NICE fetal monitoring - 1.1, 1.2, 1.3

1.1.1 When should fetal monitoring options be discussed with a woman?

As part of antenatal care

Discussions and decisions should be documented in her personalised care plan

1.1.2 What information should be provided throughout labour about fetal monitoring?

The type of fetal monitoring being advised and the reason for the advice

1.1.3 How should a woman’s decision about fetal monitoring during labour be managed?

Support the woman’s decision about fetal monitoring during labour

1.1.3 Who should be included in discussions about fetal monitoring during labour if appropriate?

Birthing companion(s), if that is what the woman wants

1.1.3 What must be done after discussions and decisions about fetal monitoring?

Document these discussions and decisions in the woman’s notes

1.1.4 What should be done if additional advice or review is being sought by the care team?

Keep women and their birthing companion(s) informed about what is happening.

1.2.1 How often should a systematic assessment of the woman and unborn baby be performed and documented during labour?

Every hour, or more frequently if there are concerns.

1.2.2 What should recommendations about care in labour be based on when discussing hourly assessment results with the woman?

• Their preferences

• Their reports of the frequency, length and strength of contractions

• Any antenatal and intrapartum risk factors for fetal compromise

• Current wellbeing of the person and unborn baby

• Labour progression

1.2.2 Who should be included in discussions about assessment and care if appropriate?

Birthing companion(s), if that is what the woman wants

1.2.3 What should be remembered about fetal heart rate monitoring?

It is a tool to provide guidance on fetal condition and not a standalone diagnostic tool.

1.2.3 How should findings from fetal monitoring be interpreted?

Together with the developing clinical picture for both woman and baby

1.2.4 What level of support should be maintained during labour?

One-to-one support by having a midwife remain with the woman throughout labour

1.2.4 What should be done if the midwife needs to leave the room or there is a change in staff?

Ensure the woman knows this is happening.

1.2.5 When should antenatal risk factors for fetal compromise be initially assessed?

At the onset of labour, to determine whether IA or CTG is offered as the initial method of fetal heart rate monitoring

1.2.5 What should be taken into account when deciding the initial method of fetal heart rate monitoring?

Recommendations for people who are higher risk due to existing medical conditions, obstetric complications, or multiple pregnancy, as outlined in relevant NICE guidelines

1.2.6 What should be confirmed with the woman regarding fetal monitoring at the start of labour?

Which method of fetal monitoring has already been advised in her personalised care plan.

1.2.7 What should be explained to the woman about risk assessment during labour?

That risk assessment is a continual process and the advised method of fetal heart rate monitoring may change during labour

1.2.8 What should be explained if there are no identified risk factors for fetal compromise regarding continuous CTG?

Continuous CTG is associated with increased interventions compared with IA, which may outweigh the benefits

1.2.8 What should be taken into account when using the method of FHR monitoring when there are no risk factors?

The whole clinical picture, as assessed by the midwife or obstetrician

1.2.9 Who should be offered intermittent auscultation in established first stage of labour?

Women with a low risk of complications

1.2.9 What devices can be used for intermittent auscultation?

Pinard stethoscope or Doppler ultrasound.

1.2.9 How should intermittent auscultation be performed in the first stage of labour?

Immediately after a palpated contraction

For at least 1 minute, listen every 15 minutes

Recorded as a single rate on a partogram and in the woman’s notes.

1.2.9 What else should be recorded during intermittent auscultation in first stage?

Accelerations and decelerations, if heard.

1.2.9 How often should the maternal pulse be palpated during first stage with intermittent auscultation?

Hourly, or more often if there are concerns, and recorded on the partogram to differentiate maternal and fetal heartbeats.

1.2.9 What should be offered if no fetal heartbeat is detected on intermittent auscultation?

Urgent real-time ultrasound assessment to check fetal viability.

1.2.10 How should intermittent auscultation be performed in second stage of labour?

Immediately after a palpated contraction for at least 1 minute

At least once every 5 minutes

Recorded as a single rate on a partogram and in the woman’s notes

1.2.10 What should be done if there are concerns about differentiating maternal and fetal heart rates?

Seek help and consider changing the method of fetal heart rate monitoring.

1.2.11 What should be done if there is a rise in fetal heart rate of ≥20 bpm from start of labour or a deceleration is heard on intermittent auscultation?

Increase frequency of auscultation (for example after 3 consecutive contractions)

Carry out a full review of the whole clinical picture, including risk factors, maternal observations, contraction frequency (including hypertonus), and progress of labour.

1.2.12 What actions should be taken if fetal heart rate concerns are confirmed?

Summon help

Advise continuous CTG with explanation and implications

Transfer from midwifery-led to obstetric-led care if safe and appropriate.

1.2.13 If CTG was started because of concerns from IA, when can monitoring go back to intermittent auscultation?

When the CTG is normal after 20 minutes, unless the woman chooses to stay on continuous CTG

1.2.14 When should continuous CTG be advised instead of intermittent auscultation?

If fetal heart rate concerns are ongoing or if intrapartum maternal or fetal risk factors develop.

1.2.15 Should this guideline be used to categorise antenatal CTG traces?

No

1.2.16 When should this guideline be used to interpret and categorise CTG traces?

For intrapartum CTG traces, and interpretation should also take into account maternal, fetal and labour factors, not just CTG changes.

1.2.17 When should a lower threshold for escalation be considered?

When there are any antenatal or intrapartum risk factors that could lead to fetal compromise.

1.2.18 What should be encouraged during continuous CTG monitoring?

Encourage and help women to be as mobile as possible, to find comfortable positions, and to change position as often as they wish.

1.2.19 When should continuous CTG monitoring be offered as part of fetal monitoring?

If any antenatal or intrapartum risk factors for fetal compromise are present.

1.2.20 What should be discussed with the woman and birth companion(s) when offering continuous CTG monitoring?

• Antenatal and intrapartum risk factors

• Continuous CTG monitoring is used to evaluate the baby's condition in labour

• Monitors the baby's heart rate and the labour contractions

• Restricts her mobility and the option to labour in water

• A normal CTG trace indicates that the baby is coping well with labour

• Changes to the baby's heart rate pattern during labour are common and do not necessarily cause concern; however, they may represent developing fetal compromise, so maintaining continuous CTG monitoring is advised if these occur

• If the CTG trace changes or is not normal, maintaining continuous CTG monitoring, and a full assessment including checks for developing intrapartum risk factors such as the presence of meconium, sepsis and slow progress in labour is advised

• Advice about her care will be based on her preferences, her condition, the condition of her baby, and findings from the CTG.

1.2.21 What should be ensured about wireless CTG transducers?

They should be kept charged and maintained so they are ready to use

1.2.22 When should monitoring switch from wireless to wired transducers?

If there is signal loss not resolved by reducing the distance between the base unit and the woman, to confirm whether there is a clinical problem.

1.3.1 When should CCTG be offered?

Offer continuous cardiotocography (CTG) monitoring to women in labour if it is in their personalised care plan.

1.3.2 Which antenatal maternal risk factors require continuous CTG monitoring in labour?

• Previous caesarean birth or other full thickness uterine scar

• Any hypertensive disorder needing medication

• Prolonged ruptured membranes (but women who are already in established labour at 24 hours after their membranes ruptured do not need CTG unless there are other concerns)

• Any vaginal blood loss other than a show

• Suspected chorioamnionitis or maternal sepsis

• Pre-existing diabetes and gestational diabetes requiring medication.

1.3.3 Which antenatal fetal risk factors require continuous CTG monitoring in labour?

• Non-cephalic presentation (including breech, transverse, oblique and cord), including while a decision is made about mode of birth

• Fetal growth restriction (estimated fetal weight below 3rd centile)

• Small for gestational age (estimated fetal weight below 10th centile) with other high-risk features such as abnormal doppler scan results, reduced liquor volume or reduced growth velocity

• Advanced gestational age (more than 42+0 weeks at the onset of established labour)

• Anhydramnios or polyhydramnios

• Reduced fetal movements in the 24 hours before the onset of regular contractions.

1.3.5 What should be included in the full hourly assessment of the woman and baby?

• Maternal antenatal risk factors for fetal compromise

• Fetal antenatal risk factors for fetal compromise

• New or developing intrapartum risk factors

• Progress in labour including characteristics of contractions (frequency, strength and duration)

• Fetal heart rate monitoring, including changes to the fetal heart rate pattern.

1.3.5 What should be discussed with the woman during hourly assessments?

Discuss with the woman any changes identified since the last review, and the implications of these changes

Include birthing companion(s) in these discussions if appropriate and if that is what the woman wants.

1.3.6 What review is required for women on CTG after each hourly assessment?

“fresh eyes”

Obtain an in-person review of every hourly assessment by another clinician for women on CTG, to be completed before the next assessment takes place

1.3.7 What should be recognised about intrapartum risk factors and fetal compromise?

Be aware that intrapartum risk factors may increase the risk of fetal compromise

Intrapartum risk factors that develop as labour progresses are particularly concerning.

1.3.8 Which intrapartum risk factors require continuous CTG monitoring?

• Contractions that last longer than 2 minutes, or 5 or more contractions in 10 minutes

• Presence of meconium

• Maternal pyrexia (a temperature of 38°C or above on a single reading or 37.5°C or above on 2 consecutive occasions 1 hour apart)

• Suspected chorioamnionitis or sepsis

• Pain reported by the woman that appears, based on her description or her previous experience, to differ from the pain normally associated with contractions

• Fresh vaginal bleeding that develops in labour

• Blood-stained liquor not associated with vaginal examination, that is likely to be uterine in origin

• Maternal pulse over 120 beats a minute on 2 occasions 30 minutes apart

• Severe hypertension

• Hypertension

• A reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure or raised diastolic blood pressure

• Confirmed delay in the first or second stage of labour

• Insertion of regional analgesia (for example, an epidural)

• Use of oxytocin.

1.3.10 What should be recognised about the presence of meconium during labour?

Can indicate possible fetal compromise

May lead to complications, such as meconium aspiration syndrome.

1.3.11 How should meconium be considered when assessing risk during labour?

High risk

Consider the character of the meconium

Other antenatal or intrapartum risk factors

Discuss CTG monitoring with the woman

Recognise that the type of monitoring method used is the woman’s choice, and support her decision

1.3.12 Post term babies and meconium

Meconium is more common post-term

Should still trigger a full risk assessment and discussion with the woman about the option of CTG monitoring