atypical or abnormal fetal heart rate tracing ambulatory EFM will not be
used.
Twin Gestation:
In assessing fetal heart rates for twin gestation, ensure each baby is being monitored
separately. With twin gestation, the tracings should differ although there may be periods of time
when the FHRs will look the same.
It is helpful to document the location of each baby being monitored in relation to the maternal
abdomen due to the potential for fetal position changes. Every effort should be made to ensure
monitoring consistency.
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If possible a fetal spiral electrode is applied to the presenting twin prior to a vaginal delivery for
ease of continuous monitoring of the presenting twin. An external monitor will be used for the
second twin.
At the time of birth the first twin who is delivered will be identified as the “first twin or Twin A” and
the other baby is identified as “second twin or Twin B”.(P.135 Murray, 2007).
Following delivery of first twin, continuous fetal monitoring will be maintained for second twin
either externally or with fetal spiral electrode.
REFERENCES
American College of Obstetricians & Gynecologists (2009). Intrapartum Fetal Heart Rate
Monitoring: Nomenclature, Interpretation, and General Management Principles. ACOG
Practice Bulletin #106. Obstetrics & Gynecology, 114(1), 192-202.
Association of Women’s Health Obstetrical and Neonatal Nurses (AWHONN) Feinstein, N.,
Torgersen, K., and Atterbury, J. Eds. (2009). Fetal Heart Monitoring Principles and
Practices. 4th edition, Dubuque, Iowa: Kendall/Hunt Publishing Company.
Bakker, P.C.A.M., Rijsiwijk, S.V. & vanGeijn, H.P. (2007). Uterine activity monitoring during
labour. Journal of Perinatal Medicine, 35; 468-477.
BC Women’s & Children’s Hospital (2009). Intrapartum Electronic Fetal Heart Monitoring. Policy
#CF0500. Fetal Maternal Newborn and Family Health Policy & Procedure Manual
Canadian Perinatal Programs Coalition (2009). Fundamentals of Fetal Health Surveillance: A
Self-Learning manual (4Th Edition). L. Lee, A. Sprague, J. Yee & W. Ehman Editors.
British Columbia Perinatal Health program.
Chez,B.F. & Bard, S.M. (2011). Electronic fetal monitoring: Where are we now? Journal of
Perinatal and Neonatal Nursing, 25(2), 180-192.
Feinstein, N.F., Sprague, A. & Trepanier, MJ. (2008). Fetal Heart Rate Auscultation. 2 nd edition.
Association of Women’s Health, Obstetric and Neonatal Nurses Practice Monograph.
Macones, G.A., Hankins, G.D.V., Spong, C.Y., Hauth, J. & Moore, T. (2008). The 2008 National
Institute of Child Health and Human Development Workshop Report on Electronic Fetal
Monitoring: Update on Definitions, Interpretation, and Research Guidelines. JOGNN,
37(5), 510-515
.
Murray, M. (2007) Antepartal and Intrapartal Fetal Monitoring (3rd Edition).Springer
Publishing Company: New York.
Parer, J.T., Ikeda, T. & King, T.L. (2009). The 2008 National Institute of Child Health and Human
Development Report on fetal heart rate monitoring. Obstetrics & Gynecology, 114(1),
136-138.
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Intrapartum Fetal Health Surveillance
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Philips Healthcare (2006). Avalon CTS Cordless Fetal Transducer System: Instructions for Use
Manual.
Royal University Hospital (2011). Auscultation of the Fetal Heart Rate Policy #403 Labour &
Birth Policy & Procedure Manual. Saskatoon: Saskatchewan.
Royal University Hospital (2011).Intrapartum Electronic Fetal Monitoring #402 Labour & Birth
Policy & Procedure Manual. Saskatoon: Saskatchewan.
Society of Obstetricians and Gynaecologists of Canada (SOGC) Council (2007). Fetal Health
Surveillance: Antepartum and Intrapartum Consensus Guideline. JOGC, 29 (9),
Supplement 5, S1 –S53. www.sogc.org
RELATED DOCUMENTS
Policies:
IWK Administrative Policy #324.2 - Approval and Performance of Beyond Entry Level
Competencies (BELCs) by Registered Nurses at the IWK Health Centre
IWK Health Centre Birth Unit Clinical Policy #7050 Electronic Fetal Heart Rate Monitoring
(Internal)
IWK Health Centre Birth Unit Clinical Policy #7095 Intrauterine Pressure Catheter
(IUC)/Amnioinfusion
IWK Health Centre Women’s & Newborn Health Multi-team Policy # TBA Antenatal Fetal Health
Surveillance
IWK Health Centre Women’s & Newborn Health Program Policy #50015 IWK Community
Midwives Planned Home Birth Policy
IWK Health Centre Birth Unit Clinical Policy #7115 Print Policy: Obstetrical TraceVue System
IWK Health Centre Birth Unit Clinical Policy # 7116 Electronic Documentation: Obstetrical
TraceVue System
IWK Health Centre Birth Unit Clinical Policy # 7117 Down Time Procedures: Obstetrical
TraceVue System
IWK Health Centre Birth Unit Clinical Policy # 7118 Quality Practices for Paper Fetal Tracing
IWK Health Centre Birth Unit Clinical Policy # 7119 Roles & Responsibilities: Obstetrical
TraceVue System
Forms:
Obstetrical Partogram Form# IWKPA
Appendices:
Appendix A - Antenatal Conditions Associated With Increased Risk of Adverse Fetal Outcomes
Appendix B - Abbreviations for Charting Fetal Heart Rate (FHR) and
Characteristics for Electronic Fetal Monitoring
Appendix C - National Institute for Child Health & Development (NICHD) Definitions
Appendix D - SOGC Auscultation Clinical Decision Making Tree
Appendix E - Classification of EFM Tracings
Appendix F - Interventions for EFM Tracings
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APPENDIX A
Antenatal Conditions Associated With Increased Risk
of Adverse Fetal Outcomes
Table 12. Antenatal and intrapartum conditions associated with increased risk of adverse
fetal outcome* where intrapartum electronic fetal surveillance may be beneficial
Antenatal
Maternal
Intrapartum
Antepartum hemorrhage
Hypertensive disorders of pregnancy
Maternal trauma/MVA (Motor Vehicle Accident)
Maternal medical disease
Morbid obesity (bariatric)
Pre-existing diabetes melilitus/Gestational
diabetes
Fetal Abnormal umbilical artery doppler velocimetry
Breech presentation
Intrauterine growth restriction
Isoimmunization
Multiple pregnancy
Oligohydramnios
prematurity
Maternal Augmented labour
Hypertonic uterus
Induced labour
Intrauterine infection/chorioamnioitis
Post term pregnancy (greater than42 weeks)
Preterm labour
Previous cesarean section
Prolonged membrane rupture greater than 24
hours at term
Vaginal bleeding in labor
Fetal Abnormal fetal heart rate on auscultation
Meconium staining of the amniotic fluid
SOGC (2007) Table 12 page S33
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APPENDIX B
Abbreviations for Charting Fetal Heart Rate (FHR) and
Characteristics for Electronic Fetal Monitoring
Examples of abbreviations for charting fetal heart rate (FHR) characteristics/electronic fetal
monitoring.
ausc
EFM
U/S
Toco
SE
IUPC
BL
FHR
bpm
Variability:
Abs
Min
or equal to 5 bpm)
Mod
Mar
Decel
accel
Var Decel
prolonged decel
tachy
brady
sec
min
UC
mod
ext
int
palp
stim
auscultation
Electronic Fetal Monitoring
Ultrasound (external)
tocodynamometer (external)
Spiral Electrode (internal)
intrauterine Pressure Catheter (internal)
Baseline
fetal heart rate
beats per minute
Absent variability (amplitude range undetectable from baseline)
Minimal variability (amplitude range greater than undetectable and less than
Moderate variability (amplitude range 6 – 25 bpm)
Marked variability (amplitude range greater than 25 bpm)
Deceleration (a decrease in the FHR, may be gradual or abrupt
depending on type. e.g. early, variable or late). Refer to partogram key for
documentation)
acceleration (a rise in the baseline FHR of at least 15 BPM for at
least 15 seconds, transitory)
variable deceleration
prolonged deceleration
tachycardia (FHR greater than 160 BPM for at least 10 minutes)
bradycardia (FHR less than110 BPM for at least 10 minutes)
second(s)
minute(s)
Uterine contraction
moderate
external
internal
palpation
stimulation
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APPENDIX C - National Institute for Child Health & Development (NICHD) Definitions
FETAL HEART RATE CHARACTERISTICS AND PATTERNS
Term
Definition
Baseline Rate
Bradycardia
Tachycardia
Baseline Variability
Absent variability
Minimal Variability
Moderate variability
Marked variability
Acceleration
Prolonged acceleration
Early deceleration
Late deceleration
Variable deceleration
Prolonged deceleration
Approximate mean FHR rounded to increments of 5 bpm during a 10 min
segment excluding periodic or episodic changes, periods of marked
variability and segments of baseline that differs by greater than 25 bpm. In
any 10 minute window, the minimum baseline duration must be at least 2
min. or the baseline for that period is indeterminate. In this case, one may
need to refer to the previous 10 min. segment for determination of the
baseline.
Fetal heart rate baseline rate of less than 110 bpm for at least 10 minutes
Fetal heart rate baseline rate of greater than 160 bpm for 10 minutes or
longer
Fluctuations in the baseline FHR of 2 cycles/minute or greater. These
fluctuations are irregular in amplitude and frequency and are visually
quantified as the amplitude of the peak to trough in bpm
Amplitude range undetectable
Amplitude range greater than undetectable and less than or equal to 5
bpm.
Amplitude range 6-25 bpm.
Amplitude range greater than 25 bpm.
Visually apparent abrupt increase (onset to peak is less than 30 sec.) in
FHR above baseline. The increase is calculated from the most recently
determined portion of the baseline. Acme is greater than or equal to 15
bpm above the baseline and lasts greater than or equal to 15 sec. and
less than 2 min. from the onset to return to baseline. Before 32 weeks of
gestation, an acme greater than10 bpm above the baseline and duration
of greater than 10 sec. is an acceleration.
Acceleration greater than 2 min. and less than 10 min. duration.
Visually apparent gradual decrease (onset to nadir is greater than or
equal to 30 sec.) of the FHR and return to baseline associated with a
uterine contraction. This decrease is calculated from the most recently
determined portion of the baseline. It is coincident in timing, with the nadir
of deceleration occurring at the same time as the peak of the contraction.
In most cases, the onset, nadir and recovery of the deceleration are
coincident with the beginning, peak and ending of the contraction,
respectively.
Visually apparent gradual decrease (onset to nadir is greater than or equal
to 30 sec.) of the FHR and return to baseline associated with a uterine
contraction. This decrease is calculated from the most recently
determined portion of the baseline. It is delayed in timing, with the nadir of
deceleration occurring after the peak of the contraction. In most cases, the
onset, nadir and recovery of the deceleration occur after the onset, peak
and ending of the contraction respectively.
Visually apparent abrupt decrease (onset to beginning of nadir is less than
30 sec.) in FHR below baseline. The decrease is calculated from the most
recently determined portion of the baseline. Decrease is greater than or
equal to 15 bpm, lasting greater than or equal to 15 sec. and less than 2
min. from onset to return to baseline. When variable decelerations are
associated with uterine contractions, their onset, depth and duration vary
with successive uterine contractions.
Visually apparent decrease in FHR below baseline. The decrease is
calculated from the most recently determined portion of the baseline.
Decrease is greater than or equal to 15 bpm, lasting greater than 2 min.
but less than 10 min. from onset to return to baseline.
Reference: Adapted from Chez & Bard, 2011, page 181.NICHD Definitions
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APPENDIX D
SOGC Auscultation Clinical Decision Making Tree
Clinical Decision Making – Intermittent Auscultation in Labour (SOGC, 2007)
Legend for above algorithm:
< Less than
>Greater than
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APPENDIX E
Classification of EFM Tracings
Reference: Adapted from SOGC (2007)
Legend for above table:
< Less than
≤ Less than or equal to
>Greater than
≥ Greater than or equal to
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APPENDIX F
INTERVENTIONS For EFM Tracings (SOGC, 2007)
And operative delivery
Legend for algorithm:
>Greater than
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