ACOG Practice Bulletin: Intrapartum Fetal Heart rate Monitoring

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Are there ancillary tests that can aid in themanagement of Category II or Category IIIfetal heart rate tracings?There are some ancillary tests available that help toensure fetal well-being in the face of a Category II orCategory III FHR tracing, thereby reducing the highfalse-positive rate of EFM.In the case of an EFM tracing with minimal orabsent variability and without spontaneous acceleration,an effort should be made to elicit one. A meta-analysis of11 studies of intrapartum fetal stimulation noted thatfour techniques are available to stimulate the fetus: 1)fetal scalp sampling, 2) Allis clamp scalp stimulation,3) vibroacoustic stimulation, and 4) digital scalp stimulation(37). Because vibroacoustic stimulation and digitalscalp stimulation are less invasive than the other twomethods, they are the preferred methods. When there isan acceleration following stimulation, acidemia isunlikely and labor can continue.When a Category III FHR tracing is persistent, ascalp blood sample for the determination of pH or lactatemay be considered. However, the use of scalp pH assessmenthas decreased (38), and this test may not even beavailable at some tertiary hospitals (39). There are likelymany reasons for this decrease, including physicianexperience, difficulty in obtaining and processing anadequate sample in a short amount of time, and the needfor routine maintenance and calibration of laboratoryequipment that may be used infrequently. More importantly,scalp stimulation, which is less invasive, providessimilar information about the likelihood of fetalacidemia as does scalp pH.In one study, the sensitivity and positive predictivevalue of a low scalp pH (defined in the study as less than7.21 because it is the 75th percentile) to predict umbilicalarterial pH less than 7.00 was 36% and 9%, respectively(40). More importantly, the sensitivity and positivepredictive value of a low scalp pH to identify a newbornwith hypoxic–ischemic encephalopathy was 50% and3%, respectively. However, the greater utility of scalp pHis in its high negative predictive value (97–99%). Thereare some data to suggest that fetal scalp lactate levelshave higher sensitivity and specificity than scalp pH(40). However, a recent large randomized clinical trialthat compared the use of scalp pH assessment to scalplactate level assessment in cases of intrapartum fetaldistress did not demonstrate a difference in the rate ofacidemia at birth, Apgar scores, or neonatal intensivecare unit admissions (41). Although scalp stimulationhas largely replaced scalp pH and scalp lactate assessmentin the United States, if available, these tests mayprovide additional information in the setting of aCategory III tracing.Pulse oximetry has not been demonstrated to be aclinically useful test in evaluating fetal status (42–44).Are there methods of intrauterine resuscitationthat can be used for Category II orCategory III tracings?A Category II or Category III FHR tracing requires evaluationof the possible causes. Initial evaluation and treatmentmay include the following:• Discontinuation of any labor stimulating agent• Cervical examination to determine umbilical cordprolapse, rapid cervical dilation, or descent of thefetal head• Changing maternal position to left or right lateralrecumbent position, reducing compression of thevena cava and improving uteroplacental blood flow• Monitoring maternal blood pressure level for evidenceof hypotension, especially in those withregional anesthesia (if present, treatment with volumeexpansion or with ephedrine or both, orphenylephrine may be warranted)• Assessment of patient for uterine tachysystole byevaluating uterine contraction frequency and durationSupplemental maternal oxygen commonly is used incases of an indeterminate or abnormal pattern. There areno data on the efficacy or safety of this therapy. Often,the FHR patterns persist and do not respond to change inposition or oxygenation. In such cases, the use oftocolytic agents has been suggested to stop uterine contractionsand perhaps avoid umbilical cord compression.A meta-analysis reported the pooled results of three randomizedclinical trials that compared tocolytic therapy(terbutaline, hexoprenaline, or magnesium sulfate) withuntreated controls in the management of a suspectednonreassuring FHR tracing (45). Compared with notreatment, tocolytic therapy more commonly improvedthe FHR tracing. However, there were no differences inrates of perinatal mortality, low 5-minute Apgar score, oradmission to the neonatal intensive care unit between thegroups (possibly because of the small sample size).Thus, although tocolytic therapy appears to reduce thenumber of FHR abnormalities, there is insufficient evidenceto recommend it.Tachysystole with associated FHR changes can besuccessfully treated with β 2-adrenergic drugs (hexoprenalineor terbutaline). A retrospective study suggested that98% of such cases respond to treatment with a β-agonist(46).VOL. 114, NO. 1, JULY 2009 ACOG Practice Bulletin Intrapartum Fetal Heart Rate Monitoring 199
When the FHR tracing includes recurrent variabledecelerations, amnioinfusion to relieve umbilical cordcompression may be considered (47). A meta-analysis of12 randomized trials that allocated patients to no treatmentor transcervical amnioinfusion noted that placementof fluid in the uterine cavity significantly reducedthe rate of decelerations (RR, 0.54; 95% CI, 0.43–0.68)and cesarean delivery for suspected fetal distress (RR,0.35; 95% CI, 0.24–0.52) (48). Because of the lower rateof cesarean delivery, amnioinfusion also decreased thelikelihood that either the patient or the newborn will stayin the hospital more than 3 days (48). Amnioinfusion canbe done by bolus or continuous infusion technique. Arandomized trial compared the two techniques of amnioinfusionand concluded that both have a similar ability torelieve recurrent variable decelerations (49).Another common cause of a Category II or CategoryIII FHR pattern is maternal hypotension secondary toregional anesthesia. If maternal hypotension is identifiedand suspected to be secondary to regional anesthesia,treatment with volume expansion or intravenous ephedrineor both is warranted.Summary ofRecommendations andConclusionsThe following recommendations and conclusionsare based on good and consistent scientific evidence(Level A):The false-positive rate of EFM for predicting cerebralpalsy is high, at greater than 99%.The use of EFM is associated with an increasedrate of both vacuum and forceps operative vaginaldelivery, and cesarean delivery for abnormal FHRpatterns or acidosis or both.When the FHR tracing includes recurrent variabledecelerations, amnioinfusion to relieve umbilical cordcompression should be considered.Pulse oximetry has not been demonstrated to be aclinically useful test in evaluating fetal status.The following conclusions are based on limited orinconsistent scientific evidence (Level B):There is high interobserver and intraobserver variabilityin interpretation of FHR tracing.Reinterpretation of the FHR tracing, especially ifthe neonatal outcome is known, may not be reliable.The use of EFM does not result in a reduction ofcerebral palsy.The following recommendations are based onexpert opinion (Level C):A three-tiered system for the categorization of FHRpatterns is recommended.The labor of women with high-risk conditions shouldbe monitored with continuous FHR monitoring.The terms hyperstimulation and hypercontractilityshould be abandoned.References1. Martin JA, Hamilton BE, Sutton PD, Ventura SJ,Menacker F, Munson ML. Births: final data for 2002. NatlVital Stat Rep 2003;52:1–113. (Level II-3)2. Low JA, Pickersgill H, Killen H, Derrick EJ. The predictionand prevention of intrapartum fetal asphyxia in termpregnancies. Am J Obstet Gynecol 2001;184:724–30.(Level II-2)3. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T.The 2008 National Institute of Child Health and HumanDevelopment workshop report on electronic fetal monitoring:update on definitions, interpretation, and researchguidelines. Obstet Gynecol 2008;112:661–6. (Level III)4. Royal College of Obstetricians and Gynaecologists. Theuse of electronic fetal monitoring: the use and interpretationof cardiotocography in intrapartum fetal surveillance.Evidence-based Clinical Guideline No. 8. London (UK):RCOG; 2001. http://www.rcog.org.uk/files/rcog-corp/uploaded-files/NEBEFMGuidelineFinal2may2001.pdf(Level III)5. Liston R, Sawchuck D, Young D. Fetal health surveillance:antepartum and intrapartum consensus guideline.Society of Obstetrics and Gynaecologists of Canada;British Columbia Perinatal Health Program [publishederratum appears in J Obstet Gynaecol Can 2007;29:909].J Obstet Gynaecol Can 2007;29(suppl 4):S3–56. (Level III)6. Parer JT, Ikeda T. A framework for standardized managementof intrapartum fetal heart rate patterns. Am J ObstetGynecol 2007;197:26.e1–26.e6. (Level III)7. Freeman RK. Problems with intrapartum fetal heart ratemonitoring interpretation and patient management. ObstetGynecol 2002;100:813–26. (Level III)8. Alfirevic Z, Devane D, Gyte GML. Continuous cardiotocography(CTG) as a form of electronic fetal monitoring(EFM) for fetal assessment during labour. CochraneDatabase of Systematic Reviews 2006, Issue 3. Art. No.:CD006066. DOI: 10.1002/14651858.CD006066. (Metaanalysis)9. Nelson KB, Dambrosia JM, Ting TY, Grether JK.Uncertain value of electronic fetal monitoring in predictingcerebral palsy. N Engl J Med 1996;334:613–8. (LevelII-2)200 ACOG Practice Bulletin Intrapartum Fetal Heart Rate Monitoring OBSTETRICS & GYNECOLOGY
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ACOG Practice Bulletin: Intrapartum Fetal Heart rate Monitoring

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