Admission Cardiotocography Essay Example

with intrapartum hypoxia (Royal College of Obstetricians and Gynaecologists) (RCOG 2001).

The National Institute of Clinical Excellence (NICE) guideline on CTG monitoring in labour (NICE 2001) suggests intermittent monitoring for low-risk labours and discourages the use of admission CTG. It provides a list of risk factors that would categorize a labour as high risk, for which it recommends continuous CTG monitoring. The primary goal of introducing CTG monitoring was to decrease perinatal mortality and cerebral palsy (Walsh 2003).

The following maternal problems are assessed in women deemed high risk: previous caesarean section, pre-eclampsia, post-term pregnancy (>42 weeks), prolonged rupture of membranes (>24hrs), induced labour, diabetes, antepartum haemorrhage, and other maternal medical disease. Fetal problems include fetal growth restriction, prematurity, oligohydramnios, abnormal Doppler artery velocimetry, multiple pregnancies, meconium-stained liquor, or breech presentation.

According to the NICE Guidelines (2001), these issues are classified as problems that midwives should address by recommending continuous Electronic Fetal Monitoring (EFM). The NICE Guidelines (2001) also indicate that continuous Cardiotocography (CTG) is necessary for intrapartum risk factors, such as Oxytocin augmentation and epidural analgesia. However, Advanced Life Support in Obstetrics (ALSO) (Ailsworth et al 2000) states that continuous CTG is not required for mobile or continuous infusions. Nevertheless, ALSO advises the use of CTG when initial bolus or top-ups are administered.

Vaginal bleeding in labor, maternal pyrexia, and fresh meconium-stained liquor also justify the recommendation for continuous electronic fetal monitoring (EFM). An audit conducted by Princess Alexandra Hospital NHS Trust in Harlow, Essex revealed that certain midwives were conducting unnecessary cardiotocographs (CTGs) as part of their routine practice. This audit aimed to assess midwives' methods of monitoring fetal heart during labor and compare them to the

guidelines outlined in the NICE guideline on cardiotocography (2001).

Overall, the majority of midwives in the unit followed the NICE guideline effectively. However, there was a discrepancy in compliance when it came to admission CTG's for low-risk patients. According to Harvey (2004), just under half of the low-risk classified individuals were found to have undergone an admission CTG. Nonetheless, there were other situations that posed challenges. One such scenario is when a low-risk mother with early or pre-labour and spontaneous rupture of membranes (SROM) comes to the labour ward seeking reassurance about their baby's well-being. In such cases, breaking the habit of performing an admission CTG can be difficult.

Reduced fetal movements may suggest fetal hypoxia and are a reasonable justification for a CTG admission (Verralls 1993). In my trust, midwives have been observed to follow the NICE Guidelines (2001) and trust policies (RWST ?). The NICE Guidelines (2001) also suggest that intermittent auscultation should be done every 15 minutes in the first stage, every 5 minutes in the second stage, and after every contraction for one minute during the active stage of labor, which is also endorsed by the RCOG (2001).

The importance of infection control in relation to EFM is emphasized. The monitors are thoroughly cleaned after each use to prevent the spread of infections. The straps are not reused as they may be contaminated with amniotic fluid and blood products. This practice aligns with the standard precautions set by the Nursing and Midwifery Council (NMC 2006) to minimize infection risks. Guidelines issued by the Department of Health (2006) aim to reduce healthcare-associated infections, which have received significant media attention due to concerns about insufficient hygiene

and increasing rates of hospital-acquired infections.

The classification of normal, suspicious, and pathological CTGs, as well as the categorization of fetal heart rate, is also defined. The Confidential Enquiry into Stillbirths and Neonatal Deaths in Infancy (1997) investigated potential additions to electronic fetal monitoring (EFM) but encountered difficulties in interpreting CTGs that were concerning. Despite its limitations, there is a continued motivation to use EFM in order to decrease neurological damage and infant deaths during labor. However, attention has been drawn to significant problems with intrapartum EFM and the interpretation of CTG tracings.

The problem of inconsistencies in the visual interpretation and classification of CTG tracings, both between observers and within the same observer, has been well-documented (Ayres-de-Campos et al 1999; Devane and Lalor 2005). This issue has serious implications for the clinical decision-making process in the management of labor (Devane and Lalor 2005). According to the Fourth Annual Confidential Enquiry into Stillbirths and Deaths in Infancy (CESDI) report, which provides an annual summary of stillbirth and infant death numbers and causes in England, Wales, and Northern Ireland, there were 873 intrapartum deaths of infants weighing over 1.5kg in the UK in 1995.

According to the Maternal and Child Health Research Consortium (1997), approximately 80% of cases showed sub-optimal care when alternative management options existed that could have potentially improved the outcome. The primary avoidable errors involved issues with the use and interpretation of CTG tracings, as well as the failure to take necessary action when an abnormal FHR was detected. One notable criticism regarding CTG interpretation was the lack of changes in management despite the presence of suspicious or abnormal tracings (Maternal and Child Health Research

Consortium, 1997).

According to the report, inadequate education is identified as the main reason for the failure to use EFM when clinically necessary, as well as for misidentifying and misinterpreting abnormal FHR patterns. It also highlights the issue of improper actions taken after recognizing abnormal FHR patterns. The fifth and sixth CESDI annual reports emphasized the persistent problems associated with the use and interpretation of CTG's and consistently stressed the importance of adequate education (Maternal and Child Health Research Consortium 2000).

Despite the implementation of in-service fetal monitoring education programs in many institutions, the impact of these programs on fetal monitoring knowledge and CTG interpretation skills has been seldom evaluated. Additionally, litigation has emerged as a significant concern. Despite the limitations of intermittent auscultation for fetal monitoring in uncomplicated pregnancies, continuous electronic fetal monitoring (EFM) has become a routine component of intrapartum care partly because of the constant fear of litigation (Symon 1998a) and the perceived sense of security provided by a continuous record of fetal heart rate (FHR).

However, according to Nelson (1999), the use of EFM may not be advantageous for both mothers and their babies. Walsh (1998) also suggests that it may lead to increased litigation due to unnecessary interventions based on technology rather than evidence. In fact, the CTG tracing is commonly utilized in situations involving alleged negligence in maternity care, as stated by the Maternity Defence Union in 1998.