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Improving fetal monitoring

The Each Baby Counts 2015 report identified that out of the 556 babies for whom different care might have led to a different outcome, there were 409 babies for whom fetal monitoring was identified as a critical contributory factor by one or more reviewer. It is also clear from the report that fetal monitoring, whether through intermittent auscultation or continuous cardiotocography (CTG), requires a complex interplay of staff knowledge, use of equipment, team working and interpretation of what is inevitably a dynamically changing picture.

Here are the key recommendations and the practical ‘things you can do’ set out in the report, together with up-to date resources to help your team find guidance and courses to plan and support your maternity safety training strategy.

We have also indicated who is likely to take responsibility for these improvements. For projects that require national implementation, we recommend that responsible bodies commence discussion to address these issues. For local or regional service improvements, we recommend these are addressed within 1 year of this report’s publication.


Intermittent auscultation

Key recommendations

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

Things you can do

  • A local IT system to facilitate adequate risk assessment at the onset of labour should be designed, to ensure that mothers are giving birth in the most appropriate setting with the appropriate monitoring. (Government in partnership with relevant professional bodies)
  • When labour deviates from a low-risk pathway, for example, when decelerations, a rising baseline rate, presence of meconium or vaginal bleeding are detected, the mother’s care should be reassessed in a holistic manner. Care should be escalated through the use of continuous CTG monitoring including, if necessary, transfer to a unit with access to obstetric and neonatal support.(Local clinical management and midwifery staff)
  • Employing a ‘fresh ears’ approach to intermittent auscultation, whereby a second midwife confirms the fetal heart rate pattern every hour, may reduce interpretation errors. (Local clinical management and midwifery staff)
  • When there is a concern regarding the fetal heart rate, immediate help should be sought. (All clinical staff)
  • 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. (All clinical staff)
  • Listening, acknowledging and reacting appropriately to what a mother is communicating should be central to the care provided to her. It may be necessary to bring forward an examination or fetal heart rate assessment, rather than sticking rigidly to a previous plan. The clinical situation and the risk status are continuously evolving during labour and healthcare professionals must be alive to such change. (All clinical staff)

Continuous CTG

Key recommendations:

  • Staff tasked with CTG interpretation must have documented evidence of annual training.
  • Key management decisions should not be based on CTG interpretation alone.

Things you can do:

  • Formal recording of the CTG assessment (e.g. stickers in the notes) should be undertaken as it has been shown to reduce the incidence of babies born with an Apgar score of less than 7. (Local clinical management and all clinical staff)
  • A buddy system and a ‘fresh eyes’ approach to CTG interpretation should be used in all units interpreting continuous CTG as there is evidence this may reduce errors in CTG interpretation. (Local clinical management and all clinical staff)
  • Ultrasound scanning should be used to exclude severe fetal heart rate abnormalities when a CTG recording cannot be obtained reliably via a transabdominal transducer or a fetal scalp electrode. (All clinical staff)
  • A robust system should be developed locally to ensure that the urgency of a delivery is communicated effectively between all teams involved in the mother’s care. Any delay in delivery must be flagged up to the most senior obstetrician in charge and action should be taken immediately to reassess the necessity and potential impact of such a delay. (Local clinical management and all clinical staff)
  • A holistic approach that takes into account the risk factors for both the mother and the baby as well as the stage and progress in labour should be adopted when making any management decisions. (All clinical staff)
  • The identification and consideration of risk factors such as persistently reduced fetal movements before labour, fetal growth restriction, previous caesarean section, thick meconium, suspected infection, vaginal bleeding or prolonged labour must become standard practice when reviewing a CTG. (Local clinical management and all clinical staff)