Categorization of cerebral palsy cases: a different perspective TO THE EDITORS: Nakao et al 1 rigorously categorized electronic fetal monitoring (EFM) for 1069 cases of severe cerebral palsy (CP). However, our interpretation of their data is somewhat different than the authors. They concluded that, on admission, approximately 30% of cases were already damaged. Accurately identifying such cases would suggest that better strategies for antepartum assessment and action are needed. Some cases of CP certainly have genetic origin and are not preventable, but other cases of CP might have benefited from earlier intervention. We believe that using our multipublished metric, the Fetal Reserve Index (FRI), those cases would likely on admission have been scored as red zone, implying that the fetuses were already in trouble. We consider EFM to be a classic screening test. As such, frequent unanalyzable cases constitute poor screening test metrics. Consequently, more than 20% of their cases were "unclassified" and not included. In addition, they concluded that another 20% of their cases were of postpartum origin.Focusing only on the R-Hon pattern, the authors concluded that only 16% of cases were preventable, which artificially dilutes the importance of labor management. Such method perceptually minimizes the need for adequate evaluation, management, and personnel being available. By removing the damaged cases and 10% of unclassified cases (hypothesizing half of unclassified cases might be identified with a better system), many more cases could actually be amenable to risk reduction with precision evaluation.We have taken an expansive approach to EFM interpretation. With EFM evaluation contextualized by uterine activity and maternal, fetal, and obstetrical risk factors (FRI), our data suggested that screening metrics can be improved. 2e4 In addition, the 20% of cases that Nakoa categorized as having "postpartum" etiologies were consistent with our published observations that fetal and neonatal acid base balances (pH and base excess) typically worsen after birth before they get better, and 85% of neonates have a transient, significant tachycardia (both often beyond risk threshold levels). 4 The -