No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

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 1Definitions 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). 2When 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). 3Communication to the interprofessional team should be done clearly and efficiently (III-C). Support During Active Labour 4Women in active labour should receive continuous close support from an appropriately trained person (I-A). 5Fetal 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). 6One-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 7The 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 8Intermittent auscultation, following an established protocol of surveillance and response, is the recommended method of intrapartum fetal surveillance for healthy women between 370 and 413 weeks gestation in spontaneous labour, in the absence of risk factors for adverse perinatal and neonatal outcomes (I-B). 9Intermittent auscultation may be used for women who are 414 weeks gestation to 420 weeks, provided there is documentation of a normal non-stress test and normal amniotic fluid volume (III-C). 10Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome (II-A). Paper Speed 11Canadian 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 12Admission 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). 13Admission electronic fetal monitoring assessments are recommended for women with risk factors for adverse perinatal outcome (III-B). 14When 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 15Intermittent 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). 16Electronic 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 17After 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). 18When 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). 19When 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 20When 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). 21Electronic 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 22The terms normal and abnormal are used to classify intermittent auscultation (III-C). 23The presence of uterine tachysystole during IA classifies intermittent auscultation fetal health surveillance assessment as abnormal, and electronic fetal monitoring should be initiated (III-C). 24The terms normal, atypical, and abnormal are used to classify electronic fetal monitoring (III-C). Maternal Heart Rate 25Assess 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: aAt initial assessment when determining baseline fetal heart rate bAt any time when there is uncertainty between the maternal heart rate and fetal heart rate cBased on the stage of labour: iIn the active first stage and passive second stage of labour: every 4 hours with intact membranes iiIn the active first stage and passive second stage of labour: every 2 hours with ruptured membranes iiiIn the active second stage of labour: every 15–30 minutes (III-C) Fetal Health Surveillance Assessment in the Active Second Stage of Labour 26Intermittent auscultation is recommended if the woman continues to meet the criteria for intermittent auscultation assessments (IB). 27Electronic fetal monitoring should be used for pregnancies at risk of adverse perinatal outcomes (IIA). Intrauterine Resuscitation 28Maternal vital signs should be obtained as part of intrauterine resuscitation (III-C). 29Maternal 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). 30An intravenous bolus should be used only in the event of maternal hypovolemia and/or hypotension (III-C). Digital Fetal Scalp Stimulation 31Digital 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). 32The 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 33Where 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 aatypical/abnormal electronic fetal monitoring tracings are identified and not resolved with intrauterine resuscitation measures (III-C); bdigital fetal scalp stimulation does not result in an acceleratory fetal heart rate response (III-C). 34Fetal 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 35Cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births (III-C). Documentation 36Fetal health surveillance terminology should be used to describe the uterine activity, fetal heart rate and the classification in documentation (III-A). 37Classification should be included whenever fetal health surveillance is documented (III-A). 38Recommended 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 39Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended (III-C). 40ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended (I-A). 41Computer-based interpretation of electronic fetal monitoring tracing is not recommended (I-D). Fetal Health Surveillance Education 42All 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). 43Each 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).