This essay will demonstrate evidence for the midwifery management of admission cardiotocography (CTG) and how this affects women’s choice.
Fetal heart monitoring has been practised for centuries. The first person to document the fetal beat was Phillipe LeGaust in 1650 placing the ear directly to the abdomen of the pregnant woman. In the UK, Ferguson was the first person to describe it in 1827. In 1976, the French physician Dr. A. Pinard designed the fetal stethoscope (that takes his name) which is still used today for intermittent auscultation. The first commercial fetal monitoring was produced by Hammacher and Hewlett Packard in 1968 (Cutlan 2006) and its introduction in the 1970s caused much debate when child birth groups began to question its appropriate use (Blincoe 2005).
A CTG is a record of the fetal heart rate (FHR) either measured from a transducer on the abdomen or a probe on the fetal scalp. In addition to the fetal heart rate another transducer measures the uterine contractions over the fundus (Impey 1999). The fetal condition is monitored by both intermittent and continuous auscultation depending on the mother’s and baby’s condition and needs during labour and its aim is to identify babies who may be at risk, so additional assessment of fetal well-being may be used (Alfirevic et al. 2007). At the same time EFM was made-up in order to reduce the risk of fetal infection as a consequence of too many vaginal examinations. The midwife may be the first individual to identify it, being her immediate action essential for minimising detrimental effects and improve general outcomes (McDonald, 2003). In order to find out what method of monitoring to use, all women on admission to labour ward should be carefully assessed and allocated into a correspondent risk group (Fetal Monitoring Police 2004). The Royal College of Obstetricians and Gynaecology (RCOG 2001) states that admission CTG in low risk pregnancy is not recommended therefore should be avoided. Meanwhile, women who are considered at high risk should have the fetal heart monitored continuously for the duration of labour. Consideration of maternal choice and needs should also be considered (Fetal Monitoring Police, 2004). High risk women are at potential risk of fetal morbidity and mortality including maternal and fetal problems such as induction of labour with intravenous syntocinon, pregnancy induced hypertension, ante partum haemorrhage, diabetes and placenta praevia or medical conditions such as cardiac problems or renal disease as a maternal problem (Williams and Blanchard 1996), and grade two/three meconium, defined intrauterine growth retardation, preterm labour (< 37 weeks), Multiple pregnancy and breech presentation as a fetal problem (Fetal Monitoring Police 2004). Moreover, McCormick (2003) state that electronic fetal monitoring (EFM) may be appropriate for women at high risk. The National Institute for Health and Clinical Excellence (NICE 2003) suggests that there is no evidence to evaluate the use of admission CTG for women with low risk pregnancy and are poor at predicting fetal compromise during labour. Impey et al. (2003) proposes that admission CTG should not be undertaken routinely on women at low risk of complications. According to Walsh (2006) EFM had a notorious high false positive rate therefore does note improve outcome. In addition Wash (2004) also suggests that current data does not support the use of the fetal monitoring as it results in more birth interventions. Parer (2000) wondered whether the use of electronic fetal heart rate monitoring should be avoided. Alfirevic and Devane (2007) state that studies showed no significant difference in overall perinatal death rate when comparing intermittent auscultation and continuous CTG. After the introduction of the EFM doubts concerning its efficacy of fetal heart rate monitoring in improving fetal outcome started to arise (Parer 2000). Fetal heart rate...
References: Impey, L. Obstetrics and Gynaecology (1999) Blackwell Science
Impey L; Reynolds M; MacQuillan K; Gates S; Murphy J; Sheil O (2003) Admission cardiotocography: a randomised controlled trial
Ramanathan Lindsay, P. (2004) Complications of the third stage of labour. In Henderson, C. and Macdonald, S. Mayes’ Midwifery. A textbook for midwives (13th Ed.) Edinburgh, Baillière Tindall, pp 987-1002.
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Nursing and Midwifery Council (2004b) Midwifes rules and Standards. London. Nursing and Midwifery Council.
McCormick, C (2003) The first stage of labour: Management In Fraser, m. and Cooper, A. Myles textbook for midwives (14th Ed.) Edinburgh. Elsevier, Churchill Livingston, pp 455-469
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