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.

Electronic fetal monitoring

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.