No. 197b-Fetal Health Surveillance: Intrapartum Consensus Guideline

Objective: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada. Options: Consideration has been given to all methods of fetal surveillance currently available in Canada. Outcomes: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. Evidence: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). Sponsor: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. Recommendation 1: Labour Support During Active Labour: 1. Women in active labour should receive continuous close support from an appropriately trained person (I-A).Recommendation 2: Professional One-to One Care and Intrapartum Fetal Surveillance: 1. Intensive fetal surveillance by intermittent auscultation or electronic fetal monitoring requires the continuous presence of nursing or midwifery staff. One-to-one care of the woman is recommended, recognizing that the nurse/midwife is really caring for two patients, the woman and her unborn baby (III-C).Recommendation 3: Intermittent Auscultation in Labour: 1. Intrapartum fetal surveillance for healthy term women in spontaneous labour in the absence of risk factors for adverse perinatal outcome. Intermittent auscultation following an established protocol of surveillance and response is the recommended method of fetal surveillance; compared with electronic fetal monitoring, it has lower intervention rates without evidence of compromising neonatal outcome (I-B).2. Epidural analgesia and intermittent auscultation. Intermittent auscultation may be used to monitor the fetus when epidural analgesia is used during labour, provided that a protocol is in place for frequent intermittent auscultation assessment (e.g.,every 5 minutes for 30 minutes after epidural initiation and after bolus top-ups as long as maternal vital signs are normal) (III-B).Recommendation 4: Admission Fetal Heart Test: 1. Admission fetal heart tracings are not recommended for healthy women at term in labour in the absence of risk factors for adverse perinatal outcome, as there is no evident benefit (I-A).2. Admission fetal heart tracings are recommended for women with risk factors for adverse perinatal outcome (III-B).Recommendation 5: Intrapartum Fetal Surveillance for Women With Risk Factors for Adverse Perinatal Outcome: 1. Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome (II-A).2. Normal electronic fetal monitoring tracings during the first stage of labour.When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). Recommendation 6: Digital Fetal Scalp Stimulation: 1. Digital fetal scalp stimulation is recommended in response to atypical electronic fetal heart tracings (II-B).2. In the absence of a positive acceleratory response with digital fetal scalp stimulation, • Fetal scalp blood sampling is recommended when available (II-B).• If fetal scalp blood sampling is not available, consideration should be given to prompt delivery, depending upon the overall clinical situation (III-C).Recommendation 7: Fetal Scalp Blood Sampling: 1. Where facilities and expertise exist, fetal scalp blood sampling for assessment of fetal acid–base status is recommended in women with “atypical/abnormal” fetal heart tracings at gestations > 34 weeks when delivery is not imminent, or if digital fetal scalp stimulation does not result in an acceleratory fetal heart rate response (III-C).Recommendation 8: Umbilical Cord Blood Gases: 1. Ideally, cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births, for quality assurance and improvement purposes. If only one sample is possible, it should preferably be arterial (III-B).2. When risk factors for adverse perinatal outcome exist, or when intervention for fetal indications occurs, sampling of arterial and venous cord gases is strongly recommended (I-insufficient evidence. See Table 1).Recommendation 9: Fetal Pulse Oximetry: 1. Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended for routine use at this time (III-C).Recommendation 10: ST Waveform Analysis: 1. The use of ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended for routine use at this time (I-A).Recommendation 11: Intrapartum Fetal Scalp Lactate Testing: 1. Intrapartum scalp lactate testing is not recommended for routine use at this time (III-C).