NICE recommends that the fetal heart should be auscultated for 1 minute after a contraction every 15 minutes in the first stage of labour and at least every 5 minutes in the second stage.[i]
A mother attended in labour at 9 cm dilatation. Her membranes had ruptured spontaneously and the liquor was blood-stained. She was reassessed 4 hours later and found to be fully dilated but with no urge to push. A passive second stage was allowed for 2 hours. The fetal heart was auscultated every 15 minutes in the second stage. One hour after being fully dilated, the fetal heart rate could not be heard; however, help was not summoned for more than 20 minutes. The mother was transferred to the delivery suite and a forceps delivery was performed 50 minutes after the loss of the fetal heart rate.
The baby was born with no signs of life. Resuscitation was unsuccessful and was abandoned at 25 minutes of age.
If the fetal heart was not auscultated every 5 minutes in the second stage we may miss subtle signs that the baby is becoming distressed. The baseline rate may start to rise or decelerations may be noted. Although we cannot be sure that this baby would have demonstrated these signs we need to do our utmost to look for these signs in the second stage. The time taken to establish the absence of the fetal heart is also worth noting.
A mother attended at 5 cm dilatation. She laboured in the birthing pool and the fetal heart was auscultated every 15 minutes. 3 hours later she was examined and was fully dilated. The midwife continued with auscultation every 15 minutes.
The baby was born after around 60 minutes of active pushing. The baby was born in poor condition and required active therapeutic cooling. In her statement the midwife reported that she was not aware the fetal heart should be auscultated every 5 minutes in the second stage.
The second stage of labour is more demanding upon both the mother and the baby and this is why increased monitoring is recommended in the second stage. A baby can quickly become distressed in the second stage and in this instance the signs of distress may have been missed through the infrequent fetal heart assessment that did not comply with NICE guidance for intermittent auscultation.
Things you can do
When there is a concern regarding the fetal heart rate, immediate help should be sought.
Full compliance with the NICE recommendations for intermittent auscultations whilst also providing support to the mother and her birth partners, performing maternal observations and maintaining contemporaneous record keeping is a challenge, particularly in the second stage of labour. When full compliance may not be achievable, help should be sought including asking someone to act as a scribe or to provide support to the mother. If this is not possible, continuous CTG must be considered to ensure adequate fetal monitoring.
[i] National Institute of Clinical Excellence (NICE). Intrapartum Care for Healthy Women and Babies. NICE Clinical Guideline 190. London: NICE; 2014 (update 2017). Available from: https://www.nice.org.uk/guidance/cg190 [accessed on 6th October 2017].