Indications

• prolonged, augmented or induced labours
• multiple pregnancies
• thick meconium staining of amniotic fluid
• growth retardation
• preterm fetus
• audible heart rate decelerations
• during the trial of a caesarian scar
• patient preference
• medicolegal indications:
  • the trace provides a permanent record which may help to show that any complications of labour were neither preventable nor predictable

NICE guidance is summarised below (1):

Indications for continuous cardiotocography monitoring in labour

• antenatal risk factors
  • offer continuous cardiotocography (CTG) monitoring to women in labour if it is in their personalised care plan
  • offer continuous CTG monitoring for women in labour who have any of the following antenatal maternal risk factors:
    • previous caesarean birth or other full thickness uterine scar
    • any hypertensive disorder needing medication
    • prolonged ruptured membranes (but women who are already in established labour at 24 hours after their membranes ruptured do not need CTG unless there are other concerns)
    • any vaginal blood loss other than a show
    • suspected chorioamnionitis or maternal sepsis
    • pre-existing diabetes (type 1 or type 2) and gestational diabetes requiring medication
  • offer continuous CTG monitoring for women in labour who have any of the following antenatal fetal risk factors:
    • non-cephalic presentation (including breech, transverse, oblique and cord), including while a decision is made about mode of birth
    • fetal growth restriction (estimated fetal weight below 3rd centile)
    • small for gestational age (estimated fetal weight below 10th centile) with other high-risk features such as abnormal doppler scan results, reduced liquor volume or reduced growth velocity
    • advanced gestational age (more than 42+0 weeks at the onset of established labour)
    • anhydramnios or polyhydramnios
    • reduced fetal movements before the onset of contractions
  • consider continuous CTG monitoring if, based on clinical assessment and multidisciplinary review, there are concerns about other antenatal factors not listed above that may lead to fetal compromise
    
    
• ongoing risk assessment
  • carry out a full assessment of the woman and her baby every hour. At each assessment include:
    • maternal antenatal risk factors for fetal compromise
    • fetal antenatal risk factors for fetal compromise
    • new or developing intrapartum risk factors
    • progress in labour including characteristics of contractions (frequency, strength and duration)
    • fetal heart rate monitoring, including changes to the fetal heart rate pattern
      • discuss with the woman any changes identified since the last review, and the implications of these changes. Include birthing companion(s) in these discussions if appropriate and if that is what the woman wants
    • obtain an in-person review of every hourly assessment by another clinician ("fresh eyes") for women on CTG, to be completed before the next assessment takes place
      
      
• intrapartum risk factors
  • be aware that intrapartum risk factors may increase the risk of fetal compromise, and that intrapartum risk factors that develop as labour progresses are particularly concerning
  • offer continuous CTG monitoring for women who have or develop any of the following new intrapartum risk factors:
    • contractions that last longer than 2 minutes, or 5 or more contractions in 10 minutes
    • the presence meconium
    • maternal pyrexia (a temperature of 38 degrees C or above on a single reading or 37.5 degrees C or above on 2 consecutive occasions 1 hour apart)
    • suspected chorioamnionitis or sepsis
    • pain reported by the woman that appears, based on her description or her previous experience, to differ from the pain normally associated with contractions
    • fresh vaginal bleeding that develops in labour
    • blood-stained liquor not associated with vaginal examination, that is likely to be uterine in origin (and may indicate suspected antepartum haemorrhage)
    • maternal pulse over 120 beats a minute on 2 occasions 30 minutes apart
    • severe hypertension (a single reading of either systolic blood pressure of 160 mmHg or more or diastolic blood pressure of 110 mmHg or more, measured between contractions)
    • hypertension (either systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90 mmHg or more on 2 consecutive readings taken 30 minutes apart, measured between contractions)
    • a reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure (140 mmHg or more) or raised diastolic blood pressure (90 mmHg or more)
    • confirmed delay in the first or second stage of labour
    • insertion of regional analgesia (for example, an epidural)
    • use of oxytocin
  • consider continuous CTG monitoring if, based on clinical assessment and multidisciplinary review, there are concerns about other intrapartum factors not listed above that may lead to fetal compromise

Reference:

1. NICE (December 2022). Fetal monitoring in labour