Intrapartum Fetal ST Analysis Clinical Guideline V4.2 ...€¦ · Intrapartum Fetal ST- Analysis Clinical Guideline V4.2 Page 5 of 16 most appropriate method for intrapartum fetal

Intrapartum Fetal ST- Analysis Clinical Guideline

V4.2

February 2020

Intrapartum Fetal ST- Analysis Clinical Guideline V4.2 Page 2 of 16

Summary

Prior to commencing ST- Analysis Exclude contraindications Consider overall clinical picture

Classify CTG as per FIGO

Normal – or evidence of sufficient fetal reserves to

respond to hypoxia (i.e. stable baseline and normal variability). Consider FBS if in doubt. Commence ST-analysis

Pre-terminal CTG

Delivery immediately

STAN event detected

Classify CTG as per

STAN

Normal CTG Ignore ST events

CTG intermediary or abnormal Check the type and magnitude of the ST event against the STAN CTG

classification to

Determine the significance of the ST event according to STAN guidelines

Significant ST events

Take action – this could be stopping oxytocin, giving

terbutaline maternal position change or immediate delivery

A significant ST event in the active second stage should prompt immediate delivery

Non-significant ST event

No action needs to be taken but consider the overall picture and

assess CTG trace every 60 minutes to exclude features of

fetal compromise


1. Aim/Purpose of this Guideline 1.1. This document gives guidance for obstetricians and midwives on the usage

and interpretation of ST Analysis (using a STAN monitor) of intrapartum fetal electrocardiotocography (ECG).

1.2. This guideline should be read in conjunction with the Royal Cornwall

Hospital Trust (RCHT) guidance: ‘Clinical Guideline for the use of Electronic Fetal Monitoring (EFM) in Labour, Fetal Blood Sampling (FBS) and Paired Cord Sampling’

1.3. ST Analysis is an adjunct for fetal cardiotocography (CTG) and must be

used in combination with the CTG. It provides guidance for intervention when there is an increased risk of fetal hypoxia and acidosis (NEW 2020).

1.4. A documented systematic assessment of the fetal and maternal condition,

including the CTG, should continue to be undertaken every 60 minutes, using the “Fresh Eyes” sticker (NEW 2020).

1.5. This version supersedes any previous versions of this document. 1.6. Data Protection Act 2018 (General Data Protection Regulation – GDPR)

Legislation

The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in.

DPA18 is applicable to all staff; this includes those working as contractors and providers of services.

For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team [email protected]

1.7. This guideline makes recommendations for women and people who are

pregnant. For simplicity of language the guideline uses the term women throughout, but this should be taken to also include people who do not identify as women but who are pregnant, in labour and in the postnatal period. When discussing with a person who does not identify as a woman please ask them their preferred pronouns and then ensure this is clearly documented in their notes to inform all health care professionals.

2. The Guidance 2.1. Definition and background

ST- analysis is an adjunct to cardiotocography (CTG) monitoring which aims to detect fetal hypoxia in order to aid the management of labour. STAN technology works by determining a normal baseline ECG for each individual fetus. It is important that the fetus still has the capacity to respond to hypoxia.

mailto:[email protected]


2.1.1. Analysing the CTG prior to and during ST-analysis is crucial. Fetal ECG refers to a graphic record of the electrical activity of myocardial cells. This reflects the oxygenation of the myocardium – this is a central fetal organ therefore indirectly provides information about the oxygenation of the fetal brain.

2.1.2. STAN specifically analyses T/QRS ratios and ST segment changes of fetal ECG complexes and produces 2 types of ST events: T/QRS events and Biphasic ST events.

2.1.3. Due to the analysis of ECG complexes, STAN provides continuous

information on fetal wellbeing throughout labour.

2.2. Who should be offered ST-analysis as an adjunct to CTG? 2.2.1. All women in labour who are at risk of developing fetal

hypoxia/acidosis may benefit from ST- analysis. Therefore, the indications for ST-analysis are the same as those for CTG monitoring – please refer to RCHT EFM Guideline as referenced above. Women should be counselled regarding the rationale for CTG/STAN usage, and its risks and limitations if appropriate.

2.2.2. The following are CONTRAINDICATIONS to the use of ST-analysis:

Maternal blood borne disease e.g. HIV, Hepatitis B, active herpes.

Prematurity <36+0.

Intact membranes. o The fetal scalp electrode should NOT be used to rupture

membranes, if artificial rupture of membranes (ARM) is indicated to commence ST analysis use an amnihook .

Suspicion of fetal bleeding disorder.

Prior to established labour.

Any contraindication to vaginal examination e.g. placenta praevia

Woman declines its use.

ST-analysis should not be commenced in ACTIVE second stage.

2.3 Commencing STAN 2.3.1. Having identified a significant risk of developing fetal hypoxia or

acidosis, ST-analysis should be commenced as early as possible, preferably while the CTG is normal.

2.3.2. The patient information card (See Appendix A) should be given to the mother to explain the reason for using ST-analysis. Her verbal consent to proceed once she has read the information should be documented in the woman’s notes (New 2019).

2.3.3. If the CTG classification is suspicious or pathological, if the fetal heart baseline is clearly determined and variability 5bpm or over, fetal hypoxia can be excluded and ST-analysis can be commenced.

2.3.4. After 20 minutes of CTG and/or at initiation of ST Analysis, complete

the “Initial cardiotocography assessment” sticker and place in the contemporaneous maternity record. A management plan indicating the


most appropriate method for intrapartum fetal monitoring is documented (New 2019)

2.3.5. The initial CTG should be assessed as per FIGO guidelines (please see RCHT EFM guideline). If the CTG is thought to reflect a hypoxic fetus, an FBS may be performed prior to starting ST-analysis. If the CTG is pre-terminal or if FBS is not possible then immediate delivery is indicated (see flow chart in Summary section of this guideline).

2.3.6. ST-analysis must not be started in the active 2nd stage labour.

2.3.7. If a STAN event occurs when the CTG is suspicious or pathological, the CTG should be interpreted using the modified FIGO guidelines as summarised below:


2.4. Electrode Placement: A specialised spiral fetal scalp electrode must be

applied:- 2.4.1. Avoid large areas of caput. 2.4.2. Hold the electrode firmly on the fetal presenting part and rotate

clockwise at least 1.25 turns. Resistance should then be felt on gentle traction.

2.4.3. Check the FSE is not applied to maternal tissue. Additionally a

reference electrode is placed on the mother’s thigh in order to differentiate maternal ECG waveforms.

2.4.4. Only use a STAN approved skin electrode. 2.4.5. Place on upper inner thigh. 2.4.6. Large muscle (e.g. quadriceps) can cause interference. 2.4.7. Use elasticated belts to hold the leg plate in place.

2.4.8. TENS machines also interfere with the ECG waveform and so

should be during ST-analysis.

2.5. STAN can be used in breech presentation with the safe application of the electrode.

BREECH MODE must be selected on the STAN monitor. 2.6. A tocodynamometer is placed abdominally to monitor contractions as in

normal CTG monitoring. 2.7. The STAN SCREEN

2.7.1. The STAN monitor displays the cardiotocograph in a similar way to standard CTG monitoring. Additionally, the channel below the


tocograph displays a series of black ‘x’s’ (see below). Each ‘x’ represents the analysis of 30 ECG complexes and therefore heartbeats.

2.7.2. At initial setup, the event log will report ‘Baseline T/QRS

determined’ after 20 crosses (this usually takes 4-5 minutes).

2.7.3. Signal quality should be considered poor in the following circumstances:

4 minutes of CTG without T/QRS complexes (‘x’)

Less than one T/QRS (‘x’) occurs in each 1 minute of the CTG. 2.7.4. In these circumstances, a STAN event may have been missed and

subsequent ST-analysis may be unreliable. 2.7.5. The CTG must then be classified using FIGO; if this is pathological,

action will be required even if there is no STAN event.

2.7.6. STAN will remember its initial assessment of the baseline fetal ECG for 2 hours and can be relied upon if adequate signal quality is re-obtained within this time period and the CTG has not been classified as pathological using FIGO.

2.7.7. The generation of STAN events relies on the ability of the fetus to

respond to hypoxia. In severe cases, this ability may be compromised and so a further STAN event may not be generated. This highlights the importance of not ignoring STAN events or periods of poor signal.

2.8. STAN Events

Significant STAN events are generated by the monitors and reported as black boxes on the CTG monitor (along with an audible ‘beep’). STAN events are of 3 types – episodic T/QRS rise, baseline T/QRS rise and biphasic ST. The significance of these events must be determined within the context of the CTG classification as detailed below:

2.8.1. If a significant STAN event occurs, intervention is required. Escalate


care to the Delivery Suite coordinator and the obstetrician (New 2019) This will usually involve improving the fetal environment by changing maternal position, reducing the strength/ frequency of uterine contractions (stopping or reducing oxytocin and/or administering subcuticular terbutaline), or administering IV fluids.

2.8.2. If, despite appropriate intervention, the CTG does not promptly

improve, delivery is indicated. The timing of delivery is dependent upon the whole clinical picture; this will determine whether it is a Category 1 or Category 2 delivery.

2.8.3. During the active second stage of labour, the intervention will usually

be delivery of the baby, unless spontaneous delivery is anticipated within the next 5-10 minutes. Non-significant ST events in 2nd stage do not warrant delivery of the baby.

2.8.4. If a pathological CTG persists beyond 60 minutes in active second

stage, then delivery should be achieved even without ST events occurring, unless spontaneous delivery is anticipated within the next 10 minutes. This is because fetal hypoxia or acidosis may develop rapidly during prolonged active second stage.

2.8.5. STAN events may occur in the presence of a NORMAL CTG. These

represent the normal physiological adaption of the fetus to the stresses of labour and should not be acted upon outside the context of standard CTG interpretation.

2.8.6. In cases of maternal pyrexia/suspected chorioamnionitis, it is

important to remember that hypoxia is not the only pathway to brain damage. Also, a co-existing infection may enhance the damaging effects of hypoxia on the fetal brain.

2.8.7. In the presence of suspected chorioamnionitis, any ST event is

significant, unless the CTG is normal.

2.9. Documentation 2.9.1. The patient history should be recorded in the Event Log on the

MOSOS electronic system. All these entries are identifiable by the unique code for each staff member on the STAN monitor. This log should be updated with any significant intrapartum events.

2.9.2. Any STAN events must be recorded in the maternal intrapartum

notes, along with a CTG classification and what action (if any) is taken.

2.9.3. The STAN CTG Identifier number (e.g. 1RC00001) must be

recorded in the maternal notes on the initial CTG assessment sticker and in the MOSOS event log at commencement of STAN.

2.10.Troubleshooting lack of signal

2.10.1. Inspect the information window for messages.


2.10.2. Check whether normal fetal ECG complexes can be seen on the screen.

2.10.3. Make sure the maternal skin electrode is properly applied.

2.10.4. Check the scalp electrode is attached to the fetal scalp (not the

cervix) and not loose. If necessary apply a new electrode.

2.10.5. If a STAN signal cannot be obtained, the monitor can still be used for CTG only.

2.11. Removal of Fetal Scalp Electrode (FSE) (NEW 2020)

2.11.1. Remove the FSE lead from the legplate connection.

2.11.2. Remove the spiral needle by grasping the hub (which houses the

electrode) or the electrode wires as close as possible to the fetal scalp

and rotating counter-clockwise.

DO NOT apply forceful downward pressure to remove the spiral or pull

the wires apart as a means to rotate counter-clockwise.

2.11.3. Inspect the spiral needle tip to ensure that it is intact and is still attached

to the hub. Document that it is intact on E3.

Escalate to the neonatal team if the spiral is not intact or if there are any

concerns about the site of FSE insertion.

3. Monitoring compliance and effectiveness Element to be monitored

Is the rationale for commencing appropriate

Are appropriate interventions undertaken and accordance with STAN guideline

If the trace was assessed as being intermediary or abnormal was the plan of care and action taken documented in the maternal notes

Lead Fetal monitoring lead midwife

Tool Is the rationale for commencing appropriate

Are appropriate interventions undertaken and accordance with STAN guideline

If the trace was assessed as being intermediary or abnormal was the plan of care and action taken documented in the maternal notes

Audit and review Tool using patient documentation.

Frequency Annually - 1% or 10 sets, whichever the greatest, of all health records of women who have had FBS, EFM and paired cord sampling

Annually - 1% or 10 sets, whichever the greater, of all health records of women where there has been concern about the baby in labour, or immediately following birth, in whom paired cord sampling only has been undertaken


Reporting arrangements

Maternity Patient Safety Forum

Acting on recommendations and Lead(s)

Any deficiencies identified at Patient Safety meetings will be discussed at the Patient Safety Forum and an action plan developed

Action leads will be identified and a time frame for the action to be completed by

The action plan will be monitored by the Maternity Patient Safety Forum or Clinical Audit Forum until all actions complete

Change in practice and lessons to be shared

Required changes to practice will be identified and actioned within a time frame agreed on the action plan

The fetal monitoring lead midwife takes each change forward where appropriate

The results of the audits will be distributed to all staff through the Patient Safety Newsletter or Practice Development newsletter and Clinical Audit Forum as per the action plan

4. Equality and Diversity

4.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

4.2. Equality Impact Assessment The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Intrapartum Fetal ST- Analysis Clinical Guideline V4.2

Date Issued/Approved: February 2020

Date Valid From: February 2020

Date Valid To: June 2022

Directorate / Department responsible (author/owner):

Sally Budgen, Fetal Monitoring Midwife

Contact details: 01872 25 23 61

Brief summary of contents

This document gives guidance for obstetricians and midwives on the usage and interpretation of ST Analysis (using a STAN monitor) of intrapartum fetal electrocardiotocography

Suggested Keywords: CTG, EFM, monitoring, FBS, cord, labour, NICE fetal, blood, sampling, labour, paired, trace

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Date revised: February 2020

This document replaces (exact title of previous version):

Intrapartum Fetal ST-Analysis Clinical Guideline V4.1

Approval route (names of committees)/consultation:

Maternity Guidelines Group Care Group Board PRG

Care Group General Manager confirming approval processes

Debra Shields

Name and Post Title of additional signatories

Not required

Name and Signature of Care Group/Directorate Governance Lead confirming approval by specialty and care group management meetings

{Original Copy Signed}

Name: Caroline Amukusana

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only


Document Library Folder/Sub Folder Clinical / Midwifery and Obstetrics

Links to key external standards CNST 2.3 and 2.4

Related Documents:

References: 1. The Physiology of Fetal Surveillance

(The Green Book of Neoventa Part1) K Rosen & Annika Martendal 2014 Neoventa Medical

2. STAN: An introduction to its use, limitations and caveats. Edwin Chandraharan 2010 www.neoventa.com

3. Townsend R & Chandraharan E. Fetal ECG (ST analysis); An evolving standard for intrapartum fetal surveillance. Chapter in: Current Progress in Obstetrics and Gynaecology, 2015.

4. Saving Babies’ Lives Version Two A care bundle for reducing perinatal mortality NHS England, March 2019

Training Need Identified? Yes – All staff providing intrapartum care will complete the recognised STAN training and competency assessment.

Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job Title)

9/1/2017 V1.0 Initial Issue

Sally Budgen Senior Midwife, fetal monitoring Richard Keedwell, Obs & Gynae Speciality Registrar

10/1/2019 V2.0

2.3.3 Addition of the CTG sticker and management plan. 2.9.1 Addition of the event log on MOSOS 2.9.4 Recording of the STAN identifier number in the MOSOS event log.

Sally Budgen Senior Midwife, fetal monitoring

6th June 2019

V3.0

2.3.2 To include patient information leaflet and documented evidence of informed verbal consent 2.8.1 Addition of escalation of care, in line with Saving Babies’ Lives Bundle V2

Sally Budgen Fetal Monitoring Lead Midwife

December 2019

V3.1 Flow Chart updated Sally Budgen Fetal Monitoring Lead Midwife


January 2020

V4.1 Following Datixed trauma to fetal scalp Removal of FSE

Sally Budgen Fetal Monitoring Lead Midwife

February 2020

V4.2 Change to “Fresh Eyes” timings Sally Budgen Fetal Monitoring Lead Midwife

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the express permission of the author or their Line Manager.


Appendix 2. Initial Equality Impact Assessment Form

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Unsure Rationale for Assessment / Existing Evidence

Age X

Name of the strategy / policy /proposal / service function to be assessed: Intrapartum Fetal ST-Analysis Clinical Guideline V4.2

Directorate and service area: Obs and Gynae

New or existing document: Existing

Name of individual completing assessment: Sally Budgen

Telephone: 018722525361

1. Policy Aim* Who is the strategy / policy / proposal / service function aimed at?

The aim of this guideline is guidance for obstetricians and midwives on the usage and interpretation of ST Analysis (using a STAN monitor) of intrapartum fetal electrocardiotocography.

2. Policy Objectives*

Early detection of fetal hypoxia by the usage and interpretation of ST Analysis (using a STAN monitor) of intrapartum fetal electrocardiotocography and the appropriate management

3. Policy – intended Outcomes*

Improved outcome for the new born baby

4. *How will you measure the outcome?

Compliance monitoring tool

5. Who is intended to benefit from the policy?

All pregnant women

6a Who did you consult with b). Please identify the groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

x

Maternity Guidelines Group Board for noting PRG

What was the outcome of the consultation?

Guidelines agreed

7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step.


Sex (male,

female, trans-gender / gender reassignment)

X

Race / Ethnic communities /groups

X

Disability - Learning disability, physical impairment, sensory impairment, mental health conditions and some long term health conditions.

X

Religion / other beliefs

X

Marriage and Civil partnership

X

Pregnancy and maternity

X

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian

X

You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major this relates to service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No x

9. If you are not recommending a Full Impact assessment please explain why.

Not indicated

Date of completion and submission

December 2019 Members approving screening assessment

Policy Review Group (PRG) ‘APPROVED’

This EIA will not be uploaded to the Trust website without the approval of the Policy Review Group. A summary of the results will be published on the Trust’s web site.


Appendix 3.