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Intrapartum Fetal Surveillance Clinical Guideline updated

20 January 2020

RANZCOG has published an updated edition of the Intrapartum Fetal Surveillance Clinical Guideline.

The guideline has been revised in light of the evolving evidence supporting the use of various fetal surveillance techniques.

“The guideline has become a widely utilised and highly regarded resource for those providing intrapartum care for women and their fetuses and also those developing locally relevant institutional policies,” FRANZCOG Dr Scott White, Deputy Chair (Obstetrics), Women’s Health Committee, writes in the Foreword to the guideline.

“The evidence is clear that a standardised approach to the assessment, description, and management of fetal heart rate abnormalities results in improved outcomes for women and their babies. This is particularly important in light of the increasing complexity of contemporary pregnancies.”

The Guideline is intended to stand beside and complement the now well-established and successful Fetal Surveillance Education Program which has delivered quality training in intrapartum fetal surveillance since 2004.

Download the guideline.

The main changes in this fourth edition are:

 

  • A broad literature search was undertaken for articles published between January 2013 and January 2019 regarding any aspect of intrapartum fetal surveillance. Sixty-two articles were identified of direct relevance to this Guideline and were reviewed in detail, with minor changes being made to several of the recommendations.
  • Risk factors: An expanded list of antenatal and intrapartum risk factors where intrapartum cardiotocography is recommended. There is also a new listing of conditions where, if multiple of these conditions are present, intrapartum cardiotocography should be considered due to the synergistic effect
  • Modified antenatal risk factor: If fetal movements altered unless there has been demonstrated wellbeing and return to normal fetal movements.
  • New antenatal risk factors: oligohydramnios defined as MVP <2cm or AFI < 5cm; low cerebroplacental ratio and abnormal placental cord insertion such as velamentous, hyper/hypocoiled;
  • New recommendation: Each institution should develop standardised clinical protocols for the response to abnormal intrapartum fetal heart rate patterns
  • New recommendation: Institutions should ensure that their staff have access to and are supported to use suitable educational resources, such as the FSEP and its suite of educational resources.
  • Modified Recommendation: Cord gases - Paired umbilical cord blood gas or lactate analysis should be taken at delivery either routinely or where any of the following are present:
    • Apgar score < 4 at 1 minute.
    • Apgar score < 7 at 5 minutes.
    • Fetal scalp sampling performed in labour.
    • Operative delivery undertaken for fetal compromise.

Where paired umbilical cord blood gas or lactate analysis is taken at delivery as part of a clinical audit regimen, this process should not interfere with management of the third stage of labour.

  • Change to recommendation: Lactate vs pH - If fetal blood sampling is indicated, the use of either scalp lactate or pH measurement is reasonable. In some institutions, lactate will provide an easier and more affordable adjunct to electronic fetal monitoring.
  • Clearer definition: Prolonged decelerations - A fall in the baseline fetal heart rate for more than 90 seconds and up to 5 minutes
  • Clearer definition: Bradycardia - A fall in the baseline fetal heart rate for more than 5 minutes
  • Good practice notes have been expanded and strengthened regarding interruptions to fetal heart rate monitoring for personal care, procedures and transfers, particularly during transfer to the operating theatre and prior to delivery of the fetus, in the context of suspected fetal compromise.
  • Enhanced guidance on the use of intrauterine pressure catheters for better assessment of uterine activity and the subsequent assessment of fetal well-being when uterine activity is not readily palpable.
  • Stronger wording regarding this being the recommended guideline for Australia and New Zealand and the importance of ongoing standardised education and credentialing.
  • Removal of information regarding the use of paracervical block.
  • Inclusion of patient information pamphlet



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