Fetal Monitoring during Labor

Abstract
For three decades, cardiotocography has been the basic technique for fetal surveillance
during labor, but its impact on fetal well-being remains controversial. The benefits and
disadvantages of fetal monitoring with cardiotocography during labor are reviewed.
Special reference is made to the possible effect on the rate of neonatal seizures in
newborns and their long-term outcome.
Introduction
The aim of fetal monitoring during labor is to identify fetal hypoxia and intervene
appropriately before severe asphyxia or death occurs. Technical advances in the mid20th century allowed the fetal heart rate (FHR) to be recorded continuously, and this
has become an important aspect of the management of labor. With cardiotocography
(CTG) the FHR and uterine contractions are continuously recorded and this provides
the possibility of monitoring the development of a process of hypoxia. The basal heart
rate, its variability and reactivity and possible decelerations in association with
contractions are important measures for evaluation of fetal well-being [1] . A reactive
pattern with FHR accelerations in response to fetal movements has a very high
predictive value for a fetus with adequate oxygenation and fetal asphyxia after a
reactive trace is extremely rare. Unfortunately, CTG changes, particularly FHR
decelerations, are common and occur in about half of all recordings. Thus, CTG has a
high sensitivity but a low specificity for fetal hypoxia/asphyxia. As this difficulty remains,
our incomplete understanding of the mechanisms of the fetal response to these varying
circumstances means that it is often difficult to predict fetal well-being from the FHR
alone.
Fetal Monitoring with CTG and Auscultation
Formal assessment of the value of FHR monitoring has focused attention on the
comparison between CTG and auscultation of the FHR with a fetal stethoscope, without
acknowledging that auscultation itself has never been evaluated impartially. With
auscultation, accelerations and basal heart rate can be identified together with
moderate/severe decelerations heard soon after the contraction. However, sharply
reduced/absent baseline variability, the most important measures of fetal compromise,
is not possible to diagnose by auscultation. Continuous monitoring by auscultation
cannot be carried out and it may be difficult in a busy labor ward to listen to the FHR at
frequent intervals that are necessary. In fact, a study showed that only 3% of the
laboring women received auscultation according to agreed guidelines
Randomized Controlled Trials
Nine randomized controlled trials (RCTs) performed between 1976 and 1993 including
18,561 pregnant women in both high- and low-risk pregnancies comparing CTG with
auscultation during labor have been subjected to meta-analysis [3] . Most of the
included studies were small, were carried out 3035 years ago and facilities for
determination of pH in scalp blood were available in only four studies. It is reasonable to
believe that interpretation of CTG records may be better today with increased
experience through the years. The largest study performed in Dublin included 13,084
women [4] and this provides a weight of 70% in the meta-analysis [3] .
CTG and Perinatal Mortality
In most studies only 02 deaths were recorded. In the meta-analysis [3] , no difference
between the two study groups was noticed with the exception of the most recently

published study from Athens [5] . In this study, 2 deaths occurred in the CTG group
compared to 9 in the auscultation group and this resulted in early closure of the study
for ethical reasons. In the Dublin study, women with meconium-stained amniotic fluid,
short labors and deliveries before 28 weeks gestation were excluded (in all 3,676
deliveries) and with that 56 of the 82 neonatal deaths. In another meta-analysis of the
same RCTs but including only cases where fetal asphyxia was the likely cause of death,
a significant reduction in perinatal mortality was found [6] . This method of analyzing
results from the RCTs has been criticized as the principle of intention to treat was not
used. However, the authors argue that one cannot expect CTG to predict obstetric
catastrophes like large placental abruption, cord prolapse, uterine rupture, shoulder
dystocia and trauma. Intrapartum asphyxia accounts for a small proportion of perinatal
mortality. Fetal death during labor is rare today and predominantly due to obstetric
catastrophes. One may speculate that FHR monitoring has played a role in reducing
intrapartum deaths due to asphyxia through the years, although this is not evident from
the RCTs which enrolled a limited number of participants. In general, an intrapartum
death due asphyxia is a sign of inadequate fetal monitoring.
CTG and Neonatal Seizures
The most conspicuous finding in the RCTs was a 50% reduction in the rate of neonatal
seizures (relative risk 0.51, 95% confidence interval (CI) 0.320.82). The authors of the
meta-analysis, however, suggested that the long-term implications of this outcome
appear less serious than once believed [3] , a statement that has been disputed.
Support for the benign nature of neonatal seizures comes from a study of young adults
who had various degrees of neonatal encephalopathy [7] . If they did not have evidence
of brain damage at 18 months of age and were without neurological impairment as
young adults, then their educational achievements and social adjustment were similar to
controls [7] . Indeed, the outcome of neonatal encephalopathy has often been treated
as an all-ornothing phenomenon: either a completely normal development or severe
disability. In contrast, a large number of studies have come to different conclusions.
Robertson and Finer [8] found that unimpaired survivors of moderate encephalopathy
after birth asphyxia at term had poorer school performance than their peers. Similar
results have been reported by others [9, 10] . Van Handel et al. [11] in a comprehensive
review concluded that subjects who had moderate neonatal encephalopathy had
variable outcomes but in general lower intelligence scores and more difficulties in
reading, spelling and arithmetic/mathematics than controls. In a recent national cohort
study involving all 97,468 children born in Sweden in 1985, Lindstrm et al. [12]
identified all 684 children born at term with an Apgar score ! 7 at 5 min. After exclusion
of those with major malformations, severe perinatal infections and opioid-induced
depression, 56 of the 684 surviving children who had moderate neonatal
encephalopathy were traced at age 1519 years. 13 mothers declined to participate
leaving 43 to be assessed. 15 of these had cerebral palsy or other major neuroimpairments. Of the 28 without cerebral palsy, 20 had cognitive dysfunction that
interfered with their daily lives. Only 8 teenagers were without impairments. Taking
these results into consideration, the reduction of neonatal seizures after use of CTG in
both high-risk and low-risk women compared to auscultation speaks strongly in favor of
use of CTG.
CTG and Cerebral Palsy
Long-term follow-up of the infants was performed in only two of the RCTs [4, 13] .
Despite a sharp reduction in cases with neonatal seizures in the Dublin study [4] , the
long-term follow-up showed a similar rate of cerebral palsy at 4 years of age. In the
Seattle study [13] , the effect of fetal monitoring was investigated in the preterm period
(fetal weights of 7001,750 g). No significant differences were noted in the prevalence
of low 5-min Apgar scores, intrapartum acidosis, intracranial hemorrhage, perinatal

deaths or frequency of cesarean sections. However, there was a higher rate of cerebral
palsy in the CTG group (16/122) compared with auscultation (7/124). The design of the
study may have influenced the results. In the CTG group, intervention with cesarean
section according to the protocol should not be done unless scalp blood pH was ! 7.20,
while in the auscultation group intervention was allowed if some aberrations in the fetal
tone could be heard. In fact, the authors found an association between long-lasting
pathological CTG traces and brain damage which, in contrast to their own conclusions,
seemed to support the use of CTG. We found that infants with fetal acidosis (pH ! 7.25
in scalp blood) had more neurologic abnormalities in the neonatal period and a higher
rate of neurodevelopmental disability at follow-up than non-acidotic infants of the same
gestational age [14] . Cerebral palsy is a rare condition occurring in about 2 per 1,000
births in term infants. Can we expect a significant reduction in the rate of cerebral palsy
by using intrapartum fetal monitoring? Indeed, this hope was frequently voiced in the
literature after the introduction of continuous fetal monitoring into obstetric practice.
Intrapartum asphyxia is responsible for only a small proportion of cases of brain
damage, such as cerebral palsy, according to long-term studies from USA, Australia and
Sweden [1517] . In only 827% of all children with spastic cerebral palsy was
intrapartum asphyxia considered the likely cause of brain damage. Confounding factors
were present in some of these cases, which made the relationship even more uncertain.
In a recent review, it was concluded that intrapartum hypoxia is the possible cause in
only about 10% of cases of cerebral palsy [18] . In fact, it has been suggested that one
explanation for the association between birth asphyxia and spastic cerebral palsy is that
asphyxia is more likely to occur if there has already been cerebral damage during the
antenatal period or that there is a greater predisposition to further damage during labor
[16] . Thus, severe acidemia may be a marker of brain damage rather than the cause.
Brain damage may already be present when labor starts, and although intervention may
not improve the outcome, it may prevent it from becoming worse. There is no specific
FHR pattern for fetuses with intrauterine brain damage, although some changes are
more common. Phelan and Ahn [19] investigated the FHR pattern during labor in 300
brain-damaged infants. In 51% of cases, the FHR admission test (see below) was
reactive. An ominous FHR pattern, in some cases a preterminal pattern, developed
during labor in 84%. In 49%, the trace was non-reactive on admission and in most
cases it showed a fixed, flat baseline during labor. The FHR pattern on admission may
provide a clue that antenatal damage may already have occurred.
CTG and Intervention with Cesarean Section and Instruments
In the nine RCTs [3] comparing CTG and auscultation for monitoring in labor, a
significant increase was observed in the CTG group in the rate of cesarean delivery (RR
1.41, 95% CI 1.111.30) and operative vaginal delivery (RR 1.20, 95% CI 1.111.30).
Indeed, the low specificity of the method in predicting fetal hypoxia results in
unnecessary interventions and is a great disadvantage. However, this should be
balanced against the sharp reduction in the rate of neonatal seizures. This increase in
the rate of cesarean deliveries may today be of less importance as the overall section
rate in Western Europe is about 20% and in the USA above 30%. A considerable
number of operations are done on maternal request without medical indication.
Fetal Scalp Blood and Electrocardiogram Measurements
To, at least partially, overcome the problems with the low specificity of CTG for fetal
hypoxia/asphyxia, supportive techniques such as measuring scalp blood pH [20] ,
lactate [21] or changes in the fetal electrocardiogram (ECG), the STAN method [22] ,
have been introduced. Scalp blood measurements of pH were introduced in order to
add information of the well-being of the fetus when pathological changes appear on the
CTG. However, a single fetal scalp pH assessment may give limited information
regarding the significance of an abnormality of FHR.

trace. Significant hypoxia will produce progressive acidemia that will only be recognized
by repeated measurements at short intervals. The development of a bedside method for
measurement of lactate in fetal blood made monitoring of fetal acid-base assessment
more reliable and easier. The respiratory component of acid-base balance is not
measured which may facilitate interpretation and only 5 l of blood is needed compared
with 25 l for pH determination [23] . ST waveform analysis of the fetal ECG (STAN) has
been introduced as a support aid to CTG. There are two randomized studies of this
method with different conclusions regarding its benefit in reducing severe metabolic
neonatal acidosis [22, 24] . In a recent study [25] , the STAN method was found to
display events during labor with pathological CTG changes in two thirds of cases when
the newborn had severe metabolic acidemia (cord artery pH ! 7.00 and lactate ^ 10
mmol/l). On the other hand, events occurred in 49% of controls without acidemia.
FHR Admission Test
A FHR admission test is a short CTG recording of a laboring woman soon after
admission to the labor ward [26] . The test may detect fetal hypoxia already present on
admission allowing appropriate intervention before asphyxia has progressed to cause
brain damage. An ominous FHR pattern with fixed baseline and absent variability may
indicate an already compromised fetus and may be of importance in assessment of
subsequent management of labor [19] . A third possible advantage is that continuous
FHR monitoring may not be needed after a reactive test [27] . However, randomized
studies have not shown any advantage of the FHR admission test in detecting fetal
acidemia at birth in low-risk women [27, 28] . These studies could be criticized for using
the test for only 20 min, so fetal sleep phases could be interpreted wrongly as nonreactive traces. Further, a very high rate of pathological traces (2232%) casts doubt on
the skills of the personnel to interpret the traces correctly. Anyhow, the test is widely
used probably because it is regarded a necessary part, together with examination of the
mother, of establishing fetal well-being and reassuring the mother soon after her
admission for labor. It has been argued that after a reactive test it takes a catastrophic
event to cause fetal death during labor [30] .
Use of CTG in Clinical Practice
The International Federation of Gynecology and Obstetrics (FIGO) appointed a
subcommittee to draw up guidelines for use of monitoring and interpretation of FHR
patterns [1] . The value of FHR monitoring of highrisk women in labor was considered
certain, but there remained differences of opinion as to the value of routine monitoring in
all labors. The admission test was considered by many to be of value. Other consensus
reports have stated that FHR monitoring should be strongly considered in any at-risk
patient. It is recognized that fetal hypoxia during labor may occur in any pregnancy,
although it is more common in a pregnancy with risk factors for placental dysfunction.
Unexpected events can also arise during labor in low-risk labors that subsequently
require intensive surveillance. Equipment and training for FHR monitoring must be
considered at any birth center. However, routine continuous FHR monitoring is not
necessary for most women and should be restricted as far as possible to avoid the
associated disadvantages of the method. In one study, low-/moderate-risk women (80%
of the population) were randomized to either continuous FHR monitoring during the
whole labor or to intermittent FHR monitoring every second hour with auscultation in
between [27] . All were screened with a FHR admission test that had to be reactive
before enrollment in the study. In the intermittent FHR monitoring group, monitoring time
was halved (38.8%) compared with that in the continuous FHR monitoring group
(78.6%). The incidence of cesarean section for fetal distress was similarly low in both
groups. There were no significant differences in immediate neonatal outcome in terms
of umbilical artery pH, Apgar scores or admissions to the neonatal unit.