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Cardio-Toco in Antenatal-NHSCT-09-98-_EPCOPS - Obstet & Gynae_

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Guidelines for Midwifery and Obstetric Staff in the use and interpretation of Cardio-Tocography in Antenatal and Intrapartum Fetal Surveillance

NHSCT/09/98
Responsible Directorate: Women and Children’s Services Replaces (if appropriate): Guidelines, Antepartum, Intrapartum Fetal Heart Rate Monitoring and the interpretation of Continuous Electronic Fetal Monitoring (EFM) June 2007 (AAH) NICE Fetal Monitoring Guidelines (2001) (Adapted by Causeway 2002) Policy Author/Team: Dr Briege Lagan Clinical Midwife Specialist Caroline Keown Lead Midwife Frances Stewart Consultant Obstetrician Review Date: 31 October 2011 Approved by: Margaret Gordon Assistant Director Obstetrics and Gynaecology Date Approved: 8 December 2008 NHSCT MISSION STATEMENT To provide for all the quality of services we would expect for our families and ourselves Date Policy disseminated by Equality Unit: 12 January 2009 Type of document: Departmental Guidelines

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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GUIDELINES FOR MIDWIFERY AND OBSTETRIC STAFF IN THE USE AND
INTERPRETATION OF CARDIOTOCOGRAPHY IN ANTENATAL AND INTRAPARTUM FETAL SURVEILLANCE

Introduction The aim of these guidelines is to educate and support best practice for Midwifery and Obstetric Staff in the use and interpretation of cardiotocography in antenatal and intrapartum fetal surveillance and avoid adverse outcome from intrapartum acidotic/ hypoxic insult. The objective of these guidelines is to encourage a consistent approach to the use and interpretation of cardiotocography in antenatal and intrapartum fetal surveillance by medical and midwifery staff across the Northern Health and Social Care Trust. There are very few properly randomized trials comparing different modalities of fetal monitoring, apart from those comparing electronic fetal monitoring and auscultation. The recommendations in this guideline therefore, are made on the best evidence and information available to date. These guidelines should be read in conjunction with the Northern Health and Social Care Guidelines on Intrapartum Care and Guidelines on Induction of Labour. The guidelines will be monitored through clinical midwifery supervision, issues raised through training days, the Incident reporting system and risk management forums. Antenatal Fetal Monitoring • All women who attend the admission/day assessment units should be individually assessed by the midwife and/or obstetric medical staff to determine if cardiotograph (CTG) monitoring is indicated. Method (intermittent auscultation or continuous CTG monitoring) must be decided in partnership with the woman according to her needs. The fetal heart should be auscultated whenever a woman attends the maternity unit for assessment during the second and third trimester. Below 24 weeks auscultate with a Pinard or hand-held doppler. Between 24-28 weeks CTG should only be performed on medical request or if there is concern on auscultation.

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NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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CTGs performed before 30 weeks should be interpreted with caution because of a physiologically higher baseline, lack of accelerations, lower variability and the occurrence of sporadic decelerations. Current evidence does not support the use of the admission CTG in lowrisk pregnancy and it is therefore not recommended. All CTGs should be assessed utilising the CTG Assessment Label (Appendix 1). The CTG must be classified (see Appendix 2) and signed by the midwife when completed. Document action taken on the CTG and on the CTG Assessment Label which must be inserted into the maternity records. Where indicated (see Table 1) a cardiotocograph (CTG) should be performed for at least 20mins (Preferably using a monitor that would also record fetal movements).

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Table 1: Indications for Antenatal Electronic Fetal Monitoring (RCOG 2001) Maternal Conditions
• Hypertensive Disorders of Pregnancy • Diabetes • Antepartum haemorrhage • Abdominal Pain • Other maternal medical disease – Cardiac Disease – Severe Anaemia – Hyperthyroidism – Vascular disease – Renal disease • Abdominal trauma

Fetal Conditions
• Small fetus – Growth restriction – Constitutionally small • Prematurity • Oligohydramnios/Polyhydramnios • Abnormal umbilical artery Doppler Velocimetry • Isoimmunisation • Multiple Pregnancy • Breech Presentation • Reduced Fetal Movement • Post-term pregnancy

Note: This list is not exhaustive.

• •

NORMAL CTG: this should be noted in the hand held records or case notes by the midwife. SUSPICIOUS CTG: the CTG should be continued for a further 20 minutes. If then normal, discontinue and arrange a repeat if necessary following medical review. If the CTG remains suspicious, continue monitoring until the registrar (AAH) or Staff Grade (Causeway) has reviewed the woman and the CTG. If bedside review within one hour is not possible, the CTG may be taken to the doctor.
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NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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PATHOLOGICAL: the Registrar (AAH) / Staff Grade (Causeway) or Consultant must be asked to see the CTG and woman without delay Only antenatal inpatients who are regarded as ‘high risk’ (see Table 1) should have CTG monitoring performed for a minimum of 20 minutes daily or more frequently if clinically indicated.

Intrapartum Fetal Monitoring • • • • • Method (intermittent auscultation or continuous CTG monitoring) should be decided in partnership with the woman according to her needs Intermittent auscultation is equally as effective as continuous CTG monitoring for low risk women in labour Prior to any form of fetal monitoring, the maternal pulse should be checked simultaneously with FHR auscultation in order to differentiate between maternal and fetal heart rates. If fetal death is suspected despite the presence of a recordable FHR, then fetal viability should be confirmed with real time ultrasound assessment. With regard to the conduct of intermittent auscultation: The FHR should be auscultated at specified intervals Any intrapartum events that may affect the FHR should be noted contemporaneously in the maternity records, signed and the time noted. For a woman who is healthy and has had an otherwise uncomplicated pregnancy, intermittent auscultation should be offered and recommended in labour to monitor fetal wellbeing. In the active stages of labour, intermittent auscultation should occur after a contraction, for a minimum of 60 seconds, and at least: Every 15 minutes in the first stage Every 5 minutes in the second stage Continuous electronic fetal monitoring is recommended - if there is evidence on auscultation of a baseline less than 110 bpm or greater than 160 bpm - if there is evidence on auscultation of any decelerations - if any pregnancy/intrapartum risk factors are present (see Table 2). Where continuous EFM is required for the substantial part of labour, and if the EFM to date is considered to be normal, monitoring may be interrupted for short periods of up to 15 minutes to allow personal care (e.g. shower, toilet). Such interruptions should be infrequent and not occur immediately after any intervention that might be expected to alter the FHR (e.g. amniotomy, epidural insertion, or top-up etc). If unable to obtain good quality CTG trace, record the reason and consider use of a fetal scalp electrode

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NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Women who are to have a trial of instrumental delivery in theatre should be continuously monitored as soon as possible after arrival in theatre.

Table 2: Indications for Continuous Intrapartum Electronic Fetal Monitoring Maternal Conditions
• • • • • Hypertensive Disorders of Pregnancy Diabetes Antepartum haemorrhage Abdominal Pain Other maternal medical disease – Cardiac Disease – Severe Anaemia – Hyperthyroidism – Vascular disease – Renal disease Vaginal bleeding in labour Intrauterine infection Regional analgesia Multiple Pregnancy Previous caesarean section Prolonged membrane rupture (>24hrs) Induced/ Augmented labour Hypertonic uterus

Fetal Conditions
• Prematurity • Meconium staining of the amniotic fluid • Suspicious fetal heart rate on auscultation • Post-term pregnancy • Any evidence of/or suspected fetal compromise e.g. – Abnormal Doppler – Oligohydramnios – Polyhydramnios – Intrauterine growth retardation

• • • • • • • •

Note: This list is not exhaustive General Principles of EFM and Record- Keeping In order to ensure accurate record-keeping regarding EFM: • • • • • The date, time clock, and speed i.e. 1cm/min on the EFM machine should be checked and if necessary correctly set prior to use. All EFM recordings should be labelled with the mother’s name, date of birth, hospital number, parity, and gestation. The FHR must always be auscultated with a Pinard stethoscope or fetal doppler and recorded with the mother’s pulse rate at the start of a CTG The trace must be dated, timed at commencement. Reason must be stated for commencement and discontinuation of CTG must be recorded in the maternity record.

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Any intrapartum procedures and/or events occurring whilst cardiotocograph in progress that may affect the FHR should be should be recorded on the graph, which should be signed and the date and time noted (for example, vaginal examination, FBS or siting of an epidural). Any member of staff who is asked to provide an opinion on a trace should note their findings on both the trace and the woman’s maternity records along with the date, time and signature. Following birth, the healthcare professional should sign and note the date, time and mode of birth on the FHR trace. Safe storage of CTGs is required for legal reasons, to fulfill Midwives Rule no 9 (NMC, 2004) and to comply with Clinical Negligence Scheme for Trusts (CNST) requirements. All CTGs should be stored securely with the woman’s medical records at the end of the monitoring process.

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Interpretation of FHR traces/Cardiotocographs • CTGs must always be interpreted in the light of the clinical evidence and each individual situation.

The recommended classifications and definitions of the FHR trace/ cardiotocograph produced during EFM are shown in tables 3 and 4.

Table 3 Classification of FHR trace features
Feature Baseline (bpm) Variability (bpm) 5 < 5 for 40– 90 minutes Decelerations None Typical variable decelerations with over 50% of contractions, occurring for over 90 minutes Single prolonged deceleration for up to 3 minutes Either atypical variable decelerations with over 50% of contractions or late decelerations, both for over 30 minutes Single prolonged deceleration for more than 3 minutes Accelerations Present The absence of accelerations with otherwise normal trace is of uncertain significance

Reassuring 110–160 Nonreassuring 100–109 161–180

Abnormal

< 100 < 5 for 90 minutes > 180 Sinusoidal pattern 10 minutes

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Table 4 Definition of normal, suspicious and pathological FHR traces Category Normal Suspicious Pathological Definition An FHR trace in which all four features are classified as reassuring An FHR trace with one feature classified as non-reassuring and the remaining features classified as reassuring An FHR trace with two or more features classified as nonreassuring or one or more classified as abnormal

For women having continuous EFM, a documented systematic assessment based on these definitions and classifications should be undertaken every hour utilising the CTG Assessment Label (Appendix 1) which is inserted into the maternity records. • SUSPICIOUS CTG: consider possible causes and take appropriate action (Appendix 3). If the CTG does not return to normal and has one non-reassuring characteristic and delivery is not imminent, midwife must inform registrar/staff grade. If CTG continues to be suspicious, the registrar/staff grade must inform the consultant on call for delivery suite. If the CTG has two or more non-reassuring characteristics for more than 30 minutes (i.e. pathological CTG), consider fetal blood sampling (FBS) or expedite delivery. Reasons for any deviation from this standard must be clearly documented

•

PATHOLOGICAL CTG: Midwife must inform the registrar (AAH) / Staff grade (Causeway) immediately (Appendix 4). This should be done prior to any interventions. Prepare for delivery. The Co-coordinator/midwife in charge may refer directly to the Consultant on call in the event of suspected mismanagement. The “decision to deliver” to delivery time interval should be as short as possible, but ideally within 30 minutes. Paired cord blood gases (arterial and venous) should always be obtained when fetal blood sampling has been performed in labour, or when delivery is expedited for an abnormal CTG. Obtaining blood for cord gases is the responsibility of the person who delivers the baby.

Professional Accountability All midwifery and obstetric staff that use continuous fetal monitoring in their clinical practice must: Act within their scope of practice Work within the NHSCT organisational guidelines

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Be able to interpret the trace and act accordingly Maintain knowledge and skills Complete the K2 self-assessment tool in relation to CTG interpretation at least once a year and 4 simulated cases within K2. Attend at least four in-house CTG training seminar sessions per annum Self-assessment of skills for all midwives and obstetric staff involved in antenatal and intrapartum care will be assessed formally in the use and interpretation of cardiotocography in antenatal and intrapartum fetal surveillance at least once a year, in their annual appraisal. The training and education required will be recorded in their personal development plan.

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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References: 1. Advanced Life Support in Obstetrics (ALSO) (2000) Provider Course Syllabus, (4th Edition) American Academy of Family Physicians: Kansas. 2. Alfirevic Z, Devane D, Gyte GML. (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD006066. DOI: 10.1002/14651858.CD006066. Available at URL: http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles /CD006066 /frame.html [Accessed August 11th 2008]. 3. Mooney, S. E, Ogrinc, G., Steadman, W. (2007). Improving emergency caesarean delivery response times at a rural community hospital. Qual Saf Health Care 16: pp.60-66. 4. National Institute for Clinical Excellence (September 2007). Intrapartum Care. Available at: http://www.nice.org.uk/nicemedia/pdf/word/IPCNICEv8. 7.doc [Accessed August 11th 2008]. 5. Royal Australian and New Zealand College of Obstetricians and Gynecologists (2006) Intrapartum fetal surveillance: clinical guidelines. 2nd ed. Melbourne: The College. Available at: http://www.ranzcog. edu.au/publications/pdfs/ 6. Royal College of Midwives (2007) Safer Childbirth: Minimum Standards for the Organisation and Delivery of Care in Labour. Available at: http://www.rcm.org. [Accessed August 11th 2008]. 7. Royal College of Obstetricians and Gynecologists (2001) The use of electronic fetal monitoring: the use and interpretation of cardiotogography in intrapartum fetal surveillance. [Evidence-based clinical guideline no 8]. London 8. Society of Obstetricians and Gynecologists of Canada (2007) Fetal Health Surveillance: Antepartum and Intrapartum Consensus Guideline. Journal of Obstetrics and Gynecology Canada, 29(9): Supplement 4. 9. Thomas J, Paranjothy S, James D (2004) National cross sectional survey to determine whether the decision to delivery interval is critical in emergency caesarean section.; British Medical Journal, 20;328(7441): 665.

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Appendix 1

CTG ASSESSMENT LABEL
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Appendix 2 ASSESSMENT OF NEED AND CLASSIFICATION OF ELECTRONIC FETAL MONITORING (EFM) Consideration should be given to Maternal Preferences and Priorities
Admission Assessment
Any risk factors? (List not exhaustive): Maternal Previous Caesarean Pre-eclampsia Post term (>42 wks gestation) SROM >24 hrs Induced labour Diabetes Antepartum haemorrhage Other maternal medical problem Fetal Growth restriction Prematurity Oligohydramnios Abnormal Doppler Multiple pregnancy Meconium-stained liquor Breech presentation Rhesus iso-immunisation If YES: Offer and recommend continuous EFM

Intermittent auscultation

NO

Full minute after contraction with a doppler or pinnard At least every: 15 minutes in 1 stage 5 minutes in second stage
st

Abnormal Fetal Heart Rate (FHR) on auscultation Baseline 110 bpm or 160 bpm Any deceleration

CONTINUOUS ELECTRONIC FETAL MONITORING

Cardiotocograph (CTG) Classification
NORMAL: SUSPICIOUS: All four features in reassuring category One non-reassuring feature, remainder reassuring

PATHOLOGICAL: Two or more non-reassuring features, one or more abnormal features

Fetal Heart-Rate Feature Classification
Baseline bpm Reassuring NonReassuring 110-160 bpm 100-109 bpm 161-180 bpm <100 bpm >180 bpm Sinosodal pattern for 10minutes Variability bpm 5bpm None Early deceleration Variable decelerations Single prolonged deceleration up to 3 minutes Atypical variable decelerations Single prolonged deceleration over 3 minutes Decelerations Accellerrattiions Acce e a ons Present The absence of accelerations with an other wise normal CTG is of uncertain significance

Intrapartum Risk Factors?
Oxytocin augmentation Epidural analgesia Vaginal bleeding in labour Maternal pyrexia Fresh meconium-stained liquor Maternal request If YES: Offer and recommend continuous EFM

Less than 5 bpm for 40 90mins (in the absence of accelerations) Typical variable decelerations with over 50% of contractions for over 90mins Single prolonged deceleration up to 3mins

Abnormal

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Appendix 3

MANAGEMENT OF SUSPICIOUS CARDIOTOCOGRAPH (CTG) Ensure adequate quality recording of both fetal heart rate and contraction pattern, and the mother is informed of any concerns and included in the management plan
INADEQUATE QUALITY CTG? Check maternal pulse Poor contact from external transducer? - check position of transducer - consider applying fetal scalp electrode (FSE) FSE not working? - Check position of FSE/reapplying FSE - Confirm FH with Pinard stethoscope/fetal doppler and/or Ultrasound scan UTERINE HYPERCONTRACTILITY Is the mother receiving oxytocin? - Reduce/stop infusion Has the mother recently received vaginal prostaglandins? - Consider tocolysis: Terbutaline 0.25mg subcutaneously

MATERNAL TACHYCARDIA/PYREXIA Is there a maternal infection? - Check temperature. If 37.5 C on two occasions two hours apart or 38 C or higher, consider screening and treatment. Is mother dehydrated? - Check blood pressure and given 500mls crystalloid (IV) if appropriate Has the woman had a tocolysis? - If pulse 140bpm do not give any further tocolysis Check:

OTHER MATERNAL FACTORS

What is the maternal position? Ensure woman not supine Ensure left lateral position

The mother is not hypotensive? Has she just: Had a vaginal examination Been vomiting or vasovagal? Had an epidural sited/topped up?

Give 500mls crystalloid if appropriate The midwife who has direct care for the woman must inform a senior obstetrician of any suspicious CTG tracing. If CTG remains suspicious continue to observe for further non-reassuring or abnormal features and always consider in context of overall clinical picture of mother and fetus. If CTG becomes pathological, see action for pathological CTG (Appendix 4).

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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Appendix 4

MANAGEMENT OF PATHOLOGICAL CARDIOTOCOGRAPH (CTG)
Inform Senior Obstetrician

Fetal Blood Sampling (FBS) Possible and/or Appropriate?
• • Encourage mother to adopt left lateral position. Check B/P and give 500mls crystalloid (IV) if appropriate. Interpretation Normal Recommended Action FBS should be repeated in one hour if FHR abnormality persist, or sooner if there are further abnormalities. If results remains stable after 2nd test, then a third/further sample may be deferred unless there are further abnormalities of the CTG Repeat FBS within 30 minutes if the FHR remains pathological, or sooner if there are further abnormalities. (Consideration should be given to the time taken to perform FBS when planning repeat samples) If a third sample is indicated, a consultant obstetric opinion should be sought. Consultant obstetric advice must be sought

FBS Result (pH) 7.25

-

7.21 – 7.24

Borderline

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7.20

Abnormal

All FBS results should be interpreted taking into account the previous pH measurement, progress of labour and the clinical features of the mother and fetus.

Fetal Blood Sampling (FBS) Not Possible and/or Inappropriate?
• • Encourage mother to adopt left lateral position Check B/P and give 500mls crystalloid (IV) if appropriate

EXPEDITE DELIVERY: The urgency and mode of delivery should take into account the severity of the FHR and maternal factors The accepted standard is that delivery should be accomplished within 30 minutes from decision to deliver

Following delivery, take paired umbilical cord samples and calculate apgar scores. Document all results in the mother’s maternity notes and on the CTG tracing.

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008

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