Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-5f56664f6-w4vgn Total loading time: 0 Render date: 2025-05-07T06:49:54.663Z Has data issue: false hasContentIssue false

15 - Intrapartum evaluation of the fetus

from Section 2 - Pregnancy, labor, and delivery complications causing brain injury

Published online by Cambridge University Press:  12 January 2010

By
Israel Hendler  and
Daniel S. Seidman
Edited by
David K. Stevenson ,
William E. Benitz ,
Philip Sunshine ,
Susan R. Hintz  and
Maurice L. Druzin
David K. Stevenson
Affiliation:
Stanford University School of Medicine, California
William E. Benitz
Affiliation:
Stanford University School of Medicine, California
Philip Sunshine
Affiliation:
Stanford University School of Medicine, California
Susan R. Hintz
Affiliation:
Stanford University School of Medicine, California
Maurice L. Druzin
Affiliation:
Stanford University School of Medicine, California
Get access

Summary

Introduction

The preliminary estimate of total births in the USA for 2005 was 4,138,349. Intrapartum fetal heart-rate (FHR) monitoring was used in more than 85% of the deliveries. Fetal heart-rate monitoring was introduced into clinical practice in the 1970s. At that time, obstetric providers and researchers in fetal physiology believed electronic fetal monitoring (EFM) would identify changes in the FHR and/or rhythm that reflect fetal acidosis. It was presumed that detection would be early enough to allow clinical intervention that would prevent perinatal asphyxia. Despite 30 years of widespread use and multiple randomized clinical trials, FHR monitoring has not yet been shown to decrease perinatal mortality other than by decreasing intrapartum fetal deaths. Moreover, some experts believe that the use of EFM leads to over-detection of non-reassuring FHR patterns, thereby directly contributing to the escalating rate of cesarean-section deliveries in the USA, which by 2005 increased to 30.3%. We will review the physiology underlying FHR patterns, and the possible reasons why randomized trials of EFM have so far failed to demonstrate efficacy. The current knowledge that guides interpretation of EFM in the intrapartum period will be discussed, with special emphasis on newer methods for intrapartum fetal surveillance.

Type
Chapter
Information
Fetal and Neonatal Brain Injury , pp. 174 - 186
Publisher: Cambridge University Press
Print publication year: 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Book purchase

Temporarily unavailable

References

Martin, JA, Hamilton, BE, Sutton, PD, et al. Births: final data for 2005. Natl Vital Stat Rep 2007; 56: 1–103.Google ScholarPubMed
Benson, RC, Shubeck, F, Deutschberger, J, et al. Fetal heart rate as a predictor of fetal distress: a report from the collaborative project. Obstet Gynecol 1968; 32: 259–66.Google ScholarPubMed
Banta, DH, Thacker, SB. Historical controversy in health technology assessment: the case of electronic fetal monitoring. Obstet Gynecol Surv 2001; 56: 707–19.CrossRefGoogle ScholarPubMed
Wenske, P. Doctor told to pay $2 million. Daily Oklahoman 1981 June 17.
Little, WJ. On the influence of abnormal parturition, difficult labors, premature birth, and asphyxia neonatorum, on the mental and physical condition of the child, especially in relation to deformities. Trans Obstet Soc Lond 1862; 3: 293–344.Google Scholar
Hon, EH. The electronic evaluation of the fetal heart rate: preliminary report. Am J Obstet Gynecol 1958; 75: 1215–30.CrossRefGoogle ScholarPubMed
,Interview with Dr. Edward Hon. Watching the unborn inside the womb: high-risk mothers and the graph that raises their babies' chances. Life Magazine 1969 July 25: 63–5.
Quilligan, EJ, Paul, RH. Fetal monitoring: is it worth it?Obstet Gynecol 1975; 45: 96–100.Google ScholarPubMed
Yeh, SY, Diaz, F, Paul, RH. Ten-year experience of intrapartum fetal monitoring in Los Angeles County/University of Southern California Medical Center. Am J Obstet Gynecol 1982; 143: 496–500.CrossRefGoogle ScholarPubMed
Haverkamp, AD, Thompson, HE, McFee, JG, et al. The evaluation of continuous fetal heart rate monitoring in high-risk pregnancy. Am J Obstet Gynecol 1976; 125: 310–20.CrossRefGoogle ScholarPubMed
Parer, JT. Fetal heart-rate monitoring. Lancet 1979; 2: 632–3.CrossRefGoogle ScholarPubMed
MacDonald, D, Grant, A, Sheridan-Pereira, M, et al. The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring. Am J Obstet Gynecol 1985; 152: 524–39.CrossRefGoogle ScholarPubMed
Grant, A, O'Brien, N, Joy, MT, et al. Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring. Lancet 1989; 2: 1233–6.CrossRefGoogle ScholarPubMed
Thacker, SB, Stroup, DF, Peterson, HB. Efficacy and safety of intrapartum electronic fetal monitoring: an update. Obstet Gynecol 1995; 86: 613–20.CrossRefGoogle ScholarPubMed
Thacker, SB, Stroup, D, Chang, M. Continuous electronic heart rate monitoring for fetal assessment during labor. Cochrane Database Syst Rev 2001; (2) CD000063.Google ScholarPubMed
Nelson, KB, Dambrosia, JM, Ting, TY, et al. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. N Engl J Med 1996; 334: 613–18.CrossRefGoogle ScholarPubMed
Larma, JD, Silva, AM, Holcroft, CJ, et al. Intrapartum electronic fetal heart rate monitoring and the identification of metabolic acidosis and hypoxic–ischemic encephalopathy. Am J Obstet Gynecol 2007; 197: 301. e1–8.CrossRefGoogle ScholarPubMed
Martin, CB, Gingerich, B. Uteroplacental physiology. JOGN Nurs 1976; 5: 16–25s.Google ScholarPubMed
Jepson, JH. Factors influencing oxygenation in mother and fetus. Obstet Gynecol 1974; 44: 906–14.Google ScholarPubMed
Parer, JT. Handbook of Fetal Heart Rate Monitoring, 2nd edn. Philadelphia, PA: Saunders, 1997.Google Scholar
Richardson, BS. Fetal adaptive responses to asphyxia. Clin Perinatol 1989; 16: 595–611.CrossRefGoogle ScholarPubMed
Park, MI, Hwang, JH, Cha, KJ, et al. Computerized analysis of fetal heart rate parameters by gestational age. Int J Gynaecol Obstet 2001; 74: 157–64.CrossRefGoogle ScholarPubMed
Sadovsky, G, Nicolaides, KH. Reference ranges for fetal heart rate patterns in normoxaemic nonanaemic fetuses. Fetal Ther 1989; 4: 61–8.CrossRefGoogle ScholarPubMed
Pillai, M, James, D. The development of fetal heart rate patterns during normal pregnancy. Obstet Gynecol 1990; 76: 812–16.CrossRefGoogle ScholarPubMed
Anderson, PA, Glick, KL, Killam, AP, et al. The effect of heart rate on in utero left ventricular output in the fetal sheep. J Physiol 1986; 372: 557–73.CrossRefGoogle ScholarPubMed
Anderson, PA, Killam, AP, Mainwaring, RD, et al. In utero right ventricular output in the fetal lamb: the effect of heart rate. J Physiol 1987; 387: 297–316.CrossRefGoogle ScholarPubMed
Rudolph, AM, Heymann, MA. Control of the foetal circulation. In Comline, KS, Cross, KW, Dawes, GS, et al., eds., Fetal and Neonatal Physiology: Proceedings of the Barcroft Centenary Symposium. Cambridge: Cambridge University Press, 1973: 89–111.Google Scholar
Hon, EH, Quilligan, EJ. The classification of fetal heart rate. II. A revised working classification. Conn Med 1967; 31: 779–84.Google Scholar
,National Institute of Child Health and Human Development Research Planning Workshop. Electronic fetal heart rate monitoring: research guidelines for interpretation. Am J Obstet Gynecol 1997; 17: 1385–90.
Vlastos, EJ, Tomlinson, TM, Bildirici, I, et al. Fetal heart rate accelerations and the risk of cerebral lesions and poor neurodevelopmental outcome in very low birthweight neonates. Am J Perinatol 2007; 24: 83–8.CrossRefGoogle ScholarPubMed
,American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring. ACOG Practice Bulletin No. 70. Obstet Gynecol 2005; 106: 1453–61.
Paul, RH, Suidan, AK, Yeh, S, et al. Clinical fetal monitoring. VII. The evaluation and significance of intrapartum baseline FHR variability. Am J Obstet Gynecol 1975; 123: 206–10.CrossRefGoogle ScholarPubMed
Ball, RH, Parer, JT. The physiologic mechanisms of variable decelerations. Am J Obstet Gynecol 1992; 166: 1683–9.CrossRefGoogle ScholarPubMed
Parer, JTP, King, T. Whither fetal heart rate monitoring?Obstet Gynecol Fertil 1999; 22: 149–92.Google Scholar
Krebs, HB, Petres, RE, Dunn, LJ, et al. Intrapartum fetal heart rate monitoring. I. Classification and prognosis of fetal heart rate patterns. Am J Obstet Gynecol 1979; 133: 762–72.CrossRefGoogle ScholarPubMed
Beard, RW, Filshie, GM, Knight, CA, et al. The significance of the changes in the continuous fetal heart rate in the first stage of labour. J Obstet Gynaecol Br Commonw 1971; 78: 865–81.CrossRefGoogle ScholarPubMed
Berkus, MD, Langer, O, Samueloff, A, et al. Electronic fetal monitoring: what's reassuring?Acta Obstet Gynecol Scand 1999; 78: 15–21.CrossRefGoogle ScholarPubMed
Low, JA, Victory, R, Derrick, EJ. Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis. Obstet Gynecol 1999; 93: 285–91.Google ScholarPubMed
Tejani, N, Mann, LI, Bhakthavathsalan, A, et al. Correlation of fetal heart rate–uterine contraction patterns with fetal scalp blood pH. Obstet Gynecol 1975; 46: 392–6.Google ScholarPubMed
Low, JA, Cox, MJ, Karchmar, EJ, et al. The prediction of intrapartum fetal metabolic acidosis by fetal heart rate monitoring. Am J Obstet Gynecol 1981; 139: 299–305.CrossRefGoogle ScholarPubMed
Gilstrap, LC, Hauth, JC, Hankins, GD, et al. Second-stage fetal heart rate abnormalities and type of neonatal acidemia. Obstet Gynecol 1987; 70: 191–5.Google ScholarPubMed
Gull, I, Jaffa, AJ, Oren, M, et al. Acid accumulation during end-stage bradycardia in term fetuses: how long is too long?Br J Obstet Gynaecol 1996; 103: 1096–101.CrossRefGoogle Scholar
Dellinger, EH, Boehm, FH, Crane, MM. Electronic fetal heart rate monitoring: early neonatal outcomes associated with normal rate, fetal stress, and fetal distress. Am J Obstet Gynecol 2000; 182: 214–20.CrossRefGoogle ScholarPubMed
Rochard, F, Schifrin, BS, Goupil, F, et al. Nonstressed fetal heart rate monitoring in the antepartum period. Am J Obstet Gynecol 1976; 126: 699–706.CrossRefGoogle ScholarPubMed
Parer, JT, Livingston, EG. What is fetal distress?Am J Obstet Gynecol 1990; 162: 1421–7.CrossRefGoogle ScholarPubMed
Clark, SL, Gimovsky, ML, Miller, FC. The scalp stimulation test: a clinical alternative to fetal scalp blood sampling. Am J Obstet Gynecol 1984; 148: 274–7.CrossRefGoogle ScholarPubMed
Wood, C, Ferguson, R, Leeton, J, et al. Fetal heart rate and acid–base status in the assessment of fetal hypoxia. Am J Obstet Gynecol 1967; 98: 62–70.CrossRefGoogle ScholarPubMed
Helfand, M, Marton, K, Ueland, K. Factors involved in the interpretation of fetal monitor tracings. Am J Obstet Gynecol 1985; 151: 737–44.CrossRefGoogle ScholarPubMed
Nielsen, PV, Stigsby, B, Nickelsen, C, et al. Intra- and inter-observer variability in the assessment of intrapartum cardiotocograms. Acta Obstet Gynecol Scand 1987; 66: 421–4.CrossRefGoogle ScholarPubMed
Blix, E, Sviggum, O, Koss, KS, et al. Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts. BJOG 2003; 110: 1–5.CrossRefGoogle ScholarPubMed
Zain, HA, Wright, JW, Parrish, GE, et al. Interpreting the fetal heart rate tracing: effect of knowledge of neonatal outcome. J Reprod Med 1998; 43: 367–70.Google ScholarPubMed
Helwig, JT, Parer, JT, Kilpatrick, SJ, et al. Umbilical cord blood acid–base state: what is normal?Am J Obstet Gynecol 1996; 174: 1807–14.CrossRefGoogle Scholar
Lilien, AA. Term intrapartum fetal death. Am J Obstet Gynecol 1970; 107: 595–603.CrossRefGoogle ScholarPubMed
Nelson, KB. What proportion of cerebral palsy is related to birth asphyxia?J Pediatr 1988; 112: 572–4.CrossRefGoogle ScholarPubMed
Paneth, N, Kiely, J. The frequency of cerebral palsy: a review of population studies in industrial nations since 1950. In Stanley, FJ, Alberman, E, eds., The Epidemiology of the Cerebral Palsies. Philadelphia, PA: Lippincott, 1984: 46–56.Google Scholar
Shy, KK, Luthy, DA, Bennett, FC, et al. Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. N Engl J Med 1990; 322: 588–93.CrossRefGoogle ScholarPubMed
Skupski, DW, Rosenberg, CR, Eglinton, GS. Intrapartum fetal stimulation tests: a meta-analysis. Obstet Gynecol 2002; 99: 129–34.Google ScholarPubMed
Goodwin, TM, Milner-Masterson, L, Paul, RH. Elimination of fetal scalp blood sampling on a large clinical service. Obstet Gynecol 1994; 83: 971–4.CrossRefGoogle ScholarPubMed
Yam, J, Chua, S, Arulkumaran, S. Summary minutes: Meeting of the Obstetrics and Gynecology Devices Advisory Panel, open session, June 9, 2003. www.fda.gov/ohrms/dockets/ac/03/minutes/3963m1_summary%20minutes.pdf.Google Scholar
Yam, J, Chua, S, Arulkumaran, S. Intrapartum fetal pulse oximetry. Part I: Principles and technical issues. Obstet Gynecol Surv 2000; 55: 163–72.CrossRefGoogle ScholarPubMed
Garite, TJ, Dildy, GA, McNamara, H, et al. A multicenter controlled trial of fetal pulse oximetry in the intrapartum management of nonreassuring fetal heart rate patterns. Am J Obstet Gynecol 2000; 183: 1049–58.CrossRefGoogle ScholarPubMed
Bloom, SL, Spong, CY, Thom, E, et al. Fetal pulse oximetry and cesarean delivery. N Engl J Med 2006; 355: 2195–202.CrossRefGoogle ScholarPubMed
Rosen, KG, Amer-Wahlin, I, Luzietti, R, et al. Fetal ECG waveform analysis. Best Pract Res Clin Obstet Gynaecol 2004; 18: 485–514.CrossRefGoogle ScholarPubMed
Amer-Wahlin, I, Bordahl, P, Eikeland, T, et al. ST analysis of the fetal electrocardiogram during labor: Nordic observational multicenter study. J Matern Fetal Neonatal Med 2002; 12: 260–6.CrossRefGoogle ScholarPubMed
Amer-Wahlin, I, Hellsten, C, Noren, H, et al. Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial. Lancet 2001; 358: 534–8.CrossRefGoogle ScholarPubMed
Neilson, JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst Rev 2003; (2): CD000116.CrossRefGoogle ScholarPubMed
Westgate, J, Harris, M, Curnow, JS, et al. Plymouth randomized trial of cardiotocogram only versus ST waveform plus cardiotocogram for intrapartum monitoring in 2400 cases. Am J Obstet Gynecol 1993; 169: 1151–60.CrossRefGoogle ScholarPubMed
Devoe, LD, Ross, M, Wilde, C, et al. United States multicenter clinical usage study of the STAN 21 electronic fetal monitoring system. Am J Obstet Gynecol 2006; 195: 729–34.CrossRefGoogle ScholarPubMed
Macones, G, Hankins, G, Spong, C, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretations, and research guidelines. Obstet Gynecol 2008; 112: 661–6.CrossRefGoogle Scholar

Save book to Kindle

To save this book to your Kindle, first ensure [email protected] is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×