Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6

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Best Practice & Research Clinical

Obstetrics and Gynaecology
journal homepage: www.elsevier.com/locate/bpobgyn

Introduction: Why is intrapartum foetal

monitoring necessary e Impact on outcomes and
interventions
Diogo Ayres-de-Campos, MD, PhD *
Department of Obstetrics and Gynecology, Medical School, Institute of Biomedical Engineering, University of
Porto, Porto, Portugal

Maintaining maternal oxygen supply is essential for foetal life, and

Keywords:
labour constitutes an increased challenge to this. Good clinical
heart rate
foetal judgement is required to evaluate the signs of reduced foetal
cardiotocography oxygenation, to diagnose the underlying cause, to judge the
monitoring reversibility of the condition and to determine the best timing for
physiologic delivery. The main aim of intrapartum foetal monitoring is to
foetal oxygenation identify foetuses that are being inadequately oxygenated, enabling
appropriate action before the occurrence of injury. It is also to
provide reassurance in cases of adequate foetal oxygenation, and
thus to avoid unnecessary obstetric intervention. Poor foetal
oxygenation is diagnosed by documenting metabolic acidosis in
the umbilical cord immediately after birth or in the newborn cir-
culation during the first minutes of life. However, most newborns
recover quickly, and they do not develop relevant short- or long-
term complications. Hypoxiceischaemic encephalopathy is the
short-term neurological dysfunction caused by inadequate intra-
partum foetal oxygenation, and cerebral palsy of the spastic
quadriplegic or dyskinetic types is the long-term neurological
complication most commonly associated with it. Although there is
insufficient evidence from randomised controlled trials to
demonstrate that any form of intrapartum foetal monitoring re-
duces the incidence of adverse outcomes, reports from the clinical
setting have documented a decrease in metabolic acidosis, hypoxic
eischaemic encephalopathy and intrapartum death over the last
decades. It may be difficult to demonstrate the benefit of

* Departamento de Obstetrícia e Ginecologia, Faculdade de Medicina da Universidade do Porto, Alameda Hernani Monteiro,
4200-319 Porto, Portugal. Tel.: þ351 966707112.
E-mail address: [email protected].

http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
1521-6934/© 2015 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
2 D. Ayres-de-Campos / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6

diagnostic techniques in complex environments such as the labour

ward, but a reduction in the incidence of adverse clinical outcomes
constitutes important evidence that intrapartum foetal monitoring
makes a difference.
© 2015 Elsevier Ltd. All rights reserved.

The importance of oxygen supply to the foetus

The foetus requires oxygen and glucose to maintain cellular aerobic metabolism, its main source of
energy production. Although glucose can be stored and later mobilised, oxygen needs to be supplied
continuously, as an interruption of only a few minutes is enough to place the foetus at risk. Oxygen is
obtained via the maternal respiration and circulation, placental perfusion, placental gas exchange,
umbilical cord and foetal circulation. Complications occurring at any of these levels may result in
decreased oxygen supply, with a subsequent reduction in foetal arterial oxygen concentration
(hypoxaemia), and ultimately oxygen supply to the foetal tissues (hypoxia).
In the absence of oxygen, the energy production in the foetal cells can still be maintained for a
limited period of time, using the anaerobic metabolism pathway, but this yields 19 times less energy
and results in the production of lactic acid. The consequent increase in hydrogen ion concentration
inside the cell, in the extracellular fluid and in the foetal circulation is called metabolic acidosis.
Reduced energy production and increased hydrogen ion concentration will ultimately lead to cell death
and to tissue injury.

Why does labour increase the risk of foetal hypoxia/acidosis?

Uterine contractions compress the blood vessels running inside the myometrium, and this may
temporarily decrease the perfusion of the placental bed. Sometimes, the umbilical cord is compressed
between foetal parts, or between the foetus and the uterine wall, and umbilical blood circulation may
be reduced during contractions. The frequency, duration and intensity of uterine contractions deter-
mine the magnitude of these disturbances, and the interval between contractions is crucial for re-
establishment of foetal oxygenation. Excessive uterine activity is the most common cause of foetal
hypoxia/acidosis, and should be avoided irrespective of the occurrence of foetal heart rate (FHR)
changes [1]. This can usually be accomplished by reducing oxytocin infusion, removing administered
prostaglandins and/or starting acute tocolysis with beta-adrenergic agonists (salbutamol, terbutaline
and ritodrine), atosiban or nitroglycerin. During the second stage of labour, maternal pushing may
aggravate the effect of uterine contractions, so the mother should also be asked to stop pushing until
the situation is reversed. Transient cord compression can sometimes be resolved by changing the
maternal position or performing amnioinfusion [2].
Another frequent cause of reduced foetal oxygenation is the maternal supine position, which may
cause aorto-caval compression by the pregnant uterus and decreased placental perfusion. Turning the
mother on her side or asking her to stand up is usually followed by the normalisation of foetal
oxygenation.
Other maternal respiratory or circulatory complications may affect foetal oxygenation, such as acute
respiratory distress, sudden hypotension or cardiac dysfunction. Sudden maternal hypotension occurs
more frequently after epidural or spinal analgesia, and it can usually be reversed by rapid fluid
administration and/or an intravenous ephedrine bolus. Other maternal complications require specific
management, and the normalisation of foetal oxygenation depends on their reversible nature and on
the expected speed of recovery.
Major placental abruption and uterine rupture usually have a severe impact on foetal oxygenation
due to maternal blood loss and to the disruption of placental gas exchange. Both situations cause an
irreversible foetal hypoxia, and they require expedite delivery to avoid an adverse outcome.

Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
 D. Ayres-de-Campos / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6 3

Several mechanical complications of labour and delivery, such as umbilical cord prolapse, shoulder
dystocia and retention of the aftercoming head, may cause compression of the umbilical cord and/or a
part of the foetal circulation, thus conditioning foetal oxygenation. Specific obstetric measures are
required to resolve these situations, and once more the duration, intensity and recurrent nature of the
hypoxic insult will determine foetal outcome.
Acute foetal haemorrhage, associated with ruptured vasa praevia, or foetalematernal haemorrhage
reduces the oxygen-carrying capacity of the foetal circulation, and may result in foetal hypoxia.
Expedite delivery is required to avoid adverse foetal outcome associated with continued haemorrhage.
In all situations of foetal hypoxia/acidosis, good clinical judgement is required to diagnose the
underlying cause, to judge the reversibility of the condition and to determine the best timing of de-
livery, with the objective of avoiding adverse foetal outcome, as well as unnecessary obstetric
intervention.

The main objectives of intrapartum foetal monitoring

The main aim of intrapartum foetal monitoring is to identify foetuses that are being inadequately
oxygenated, enabling appropriate action before the occurrence of injury due to hypoxia/acidosis. It is
also to provide reassurance in cases of adequate foetal oxygenation, and thus to avoid unnecessary
obstetric intervention. It should be emphasised that in order to avoid adverse outcome related to
hypoxia/acidosis, in addition to foetal monitoring, an appropriate and timely clinical response is
required to revert the situation or to expedite delivery.

What are adverse foetal outcomes?

Oxygen concentration in tissues cannot in practice be quantified, so the occurrence of foetal hypoxia
can only be assessed by the documentation of metabolic acidosis in the umbilical cord immediately
after birth or in the newborn circulation during the first minutes of life [1]. A pH value below 7.00
together with a base deficit (BD) in excess of 12 mmol/l, or alternatively a blood lactate concentration
exceeding 10 mmol/l, is commonly regarded as indicating foetal metabolic acidosis [1].
Apgar scores at birth reflect the pulmonary, cardiovascular and neurological functions of the
newborn, and they are depressed when hypoxia/acidosis is sufficiently intense and prolonged to affect
these systems. The 1-min Apgar score is important to decide newborn resuscitation, but it has a limited
value in identifying intrapartum hypoxia/acidosis. With severe and prolonged hypoxia/acidosis, low 1-
and 5-min Apgar scores will occur, but lesser degrees will usually not affect them, and values can be
low due to other causes, such as prematurity, birth trauma, congenital anomalies, pre-existing lesions,
medication administered to the mother and vigorous endotracheal aspiration [1]. The 5-min Apgar
score has the strongest association with subsequent neurological outcome and neonatal death [1].
Most newborns with metabolic acidosis, with or without decreased Apgar scores, recover quickly,
and do not develop relevant short- or long-term complications. In only a few cases will hypoxia/
acidosis be of sufficient intensity and duration to affect important organs and systems, and put the
newborn at risk of death or of long-term disability.
The short-term neurological dysfunction caused by intrapartum hypoxia/acidosis is called hypo-
xiceischaemic encephalopathy (HIE), and the diagnosis requires the confirmation of metabolic
acidosis, low Apgar scores, early imaging evidence of cerebral oedema, together with changes in
muscular tone, sucking movements, seizures or coma in the first 48 h of life [1]. HIE may also be
accompanied by the dysfunction of the cardiovascular, gastrointestinal, haematological, pulmonary
and/or renal systems. The appearance of seizures or coma in the context of HIE increases the proba-
bility of long-term neurological sequelae and neonatal death. Cerebral palsy of the spastic quadriplegic
or dyskinetic types is the long-term neurological complication most commonly associated with
intrapartum hypoxia/acidosis, and together with perinatal death, it is the most feared adverse
outcome. However, only 10e20% of cerebral palsy cases are caused by intrapartum hypoxia/acidosis
[1]. Infection, congenital diseases, metabolic diseases, coagulation disorders, antepartum and postnatal
hypoxia, birth trauma and the complications of prematurity constitute the majority of causal situations.

Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
4 D. Ayres-de-Campos / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6

Avoiding unnecessary obstetric intervention

Although avoiding adverse foetal outcomes related to hypoxia/acidosis is the main objective of
intrapartum foetal monitoring, it is equally important that it does not result in unnecessary obstetrical
intervention, as this is associated with increased maternal and foetal risks. Caesarean section has been
associated with an increased risk of anaesthetic complications, urological lesions, major haemorrhage,
infection, thromboembolism, neonatal respiratory morbidity, childhood asthma and diabetes, stillbirth
and placenta praevia/acreta in subsequent pregnancies [3e8]. Instrumental vaginal delivery is also
associated with increased perineal lacerations and birth trauma [9].

Does intrapartum foetal monitoring avoid adverse outcomes and unnecessary intervention?

There are no good-quality data on the incidence of adverse foetal outcome in labouring women who
are not submitted to any form of foetal monitoring, because intermittent auscultation became part of
routine intrapartum care in most high-resource countries during the 19th century [10]. Most studies
have compared different monitoring technologies, using intermittent auscultation or continuous car-
diotocography (CTG) as the control group.
Continuous CTG was developed in the 1960s, and it rapidly gained a central role in intrapartum care
in high-resource countries. In many parts of the world, it is used routinely in both low- and high-risk
labours, in spite of inconclusive scientific evidence from randomised controlled trials to support this. In
other centres, intermittent auscultation is used in low-risk cases, but usually a relatively large per-
centage of women are monitored with CTG. In many low-resource countries, intermittent auscultation
is the only available option.
A large number of randomised controlled trials were conducted in the 1970s and 1980s comparing
continuous CTG monitoring with intermittent auscultation, in both low- and high-risk women [11]. It is
difficult to establish how the results of these trials relate to current clinical practice, as the under-
standing of the physiology of foetal oxygenation, CTG monitors, CTG interpretation and outcome
measures has meanwhile evolved considerably. With these limitations in mind, they indicate a limited
benefit of continuous CTG during labour, as the only significant improvement was a 50% reduction in
neonatal seizures (metabolic acidosis and HIE were not evaluated in most trials), and no differences
were found in the incidences of overall perinatal mortality and cerebral palsy. However, it is widely
recognised that the trials were underpowered to detect differences in these major outcomes [2]. On the
other hand, continuous CTG was associated with a 63% increase in caesarean delivery and a 15% in-
crease in instrumental vaginal deliveries [11]. On the whole, it must be concluded that the existing
evidence from randomised controlled trials for the benefits of continuous CTG monitoring, as
compared with intermittent auscultation, in both low- and high-risk labours is scientifically incon-
clusive [1].
CTG has been shown to have a high sensitivity but a limited specificity in predicting foetal hypoxia/
acidosis. In other words, a normal CTG is reassuring regarding the state of foetal oxygenation, but a
large number of foetuses with abnormal CTG patterns will not have clinically important hypoxia/
acidosis [12]. To reduce false-positive rates and the resulting unnecessary medical intervention,
adjunctive technologies to CTG were developed, such as foetal blood sampling (FBS), continuous foetal
pH monitoring, foetal lactate measurement, foetal pulse oximeter and ST waveform analysis, and some
of them were successfully implemented. However, there is still much uncertainty regarding the use of
these techniques, and further research is needed to provide more robust evidence on how they affect
intervention and adverse outcome rates [12].
Although there is insufficient scientific evidence from randomised controlled trials to demonstrate
that any form of intrapartum foetal monitoring improves clinical outcomes, several centres have re-
ported a decrease over time in metabolic acidosis rates with no increase in caesarean sections [13e15],
as well as reductions in HIE [16] and intrapartum death rates [17]. It may well be that randomised
controlled trials are not the best way of evaluating the real benefit of diagnostic techniques that are
used in a complex environment such as the labour ward, where health-care professionals are not al-
ways available to evaluate the signal, interpretation is subjective and poorly reproducible, the rela-
tionship between findings and clinical management may not be clear and the appropriateness of

Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
 D. Ayres-de-Campos / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6 5

clinical action plays a major role in avoiding adverse outcome and unnecessary intervention. It is time
to move on from the outdated evidence of randomised clinical trials of the 1970s and 1980s evaluating
continuous CTG, and to give more relevance to the reports of improved outcomes in routine clinical
practice. Improvements at all levels of the diagnosis and decision process in intrapartum foetal
monitoring may be required before a clear demonstration of benefit is seen, and the importance of
guidelines and training should not be underestimated.

Practice points

 Labour constitutes a challenge for the maintenance of maternal oxygen supply to the foetus
 There are many different causes for foetal hypoxia/acidosis during labour, some of which are
reversible, whereas others require expedite delivery
 The main aim of intrapartum foetal monitoring is to identify foetuses that are being inade-
quately oxygenated, enabling appropriate action before the occurrence of injury
 Another aim of intrapartum foetal monitoring is to provide reassurance in cases of adequate
foetal oxygenation, and thus to avoid unnecessary obstetric intervention
 Poor intrapartum foetal oxygenation can only be objectively demonstrated by documenting
metabolic acidosis in the umbilical cord immediately after birth or in the newborn circulation
during the first minutes of life
 Hypoxiceischaemic encephalopathy is the short-term neurological dysfunction caused by
inadequate intrapartum foetal oxygenation
 Perinatal death and cerebral palsy of the spastic quadriplegic or dyskinetic types are the most
feared complications of intrapartum foetal hypoxia/acidosis
 The evidence from randomised controlled trials to demonstrate that any form of intrapartum
foetal monitoring reduces the incidence of adverse outcomes is scientifically inconclusive
 Reports from the clinical setting have documented a decrease in metabolic acidosis, hypoxic
eischaemic encephalopathy and intrapartum death over the last decades

Research agenda

 To develop intrapartum foetal monitoring techniques to assure that health-care professionals

have an easier access to the information in busy labour wards
 To develop interpretation guidelines that are simple, objective and have a more direct rela-
tionship between interpretation and management
 To evaluate the effect of guidelines and training on the incidence of adverse outcomes
 To re-evaluate the benefit of the different intrapartum foetal monitoring technologies ac-
cording to current practice

Conflicts of interest

D. Ayres-de-Campos is one of the developers of the Omniview-SisPorto® (Alfragide, Portugal)

system for computer analysis of cardiotocographs. The Institute of Biomedical Engineering receives
royalties for the commercialisation of this system, which are entirely reinvested in research.

References

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Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004
6 D. Ayres-de-Campos / Best Practice & Research Clinical Obstetrics and Gynaecology xxx (2015) 1e6

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Please cite this article in press as: Ayres-de-Campos D, Introduction: Why is intrapartum foetal moni-
toring necessary e Impact on outcomes and interventions, Best Practice & Research Clinical Obstetrics
and Gynaecology (2015), http://dx.doi.org/10.1016/j.bpobgyn.2015.06.004