The Big Lie "As long as the baby and mom are health"

The ACOG guidelines highlight a case in which four obstetricians examined 50 FHR tracings; they agreed in only 22% of the cases. Two months later, these four physicians reevaluated the same 50 FHR tracings, and they changed their interpretations on nearly one out of every five tracings.

Think about this when discussing electronic fetal monitoring with your OB at your prenatal visits. Consider why he or she insists on using EFM. Ask yourself how continuously listening to the baby's heart rate can in any way ensure a better outcome or if it will more than likely ensure you are forced into an unnecessary c-section.

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For Release: June 22, 2009

ACOG Refines Fetal Heart Rate Monitoring Guidelines

Washington, DC -- Refinements of the definitions, classifications, and
interpretations of fetal heart rate (FHR) monitoring methods were
issued today in new guidelines released by The American College of
Obstetricians and Gynecologists (ACOG). The objective of the
guidelines is to reduce the inconsistent use of common terminology and
the wide variability that sometimes occurs in FHR interpretations.
ACOG's Practice Bulletin, published in the July 2009 issue of
Obstetrics & Gynecology, supports the recommendations of the Eunice
Kennedy Shriver National Institute of Child and Health Development
workshop* on electronic fetal monitoring (EFM) held in April 2008.

The intent of FHR monitoring is to help keep an eye on the status of
the fetus during labor and intervene if necessary. There are two main
FHR monitoring methods. The most commonly used method is EFM, which
detects the fetal heart rate and the length of uterine contractions
and the time between them. EFM allows physicians and nurses to measure
the response of the fetal heart rate to uterine contractions. A lesser-
used method is manual auscultation, which employs either a small
handheld Doppler device or a fetoscope (similar to a stethoscope) . A
normal fetal heart varies between 110 and 160 beats per minute. A
heart rate that doesn't vary or is too low or too high may signal a
potential problem with the fetus.

"Since 1980, the use of EFM has grown dramatically, from being used on
45% of pregnant women in labor to 85% in 2002," says George A.
Macones, MD, who headed the development of the ACOG document.
"Although EFM is the most common obstetric procedure today,
unfortunately it hasn't reduced perinatal mortality or the risk of
cerebral palsy. In fact, the rate of cerebral palsy has essentially
remained the same since World War II despite fetal monitoring and all
of our advancements in treatments and interventions. "

One notable update in the guidelines is the three-tier classification
system for FHR tracings (print-outs of the fetal heart rate). Category
1 FHR tracings are considered normal and no specific action is
required. Category 2 tracings are considered indeterminate. This
category requires evaluation and surveillance and possibly other tests
to ensure fetal well-being. Category 3 tracings are considered
abnormal and require prompt evaluation, according to ACOG. An abnormal
FHR reading may require providing oxygen to the pregnant woman,
changing the woman's position, discontinuing labor stimulation, or
treating maternal hypotension, among other things. If the tracings do
not return to normal, the fetus should be delivered.

"Our goal with the ACOG guidelines was to define existing terminology
and narrow definitions and categories so that everyone is on the same
page," says Dr. Macones. One of the problems with FHR tracings is the
variability in how they're interpreted by different people. The ACOG
guidelines highlight a case in which four obstetricians examined 50
FHR tracings; they agreed in only 22% of the cases. Two months later,
these four physicians reevaluated the same 50 FHR tracings, and they
changed their interpretations on nearly one out of every five tracings.

A meta-analysis study shows that although EFM reduced the risk of
neonatal seizures, there is still an unrealistic expectation that a
nonreassuring FHR can predict the risk of a baby being born with
cerebral palsy. The false-positive rate of EFM for predicting cerebral
palsy is greater than 99%. This means that out of 1,000 fetuses with
nonreassuring readings, only one or two will actually develop cerebral
palsy. The guidelines state that women in labor who have high-risk
conditions such as preeclampsia, type 1 diabetes, or suspected fetal
growth restriction should be monitored continuously during labor.

Practice Bulletin #106, "Intrapartum Fetal Heart Rate Monitoring:
Nomenclature, Interpretation, and General Management Principles," is
published in the July 2009 issue of Obstetrics & Gynecology.

* In 2008, The Eunice Kennedy Shriver National Institute of Child
Health and Human Development partnered with ACOG and the Society for
Maternal-Fetal Medicine to sponsor a workshop focused on EFM.

# # #

The American College of Obstetricians and Gynecologists (ACOG) is the
nation's leading group of physicians providing health care for women.
As a private, voluntary, nonprofit membership organization, ACOG:
strongly advocates for quality health care for women; maintains the
highest standards of clinical practice and continuing education of its
members; promotes patient education; and increases awareness among its
members and the public of the changing issues facing women's health
care.