Appendix 4 Fetal Surveillance – Intrauterine Pressure Catheter Insertion External Cardiotogography (CTG) provides an objective record of the frequency and duration of contractions however the tracing can be interrupted by maternal movement or difficult to capture due to maternal habitus. An intrauterine pressure catheter (IUPC) provides a quantifiable measure of uterine activity where clinically indicated. Indications for use For direct measurement of uterine contractions including: inability to monitor contractions well enough to assess timing of decelerations inability to monitor frequency of contractions as in the obese patient evaluation of contraction strength if patient’s labor process fails to progress. Requirements include the following: confirmed rupture of membranes (spontaneous or artificial) engaged vertex presenting part cervical dilatation of at least 1-2cm patient’s consent and ability to cooperate with sterile vaginal examination Contraindications Contraindications for use include the following: diagnosed or suspected placenta praevia undiagnosed vaginal bleeding non-rupture of amniotic membranes maternal infection (chorioamnionitis, active genital herpes, HIV) non-vertex fetal presentation any condition that precludes vaginal delivery Issues to Consider Potential complications for consideration infection postpartum endomyometritis uterine perforation umbilical core perforation CPP0487-Fetal Surveillance May 2019 cord entanglement extra-membranous catheter placement leading to complications (e.g. placental abruption, fetal distress, disseminated intravascular coagulation, and rarely anaphylactoid syndrome) Considerations To be discussed with the consultant on call and only inserted by senior registrar or consultant who is experienced in the procedure The intrauterine pressure catheter (IUPC) should not be left in situ for longer than 24 hours. Prior to attempting insertion the manufacturer’s product instructions should be read - different companies may have product insertion variations. Intrauterine pressure recordings vary according to site of where the recording is taken from – higher amplitude is found in the fundus, decreasing in the middle portion of the uterus, and further decreases in the lower portion near the cervix. The presence of thick meconium may cause inaccurate readings of amplitude of the contractions Prior to insertion of an IUPC placental localisation should be found to decrease risk of extra-ovular placement. IUPC insertion should be administered without any force or resistance The IUPC is for single item use only. Ensure the catheter, cable and CTG monitor are compatible before insertion Equipment Sterile pelvic pack Intrauterine pressure catheter pack and 1 ml syringe Lubricating gel (sterile) CTG monitor Adhesive tape, optional Detailed Steps, Procedures and Actions Preparation 1. Senior registrar in consultation with consultant on call reviews client and assesses suitability for IUPC including checking/confirming the position of the placenta. 2. Explain procedure risks and indications to client and obtain verbal consent. Review the manufacturer’s instructions in or on the packaging regarding the IUPC insertion. CPP0487-Fetal Surveillance May 2019 3. Position the woman in the lithotomy position with a wedge under the buttock or lower back to prevent aorto-caval compression. 4. Plug the reusable interconnect cable into the pressure monitoring connector on the CTG monitor. 5. Ensure the amnioport caps are firmly in place on the IUPC. Procedure 1. Using an aseptic technique, remove the catheter from the package. 2. Zero the system if required according to the manufacturer’s instructions.For true zero, ensure catherter is disconnected from cable/connector and zero monitor 3. Perform a vaginal examination to ensure adequate cervical dilatation and confirm rupture of the membranes. The optimal position for IUPC placement can be determined by using the index finger to palpate the presenting part. 4. Insert the introducer and catheter into the vagina and to the cervical os. Do not advance the introducer through the cervix. 5. Attempt to insert the catheter opposite to the placental site. 6. Gently advance the catheter into the uterus according to manufacturer’s instructions. Placement of the catheter in the amniotic space can be determined by visualising amniotic fluid in the opaque tubing of the catheter. Evidence of blood indicates extra-ovular placement of the catheter. Forced insertion may result in fetal or maternal injury, maternal discomfort, or malfunction. 7. If resistance is met at any time during insertion pull the catheter tip back to the introducer and alter the direction of the catheter by changing direction of the introducer and then determine an alternative position for placement and proceed. 8. Remove the introducer by gently sliding back out of the vagina according to the manufacturer’s instructions. 9. Secure the catheter to the woman’s leg. The catheter should be secured as close as possible to the introitus to prevent the catheter from working its way out of the uterus when it is flexed. 10. Zero the CTG monitor if required according to instructions and connect the catheter to the cable according to instructions. 11. Instruct the woman to cough .A spike on the CTG tracing in response to a cough indicates correct positioning 12. Document in the medical records noting time of insertion, baseline resting tone pressures in the semi-fowlers position and left and right lateral positions. When a change in resting tone is observed, the maternal position and manual palpation of the uterine tone should be documented. 13. Document time of insertion on the CTG trace if not automatically done. CPP0487-Fetal Surveillance May 2019 Troubleshooting If the IUPC is not recording: ensure the catheter, cable and CTG monitor are compatible before insertion. check the cables are plugged in and all connections are correct. disconnect the catheter from the cable and inject 10cc of sterile normal saline through the amnioport. Reconnect the cap and cable. liaise with the doctor who may decide to disconnect the catheter from the cable, rotate, retract or advance the catheter. wait 15 seconds before reconnection. Measurements are in Montevideo units, measure from the base to the peak of the contraction, total of at least 200 over a 10 minute cycle is deemed enough for labour to progress. Make sure you grab the Toco lead for external monitoring Removal Grasp the catheter and gently pull until fully withdrawn. Disconnect the catheter from the cable (Note the cable is not disposable). Amniotic sampling Remove the cap from the amnio port and collect the sample. CPP0487-Fetal Surveillance May 2019 .