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

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:                                         Type of document:

Dr Briege Lagan                                             Departmental Guidelines
Clinical Midwife Specialist

Caroline Keown
Lead Midwife

Frances Stewart
Consultant Obstetrician

Review Date: 31 October 2011

Approved by:                                                Date Policy disseminated by
Margaret Gordon                                             Equality Unit:
Assistant Director Obstetrics and
Gynaecology                                                 12 January 2009

Date Approved:
8 December 2008
                         NHSCT MISSION STATEMENT
  To provide for all the quality of services we would expect for our families
                                 and ourselves




NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008   1
    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.




NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008   2
    •    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 low-
         risk 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).



Table 1:

        Indications for Antenatal Electronic Fetal Monitoring (RCOG 2001)

            Maternal Conditions                                            Fetal Conditions
   • Hypertensive Disorders of                                • Small fetus
     Pregnancy                                                   – Growth restriction
   • Diabetes                                                    – Constitutionally small
   • Antepartum haemorrhage                                   • Prematurity
   • Abdominal Pain                                           • Oligohydramnios/Polyhydramnios
   • Other maternal medical disease                           • Abnormal umbilical artery Doppler
      – Cardiac Disease                                         Velocimetry
      – Severe Anaemia                                        • Isoimmunisation
      – Hyperthyroidism                                       • Multiple Pregnancy
      – Vascular disease                                      • Breech Presentation
      – Renal disease                                         • Reduced Fetal Movement
   • Abdominal trauma                                         • 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.


NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008   3
    •    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



NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008   4
     •   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                                             Fetal Conditions
 •    Hypertensive Disorders of                               • Prematurity
          Pregnancy                                           • Meconium staining of the amniotic
 •    Diabetes                                                  fluid
 •    Antepartum haemorrhage                                  • Suspicious fetal heart rate on
 •    Abdominal Pain                                            auscultation
 •    Other maternal medical disease                          • Post-term pregnancy
      – Cardiac Disease                                       • Any evidence of/or suspected fetal
                                                                compromise e.g.
      – Severe Anaemia
                                                                  – Abnormal Doppler
      – Hyperthyroidism
                                                                  – Oligohydramnios
      – Vascular disease
                                                                  – Polyhydramnios
      – Renal disease
                                                                  – Intrauterine growth retardation
 •    Vaginal bleeding in labour
 •    Intrauterine infection
 •    Regional analgesia
 •    Multiple Pregnancy
 •    Previous caesarean section
 •    Prolonged membrane rupture
       (>24hrs)
 •    Induced/ Augmented labour
 •    Hypertonic uterus


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   5
    •    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.



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           Variability              Decelerations                 Accelerations
                    (bpm)               (bpm)
Reassuring 110–160                     5                   None                              Present

Non-              100–109           < 5 for                Typical variable                  The absence of
reassuring        161–180           40–                    decelerations with over           accelerations
                                    90 minutes             50% of contractions,              with otherwise
                                                           occurring for over                normal trace is
                                                           90 minutes                        of uncertain
                                                           Single prolonged                  significance
                                                           deceleration for up to
                                                           3 minutes

Abnormal          < 100        < 5 for                     Either atypical variable
                  > 180        90 minutes                  decelerations with over
                  Sinusoidal                               50% of contractions or
                  pattern                                  late decelerations, both
                    10 minutes                             for over 30 minutes
                                                           Single prolonged
                                                           deceleration for more
                                                           than 3 minutes




NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008      6
Table 4 Definition of normal, suspicious and pathological FHR traces
  Category             Definition
  Normal               An FHR trace in which all four features are classified as
                       reassuring

  Suspicious           An FHR trace with one feature classified as non-reassuring and
                       the remaining features classified as reassuring

  Pathological         An FHR trace with two or more features classified as non-
                       reassuring 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   7
          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   8
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   9
                                                                                                                                                                           Appendix 1

                                                                             CTG ASSESSMENT LABEL

Northern Health and
 Social Care Trust

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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                                              Intermittent auscultation                                   Abnormal Fetal Heart Rate (FHR) on
                                                                                                                              auscultation
Any risk factors?                                                 Full minute after contraction with a
(List not exhaustive):
                                      NO                          doppler or pinnard                                          Baseline 110 bpm or 160 bpm
                                                                                                       st
Maternal                                                          At least every: 15 minutes in 1 stage                       Any deceleration
Previous Caesarean                                                                 5 minutes in second stage
Pre-eclampsia
Post term (>42 wks gestation)
SROM >24 hrs                                                                               CONTINUOUS ELECTRONIC FETAL MONITORING
Induced labour
Diabetes
Antepartum haemorrhage                         Cardiotocograph (CTG) Classification
Other maternal medical problem
                                               NORMAL:                     All four features in reassuring category
Fetal
Growth restriction                             SUSPICIOUS:                 One non-reassuring feature, remainder reassuring
Prematurity
Oligohydramnios                                PATHOLOGICAL: Two or more non-reassuring features, one or more abnormal features
Abnormal Doppler
Multiple pregnancy                             Fetal Heart-Rate Feature Classification
Meconium-stained liquor
Breech presentation                                                        Baseline bpm                     Variability bpm          Decelerations            Accellerrattiions
                                                                                                                                                              Acce e a ons
Rhesus iso-immunisation
                                                 Reassuring             110-160 bpm                5bpm                       None                            Present
If YES:
Offer and recommend                                                                                                           Early deceleration
continuous EFM                                   Non-                   100-109 bpm              Less than 5 bpm for 40 -                                     The absence
                                                 Reassuring                                      90mins (in the absence of    Variable decelerations          of
                                                                        161-180 bpm
Intrapartum Risk Factors?                                                                        accelerations)               Single prolonged deceleration   accelerations
                                                                                                                              up to 3 minutes                 with an other
Oxytocin augmentation
                                                                                                 Typical variable             Atypical variable               wise normal
Epidural analgesia                               Abnormal               <100 bpm
Vaginal bleeding in labour                                                                                                                                    CTG is of
                                                                                                 decelerations with over      decelerations
Maternal pyrexia                                                        >180 bpm                                                                              uncertain
Fresh meconium-stained liquor                                                                    50% of contractions for      Single prolonged deceleration   significance
Maternal request                                                        Sinosodal pattern        over 90mins                  over 3 minutes
                                                                        for 10minutes
If YES:                                                                                          Single prolonged
Offer and recommend                                                                              deceleration up to 3mins
continuous EFM

NHSCT CTG Guidelines: Developed by CMS B Lagan/Lead Midwife C Keown/Con. Obstetrician F Stewart, Dec 2008                                                                         9
                                                                                                                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?                                               UTERINE HYPERCONTRACTILITY

   Check maternal pulse                                                    Is the mother receiving oxytocin?
                                                                                - Reduce/stop infusion
   Poor contact from external transducer?
      - check position of transducer                                       Has the mother recently received vaginal
      - consider applying fetal scalp electrode                            prostaglandins?
          (FSE)                                                               - Consider tocolysis:
                                                                                  Terbutaline 0.25mg subcutaneously
   FSE not working?
      - Check position of FSE/reapplying FSE
      - Confirm FH with Pinard
         stethoscope/fetal doppler and/or
         Ultrasound scan




           MATERNAL TACHYCARDIA/PYREXIA                                               OTHER MATERNAL FACTORS

   Is there a maternal infection?                                           Check:
        - Check temperature. If 37.5 C on two
                                                                            What is the maternal position?
           occasions two hours apart or 38 C or
           higher, consider screening and                                        -    Ensure woman not supine
           treatment.                                                            -    Ensure left lateral position

   Is mother dehydrated?
       - Check blood pressure and given                                     The mother is not hypotensive?
          500mls crystalloid (IV) if appropriate                            Has she just:
                                                                                 -    Had a vaginal examination
   Has the woman had a tocolysis?
                                                                                 -    Been vomiting or vasovagal?
      - If pulse 140bpm do not give any
          further tocolysis                                                      -    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                    10
                                                                                                            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.

    FBS Result (pH)            Interpretation                                Recommended Action

             7.25             Normal                    -    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

        7.21 – 7.24           Borderline                -    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.

             7.20             Abnormal                       Consultant obstetric advice must be sought


   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                11

				
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