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The Admission Test

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Active Management of Labour
The Admission Test

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This was originally developed in Singapore, in a hospital with 25,000 deliveries per year with 28 high risk and 18 low risk rooms staffed by 4 trained and 4 axillary staff. As a consequence there was little time for adequate auscultation and the intrapartum asphyxia rate was high. The hypothesis behind the admission CTG was that a reactive trace with accelerations would be predictive of a baby at low risk of intrapartum asphyxia whereas a non reactive, suspicious or pathological trace would need either more intense monitoring or expedited delivery. For those with a reactive trace, any slowly developing compromise would be accompanied with a rise in baseline which could be detected by auscultation and acute bradycardias would usually be accompanied with an acute event or take place in late first or early second stage.

The original research examined a low risk population. The test was applied to 130 women in labour with pH determinants in scalp blood and cord blood at birth (Reference1). Only 0.9% of those with a reactive test had intrauterine asphyxia in labour as compared to half of those with ominous traces. The test was then used as a screening test in 1041 women with similar results.

Two subsequent studies have examined high risk pregnancies, which by current definitions should have continuous intrapartum monitoring (Reference2),Reference3). The one randomised controlled trial of admission CTG vs Doppler auscultation in a population of 3751 women with no pre identified risk factors showed no significant difference in metabolic acidosis or any other measure of neonatal outcome (Reference4).

The NICE guidelines concluded that current evidence does not support the admission CTG in a low risk pregnancy and it is therefore not recommended (Reference5). They list risk factors to distinguish between high and low risk. However, whilst the maternal conditions are usually evident, the fetal complication of growth restriction is currently poorly detected. Only 26% of small for gestational age babies were detected as small before birth in an unselected hospital population (Reference6). This was even less in a low risk population (Reference7).

In addition the complications of oligohydramnios and abnormal uterine artery Dopplers will only have been detected if there has been previous suspicion of growth restriction and therefore an ultrasound scan to investigate this. If these women are then subject to intermittent auscultation only, as current evidence suggests is appropriate for truly low risk pregnancy, there is a risk that fetal heart abnormalities of reduced baseline variability and shallow decelerations representing chronic in utero compromise may be missed.


1.Ingemarsson I, Arulkumaran S, Ingemarrson E, Tambyraja RL, Ratnam SS. Admission test: a screening test for fetal distress in labour. Obstet Gynecol 1986; 68: 800.

2. Umstat MP. The predictive value of abnormal fetal heart rate patterns in early labour. Aust N Z J Obstet Gynaecol 1993; 33: 145-9.

3. Kulkarni AA, Shotri AN. Admission test: a predictive test for fetal distress in high risk labour. J Obstet Gynaecol Res 1998; 24: 255-9.

4. Mires G, Williams F, Howie P. Randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour in low risk obstetric population. BMJ 2001; 322: 1435-1498.

5. The Use Of Electronic Fetal Monitoring: The use and interpretation of cardiotocography in intrapartum fetal surveillance. Evidence-based Clinical Guideline Number 8. RCOG Press.

6. Hepburn M, Rosenberg K. An audit of the detection and management of small for gestational age babies. Br J Obstet Gynecol 1986;93: 212-216

7. Kean LH, Liu DT. Antenatal care as a screening tool for the detection of small for gestational; age babies in the low risk population. J Obstet Gynaecol 1996; 16:77-82.

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