Download Combined fetal monitoring guideline (GL964)

Combined fetal monitoring
guideline (GL964)
Approval
Approval Group
Job Title, Chair of Committee
Maternity & Children’s Services
Clinical Governance Committee
Chair, Maternity Clinical
Governance Committee
Date
th
10 April 2015
5th Feb 2016
Change History
Version
Date
Author, job title
Reason
1.0
March 2015
Rebecca Blakely (Antenatal
Services Manager)
1.1
January
2016
April 2016
Christine Harding, Clinical
Lead Midwife
A Mansfield, Mat Info Officer
Jane Siddall, Consultant in
Fetomaternal medicine
C Harding, Clinical lead MW
Amalgamation of existing
separate guidelines (see list
below)
Pg 8 typo error on CTG sticker
August
2016
S Bailey (Marsh Ward mngr)
1.2
1.3
Pg 2 - additions re: RFM
Pg 2 - Addition of DawesRedman information
Pg 7 – Central monitoring added
Pg 7 Uterine activity – 3rd para
expanded following review of
serious incident
This is an amalgamation of the following existing guidelines which are now removed:

Antenatal CTG monitoring (GL803) V8.0 written by Jane Siddall & Mark Selinger
(Consultants in Fetomaternal medicine)

Intrapartum electronic monitoring of Fetal heart rate and contractions guideline (GL842)
V8.3 Feb 2015 written by J Siddall (Consultant Obstetrician)

Monitoring fetal wellbeing by Intermittent Auscultation of the fetal heart in labour (GL843)
V6.1 Sept 2014 written by A Weavers (Consultant Midwife)

Fetal Monitoring Resource File (GL844) March 2014 written by Rebecca French/Sara
Phillips/Rebecca Blakely (Clinical Lead Midwives and Fetal Monitoring Midwife)
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 1of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Antenatal CTG monitoring
Prior to 26 weeks gestation a CTG should not be performed, auscultation of Fetal heart
should be undertaken with sonicaid or pinard or visualisation of FH with USS.
Women between 26 – 28 weeks who require a CTG following a consultant review must be
monitored using the Dawes-Redman criteria.
CTG should NOT be undertaken prior to 28 weeks for reduced fetal movements (see
guideline on Reduced Fetal Movement GL903).
The Dawes Redman CTG analysis can be used for antenatal CTG, priority should be
given to cases where there is concern about fetal wellbeing, e.g. SFD/abnormal Doppler’s.
It is valid for any gestation over 26 weeks but it is not suitable for intrapartum CTG
analysis.
Criteria met: The Dawes/Redman criteria can meet the criteria as early as 10mins, if the
criteria is met at this point the CTG can be considered normal and discontinued, it does
not need to continue for the traditional 20 minutes. The CTG should be reviewed but the
measurements and STV are insignificant as the CTG has been classified as normal.
Criteria not met: If the criteria is not met it must be continued for 60 minutes, at this point
the CTG should be discontinued and an appropriate clinical review/action must be taken.
There will be specific reason codes as to why the criteria has not been met (see
information attached to CTG). The STV should be taken into account and the trend
reviewed if previous analysis has been performed. A low STV is most commonly
associated with growth retarded, chronically stressed fetuses.
STV values:
≥4 is normal
<4 is low
<3 is abnormal
<2 highly abnormal
An antenatal CTG sticker and signature should still be applied at the end of the CTG to
ensure that it has been reviewed by a qualified member of staff.
Record keeping
The following data should be checked documented at the beginning of every CTG
1. Correct date and time on the clocks of fetal monitor- should be hand written or print
out confirmed to be correct.
2. The paper speed is 1cm/min
3. Mother’s name, and hospital number
4. Maternal pulse and fetal heart after auscultation at the initiation of the CTG.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 2 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Or use preformatted ‘start of CTG’ sticker
Date & time of start
Date / time / paper
speed correct?
Name/DOB/number
Indication for CTG
FH auscultated
Gest:
Pinard / sonicaid
MP:
Sign:
FH:
Print:
Induction of labour with propess
There should be a minimum of 20 minute CTG prior to induction. Once contractions
establish, a CTG should be performed and labour monitored in the usual way.
Interpretation
The CTG should be no less than 20 minutes in
duration, if the CTG continues for longer there
should be regular reviews of the CTG by a qualified
member of staff, every 20 minutes, this should be
annotated on the CTG with a signature/print name
and time. A CTG should never be left unattended
without review for any longer periods. A structured
review of all the features of CTG (Contractions,
baseline rate, variability, accelerations, and
decelerations)
should
be
performed
and
documented on the preformatted ‘antenatal’ CTG
sticker at the end of the CTG and the notes the
trace should be classified as NORMAL or
ABNORMAL.
Normal
Abnormal
100-160bpm
<100 or
>160bpm
Accelerations
At least 2 in 20
mins
None in >40
mins
Variability
>5 bpm
<5 bpm
Decelerations
None/ early
Present
CTG last
normal
Now
Baseline rate
min/hr/
days
ago
Uterine activity:
Signed
________:10
F/ M / S
Date/time
Twins
An ultrasound examination should be performed prior to commencing any CTG in a twin
pregnancy to confirm location of two individual Fetal hearts. An FSE should be applied to
twin one if cephalic as soon as viably possible. The 20 beat separation of the two fetal
hearts should be applied to differentiate more easily between the twins.
Storage of Ante-natal CTGs
CTG’s should be stored in the brown Antenatal CTG envelope in the maternal notes and
the front of the envelope signed. Other results should not be filed in this envelope, such
as fetal blood sampling results.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 3 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Monitoring of Standards:
The audit team will comprise
A midwife and/or a doctor and/or a maternity support worker
Audit and quality midwife
A clinical audit facilitator
Auditable standards:
1. The minimum data set that will be recorded on commencement of all CTG monitoring
traces includes: woman’s name, hospital number, date & time, maternal pulse.
2. Maternal pulse will be auscultated and documented on CTG trace in all cases when the
FHR deviates from the norm.
3. A CTG assessment will be carried out on completion of CTG recording during the
antenatal period by completing a CTG assessment label and attaching it to the CTG
trace and in the maternal health record.
The audit will compare results with previous audits, if applicable. The audit will review
documentation stated in the maternal health records as evidence of compliance with
standards.
References:
4. FIGO (1987) Guidelines for the use of fetal monitoring. IJO&G 25:159-167
5. Gibb D, Ingermarrson S. (1992) Fetal Monitoring in Practice. Butterworth - Heinemann
Ltd. London
6. NICE inherited clinical guideline www.nice.org.uk/page.aspx?o=20256
7. Ingemarrson I, Ingemarrson E, Spencer J (1993) Fetal heart Rate Monitoring. Oxford
Medical Publications, Oxford
www.rcog.org.uk/guidelines/efm_guideline_final_2may2001.pdf
8. NPSA www.npsa.nhs.uk/
9. NICE (2014) Intrapartum care. Clinical Guideline 55. December 2014 Available
www.nice.org.uk/CG190
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 4 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Intrapartum electronic monitoring of Fetal
heart rate and contractions
The objective of fetal heart rate (FHR) monitoring in labour is to reduce fetal
mortality/morbidity by ensuring that any fetal hypoxic insult is identified in time to allow
either:
 Removal/amelioration of the hypoxic insult
 Delivery of the fetus from the uterus before irreversible asphyxial damage
occurs
The purpose of this document is to provide guidance and standardise the documentation,
interpretation and management of intrapartum fetal monitoring.
Indications for CTG in labour
Please use the Trust Labour Risk Assessment Tool to identify all the pregnancies where
continuous electronic fetal monitoring is clinically indicated or recommended.
In addition, continuous electronic monitoring should be performed at:
 Maternal request
 Midwifery discretion
 Consultant request
Fetal heart rate
The presence of fetal heart beat must be confirmed with auscultation using pinard,
sonicaid or visualisation of FH with USS.
1. Before the CTG is commenced
2. Every time the CTG is recommenced after periods of break or no recording
3. When there is sudden change in the FHR pattern i.e. a previously abnormal trace
becomes suddenly normal.
4. Before the application of fetal scalp electrode (FSE) if there is no previous CTG
recording.
The FHR should be documented on the trace and in the woman’s medical records.
The following problems associated with the recording of the FHR are expected to be
addressed within 5 minutes initially by the midwife in the room. If the problem persists
support by the co-ordinator or registrar should be sought promptly:
1. Fetal heart not present at the initial auscultation
2. Uninterpretable CTG in first or second stage of labour
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 5 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Quality of monitoring.
The quality of monitoring of both uterine activity and FHR must allow for accurate
interpretation even during the siting of an epidural. The monitoring of the FHR during the
insertion of regional anaesthesia may be difficult but it is important to maintain a good
quality trace even during that time. If you anticipate such a problem consider applying an
FSE prior to the procedure being commenced.
Contraindications for applying an FSE
1.
2.
3.
4.
Maternal infection such HIV, Hepatitis B, C
Suspected or confirmed bleeding disorder of the fetus
Prematurity <34 weeks
Face presentation
Refer to table 1 for problem solving solution.
Table 1. - Solving problems with recording of FHR
Solving problems with Recommended action
recording of FHR
No fetal heart rate
a. Before the CTG is
commenced
 The Registrar and Coordinator should be
informed immediately
 A portable US machine should be brought to the bedside.
 Visualise fetal heart beating with
ultrasound.
 Confirm fetal life
 Reposition US transducer
Erratic recording, loss
of contact with external
US transducer





Erratic or no recording
with FSE





Perform Leopold’s manoeuvres to locate fetal back
Reposition US transducer over fetal back
Readjust belt and apply enough gel over US transducer
If recording still suboptimal, locate fetal heart with
ultrasound and reposition US transducer
If membranes ruptured and there are no contraindications,
apply fetal scalp electrode.
Confirm presence of fetal heart beat with ultrasound or
auscultation
Check that FSE wire is attached to the leg plate
Check FSE connection to fetus, and replace it if detached
Check that external monitor is discontinued
Transcutaneous Electrical Nerve Stimulation (TENS) may
interfere with the acquisition of FHR signal.
Call registrar. Full evaluation of history and labour to this
point. Consider expediting delivery if fetal wellbeing cannot
be adequately confirmed
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 6 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Artifacts with FSE



Confirm presence of fetal heart beat with ultrasound or
auscultation
Commence external monitor
Reposition FSE and ensure it is not attached over
membranes or close to cervix or vaginal walls.
Erroneous recording of the maternal heart rate MHR
Inadvertent recording of the maternal heart rate should be suspected in the following
situations
1. Sudden shift in the baseline rate
2. Sudden improvement of a previously abnormal trace
3. Accelerations that coincide with the contractions especially in the second stage of
labour.
In these cases one of the following options should be undertaken
1. Check maternal pulse. This should differ from what is displayed on CTG. pulse
oximeter allows continuous monitoring of MHR and this can be helpful in the second
stage when the MHR can accelerate significantly during the pushing efforts and can
be mistaken for fetal.
2. Ultrasound examination of the fetal heart and repositioning of external transducer
3. Apply a FSE only once positive FH has been confirmed with sonicaid, pinard or
USS.
Uterine activity
Confirm the uterine activity pattern (frequency, strength, duration and uterine resting tone)
by abdominal palpation; this should be clearly documented in the medical records.
Place the toco transducer at the level of uterine fundus. In preterm pregnancies this level
is expected to be lower and closer to the umbilicus.
If monitoring of the contractions is not possible;




Change maternal position
Consider using the extra large straps for women with increased BMI
Palpate contraction and place toco on abdomen where contraction palpated at
strongest
Escalate to senior midwife
In order for the CTG to be assessed accurately the recording of the contractions is a
vital element therefore every effort should be made to record on the CTG the presence
of contractions. If the toco is not picking them up the midwife may use another method
to ensure this is done, e.g. press the toco lightly during contraction, or mark the CTG
but accuracy must be sought.
Any difficulties in monitoring the contractions should be evidenced within the maternal
records including actions taken.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 7 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
The midwife should monitor contractions by palpating continuously for 10 mins every 30
mins. They should document in the maternal records difficulties of monitoring contraction
and how they are palpating for strength, duration via palpates.
Alternatively the woman may be asked to assist by using fetal movement button. This
should be documented in the woman’s medical records.
Telemetry
This should be offered, when available, to women to encourage mobility and
normalisation.
Twins
An ultrasound examination should be performed prior to commencing any CTG in a twin
pregnancy to confirm location of two individual Fetal hearts. An FSE should be applied to
twin one if cephalic as soon as viably possible. The 20 beat separation of the two fetal
hearts should be applied to differentiate more easily between the twins.
Interpretation
The CTG should be reviewed continuously and the FHR baseline recorded in the
partogram every 15 minutes in the first stage and every 5 minutes in the second stage.
A structured review of all the features of CTG (Contractions, baseline rate, variability,
accelerations, and decelerations) should be performed and documented in the notes
hourly; the trace should be classified as NORMAL, NON-REASSURING or ABNORMAL
requiring conservative management or ABNORMAL requiring urgent intervention.
When reviewing a CTG consideration of previous CTG tracings should be made to identify
when the CTG was last normal.
Central monitoring
Every effort should be made to admit the patient onto the K2 Guardian system to allow
central monitoring to take place. This is to reduce unnecessary interruptions in the room,
enable the electronic storage of CTGs and facilitate teaching. The ongoing review of the
CTG and escalation of concerns remain the responsibility of the midwife providing care for
the patient. The central station will not be constantly observed.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 8 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Record keeping
The following data should be checked documented at the beginning of every CTG
1. Correct date and time on the clocks of fetal monitor- should be hand written or print
out confirmed to be correct.
2. The paper speed is 1cm/min
3. Mother’s name, and hospital number, and DOB
4. Maternal pulse and fetal heart after auscultation at the initiation of the CTG.
5. Signature and Printed name of person commencing CTG
6. Reviews of CTG (Hourly review of the FHR to a maximum of 90 mins or more
frequently if clinically indicated). Pre-formatted ‘intrapartum’ CTG stickers should be
used for every CTG review and placed in the medical notes, a corresponding
coloured dot should be placed on the CTG trace, green indicates ‘normal’, amber
for ‘non-reassuring’ and red for ‘abnormal’. There should be an annotation of the
colour of next to the dot (R, A, G) to allow for black/white photocopying. The sticker
includes a note of when the CTG was last normal. The findings should also be
documented in the woman’s medical records with a written plan for on-going care.
In the event of twins two sticky labels should be used in the same way indicating
which sticker applies to which twin.
7. Intrapartum events that may affect FHR ( VE, FBS, epidural sited/top up, Oxytocin
adjustments)
8. Fresh eyes review of all intrapartum CTGs must be made by an appropriately
trained member of staff every 60-90mins. Any disagreements in the interpretation
should be referred to the delivery suite co-ordinator, registrar or consultant. Two
coloured dots should be applied to the CTG for the fetal heart and contraction
frequency whenever ‘fresh eyes’ is performed.
9. Date, time and mode of delivery at the end of the trace with the signature of the
attending midwife.
On completion of the CTG the tracing should be stored securely within the manila
envelope marked ‘Intrapartum CTG’ which should have the woman’s name and hospital
number on the front. This is located within the intrapartum section in the woman’s medical
records.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 9 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Risk Factors:
Baseline rate
Stable 100-160
161-180
<100 Rate: _______bpm
At beginning of CTG:
Rate: ______ bpm
Rate: ______ bpm
>180
_____ bpm
Sinusoidal for >10 mins
Variability
> 5 bpm
< 5 bpm for 30-90 mins
<5 bpm for >90 mins
Decelerations
None
Variable:
Continued non-reassuring
variable despite action for ≥
30 mins
Early
≤60beats for up
to 60 secs for
> 90 mins
OR
All with
>50% of
conts
Late
Overall assessment
Contractions
______ :10
OR
≥60 beats or
>60 secs for
≤30 mins
Late for over 30 mins OR
Single prolonged
decelerations for ≥3mins.
For up to 30
mins
Normal
Non-reassuring
Abnormal
All 3 features are
reassuring
1 non-reassuring feature, 2
reassuring features
2 or more non-reassuring
features, OR 1 abnormal
feature.
Oxytocin in use?
Notes/Plan:
↑ Fluids/Paracetamol
Yes/No
Position change
Rate: ______ mls/hr
Maternal pulse
(manually palpated)
______ bpm
Synto: ↑ ↓
Signed:
STOP
Escalate
FBS
Signed:
CTG Normal
Deliver within _____ mins
Fresh eyes/snr review
Now/
mins ago
Review in______ mins
If there is no evidence of an acute problem, no improvement after the initial intrauterine
resuscitation, no acceleration after the digital fetal scalp stimulation and the CTG remains
abnormal consider doing Fetal blood sampling.
Table 7 - Interpretation of FBS results.
FBS result pH
Interpretation
≥7.25
Normal
7.21-7.24
Borderline
≤ 7.20
Abnormal
Action
Repeat FBS within an hour if CTG
abnormal. Consider it sooner if CTG
deteriorates
Repeat FBS within 30 minutes if CTG
abnormal, sooner if fetal reserve is likely to
be compromised or CTG deteriorates
Expedite delivery
Discuss case with Consultant on call
Average time for completing an FBS is 18 minutes; please take this into account when planning a
repeat sample.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 10 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
If the FHR trace remains unchanged and the FBS result is stable after the second test, a
third/further sample may be deferred unless additional non-reassuring or abnormal
features develop.
Where a third FBS is considered necessary, consultant obstetric opinion should be sought.
If an FBS is indicated and the sample cannot be obtained, but the associated scalp
stimulation results in FHR accelerations, a decision should be made whether to continue
with the labour or expedite the delivery in light of the clinical circumstances and in
discussion with the consultant obstetrician and the woman.
If FBS is indicated but cannot be obtained and there is no improvement in the CTG, advise
the woman the delivery should be expedited.
Contraindications to FBS include:
 Maternal infection (for example, HIV, hepatitis viruses and herpes simplex virus) or
pyrexia>37.80C

Fetal bleeding disorders (for example, haemophilia)

Prematurity (less than 34 weeks)

Face presentation
Operative delivery for fetal distress
Operative delivery for fetal distress should be considered in the following situations
1. Acute event (Abruption, Uterine rupture, Cord prolapse, prolonged deceleration)
2. The CTG remains abnormal after the initial conservative measures and FBS is not
feasible or there are no FBS results
If the CTG remains abnormal and there are no FBS results the case must be
discussed with the Obstetric Consultant.
3. FBS results, pH less than 7.20
Once the decision has been made, the delivery must be achieved within 30 minutes.
If the woman is transferred to theatre the registrar on call should be present in theatre as
there may be a need to upgrade or downgrade the urgency of the delivery.
Paired Cord gases should always be obtained at delivery and analysed within an hour
from delivery.
The results should be recorded on the reverse of the partogram, or within free text if there
is no partogram of the woman’s health record. If the result is abnormal (arterial cord pH <
7.05 or BE < -12) record the results on the neonatal birth record and inform the
paediatrician.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 11 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
COMMUNICATION
With the woman




Maternal wishes and concerns should be discussed.
The benefits, risks and limitations of the intrapartum fetal monitoring should be
explained.
Consent should be sought for the aforementioned interventions.
The woman should be included in the decision making process regarding her care.
Interdisciplinary
A structured transfer of information among healthcare professionals in labour ward can
optimise communication, elicit appropriate response and help the prioritisation of workload.
TRAINING
Health professionals performing, interpreting and managing CTGs should update
their skills regularly.
The updates should be multidisciplinary to ensure use of common terminology and
shared understanding.
Auditable standards:
1. In all cases when a transfer from intermittent auscultation to continuous electronic
fetal monitoring occurs, the reason for transfer will be documented in the maternal
health record. The indication for transfer will be in accordance with the listed
indications for continuous electronic fetal monitoring stated in the guideline.
The maternal pulse will be palpated and documented at the beginning of the
intrapartum auscultation and hourly thereafter.
2. The minimum data set that will be recorded on commencement of all CTG
monitoring traces includes: woman’s name, hospital number, date & time and
maternal pulse.
3. A minimum of hourly assessments on the CTG trace will be carried out during the
intrapartum period by completing a CTG assessment label, signed and timed and
attaching it to the CTG trace and in the maternal health record. Assessments will be
aimed to be done hourly and within a maximum of 90 minutes of previous
assessment.
4. The indication for commencement of CTG will be in accordance with the listed
indications for continuous electronic fetal monitoring stated in the guideline.
5. “Fresh eye” reviews will be carried out hourly and within a maximum of 90 minutes
from previous fresh eyes assessment by a midwife or an obstetrician.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 12 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
6. All intrapartum events that may affect the FHR will be signalled, signed and timed
on the CTG trace.
7. All second opinions provided during labour will be notes, signed and timed on the
CTG trace by the person providing the second opinion.
8. In all cases when the CTG trace is assessed as ‘abnormal’ an action plan will be
documented in the maternal health care record.
9. All intrapartum CTG traces will be stored in the intrapartum CTG envelope securely
attached to the maternal health record.
10. The minimum data set that will be recorded on completion of CTG following birth
includes: mode of delivery, date & time, signature.
References
1. NICE (2014) Intrapartum care: care of healthy women and their babies during
childbirth. Clinical Guideline 190. December 2014 Available
www.nice.org.uk/CG190
2. SOGC Fetal Health Surveillance: Antepartum and Intrapartum Consensus
Guideline. Clinical Practice Guideline No 197 September 2007 Available
http://www.sogc.org/guidelines/documents/gui197CPG0709r.pdf
3. Gibb, D and Arulkumaran, S. 2008. Fetal monitoring in practice. 3rd Edition.
Churchill Livingstone: London
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 13 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Monitoring fetal wellbeing by Intermittent
Auscultation of the fetal heart in labour
Overview:
Intermittent auscultation (IA) of the fetal heart (FH) in labour with a sonicaid or Pinnard
should be recommended for all women who are healthy and have uncomplicated
pregnancies. In low risk women routine continuous electronic fetal monitoring (CEFM) is
associated with more caesarean sections and assisted vaginal births.
This guideline aims to highlight best practice and minimum standards when carrying out
intermittent auscultation of the fetal heart in labour. Increased fetal surveillance through
prolonged auscultation (i.e. >one minute) with a sonicaid (or Pinnard) may be indicated in
certain situations.
Antenatal:

Women can make an informed decision by discussing this form of monitoring. If this
discussion has not occurred by the time of labour, it should form part of the initial
birth plan
On assessment of labour/pre-labour rupture of membranes:

Palpate, count and document the maternal pulse to enable comparison between
the woman and the fetal heart

Auscultate the fetal heart rate (between contractions) to determine an average rate
(baseline rate), counting the rate over a period of one minute

In the presence of contractions auscultate again immediately following a contraction
to exclude decelerations

Question the woman on fetal movements (reduction in movements may indicate
fetal compromise). For further confirmation of fetal wellbeing, when the opportunity
arises, auscultate the FH during a period of fetal movements to ensure acceleration
in the heart rate

Document all findings in your records ensuring the fetal heart rate is written as
130bpm (e.g.), not as range, the length of time auscultated

Ensure you document what equipment you are using for IA i.e. Pinard/sonicaid

Carry out a risk assessment to determine the woman’s suitability for IA in labour
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
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Combined fetal monitoring guideline (GL964)
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In established labour the minimum standards are:

Intermittent auscultation consists of listening and counting the heart rate
immediately after a contraction for a minimum of 60 seconds
o
every 15 mins in the first stage
o
every 5 minutes or after every contraction in active/passive second stage of
labour in the presence of expulsive contractions
The rationale for listening immediately after a contraction is to exclude
decelerations

Continue to record the baseline rate as an average on the partogram to enable
scrutiny for a rising baseline HR and/or tachycardia which may indicate fetal
hypoxia

As a minimum, palpate and document maternal pulse hourly on the partogram or on
detection of FH anomalies to enable comparison between the 2 rates

If at any time the FH is not auscultated at the recommended intervals, document
reason on partogram (e.g. in transit to DS/theatre, or epidural )

The routine use of an admission CTG is not recommended in low risk women with
otherwise normal observations
Perform CEFM if the FH gives cause for concern or further risk factors develop
(SEE Intrapartum CEFM guideline):

Where there is a baseline HR <110bpm or >160bpm, a drifting baseline rate
towards either 110pbm or 160bpm, in the presence of decelerations or if
accelerations are heard immediately after a contraction as this could be an
overshoot from a deceleration of the FH.

For any FH anomaly, palpate the maternal pulse to enable comparison

If the CEFM is normal, the trace can be discontinued after 20 minutes, providing all
clinical/risk assessments are within normal parameters

Clearly document the reason for commencing CEFM in your records with a plan of
care and whether referral to medical aid is required.
Intermittent auscultation should be the first line option for fetal monitoring in pregnancies at
low risk of fetal compromise – see labour risk assessment proforma for care in labour or
intrapartum CEFM guidance.
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
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Combined fetal monitoring guideline (GL964)
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Auditable standards:
1. All women with a live fetus will have the fetal heart rate (FHR) monitored and
documented in the maternal health record as a minimum every 15 minutes during
the first stage of labour and every 5 minutes or after every contraction during the
second stage of labour. When using intermittent auscultation the FHR will be
auscultated for at least a minute after a contraction, and the rate will be recorded as
an average.
2. The equipment used for intermittent auscultation of the FHR will be in line with
guideline. This will be documented in the maternal health care record.
3. In all cases when a transfer from intermittent auscultation to continuous electronic
fetal monitoring occurs, the timing and reason for transfer will be documented in the
maternal health record. The indication for transfer will be in accordance with the
listed indications for continuous electronic fetal monitoring stated in the guideline.
4. The maternal pulse will be palpated and documented at the beginning of the
intrapartum auscultation and hourly thereafter.
5. The maternal pulse will be palpated and documented in the maternal health record
to differentiate between the two heart rates in all cases when a FHR abnormality is
detected such as: FHR baseline of less than 110 bpm or more than 160 bpm or any
decelerations after a contraction.
References
1. NICE (2014) - Intrapartum care – care of healthy women and their babies during
Childbirth RCOG, London
2. Thacker, S Stroup, D & Chang, M (2004) - Continuous electronic fetal heart rate
monitoring during labour. (Cochrane review) In: the Cochrane Library Issue 1 2001
Chichester, UK
3. NMC London (2009) – Record Keeping: Guidance for nurses and midwives.
Nursing and Midwifery Council: London
Author:
Job Title:
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Marsh Ward Manager
Group Director Urgent Care
Location:
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Fetal Monitoring Resource File (GL844)
Intermittent ‘Intelligent’ Auscultation (IA)
Relevant Guidelines
Monitoring fetal wellbeing by Intermittent auscultation of the fetal
heart rate in labour (see page 13 above)
Labour risk assessment proforma in labour (GL863)
Overview

Appropriate for low risk labours

Utilise trust labour risk assessment tool and
document it has been used

Enquire about fetal movements, palpate movement and record the last time they
were noted

Auscultate to determine the baseline rate when the fetus is still. Record as a single
figure

Record and document maternal pulse

Wait for a contraction and listen immediately after for 1 minute to exclude
decelerations. Document how you are doing intermittent auscultation

Wait for accelerations to be confirmed

Once baseline established, listen during fetal movements for acceleration.
Document presence of fetal movements and accelerations and absence of
decelerations at regular intervals
Equipment to use

Pinard

Sonicaid
Rationale

Accelerations demonstrate good fetal health

A fetus that becomes hypoxic will display decelerations and tachycardia (excluding
catastrophic events)

Keep an up to date partogram to recognise an evolving tachycardia and lack of
active/quiet episodes
How to do IA in the First and Second Stage of Labour
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
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First Stage
 Auscultation should take place following a contraction
 FH should be heard and counted for 1 minute every 15 minutes immediately
following a contraction (document this when writing care plans)
 Document on the partogram as one number not a range
 Document presence/absence of accelerations/ decelerations
 Palpate the maternal pulse and document
 Remember to continuously risk assess during the first stage – is it appropriate to
continue with IA? Use the labour risk assessment tool
 Be suspicious if accelerations are heard immediately after a contraction (overshoot)
Second stage
 Repeat labour risk assessment on diagnosis of second stage and then again at the
end of the first hour of pushing– is it appropriate to continue with IA? Use the labour
risk assessment tool
 Increase the rate of auscultation of the fetal heart rate to every 5 minutes when the
2nd stage is suspected even if it is not confirmed, revert back if incorrect suspicion.
 Auscultate every five minutes for 1 minute immediately following a contraction in the
second stage and document
 Remember, from this point increasing strength/frequency/duration of the
contractions and descent of the head will increase the potential for hypoxic stress be accurate in your assessment of FH
 Maternal pulse should be done manually to differentiate from FH. This should be
done and documented at least hourly and if there is any concern with the fetal heart
rate being outside normal limits.
 Record FM
Feature
Identified with IA
Baseline

Accelerations

Variability
X
Decelerations

Partogram IA
Evolving hypoxia with IA
Author:
Job Title:
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Group Director Urgent Care
Location:
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(Partogram by RM J. Frank. Edited by SP/RF)
Author:
Job Title:
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Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
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Combined fetal monitoring guideline (GL964)
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Continuous Electronic Fetal Monitoring (CEFM)
Relevant Guidelines:

Intrapartum electronic monitoring of fetal heart rate and contractions guideline (see
page 2 above)

Antenatal CTG monitoring (see page 5 above)
Overview

CEFM is achieved by using a CTG machine

Complete trust risk assessment tool/consult relevant guideline – does this patient
require CEFM?

Perform abdominal palpation, confirm FH present with Pinnard or sonicaid and
commence CTG

Ensure at the start of the CTG that toco is base lined for accurate recording of
frequency of uterine activity

Complete the CTG start sticker including patient details, date and time, speed of
paper and indication for CTG

If CTG criteria is met at 30mins and there is no indication for the trace to remain on,
discontinue CEFM and accurately record findings. Document on the CTG the date
and time it is discontinued and sign

Any event that may affect the FHR should be noted, signed, date and timed

1 hourly CEFM reviews for intrapartum CTG, use trust sticker to record findings.
Think Dr C Bravado

Following birth record date, time and mode of delivery on the trace and sign. Use
the post-delivery stamp

Store in the envelopes provided in the medical notes and sign the front of the
envelope
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
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NICE Classification of FHR trace features
Feature
Baseline Variability (bpm)
(bpm)
Decelerations
Accelerations
Normal
100160bpm
None or early
Present
Non161reassuring 180bpm
5pm or more
Variable decelerations:
The absence of
dropping from baseline by 60 accelerations with
beats/minute or less and taking
an otherwise
60 seconds or less to recover normal trace is of
present for over 90 minutes
uncertain
occurring with over 50% of
significance
contractions.
OR
Variable decelerations:
dropping from baseline by more
than 60 beats/minute or taking
over 60 seconds to recover
present for up to 30 minutes
occurring with over 50% of
contractions.
OR
Late decelerations:
present for up to 30 minutes
occurring with over 50% of
contractions.
Abnormal <100bpm < 5bpm for over
Non-reassuring variable
decelerations (see
90 minutes
>180bpm
row above):
still observed 30 minutes after
starting
conservative measures
occurring with over 50% of
contractions.
OR
Late decelerations:
present for over 30 minutes
do not improve with
conservative
measures
occurring with over 50% of
contractions.
OR
Bradycardia or a single
prolonged
deceleration lasting 3 minutes
or more.
Category
< 5bpm for 3090 minutes
Definition
Interpretation
Management
Author:
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CTG is
normal
All 3 features
are
normal /
reassuring
Normal CTG, no
non-reassuring
or
abnormal
features,
healthy fetus
CTG is
nonreassuring
and suggests
need for
conservative
measures
1 nonreassuring
feature
AND
2 normal
features
Combination of
features that may
be associated
with increased
risk of fetal
acidosis; if
accelerations are
present, acidosis
is unlikely
Continue CTG and normal care.
If CTG was started because of concerns arising
from intermittent auscultation,
remove CTG after 20 minutes if there are no nonreassuring or abnormal features and no on-going
risk factors.
Think about possible underlying causes.
If the baseline fetal heart rate is over 160
beats/minute, check the woman's temperature and
pulse. If either are raised, offer fluids and
Paracetamol.
Start 1 or more conservative measures:
encourage the woman to mobilise or adopt a leftlateral position, and in particular to
avoid being supine offer oral or intravenous fluids
reduce contraction frequency by stopping oxytocin
if being used and/or offering tocolysis.
Inform coordinating midwife and obstetrician.
CTG is
1 abnormal
Combination of
Think about possible underlying causes.
abnormal and feature
features that is
If the baseline fetal heart rate is over 180
indicates
OR
more likely to be beats/minute, check the woman's temperature and
need for
2 nonassociated with
pulse. If either are raised, offer fluids and
conservative
reassuring
fetal acidosis
Paracetamol.
measures
features
Start 1 or more conservative measures (see 'CTG
AND further
is non-reassuring…' row for details).
testing
Inform coordinating midwife and obstetrician.
Offer to take an FBS (for lactate or pH) after
implementing conservative measures, or expedite
birth if an FBS cannot be obtained
and no accelerations are seen as a result of scalp
stimulation.
Take action sooner than 30 minutes if late
decelerations are accompanied by tachycardia
and/or reduced baseline variability.
Inform the consultant obstetrician if any BS result
is abnormal.
CTG is
Bradycardia
An abnormal
Start 1 or more conservative measures (see 'CTG
abnormal and or a single
feature that is
is non-reassuring…' row for
indicates
prolonged
very likely to be
details).
need for
deceleration
associated with
Inform coordinating midwife. Urgently seek
urgent
with baseline
current fetal
obstetric help.
intervention
below 100
acidosis or
Make preparations for urgent birth.
beats/minute, imminent rapid
Expedite birth if persists for 9 minutes.
persisting for
development of
If heart rate recovers before 9 minutes, reassess
3 minutes or
fetal acidosis
decision to expedite birth in discussion with the
more*
woman.
Abbreviations: CTG, cardiotocography; FBS, fetal blood sample.
* A stable baseline value of 90–99 beats/minute with normal baseline variability (having
confirmed that this is not the maternal heart rate) may be a normal variation; obtain a senior obstetric
opinion if uncertain.
Author:
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Group Director Urgent Care
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Baseline Rate

Normal baseline rate is 100 -160 bpm

The normal baseline variability indicates an intact autonomic nervous system.
Overall this shows both the somatic and autonomic nervous system are functioning
well. CTG showing a normal baseline rate:

A tachycardic baseline is 161-180 bpm. An uncomplicated tachycardia (where no
other abnormal features appear) should be regarded as non-reassuring but may be
caused by a period of fetal activity which then settles, a maternal pyrexia (treat
maternal pyrexia, IV fluids, Paracetamol), maternal tachycardia (take steps to
correct, IV fluids, temp check), the administration of certain drugs (MgSo4,
hydralazine), changes in placental blood flow (change maternal position). Record
any events on the CTG

Gradually evolving tachycardia describes an increase in baseline rate, even within
the normal range, but with other non-reassuring or abnormal features present,
should increase concern of hypoxia

Significant Fetal Tachycardia (FHR >180 bpm)
Fetal arrhythmia or congenital defect (FHR >200 bpm)

Tachycardia is not uncommon in preterm infants due to earlier maturation of the
sympathetic nervous system

An FSE can be useful with a bradycardic baseline to exclude the possibility of
mistakenly recording maternal pulse rate

Fetal bradycardia is commonly associated with fetal hypoxemia. However, a
number of causes must be considered; drugs, maternal hypotension, hypothermia,
maternal hypoglycaemia, fetal brady arrhythmias, complete heart block, congenital
heart block, umbilical cord compression, amniotic fluid embolism and normal
variation
Acceleration
Author:
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Group Director Urgent Care
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
Fetal heart rate increases due to activity in utero which is controlled through the
somatic nervous system, it is recorded on the CTG as an acceleration. These
accelerations are considered as hallmarks of fetal wellbeing

Accelerations should be present =/> 2 episodes in 20mins, each being at least
15bpm above the baseline rate lasting for =/> 15 seconds. In an antenatal CTG

If repeated accelerations are present with reduced variability, the CTG should be
regarded as normal

Remember, the absence of accelerations with an otherwise normal CTG is of
uncertain significance, however a sick or hypoxic fetus exposed to significant
intrapartum hypoxia would reduce its movements and therefore is unlikely to show
accelerations. Continue to risk assess and review the clinical picture as a whole
when making your interpretation

Be suspicious of CTG’s where accelerations exactly mirror contractions – are you
picking up maternal pulse? In this situation FH must be confirmed with
Pinard/sonicaid or USS, the transducer repositioned to FSE applied.
Baseline Variability

Normal variability greater than 5bpm

Baseline variability is the degree to which the baseline varies within a band width
excluding any accelerations or
decelerations

Normal baseline variably shows good autonomic control, therefore hypoxia is
unlikely

It should be assessed during a reactive 1 minute period

Fetus that are neurologically stable have quiet/sleep periods and active periods.
This is known as cycling, absence of cycling can be an indication of hypoxia. The
Author:
Job Title:
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Group Director Urgent Care
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commonest reasons for reduced variability include; sleep phase, prematurity, fetal
tachycardia, drugs, congenital malformation, cardiac arrhythmias, fetal anaemia and
fetal infection
Normal Variability Over 5 bpm
Normal Cycling
Reduced Variability 3-5bpm
Silent Variability 0-3bpm
Saltatory Pattern >25bpm
Author:
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Decelerations

Decelerations are defined as a drop in heart rate of more than 15 beats, lasting for
more than 15 seconds.

Decelerations may be significant as they may be related to developing hypoxia

The majority of decelerations have NO relation to hypoxia but are caused by
mechanical changes in the fetal environment i.e. head and cord being compressed

Most decelerations in labour are variable
Early Decelerations

Early decelerations are considered as normal, they are caused by head
compression so are more common in the latter 1st stage and 2nd stage of labour.

They mirror the contraction peaks exactly, are associated with compression and
rarely fetal hypoxia

True early decelerations are uniform and bell like in shape with a slow onset and
recovery. They will not be heard with IA
Author:
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Examples of Early Decelerations:
Late Decelerations

They are characterised by a uniform pattern. There is a time lag between the onset
and peak of the contraction and the onset and peak of the deceleration. They are
frequently associated with an increase in baseline heart rate

They may also be linked to short lasting hypoxia, related to a reduction in placental
blood flow. They are often associated with abnormal uterine activity and may be
seen in relation to placental insufficiency and are more commonly seen in cases
such as abruption, hyperstimulation, aortocaval compression.

There is oxygenated blood in the retro placental space. As a contraction starts the
fetus uses up this reservoir. Due to a restricted blood supply a hypoxic deceleration
happens and will only recover sometime after a contraction when fully oxygenated
blood has been restored

They will be heard with IA due to the slow recovery
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Examples of late decelerations:
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Variable Decelerations
They are the most common type of decelerations and are called ‘variable’ because
they vary in shape, size and sometimes in timing with respect to each other.
Less than 60 beat drop for less than 60 seconds = uncomplicated

Usually rapid descent and rapid recovery.

They vary because they are a manifestation of umbilical cord compression and it is
compressed in a slightly different way each time. They are more often seen with
reduced amniotic fluid volume

Initial or mild umbilical cord compression results in occlusion of the umbilical vein,
which is larger than the arteries and less rigid. This results in decreased venous
return resulting in reflex tachycardia to maintain cardiac output. This explains the
often seen initial increase in heart rate (shoulder) preceding the deceleration.
Further compression of the cord leads to occlusion of the umbilical artery, and the
resulting increased systemic resistance, sensed by the baroreceptors, results in a
protective reflex slowing of the heart rate. As the cord is decompressed, this series
of events is reversed, and a ‘shoulder’ may follow the deceleration (artery is
decompressed but the vein is still compressed) prior to returning to baseline

A normal, well grown fetus can tolerate cord compression for a considerable length
of time before becoming hypoxic.
Mechanical issue – related to cord compression
Not heard with IA
Examples of uncomplicated variable deceleration:
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Variable Decelerations
Greater than 60 beat drop for greater than 60 seconds = complicated

The most critical feature is the evolution of the trace with time. A change in the
baseline rate and change in the baseline variability are key signs of developing
hypoxia and acidosis

These variable decelerations are indicative of fetal hypoxia including, slow return of
the fetal heart rate to the baseline, loss of variability during the deceleration, loss of
primary and/or secondary acceleration, persistence of secondary acceleration
(overshoot), continuation of the baseline fetal heart rate at a lower level
Due to cord compression and insufficient utero-placental perfusion
Late recovery
Biphasic deceleration
Loss of shouldering
Overshoot (excessive shoulder)
Loss of variability during the deceleration
Heard with IA
Slow Return
Biphasic
Loss of primary
to Baseline
Deceleration
rise in BLR
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Prolonged Deceleration/Bradycardia

Single deceleration lasting over 3 minutes is termed prolonged decelerations (see
1st picture below), lasting over 10 minutes, is a baseline change; bradycardia (see
2nd picture below). 90% of prolonged deceleration without incidences (rupture,
abruption, cord prolapse, hyperstimulation) will return to baseline within 6 minutes
and 95% within 9 minutes. Summon help and prepare the patient for theatre…you
don’t have to go!
Examples of prolonged deceleration:
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Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
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Combined fetal monitoring guideline (GL964)
September 2016
Date
Sinusoidal Pattern
Sinusoidal patterns (dog-tooth pattern) can be associated with a:

Physiological cause: thumb sucking OR

Pathological cause: anaemia due to rhesus disease, infection,
haemoglobinopathies, feto-maternal transmission or bleeding from the fetus
(abruption/vasa praevia)
It is important to realise that not all severely anaemic fetus show a sinusoidal pattern.
Characteristics of a true sinusoidal pattern include:

‘Oscillations’ instead of normal variability

Stable baseline rate

2-5 oscillations (‘teeth’) in one minute period

Each oscillation is between 5-15 bpm (height of tooth)

Most importantly there will be NO areas of normal FHR variability and NO
accelerations.
A normal CTG with intermittent areas of sinusoidal pattern suggests that the fetus is
sucking its thumb, a change in position of the mother should rectify this if concerned.
A sinusoidal pattern will not be picked up with IA. Ask about FM to confirm wellbeing - refer
to ‘Monitoring fetal wellbeing by Intermittent Auscultation of fetal heart in labour (page 13
above)
Example of sinusoidal pattern:
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 32 of 33
Combined fetal monitoring guideline (GL964)
September 2016
Date
Contractions
The optimum rate of contractions should not exceed 5:10. Hyperstimulation can occur
with or without fetal distress.
Fetal distress
No fetal distress
Spontaneous
Refer for senior opinion.
Consider terbutaline
CEFM with close
observation
Propess
Remove propess. Transfer
to delivery suite. Consider
terbutaline
If bishops score <8 or
<3cms leave propess insitu .
CEFM with close
observation
Oxytocin infusion
Reduce by half current dose, Reduce Oxytocin to achieve
a response should be seen
</= 5:10. Close observation
within 5-10 minutes. If no
for signs of fetal distress
improvement stop infusion.
In cases of prolonged
deceleration (>3 mins) stop
Oxytocin immediately
References
1. Chandraharan, E and S. Arulkumaran. 2008. Electronic fetal heart monitoring in
current and future practice. Journal of Obstetrics and Gynaecology India 58 (20):
121-129
2. Gibb, D. and S. Arulkumaran. 2007. Fetal Monitoring in Practice. Churchill
Livingstone: London
3. NICE. 2014. Intrapartum care : management and delivery of care to women in
labour CG190. December 2014. NICE: London
4. www.nhsla.com/Claims/Schemes/CNST
5. Nursing Midwifery Council (NMC). 2009. Record Keeping Guidance for nurses and
midwives. NMC: London
6. www.perinataolgy.com
7. www.registerednursern.com
Author:
Job Title:
Policy Lead:
Sarah Bailey
Marsh Ward Manager
Group Director Urgent Care
Location:
Policy hub/ Clinical/ Maternity/ Intrapartum/ GL964
This document is valid only on date last printed
Date:
Review Date:
Version:
September 2016
April 2017
1.3 ratified Mat CG mtg
Sept 2016
Page 33 of 33