Guidance
Rationale and impact
Rationale and impact
These sections briefly explain why the committee made the recommendations and how they might affect practice.
Information and supported decision-making
Recommendations 1.1.1 to 1.1.4
Why the committee made the recommendations
The committee agreed, based on their knowledge and expertise, that discussions about fetal monitoring should occur as part of antenatal care and be documented in the personalised care plan. Although healthcare professionals currently always provide advice to women in labour on options for fetal monitoring, they should also support the decision made by the woman about which method to use.
Assessment during labour and methods for fetal monitoring
Recommendations 1.2.3, 1.2.5 to 1.2.7, 1.2.15 to 1.2.17, 1.2.19, 1.2.21 and 1.2.22
Why the committee made the recommendations
Based on their knowledge and expertise, the committee emphasised that fetal heart rate monitoring is only a tool that provides information. It should be used as part of assessing the whole clinical picture including antenatal and intrapartum risk factors, not as a standalone diagnostic tool, and that multiple risk factors may lower the threshold for intervention.
The committee discussed the initial assessment that should be carried out at the start of labour and agreed that a decision on the method of monitoring should be based on antenatal risk factors. These risk factors should have been identified and discussed with the woman during antenatal care and should already be recorded in her personalised care plan. However, the committee agreed it was important to advise women that the recommended method of fetal monitoring may change during labour (based on a clinical decision or because the woman changes her mind), but that for women at low risk, the use of cardiotocography (CTG) may lead to more interventions without evidence of benefit.
The committee were aware that there was the possibility of confusion between the interpretation of antenatal and intrapartum CTG and so made a recommendation to clarify this.
The committee were aware of incidences where telemetry was not available because transducers had not been plugged in to charge, or where CTG was not used effectively because of problems with signal loss, so they made recommendations to reduce such events based on their knowledge and experience.
Indications for continuous cardiotocography monitoring in labour
Recommendations 1.3.1, 1.3.4, 1.3.6, 1.3.7 and 1.3.9 to 1.3.12
Why the committee made the recommendations
The committee agreed that a decision to use CTG monitoring may already have been discussed and recorded in a woman's personalised care plan, but that antenatal risk factors identified during pregnancy or labour, or new intrapartum risk factors would mean that CTG was advised to assess if there was developing fetal compromise. The committee were aware that the lists of antenatal and intrapartum risk factors covered all commonly recognised risk factors but clinical judgement would be needed to determine if there were other risk factors not listed which also might lead to consideration of CTG.
The committee agreed that the presence of any meconium, not just significant meconium, should be taken into account when assessing the whole clinical picture and considering the use of CTG.
Use of cardiotocography for monitoring during labour
Why the committee made the recommendations
Recommendations 1.4.2, 1.4.6 to 1.4.8 and 1.4.10: The committee used their knowledge and expertise and agreed that any changes in the CTG, including the fetal heart rate pattern, over time indicated that the baby may be suffering from hypoxia. They agreed this should be investigated, alongside a review of the clinical picture and antenatal or intrapartum risk factors, so that causes could be sought and action could be taken, if necessary.
The committee agreed, based on their knowledge and expertise, to provide advice about the actions to take when it is difficult to distinguish between the maternal and fetal heart rate, as incorrect monitoring can lead to significant harm to the baby.
Recommendations 1.4.11 to 1.4.12 and 1.4.14: The committee agreed, based on their knowledge and expertise, that as well as monitoring the fetal heart rate pattern, it was important to monitor and record contractions to determine if they were normal and, if not, to take action.
Recommendations 1.4.17 and 1.4.20: The committee defined how variability should be measured. The committee were aware, based on their knowledge and expertise, that an absence of variability was concerning and so made a recommendation to address this.
Recommendation 1.4.20: The committee were aware, based on their knowledge and expertise, that a reduction in variability is not specific for fetal hypoxia. However, it does indicate an increased risk of adverse neonatal outcome and therefore requires obstetric review when combined with antenatal or intrapartum risk factors for fetal compromise. If a reduction in variability is combined with other amber or red features on the CTG, it will be classified as pathological, and the committee have emphasised the need for urgent review in these circumstances.
Recommendation 1.4.26 and 1.4.27: The committee wanted to emphasise, based on their knowledge and expertise, that decelerations lasting longer than 30 minutes combined with other CTG abnormalities should trigger an urgent obstetric review as this combination is particularly concerning for fetal compromise.
Recommendations 1.4.31 and 1.4.33: The committee were aware, based on their knowledge and expertise, that too much reliance may be placed on the categorisation of CTG trace as a substitute for reviewing and communicating about the wider clinical picture. They stated that CTG categorisation was a tool that should be used alongside review of other antenatal and intrapartum risk factors and the wider clinical picture.
Recommendations 1.4.34 to 1.4.38: The committee were aware, based on their knowledge and expertise, that in the second stage of labour it may be more difficult to differentiate the maternal and fetal heart rates, and that hypoxia may develop more rapidly, and so made new recommendations about this.
Making care decisions based on the cardiotocography trace
Why the committee made the recommendation
The committee advised, based on their knowledge and experience, that documentation of reviews and decisions was important.
Fetal blood sampling
Why the committee made the recommendation
There was recent but very limited evidence that fetal blood sampling does not improve outcomes for women and babies compared with CTG alone, or compared with CTG in combination with fetal scalp stimulation. The comparison with CTG alone showed that fetal blood sampling may increase the proportion of babies with an Apgar score less than 7 at 5 minutes, possibly because of a delay in expediting birth to allow the fetal blood sampling to be carried out. This harm was not seen in the comparison with CTG in combination with fetal scalp stimulation, although in this comparison the number of caesarean births was increased. The committee agreed that it was difficult to define whether this outcome was harmful or a benefit as it may indicate that a birth had been expedited appropriately.
The committee were aware, based on their knowledge and experience, that the time taken to carry out fetal blood sampling can delay appropriate expedition of birth, and that it can be an unpleasant procedure for the woman, especially in the absence of an effective epidural. The committee therefore agreed that the risks of fetal blood sampling were not balanced by the benefits and agreed it was no longer appropriate to recommend fetal blood sampling and they considered making a recommendation to advise that it should not be used. However, the committee were aware of an ongoing research study comparing fetal scalp stimulation with fetal blood sampling on maternal and fetal outcomes (FIRSST study) and did not wish to make recommendations which may impact on the completion of this study. The committee therefore agreed to make a recommendation advising on the current lack of evidence to support fetal blood sampling. The committee noted that the FIRSST study is due to be completed at the end of 2024 and that on its completion the advice on use of fetal blood sampling may need to be reviewed again.
As there was on ongoing study the committee did not make a research recommendation.