An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case‐control study

Frey, H; Liu, X; Lynch, Carl; Musindi, Wanjiku; Samuels, Philip; Rood, Kara M.; Thung, S. F.; Bakk, JM; Cheng, Weiwei; Landon, MB

doi:10.1111/1471-0528.15222

Cited by 25 publications

(24 citation statements)

References 29 publications

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“…Many fetuses neurologically injured during labor do not show severe metabolic acidosis at birth and may even be asymptomatic (15)(16)(17). On the other hand, most fetuses with even severe abnormalities of BD (<15) (18) do not require assistance at birth (2).…”

Section: The Premise Of Efmmentioning

confidence: 99%

Approaches to Preventing Intrapartum Fetal Injury

et al. 2022

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Electronic fetal monitoring (EFM) was introduced into obstetric practice in 1970 as a test to identify early deterioration of fetal acid-base balance in the expectation that prompt intervention (“rescue”) would reduce neonatal morbidity and mortality. Clinical trials using a variety of visual or computer-based classifications and algorithms for intervention have failed repeatedly to demonstrate improved immediate or long-term outcomes with this technique, which has, however, contributed to an increased rate of operative deliveries (deemed “unnecessary”). In this review, we discuss the limitations of current classifications of FHR patterns and management guidelines based on them. We argue that these clinical and computer-based formulations pay too much attention to the detection of systemic fetal acidosis/hypoxia and too little attention not only to the pathophysiology of FHR patterns but to the provenance of fetal neurological injury and to the relationship of intrapartum injury to the condition of the newborn. Although they do not reliably predict fetal acidosis, FHR patterns, properly interpreted in the context of the clinical circumstances, do reliably identify fetal neurological integrity (behavior) and are a biomarker of fetal neurological injury (separate from asphyxia). They provide insight into the mechanisms and trajectory (evolution) of any hypoxic or ischemic threat to the fetus and have particular promise in signaling preventive measures (1) to enhance the outcome, (2) to reduce the frequency of “abnormal” FHR patterns that require urgent intervention, and (3) to inform the decision to provide neuroprotection to the newborn.

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Section: The Premise Of Efmmentioning

confidence: 99%

Approaches to Preventing Intrapartum Fetal Injury

et al. 2022

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“…), it is unreasonable to consider that the metabolic status or the tissue oxygen reserve of each fetus, or the time to decompensation is the same. Indeed, "Category II" pattern may reflect a normal healthy fetus, but it does not exclude either fetal acidosis or fetal neurological injury (10)(11)(12)(13).…”

Section: The Classification Of Fhr Patternsmentioning

confidence: 99%

“…A greater deficiency was the failure to understand the provenance of intrapartum fetal injury based on the assessment of both immediate and long-term outcome, not just injury associated with a very low pH. Although ACOG guidelines, at least, accept the evolution of Category I to Category III as confirmation of an intrapartum injury, most babies injured during labor do not have severely pathological patterns (11), nor are they acidemic at birth. The de rigueur requirement of acidosis to make the correlation between fetal heart rate patterns and injury made a virtue out of necessity in that no measurements of greater relevance, such as fetal blood pressure or cerebral perfusion, were available.…”

Section: Implementation Of the Category Systemmentioning

confidence: 99%

Electronic Fetal Monitoring–Prevention or Rescue?

Schifrin

2020

Front. Pediatr.

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“…In retrospect, its rapid, broad implementation was predicated on a limited number of publications that were not randomized control trials. 1 Subsequently, numerous publications have either confirmed or strongly denied the efficacy of this approach 2 -5 but invariably advanced the notion that EFM is largely responsible for the rise in cesarean delivery rate (CDR). 6,7 Indeed, some of its fundamental principles (eg, lack of fetal acidosis and the absence of neurologic injury with category [CAT] II) have been shown to be erroneous.…”

Section: Introductionmentioning

confidence: 99%

“…6,7 Indeed, some of its fundamental principles (eg, lack of fetal acidosis and the absence of neurologic injury with category [CAT] II) have been shown to be erroneous. 2 -4…”

Section: Introductionmentioning

confidence: 99%

The Fetal Reserve Index Significantly Outperforms ACOG Category System in Predicting Cord Blood Base Excess and pH: A Methodological Failure of the Category System

et al. 2019

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Objective:Electronic fetal monitoring (EFM) has been used extensively for almost 50 years but performs poorly in predicting and preventing adverse neonatal outcome. In recent years, the current “enhanced” classification of patterns (category I-III system [CAT]) were introduced into routine practice without corroborative studies, which has resulted in even EFM experts lamenting its value. Since abnormalities of arterial cord blood parameters correlate reasonably well with risk of fetal injury, here we compare the statistical performance of EFM using the current CAT system with the Fetal Reserve Index (FRI) for predicting derangements in base excess (BE), pH, and pO2in arterial cord blood.Methods:We utilized a research database of labor data, including umbilical cord blood measurements to assess patients by both worst CAT and last FRI classifications. We compared these approaches for their ability to predict BE, pH, and pO2in cord blood.Results:The FRI showed a clear correlation with cord blood BE and pH with BE being more highly correlated than pH. The CAT was much less predictive than FRI ( P < .05). The CAT II cases had FRI scores across the spectrum of severity of FRI designations and as such provide little clinical discrimination. The PO2was not discriminatory, in part, because of neonatal interventions.Conclusions:The Fetal Reserve Index (FRI) provides superior performance over CAT classification of FHR patterns in predicting the BE and pH in umbilical cord blood. Furthermore, the CAT system fails to satisfy multiple fundamental principles required for successful screening programs. Limitations of CAT are further compounded by assumptions about physiology that are not consistent with clinical observations.

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An evaluation of fetal heart rate characteristics associated with neonatal encephalopathy: a case‐control study

Abstract: Category III tracings are not uncommon prior to delivery among fetuses who develop neonatal encephalopathy.

Cited by 25 publications

References 29 publications

Approaches to Preventing Intrapartum Fetal Injury

Approaches to Preventing Intrapartum Fetal Injury

Electronic Fetal Monitoring–Prevention or Rescue?

The Fetal Reserve Index Significantly Outperforms ACOG Category System in Predicting Cord Blood Base Excess and pH: A Methodological Failure of the Category System

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