To reduce adverse perinatal outcomes by identifying potential fetal compromise and escalating care accordingly.

Refer to Reference:

The Royal Australian and New Zealand College Of Obstetricians and Gynecologists (RANZCOG) (2019) Intrapartum Fetal surveillance: clinical guidelines (4th Edition) Appendix B: Definitions pg. 28-29

Cardiotocograph (CTG): An electronic means of recording the fetal heartbeat and uterine contractions during pregnancy and labor.

Phillips ISP : A CTG Program offering surveillance and alarming with comprehensive documentation and data storage in the one system, that can be observed from a location remote from the laboring woman.

Doppler Ultrasound: A handheld device used for listening to the fetal heartbeat.

• any deviation from the guideline must be under the direction of the Consultant Obstetrician and documented in the medical record

• all private patients require a CTG on admission unless otherwise specified.

• for interpretation and quality of a CTG, a gestation of at least 28 weeks is preferred, but it will be up to the discretion of the medical officer on duty.

• to maintain a consistent CTG trace a scalp clip can be applied, unless contraindicated (Refer to Appendix 5 Fetal Surveillance-Fetal Scalp Electrode Application)

• consider using an intrauterine pressure catheter for woman with an increased BMI (Refer to Appendix 4 -Fetal Surveillance-Intrauterine Pressure Catheter Insertion)

• a woman transferring to theatre for an emergency cesarean section or waiting for an emergency cesarean section (Cat 2 Cesarean Section) must have continuous CTG monitoring via a scalp clip if possible until the commencement of the cesarean section.

• do not use telemetry CTG monitoring when transferring to theatre

• a CTG is not continued during transfer to a tertiary center as there is no option to action any abnormality before arrival at the destination hospital.

• all Grampian's Health Ballarat Obstetric Medical and Midwifery Staff who review CTGs, must attend The Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) Fetal Surveillance Education Program (FSEP)  (Refer to Appendix 1 Fetal Surveillance Practitioner Levels and Appendix 2 Fetal Surveillance Competency Flowchart)

Phillips ISP System

1. Determine the indication for fetal monitoring

2. Discuss fetal monitoring with the woman and obtain permission to commence.

3. Perform abdominal palpation to determine lie and presentation unless contraindicated (e.g. APH, abruption). The woman should be in an upright to lateral position (not supine).

4. Prior to starting a CTG admit the woman onto Phillips ISP, creating an open episode and network connection. Check accurate date and time has been set on the CTG machine and the paper speed is set on 1cm per minute.

5. Ensure the CTG is labelled with the woman's name, UR number and date/time of commencement. Record the maternal heart rate and use a finger probe where available.

6. Set the toco transducer at a uterine resting tone baseline level of 20mm of mercury..

7. Documentation of findings must be recorded in the woman's notes and if a CTG is performed all features of the CTG must be documented including:

   • Baseline heart rate

   • Variability, accelerations and decelerations

   • An assessment of the trace as normal, abnormal or pathological

If the criteria for a normal trace is not met within 30 minutes, 2 midwives are to review and document findings, following a further 30 minutes of CTG monitoring, if normal CTG criteria is not met, the obstetric team must be notified.

• in the event of a transfer from Maternity Outpatients Unit, Labour Ward, Theatre or the Emergency Department, it is the primary midwife's responsibility to ensure the CTG trace is uploaded onto the Phillips ISP system.

• where the midwives change between shifts it is the responsibility of the midwives to communicate the need for uploading the trace.

• if the trace cannot be uploaded the CTG trace in paper form, must be sent to health information with instructions for the CTG trace to be scanned.

CTG Management of Fetal Heart Rate Patterns

Refer to Reference: The Royal Australian and New Zealand College Of Obstetricians and Gynecologists (RANZCOG) (2019) Intrapartum Fetal Surveillance: clinical guidelines (4th Edition) Management of Fetal Heart Rate patterns pg.15

• all abnormal CTG traces are to be reviewed by the shift coordinator and the lead obstetrician and a management plan initiated and documented

• in the event of an abnormal CTG trace where birth must be expedited, an obstetric response must be called on 2222, the lead obstetrician may then call a caesarean response if indicated