Monitoring the fetal heart in pregnancy and labour

Monitoring the fetal heart in pregnancy and labour

Photographs show nurse using Pinard stethoscope, hand-held fetal doppler and CTG monitoring, photograph shows fetal scalp electrodes, and diagram shows electrode position on fetal skull.

It is the role of the midwife to provide appropriate care during pregnancy and labour, which promotes normal birth and detects complications in mother and/or fetus. Maternal consent is required for any procedure.

Auscultation of the fetal heart

Best practice for auscultation is to listen with a Pinard stethoscope (Figure 34.1), although a hand-held fetal Doppler may also be used (Figure 34.2). Abdominal examination (see Chapter 25) is used to identify the best location on the maternal abdomen to hear the fetal heart (FH), which is over the fetal shoulder.

Intermittent auscultation is when the FH is listened to for short periods of at least 1 minute. This is a suitable method during pregnancy and throughout low-risk labours. When listening to the FH the midwife should record the following:

  • Rate – should be counted for a full minute and recorded as a single number.
  • Variability – the differences that occur within the heart rate and should be heard during the course of auscultation.
  • Accelerations – whether or not rises in the heart rate are heard.
  • Decelerations – whether or not decreases in the heart rate are heard. Any decelerations should be noted and continuous monitoring commenced immediately.

Maternal pulse should be palpated simultaneously and recorded.

During pregnancy

During pregnancy there is no evidence to support regular auscultation of the FH as the ‘snapshot’ of wellbeing. Therefore, the midwife should not routinely auscultate during antenatal examinations but can do so if requested by the woman. Instead care should be taken to ensure that women are aware of the importance of fetal movement as an indicator of a healthy fetus.

First stage of labour

Auscultation should be performed at the first contact when the woman is in labour and at every assessment thereafter, with maternal pulse recorded to differentiate between the two.

During the first stage of established labours (from 4 cm dilatation to commencement of pushing) the FH should be auscultated every 15 minutes. The midwife should listen for at least 1 minute immediately following a contraction taking note of the features above, with any deviations from normal noted, recorded and acted upon, continuous monitoring commenced and a member of the obstetric team informed.

Second stage of labour

During the active second stage of labour (from commencement of pushing until the birth of the baby) the FH should be auscultated every 5 minutes or after every contraction. Again this should be immediately after a contraction for a minimum of 1 minute.

Electronic fetal monitoring

In cases where the pregnancy/labour is affected by complications or medical complexities, continuous monitoring of the FH may be indicated. Electronic fetal monitoring is carried out using a cardiotocograph (CTG) machine. This provides the midwife with a continuous record on paper of the FH rate as well as an indication of uterine activity.

The CTG transducer should be placed on the maternal abdomen where the FH has been heard with a Pinard stethoscope and is held in place with an elasticated belt. The toco (which is a pressure sensor to identify uterine activity) is then placed at the highest point of the fundus and held in place with a second belt (Fig. 34.3). It is important that the uterus is in a resting phase (soft) when this is applied and that the percentage reading on the machine is low, <10. If this is not the case there is a button on the machine that will reset the reading to zero.

Antenatally the woman may be given a button to press to record fetal movements felt, if this function is available on the machine. Some machines record this automatically through the transducer. Following commencement of the CTG recording the midwife should record the following details on the trace:

  • Date and time
  • Woman’s name and hospital number
  • Gestation
  • Indication for CTG
  • Maternal pulse
  • Midwife’s name and signature at completion of monitoring.

The following is an example of indications for CTG monitoring in pregnancy and/or continuous monitoring in labour (this is not exhaustive).

  • Pregnancy:

    • Maternal: abdominal trauma, prolonged rupture of membranes
    • Fetal: reduced fetal movements, deceleration on intermittent auscultation.

  • Labour:

    • Maternal: suspected sepsis or chorioamnionitis, tachycardia (>120 bpm) on two occasions 20 minutes apart, severe hypertension, obstetric emergency (e.g. haemorrhage, cord prolapse, seizure), oxytocin use, fresh vaginal bleeding, delay in first or second stage
    • Fetal: significant meconium liquor, abnormal presentation (including cord presentation), suspected growth restriction, fetal heart rate <110 bpm or >160 bpm, deceleration on intermittent auscultation, oliogohydramnios or polyhydramnios.


NICE guidelines set out the parameters used in most of the UK by which the FH should be assessed for normality. This should be done hourly, unless otherwise indicated by previous assessments in which case every 30 minutes is more appropriate.

Fetal scalp electrode

If the FH cannot be monitored adequately by abdominal transducer, a fetal scalp electrode (FSE) may be considered (Figure 34.4). An FSE is a clip or screw-like device, which is attached to the fetal scalp, with consent of the woman, during a vaginal examination. There is direct contact, giving rise to a more consistently recorded CTG. The FSE is normally applied over one of the parietal bones (Figure 34.5). They should only be used with extreme caution where there is maternal infection or malpresentation.

Jun 19, 2019 | Posted by in MIDWIFERY | Comments Off on Monitoring the fetal heart in pregnancy and labour

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