Monitor the condition of the fetus during labour. Record the findings on the partogram. Understand the significance of the findings. Understand the causes and signs of fetal distress. Interpret the significance of different fetal heart rate patterns and meconium-stained liquor. Manage any abnormalities which are detected.

1. Monitoring the condition of the
fetus during the first stage of
labour
By C Settley

2. Objectives
When you have completed this chapter you
should be able to:
• Monitor the condition of the fetus during labour.
• Record the findings on the partogram.
• Understand the significance of the findings.
• Understand the causes and signs of fetal distress.
• Interpret the significance of different fetal heart rate patterns and
meconium-stained liquor.
• Manage any abnormalities which are detected.

3. Monitoring the fetus
• Why should you monitor the fetus during labour?
• It is essential to monitor the fetus during labour in order to assess how it responds to
the stresses of labour. The stress of a normal labour usually has no effect on a
healthy fetus.
• What may stress the fetus during labour?
• Compression of the fetal head during contractions.
• A decrease in the supply of oxygen to the fetus.
• How does head compression stress the fetus?
• During uterine contractions compression of the fetal skull causes vagal stimulation
which slows the fetal heart rate.
• Head compression usually does not harm the fetus. However, with a long labour due
to cephalopelvic disproportion, the fetal head may be severely compressed. This may
result in fetal distress.

4. • What may reduce the supply of oxygen to the fetus?
• Uterine contractions
• Reduced blood flow through the placenta
• Abruptio placentae
• Cord prolapse or compression

5. • How do contractions reduce the supply of oxygen to the fetus?
• Uterine contractions may:
• Reduce the maternal blood flow to the placenta due to the increase in intra-uterine pressure.
• Compress the umbilical cord.
• When do uterine contractions reduce the supply of oxygen to the fetus?
• Usually uterine contractions do not reduce the supply of oxygen to the fetus, as
there is an adequate store of oxygen in the placental blood to meet the fetal needs
during the contraction. Normal contractions in labour do not affect the healthy fetus
with a normally functioning placenta, and, therefore, are not dangerous.
• However, contractions may reduce the oxygen supply to the fetus when:
• There is placental insufficiency.
• The contractions are prolonged or very frequent.
• There is compression of the umbilical cord.

6. • How does the fetus respond to a lack of oxygen?
• A reduction in the normal supply of oxygen to the fetus causes fetal hypoxia.
This is a lack of oxygen in the cells of the fetus. If the hypoxia is mild the fetus
will be able to compensate and, therefore, show no response. However,
severe fetal hypoxia will result in fetal distress. Severe, prolonged hypoxia will
eventually result in fetal death.
• How is fetal distress recognised during labour?
• Fetal distress caused by a lack of oxygen results in a decrease in the fetal
heart rate.
• How do you assess the condition of the fetus during labour?
• Two observations are used:
• The fetal heart rate pattern.
• The presence or absence of meconium in the liquor.

7. Fetal heart rate patterns
• What devices can be used to monitor the fetal heart rate?
• Any one of the following three pieces of equipment:
• A fetal stethoscope.
• A ‘doptone’ (Doppler ultrasound fetal heart rate monitor).
• A cardiotocograph (CTG machine).
• In most low-risk labours the fetal heart rate can be determined adequately
using a fetal stethoscope. However, a doptone is helpful if there is difficulty
hearing the fetal heart, especially if intra-uterine death is suspected. If
available, a doptone is the preferred method in primary-care clinics and
hospitals.
• Cardiotocograph is not needed in most labours but is an important and
accurate method of monitoring the fetal heart in high-risk pregnancies.

8. How should you monitor the fetal heart rate?
• Because uterine contractions may decrease the maternal blood flow
to the placenta, and thereby cause a reduced supply of oxygen to the
fetus, it is essential that the fetal heart rate should be monitored
during a contraction.
• In practice, this means that the fetal heart pattern must be checked
before, during and after the contraction. A comment on the fetal
heart rate, without knowing what happens during and after a
contraction, is almost valueless.

9. How often should you monitor the fetal heart
rate?
• For low-risk patients who have had normal observations on admission:
• 2-hourly during the latent phase of labour.
• Half-hourly during the active phase of labour.
• Patients with a high risk of fetal distress should have their observations done more
frequently.
• Intermediate-risk patients, high-risk patients, patients with abnormal
observations on admission, and patients with meconium-stained liquor
need more frequent recording of the fetal heart rate:
• Hourly during the latent phase of labour.
• Half-hourly during the active phase of labour.
• At least every 15 minutes if fetal distress is suspected.

10. What features of the fetal heart rate pattern
should you always assess during labour?
• There are two features that should always be assessed:
• The baseline fetal heart rate: This is the heart rate between contractions.
• The effect of uterine contractions on the fetal heart rate: If contractions are
present, the relation of the deceleration to the contraction must be
determined:
• Decelerations that occur only during a contraction (i.e. early decelerations).
• Decelerations that occur during and after a contraction (i.e. late decelerations).
• Decelerations that have no fixed relation to contractions (i.e. variable decelerations).

11. What fetal heart rate patterns can be recognised
with a fetal stethoscope?
• Normal.
• Early deceleration.
• Late deceleration.
• Baseline tachycardia.
• Baseline bradycardia.
• These fetal heart rate patterns (with the exception of variable
decelerations) can be easily recognised with a stethoscope or doptone.
• It is common to get a combination of patterns, e.g. a baseline bradycardia
with late decelerations. It is also common to get one pattern changing to
another pattern with time, e.g. early decelerations becoming late
decelerations.

12. • What is a normal fetal heart rate pattern?
• No decelerations during or after contractions.
• A baseline rate of 110–160 beats per minute.
• What are early decelerations?
• Early decelerations are characterised by a slowing of the fetal heart rate
starting at the beginning of the contraction, and returning to normal by the
end of the contraction. Early decelerations are usually due to compression of
the fetal head, which causes the heart rate to slow during the contraction.

13. • What is the significance of early
decelerations?
• Early decelerations do not indicate
the presence of fetal distress.
• However, these fetuses must be
carefully monitored as they are at
an increased risk of fetal distress.
• What are late decelerations?
• A late deceleration is a slowing of
the fetal heart rate during a
contraction, with the rate only
returning to the baseline 30
seconds or more after the
contraction has ended.

14. What are variable decelerations?
• Variable decelerations have no
fixed relationship to uterine
contractions.
• Therefore, the pattern of
decelerations changes from 1
contraction to another.
• Variable decelerations are usually
caused by compression of the
umbilical cord
• These fetuses must be carefully
monitored as they are at an
increased risk of fetal distress.

15. • What is a baseline tachycardia?
• A baseline fetal heart rate of more than 160 beats per minute.
• What are the causes of a baseline tachycardia?
• Maternal pyrexia.
• Maternal exhaustion.
• Salbutamol (Ventolin) administration.
• Chorioamnionitis (infection of the placenta and membranes).
• Fetal haemorrhage or anaemia.
• What is a baseline bradycardia?
• A baseline fetal heart rate of less than 100 beats per minute.
• A fetal heart rate of between 100 and 110 beats per minute with good
variability is normal but must be distinguished from the maternal heart rate.

16. • What is the cause of a baseline bradycardia of less than 100 beats per
minute?
• A baseline bradycardia of less than 100 beats per minute usually indicates
fetal distress which is caused by severe fetal hypoxia.
• If decelerations are also present, a baseline bradycardia indicates that the
fetus is at great risk of dying.
• How should you assess the condition of the fetus on the basis of the
fetal heart rate pattern?
• The fetal condition is normal if a normal fetal heart rate pattern is present.
• The fetal condition is uncertain if the fetal heart rate pattern indicates that
there is an increased risk of fetal distress.
• The fetal condition is abnormal if the fetal heart rate pattern indicates fetal
distress.

17. • What is a normal fetal heart rate pattern during labour?
• A normal baseline fetal heart rate without any decelerations.
• Which fetal heart rate patterns indicate an increased risk of fetal
distress during labour?
• Early decelerations.
• Variable decelerations.
• A baseline tachycardia.
• These fetal heart rate patterns do not indicate fetal distress but warn that the
patient must be closely observed as fetal distress may develop.

18. • What fetal heart rate patterns indicate fetal distress during labour?
• Late decelerations.
• A baseline bradycardia.
• How should the fetal heart rate pattern be observed during labour?
• The fetal heart rate must be observed before, during and after a contraction.
• The following questions must be answered and recorded on the partogram:
• What is the baseline fetal heart rate?
• Are there any decelerations?
• If decelerations are observed, what is their relation to the uterine contractions?
• If the fetal heart rate pattern is abnormal, how must the patient be managed?

19. • Which fetal heart rate pattern indicates that the fetal condition is
good?
• The baseline fetal heart rate is normal.
• There are no decelerations.
• What must be done if decelerations are observed?
• First the relation of the decelerations to the uterine contractions must be
observed to determine the type of deceleration. Then manage the patient as
follows:
• If the decelerations are early or variable, the fetal heart rate pattern warns that there
is an increased risk of fetal distress and, therefore, the fetal heart rate must be checked
every 15 minutes.
• If late decelerations are present, the management will be the same as that for fetal
bradycardia.

21. • What must be done if a fetal bradycardia is observed?
• Fetal distress due to severe hypoxia is present. Therefore, you should
immediately do the following:
• Exclude other possible causes of bradycardia by turning the patient onto her side to
correct supine hypotension, and stopping the oxytocin infusion to prevent uterine
overstimulation.
• If the fetal bradycardia persists, intra-uterine resuscitation of the fetus must be
continued and the fetus delivered as quickly as possible.

22. Fetal bradycardia

23. How is intra-uterine resuscitation of the fetus
given?
• Turn the patient onto her side.
• Start an intravenous infusion of Ringer’s lactate and give 250 μg (0.5 ml) salbutamol (Ventolin)
slowly intravenously, after ensuring that there is no contraindication to its use. (Contraindications
to salbutamol are heart valve disease, a shocked patient or patient with tachycardia). The 0.5 ml
salbutamol is diluted with 9.5 ml sterile water and given slowly intravenously over 5 minutes.
• Deliver the infant by the quickest possible route. If the patient’s cervix is 9 cm or more dilated and
the head is on the pelvic floor, proceed with the delivery (a vacuum extraction may be
performed). Otherwise, perform a Caesarean section.
• If the patient cannot be delivered immediately (i.e. there is another patient in theatre) the dose
of salbutamol can be repeated if contractions start again, but not within 30 minutes of the first
dose or if the maternal pulse is 120 or more beats per minute.
• It is important that you know how to give fetal resuscitation, as it is a lifesaving procedure when
fetal distress is present, both during the antepartum period and in labour.
• Always prepare to resuscitate the infant after birth if fetal distress is diagnosed during labour.

24. A vacuum extraction

25. The liquor
• Is the liquor commonly meconium stained?
• Yes, in 10–20% of patients, the liquor is yellow or green due to meconium staining. The incidence
of meconium-stained liquor is increased in the group of patients that go into labour after 41
completed weeks gestation.
• Is it important to distinguish between thick and thin, or yellow and green meconium?
• Although fetal and neonatal complications are more common with thick meconium, all cases of
meconium-stained liquor should be managed the same during the first stage of labour. The
presence of meconium is important and the management does not depend on the consistency of
the meconium.
• What is the importance of meconium in the liquor?
• Meconium-stained liquor usually indicates the presence of fetal hypoxia or an episode of fetal
hypoxia in the past. Therefore, fetal distress may be present. If not, the fetus is at high risk of
distress.
• There is a danger of meconium aspiration at delivery.

26. • How should you monitor the fetus during the first stage of labour if the
liquor is meconium stained?
• Listen carefully for late decelerations. If present, then fetal distress must be
diagnosed.
• If late decelerations are absent, then observe the fetus carefully during labour for
fetal distress, as about a third of fetuses with meconium-stained liquor will develop
fetal distress.
• If electronic monitoring is available, the fetal heart rate pattern must be monitored.
• How must the delivery be managed if there is meconium in the liquor?
• A normal delivery is conducted. There is no need to suction the mouth and nose
prior to the delivery of the shoulders and chest. Immediately dry the infant. No
further resuscitation is necessary if the infant is breathing well. This must be done
irrespective of whether a vaginal delivery or Caesarean section is done.
• Anticipate that the infant may need to be resuscitated at delivery if the infant is not
breathing well following drying. Infants not breathing at delivery have birth asphyxia
and need intubation. Suction the airways using an endotracheal tube before starting
ventilation.

27. • How and when are the liquor findings recorded?
• Three symbols are used to record the liquor findings on the
partogram:
• I = Intact membranes (i.e. no liquor draining).
• C = Clear liquor draining.
• M = Meconium-stained liquor draining.
• The findings are recorded in the appropriate space on the partogram
• The liquor findings should be recorded when:
• The membranes rupture.
• A vaginal examination is done.
• A change in the liquor findings is noticed, e.g. if the liquor becomes
meconium stained.

28. ADMISSION OF A WOMAN IN LABOUR
• History taking
• Physical examination
• Note the psychological state, heart rate, temperature, blood pressure,
respiratory rate and any oedema or
• Examine the abdomen
• Perform a vaginal examination:

29. GENERAL CARE OF WOMEN IN LABOUR
• Assessment of problems and risks
• Respect, privacy and companionship
• Diet and fluids
• Mobility and posture
• Enema, pubic hair shaving and insertion of urinary catheter
• Artificial rupture of membranes (amniotomy)
• Partogram

30. ROUTINE MONITORING IN THE FIRST STAGE OF
LABOUR
• Latent phase (cervix <4 cm dilated):
• Temperature, heart rate, respiratory rate and blood pressure 4 hourly.
• Uterine contractions and fetal heart rate 4 hourly.
• Vaginal examination 4 hourly.
• Any change in phase of labour, or abnormal observation, warrants
more frequent observation or action.

31. • Active phase (cervix ≥4 cm dilated, <1 cm long):
• Maternal condition
• Heart rate, BP, respiratory rate hourly.
• Temperature 4 hourly.
• Urine volume and test for protein and sugar when urine is passed
• Fetal condition
• Fetal heart rate half-hourly, before and immediately after contractions, ideally using a hand-
held
• Doppler device.
• Colour and odour of the liquor 2 hourly if the membranes have ruptured.
• Progress of labour
• Duration and frequency of uterine contractions half-hourly, per 10 minutes.
• Vaginal examination 2 hourly noting cervical dilation, sagittal moulding and caput.
• Treatment given
• All medications.
• All fluids, by whatever route.
• Summary of findings
• Identified problems.
• Management plan.

32. Analgesia in labour
• Pain relief should be offered to all women in labour:
• Support and companionship have been shown to reduce the need for
analgesic medication in labour. Promote companionship in labour.
• Pethidine 100 mg with promethazine 25 mg intramuscularly 4 hourly is
acceptable in both the latent and active phases, even up to full dilatation of
the cervix.
• Inhaled Entonox® (a mixture of 50% nitrous oxide and 50% oxygen) by mask is
useful in the late first stage (≥8 cm cervical dilatation).
• Epidural anaesthesia is generally not available in CHCs and district hospitals.
Some institutions may however have the necessary skills and equipment to
provide this form of pain management.

34. First stage:
dilation and foetal descent, divided into 2 phases
• 1) Latent phase: from the start of labour to approximately 5 cm of dilation.
Its duration varies depending on the number of prior deliveries.
• 2) Active phase: from approximately 5 cm to complete dilation. During this
phase the cervix dilates faster than during the latent phase. The time to
dilate varies with the number of previous deliveries. As a rule, it does not
last longer than 10 hours in a multipara and 12 hours in a primipara.
• Second stage: delivery of the infant
• Begins at full dilation.
• Third stage: delivery of the placenta

35. Dilation curve in the primipara (in a multipara, the curve is
shifted to the left)

36. Estimating cervical dilation

37. Amniotic sac
• – The amniotic sac bulges during contractions and usually breaks
spontaneously after 5 cm of dilation or at full dilation during delivery.
Immediately after rupture, check the fetal heart rate and if necessary
perform a vaginal examination in order to identify a potential prolapse of
the umbilical cord. Once the membranes are ruptured, always use sterile
gloves for vaginal examination.
• – Note the colour of the amniotic fluid: clear, blood-stained, or meconium-
stained.
• Meconium staining by itself, without abnormal fetal heart rate, is not
diagnostic of fetal distress, but does require closer monitoring—in
particular, a vaginal examination every 2 hours. Action must be taken if
dilation fails to progress after 2 hours.

38. Foetal progress
• – Assess foetal descent by palpating the abdomen (portion of the fetal
head felt above the symphysis pubis) before performing the vaginal
examination.
• – At each vaginal examination, in addition to dilation, check the
presentation, the position and the degree of fetal descent.
• – Look for signs that the fetal head is engaged:
• On vaginal examination, the presenting part prevents the examiner's fingers from
reaching the sacral concavity .
• The presence of caput (benign diffuse swelling of the fetal head) can lead to the
mistaken conclusion that the fetal head is engaged.
• The distance between the fetal shoulder and the upper edge of the
symphysis pubis is less than 2 finger widths

39. Diagnosing engagement
Presenting part not engaged: fingers in the
vagina can reach the sacral concavity
Presenting part engaged: fingers in the
vagina cannot reach the sacral concavity
(if caput absent)

40. Head not engaged: the shoulder is more
than 2 finger widths above the symphysis
Head engaged: the shoulder is less than 2
finger widths above the symphysis

41. SUMMARY: CTG
• Cardiotocography (CTG) is used during pregnancy to monitor fetal
heart rate and uterine contractions. It is most commonly used in the
third trimester and its purpose is to monitor fetal well-being and
allow early detection of fetal distress. An abnormal CTG may indicate
the need for further investigations and potential intervention. The
device used in cardiotocography is known as a cardiotocograph. It
involves the placement of two transducers onto the abdomen of a
pregnant woman. One transducer records the fetal heart rate using
ultrasound and the other transducer monitors the contractions of the
uterus by measuring the tension of the maternal abdominal wall
(providing an indirect indication of intrauterine pressure). The CTG is
then assessed by a midwife and the obstetric medical team.

42. How to read a CTG
• To interpret a CTG you need a structured method of assessing its various
characteristics. The most popular structure can be remembered using the
acronym DR C BRAVADO:
• DR: Define risk
• C: Contractions
• BRa: Baseline rate
• V: Variability
• A: Accelerations
• D: Decelerations
• O: Overall impression

43. Define risk
• When performing CTG interpretation, you first need to determine if
the pregnancy is high or low risk. This is important as it gives more
context to the CTG reading (e.g. if the pregnancy categorised as high-
risk, the threshold for intervention may be lower).
• Maternal factors
• Obstetric complications
• Other risks

44. Contractions
Next, you need to record the number of contractions present in a 10
minute period.

45. Baseline rate of the fetal heart: The baseline rate is the
average heart rate of the fetus within a 10-minute window.
• Look at the CTG and assess what the average heart rate has been over
the last 10 minutes, ignoring any accelerations or decelerations.
• A normal fetal heart rate is between 110-160 bpm.

46. Occiput posterior

47. Variability

49. Accelerations

50. Decelerations: Decelerations are an abrupt decrease in the
baseline fetal heart rate of greater than 15 bpm for greater than 15
seconds.

51. Variable decelerations are observed as a rapid fall in baseline fetal heart rate
with a variable recovery phase. They are variable in their duration and may not have any relationship
to uterine contractions. They are most often seen during labour and in patients’ with reduced
amniotic fluid volume. All fetuses experience stress during the labour process, as a result of uterine
contractions reducing fetal perfusion. Whilst fetal stress is to be expected during labour, the challenge
is to pick up pathological fetal distress.

52. Late deceleration
Late decelerations begin at the peak of the uterine contraction and recover after the
contraction ends. This type of deceleration indicates there is insufficient blood flow
to the uterus and placenta. As a result, blood flow to the fetus is significantly
reduced causing fetal hypoxia and acidosis.

53. Prolonged deceleration
A prolonged deceleration is defined as a deceleration that lasts more
than 2 minutes:

54. Sinusoidal pattern

55. Overall impression
• Once you have assessed all aspects of the CTG you need to determine
your overall impression.
• The overall impression can be described as either reassuring,
suspicious or abnormal.

56. Reference list
• https://medicalguidelines.msf.org/viewport/ONC/english/5-1-
normal-delivery-51416916.html
• https://www.verywellhealth.com/high-risk-pregnancy-5192302

57. Case study 1
• A primigravida with inadequate uterine contractions during labour is
being augmented with an oxytocin infusion. She now has frequent
contractions, each lasting more than 40 seconds. With the patient in
the lateral position, listening to the fetal heart rate reveals late
decelerations.

58. Case study 2
• A patient who is 38 weeks pregnant presents with an antepartum
haemorrhage in labour. On examination, her temperature is 36.8 °C,
her pulse rate 116 beats per minute, her blood pressure 120/80 mm
Hg, and there is tenderness over the uterus. The baseline fetal heart
rate is 166 beats per minute. The fetal heart rate drops to 130 beats
per minute during contractions and then returns to the baseline 35
seconds after the contraction has ended.

59. Case study 3
• During the first stage of labour a patient’s liquor is noticed to have
become stained with thin green meconium. The fetal heart rate
pattern is normal and labour is progressing well.