Re: Are we (mis)guided by current guidelines on intrapartum fetal heart rate monitoring? Case for a more physiological approach to interpretation

Abstract

Sir, I thank Dr Amin for her positive comments on my review of the role of current guidelines on intrapartum fetal heart rate (FHR) monitoring, and the proposed algorithm based on fetal cardiovascular adaptation to intrapartum asphyxia.1 The reliance of the guidelines on the morphological appearances, and the reference values for FHR features rather than on the relationships, temporal sequence, and the natural connection between FHR decelerations, tacchycardia or bradycardia, and loss of variability leaves the bedside clinician without an understanding of how the fetus defends itself from intrapartum hypoxia and the FHR patterns that suggest failure of that defense. This approach weakens the clinical utility of current guidelines and contributes to increased operative delivery of non-acidotic babies. In too many training modules, terms implying the presumed origins of the FHR decelerations are emphasised, overused, and presumed to be innocuous. As a result clinicians expend valuable time and energy trying to characterise and distinguish between the different types of FHR decelerations and the subtypes of 'complicated' variable decelerations from each other 2 even though most of them have been shown to have no association with fetal acidosis.3 The important point is how the fetus is handling the decelerations.Obstetric units like yours that have grasped the physiological principles of FHR monitoring and are prepared to invest in staff training and education will continue to enjoy lower rates of unwarranted operative delivery for presumed fetal compromise, escalating costs to their service and the resultant short-and long-term maternal morbidity. Disclosure of interestsNone. n References 1 Ugwumadu A. Are we (mis)guided by current guidelines on intrapartum fetal heart rate monitoring? Case for a more physiological approach to interpretation.