Built by Amos Grünebaum, MDProfessor of Obstetrics & Gynecology · Maternal-Fetal Medicine · 50+ years on Labor & Delivery
Uterine activity is assessed first because prevention starts before fetal heart rate changes. This tool gives every clinician the same evidence-based, contraction-first framework. Free. Share it with your team.
The First Intrapartum Tool to Apply Navigational AI — Starting with Uterine Activity
Unlike conventional AI that retrieves or summarizes text, Navigational AI follows your real-time inputs step by step, applying evidence-based rules at every branch to deliver a specific, actionable recommendation. Contractions first. Prevention always. Guided clinical reasoning.
Step 1 — Uterine Activity (start here): Enter contraction frequency, duration, resting tone, and which uterotonic agent is in use. If abnormal uterine activity is detected, an immediate red alert fires with specific actions before you proceed.
Steps 2–3 — Fetal Heart Rate: Enter baseline FHR, variability, accelerations, and decelerations only after addressing uterine activity.
Step 4 — Clinical Context: Stage, gestational age, and risk factors that modify interpretation.
Recommendation: A final evidence-based recommendation integrating all inputs — with agent-specific management (oxytocin vs. misoprostol) and prioritized action steps.
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Uterine Activity
2
FHR Baseline
3
Variability & Decels
4
Clinical Context
✓
Recommendation
Step 1 — Uterine Activity (Always First)
Assess contractions over a 10-minute window before interpreting fetal heart rate. Normal uterine activity: ≤5 contractions/10 min, each <90 seconds, with complete relaxation between contractions (ACOG/NICHD, FIGO, NICE NG229). Tachysystole and hypertonia cause fetal hypoxia even before FHR changes appear — this is why the Preventive TCG Navigator starts here.
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Navigational AI — Step 1 of 4: Complete all fields below. If abnormal uterine activity is detected, a red alert will appear immediately with required actions. You will then continue to Step 2 to assess fetal heart rate. This sequential approach is the core of preventive intrapartum care.
Contraction frequency Required
Please select one
Contraction duration Required
Please select one
Uterine resting tone Required
Please select one
Uterotonic agent in use? Required
Please select one
⚠ Misoprostol (prostaglandin E1): Once administered, it cannot be removed, reversed, or titrated. Abnormal uterine activity is an independent indication for intervention — physician notification and supportive measures are required regardless of whether FHR changes are present. Tachysystole may persist for 2–4 hours after the last dose. [FIGO 2015; ACOG CPG No. 22, 2025; Heuser et al. AJOG 2013]
🚨 ABNORMAL UTERINE ACTIVITY — ACT NOW
Step 2 — FHR Baseline
Mean FHR over a minimum 2-minute window, excluding accelerations and decelerations. Normal: 110–160 bpm (ACOG/NICHD, FIGO, NICE NG229). NICE adds an amber flag at 100–109 bpm if other features are normal.
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Navigational AI — Step 2 of 4: Uterine activity has been recorded. Now assess the fetal heart rate baseline. Any abnormal FHR finding will be integrated with your uterine activity data in the final recommendation.
Variability is assessed over 1-minute segments between contractions (NICE NG229). Decelerations are repetitive when associated with >50% of contractions (FIGO 2015).
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Navigational AI — Step 3 of 4: Complete variability, accelerations, and all deceleration types present. Select every deceleration type visible on the current tracing.
Baseline variability Required
Please select one
Accelerations Required
Please select one
Deceleration type(s) Select all present
Multiple types may be selected
Please make a selection
Step 4 — Clinical Context
All three guideline systems (ACOG, FIGO, NICE) emphasize that TCG must be interpreted in the context of clinical risk factors, not in isolation.
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Navigational AI — Step 4 of 4: Final step. Provide stage of labor, gestational age, and any applicable risk factors. The Navigational AI will then integrate all four steps and generate a recommendation with prioritized action steps.
Stage of labor Required
Please select one
Gestational age Required
Please select one
Clinical risk factors Select all that apply
FIGO, NICE, and ACOG all require risk factor integration into TCG interpretation
Why Uterine Activity Comes First
The Preventive TCG Navigator reverses the traditional CTG sequence. Fetal heart rate changes are a consequence of inadequate uteroplacental perfusion — they appear after the insult, not before. Addressing abnormal uterine activity preventively — before FHR changes develop — is the logical application of preventive ethics to intrapartum care. The TCG (Tocography + Cardiotocography) framework starts where the physiology starts: with the contraction.
Misoprostol (prostaglandin E1) presents a unique challenge: unlike oxytocin, it cannot be titrated down or discontinued once absorbed. Once tachysystole occurs with misoprostol, the only options are supportive measures and tocolysis. This is why misoprostol-associated tachysystole triggers the most urgent warnings in this tool.
Source Publications
This tool integrates four major international guideline systems and two key evidence publications on uterotonic management. Every classification, threshold, and management recommendation is traceable to one of these sources.
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ACOG Practice Bulletin No. 106: Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General Management Principles. Obstet Gynecol. 2009;114(1):192–202.
doi:10.1097/AOG.0b013e3181aef106
ACOGThree-tier systemOxytocin management
Establishes the NICHD three-tier classification (Category I/II/III) and defines tachysystole as >5 contractions in 10 minutes averaged over 30 minutes. Specifies that tachysystole with FHR changes requires oxytocin cessation as the primary resuscitative step. The principle that Category III requires immediate evaluation with possible expedited delivery is applied throughout this tool.
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Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development Workshop Report on Electronic Fetal Monitoring. Obstet Gynecol. 2008;112(3):661–666.
doi:10.1097/AOG.0b013e3181841395
NICHDCTG definitions
Consensus foundation for all NICHD-based TCG terminology: baseline rate, variability categories, acceleration thresholds, deceleration types, and normal uterine activity (≤5/10 min). These standardized definitions are applied verbatim in the input options.
International consensus by 44 experts from 14 countries. FIGO uses Normal / Suspicious / Pathological. Decelerations repetitive when >50% of contractions. Suspicious tracings require corrective measures; pathological require rapid action and — if no improvement — expedited delivery. This guideline is the basis for the comparative classification table.
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National Institute for Health and Care Excellence. Fetal monitoring in labour. NICE Guideline [NG229]. London: NICE; December 2022. Available from: https://www.nice.org.uk/guidance/ng229
Most recently updated major guideline (December 2022). Key innovation: uterine contractions are formally included as a fourth CTG feature. NICE uses white / amber / red feature coding. A tracing is Pathological if any feature is red or two or more are amber. Sepsis explicitly flagged: fetal scalp stimulation inappropriate, lower delivery threshold. Prolonged deceleration ≥3 minutes: prepare for immediate delivery.
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Simpson KR, James DC. Effects of oxytocin-induced uterine hyperstimulation during labor on fetal oxygen status and fetal heart rate patterns. Am J Obstet Gynecol. 2008;199(1):34.e1–34.e5.
doi:10.1016/j.ajog.2007.12.015
Oxytocin thresholds
Physiological evidence for oxytocin cessation thresholds. Demonstrates that tachysystole with FHR changes causes measurable fetal oxygen desaturation on pulse oximetry. Supports the principle that cessation — not mere dose reduction — is required when tachysystole coincides with abnormal FHR features.
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1. Heuser CC, Knight S, Esplin MS et al. Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. Am J Obstet Gynecol. 2013;209(1):32.e1–6. doi:10.1016/j.ajog.2013.04.030
2. FIGO Intrapartum Fetal Monitoring Consensus Panel. Excessive uterine activity and fetal hypoxia. Int J Gynaecol Obstet. 2015;131(1):13–24.
3. American College of Obstetricians and Gynecologists. Intrapartum Fetal Heart Rate Monitoring. Clinical Practice Guideline No. 22. Obstet Gynecol. 2025;146(4):583–599.
MisoprostolTachysystoleWithout FHR changes
On acting without FHR changes: FIGO 2015 explicitly states that excessive uterine activity is "the most frequent cause of fetal hypoxia/acidosis" and that intervention should address uterine abnormalities before FHR changes develop — the core principle of the Preventive TCG Navigator. On the >15 minute threshold: This is not evidence-based. ACOG CPG No. 22 (2025) states there are "no particular time allotments" to interventions; timing is individualized based on clinical assessment. On tocolysis: ACOG recommends tocolysis when tachysystole persists after cessation/pause of the uterotonic and is associated with FHR changes — not after a fixed time interval. Heuser et al. (2013) document that tachysystole significantly increases abnormal FHR features and neonatal morbidity, confirming the preventive rationale for early intervention. On misoprostol specifically: Once administered (buccal, vaginal, sublingual, or oral), it cannot be removed, reversed, or titrated. Unlike oxytocin (IV half-life 3–5 min), misoprostol effects persist 2–4 hours after the last dose. No further doses, immediate physician notification, and supportive measures are required regardless of current FHR status.
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Skupski DW, Rosenberg CR, Eglinton GS. Intrapartum fetal stimulation tests: a meta-analysis. Obstet Gynecol. 2002;99(1):129–134.
doi:10.1016/s0029-7844(01)01648-3
Fetal stimulation
Meta-analysis of scalp and vibroacoustic stimulation. Acceleration response (≥15 bpm × ≥15 sec) associated with fetal pH >7.19: sensitivity 68%, specificity 96%. Absence of response does not confirm acidosis — clinical escalation required. NICE NG229 specifies stimulation is NOT appropriate when sepsis suspected.
Three-System Classification Comparison
Feature
ACOG / NICHD [1,2]
FIGO 2015 [3]
NICE NG229 2022 [4]
TIER NAMES
Category I / Category II / Category III
Normal / Suspicious / Pathological
Normal / Suspicious / Pathological
UTERINE ACTIVITY
Assessed separately; tachysystole >5/10 min
Assessed separately; tachysystole >5/10 min
Included as 4th CTG feature in classification (2022 update)
Cannot be titrated; no further doses; tocolysis if tachysystole persists with FHR changes after supportive measures. No fixed time threshold. [CPG No.22, 2025]
Act on uterine abnormality before FHR changes. Excessive UA is independent trigger. Tocolysis with beta-agonists. [FIGO 2015]
Urgent physician review; supportive measures; tocolysis based on clinical assessment [NICE NG229]
Misoprostol vs. Oxytocin — Key Clinical Differences
Why Misoprostol Requires a Different Approach
ReversibilityOxytocin: immediate cessation stops effect within minutes (half-life 3–5 min IV). Misoprostol: cannot be stopped or reversed once absorbed. Effects persist 2–4 hours after last dose.
TitrationOxytocin: can reduce dose by 50% or stop entirely. Misoprostol: no titration option — last dose is always last dose.
Tachysystole rateMisoprostol tachysystole: 5–20% (dose and route dependent). Oxytocin tachysystole: 1–8% with standard protocols.
Management when tachysystole occursOxytocin: STOP or reduce infusion. Misoprostol: no further doses + repositioning + IV fluids + physician notification immediately (regardless of FHR status) + tocolysis (terbutaline 0.25 mg SC or nitroglycerin) when tachysystole persists with FHR changes after supportive measures. No fixed time threshold. [ACOG CPG No. 22, 2025; FIGO 2015]
TOLAC contraindicationMisoprostol is contraindicated in women with prior uterine scar (ACOG) due to markedly elevated risk of uterine rupture. Oxytocin is used with caution and heightened vigilance.
Scope & Limitations
⚠This tool applies published NICHD/ACOG/FIGO/NICE criteria and misoprostol evidence. It does not access the full clinical picture — maternal vitals, complete tracing history, fetal position, cervical exam, or comorbidities.
⚠Category II / Suspicious encompasses a wide clinical spectrum. The framework is conservative by design. Clinical judgment and trajectory assessment must modulate all recommendations.
⚠Misoprostol management is based on FIGO 2015, ACOG CPG No. 22 (2025), and Heuser et al. AJOG 2013. Acting on abnormal uterine activity before FHR changes is supported by FIGO but not yet universally mandated by ACOG, which remains primarily FHR-change-conditional. The Preventive TCG Navigator applies the more proactive FIGO standard.
⚠In any rapidly evolving or deteriorating situation: do not wait for this tool. Call for help, perform immediate bedside assessment, and act on clinical judgment.
