NICE CTG Guidelines for Intrapartum Monitoring
Important Note on Available Evidence
The evidence provided does not contain NICE (National Institute for Health and Care Excellence) specific guidelines. The available evidence primarily reflects American College of Obstetricians and Gynecologists (ACOG) and American Academy of Family Physicians (AAFP) recommendations using the three-tier classification system (Category I, II, III), rather than NICE's classification approach 1, 2, 3.
CTG Classification Systems
Three-Tier System (ACOG/AAFP - Not NICE)
The available guidelines use a three-category system rather than NICE's approach:
Category I (Normal):
- Predictive of normal fetal acid-base status
- No specific intervention required beyond routine monitoring 3
Category II (Indeterminate):
- Represents more than 50% of all fetal monitoring strips
- Falls between normal and abnormal patterns
- Requires increased surveillance and potential interventions but not necessarily immediate delivery 3
- Includes baseline FHR changes, minimal or absent variability, absence of accelerations, and periodic or episodic decelerations 3
Category III (Abnormal):
- Characterized by absent baseline variability with recurrent late decelerations
- Predicts current or impending fetal asphyxia
- Requires immediate intervention 1, 2
Management Algorithm for Abnormal Tracings
Category III (Abnormal) Management
Immediate first-line intervention: Stop oxytocin infusion - this is the priority action before any other measures, as it addresses uterine hyperstimulation causing uteroplacental insufficiency 1.
Simultaneous resuscitative measures:
- Change maternal position to left lateral to relieve cord compression and improve uteroplacental blood flow 1
- Administer oxygen at 6-10 L/min via face mask 1
- Perform vaginal examination to assess for rapid descent, cord prolapse, or other complications 1
- Check maternal vital signs to identify hypotension or contributing factors 2
- Establish or increase IV fluid administration with physiologic electrolyte solutions 2
Assessment and delivery decision:
- Continuous monitoring after stopping oxytocin is crucial to assess response 1
- If tracing improves, labor may continue with close monitoring 1
- If tracing remains abnormal despite interventions, expedite delivery via operative vaginal delivery or cesarean section 1, 2
Category II (Indeterminate) Management
Initial interventions:
- Consider discontinuing oxytocin if being administered 3
- Perform vaginal examination 3
- Check maternal vital signs 3
- Administer oxygen 3
- Change maternal position 3
- Provide intravenous fluids 3
Assessment:
- Assess fetal pH with acoustic or fetal scalp stimulation to further evaluate fetal status 3
- Consider potential need to expedite delivery if abnormalities persist or worsen 3
Critical Management Pitfalls to Avoid
Do not use fetal scalp stimulation or acoustic stimulation as a substitute for delivery when late decelerations are present - these are temporizing measures for equivocal tracings, not established fetal compromise 2.
Do not continue oxytocin when Category III patterns are present - this worsens uterine hyperstimulation and further compromises uteroplacental blood flow 1, 2.
Do not perform amniotomy in the presence of late decelerations - this could worsen uteroplacental insufficiency 2.
Monitoring Frequency for High-Risk Pregnancies
For Category II patterns with additional risk factors:
- Weekly CTG testing after viability for Category II without absent/reversed end-diastolic velocity 3
- Increase to twice weekly or more when accompanied by fetal growth restriction 3
- For abnormal umbilical artery Doppler, perform CTG at least weekly 3
Evidence Quality Considerations
The positive predictive value of CTG for intrapartum fetal hypoxia is approximately only 30%, with a false-positive rate of 60% 4. Despite this limitation, CTG remains the most commonly employed tool for intrapartum surveillance worldwide 5. The use of admission CTG for low-risk women is likely associated with a 20% increase in caesarean section rates without evidence of benefit 6.