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    Enhanced FHR monitoring: No magic bullet

     

    Dr Lockwood, Editor-in-Chief, is Senior Vice President, USF Health, and Dean, Morsani College of Medicine, University of South Florida, Tampa. He can be reached at [email protected]

     

    Over the past 35 years, the rate of emergency cesarean deliveries has more than doubled while the prevalence of live births with cerebral palsy (CP) has remained nearly constant at around 2 per 1000 live births.1 Many view this as a major failure of continuous intrapartum electronic fetal heart rate (FHR) monitoring. Indeed, a 2013 meta-analysis of controlled trials of electronic FHR monitoring versus intermittent auscultation showed that the former yielded no significant improvement in overall perinatal death or CP rates but was associated with a significant increase in caesarean deliveries (RR 1.63, 95% CI 1.29–2.07, N = 18,861, 11 trials).2

    Also read: ACOG Guidelines at a Glance: Antepartum fetal surveillance 

    For a while, it was hypothesized that FHR monitoring coupled with fetal pulse oximetry produced more accurate diagnoses with fewer cesarean deliveries, but randomized controlled trials showed no such benefit.3 The search for a “magic bullet” to enhance the diagnostic precision of FHR monitoring resumed and initial studies from Europe suggested that sophisticated computerized detection of fetal academic-associated electrocardiographic ST segment elevation and increased T-wave amplitude might be the solution. Unfortunately, a recent carefully conducted randomized control trial has once again dashed our hopes for a better fetal intrapartum surveillance method.

    A randomized trial of fetal ST segment analysis

    The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network undertook a multicenter randomized trial in laboring women with singleton pregnancies at > 36 weeks’ gestation and cervical dilation of 2 to 7 cm.4 A total of 11,108 patients were randomly assigned to either "open" or "masked" monitoring with fetal ST segment analysis. In the latter group only routine FHR monitor data were available to clinicians, whereas in the former group, additional ST segment data were available when concerning FHR patterns were detected. Exclusion criteria included frankly nonreassuring FHR patterns prior to randomization and maternal or fetal conditions precluding a trial of labor or placement of a scalp electrode.

    Study personnel were subject to pretrial training and a pilot phase to ensure competency with ST monitoring and uniformity of FHR pattern interpretation. The primary outcome was a composite of intrapartum fetal or neonatal death, Apgar score of ≤3 at 5 minutes, neonatal seizure, an umbilical-artery pH ≤7.05 or base deficit of ≥12 mmol/L, neonatal intubation, and encephalopathy. Secondary maternal outcomes included cesarean or operative vaginal delivery, chorioamnionitis, transfusion, and labor duration. Secondary neonatal outcomes included individual components of the composite score, Apgar score at 5 minutes, cord gas results, and admission to an intermediate or intensive care unit. The study was powered to detect a 40% reduction in the primary endpoint or a 25% reduction in cesarean delivery for nonreassuring FHR patterns.

    Related: Legal: Failure to timely inform physician of changes on FHR strip 

     

    Charles J. Lockwood, MD, MHCM
    Dr. Lockwood, Editor-in-Chief, is Dean of the Morsani College of Medicine and Senior Vice President of USF Health, University of South ...

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