Electronic Fetal Monitoring

CONSENSUS STATEMENT

CONTENTS
FOREWORD
PREFACE
WORKING COMMITTEE
CONSENSUS STATEMENT

ANTEPARTUM ELECTRONIC FETAL HEART RATE MONITORING

I. Introduction
II. Indications

A. Maternal medical disorder

B. Bad obstetric history
C. Post-date pregnancy
D. Fetal indications

III. Procedure
IV. Interpretation
V. Management

INTRAPARTUM FETAL HEART RATE MONITORING

I. Introduction
II. Upon admission in labour

A. EFM - How long & for whom?

B. Interpretation
C. Management

III. Patients in labour

A. Intermittent Monitoring
B. Auscultation
C. Patients refusing EFM
D. Continuous EFM
E. Interpretation
F. Management

REFERENCES
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FOREWORD

There is certainly a need for standard approaches to the management of many clinical
conditions.
Clinicians have been writing clinical practice guidelines (CPG) for several years now
on topics which are managed diversely. This CPG on electronic fetal monitoring
(EFM) is timely and represents the hard work of several people. It is commendable
effort to bring some uniformity of approach throughout the country.

I am concerned that CPGs such as this should be actively used and should not be just
another academic exercise.

I commend this excellent work for wide usage for both the private and public
services.

Datu Dr. Mohd.Taha bin Arif

Director General of Health, Malaysia

PREFACE

Consensus on Electronic Fetal Monitoring

The introduction of Electronic Fetal Monitoring (EFM) into obstetric practice in the
1970's created a major shift in the approach to the management of patients in labour
and also in ante-natal assessments.

However the medical community was not particularly discerning when this
technology was introduced as the scientific evidence of its validity was scant. There
has been much attempt in the last few years to bridge the gap between evidence and
practice.

This paper was developed to document the current position of EFM in everyday
obstetric practice. Admittedly the scientific evidence for some area of use is still thin.

Thus this paper outlines the area where it is clearly useful and also describes the
generally accepted approach to EFM in labour in Malaysia and elsewhere.

Various individuals have contributed significantly towards the preparation of this

paper which went through nine meetings.

Dato' Dr. Alex Matthews

Chairman
Consensus Committee on EFM Guidelines
 WORKING COMMITTEE

Committee Members
Dato' Dr. Alex Matthews Chairman Assoc. Prof. Patrick Chia Co-Chairman
Senior Consultant and Head Consultant
Dept. of O & G Dept. of O & G
Hospital Kuala Lumpur International Medical University
Seremban

Dr. T.P.Baskaran Secretary Assoc. Prof. Dr. Muhammad Abdul Jamil

Obstetrician & Gynaecologist Consultant
Dept. of O & G Dept. of O & G
Hospital Kuala Lumpur Hospital UKM, Kuala Lumpur

Dr. P. Boopalan Dato' Dr. Johan A. M. Thambu

President Consultant Obstetrician & Gynaecologist
College of Obstetrician & Gynaecologists Tawakal Specialist Centre
Academy of Medicine of Malaysia Kuala Lumpur

Dr. Michael J. Samy Dr. S. Rachagan

Consultant Obstetrician & Gynaecologist Consultant Obstetrician & Gynaecologist
Tawakal Specialist Centre Subang Jaya Medical Centre
Kuala Lumpur Petaling Jaya

Dato' Dr. Lim Ngok Ling Prof. C.T. Lim

Consultant Consultant
Dept. of Paediatrics Dept. of Paediatrics
Selayang Hospital, Selangor University Hospital
Kuala Lumpur

Dr. Cheah Fook Choe

Clinic Specialist
Dept. of Paediatrics
Hospital UKM, Kuala Lumpur

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CONSENSUS STATEMENT ON ELECTRONIC FETAL MONITORING

The wellbeing of the fetus is one of the main concerns in obstetric care. The
assessment of fetal wellbeing is widely practised by measuring the fetal heart rate and
monitoring its patterns1, 2, 3.

Electronic fetal monitoring (EFM) is a non-invasive method of assessing fetal

wellbeing. The use of EFM has been shown to reduce the risk of neonatal seizures in
high-risk pregnancies4. On the other hand, there is no evidence for the routine use of
EFM in low-risk pregnancies when adequate clinical monitoring (including
intermittent auscultation by trained staff) is available4.

EFM also provides a permanent documentation of fetal heart rate and its patterns5, 6.
The usefulness of EFM however, is limited by inter-observer variation in the
interpretation of its tracings7, 8. Therefore, EFM must be used together with other
modalities in the assessment of fetal wellbeing9.

EFM Guidelines:
We propose the following EFM guidelines based on current practice:
- Antepartum electronic fetal heart rate monitoring
- Intrapartum electronic fetal heart rate monitoring

ANTEPARTUM ELECTRONIC FETAL HEART RATE MONITORING

I. INTRODUCTION:
There is no strong evidence to support EFM use in the antepartum period 4, 10.
However, EFM is widely used in the assessment of fetal health, particularly in high-
risk pregnancies as there are no other objective methods of documenting the fetal
state.

EFM if adopted should be done no earlier than 32 completed weeks of gestation. It is

used in any patient at risk of developing decreased utero-placental function. The
following is a guide.

II. INDICATIONS:

A. Maternal medical disorders

1. Pregnancy induced hypertension

2. Diabetes (gestational or insulin dependent)
3. Anaemia and other haematological diseases
4. Chronic hypertension
5. Cardiac disease
6. Collagen disease
7. Renal disease
8. Thyroid disease

B. Bad obstetric history

C. Post-date pregnancy
D. Fetal indications

1. Reduced fetal movements

2. Suspected IUGR
3. Abnormal FHR by auscultation
4. Multiple pregnancies
5. Rhesus iso-immunisation

III. PROCEDURE:
1. Place the patient in the left lateral recumbent position.
2. Record the patient's name, hospital record/registration number, date and time
on the EFM strip.
3. Place and adjust the external tocodynamometer and ultrasound transducer to
obtain the best possible tracing.
4. Instruct the patient to record fetal movements on the monitor tracing using the
event marker.
5. Observe the EFM tracing until the criteria for a reactive test are met (a
minimum of 20 minutes and a maximum of 60 minutes).
6. In the event of lack of fetal movement, apply stimulation (for example: using
the fetal acoustic stimulator).
7. Record any relevant clinical information on the EFM tracing, for example the
blood pressure, temperature, maternal heart rate, loss of contact, and changes in
maternal position.
8. Keep the EFM tracings in the patient's notes.

IV. INTERPRETATION11:
1. Normal / Reassuring Trace
Baseline heart rate 110-150 bpm
Baseline variability 10-25 bpm
At least 2 accelerations (>15 beats for >15 seconds) in 20 minutes.
No decelerations
2. Suspicious / Equivocal Trace
Baseline heart rate 150-170 bpm or 100-110 bpm;
Reduced baseline variability (5-10 bpm for >40 minutes)
Absence of accelerations for >40 minutes
Sporadic deceleration of any type
3. Abnormal / Pathological Trace
Baseline heart rate <100 bpm or > 170 bpm
Silent Pattern (<5 bpm) for >40 minutes
Sinusoidal pattern (oscillation frequency = 2-5 cycles/min,
amplitude of 5-15 bpm) for >40 minutes with no accelerations and no
area of normal baseline variability
Repeated late, prolonged (> 1 minute) and severe variable (>40
bpm) decelerations.

V. MANAGEMENT:
1. Normal / Reassuring Trace - repeat and / or estimate the
amniotic fluid index (AFI) if considered necessary according to the clinical
situation and indication for testing.
2. Suspicious / Equivocal Trace - continue for up to 60
minutes to determine the presence of fetal rest/activity cycles. Consider further
evaluation according to the clinical situation e.g. fetal acoustic stimulation, AFI,
biophysical profile (BPP), Doppler ultrasound blood velocity waveform.
3. Abnormal / Pathological Trace - deliver if clinically
appropriate. Further evaluation / monitoring if not appropriate to deliver.
 ANTEPARTUM FETAL MONITORING IN HIGH RISK PREGNANCIES
EFM

Normal / Suspicious Abnormal /

Reassuring / Equivocal Pathological

Do AFI, if Continue EFM for

indicated <5 further 20-60 mins

6 <5
Options:
Biophysical
profile

>6 <4
Repeat EFM AFI
weekly or more CONSIDER
often if indication DELIVERY
exists

Note: The management options are governed not only by the clinical situation but also
by the availability of local resource and expertise.

INTRAPARTUM ELECTRONIC FETAL HEART RATE MONITORING

I. INTRODUCTION:
It is well established that EFM has value in the intrapartum period in the assessment
of the fetus12. However, it is of value only when used together with all other available
information concerning the mother and the fetus10. Furthermore those who use EFM
must be trained individuals, who are able to recognise its benefits as well as its
limitations. It is recommended that all labour and delivery units should have some
form of fetal monitoring.

II. UPON ADMISSION IN LABOUR:

A. EFM - How long and for whom?

Fetal heart rate monitoring is commonly recorded for 20 minutes. It is
recommended for high-risk patients and for those who are low-risk presenting
late in labour (where EFM is available). Discontinue monitoring only if the
tracing is reassuring or normal.

THE HIGH-RISK CONDITIONS INCLUDE:

a) Pre-existing obstetrical/medical factors:

1. Age >35 or <16.

2. Diabetes
3. Chronic hypertension
4. Cardiac disease
5. Rhesus iso-immunisation
6. Sickle cell disease. and other haemoglobinopathies
7. Previous Caesarean section
8. Previous stillbirth
9. Renal disease
10. Active pulmonary disease
11. Medical conditions requiring pharmacological therapy
12. Collagen/vascular disease
13. Seizure disorder
14. Substance abuse
15. Parity greater than 5

b) Prenatal and early intrapartum factors:

1. Anaemia
2. Pregnancy induced hypertension
3. Polyhydramnios or oligohydramnios
4. Clinical evidence of intrauterine growth restriction
5. Vaginal bleeding
6. Abnormal antepartum fetal testing
7. Induction of labour
8. No prenatal care
9. Premature rupture of membranes
10. Premature labour
11. Meconium-stained amniotic fluid
12. Abnormal fetal heart tones by auscultation
13. Pyelonephritis
14. Breech or other abnormal presentation
15. Multiple pregnancies
16. Gestational age <37 weeks or >42 weeks
17. Estimated fetal weight less than 2500 grams or greater than 4000 grams
18. Any acute or chronic maternal illness. which would increase the risk to the
mother or infant

B. INTERPRETATION11, 13:
1. Normal / Reassuring Trace
At least two accelerations (> 15 beats per minute for >15 seconds) in
20 minutes
Baseline heart rate 110-150 bpm
Baseline variability 5-25 bpm
No decelerations
Moderate tachycardia/bradycardia and accelerations
2. Suspicious / Equivocal Trace
Absence of accelerations for >40 minutes
Baseline heart rate >150 bpm or <110 bpm;
 Reduced baseline variability or silent pattern (<5 bpm for >40 minutes)
although normal baseline (110-150 bpm)
Sporadic deceleration of any type
3. Abnormal / Pathological Trace
Poor baseline variability (<5 bpm) with normal base line heart rate
(110- 150 bpm) with no accelerations
Repeated late decelerations and/or complicated variable decelerations
Baseline heart rate <100 bpm or prolonged bradycardia (i.e. drop in
baseline fetal heart rate <100 bpm for >3 minutes or <80 bpm for >2
minutes) for more than 10 minutes

C. MANAGEMENT:
1. Normal / Reassuring trace - risk of fetal hypoxia in
spontaneous labour is low for at least the next 2-3 hours of low-risk labour.
However, in high-risk cases, continuous EFM may be warranted.
2. Suspicious / Equivocal Trace - continue EFM but amniotomy
should be performed. Fetal scalp blood pH is considered if there is
meconium stained liquor, to determine subsequent management or deliver
if indicated. When scalp pH testing is unavailable, continuous EFM may
be considered if the liquor is clear.
3. Abnormal / Pathological Trace - amniotomy is performed to
observe the liquor, and subsequent management is determined as in (b)
above. Deliver if fetal scalp pH is required but not obtainable i.e. if cervix
not sufficiently dilated or equipment not available.

III. PATIENTS IN LABOUR:

A. INTERMITTENT MONITORING
1. The baseline monitor strip must be reassuring. Stable baseline FHA 110-
150 bpm with average long-term variability and NO decelerations.
Accelerations are additional reassuring feature.
2. The patient should not have risk factors present.
3. A fetal monitor strip should be obtained for at least 10 minutes every hour.
Discontinue only if the tracing is reassuring. If abnormal findings are
detected continuous monitoring should be instituted when sufficient
monitors are available.

B. AUSCULTATION:
1. If this technique is used. personnel should recognize its limitations.
2. There are no evidence based criteria available to detect fetal distress or
fetal well being using auscultation alone.
3. FHR should be auscultated in relationship to uterine contractions (UC).
Auscultation of FHR for 60 seconds should be done during and
immediately following a contraction.
4. Recommended auscultation intervals:
a. Every 60 minutes in early labour
b. Every 30 minutes in active labour
c. Every 15 minutes during second stage
5. When possible monitor patient electronically if abnormal FHR is detected.
C. PATIENTS REFUSING ELECTRONIC FETAL MONITORING:
1. Explain nature of procedure including risks versus benefits of electronic
fetal monitoring.
2. Document the explanation given.
3. Document if patient refuses to be monitored.

D. CONTINUOUS EFM:
This is recommended in high-risk patients and those who develop intrapartum
factors, which include:
1. Prolonged latent phase
2. Dysfunctional labour
3. Secondary arrest of cervical dilatation.
4. Prolonged second stage
5. Augmentation of labour
6. Temperature greater than 38 degrees Celsius
7. Significant variation of maternal blood pressure from previously recorded
values.
8. Elevation of maternal blood pressure of greater than 30 mm Hg systolic or
15 mm Hg diastolic.
9. Meconium stained liquor
10. Amnionitis
11. Placenta abruption
12. Placenta praevia
13. Bleeding of unknown cause
14. Epidural/Spinal anaesthesia

E. INTERPRETATION11, 13:
1. Normal / Reassuring Trace
At least two accelerations (> 15 beats per minute for >15 seconds) in
20 minutes
Baseline heart rate 110-150 bpm
Baseline variability 5-25 bpm
Early decelerations (in late first stage of labour)
2. Suspicious / Equivocal Trace
Absence of accelerations for >40 minutes (non reactive)
Baseline heart rate 150-170 bpm or 100-110 bpm (normal variability,
no decelerations)
Silent pattern (<5 bpm for >40 minutes) although normal baseline
(110-150 bpm), no decelerations
Baseline variability >25 bpm in the absence of accelerations
Variable decelerations (depth <60 bpm, duration <60 seconds)
Occasional transient prolonged bradycardia if FHR drops to <80 bpm
for >2 minutes or <100 bpm For >3 minutes
3. Abnormal / Pathological Trace
Baseline FHA> 150 bpm + silent pattern and /or repeated late or
variable decelerations
Silent pattern for >90 minutes
 Complicated variable decelerations (depth >60 bpm for >60 seconds,
changes in shape: over-shoot, decreased or increased baseline FHR
following the decelerations, or absence of baseline variability in or
between decelerations, slow recovery)
Combined / biphasic decelerations (variable followed by late)
Prolonged bradycardia in a suspicious trace
Prolonged bradycardia> 10 minutes with no signs of recovery
Repeated late decelerations
Pronounced loss of baseline variability regardless of baseline FHR
with shallow late decelerations
Sinusoidal pattern with no accelerations

F. MANAGEMENT:

1. Normal/Reassuring Trace - risk of fetal hypoxia in spontaneous labour is

low. Manage normally.
2. Suspicious/Equivocal Trace - continue EFM but amniotomy should be
performed +/- fetal scalp blood pH if meconium stained liquor is present.
3. Abnormal/Pathological Trace - amniotomy and consider fetal scalp blood
pH if meconium stained liquor to determine subsequent management or
deliver if clinically indicated. Deliver if fetal scalp pH required but not
obtainable i.e. if cervix not sufficiently dilated or equipment not available.

INTRAPARTUM FETAL MONITORING

When available Low risk / late
High risk in labour
Highly
recommended

EFM Suspicious Intermittent

20 minutes auscultation

Normal / Suspicious / Abnormal trace

Reassuring trace Equivocal trace

Amniotomy

Clear liquor Meconium

stained liquor

Continuous Fetal scalp

EFM blood pH
 Intermittent DELIVERY
EFM

REFERENCES

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