JOGC

No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

      Abstract

      Objective

      To present evidence and recommendations regarding use, classification, interpretation, response, and documentation of fetal surveillance in the intrapartum period and to provide information to help minimize the risk of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention.

      Intended Users

      Members of intrapartum care teams, including but not limited to obstetricians, family physicians, midwives and nurses, and their learners

      Target Population

      Intrapartum women

      Options

      All methods of uterine activity assessment and fetal heart rate surveillance were considered in developing this document.

      Outcomes

      The impact, benefits, and risks of different methods of surveillance on the diverse maternal-fetal health conditions have been reviewed based on current evidence and expert opinion. No fetal surveillance method will provide 100% detection of fetal compromise; thus, all FHS methods are viewed as screening tests. As the evidence continues to evolve, caregivers from all disciplines are encouraged to attend evidence-based Canadian educational programs every 2 years.

      Evidence

      Literature published between January 1976 and February 2019 was reviewed. Medline, the Cochrane Database, and international guidelines were used to search the literature for all studies on intrapartum fetal surveillance.

      Validation Methods

      The principal and contributing authors agreed to the content and recommendations. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

      Benefits, Harm, and Costs

      Consistent interdisciplinary use of the guideline, appropriate equipment, and trained professional staff enhances safe intrapartum care. Women and their support person(s) should be informed of the benefits and harms of different methods of fetal health surveillance.

      RECOMMENDATIONS

      Communication
      • 1
        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).
      • 2
        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).
      • 3
        Communication to the interprofessional team should be done clearly and efficiently (III-C).
      Support During Active Labour
      • 4
        Women in active labour should receive continuous close support from an appropriately trained person (I-A).
      • 5
        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).
      • 6
        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).
      Principles of Intrapartum Fetal Surveillance
      • 7
        The classified intermittent auscultation and electronic fetal monitoring findings must be interpreted in the context of the overall clinical picture (I-A).
      Selecting the Method of Fetal Heart Rate Monitoring: Intermittent Auscultation or Electronic Fetal Monitoring
      • 8
        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).
      • 9
        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).
      • 10
        Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome (II-A).
      Paper Speed
      • 11
        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 Assessments
      • 12
        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).
      • 13
        Admission electronic fetal monitoring assessments are recommended for women with risk factors for adverse perinatal outcome (III-B).
      • 14
        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).
      Epidural Analgesia
      • 15
        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).
      • 16
        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).
      Intermittent Auscultation in Labour
      • 17
        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).
      • 18
        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).
      • 19
        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).
      Electronic Fetal Monitoring in Labour
      • 20
        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).
      • 21
        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).
      Classification of Intrapartum Fetal Surveillance
      • 22
        The terms normal and abnormal are used to classify intermittent auscultation (III-C).
      • 23
        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).
      • 24
        The terms normal, atypical, and abnormal are used to classify electronic fetal monitoring (III-C).
      Maternal Heart Rate
      • 25
        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:
        • a
          At initial assessment when determining baseline fetal heart rate
        • b
          At any time when there is uncertainty between the maternal heart rate and fetal heart rate
        • c
          Based on the stage of labour:
          • i
            In the active first stage and passive second stage of labour: every 4 hours with intact membranes
          • ii
            In the active first stage and passive second stage of labour: every 2 hours with ruptured membranes
          • iii
            In the active second stage of labour: every 15–30 minutes (III-C)
      Fetal Health Surveillance Assessment in the Active Second Stage of Labour
      • 26
        Intermittent auscultation is recommended if the woman continues to meet the criteria for intermittent auscultation assessments (IB).
      • 27
        Electronic fetal monitoring should be used for pregnancies at risk of adverse perinatal outcomes (IIA).
      Intrauterine Resuscitation
      • 28
        Maternal vital signs should be obtained as part of intrauterine resuscitation (III-C).
      • 29
        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).
      • 30
        An intravenous bolus should be used only in the event of maternal hypovolemia and/or hypotension (III-C).
      Digital Fetal Scalp Stimulation
      • 31
        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).
      • 32
        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).
      Fetal Scalp Blood Sampling
      • 33
        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
        • a
          atypical/abnormal electronic fetal monitoring tracings are identified and not resolved with intrauterine resuscitation measures (III-C);
        • b
          digital fetal scalp stimulation does not result in an acceleratory fetal heart rate response (III-C).
      • 34
        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).
      Umbilical Cord Blood Gases
      • 35
        Cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births (III-C).
      Documentation
      • 36
        Fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate and the classification in documentation (III-A).
      • 37
        Classification should be included whenever fetal health surveillance is documented (III-A).
      • 38
        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 Surveillance Technology Not Recommended
      • 39
        Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended (III-C).
      • 40
        ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended (I-A).
      • 41
        Computer-based interpretation of electronic fetal monitoring tracing is not recommended (I-D).
      Fetal Health Surveillance Education
      • 42
        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).
      • 43
        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) .

      Key Words

      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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