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PubMed1992

Fetal surveillance in the intensive care unit: understanding electronic fetal monitoring.

Electronic fetal monitoring has become an integral component of current obstetric nursing care. The goals of surveillance are to establish fetal well-being and identify the fetus at risk for asphyxia and death. Fetal heart rate (FHR) responses provide a cardiovascular indication of fetal acid-base status. To evaluate FHR tracings and plan care accordingly, the nurse must understand the physiologic regularity mechanisms of the fetus, baseline patterns, and periodic changes of the fetal heart rate.

Critical Care↗
PubMed2001

Historical controversy in health technology assessment: the case of electronic fetal monitoring.

Electronic fetal monitoring (EFM) was introduced in the late 1950s as an alternative to traditional auscultation by stethoscope or fetoscope in the management of labor and delivery. The new technology was seen as a valuable tool in the prevention of cerebral palsy and other adverse fetal outcomes and diffused rapidly into clinical practice. In the late 1970s, some scepticism began to be voiced about the evidence for the effectiveness of EFM. The authors published a systematic review of the evidence in 1979 that concluded that there was insufficient evidence for the effectiveness of the routine use of EFM and a clear rise in the cesarean delivery rate associated with its use. The analysis was based on a thorough review of approximately 600 books and articles, but focused heavily on the evidence of four randomized clinical trials (RCTs) that had been published. An economic analysis further underscored the importance of this issue. The report was met with harsh ad hominem criticism from clinicians both in public venues and in the medical literature. Subsequently, additional RCTs were conducted and other analyzes were published, and in 1987 the American College of Obstetricians and Gynecologists recommended that auscultation was an acceptable alternative to EFM in routine labor and delivery. Yet, today EFM continues to be the standard of practice, used in 80% of labors in this country. The most important conclusion drawn from this experience is the need to evaluate new technologies before their widespread diffusion into clinical practice.

Attitude of Health Personnel↗
PubMed1979

Policies toward medical technology: the case of electronic fetal monitoring.

Electronic fetal monitoring (EFM) is an example of a medical technology that has been widely accepted since its introduction in the mid-1960s. However, review of the literature does not provide convincing evidence of EFM efficacy, and four recent, controlled, clinical trails show little if any benefit in terms of preventing death or long-term disability of the baby. Public and private policies have largely acted to encourage use of EFM, and none have acted to slow or prevent its spread. This need for mechanisms to assure the timely evaluation of new medical technologies before they are accepted as a medical practice has led to a new medical devices program in the Food and Drug Administration, consensus development groups at the National Institutes of Health, and congressional legislation to establish a new National Center for Health Care Technology.

Equipment and Supplies↗
PubMed1981

Impact of routine fetal monitoring during labor on fetal outcome with long-term follow-up.

A computerized system for the storage of antenatal, intrapartal, and neonatal data has been used since 1973. The present study evaluated the influence of changed neonatal and obstetric practices, with special regard to routine fetal monitoring. Three periods were studied: 1973-1974 (6,542 deliveries, only selected high-risk patients monitored); 1975-1976 (6,857 deliveries, high-risk patients monitored); 1977-1979 (9,638 deliveries, 90% monitored). The numbers of infants with an Apgar score less than 7 at 1 and 5 min were similar in 1973-1974 and 1975-1976, but the number was significantly reduced in 1977-1979. During the years studied, all but eight infants with an Apgar score less than 7 at 5 min participated in a scheduled long-term follow-up (at least 14 mo). In 1973-1974, 25 infants (35.2%) demonstrated neurological handicaps. In 1975-1976, 14 infants (19.2%) had sequelae; in 1977-1979, only three infants (4.6%) were damaged. Trend analysis showed a significant reduction in the number of infants with neurological sequelae through the years; the reduction was significant for premature and low-risk infants but not for mature high-risk infants. The improved short-term and long-term fetal outcomes seem to be largely a result of routine fetal monitoring with all its implications for obstetric and neonatal management; the significant reduction in neurological sequelae, even after correction for other changes in obstetric routines, supports this suggestion.

Apgar Score↗
PubMed1999

The medical and legal risks of the electronic fetal monitor.

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound. Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.

Auscultation↗
PubMed1976

The current status of intrapartum fetal monitoring.

Intensive intrapartum fetal monitoring, using direct fetal EKG leads and intrauterine pressure sensing transducers, seems to add another level of care for the fetus. As with other laboratory aids or devices, fetal monitoring data should not be exclusively relied on in decision making processes. When used with other modern monitor aids, such as scalp pH, it can aid immensely in the management of both normal and complicated labors. When fetal heart rate patterns remain normal throughout labor there can be a high degree of confidence that the fetal outcome will be good. If abnormal patterns occur, however, great care should be taken in interpreting these data, and it should be combined with the overall status of the mother and the fetus, and used together with the clinical acumen of the physician in determining a method of approach to the management of intrapartum situations. Continuous monitoring techniques can and should be applied in the neonatal nursery for intensive neonatal management and care (79,80). As experience is gained in clinical fetal monitoring and as new techniques and methods become available, intensuve intrapartum fetal monitoring will become an increasingly important and significant technique for management of labor (4, 139).

Acid-Base Imbalance↗
PubMed1999

Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis.

OBJECTIVE: To determine the predictive value of each fetal heart rate (FHR) variable and of patterns of FHR variables for fetal asphyxia during labor. METHODS: This matched case-control study included an asphyxia group of 71 term infants with umbilical artery base deficit greater than 16 mmol/L and a control group of 71 term infants with umbilical artery base deficit less than 8 mmol/L. Each FHR record available for the 4 hours before delivery was scored in 10-minute cycles for each FHR variable. Selected patterns of important FHR variables were examined during the last hour before delivery for their predictive value for fetal asphyxia. RESULTS: The FHR variables associated with fetal asphyxia included absent and minimal baseline variability and late and prolonged decelerations. Fetal heart rate patterns with absent baseline variability were the most specific but identified only 17% of the asphyxia group. The sensitivity of this test increased to 93% with the addition of less specific patterns. The estimated positive predictive value ranged from 18.1% to 2.6%, and the negative predictive value ranged from 98.3% to 99.5%. CONCLUSION: A narrow 1-hour window of FHR patterns including minimal baseline variability and late or prolonged decelerations will predict fetal asphyxial exposure before decompensation and newborn morbidity. Thus, with careful interpretation, predictive FHR patterns can be a useful screening test for fetal asphyxia. However, supplementary tests are required to confirm the diagnosis and to identify the large number of false-positive patterns to avoid unnecessary intervention.

Acidosis↗
PubMed1981

An evaluation of the tissue pH electrode for fetal monitoring using the fetal sheep as an experimental model.

The performance of the Roche tissue pH electrode has been assessed by comparison of values recorded by the the electrode with the pH of arterial blood, in fetal sheep. Observations were made under controlled conditions when the fetal pH was steady, during hypoxia, and after hypoxia. The results showed a highly significant correlation of the values recorded by the electrodes with the pH of arterial blood (r = 0.89, p less than 0.001 during control; and r = 0.86, p less than 0.001 during hypoxia and recovery). However, in about 10% of cases the insertion proved to be unsatisfactory, and in one half of the successful insertions there was a rapid initial drift which lasted up to 45 min. After stabilization, tissue pH values were symmetrically distributed about the atrial pH, with a SD of 0.07 unit. Multiple electrodes in the same fetus gave the same scatter. Movements of the electrode caused significant artefacts. During hypoxia (produced by compression of the cord or administration of gas mixtures low in O2), the electrodes lagged behind the changes in arterial pH by up to 10 min. The conclusion is that the inherent variability of the tissue pH electrode makes it unsuitable as an absolute indicator of fetal well-being, and that it cannot be used alone as an indication for operative intervention. Nevertheless, because of the limitations of conventional techniques, it should be valuable as an adjunct and, in particular, it should help in the interpretation of equivocal fetal heart rate tracings, thereby reducing the risk of fetal death.

Animals↗
PubMedDate not supplied

Psychological responses to the use of the fetal monitor during labor.

Fetal monitoring, a major advance in obstetrical care, transforms the labor room into an intensive care setting. The psychological effects of this new technology were investigated by means of structured interviews with 25 postpartum women. The multiplicity of psychological responses obtained are described. The relationship of demographic, obstetrical, and psychosocial variables to women's overall positive or negative reaction to the monitor was investigated. Personality characteristics and life experiences with pregnancy and childbirth were factors that shaped the manner in which the monitor was experienced. The effect of fetal monitoring on maternal anxiety is discussed. The impact of mechanization on the total experience of childbirth is noted.

Anxiety↗
PubMed1997

Results of 12 years' combined maternal serum alpha-fetoprotein screening and ultrasound fetal monitoring for prenatal detection of fetal malformations in Havana City, Cuba.

Progressively since 1982 and as part of a nationwide programme for the diagnosis and prevention of genetic diseases, maternal serum alpha-fetoprotein (MS-AFP) screening and ultrasound fetal monitoring has been implemented in all pregnant women in Cuba. In Havana City, 328,983 pregnant women underwent MS-AFP screening between 15 and 19 weeks of gestational age. With a cut-off level of > or = 2 multiples of the normal median (MOM), 1767 amniocenteses were carried out to determine the levels of amniotic fluid AFP and 685 malformed fetuses were diagnosed. By ultrasound fetal monitoring, an additional 686 malformed fetuses were detected. As a result of the programme, the birth prevalence of neural tube defects has fallen by 90 per cent.

Amniotic Fluid↗
PubMed1976

[Frequency of obstetrical operations and perinatal mortality before and after admission of continuous fetal monitoring (author's transl)].

Two groups of obstetrical patients were statistically analyzed with a computer. The first group A (2339 deliveries, January 1967-June 1968) was controlled by conservative obstetrical methods, the second group B (2512 deliveries, January 1973-June 1974) was controlled by continuous monitoring of fetal heart rate and by analysis of fetal blood during labour. The results of the statistical analysis can be summarized: 1. The frequency of obstetrical operations (vacuum, obstetrical forceps, Caesarean section) increases from 12.8% (group A) to 22.5% (group B). 2. The percentage of Caesarean sections decided on for the sake of the child rose from 45.7% (group A) to 54.7% (group B). 3. Vital indications fell due to increasingly preventive obstetrics from 54.3% to 45.3%. 4. The frequency of Caesarean sections rose due to increasing indication "absolute or relative pelvic disproportion" of the mediterranean patients. 5. However the analysis of fetal blood during labour and the continuous monitoring of fetal heart rate has prevented a further increase of Caesarean sections. 6. The increasing percentage of obstetric forceps was due to our intention of preventing prolonged labour. 7. Maternal mortality after operative delivery reached 0.04% in group A and 0% in group B. 8. Perinatal mortality of children, delivered by operation, has decreased from 3.0% (group A) to 0,7% (group B). 9. The Apgar scores after operative deliveries were much better in group B (continuous fetal monitoring) than in group A (without fetal monitoring).

Apgar Score↗
PubMed2000

Intrapartum fetal monitoring: past, present, and future.

The concept of intrapartum "monitoring" of the fetal heart rate by auscultation has been extant for almost 200 years and by electronic means for more than 30 years. This article explores historical aspects of fetal monitoring, the advent of electronic fetal monitoring and its controversies, and present and future research opportunities to enhance the reliability, validity, and efficacy of fetal monitoring.

Female↗
PubMed1996

Uncertain value of electronic fetal monitoring in predicting cerebral palsy.

BACKGROUND: Electronic monitoring of the fetal heart rate is commonly performed, in part to detect hypoxia during delivery that may result in brain injury. It is not know whether specific abnormalities on electronic fetal monitoring are related to the risk of cerebral palsy. METHODS: Among 155,636 children born from 1983 through 1985 in four California counties, we identified singleton infants with birth weights of at least 2500 g who survived to three years of age and had moderate or severe cerebral palsy. The children with cerebral palsy were compared with randomly selected control children with respect to characteristics noted in the birth records. RESULTS: Seventy-eight of 95 children with cerebral palsy and 300 of 378 controls underwent intrapartum fetal monitoring. Characteristics found to be associated with an increased risk of cerebral palsy were multiple late decelerations in the heart rate, commonly defined as slowing of the heart rate well after the onset of uterine contractions (odds ratio, 3.9; 95 percent confidence interval, 1.7 to 9.3), and decreased beat-to-beat variability of the heart rate (odds ratio, 2.7; 95 percent confidence interval, 1.1 to 5.8); there was no association between the highest or lowest fetal heart rate recorded for each child and the risk of cerebral palsy. Even after adjustment for other risk factors, the association of abnormalities on fetal monitoring with an increased risk of cerebral palsy persisted (adjusted odds ratio, 2.7; 95 percent confidence interval, 1.4 to 5.4). The 21 children with cerebral palsy who had multiple late decelerations or decreased variability in heart rate on fetal monitoring represented only 0.19 percent of singleton infants with birth weights of 2500 g or more who had these fetal-monitoring findings, for a false positive rate of 99.8 percent. CONCLUSIONS: Specific abnormal findings on electronic monitoring of the fetal heart rate were associated with an increased risk of cerebral palsy. However, the false positive rate was extremely high. Since cesarean section is often performed when such abnormalities are noted and is associated with risk to the mother, our findings arouse concern that, if these indications were widely used, many cesarean sections would be performed without benefit and with the potential for harm.

Adult↗
PubMed1976

A computerized fetal monitoring system.

A computerized fetal monitoring system has been developed at the Cedars-Sinai Medical Center in Los Angeles, California. It utilizes unmodified fetal monitors feeding fetal heart rate and uterine pressure data into a minicomputer. The overall accuracy on internal monitoring is 91%. The concept of on-line computer analysis of fetal monitoring records has met with clinical acceptance and is utilized for all patients in labor at the Cedars-Sinai Medical Center.

Blood Pressure↗
PubMed1990

[The survey on the perinatal variables and the incidence of cerebral palsy for 12 years before and after the application of the fetal monitoring systems].

The effects of electrical fetal monitoring such as cardiotocogram (CTG) and nonstress test (NST) were studied during the years 1975-86 in 6,981 cases (6,893 singletons, 41 twins and 2 triplets). These cases were divided into three groups according to the mode of fetal monitoring. The first group was managed without electrical fetal monitoring (control group). The second was managed mainly with intrapartum fetal monitoring (transitional group) and the third was managed with antepartum and intrapartum fetal monitoring (fully monitored group). The incidence of cerebral palsy (CP) was investigated at the social health center during the same period. The introduction of intrapartum fetal monitoring resulted in a reduction in neonatal asphyxia from 7.0% in the control group to 5.2% and 4.3% in the transitional group and fully monitored group respectively. The perinatal mortality rate showed a significant reduction from 0.61% in the period without antepartum fetal monitoring to 0.31% in the fully monitored group, and this was attributed to the significant reduction in the number of stillbirths. The incidence of CP in the district decreased from 2.2 to 0.2 per 1,000 children during the period studied. In these circumstances, the caesarean section rate increased from 7.0% in the control group to 11.8% in the transitional group but decreased to 9.8% in the fully monitored group. These results showed the clinical and social benefits of electrical fetal monitoring.

Cerebral Palsy↗