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Monitoring fetal heart rate is a critical skill, serving as a life-saving measure by allowing healthcare providers to assess the well-being of a fetus throughout labor and delivery. In cases where a newborn experiences injury due to labor or birth, consistent fetal monitoring serves as a tool to construct a narrative, providing insights into the progression and timing of the baby's deterioration.
Improper fetal monitoring can occur through:
Failure to monitor when indicated.
Improper or incorrect interpretation of fetal monitor traces
Misreading or confusing the heart rates of the mother and baby
Failure to take appropriate action when fetal distress is indicated,
During labour, fetal heart rate monitoring is used to monitor how well the baby is coping with the stresses of labour. This can be completed by either CTG (cardiotocograph) or through intermittent auscultation with a doppler. It is crucial that the health provider follows the relevant policy and guidelines for fetal monitoring, particularly when there are risk factors and continuous monitoring is required. Conversely, for women without risk factors, intermittent auscultation is the recommended method for assessing fetal welfare, with the procedure to be conducted in accordance with local policies.
Risk factors that increase likelihood of fetal compromise in labour and CTG is recommended. (NSW Health policy)
Antenatal (Pregnancy) Risk factors | Intrapartum (Labour) Risk Factors |
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How does a CTG work?
There are two key elements to a CTG machine: a Doppler ultrasound which is used to monitor the baby’s heart rate, and a sensor which is used to monitor uterine contractions. These monitors transmit information to the machine which prints out a graph which can be interpreted by midwives and obstetricians.
In NSW, CTGs are considered according to the above algorithm, which is used by midwives to determine whether the fetal heart rate trace is normal, suspicious, pathological or urgent/ abnormal. These are a tool used to determine whether the clinical situation should be escalated to more senior midwives or Obstetricians for medical advice and intervention.
Abbreviations
FHR: Fetal Heart Rate
CTG: Cardiotocography
Bpm: beats per minute
Feature: Heart Rate
The baseline rate is the average heart rate of the fetus.
· Normal baseline: 110- 160pm.
· Baseline Tachycardia: Greater than 160bpm.
· Baseline Bradycardia: Less than 110bpm.
Feature: Variability
Refers to the variation of FHR from one beat to the next. It is a reassuring sign of an intact neurological system in the fetus.
Normal variability (Reassuring) is between 5 – 25bpm.
Reduced or Absent variability (non-reassuring) is less than 5bpm.
Feature: Accelerations and Reactivity
An acceleration is an increase in FHR of 15bpm or more above the baseline, lasting more than 15 seconds.
Reactivity: Present when there are two accelerations in any given 20-minute period.
Feature: Decelerations
A sudden decrease in the baseline FHR of greater than 15 bpm for longer than 15 seconds.
There are a number of different types of classifications for decelerations.
Early decelerations are considered physiological, not pathological, as they are consistent with uterine contractions and resolve when the contraction ends.
Variable declarations are variable in duration and often do not have a relationship with contractions. They are often caused by umbilical cord compression. ‘Shoulders - brief accelerations on either side of the deceleration, are a reassuring sign that the fetus is coping.
Late decelerations occur after the contraction has begun and indicate there is reduced blood flow to the baby creating a greater risk of fetal hypoxia and acidosis. These are concerning and an obstetrician should consider if delivery is necessary for fetal welfare.
Prolonged decelerations
Refers to a deceleration that lasts more than 2 minutes, imminent delivery should be considered.
Feature: Uterine Activity
Normal uterine activity for women > 37 weeks gestation is four to five contractions or less in a 10-minute period.
Excessive uterine activity is:
Greater than 5 contractions in ten minutes
OR contractions lasting longer than 2 minutes in duration, without FHR abnormalities.
Uterine hyperstimulation (Tachysystole)
Excessive uterine activity with FHR abnormalities.
Tachysystole is often associated with induction of labour processes, including synthetic prostaglandins and oxytocin infusion.
However, it can also occur in spontaneous labours where it can be even more concerning - occurring in association with placental abruption or intrauterine infection.[1]
The CTG should not be used as a single diagnostic tool to assess fetal wellbeing, but as information to guide further management such as:
Escalating to a senior obstetrician or consultant
Assessing the clinical picture for obstetric emergencies including; cord prolapse or uterine abruption.
Repositioning the mother or giving IV fluid bolus
Fetal scalp blood sampling to test for fetal acidosis – a sign of fetal hypoxia.
Bedside ultrasound to determine fetal positioning
Expediting Delivery of the baby through emergency caesarean section, instrumental delivery, or vaginal birth.
Early detection of fetal distress is crucial for medical providers to resolve the critical situation in a timely and safe manner. Through prompt and skilled intervention, injury to the neonate can be avoided or minimised. However, failure to recognise signs of fetal distress can lead to permanent brain injury, disability or death.
Your medical provider should interpret, consider, and respond to any non-reassuring or abnormal features of the CTG with the required expertise, to meet the relevant standard of care. Failure to do so and as a result, your baby has suffered harm, would establish grounds for a medical negligence claim.
How to Establish a Claim
To establish an action in negligence, with your consent, our firm will collect your personal medical records. These will be reviewed by specialised medical negligence solicitors and expert medical advice to determine whether the care you received failed to meet the standard of reasonable care which resulted in further harm to you.
Reach out to our team at Stern Law, offering a unique and individualised understanding of the sensitive nature of medical negligence claims. We will listen with empathy and provide guidance through the complex claims process.
Please call us on (02) 9387 1399 or email us at reception@sternlaw.com.au
We look forward to sharing this journey with you.
Disclaimer: The content of this article is intended only to provide a summary and general overview of matters of interest. It does not constitute medical or legal advice and should not be relied on as such.
[1] RANZCOG ‘Intrapartum Fetal Surveillance’
Video Source: Xuereb
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