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Group Issues Revised Guideline for Fetal Heart Rate Monitoring During Labor

Group Issues Revised Guideline for Fetal Heart Rate Monitoring During Labor A revised guideline on monitoring fetal heart rate during labor from the American College of Obstetricians and Gynecologists (ACOG) seeks to decrease perinatal morbidity and mortality by improving communication among members of the health care delivery team. The updated guideline also highlights the uncertain efficacy of electronic fetal monitoring and limitations such as a high false-positive rate for predicting cerebral palsy and poor consistency among physicians in interpreting fetal heart rate tracings (Obstet Gynecol. 2009;114[1]:192-202). Revisions to guidelines on electronic fetal monitoring during labor provide standardized and unambiguous definitions intended to improve communication among members of the health care delivery team and outcomes for mothers and neonates. Suboptimal efficacy When electronic fetal monitoring was introduced in the 1960s, clinicians hoped that the procedure, which provides information predictive of the acid-base status of the fetus, would help diagnose fetal acidemia and reduce perinatal morbidity and mortality. By 1980, 45% of women in labor underwent electronic fetal monitoring; by 2002, it was being used in 85% of deliveries. To some observers, the suboptimal efficacy of electronic fetal monitoring results from a lack of consistent and systematic interpretation of fetal heart tracings. To improve such interpretation, the National Institute of Child Health and Human Development (NICHD) held a series of workshops in 1995 and 1996 to develop standardized and unambiguous definitions and publish recommendations for interpreting fetal heart rate patterns. This effort led to the ACOG adopting those definitions in a 2005 practice bulletin (Obstet Gynecol. 2005;106[6]:1453-1460). In 2008, the NICHD convened a new workshop to reevaluate the earlier recommendations and unify terminology being promulgated through a number of sources, including the 2005 ACOG practice bulletin, the executive summary from the NICHD's 1990s workshops, and subsequent expert articles (Macones GA et al. Obstet Gynecol. 2008;112[3]:661-666). The ACOG's revision lists terminology to be used to describe uterine activity and the characteristics of uterine contractions. It also notes that the terms hyperstimulation and hypercontractility are undefined and should be abandoned. The cornerstone of the revised guideline is the classification of fetal heart rate patterns into 3 categories—normal, indeterminate, and abnormal—that are simple and easy to teach, said George A. Macones, MD, who headed the ACOG guideline revision. “The main change in the document is that we are trying to move closer to much better and clearer communication among the entire health care team to avoid ambiguity and ultimately improve the health of the mother and child,” said Macones, who is also professor and chair of the department of obstetrics and gynecology at St Louis University School of Medicine in Missouri. In the 3-tier classification, normal tracings can be monitored in a routine manner with no specific actions required. Abnormal tracings require prompt evaluation and expeditious resolution, which can include providing supplemental maternal oxygen, changing maternal position, and discontinuation of labor stimulation. Indeterminate tracings require evaluation and continued surveillance, but they are not predictive of abnormal fetal acid-base status; there is not yet evidence to classify them as either normal or abnormal. Macones noted this 3-tier classification system is based on expert opinion, not rigorous scientific evidence. “Despite the fact that it is used in 85% of births, there has been no new research in the last decade on fetal heart monitoring, so our document calls for more research,” he said. Such research appears long overdue. Macones and colleagues wrote that there are no randomized controlled trials comparing the benefits of electronic fetal monitoring with other forms of observation during labor and that benefits attributed to the technique are based on studies comparing it with intermittent fetal heart rate auscultation. Such studies indicate that electronic monitoring, when compared with auscultation, reduces the risk of neonatal seizures. However, electronic fetal monitoring also increased the overall cesarean delivery rate as well as the risk of use of both vacuum and forceps operative techniques during a vaginal delivery, without reducing perinatal mortality or the risk of cerebral palsy. In addition, the false-positive rate of electronic monitoring for predicting cerebral palsy is greater than 99%, the guideline authors said. As for interpreting fetal heart rate tracings, Macones said work is needed to decrease variability and increase accuracy. The ACOG's revision cited 1 study in which 4 obstetricians independently examined 50 tracings and reached similar interpretations in only 22% of the cases; 2 months later, in a review of the same 50 tracings, the obstetricians’ second interpretation differed from their initial evaluation in 21% of the tracings (Nielsen PV et al. Acta Obstet Gynecol Scand. 1987;66[5]:421-424). The same study found that reinterpretation of fetal heart rate tracings is subject to bias based on outcomes. The researchers found that a reviewer was more likely to find evidence of fetal hypoxia and to criticize an obstetrician's management of the labor and delivery if the outcome for the fetus was poor instead of good. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Group Issues Revised Guideline for Fetal Heart Rate Monitoring During Labor

JAMA , Volume 302 (9) – Sep 2, 2009

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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2009.1185
Publisher site
See Article on Publisher Site

Abstract

A revised guideline on monitoring fetal heart rate during labor from the American College of Obstetricians and Gynecologists (ACOG) seeks to decrease perinatal morbidity and mortality by improving communication among members of the health care delivery team. The updated guideline also highlights the uncertain efficacy of electronic fetal monitoring and limitations such as a high false-positive rate for predicting cerebral palsy and poor consistency among physicians in interpreting fetal heart rate tracings (Obstet Gynecol. 2009;114[1]:192-202). Revisions to guidelines on electronic fetal monitoring during labor provide standardized and unambiguous definitions intended to improve communication among members of the health care delivery team and outcomes for mothers and neonates. Suboptimal efficacy When electronic fetal monitoring was introduced in the 1960s, clinicians hoped that the procedure, which provides information predictive of the acid-base status of the fetus, would help diagnose fetal acidemia and reduce perinatal morbidity and mortality. By 1980, 45% of women in labor underwent electronic fetal monitoring; by 2002, it was being used in 85% of deliveries. To some observers, the suboptimal efficacy of electronic fetal monitoring results from a lack of consistent and systematic interpretation of fetal heart tracings. To improve such interpretation, the National Institute of Child Health and Human Development (NICHD) held a series of workshops in 1995 and 1996 to develop standardized and unambiguous definitions and publish recommendations for interpreting fetal heart rate patterns. This effort led to the ACOG adopting those definitions in a 2005 practice bulletin (Obstet Gynecol. 2005;106[6]:1453-1460). In 2008, the NICHD convened a new workshop to reevaluate the earlier recommendations and unify terminology being promulgated through a number of sources, including the 2005 ACOG practice bulletin, the executive summary from the NICHD's 1990s workshops, and subsequent expert articles (Macones GA et al. Obstet Gynecol. 2008;112[3]:661-666). The ACOG's revision lists terminology to be used to describe uterine activity and the characteristics of uterine contractions. It also notes that the terms hyperstimulation and hypercontractility are undefined and should be abandoned. The cornerstone of the revised guideline is the classification of fetal heart rate patterns into 3 categories—normal, indeterminate, and abnormal—that are simple and easy to teach, said George A. Macones, MD, who headed the ACOG guideline revision. “The main change in the document is that we are trying to move closer to much better and clearer communication among the entire health care team to avoid ambiguity and ultimately improve the health of the mother and child,” said Macones, who is also professor and chair of the department of obstetrics and gynecology at St Louis University School of Medicine in Missouri. In the 3-tier classification, normal tracings can be monitored in a routine manner with no specific actions required. Abnormal tracings require prompt evaluation and expeditious resolution, which can include providing supplemental maternal oxygen, changing maternal position, and discontinuation of labor stimulation. Indeterminate tracings require evaluation and continued surveillance, but they are not predictive of abnormal fetal acid-base status; there is not yet evidence to classify them as either normal or abnormal. Macones noted this 3-tier classification system is based on expert opinion, not rigorous scientific evidence. “Despite the fact that it is used in 85% of births, there has been no new research in the last decade on fetal heart monitoring, so our document calls for more research,” he said. Such research appears long overdue. Macones and colleagues wrote that there are no randomized controlled trials comparing the benefits of electronic fetal monitoring with other forms of observation during labor and that benefits attributed to the technique are based on studies comparing it with intermittent fetal heart rate auscultation. Such studies indicate that electronic monitoring, when compared with auscultation, reduces the risk of neonatal seizures. However, electronic fetal monitoring also increased the overall cesarean delivery rate as well as the risk of use of both vacuum and forceps operative techniques during a vaginal delivery, without reducing perinatal mortality or the risk of cerebral palsy. In addition, the false-positive rate of electronic monitoring for predicting cerebral palsy is greater than 99%, the guideline authors said. As for interpreting fetal heart rate tracings, Macones said work is needed to decrease variability and increase accuracy. The ACOG's revision cited 1 study in which 4 obstetricians independently examined 50 tracings and reached similar interpretations in only 22% of the cases; 2 months later, in a review of the same 50 tracings, the obstetricians’ second interpretation differed from their initial evaluation in 21% of the tracings (Nielsen PV et al. Acta Obstet Gynecol Scand. 1987;66[5]:421-424). The same study found that reinterpretation of fetal heart rate tracings is subject to bias based on outcomes. The researchers found that a reviewer was more likely to find evidence of fetal hypoxia and to criticize an obstetrician's management of the labor and delivery if the outcome for the fetus was poor instead of good.

Journal

JAMAAmerican Medical Association

Published: Sep 2, 2009

Keywords: labor,guidelines,fetal heart rate monitors

There are no references for this article.