NICE fetal Monitoring Flashcards
How frequently should an assessment be done?
Hourly
Fetal monitoring general principles
Maternal reports of frequency, length, and strength of her contractions
Any antenatal and intrapartum risk factors for fetal compromise
The current wellbeing of the woman and unborn baby
Offer CTG for
VBAC / full thickness myomectomy
HTN requiring medication
PROM (if not in established labour at 24 hours)
PV bleeding other than show
Suspected chorio or maternal sepsis
T1 / T2 DM and GDM requiring medication
Anhydramnios / polyhydramnios
RFM before contractions
Meconoium
Contractions categories
White - <5/10
Orange - >5/10
Full risk assessment
Take action reduce contraction frequency
Reduced interval in between contractions with hypertonus
NICE CTG categories
White - 110-160
Orange - increase of 20 beats a minute or more from the start of labour or since the last review an hour ago, or, 100 to 109 beats a minute
Unable to determine baseline
Although 100-109 is abnormal, continue usual care if this has been stable throughout labour and there is normal variability and no variable / late decels
Red
<100 bpm or > 160 bpm
Heart rate categories
110-160 reassuring
100-109, 160-80 non reassuring
<100, > 180 abnormal
Variability categories
5-25 reassuring
<5 30-50 minutes , >25 15-25 minutes non reassuring
<5 (>50 minutes ) > 25 > 10 minutes
CTG decelerations
White -
No decels
Early decels
Variable decels that are not evolving to have concerning characteristics
Amber -
Repetitive variable decels with concerning characteristics for < 30 mins
Variable decels with concerning features for > 30 mins, or, repetitive late decels for < 30
Mins
Red
Repetitive variable decels with concerning features for > 30 minutes
Repetitive late decels for > 30 minutes
Acute bradycardia
Single prolonged decel > 3 minutes
Decelerations reasons
Early - head compression
Variable - cord compression
CTG concerning characteristics variable characteristics
> 60s
Reduced baseline variability
Failure to return to baseline
Biphasic W shape
No shouldering
Late decelerations categories
> 50% Contractions < 30 minutes
No fetomaternal risk (significant méconium, vaginal bleed)
Non reassuring
If fetomaternal risk present - abnormal
> 30 minutes - abnormal
Late deceleration reasons
Placental insufficiency
Compromised fetal distress
CTG features and categories
Features - reassuring , non reassuring, abnormal
=
Normal
Suspicious
Pathological
CTG categories
Normal - all features reassuring
Suspicious - 1 non reassuring feature, 2 reassuring features
1 amber / 2 white
Actions: correct underlying causes
Low BP, uterine hyperstimulation
Full set maternal obs
1+ conservative measures
Inform Obs / senior midwife
Document plan for reviewing whole clinical picture and CTG findings
Talk to woman and her birth companion about what is happening and take her preferences into account
CTG management : pathological features
1 abnormal or 1 non reassuring features
Obtain review by obstetrician and senior midwife
Exclude acute events (cord prolapse, suspected placental abruption, suspected uterine rupture)
Correct any underlying causes such as low BP or uterine hyper stimulation
1 or more conservative measures
Talk to woman and BP about what is happening and take preferences into account
If CTG is pathological after implementing Cx measures
Obtain further review by obstetrician and senior midwife
Offer digital fetal scalp stimulation
If CTG trace pathological after FSS consider expediting birth
Take woman’s preferences into account
Need for urgent intervention
Acute bradycardia or a single prolonged deceleration for 3 minutes or more
Urgently seek obstetric help
If there has been an acute event - cord prolapse, suspected placental abruption or uterine rupture, expedite their birth
Correct any underlying causes such as hypotension or uterine hyperstimulation
Start 1 or more conservative measure
Make preparations for an urgent birth
Talk to the woman and her birth companions about what is happening and take preferences into account
Expedite birth if acute bradycardia persists for 9 minutes
If FHR recovers at any time up to 9 minutes, reassess any decision to expedite the birth, in discussion with the woman
FHR pattern : suspicious
Consider overall clinical picture, parity, current cervical dilatation and rate of progress of labour and fetal reserve
Consider hyperstimulation, pyrexia, epidural, dehydration, reposition
If CTG becomes normal : continue close monitoring
FHR pattern : pathological
Consider overall clinical picture, parity, current cervical dilatation and rate of progress of labour and fetal reserve
Consider hyperstimulation, pyrexia, epidural, dehydration, reposition
If CTG worsens / continues to be pathological
consider fetal blood sample if possible
FBS possible?
Yes - FBS performed
Normal ph => 7.25
Repeat FBS within 1 hour if CTG remains pathological
Borderline pH 7.21 - 7.24
Repeat FBS within 30 minutes if CTG pathological
If abnormal pH after repeat FBS, deliver. If repeat FBS stable, monitor CTG and clinical situation. Repeat FBS only if further abnormalities appear.
Abnormal pH < 7.2 _ deliver
If third FBS needed, seek consultant opinion and review overall clinical picture to consider if delivery is needed.
If FBS not possible
Consider immediately delivery
Pathological CTG management
1) Conservative management : left lateral, hydration
2) Fetal scalp stimulation
If no acceleration -> FBS
0+1 FBA first
+2 direct OVD
If no acceleration
FBS
<7.2
Deliver - IVS / CS
When not to do FBS in exam
Fetal
Premature < 34/40
Active heroes
Known HIV / Hep B, Hep C +ve
Thrombocytopenia
Maternal - unfavourable Cx
Mobile PP
Malpresentation (face etc) uncertain
PI Praevia or APH
Sepsis
