Electronic Fetal Monitoring—Imperfect but Opportunities for Improvement

Abstract

Being born is one of the riskiest endeavors that most of us have undertaken. For example, the risk of dying or developing cerebral palsy ranges from 1 in 500 to 1 in 1000 associated with events around the time of birth. Electronic fetal monitoring was specifically developed to reduce the risk of cerebral palsy. While an initial study of electronic fetal monitoring reported a reduction in neonatal seizures, 1 a follow-up study did not find similar reductions in cerebral palsy. 2 Furthermore, because it appears that only approximately 25% to 35% of cases of cerebral palsy are associated with intrapartum events, 3 a modified goal would be to reduce the risk of neonatal encephalopathy or metabolic acidemia, 2 relatively common precursors of cerebral palsy associated with birth asphyxia.Over the past 2 decades there have been efforts to refine how electronic fetal monitoring may reduce perinatal asphyxia. The Fetal Pulse-Oximetry Trial randomized approximately 1000 laboring women to a fetal oxygen saturation assessment vs standard fetal monitoring and found no differences in neonatal acidemia. 4 The STAN fetal heart monitor (Neoventa Medical) trial randomized more than 11 000 women to a new tool that analyzed the fetal electrocardiogram ST wave form vs standard fetal monitoring and again found no differences. 5 Another recent study 6 randomized more than 45 000 laboring women to receive care that was augmented by a computer algorithm and support tool designed to both identify abnormal fetal heart rate tracings and provide standardized care plans to the clinicians. This study found no difference in worse neonatal outcomes (0.7% in each group) between the computer-supported care group or the usual care group. Of note, while there was no difference in outcomes between the groups, clinicians were not blinded regarding the study, and the overall rates of both perinatal mortality and neonatal encephalopathy were lower than had been estimated by prestudy institutional data. Because the clinicians in the study were trained in the use of the algorithm, these data suggest that outcomes were associated with improved training and algorithmic approaches, even if not demonstrated by the comparative portion of the study.Additionally, in both groups of the study, 38% of the time when the computer identified abnormal fetal heart rate readings that would have resulted in changes from a care algorithm, the clinicians did not engage in the change in care.Thus, there are multiple opportunities to use electronic fetal monitoring in the context of neonatal encephalopathy: (1) there must be identifiable events that can be detected by continuous electronic fetal monitoring; (2) the events must be interpretable by clinicians; (3) there need to be practice changes that clinicians can engage in that prevent the progression to fetal acidemia; and (4) the consequences must be substantial enough to prevent the fetal or neonatal injury. There appear to be limitations for each of these steps.Farquhar and colleagues 8 designed a case-control study to ...

Study on effectiveness of systematic cardiotocography use in National Maternal and Child Health Center in Cambodia: A study protocol for an explanatory clinical trial

“…CTG use in HICs is a de facto standard despite several recommendations. In 2004, 86% of women in labor were monitored using CTG in the United States [11]. However, no data on the coverage of intrapartum monitoring in LMICs is available [12].…”