Institutional protocols for fetal heart monitoring (FHM) prior to cesarean birth should be based on maternal-fetal risk status and whether the surgery is scheduled or unscheduled. When cesarean birth is unscheduled, guidelines are based on the type of monitoring method used prior to entering the surgical suite (American Academy of Pediatrics [AAP] & American College of Obstetricians and Gynecologists [ACOG], 2012).

Planned Cesarean Birth

There are insufficient data to support routine electronic fetal monitoring (EFM) prior to surgery in low-risk women admitted to the hospital for planned cesarean birth (AAP & ACOG, 2012). The fetal heart rate (FHR) should be assessed and documented prior to surgery (AAP & ACOG). Although most institutions in the United States require EFM for admission assessment of fetal status, guidance from AAP and ACOG and the Association of Women's Health, Obstetric, and Neonatal Nurses ([AWHONN], 2011) allows for the use of a fetoscope, handheld Doppler, or EFM as methods for fetal evaluation. When using a handheld device, documentation of FHR should include baseline rate, presence of increases or decreases, and whether the rhythm is regular or irregular (AWHONN). Because absence of fetal well-being prior to birth has repercussions for the baby's condition at birth and can guide planning for the neonatal care team (AWHONN), any abnormal FHR findings on intermittent auscultation should be evaluated further with use of EFM. Once a reactive FHR tracing is confirmed, low-risk women in these circumstances may not require continuous EFM.

Guidance is less clear for women with maternal or fetal risk factors presenting for scheduled cesarean birth. If the woman has been managed expectantly on an outpatient basis with weekly or twice weekly antepartum testing, including fetal nonstress testing, it may be reasonable to assess these women on admission with EFM, and discontinue monitoring once a reactive FHR tracing is obtained. If the woman has been hospitalized for the high-risk condition, monitoring should continue based on risk status and provider orders.

Unplanned Cesarean Birth

When cesarean birth is unplanned, fetal surveillance should continue in the surgical suite until the abdominal preparation has begun. If an external ultrasound device is being used, surveillance should continue until its removal is required for sterile abdominal preparation. If in internal fetal scalp electrode is in place, fetal surveillance should continue until the sterile preparation is completed (AAP & ACOG, 2012).

Administration of Anesthesia

Although evidence suggests that administration of anesthesia affects the FHR pattern and characteristics, there are insufficient data to support continuous EFM during administration of regional anesthesia as a means to prevent adverse neonatal outcomes (American Society of Anesthesiologists [ASA], 2007). The ASA recommends continuous monitoring when possible, but recognizes that this may not be feasible in all clinical situations or scenarios. The FHR should be assessed before and after administration of regional anesthesia (ASA, 2007). The FHR may be assessed in the patient's room just prior to entering the surgical suite. No guidance is offered for FHM during administration of general anesthesia. Because general anesthesia has been associated with lower Apgar scores and may increase maternal and neonatal complications (ASA, 2007), monitoring should continue in the surgical suite for as long as possible prior to the start of surgery. The neonatal resuscitation team should be aware of the type of anesthesia used.

Clinicians should be familiar with guidelines for cesarean birth from AAP and ACOG (2012), ASA (2007), and AWHONN (2011), and incorporate them into clinical practice. It is acknowledged that EFM is commonly used prior to planned cesarean birth; however, consider that other methods of fetal assessment such as a handheld Doppler are reasonable available options.

References