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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 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 14 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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 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 15 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 16 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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 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 17 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 18 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date (Partogram by RM J. Frank. Edited by SP/RF) 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 19 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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 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 20 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 21 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 22 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 23 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 24 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 25 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 26 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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 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 27 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date Examples of late decelerations: 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 28 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 29 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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 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 30 of 33 Combined fetal monitoring guideline (GL964) September 2016 Date 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: 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 31 of 33 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