Fetal heart rate monitoring in labour: A critical review

  • John A. D. Spencer
Conference paper

Abstract

Continuous monitoring of the fetal heart rate (FHR) during labour has become widespread since its introduction into clinical practice during the 1960s. However, there has been increasing criticism of its routine use in recent years because of growing doubts about its effectiveness. Although early reports suggested that continuous FHR monitoring in high risk labour was associated with a reduction in the incidence of fetal and neonatal deaths related to labour (23, 36) there has been no evidence to show a similar benefit in terms of perinatal morbidity or long-term neurodevelopmental handicap. If anything, routine use of continuous FHR monitoring has been associated with an increase in operative delivery rates and an increasing rate of medico-legal cases against hospitals. Clearly, early expectations of the value of continuous FHR monitoring have not been realised.

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References

  1. 1.
    Beard RW, Filshie GM, Knight CA, Roberts GM (1971) The significance of the changes in the continuous fetal heart rate in the first stage of labour. J Obstet Gynaecol Br Commonw 78: 865–881PubMedCrossRefGoogle Scholar
  2. 2.
    Bissonnette JM (1975) Relationship between continuous fetal heart rate patterns and Apgar score in the newborn. Br J Obstet Gynaecol 82: 24–28CrossRefGoogle Scholar
  3. 3.
    Chik L, Sokol R, Rosen MG (1976) ’Prediction’ of the one-minute Apgar score from fetal heart rate data. Obstet Gynecol 48: 452–455PubMedGoogle Scholar
  4. 4.
    Cibils LA (1978) Clinical significance of fetal heart rate patterns during labour V. Variable decelerations. Am J Obstet Gynaecol 132: 791–803Google Scholar
  5. 5.
    Curzen P, Bekin JS, McLintock DG, Patel M (1984) Reliability of cardiotocography in predicting baby’s condition at birth. Br Med J 289:1345–1347CrossRefGoogle Scholar
  6. 6.
    Dennis J, Johnson A, Mutch L, Yudkin P, Johnson P (1989) Acid-base status at birth and neurodevelopmental outcome at four and one-half years. Am J Obstet Gynecol 161: 213–220PubMedGoogle Scholar
  7. 7.
    Dijxhoorn MJ, Visser GHA, Fidler VJ, Touwen BCL, Huisjes HJ (1986) Apgar score, meconium and acidaemia at birth in relation to neonatal neurological morbidity in term infants. Br J Obstet Gynaecol 93: 217–222PubMedCrossRefGoogle Scholar
  8. 8.
    Eskes TKAB, Jongsma HW, Houx PCW (1983) Percentiles for gas values in human umbilical cord blood. Eur J Obstet Gynecol Reprod Biol 14: 341–346PubMedCrossRefGoogle Scholar
  9. 9.
    Fee S, Malee K, Deddish R, Minogue JP, Socol ML (1990) Severe acidosis and subsequent neurological status. Am J Obstet Gynecol 162: 802–806PubMedGoogle Scholar
  10. 10.
    FIGO News (1987) Guidelines for the use of fetal monitoring. Int J Gynaecol Obstet 25:159–167CrossRefGoogle Scholar
  11. 11.
    Fleischer A, Schulman H, Jagani N, Mitchell J, Randolph G (1982) The development of fetal acidosis in the presence of an abnormal fetal heart rate tracing 1. The average for gestational age fetus. Am J Obstet Gynecol 144: 55–60PubMedGoogle Scholar
  12. 12.
    Gilstrap LC, Hauth JC, Hankins GDV, Beck AW (1987) Second-stage fetal heart rate abnormalities and type of neonatal acidemia. Obstet Gynecol 70:191–195PubMedGoogle Scholar
  13. 13.
    Gilstrap LC, Leveno KJ, Burris J, Williams ML, Little BB (1989) Diagnosis of birth asphyxia on the basis of fetal pH, Apgar score, and newborn cerebral dysfunction. Am J Obstet Gynecol 161:825–830PubMedGoogle Scholar
  14. 14.
    Giussani DA, Spencer JAD, Moore PJ, Bennet L, Hanson MA (1993) Afferent and efferent components of the cardiovascular reflex responses to acute hypoxia in term fetal sheep. J Physiol 461: 431–449PubMedGoogle Scholar
  15. 15.
    Goldaber KG, Gilstrap LC, Leveno KJ, Dax JS, McIntire DD (1991) Pathological fetal acidemia. Obstet Gynecol 78:1103–1107PubMedGoogle Scholar
  16. 16.
    Grant A, O’Brien N, Joy MT, Hennessy E, MacDonald D (1989) Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring. Lancet II: 1233–1235CrossRefGoogle Scholar
  17. 17.
    Hammacher K, Huter KA, Bokelmann J, Werners PH (1968) Foetal heart rate frequency and perinatal condition of the foetus and newborn. Gynaecologia 166: 349–360PubMedGoogle Scholar
  18. 18.
    Heinrich J (1982) Elective fetal monitoring and obstetrical operative frequency. Europ J Obstet Gynecol Reprod Biol 14:143–152CrossRefGoogle Scholar
  19. 19.
    Hon EH (1968) An atlas of fetal heart rate patterns. Harty Press, New Haven.Google Scholar
  20. 20.
    Ingemarsson E (1981) Routine electronic fetal monitoring during labour. Acta Obstet Gynecol Scand, suppl 99Google Scholar
  21. 21.
    James LS, Adamsons K (1964) Respiratory physiology of the fetus and newborn infant. New Eng J Med 271:1352–1409PubMedCrossRefGoogle Scholar
  22. 22.
    James LS, Weisbrot IM, Prince CE, Holaday DA, Apgar V (1958) The acid-base status of human infants in relation to birth asphyxia and the onset of respiration. J Pediatr 52: 379–394PubMedCrossRefGoogle Scholar
  23. 23.
    Johnstone FD, Campbell DM, Hughes GJ (1978) Has continuous intrapartum monitoring made any impact on fetal outcome? Lancet I:1290–1300Google Scholar
  24. 24.
    Krebs HB, Petres RE, Dumm LJ, Jordaan HVF, Segreti A (1979) Intrapartum fetal heart rate monitoring. 1 classification and prognosis of fetal heart rate patterns. Am J Obstet Gynecol 133:762–772PubMedGoogle Scholar
  25. 25.
    Kubli FW, Hon EH, Khazin AF, Takemura H (1969) Observations on heart rate and pH in the human fetus during labour. Am J Obstet Gynecol 104:1190–1206PubMedGoogle Scholar
  26. 26.
    Liu DTY, Thomas G, Blackwell RJ (1975) Progression in response patterns of fetal heart rate throughout labour. Br J Obstet Gynaecol 82: 943–951PubMedCrossRefGoogle Scholar
  27. 27.
    Low JA, Pancham SR, Worthington D, Boston RW (1975) The incidence of fetal asphyxia in six hundred high-risk monitored pregnancies. Am J Obstet Gynecol 121: 456–459PubMedGoogle Scholar
  28. 28.
    Low JA, Cox MJ, Karchmar EJ, McGrath MJ, Pancham SR, Piercy WN (1981) The prediction of intrapartum fetal metabolic acidosis by fetal heart rate monitoring. Am J Obstet Gynecol 139: 299–305PubMedGoogle Scholar
  29. 29.
    Low JA, Galbraith RS, Muir DW, Killen HL, Patet EA, Karchmar EL (1983) Intrapartum fetal hypoxia: a study of long-term morbidity. Am J Obstet Gynecol 145:129–134PubMedGoogle Scholar
  30. 30.
    MacLachlan NA, Spencer JAD, Harding K, Arulkumaran S (1992) Fetal acidaemia, the cardiotocograph and the T/QRS ratio of the fetal ECG in labour. Br J Obstet Gynaecol 99: 26–31PubMedCrossRefGoogle Scholar
  31. 31.
    Modanlou H, Yeh S-Y, Hon EH (1974) Fetal and neonatal acid-base balance in normal and high-risk pregnancies. Obstet Gynecol 43: 347–353PubMedGoogle Scholar
  32. 32.
    Myers RE, Mueller-Heubach E, Adamsons K (1973) Predictability of the state of fetal oxygenation from a quantitative analysis of the components of late deceleration. Am J Obstet Gynecol 115:1083–1094PubMedGoogle Scholar
  33. 33.
    O’Gureck JE, Roux JF, Neuman MR (1972) Neonatal depression and fetal heart rate patterns during labour. Obstet Gynecol 40: 347–355PubMedGoogle Scholar
  34. 34.
    Painter MJ, Scott M, Hirsch RP, O’Donoghue P, Depp R (1988) Fetal heart rate patterns during labour: neurologic and cognitive development at six to nine years of age. Am J Obstet Gynecol 159: 854–858PubMedGoogle Scholar
  35. 35.
    Parer JT, Krueger TR, Harris JL (1980) Fetal oxygen consumption and mechanisms of heart rate response during artificially produced late decelerations of fetal heart rate in sheep. Am J Obstet Gynecol 136: 478–482PubMedGoogle Scholar
  36. 36.
    Paul RH, Hon EH (1974) Clinical fetal monitoring. Am J Obstet Gynecol 118: 529–533PubMedGoogle Scholar
  37. 37.
    Piquard F, Hsiung R, Mettauer M, Schaeffer A, Haberey P, Dellenbach P (1988) The validity of fetal heart rate monitoring during the second stage fo labour. Obstet Gynecol 72: 746–751PubMedGoogle Scholar
  38. 38.
    Ruth VJ, Raivio KO (1988) Perinatal brain damage: predictive value of metabolic acidosis and Apgar score. Br Med J 297: 24–27CrossRefGoogle Scholar
  39. 39.
    Spencer JAD (1989) Fetal heart rate variability. In Progress in Obstetrics and Gynaecology, volume 7 (Studd J ed), Churchill Livingstone, Edinburgh, pp 103–122Google Scholar
  40. 40.
    Spencer JAD (1991) The predictive value of a fetal heart rate acceleration at the time of fetal blood sampling in labour. J Perinat Med 19: 207–215PubMedCrossRefGoogle Scholar
  41. 41.
    Spencer JAD, Johnson P (1986) Fetal heart rate variability changes and fetal behavioural cycles during labour. Br J Obstet Gynaecol 93: 314–321PubMedGoogle Scholar
  42. 42.
    Spencer JAD, Ward HRT (1993) Intrapartum Fetal Surveillance. Royal College of Obstetricians and Gynaecologists Press, LondonGoogle Scholar
  43. 43.
    Spencer JAD, Koutsoukis M, Lee A (1991) Fetal heart rate and neonatal condition related to epidural analgesia in women reaching the second stage of labour. Eur J Obstet Gynecol Reprod Biol 41:173–178PubMedCrossRefGoogle Scholar
  44. 44.
    Spencer JAD, Robson SC, Farkas A (1993) Spontaneous recovery after severe metabolic acidaemia at birth. Early Hum Dev 32:103–111PubMedCrossRefGoogle Scholar
  45. 45.
    Sykes GS, Molloy PM, Johnson P, Gu W, Ashworth F, Stirrat GM and Turnbull AC (1982) Do Apgar scores indicate asphyxia? Lancet I: 494–496CrossRefGoogle Scholar
  46. 46.
    Tejani N, Mann LI, Bhakthavathsalan A, Weiss RR (1975) Correlation of fetal heart rate — uterine contraction patterns with fetal scalp blood pH. Obstet Gyncol 46, 392–396Google Scholar
  47. 47.
    Tejani N, Mann LI, Bhakthavathsalan A (1976) Correlation of fetal heart rate paterns and fetal pH with neonatal outcome. Obstet Gynecol 48: 460–463PubMedGoogle Scholar
  48. 48.
    Thacker SB (1991) Effectiveness and safety of intrapartum fetal monitoring. In Fetal Monitoring (Spencer JAD ed), Oxford University Press, Oxford, pp 211–217.Google Scholar
  49. 49.
    Thorp JA, Sampson JE, Parisi VM, Creasy RK (1989) Routine umbilical cord blood gas determinations. Am J Obstet Gynecol 161: 600–605PubMedGoogle Scholar
  50. 50.
    Wheble AM, Gillmer MDG, Spencer JAD, Sykes GS (1989) Changes in fetal monitoring practice in the UK: 1977–1984. Br J Obstet Gynaecol 96:1140–1147PubMedCrossRefGoogle Scholar
  51. 51.
    Winkler CL, Hauth JC, Tucker JM, Owen J, Brumfield CG (1991) Neonatal complications at term as related to the degree of umbilical artery acidemia. Am J Obstet Gynecol 164: 637–641PubMedGoogle Scholar
  52. 52.
    Young DC, Gray JH, Luther ER, Peddle LJ (1980) Fetal scalp blood pH sampling: its value in an active obstetric unit. Am J Obstet Gynecol 136: 276–281PubMedGoogle Scholar

Copyright information

© Dr. Dietrich Steinkopff Verlag, GmbH & Co. KG, Darmstadt 1994

Authors and Affiliations

  • John A. D. Spencer
    • 1
  1. 1.Department of Obstetrics and GynaecologyUniversity College London Medical SchoolLondonUK

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