INTRAPARTUM:

Vaginal Bleeding	Placental abruption is associated with an increased risk of death and cerebral palsy.0701 Clearly when placental abruption occurs there is an indication for caesarean section.
Intrauterine Infection	Maternal pyrexia alone has been shown to be associated with an increased risk of neonatal encephalopathy9501 9802 and cerebral palsy.9701, 0501
Meconium Staining of the Liquor	Meconium-stained liquor was found to be associated with an increased risk of cerebral palsy0702 anddeath.0002 Meconium-stained liquor is a significant risk factor for neonatal encephalopathy.9501
Post-term Pregnancy	There was an increase in the rate of neonatal encephalopathy with rising gestation after 39 weeks.9801 Furthermore, there was a rise in perinatal death rate from 41 weeks.9803 Recent data have suggested that the risks of stillbirth increases from 1 per 3000 continuing pregnancies at 37 weeks, to 3 per 3000 continuing pregnancies at 42 weeks, to 6 per 3000 continuing pregnancies at 43 weeks. A similar increase in neonatal mortality is also reported.9803
Prolonged Membrane rupture	Prolonged rupture of the membranes has been reported to be associated with an increased risk of death and cerebral palsy particularly with increasing prematurity.9803
Induction and Augmentation of Labour	If induction or augmentation of labour is undertaken with oxytocin there is a significant risk of hypercontractility and EFM should be used. RCOG
Previous Caesarean Section	The rate of spontaneous scar dehiscence with a previous caesarean section is 0.3?0.7%. This may present with a variety of warning signs, including poor progress in labour, scar tenderness, vaginal bleeding or FHR abnormality. The RCOGtherefore recommends ?attentive intrapartum fetal an maternal surveillance in a setting where the baby can be delivered within 30 minutes?.
Augmented labour; Hypertonic uterus; Suspicious fetal heart rate on auscultation.	EFM has not been extensively and prospectively evaluated with respect to individual risk factors. Furthermore, the systematic reviews and the constituent trials do not contain sufficient participants to allow a subgroup analysis with respect to individual indications even if those data were provided.

 

Both the maternal notes and CTG are continuous records of intrapartum events. It is imperative that any events occurring during labour that may affect FHR are contemporaneously noted in both these records. These include change in maternal position, vaginal examination and administration of drugs. The notes should be timed, dated and signed. If intermittent auscultation is being used then details of the features of FHR should be recorded contemporaneously in the maternal notes, together with any other intrapartum events that might affect the FHR.

There should be established paths of communication to allow concerns regarding intrapartum FHR traces to be dealt with effectively there should be established guidelines for communicating the urgency of situations and decisions about fetal wellbeing on an interprofessional level, to avoid unwarranted delays.

There is debate about the value of intrapartum electronic fetal monitoring. At one extreme,

Natale and Dodman

⁰³⁰¹  believe, that as practitioners of and investigators in fetal health surveillance, that there is not good supporting evidence for recommending continuous intrapartum EFM for pregnancies in which there is an increased risk of perinatal death, cerebral palsy, or neonatal encephalopathy, or when oxytocin is being used for induction of labour, and that if we recommend that the fetal heart be electronically monitored while the nurse is elsewhere, we are on a slippery slope. Difficulty would arise, however, when there is an unfavourable outcome and frequently accepted indications for electronic fetal monitoring have been ignored.