Main Site / Taonga Tuku Iho / Preparing for preterm birth when it is anticipated or planned / Fetal monitoring in preterm labour

Fetal monitoring in preterm labour

#Background

Preterm labour is commonly associated with conditions such as small for gestational age and/or fetal growth restriction, antepartum haemorrhage, and infection, meaning pēpi who are already susceptible to hypoxic injury (due to prematurity) are more vulnerable to compromise in labour. Intrapartum surveillance by continuous cardiotocograph (CTG), although not demonstrated through randomised trials to be beneficial for term or preterm pēpi, is accepted and recommended as the standard of care for pēpi with antenatal and intrapartum risk factors including preterm labour.1

The lack of evidence from randomised trials to support continuous CTG monitoring is in part related to insufficient sample sizes. However, also of importance is the quality of the fetal heart rate recording with signal loss common in the preterm pēpi2,3 and the reliance on individual clinician interpretation and judgement of recordings. Interpretation of fetal heart rate patterns for extreme preterm gestations can add further complexity and so use should be very carefully considered for preterm labour at the limits of survival.

#Recommendations and Practice

Active preterm labour

Guideline Recommendations
— Fetal monitoring during active preterm labour

  • Continuous CTG monitoring is recommended for wāhine/people in active preterm labour <37 weeks gestation.

Good Practice
— Fetal monitoring during active preterm labour

  • Wāhine/people with a small for gestational age and/or growth restricted pēpi should have continuous CTG commenced as soon as regular uterine activity has started.
  • Interpretation of fetal heart rate pattern may be challenging at early preterm gestation, senior obstetric review should be requested as required.
  • Caution should be taken in interpreting CTG recording where there is a large volume of signal loss.
  • Avoid use of a fetal scalp electrode and fetal blood sampling <34 weeks due to an increased risk of bleeding. The time taken to perform fetal blood sampling may also delay birth for pēpi that are more susceptible to hypoxic injury.
  • Birth should be expedited where there is clear evidence of serious pēpi compromise, either in the fetal heart rate pattern, or other clinical concerns such as suspected placenta abruption or sepsis.
  • Wāhine/people should be provided with verbal and written information on intrapartum surveillance during preterm labour.

The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau.

Published: October 2024 | PDF

Download - The Carosika Whānau Information on Care in Preterm Labour may be used to support conversations with wāhine/people and whānau.

 

Extreme preterm gestation (23+0 to 24+6 weeks)

Guideline Recommendations
— Fetal monitoring at extreme preterm gestations close to the limits of survival (23+0 to 24+6 weeks)

  • There is limited evidence to guide practice for fetal monitoring in labour at gestations near the limits of survival.
  • Care should be individualised.

Good Practice
— Fetal monitoring at extreme preterm gestations close to the limits of survival (23+0 to 24+6 weeks)

  • An obstetrician (specialist, medical officer of specialist scale or fellow) should discuss the benefits and risks of fetal monitoring in labour with wāhine/people and whānau. Interpretation of fetal heart rate pattern may be challenging, and the limitations should be acknowledged.
  • A plan should be developed through shared decision-making and clearly documented including plans in event of an abnormal recording.
  • Continuous CTG, intermittent auscultation or no monitoring may be considered appropriate.

Options for monitoring will include:

  • Continuous CTG if there is a plan for active treatment including caesarean section for fetal distress.
  • Intermittent auscultation if there is a plan for active treatment without caesarean section for fetal distress, this will assist planning of immediate resuscitation after birth. It should ideally be performed every 15 minutes in the first stage of labour and every 5 minutes in the second stage of labour.
  • No fetal monitoring if there is a plan for comfort/palliative care. Intermittent auscultation should be offered to wāhine/people as they may appreciate knowledge of whether their pēpi will be born alive.
  • Wāhine/people should be provided with verbal and written information on the benefits and risks of intrapartum fetal monitoring when birth is anticipated or planned at extremely preterm gestations close to the threshold of survival.

Care for wāhine/people and pēpi at extreme preterm gestations including fetal monitoring in labour should be considered as a package of care with all areas considered and addressed through shared decision-making.

#Auditable Standards

To be developed.

 

#Included guidelines

The search identified ten guidelines relevant to fetal monitoring during preterm labour that met criteria for high-quality and/or were recommended for use.1,4-12 One of these was assessed to be high-quality in Rigour of Development (score >60%) and in Overall Assessment (score >60%).1 This ‘Intrapartum Fetal Surveillance’ guideline (fourth edition), was developed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and updated in 2019.1 A further guideline was assessed to be high-quality in Overall Assessment (score >60%) only and was recommended for use by the Review Panel.4 The ‘New Zealand Consensus Statement on the care of mother and baby(ies) at periviable gestations’ was developed by a transdisciplinary team with the aim of achieving equitable care across Aotearoa for parents facing birth at gestations at the limits of survival, and although not specific to fetal monitoring does provide some guidance.4 The remaining eight guidelines did not meet high-quality criteria but were recommended for use with modifications by the Review Panel.5-7,9-13 These were all local guidelines developed by district health boards and were on the general acute management of preterm labour and included guidance on fetal monitoring in labour.

Recommendations in this section have been based on the RANZCOG Intrapartum Fetal Surveillance guideline and New Zealand Consensus Statement on the care of mother and baby(ies) at periviable gestations’.1,4 The recommendations are consistent with those provided in the local district health board guidelines.

#Impact on equity

Review Panel assessments identified that the recommendations for fetal monitoring in preterm labour guidelines had potential to both reduce and increase differences by equity factors. Standardisation of the approach to monitoring and consistency in use will improve equity in care. However, cultural and language barriers and rural location were all noted as potential factors that may exacerbate differences in care for some. It was noted that these may be overcome by inclusion of Māori and Pacific leadership and communities in implementation work, improved resources for culturally and linguistically appropriate care, improved resources for monitoring in smaller units and support for whānau needing to relocate for care.Content for the About tab should be added here.

#Research in progress that may inform future practice recommendations

None identified.

#Statement on rationale for any differing recommendations from the high-quality guidelines

Recommendations are consistent with the RANZCOG Intrapartum Fetal Surveillance guideline1 and the New Zealand Consensus Statement on the care of mother and baby(ies) at periviable gestations.4

#References

1. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists. Intrapartum Fetal Surveillance Clinical Guideline. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists; 2019. Available from: https://fsep.ranzcog.edu.au/FSEP/media/FSEP/IFS Clinical Guideline/FINAL-RANZCOG-IFS-Clinical-Guideline-2019.pdf.

2. Li Y, Gonik B. Continuous fetal heart rate monitoring in patients with preterm premature rupture of membranes undergoing expectant management. J Matern Fetal Neonatal Med. 2009;22(7):589-92. DOI: 10.1080/14767050902906378.

3. Faiz Z, Hof EMVt, Colenbrander GJ, Lippes R, Bakker PCAM. The quality of intrapartum cardiotocography in preterm labour. J Perinat Med. 2022;50(1):74-81. DOI: 10.1515/jpm-2021-0214.

4. Newborn Clinical Network. New Zealand Consensus Statement on the Care of Mother and Baby(ies) at Periviable Gestations. Newborn Clinical Network; 2019. Available from: https://www.starship.org.nz/guidelines/new-zealand-consensus-statement-on-the-care-of-mother-and-baby-ies-at/.

5. Counties Manukau District Health Board. Extreme Preterm Birth at 22 to 25+6 weeks. Auckland: Counties Manukau District Health Board; 2021.

6. Counties Manukau District Health Board. Preterm Labour Antenatal management of women at high risk of Preterm Birth, management of threatened and acute Preterm Labour (including cervical cerclage insertion). Auckland: Counties Manukau District Health Board; 2020.

7. Lakes District Health Board. Preterm labour: Management of threatened and active preterm labour guideline. Rotorua: Lakes District Health Board; 2021.

8. MidCentral District Health Board. Management of threatened and active preterm labour. Palmerston North: MidCentral District Health Board; 2021.

9. Nelson Marlborough District Health Board. Pre-term labour guideline. Nelson: Nelson Marlborough District Health Board; 2020.

10. Northland District Health Board. Preterm labour treatment guideline. Whangarei: Northland District Health Board; 2019.

11. Tairāwhiti District Health Board. Preterm labour and birth. Gisborne: Tairāwhiti District Health Board; 2019.

12. Waikato District Health Board. Preterm Labour. Hamilton: Waikato District Health Board; 2021.

13. MidCentral District Health Board. Antenatal magnesium sulphate prior to preterm birth for neuroprotection of the fetus, infant and child. Palmerston North: MidCentral District Health Board; 2018.

 

Related Topics

Antenatal counselling for wāhine and whānau when preterm birth is anticipated or planned

Learn more - Antenatal counselling for wāhine and whānau when preterm birth is anticipated or planned

Antibiotic use for preterm birth

Learn more - Antibiotic use for preterm birth

Antenatal corticosteroids

Learn more - Antenatal corticosteroids

Antenatal magnesium sulphate

Learn more - Antenatal magnesium sulphate

Umbilical cord clamping practice after preterm birth

Learn more - Umbilical cord clamping practice after preterm birth

Mode of preterm birth

Learn more - Mode of preterm birth

Preterm birth care in the birthing room or an unexpected place of birth

Learn more - Preterm birth care in the birthing room or an unexpected place of birth

Place of preterm birth and hospital transfer

Learn more - Place of preterm birth and hospital transfer