During prenatal care, the clinician and patient will discuss common events and procedures in labor, including methods of assessing fetal well-being.
Admission to Labor and Delivery
The responsible clinician or designee shall evaluate the patient, enter a note, and provide orders within two hours of his or her patient arriving at the Labor and Delivery unit.
- 37–41 weeks gestation
- appropriate weight for gestational age
- has a Category I electronic fetal monitoring strip on admission, or a reassuring auscultation and a note written by the clinician if she (patient) refuses electronic fetal monitoring
- absence of moderate or thick meconium
- vertex presentation
- absence of any medical or obstetrical complications
- a risk factor is identified
- the patient enters active labor
- the patient requests pain medication
Initial Evaluation by Clinician in Labor and Delivery
The clinician’s initial evaluation and documentation in Labor and Delivery shall include, at a minimum:
- reviewing and summarizing the antenatal course;
- physical exam (including an estimated fetal weight);
- evaluation of status of labor, including a description of uterine activity, cervical dilation and effacement, and fetal station and presentation, unless vaginal exam deferred;
- evaluation of fetal status, including interpretation of auscultation or electronic fetal monitoring strips, if generated; and
- the plan for delivery.
Fetal status must be assessed on every patient who is evaluated or admitted in a triage unit. This should be performed without delay for any fetus of 24 or more weeks. A recording of fetal heart rate (FHR) and uterine contractions is advised until categorization of the FHR tracing is determined. If a Category I pattern cannot be obtained in a reasonable time frame, continued evaluation should proceed.
First Stage of Labor After Initial Evaluation
For a patient without complications, continuous FHR monitoring is not required if the initial FHR tracing exhibits a Category I tracing.
“Categorization of the FHR tracing evaluates the fetus at that point in time; tracing patterns can and will change. An FHR tracing may move back and forth between categories depending on the clinical situation and management strategies employed.”1
Fetal heart rate (and variability—if electronically monitored) should be evaluated and recorded at least every 15–30 minutes, depending on the risk status of the patient, during the active phase of labor).2,3 The FHR should be evaluated as soon as is feasible after spontaneous rupture, or immediately after artificial rupture of the membranes.
Continuous fetal heart rate monitoring should be done for patients with any of these indicators:
- history of an abnormal antepartum FHR or rhythm,
- breech presentation,
- history of prior cesarean delivery,
- multiple gestation,
- nonreassuring fetal assessment,
- significant maternal illness,
use of oxytocin,
abnormality of active or second stage labor,
thick meconium, or
heavy vaginal bleeding.
Electronic fetal monitoring is also preferred when auscultation is not feasible. Once continuous electronic fetal monitoring is chosen and initiated, a technically satisfactory and continuous tracing should be achieved. If this cannot be accomplished, the reasons must be documented and an alternative plan for fetal assessment must be developed.
In the event of a Category III FHR tracing, the attending clinician or his or her designee shall promptly evaluate the fetal status and initiate efforts to resolve the abnormal FHR pattern. If corrective measures are not successful, preparations for delivery will be initiated.2
An amnioinfusion may be considered when persistent variable decelerations are seen on the FHR tracing.2
Evaluation During First Stage
The patient shall be evaluated during labor at appropriate intervals. Each evaluation should include:
- assessment of maternal status, including level of pain during labor;
- description of uterine activity;
- assessment of fetal status;
- description of findings on vaginal exam, if performed, including cervical dilation and effacement, fetal station, change in status of membranes, and progress since last exam;
- summary of maternal and fetal status; and
- plan, including plans for or performance of clinical interventions and pain management.
Each evaluation should be recorded in the medical record.
Second Stage Labor
The monitoring clinician should document in the medical record at the time of identification of second stage, after two hours of second stage, and hourly thereafter. This documentation, which should be dated and timed, should include, at a minimum:
- maternal status;
- fetal status;
- fetal station and, if known, position;
- presence of caput and molding; and
- the plan for delivery.
Fetal heart rate should be evaluated and recorded at least every 5–15 minutes, depending on the risk status of the patient.2,3
In the event of a Category III FHR tracing, the attending clinician or his or her designee shall promptly evaluate the fetal status and promptly initiate efforts to resolve the abnormal FHR pattern. He or she may consider obtaining another opinion about the fetal status.
No later than the end of the second hour of the second stage of labor, and every hour thereafter, the attending physician or midwife should personally evaluate the patient and document in the medical record the minimum as noted above. Additionally, the providers involved (which may include the attending physician, resident, nurse midwife, RN, and/or charge nurse) shall discuss the patient’s progress and plan of care at each hourly interval.
By the end of the third hour of the second stage of labor, the attending obstetrician should personally evaluate and examine the patient, immediately document details of this evaluation, and be involved in continued planning.
If a patient is moved to another room for delivery, fetal monitoring should be established in that room unless delivery is reasonably expected to occur imminently. For patients about to undergo cesarean delivery, monitoring should continue as is feasible until abdominal preparation for surgery is begun.
When the clinician is concerned about the fetal status at delivery, a double-clamped segment of the umbilical cord should be set aside for possible arterial blood gas assessment. If the neonatal 5-minute Apgar score is 4 or less, umbilical artery blood should be sent for analysis whenever possible. Blood can be drawn from the clamped segment of cord at any time within an hour of delivery.
Following delivery, the clinician must record all the events in the medical record, using forms, notation, and/or dictation as appropriate to the case. The clinician should be readily available to return to the unit until the immediate (30 minute) postpartum period is complete and the patient is stable.
Each institution shall provide and maintain appropriate fetal monitoring apparatus to meet the needs of its patients. Accommodations for preserving all electronic fetal monitoring tracings (see Guideline 1) is also the responsibility of the institution, with special consideration and allocation of resources to assure permanent and secure preservation of fetal monitor tracings (antenatal and intrapartum) for all babies born with five minute Apgar scores of 4 or less. If copies of electronic fetal monitor strips are kept, then preservation and storage of paper fetal monitor strips is not necessary.
Each hospital shall have at least daily multidisciplinary meetings held on the Labor and Delivery unit, at which time all patients’ relevant clinical issues shall be discussed and appropriate clinical and administrative plans agreed upon by the team caring for the patients.
Ongoing continuing education should be provided by each institution for all obstetrical personnel. Subjects to be reviewed may include FHR monitoring, emergency measures for the treatment of shoulder dystocia and eclampsia, and forceps or vacuum application. Each institution shall develop a program to evaluate and document staff competence.
- Macones GA, et al. The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring Update on Definitions, Interpretation, and Research Guidelines. Obstet Gynecol. 2008;112:661–66.
- Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2009;114:192–202.
- American College of Nurse-Midwives. Intermittent auscultation for intrapartum fetal heart rate surveillance. Clinical Bulletin no. 11. J Midwifery Womens Health 2010;55:397–403.