Intrapartum Fetal Monitoring

 

Am Fam Physician. 2020 Aug 1;102(3):158-167.

  Patient information: See related handout on intrapartum fetal monitoring, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Continuous electronic fetal monitoring was developed to screen for signs of hypoxic-ischemic encephalopathy, cerebral palsy, and impending fetal death during labor. Because these events have a low prevalence, continuous electronic fetal monitoring has a false-positive rate of 99%. The widespread use of continuous electronic fetal monitoring has increased operative and cesarean delivery rates without improved neonatal outcomes, but its use is appropriate in high-risk labor. Structured intermittent auscultation is an underused form of fetal monitoring; when employed during low-risk labor, it can lower rates of operative and cesarean deliveries with neonatal outcomes similar to those of continuous electronic fetal monitoring. However, structured intermittent auscultation remains difficult to implement because of barriers in nurse staffing and physician oversight. The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. Category I tracings reflect a lack of fetal acidosis and do not require intervention. Category II tracings are indeterminate, are present in the majority of laboring patients, and can encompass monitoring predictive of clinically normal to rapidly developing acidosis. Presence of moderate fetal heart rate variability and accelerations with absence of recurrent pathologic decelerations provides reassurance that acidosis is not present. Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. Recurrent deep variable decelerations can be corrected with amnioinfusion. Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing.

Continuous electronic fetal monitoring is the continuous monitoring of fluctuations of the fetal heart rate (FHR) in relation to maternal contractions and is considered standard practice during active labor.13 Continuous electronic fetal monitoring was developed for widespread use in the 1970s as a screening test for fetal hypoxia/acidosis during labor, specifically to reduce hypoxic-ischemic encephalopathy, cerebral palsy, and fetal death.13

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Structured intermittent auscultation can be used for low-risk labor because it statistically decreases cesarean and operative vaginal delivery rates without increasing cerebral palsy or fetal death.1,14,16

B

Cochrane review of low-quality evidence and practice guidelines from the American College of Obstetricians and Gynecologists

The presence of moderate variability and/or accelerations is predictive of a lack of fetal acidosis.34,3638

C

Reviews of disease-oriented outcomes

Treat placental fetal perfusion through intrauterine resuscitation before proceeding to immediate delivery for all Category II or III tracings with concern for fetal acidosis.27,32,33

C

Guidelines, with one small disease-oriented randomized controlled trial and one Cochrane review focusing on tocolytics aspect of intrauterine resuscitation

Perform amnioinfusion for recurrent variable decelerations to reduce the risk of cesarean delivery.42

B

Cochrane review of low-quality evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Structured intermittent auscultation can be used for low-risk labor because it statistically decreases cesarean and operative vaginal delivery rates without increasing cerebral palsy or fetal death.1,14,16

B

Cochrane review of low-quality evidence and practice guidelines from the American College of Obstetricians and Gynecologists

The presence of moderate variability and/or accelerations is predictive of a lack of fetal acidosis.34,3638

C

Reviews of disease-oriented outcomes

Treat placental fetal perfusion through intrauterine resuscitation before proceeding to immediate delivery for all Category II or III tracings with concern for fetal acidosis.27,32,33

C

Guidelines, with one small disease-oriented randomized controlled trial and one Cochrane review focusing on tocolytics aspect of intrauterine resuscitation

Perform amnioinfusion for recurrent variable decelerations to reduce the risk of cesarean delivery.42

B

Cochrane review of low-quality evidence


A = consistent, good-quality patient-oriented evidence; B = inconsistent or lim

The Authors

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JAMES J. ARNOLD, DO, FACOFP, FAAFP, is the Director of Osteopathic Education and family medicine obstetric faculty of the Eglin Family Medicine Residency, Eglin Air Force Base, Fla., and an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md....

BREANNA L. GAWRYS, DO, is family medicine obstetric faculty of the Saint Louis University Family Medicine Residency Program, Scott Air Force Base, Ill.; an assistant professor in the Department of Family Medicine at the Saint Louis School of Medicine, O'Fallon, Ill.; a faculty physician at the Health Sisters Hospital System, O'Fallon; and an assistant professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences.

Address correspondence to James J. Arnold, DO, FACOFP, FAAFP, 307 Boatner Rd., Eglin AFB, FL 32542 (email: james.j.arnold42.mil@mail.mil). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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