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Cardiotocography Duringlabour LONDON, SATURDAY 6 FEBRUARY 1993 BMJ BMJ: first published as 10.1136/bmj.306.6874.347 on 6 February 1993. Downloaded from Cardiotocography during labour An unsatisfactory technique but nothing betteryet Maternal blood flow to the placenta may be severely trials of intrapartum monitoring) showed the subsequent diminished by uterine contractions, so labour has the potential prevalence of cerebral palsy among survivors to be no lower sometimes to damage the fetus.' In the last century some in the monitored group.8 asphyxiated babies were noted to have abnormally fast-or Continuous cardiotocography is more restricting than slow-heart rates, and auscultation evolved as a component of intermittent auscultation, although the method of fetal intrapartum care. The human ear is insensitive to subtle monitoring is less important to women than the support they changes in rate, so electronic methods of recording were receive from staff or companions.9'0 The cardiotocography developed. These generate paper traces that show features machine must certainly not be used as a poor substitute for not obvious on auscultation, including the degree of midwifery care, nor should a shortage of midwives be used as variation of the heart rate and the shape of accelerations and an argument for a policy of continuous cardiotocography. A decelerations in rate. But more information is not compromise in current favour-is the admission cardiotoco- necessarily more instructive, or we should judge textbooks graphy test'" followed by intermittent auscultation and simply by their size. cardiotocography. This approach has appeal, but its effec- The effectiveness of medical interventions is best evaluated tiveness has not yet been rigorously assessed. by a systematic analysis of randomised controlled trials. The With these disadvantages established for intrapartum overviews of intrapartum monitoring in the Oxford database cardiotocography (not to mention local trauma and infection of perinatal trials (now the Cochrane Collaboration from scalp electrodes), should the technique be abandoned http://www.bmj.com/ pregnancy and childbirth module2) have been discussed altogether?'2 The answer is complicated by medicolegal widely.' Briefly, they showed that the use of continuous implications. Cardiotocography records are carefully scruti- electronic fetal heart rate monitoring caused higher rates of nised and sometimes pivotal in expensive legal actions. The medical intervention, including caesarean section during the trace provides a permanent record, which may be used, for first stage of labour and instrumental vaginal delivery during example, to show that the poor condition of a baby at birth the second. When compared with intermittent auscultation was neither predictable nor preventable. Arguably, however, alone continuous fetal heart rate doubled rates the midwife's record of a normal fetal heart rate should be just monitoring on 1 October 2021 by guest. Protected copyright. of caesarean section for "fetal distress" even when it was as acceptable as evidence. complemented by selective fetal blood sampling and pH Where, then, do we stand? The available evidence does not estimation4; the rate was quadrupled when monitoring was support routine continuous fetal heart rate monitoring during used alone.5 Further evidence of excessive intervention came all labours. In a normal labour intermittent auscultation with from a recent trial in Plymouth of analysis during labour of a Pinard stethoscope could not be regarded as an inadequate the waveform of the fetal electrocardiogram.6 In this, 1200 or negligent form of assessment. Some obstetricians argue women were randomly assigned to either cardiotocography that the choice of method should be left to the woman. If she alone or cardiotocography plus waveform analysis; the opts for cardiotocography it must be done properly. Any operative delivery rate for "fetal distress" was double in the unusual features should be noted and the response to them group assigned to cardiotocography alone. made by a qualified and experienced person. All members of Increased rates of operative delivery are not necessarily the obstetric and midwifery staff should speak the same bad if genuinely compromised babies are rescued from language and use the same method of classification- death and damage. Various outcomes have been examined something that can be achieved only by regular meetings on in randomised controlled trials of intrapartum fetal cardiotocography. The classification of decelerations as early, monitoring; the only complication to show a lower (and late, and variable, as used in the Dublin trial, seems best; largely consistent) decrease in the monitored groups was the terms "type I" and "II dips" are archaic. Staff should neonatal convulsion,4 and this protective effect seemed to be be made aware that some of the most sinister fetal heart rate confined to prolonged, induced, or augmented labours. decelerations (late) are often shallow and difficult to detect; Neonatal convulsion is an uncommon problem but one that some of the most obvious with greatest amplitude (variable) is potentially serious. Many parents would presumably place may be of little pathological importance. In practice, high priority on avoiding this risk, even though the Dublin adherence to a clearly defined policy for fetal heart rate trial7 (which by its size and quality dominates overviews of monitoring may be more important than the actual method. BMJ VOLUME 306 6 FEBRUARY 1993 347 If only because cardiotocography has been shown to reduce popular alternative has not yet emerged for either. The the rate of neonatal convulsions after complicated labours its search for better techniques of fetal assessment during use should not be abandoned. Maternity units should have labour continues. For "high risk" fetuses, waveform analysis clear, explicit guidelines on the grounds for recommending of the electrocardiogram shows promise6; oximetry still has cardiotocography so that the clinical and legal responsibility some way to go.14 does not lie with a junior obstetrician or midwife. Suitable JAMES P NEILSON BMJ: first published as 10.1136/bmj.306.6874.347 on 6 February 1993. Downloaded from grounds might include prolonged, augmented, or induced Professor of Obstetrics and Gynaecology labours; multiple pregnancies; thick meconium staining of amniotic fluid; and a growth retarded or preterm fetus. Royal Liverpool University Hospital, Audible heart rate decelerations also indicate a need for Liverpool L7 8XP electronic monitoring. Improvements in the results of monitoring will come not 1 Janbu T, Nesheim B-I. Uterine artery blood velocities during contractions in pregnancy and labour related to intrauterine pressure. BrJ Obstet Gynaecol 1987;94:1150-5. only by better identification and interpretation of abnormali- 2 Chalmers I, Dickersin K, Chalmers TC. Getting to grips with Archie Cochrane's agenda. BMJ ties of the fetal heart rate but also through better responses by 1992;305:786-8. 3 Grant A. Monitoring the fetus during labour. In: Chalmers I, Enkin M, Keirse MJNC, eds. attendants to unusual patterns. Simple measures (stopping Effective care in pregnancy and childbirth. Oxford: Oxford University Press, 1989:846-82. the oxytocin the mother's posture, 4 Grant AM. EFM+scalp sampling vs intermittent auscultation in labour. In: Chalmers I, ed. Oxford infusion, altering restoring database of perinatal trials. Version 1.3, disk issue 8. Oxford: Oxford University Press, blood pressure to normal) often suffice; techniques such as 1992:record 3297. 5 Grant AM. EFM alone vs intermittent auscultation in labour. In: Chalmers I, ed. Oxford database amnioinfusion deserve further investigation as alternatives to ofperinatal trials. Version 1.3, disk issue 8. Oxford: Oxford University Press, 1992:record 3298. operative delivery.'3 6 Westgate J, Harris M, Cumow JSH, Greene KR. Randomised trial of cardiotocography alone or with ST waveform analysis for intrapartum monitoring. Lancet 1992;340:194-8. Recording the fetal heart rate has become a fixed feature of 7 MacDonald D, Grant AM, Sheridan-Pereira M, Boylan P, Chalmers I. The Dublin randomized intrapartum care; we need to reconsider and remember that it controlled trial ofintrapartum fetal heart rate monitoring. AmJ Obstet Gynecol 1985;152:524-39. 8 Grant AM, O'Brien N, Joy M-T, Hennessy E, MacDonald D. Cerebral palsy among children bom is an extremely limited method for assessing the health of the during the Dublin randomised trial ofintrapartum monitoring. Lancet 1989;ii: 1233-6. fetus. We do not expect doctors to run an intensive care unit 9 Grant AM. EFM vs intermittent auscultation in labour. In: Chalmers I, ed. Oxford database of perinatal trials. Version 1.3, disk issue 8. Oxford: Oxford University Press, 1992:record 3884. simply by measuring the pulse rates of their patients. The 10 Garcia J, Corry M, MacDonald D, Elboume D, Grant A. Mothers' views of continuous electronic fetal heart rate monitoring and intermittent auscultation in a randomized controlled trial. Birth status of intrapartum fetal heart rate recording (whether 1985;12:79-85. assessed by ear or by machine) is similar to that ofthe neonatal 11 Ingemarsson I, Arulkumaran S, Ingemarsson E, Tamby Raja RL, Ratnam SS. Admission test-a screening test for fetal distress in labor. Obstet Gynecol 1986;68:800-6. test frequently used to assess the effectiveness of the 12 CockbumJE, Pearce JM, Chamberlain GVPC. Intrapartum fetal monitoring. Lancet 1992;340:610. measure-the much
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