The grades of recommendations (A-E and I) and levels of evidence (I, II-1, II-2, II-3, and III) are defined at the end of the "Major Recommendations" field.
Fetal Surveillance in Labor
Labour Support During Active Labor
- Women in active labour should receive continuous close support from an appropriately trained person. (I-A)
Professional One-to-One Care and Intrapartum Fetal Surveillance
- Intensive fetal surveillance by intermittent auscultation or electronic fetal monitoring requires the continuous presence of nursing or midwifery staff. One-to-one care of the woman is recommended, recognizing that the nurse/midwife is really caring for two patients, the woman and her unborn baby. (III-C)
Intermittent Auscultation in Labour
- Intrapartum fetal surveillance for healthy term women in spontaneous labour in the absence of risk factors for adverse perinatal outcome. Intermittent auscultation following an established protocol of surveillance and response is the recommended method of fetal surveillance; compared with electronic fetal monitoring, it has lower intervention rates without evidence of compromising neonatal outcome. (I-B)
- Epidural analgesia and intermittent auscultation. Intermittent auscultation may be used to monitor the fetus when epidural analgesia is used during labour, provided that a protocol is in place for frequent intermittent auscultation assessment (e.g., every 5 minutes for 30 minutes after epidural initiation and after bolus top-ups as long as maternal vital signs are normal). (III-B)
Admission Fetal Heart Test
- Admission fetal heart tracings are not recommended for healthy women at term in labour in the absence of risk factors for adverse perinatal outcome, as there is no evident benefit. (I-A)
- Admission fetal heart tracings are recommended for women with risk factors for adverse perinatal outcome. (III-B)
Intrapartum Fetal Surveillance for Women with Risk Factors for Adverse Perinatal Outcome
- Electronic fetal monitoring is recommended for pregnancies at risk of adverse perinatal outcome. (II-A)
- Normal electronic fetal monitoring tracings during the first stage of labour. When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased. (III-B)
Digital Fetal Scalp Stimulation
- Digital fetal scalp stimulation is recommended in response to atypical electronic fetal heart tracings. (II-B)
- In the absence of a positive acceleratory response with digital fetal scalp stimulation:
- Fetal scalp blood sampling is recommended when available. (II-B)
- If fetal scalp blood sampling is not available, consideration should be given to prompt delivery, depending upon the overall clinical situation. (III-C)
Fetal Scalp Blood Sampling
- Where facilities and expertise exist, fetal scalp blood sampling for assessment of fetal acid–base status is recommended in women with "atypical/abnormal" fetal heart tracings at gestations > 34 weeks when delivery is not imminent, or if digital fetal scalp stimulation does not result in an acceleratory fetal heart rate response. (III-C)
Umbilical Cord Blood Gases
- Ideally, cord blood sampling of both umbilical arterial and umbilical venous blood is recommended for ALL births, for quality assurance and improvement purposes. If only one sample is possible, it should preferably be arterial. (III-B)
- When risk factors for adverse perinatal outcome exist, or when intervention for fetal indications occurs, sampling of arterial and venous cord gases is strongly recommended. (I-insufficient evidence. See Table 1 in the original guideline document).
Fetal Pulse Oximetry
- Fetal pulse oximetry, with or without electronic fetal surveillance, is not recommended for routine use at this time. (III-C)
ST Waveform Analysis
- The use of ST waveform analysis for the intrapartum assessment of the compromised fetus is not recommended for routine use at this time. (I-A)
Intrapartum Fetal Scalp Lactate Testing
- Intrapartum scalp lactate testing is not recommended for routine use at this time. (III-C)
Definitions:
Levels of Evidence*
I: Evidence obtained from at least one properly randomized controlled trial.
II-1: Evidence obtained from well-designed controlled trials without randomization.
II-2: Evidence obtained from well-designed cohort or case–control studies, preferably from more than one center or research group.
II-3: Evidence obtained from comparison between times or places with or without the intervention. Dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.
*The quality of evidence reported in these guidelines has been adapted from The Evaluation of Evidence criteria described in the Canadian Task Force on Preventive Health Care.
Grades of Recommendations †
A. There is good evidence to recommend the clinical preventive action
B. There is fair evidence to recommend the clinical preventive action
C. The existing evidence is conflicting and does not allow to make a recommendation for or against use of the clinical preventive action; however, other factors may influence decision-making
D. There is fair evidence to recommend against the clinical preventive action
E. There is good evidence to recommend against the clinical preventive action
L. There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making
† Recommendations included in these guidelines have been adapted from the Classification of Recommendations criteria described in the Canadian Task Force on Preventive Health Care.
