Fetal surveillance modalities in labour — structured SAQ (15 marks)

(a) Case A — recommended monitoring, criteria and technique (5 marks)

One mark for the recommendation, one for the criteria, two for the technique, one for the frequency. ^[1][2]

Recommendation: intermittent auscultation, with a hand-held Doppler or Pinard stethoscope, in the context of one-to-one midwifery care. She may use the birth pool and remain mobile.^[1][2]

Criteria that make it appropriate — all must hold: ^[1][2]

• No antenatal or intrapartum risk factors.
• Cephalic presentation with normal fetal growth and liquor volume.
• Normal uterine activity and normal resting tone.
• Fetal heart rate 110 to 160 bpm, regular rhythm, no decelerations heard.^[1]

Technique: ^[1][7]

• Palpate the abdomen first to confirm lie, position, presentation and descent.
• Palpate the contraction — onset, duration, frequency, strength and resting tone.
• Auscultate immediately after a contraction so the fetal heart rate response to it is captured.
• Count for one full minute.
• Palpate the maternal pulse simultaneously to confirm the rate is fetal.
• Document as a single number, plus any accelerations, decelerations, irregular rhythm or change from the previous value.^[1][7]

Frequency: every 15 to 30 minutes in the active first stage; after every contraction, or at least every 5 minutes, in the active second stage.^[1][2]

(b) Case A — triggers to convert to continuous CTG (3 marks)

One mark per group of three correct triggers. ^[1][2]

• From auscultation itself: a rate outside 110 to 160 bpm; decelerations heard; an irregular rhythm; a significant change from the previous documented rate.
• New intrapartum risk factors: oxytocin augmentation, regional analgesia, meconium-stained liquor, maternal pyrexia above 38 degrees Celsius, clinical chorioamnionitis, bleeding in labour, tachysystole or hypertonus, prolonged first or second stage, unstable maternal circulation.
• Loss of the preconditions: malpresentation identified, suspected growth restriction, or the woman no longer receiving one-to-one care.^[1][2]

If the CTG is normal after 20 minutes and the trigger has resolved, returning to intermittent auscultation is reasonable. ^[1]

(c) Case B — the inadequate trace (5 marks)

One mark for the systematic troubleshooting, one for confirming the signal is fetal, one for naming the escalation, one for prerequisites, one for contraindications. ^[1][4]

Troubleshoot first: ^[1][7]

• Check and monitor the maternal pulse — an inadequate trace and maternal heart rate contamination often travel together.^[7]
• Re-palpate the abdomen and reposition the ultrasound transducer over the fetal back, and reposition the tocodynamometer.
• Consider wireless or beltless technology if available.
• Never document an unreadable trace as normal — an uninterpretable trace is an abnormal finding, and in a woman on oxytocin it demands a decision.^[1]

Escalate to a fetal scalp electrode. Indicated when external monitoring cannot give a continuous trace or when baseline variability cannot be assessed.^[1]

Prerequisites: ruptured membranes, adequate cervical dilatation, and relative certainty about the position of the presenting part so the electrode is not placed on a fontanelle, suture, eye, face or genitalia.^[1]

Contraindications — the same list as fetal blood sampling: maternal HIV, hepatitis B or hepatitis C; active genital herpes lesions; suspected intrauterine sepsis; known or suspected fetal bleeding disorder or thrombocytopenia. Group B streptococcus colonisation is not a contraindication, so it does not stop you here.^[1][5]

Consent and counsel: absolute neonatal risk is low — scalp injury 1.2% versus 0.9% and cephalohaematoma 1.0% versus 0.9% in a large cohort — and the device should be used when clinically indicated.^[4]

(d) Case B — explaining why she cannot walk (2 marks)

One mark for an honest explanation of the trade-off, one for offering a solution rather than a refusal. ^[3][6]

• Be honest about the reason: "She is on a drip to strengthen contractions and has an epidural, so we recommend watching the baby's heartbeat continuously. Continuous monitoring roughly halves the risk of newborn seizures, but it does not reduce cerebral palsy and it does increase the chance of a caesarean — so it is a genuine trade-off, not a rule."^[3]
• Offer the solution: "The reason she is in bed is the cables, not the monitoring. If we have a wireless monitor available I will get it, and she can stand, kneel or walk. If we do not have one, I will make sure she can change position freely and I will keep reviewing whether she still needs continuous monitoring."^[6]
• Document the discussion and her preference.^[1]