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Fetal Monitoring

fetal heart monitoring

Fetal monitoring occurs when trained care providers use tools to monitor and interpret the baby’s heartbeat during labor and birth.

This information helps to inform the decision whether or not to intervene in the birth process. 

What Are the Different Types of Fetal Monitoring?

Electronic Fetal Monitoring

Electronic fetal monitoring (EFM), also called cardiotocography (CTG), is when the baby’s heart rate is monitored with an ultrasound machine while the mother’s contractions are monitored with a pressure sensor (Alfirevic et al. 2017). Both of these sensors are linked to a recording machine, which shows a print-out or computer screen of the baby’s heart rate and the mother’s contractions shown together, often called EFM tracings. The monitor is assessing the baseline fetal heart rate and how it changes with contractions. It records any increases in the fetal heart rate (accelerations) and any decreases (decelerations), as well as the frequency and duration of the mother’s uterine contractions (Smith et al. 2016).

According to the Listening to Mothers III national survey, 89% of mothers who experienced labor in a U.S. hospital in 2011-2012 used EFM at some point during labor (Declercq et al. 2014).

Continuous Electronic Fetal Monitoring

Many hospitals routinely use continuous electronic fetal monitoring during labor. Among mothers who used EFM in the Listening to Mothers III survey, most described using it either continuously (60%) or for most of the time during labor (20%).

The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) in the U.S. recommends “initial and ongoing” assessment of EFM tracings (AWHONN, 2015). Some people interpret this language to mean that hospital staff should actually watch EFM tracings continuously. If the person giving birth has risk factors, then assessment and charting of the EFM tracings may be done as frequently as every 5-15 minutes. Monitors are also usually set to alarms, so staff are notified when the heart rate is abnormal or the monitor is not picking up the heart rate.

Mobile Electronic Fetal Monitoring

Some hospitals have wireless, waterproof electronic fetal monitors. Unlike traditional fetal monitors, some wireless monitors (like the Novii) are water resistant (can be used in the shower) or while the birthing person is laboring in upright, active positions away from a hospital bed.

Intermittent Electronic Fetal Monitoring

Intermittent means using something at regular time intervals, and not using it continuously. The Listening to Mothers III survey reports that for 23% of U.S. mothers, EFM is used only intermittently during labor or only for a short time after hospital admission as a baseline measure (Declercq et al. 2014). Intermittent electronic fetal monitoring, although fairly common, hardly has any research evidence backing its use. Some hospitals have their own definitions of intermittent EFM; however, we could not find any professional guidelines that recommend how to use intermittent EFM during labor.

Hands-On-Listening (Intermittent Auscultation)

Another fetal monitoring option is intermittent auscultation, which we call hands-on listening. With hands-on listening, the care provider listens to the fetal heart rate for short periods of time at regular intervals. They document the fetal heart rate, rhythm (regular or irregular), any fetal heart rate accelerations, and the depth, timing, and duration of any decelerations (Smith et al. 2016). While listening, the care provider also feels the mother’s contractions by placing a hand on the abdomen, and documents the frequency, duration, and intensity of the contractions.

Hands-on listening alone is used with about 11% of mothers giving birth in U.S. hospitals (Declercq et al. 2014), and is the primary method of checking fetal well-being at planned home births and freestanding birth centers. Most guidelines state that hands-on listening should be done for at least 60 seconds at a time, at least every 15-30 minutes during the active phase of the first stage of labor and at least 5-15 minutes during the pushing phase of the second stage of labor (ACNM 2015). The Society of Obstetricians and Gynecologists of Canada proposes that hands-on listening be done at first assessment and about every one hour during early labor (Liston et al. 2007). See the list of resources at the end of this article for links to several professional guidelines for hands-on listening protocols.

There are several different devices that can be used for hands-on listening during labor (Lewis et al. 2015); (Cascade 2018). The most popular option in the U.S. is probably the handheld fetal Doppler ultrasound device. The fetal Doppler detects the fetal heart motion and converts it to sound, which can be heard out loud. Dopplers can be audio-only or come with a digital display of the baby’s heartbeat. The features of the fetal Doppler include:

  • Comfortable for the mother
  • Everyone in the room can hear the fetal heart beat
  • Can be used in many different laboring positions
  • Can be used underwater
  • Allows for more personal space
  • Does not require wearing uncomfortable belts
  • May calculate and display fetal heart rate values

The drawbacks of the fetal Doppler are that it is costlier to purchase and maintain than some of the other options listed below, the probe is very sensitive to damage, and sometimes the Doppler may display the maternal heart rate instead of the baby’s, which can cause confusion.

Other options for hands-on listening include:

  • The Pinard fetal stethoscope the most common tool for hands-on listening used around the world. It is a hollow, horn-shaped tube made of wood or metal that amplifies sound waves carried from the fetal heart to one of the listener’s ears.
    • Pros: Inexpensive and available in most countries
    • Cons: May be uncomfortable for the mother, difficult to use in some laboring positions, and allows for listening with only one ear at a time
  • The DeLee fetal stethoscope has a bell-shaped end that amplifies sound waves from the fetal heart and carries them to both of the listener’s ears. The metal headband allows the listener to be hands-free.

    • Pros: Inexpensive and allows for listening with both ears
    • Cons: May be uncomfortable for the mother and difficult to use in some laboring positions
  • The Cascade Allen Type fetal stethoscope is a type of fetoscope that is popular with midwives in the U.S. It is similar to the DeLee fetal stethoscope in design but without the metal headband.
    • Pros: Inexpensive, allows for listening with both ears, and comes with the option of extra long tubing so that the mother can also listen to the fetal heart rate
    • Cons: May be uncomfortable for the mother and difficult to use in some laboring positions
  • The Leff fetal stethoscope is another fetoscope that is popular with midwives in the U.S. It has a weighted bell that enhances fetal heart tones and blocks external noise.
    • Pros: Best sound quality of the different fetoscopes, allows for listening with both ears, can be used underwater, and possible to use in many different laboring positions
    • Cons: More expensive than the other fetoscopes and may be uncomfortable for the mother
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