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Intermittent auscultation: Key recommendations

 

Key recommendations

Recommendation

Women who are apparently at low risk should have a formal fetal risk assessment on admission in labour irrespective of the place of birth to determine the most appropriate fetal monitoring method.[i]

 

It is not always easy to identify in maternity notes all risk factors that may make intermittent auscultation inappropriate. The relevant information may be contained in the latest ultrasound report (small for gestational age, abnormal fetal Doppler), a recent, as yet unfilled laboratory report or the mother’s history when she presents in labour.

 

The development of IT tools that bring together data from across a hospital’s systems to support accurate, easily accessible risk assessment should be prioritised.

 

 

Recommendation

NICE guidance on when to switch from intermittent auscultation to continuous CTG monitoring should be followed (Table 6).

 

This requires regular reassessment of risk during labour as recommended in the guideline on intermittent auscultation from the Royal College of Midwives. Fetal heart rate abnormalities identified or suspected through intermittent auscultation need careful assessment to ensure the baby is coping with labour. The stage of labour, progress through labour, the well-being of the mother and the baby and the ability to access help must be an integral part of any decision making in labour.

 

 

Recommendation

Healthcare professionals should be alert to the possibility of quick transition between different phases of labour (latent phase to active stage, active stage to second stage).

 

In contrast to continuous CTG monitoring, the frequency of fetal monitoring with intermittent auscultation varies according to the labour phase and yet the transitions from the latent to the active phase and from the active to the second stage may occur unnoticed. There needs to be a careful balance between too frequent, intrusive assessments of progressive cervical dilatation and the risks associated with inadequate fetal monitoring. There is no objective method as an alternative to vaginal examination which can be recommended to determine the stage of labour. Therefore, clinicians have to rely on their clinical experience and judgement if they choose not to perform vaginal examination.

 

Table 6. Main indications for continuous CTG (adapted from the NICE guideline on intrapartum care for healthy women and babies[i]

Maternal Assessment

Baby’s assessment

Pulse over 120 beats/minutes on 2 occasions 20 minutes apart

Any abnormal presentation including cord presentation

Single reading of either raised diastolic blood pressure of 110mmHg or more or raised systolic blood pressure of 16mmHg or more

Reduced fetal movements in the last 24 hours reported by the mother

Either raised diastolic blood pressure of 90mmHg or more or raised systolic blood pressure of 140mmHg or more on 2 consecutive readings taken 30 minutes apart

Deceleration heard in the fetal heart rate on intermittent auscultation

A reading of 2+ of protein on urinalysis and a single reading of either raised diastolic blood pressure (90mmHg or more) or raised systolic blood pressure (140mmHg or more)

Suspected fetal growth restriction or macrosomia

Temperature of 38oC or above on a single reading, or 37.5oC on 2 consecutive readings 1 hour apart

Suspected anhydramnios or polyhydramnios

Any vaginal blood loss other than a show

Fetal heart rate below 110 or above 160 beats/minutes

Rupture of membranes more than 24 hours before the onset of established labour

 

Presence of significant meconium

 

Pain reported by the woman that differs from the pain normally associated with contractions

 

Any risk factors recorded in the woman’s notes that indicate the need for obstetric led care

 

Confirmed delay in the first or second stage of labour

 

Request by the woman for additional pain relief involving regional anaesthesia

 

Obstetric emergency, including antepartum haemorrhage, cord prolapse, postpartum haemorrhage, maternal seizure or collapse, or a need for advanced neonatal resuscitation

 

 

 

 


[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].