What is fetal heart rate monitoring?

During labour, contractions cause the blood flow to the placenta to be reduced. This is normal and most babies cope with this without any problems. However, heart rate monitoring can help to detect problems, and show if a baby is struggling to cope (if the heart rate slows down for example).

A baby's heart rate can be monitored in various ways, either at regular intervals (intermittent auscultation) or continuously (electronic fetal monitoring).

Intermittent auscultation can be done with a Pinard stethoscope, which is trumpet shaped and allows the treating midwife or doctor to listen to the baby's heart rate through the abdomen, or hand held Doppler, which is an ultrasound device which looks like a microphone and again allows the baby's heart beat to be heard through the abdomen.

Intermittent monitoring heart rate will be recommended if the mother is healthy and has had a problem free pregnancy.

Continuous electronic fetal heart rate monitoring (EFM) keeps track of the baby's heart rate for the entirety of the labour. This is done using a cardiotocograph machine (CTG). Sensors, which detect the baby's heart rate, are secured to the abdomen. The sensors are in turn connected to a monitor and the baby's heart rate is recorded as a pattern on a strip of paper (called a 'trace'). The frequency of contractions is also recorded. The treating midwife or doctor will read and interpret the CTG trace. Wireless monitoring, known as telemetry, may also be offered.

Continuous monitoring may be recommended for a number of reasons, including if there has been a change in the baby's heart rate during intermittent monitoring or if the mother has health problems, such as diabetes or high blood pressure. It may also be suggested if the mother has experienced complications during the current or previous pregnancies, such as a high temperature, a previous caesarean section or if the baby is small, premature, or in the breech position.

A more invasive type of heart beat monitoring can be done whereby a small clip is attached to the unborn baby's scalp. The waters around the baby need to have been broken before this can be used.

The NHS Report and its findings

The report ('The Early Notification scheme progress report: collaboration and improved experience for families[1]) provides an overview of the 'early notification scheme'. The scheme was launched in 2017 as a national programme for the early reporting to NHS Resolution (which manages claims for compensation on behalf of the NHS) of infants born with a potential severe brain injury following term labour.

The scheme aims to "support the stated government priorities to halve the rate of stillbirth, neonatal death and brain injury and improve the safety of maternity care…" by 2025.

Amongst its findings, the report identifies that there were problems with checking fetal heart rates during labour in 70% of cases and, in cases where this was a factor, it resulted in an adverse outcome for the infant in 84% of cases. In addition, 63% of cases reported had two or more adverse factors involving fetal heart rate monitoring. The problems surrounding fetal heart rate monitoring included delays in acting on an abnormal CTG or abnormal fetal heart on intermittent auscultation (51.7%) and delays in escalation (44.6%).

What recommendations does the report make?

The report highlights that urgent research is needed to develop a "standardised approach" to monitoring fetal heart rates and recognises that interpreting and reacting to a CTG trace involves individuals from multiple disciplines. It takes place in stages and in a highly pressurised environment. As a result of this the report acknowledges that this may be why previously "purely technical interventions and individual-based training have not fully addressed these challenges".

The report emphasises that human factors, such as communication and timely decision-making, are as vital as the technical interpretation of the trace itself.

Failures to take appropriate action in relation to dangerous changes in fetal heart rate can result in life-changing injuries, including cerebral palsy, and may give rise to clinical negligence claims. These claims can take many years to conclude and can cost the NHS millions highlighting that research into the current fetal monitoring practices in England, and guidance on how to make them more consistent, is urgently required to ensure safer practice.

[1] https://resolution.nhs.uk/wp-content/uploads/2019/09/NHS-Resolution-Early-Notification-report.pdf