Monitoring your baby in labour involves periodically, or continuously listening in to their heartbeat- not simply just the ‘rate’, but the sound, pattern, variability and for any changes that may occur. This information, in combination with other signs from you and your baby, enables healthcare professionals to monitor the overall wellbeing of your baby during labour.
There are actually many more ways to monitor your baby’s heartbeat in labour than you may realise, and it’s important that you are part of the decision making process as to which method feels right for you.
The recommendation for all women with an uncomplicated pregnancy, is to have ‘intermittent auscultation’, meaning your midwife will listen in to baby’s heartbeat for 60 seconds, every 15 minutes in the first stage of labour, and every 5 minutes in the second (pushing) phase of labour. They will only listen in between your contractions, and you shouldn’t need to change position. Intermittent monitoring can be done using two tools-
Doppler/Sonicaid- You may recognise this from your antenatal appointments. A dopller uses ultrasound to pick up and recreate the sound of your baby’s heart beat. This can be used in water too.
Pinnard Stethoscope- A pinnard is a wooden, plactic or metal tool- a little like a ‘trumpet’ that enables your midwife to listen directly to the sound of your baby’s heart beat. You may have seen this in your antenatal appointments.. or maybe on call the midwife! This tool won’t pick up placental sounds like a doppler may, however only the midwife will be able to hear it. It cannot be used in water (without your poor midwife getting a very wet head!)
In the UK intermittent monitoring is recommended for all uncomplicated pregnancies, however If you are facing any complexities with your pregnancy, or you are facing any interventions- such as an induction or epidural, or if an extended period of ‘abnormal’ fetal heart sounds are detected using intermittent monitoring- you may be offered continuous monitoring. As with anything in pregnancy and birth, whether or not to accept is entirely your decision. There are also many options here that you may not have yet considered. SO, what are your options here?
CTG- A CTG involves having two round discs (about the size of a jam jar lid) attached to your abdomen with two stretchy belts that pick up both baby’s heart beat and the contractions of your uterus. There are wires coming from the discs, connected a machine that plots the pattern of baby’s heart beat. This cannot be used in a pool. Sometimes, as baby descends further down the pelvis, the monitor can ‘lose contact’ in some positions, so you may find yourself being more directed in the positions you adopt in labour.
Telemetry- This works in the same way as a CTG, however it is a wireless monitor and can be used in water (be that a birth pool or simply bath or shower for comfort). Generally this enables you to remain more mobile as you don’t risk getting tangled up in a host of wires or need to remain close to the machine itself during labour. Most UK hospitals will have telemetry, though it’s often not offered unless you know to ask!
FSC- ‘Fetal Scalp Electrode’- (You may also hear this called ‘STAN’). A relatively new tool in the continuous monitoring camp! A fetal scalp electrode is a small clip applied directly to your baby’s head throughout labour. This obviously requires your baby to be in a head down position, your waters to have broken and your cervix to have dilated enough for your midwife to reach baby’s head during a vaginal examination. This replaces ONE of the monitors attached to your abdomen that would have been used during CTG monitoring.
This works by picking up the electrical signals of your baby’s heat beat, rather than through ultrasound. In this way healthcare professionals hope to get a more accurate picture of baby’s wellbeing during labour. The current research has shown similar levels of caesarean and other birth outcomes to CTG monitoring, however it has shown a lower rate of instrumental births for women with this kind of monitoring.
This is not currently on offer in all UK hospitals, however It is being increasingly used in some units in the in line with the evidence that it reduces obstetric intervention and the hope that it will improve neonatal outcomes.
A dip into the research
Continuous Electronic fetal monitoring was introduced in the 1970s based on no evidence whatsoever, but in the hope that it could improve outcomes for women and babies. I’ve dipped into the research behind continuous monitoring below.
In a recent review of the evidence comparing continuous monitoring and intermittent monitoring, for both ‘low’ and ‘high’ risk pregnancies, there was found to be no difference in Apgar scores (baby’s health at birth) or cord blood gases, rates of low-oxygen brain damage, admission to the neonatal intensive care unit, or perinatal death. They also found no difference between groups in the percentage of people using medication for pain relief during labour. Continuous monitoring did however reduce the rate of infant seizures from 0.3% to 0.15%. The researches estimated continuous monitoring increases the chances of having a caesarean from 15% to 24% across all women.
A lot of the guidelines on ‘who’ should be offered continuous monitoring in labour are based on ‘expert opinion’. When guidelines are created- they are generally based on research which is ‘ranked’. The very best research- a randomised controlled trial, is considered ‘level one’ evidence- expert opinion, whilst valid, is not as reliable and considered ‘level four’ (the lowest level of information used to make recommendations/guidelines).
In order to make a fully informed choice, it’s important that you understand both the risks and benefits of each method of monitoring. If possible have these conversations with your care provider in pregnancy rather than labour.
How to make a choice of continuous monitoring positive
Be involved in the decision making around whether or not continuous monitoring feels like the right choice for you.
Maintain a calm, safe and relaxed atmosphere as much as possible. Tips for giving birth on a labour ward can be found here.
Ask for the machine sounds to be turned down to a minimum, so you aren’t disturbed by the ‘beeping’
Turn the machine away from you, so you don’t feel distracted or concerned by the numbers that you see.
Remain as upright and mobile as you can, it doesn’t mean you are suddenly bound to a bed!
Consider discussing intermittent continuous monitoring- research shows that their neither improves or worsens outcomes, but may mean you are able to feel freer, or use a shower or pool for parts of your labour.
REFERENCES (All access 26/02/2019)
· Alfirevic, Z., Devane, D. and Gyte, G.M. (2006). “Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.” Cochrane Database Syst Rev(3): CD006066.
· Alfirevic, Z., Devane, D., Gyte, G. M., et al. (2017). “Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour.” Cochrane Database Syst Rev 2: CD006066.
· American College of Nurse-Midwives. (2015). Intermittent Auscultation for Intrapartum Fetal Heart Rate Surveillance NUMBER 13. J Midwifery Womens Health. 60(5):626–632.
· American College of Obstetricians and Gynecologists (2009). “ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles.” Obstetrics and gynecology 114(1): 192-202.
· American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Caughey, A. B., et al. (2015). “The Safe Prevention of the Primary Cesarean.” Clin Obstet Gynecol 58(2): 207-210.
· American College of Obstetricians and Gynecologists (2017). “Committee Opinion No. 687: Approaches to Limit Intervention During Labor and Birth.” Obstet Gynecol 129(2): e20-e28.
· American College of Obstetricians and Gynecologists (2017). Practice Bulletin No. 184: Vaginal Birth After Cesarean Delivery. Obstet Gynecol. Nov;130(5):e217-e233.
· Association of Women’s Health, Obstetric and Neonatal Nurses (Revised 2015). Position Statement: Fetal Heart Monitoring; JOGNN, 44, 683-686.
· AWHONN (2017) Intermediate Course Instructor Resource Manual, 6th edition.
· Bailey, R. E. (2009). “Intrapartum fetal monitoring.” Am Fam Physician 80(12): 1388-1396.
· Boatin, A. A., Wylie, B., Goldfarb, I., et al. (2015). “Wireless fetal heart rate monitoring in inpatient full-term pregnant women: testing functionality and acceptability.” PLoS One 10(1): e0117043.
· Bohren, M. A., Hofmeyr, G. J., Sakala, C., et al. (2017). “Continuous support for women during childbirth.” Cochrane Database Syst Rev 7: CD003766.
· BusinessWire (2012). MindChild Medical, Inc., Announces Results of National Fetal Monitoring Market Survey. Accessed online March 13, 2018.
· Cascade Healthcare Products, Inc. (2018). Fetoscopes. Accessed online March 30, 2018.
· Centers for Disease Control and Prevention (2018). Data and Statistics for Cerebral Palsy. Accessed online March 30, 2018.
· Declercq, E. R., Sakala, C., Corry, M. P., et al. (2014). “Major Survey Findings of Listening to Mothers(SM) III: New Mothers Speak Out: Report of National Surveys of Women’s Childbearing Experiences, Conducted October-December 2012 and January-April 2013.” J Perinat Educ 23(1): 17-24.
· Devane, D., Lalor, J. G., Daly, S., et al. (2017). “Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing.” Cochrane Database Syst Rev 1: CD005122. Click here.
· Grimes, D. A. and Peipert, J. F. (2010). Electronic Fetal Monitoring as a Public Health Screening Program: The Arithmetic of Failure. Obstetrics & Gynecology. Vol. 116, No. 6, Dec: 1397-1399.
· Gupta, J. K., Sood, A., Hofmeyr, G. J., et al. (2017). “Position in the second stage of labour for women without epidural anaesthesia.” Cochrane Database Syst Rev 5: CD002006.
· Heelan, L. (2013). “Fetal monitoring: creating a culture of safety with informed choice.” J Perinat Educ 22(3): 156-165.
· Herbst, A. and Ingemarsson, I. (1994). “Intermittent versus continuous electronic monitoring in labour: a randomised study.” Br J Obstet Gynaecol101(8): 663-668.
· Hodnett, E. D. (2002). “Pain and women’s satisfaction with the experience of childbirth: a systematic review.” Am J Obstet Gynecol 186(5 Suppl Nature): S160-172.
· Hon, E. H. (1958). “The electronic evaluation of the fetal heart rate; preliminary report.” Am J Obstet Gynecol 75(6): 1215-1230.
· Hornbuckle, J., Vail, A., Abrams, K. R., et al. (2000). Bayesian interpretation of trials: the example of intrapartum electronic fetal heart monitoring. Br J Obstet Gynaecol;107:3±10.
· Landon, M. B., Spong, C. Y., Thom, E., et al. (2006). “Risk of uterine rupture with a trial of labor in women with multiple and single prior cesarean delivery.” Obstet Gynecol 108(1): 12-20. Click here.
· Lear, C. A., Galinsky, R, Wassink, G., et al. (2016). The myths and physiology surrounding intrapartum decelerations: the critical role of the peripheral chemoreflex. J Physiol. Sep 1;594(17):4711-25.
· Lewis, D. and Downe, S. (2015). “FIGO consensus guidelines on intrapartum fetal monitoring: Intermittent auscultation.” Int J Gynaecol Obstet131(1): 9-12.
· Liston, R. M., Sawchuck, D. and Young, D. C. (2007). “Fetal health surveillance guideline: antenatal and intrapartum consensus.” J Obstet Gynaecol Can 29(12): 972.
· Madaan, M. and Trivedi, S.S. (2006). “Intrapartum electronic fetal monitoring vs. intermittent auscultation in postcesarean pregnancies.” Int J Gynaecol Obstet 94(2): 123-125.
· Mahomed, K., Nyoni, R., Mulambo, T., et al. (1994). “Randomised controlled trial of intrapartum fetal heart rate monitoring.” BMJ 308(6927): 497-500.
· Martis, R., Emilia, O., Nurdiati, D.S., et al. (2017). “Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being.” Cochrane Database Syst Rev 2: CD008680.
· Mugyenyi, G. R., Atukunda, E. C., Ngonzi, J., et al. (2017). “Functionality and acceptability of a wireless fetal heart rate monitoring device in term pregnant women in rural Southwestern Uganda.” BMC Pregnancy Childbirth 17(1): 178.
· Nelson, K. B., Dambrosia, J. M., Ting, T. Y., et al. (1996). “Uncertain value of electronic fetal monitoring in predicting cerebral palsy.” N Engl J Med334(10): 613-618.
· National Institute for Health and Care Excellence (2017). Intrapartum care for healthy women and babies. Clinical Guideline.
· Obladen, M. (2018). “From “apparent death” to “birth asphyxia”: a history of blame.” Pediatr Res.
· Patey, A. M., Curran, J. A., Sprague, A. E., et al., (2017). “Intermittent auscultation versus continuous fetal monitoring: exploring factors that influence birthing unit nurses’ fetal surveillance practice using theoretical domains framework.” BMC Pregnancy Childbirth 17(1): 320.
· Sartwelle, T. P., Johnston, J. C. and Arda, B. (2017). “A half century of electronic fetal monitoring and bioethics: silence speaks louder than words.” Matern Health Neonatol Perinatol 3: 21.
· Smith, H., Peterson, N., Lagrew, D., et al. (2016). Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal Quality Care Collaborative.
· Smith, V., Begley, C. M., Clarke, M., et al. (2012). “Professionals’ views of fetal monitoring during labour: a systematic review and thematic analysis.” BMC Pregnancy Childbirth 12: 166.
· Spector-Bagdady, K., De Vries, R., Harris, L. H, et al. (2017). “Stemming the Standard-of-Care SPRAWL: Clinician Self-Interest and the Case of Electronic Fetal Monitoring.” Hastings Cent Rep 47(6): 16-24.
· Van Naarden Braun, K., Doernberg, N., Schieve, L., et al. (2015). Birth Prevalence of Cerebral Palsy: A Population-Based Study. Pediatrics Dec, peds.2015-2872.
· Whitburn, L. Y., Jones, L. E., Davey, M. A., et al. (2014). “Women’s experiences of labour pain and the role of the mind: an exploratory study.” Midwifery 30(9): 1029-1035.
· Wolf, J. H. (2018). Risk and Reputation: Obstetricians, Cesareans, and Consent. J Jist Med Allied Sci. Jan 1;73(1):7-28.