Benefits, Harm, and Costs
Definitions outlined in this guideline should be adapted into facility policies and fetal health surveillance educational programs for consistency and clarity of terminology and communication (II-3 A).
When communicating with colleagues and documenting fetal surveillance, fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate, and the classification (III-C).
Communication to the interprofessional team should be done clearly and efficiently (III-C).
Women in active labour should receive continuous close support from an appropriately trained person (I-A).
Fetal surveillance by intermittent auscultation or electronic fetal monitoring requires the presence a professional caregiver (nurse, midwife, and/or physician) with knowledge of fetal surveillance methods, response, and labour support strategies (I-A).
One-to-one care of the woman is recommended, recognizing that the caregivers are really caring for more than 1 patient: the woman and her unborn baby or babies (III-C).
The classified intermittent auscultation and electronic fetal monitoring findings must be interpreted in the context of the overall clinical picture (I-A).
Intermittent auscultation, following an established protocol of surveillance and response, is the recommended method of intrapartum fetal surveillance for healthy women between 37 0 and 41 3 weeks gestation in spontaneous labour, in the absence of risk factors for adverse perinatal and neonatal outcomes (I-B).
Intermittent auscultation may be used for women who are 41 4 weeks gestation to 42 0 weeks, provided there is documentation of a normal non-stress test and normal amniotic fluid volume (III-C).
Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome (II-A).
Canadian health care facilities should move towards a universal paper speed of 3 cm/minute for electronic fetal monitoring tracings to facilitate national consistency of practice, education, and research (III-B).
Admission intermittent auscultation assessments are recommended for healthy term women presenting in labour, early labour, or query labour in the absence of risk factors for adverse perinatal outcome (I-A).
Admission electronic fetal monitoring assessments are recommended for women with risk factors for adverse perinatal outcome (III-B).
When a woman begins labour following cervical ripening, the method of intrapartum fetal health surveillance monitoring should be determined by the ongoing maternal and fetal risk factors (III-C).
Intermittent auscultation may continue to be used to monitor the fetus when epidural analgesia is initiated and used during labour in low-risk, term pregnancies in spontaneous labour provided that a protocol is in place for frequent intermittent auscultation assessment (III-C).
Electronic fetal monitoring is recommended for combined spinal–epidural analgesia (CSE) because CSE is associated with a higher risk of an atypical or abnormal fetal heart pattern than with the use of epidural alone (1-B).
After establishing the baseline fetal heart rate, fetal heart rate assessments should be conducted by listening and counting immediately after the contraction for 30–60 seconds to ensure that the fetal heart rate is consistent with the established fetal baseline rate and to detect accelerations or decelerations from baseline (II-3 B).
When using intermittent auscultation, if a deceleration is heard or suspected immediately following a contraction, further assessment is required by changing position and listening again or by initiating EFM. If decelerations are confirmed by the further IA, EFM is indicated. Intrauterine resuscitation should be initiated as required (III-C).
When electronic fetal monitoring is initiated in response to abnormal intermittent auscultation, it may be removed when no maternal fetal risk factors are identified based on a review of the overall clinical picture and a normal tracing is observed; a minimum of 20 minutes of electronic fetal monitoring tracing is suggested (III-C).
When a normal tracing is identified during first stage of labour, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, hydrotherapy, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is stable (III-B).
Electronic fetal monitoring is best interpreted with a continuous tracing of the uterine activity and fetal heart rate. If a continuous tracing is not possible, or there is uncertainty of interpretation due to the quality of the tracing, use of an intrauterine pressure catheter and/or fetal spiral electrode could be considered, if available (III-B).
The terms normal and abnormal are used to classify intermittent auscultation (III-C).
The presence of uterine tachysystole during IA classifies intermittent auscultation fetal health surveillance assessment as abnormal, and electronic fetal monitoring should be initiated (III-C).
The terms normal, atypical, and abnormal are used to classify electronic fetal monitoring (III-C).
Assess and document the maternal heart rate concurrently with the fetal heart rate, when using either IA or EFM, to differentiate maternal from fetal heart rate:
At initial assessment when determining baseline fetal heart rate
At any time when there is uncertainty between the maternal heart rate and fetal heart rate
Based on the stage of labour:
In the active first stage and passive second stage of labour: every 4 hours with intact membranes
In the active first stage and passive second stage of labour: every 2 hours with ruptured membranes
In the active second stage of labour: every 15–30 minutes (III-C)
Intermittent auscultation is recommended if the woman continues to meet the criteria for intermittent auscultation assessments (IB).
Electronic fetal monitoring should be used for pregnancies at risk of adverse perinatal outcomes (IIA).
Maternal vital signs should be obtained as part of intrauterine resuscitation (III-C).
Maternal oxygen should be administered for confirmed maternal hypoxia or hypovolemia, and NOT routinely used as a resuscitative measure for atypical or abnormal fetal heart tracings (1-A).
An intravenous bolus should be used only in the event of maternal hypovolemia and/or hypotension (III-C).
Digital fetal scalp stimulation is recommended as an indirect assessment of acid-base status in response to atypical or abnormal electronic fetal monitoring tracings (II-B).
The absence of an acceleration with digital fetal scalp stimulation does not necessarily indicate fetal compromise. When acceleration does not occur:
Fetal scalp blood sampling should be considered when available (II-B).
If fetal scalp blood sampling is not possible, consider ongoing vigilant evaluation of the fetal health surveillance tracing if other elements of the fetal health surveillance and the clinical situation are normal or prompt delivery depending on the overall clinical situation (III-C).
Where facilities and expertise exist, fetal scalp blood sampling for assessment of fetal acid-base status (using lactate or pH) is recommended in women at gestations >34 weeks when delivery is not imminent and when
atypical/abnormal electronic fetal monitoring tracings are identified and not resolved with intrauterine resuscitation measures (III-C);
digital fetal scalp stimulation does not result in an acceleratory fetal heart rate response (III-C).
Fetal scalp lactate blood sampling is a reliable tool to assess intrapartum fetal acidosis and may be used when clinically indicated, available, and with resources to respond (I-A).
Cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births (III-C).
Fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate and the classification in documentation (III-A).
Classification should be included whenever fetal health surveillance is documented (III-A).
Recommended criteria for frequency of assessment, classification, and documentation vary based on the stage of labour, maternal fetal status, and method of fetal surveillance (III-B).
Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended (III-C).
ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended (I-A).
Computer-based interpretation of electronic fetal monitoring tracing is not recommended (I-D).
All providers of intrapartum obstetrical care (physicians, nurses, midwives) should be required to commit to formal education in fetal health surveillance and maintain up-to-date competence with formal education review of both intermittent auscultation and electronic fetal monitoring every 2 years (II-B).
Each facility should provide opportunities for all intrapartum care providers (physicians, nurses, midwives) to regularly attend an interdisciplinary educational discussion of fetal health surveillance clinical situations, including both intermittent auscultation and electronic fetal monitoring, to ensure common terminology and shared understanding and to foster the concept of team responsibility (III-C) .
Abbreviations:BD ( Base deficit), BMI ( Body mass index), bpm ( Beats per minute), CP ( Cerebral palsy), CD ( Cesarean delivery), CTG ( Cardiotocography), EFM ( Electronic fetal monitoring), FHR ( Fetal heart rate), FHS ( Fetal health surveillance (UA and FHR)), FSBS ( Fetal scalp blood sampling), FSE ( Fetal spiral electrode), HIE ( Hypoxic-ischemic encephalopathy), IA ( Intermittent auscultation), IUPC ( Intrauterine pressure catheter), MHR ( Maternal heart rate), MVU ( Montevideo units), toco ( Tocodynamometer), TOLAC ( Trial of labour after CD), UA ( Uterine activity)
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This document reflects clinical and scientific consensus on the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the publisher.
Patients have the right and responsibility to make informed decisions about their care in partnership with their health care providers. In order to facilitate informed choice, patients should be provided with information and support that is evidence based, culturally appropriate, and tailored to their needs. The values, beliefs, and individual needs of each patient and their family should be sought and the final decision about care and treatment options chosen by the patient should be respected.
This guideline was written using gendered language but it is meant to be inclusive of individuals who may not identify as women/female. The SOGC is committed to respecting the rights of all people for whom this document may apply, including but not limited to transgender, gender non-binary, and intersex people. The SOGC encourages health care providers to engage in respectful conversation with patients regarding their gender identity and their preferred gender pronouns, and to apply these guidelines as appropriate to meet each person's needs.