Fetal Monitoring Guideline | Right Decisions (2025)

The appropriate method of fetal monitoring will be dictated by the maternal and fetal risk factors identified and a thorough assessment of the woman’s medical and obstetric history should be taken. The NICE guidelines (NICE Dec 2022) should be used to aid assessment of risk factors which necessitate continuous monitoring

The Intrapartum Risk Assessment on Badgernet indicates the appropriate method of fetal monitoring. Complete a CTG label upon commencement of the CTG.

1 Admission of Low Risk woman in Labour

For women categorised as ‘Low Risk’ with an uncomplicated pregnancy, current evidence does not support the use of an admission CTG or EFM and it is therefore not recommended (NICE 2022). However, risk assessment is a continual process, and women should be advised that the method of fetal heart rate monitoring may change throughout the course of labour.

During the initial assessment the fetal heart should be auscultated for a minimum of one minute immediately after a contraction and recorded as a single rate. The maternal pulse must be palpated to differentiate between maternal and fetal heart rate and recorded as part of a full set of maternal observations.

If a CTG had been commenced due to concerns from intermittent auscultation but there are no abnormal or non-reassuring features on the CTG, then the CTG can be discontinued after 30 minutes and return to intermittent auscultation.

In the 1^st stage of labour the fetal heart should be auscultated after a contraction for at least a minute, every 15 minutes and documented in a labour assessment on Badgernet.

In the 2^nd stage of labour the fetal heart should be auscultated after a contraction for at least a minute every 5 minutes and documented in a labour assessment on Badgernet or on paper records.

The maternal pulse should be palpated hourly throughout labour and documented in a labour assessment on Badgernet. If a fetal heart rate abnormality is detected, the maternal pulse should be palpated to differentiate the maternal and fetal heart rates.

2 Intrapartum indications to transfer from intermittent auscultation to continuous EFM

Base any decisions about moving to EFM from IA on clinical findings and discuss your recommendations with the woman and her birth partner.

Be aware intrapartum risk factors may increase the risk of fetal compromise, and that intrapartum risk factors that develop as labour progresses are particularly concerning. Staff should use the fetal monitoring risk assessment on Badgernet

Indications to offer transfer from IA to continuous fetal monitoring:

• Contractions that last longer than 2 minutes, or 5 or more contractions in 10 minutes
• Maternal pulse over120 beats/minuteon2 occasions30 minutesapart
• Severe hypertension (a single reading systolic of 160mmHg or more or diastolic of 110mmHg or more, measured between contractions.
• Hypertension – either systolic of 140mmHg or more or diastolic 90mmHg or more on 2 consecutive readings taken 30 minutes apart.
• A reading of 2+ of protein on urinalysis and a single reading of BP systolic greater than 140mmHg or diastolic greater than 90mmHg, temperature of 38°C or above on a single reading, or 37.5°C or above on2 consecutiveoccasions1 hourapart
• suspected chorioamnionitis or sepsis
• Pain reported by the woman that differs from the pain normally associated with contractions
• Meconium stained liquor
• Fresh vaginal bleeding
• Blood stained liquor not associated with vaginal examination
• Use of oxytocin
• Epidural analgesia
• Confirmed delay in first or second stage of labour
• Consider continuous fetal monitoring if based on clinical assessment and multidisciplinary review, there are concerns about other intrapartum factors not listed above that may lead to fetal compromise

3 Antenatal indications for continuous fetal monitoring in labour

The NICE guidelines recommend continuous EFM for high risk women when in active labour;

Maternal Risk Factors

• If it is in their personalised care plan to have continuous fetal monitoring
• Previous Caesarean section or other full thickness uterine scar
• Any hypertensive disorder needing medication
• Prolonged rupture of membranes >24hrs
• Antepartum haemorrhage
• Type 1 or 2 Diabetes or GDM requiring medication

Fetal Risk Factors

• Non cephalic presentation ( breech, transverse, oblique and cord)
• EFW < 3^rd centile)
• SGA (EFW <10^th centile) other risk factors eg. Abnormal doppler, reduced LV or reduced growth velocity.
• > 42 weeks at onset of labour
• Oligohydramnious or polyhydramnious
• Reduced fetal movements in the 24 hours before onset of labour
• < 37 weeks

Attach a CTG label at commencement of the CTG. Record the maternal pulse at commencement of EFM and hourly during labour.

Link the CTG to the record on BadgerNet.

Complete a CTG review hourly on BadgerNet and have a peer review completed by a colleague.

If there are concerning features on a CTG escalate to the labour ward co-ordinator without delay.

Mark significant intrapartum events on the CTG using the ‘CTG comments’ note on BadgerNet or by marking the CTG paper e.g;

• Analgesia
• Augmentation
• Pyrexia
• Position change
• FSE application
• Epidural

If the quality of the CTG recording is unsatisfactory adjust the tocograph or transducer. If necessary apply a FSE with maternal consent to ensure accurate recording of the fetal heart. Please note that use of a FSE is contraindicated in the following circumstances;

• < 34+0 weeks gestation
• Malpresentation
• Placenta Praevia
• Excessive vaginal bleeding
• Genital infection (Herpes, gonorrhoea)
• Blood borne virus (Hep B, HIV, Hep C)

4 Interpretation of the CTG

Make a documented systematic assessment of the condition of the woman and unborn baby (including cardiotocography [CTG] findings) every hour, or more frequently if there are concerns.

Do not make any decision about a woman's care in labour based on CTG findings alone.

Take into account the woman's preferences, any antenatal and intrapartum risk factors, the current wellbeing of the woman and unborn baby and the progress of labour. Ensure that the focus of care remains on the woman rather than the CTG trace.

Remain with the woman in order to continue providing one-to-one support.

Talk to the woman and her birth companion(s) about what is happening and take her preferences into account.

Principles for intrapartum CTG trace interpretation

When reviewing the CTG trace, categorise the 4 features of the CTG trace (contractions, baseline fetal heart rate; variability and decelerations) as WHITE, AMBER or RED – indicating levels of concern.

Categorise CTG traces as –

• NORMAL – no amber or red features (all 4 features are white)
• SUSPICIOUS – any 1 feature is amber
• PATHOLOGICAL – any 1 feature is red or 2 or more features are amber.

If there is a stable baseline fetal heart rate between 110and 160beats/minute and normal variability, continue usual care as the risk of fetal acidosis is low. If it is difficult to categorise or interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician.

Accelerations

The presence of fetal heart rate accelerations, even with reduced baseline variability, is generally a sign that the baby is healthy

Regard the following as concerning characteristics of variable decelerations:

• lasting more than 60seconds
• reduced baseline variability within the deceleration
• failure to return to baseline
• Loss of previously present shouldering

5Management based on interpretation of CTG

6 Fetal scalp stimulation

If the cardiotocograph trace is suspicious, offer digital fetal scalp stimulation. If this leads to an acceleration in fetal heart rate and a sustained improvement in the CTG trace, continue to monitor the fetal heart rate and clinical picture. Absence of an acceleration in response to fetal scalp stimulation is a worrying sign that fetal compromise may be present, and plan to expedite delivery should be considered. Fetal blood sampling is not currently recommended.