Fetal health surveillance in labour.

OBJECTIVE: This guideline defines the standards pertaining to the application and documentation of fetal surveillance in labour that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Both high- and low-risk obstetrical populations are considered. It is intended that this guideline could be used by all persons providing intrapartum care in Canada, including nurses, physicians, and midwives.

OPTIONS: Consideration has been given to methods of fetal surveillance currently available in Canada, including intermittent auscultation, electronic fetal monitoring (alone and when paired with vibro-acoustic or scalp stimulation and fetal scalp blood sampling), the "admission strip," computerized heart rate analysis, fetal oxygen saturation monitoring, fetal electrocardiogram analysis, and near-infrared spectroscopy.

OUTCOMES: Short- and long-term outcomes were considered that may indicate the presence of birth asphyxia. The associated rates of operative or other labour interventions were also considered.

EVIDENCE: A comprehensive review of randomized controlled trials performed from 1995 to date and a search of the literature using Medline and the Cochrane Database of all new studies on fetal surveillance. The level of evidence has been determined using the criteria described by the Canadian Task Force on the Periodic Health Examination.

RECOMMENDATIONS: Part I: Standard Fetal Surveillance in Labour 1. Women in active labour should receive continuous close support from an appropriately trained professional. One-to-one nursing is recommended. (I-A) 2. Intermittent auscultation following an established protocol of surveillance and response (Figure 1) is the preferred method of fetal surveillance in healthy pregnancies in the active phase of labour. (I-A) 3. Labour induction requires close monitoring of uterine activity and fetal heart rate. (III-B) 4. In the presence of abnormal fetal heart rate characteristics detected by intermittent auscultation and unresponsive to resuscitative measures, increased surveillance by continuous electronic fetal monitoring or fetal scalp sampling or delivery should be instituted. (I-A) 5. Continuous intrapartum electronic fetal monitoring is recommended: a) for pregnancies where there is an increased risk of perinatal death, cerebral palsy, or neonatal encephalopathy (III-C) b) when oxytocin is being used for augmentation of labour (1-A) c) when oxytocin is being used for induction of labour (III-C). 6. With respect to continuous electronic fetal monitoring, all professionals must be familiar with the paper speed used in each case to avoid misinterpretation. The correct time should be recorded on the electronic fetal monitoring record. (III-C) 7. Electronic fetal monitoring records should be inspected and documented every 15 minutes in the active phase of labour and at least every 5 minutes in the second stage of labour. (III-C) 8. The timing of electronic fetal monitoring patterns should be determined in association with uterine contractions. The contraction frequency, duration, intensity, and resting tone should be assessed and documented. Abdominal palpation, a tocodynamometer, or an intrauterine pressure catheter may be used to facilitate the assessment. (III-C) 9. Practitioners should use standard terminology when describing fetal heart rate characteristics of an electronic fetal monitoring record. (III-C) 10. Fetal scalp blood sampling is recommended in association with electronic fetal monitoring patterns that are uninterpretable or non-reassuring, such as sustained minimal or absent variability, uncorrectable late decelerations, increasing fetal tachycardia, and abnormal FHR characteristics on auscultation. (II-3B) 11. The limited knowledge available on the use of labour admission tests warrants further research to establish the usefulness of this screening approach. (III-C) Part II: New Technologies for Fetal Surveillance in Labour 12. The use of computer-based algorithms alone to interpret fetal heart rate patterns is not recommended as a standard of care at the present time. (III-D) 13. Fetal pulse oximetry as an adjunct to electronic fetal heart monitoring in patients with non-reassuring HR status is not recommended as a standard of care at the present time. (III-D) 14. ST waveform analysis technology is under development but is not recommended as a standard of care at this time. (III-C) 15. Near-infrared spectroscopy as an adjunct to electronic fetal monitoring is currently not recommended as there is insufficient evidence to assess its efficacy in fetal surveillance. (III-D) 16. Further study of fetal pulse oximetry, ST waveform analysis, and near-infrared technology in clinical research settings is encouraged. (III-B) VALIDATION: This guideline was reviewed by the SOGC Clinical Practice Obstetrics Committee, Maternal Fetal Medicine Committee, and ALARM Committee, as well as by the Canadian Medical Protective Association.

SPONSOR: The Society of Obstetricians and Gynaecologists of Canada.