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Anti-Ro/SSA antibodies are associated with a risk of 1-2 % to develop complete atrioventricular block (AVB) in fetuses of positive mothers. Complete AVB is irreversible, but studies suggest that anti-inflammatory treatment during the transition period from a normal fetal heart rate (FHR) to an AVB might stop this progression and restore sinus rhythm. The most efficient method for diagnostic evaluation of this arrhythmia is the pulsed-Doppler fetal echocardiography. However, weekly or bi-weekly recommended fetal echocardiographic surveillance can rarely identify an AVB in time for treatment success, also because the transition from a normal rhythm to a third degree AVB is very fast. Daily FHR monitoring in a medical facility could increase the chances of identifying the AVB onset but is difficult to realize. For this reason, an alternative method of FHR monitoring, performed directly by mothers in their home context, has been recently proposed. We present a case report utilizing this approach and review the current evidence about this condition.

Objective Monitoring the heartbeat of the fetus during pregnancy is a vital part in determining their health. Current fetal heart monitoring techniques lack the accuracy in fetal heart rate monitoring and features acquisition, resulting in diagnostic medical issues. The demand for a reliable method of non-invasive fetal heart monitoring is of high importance. Method Electrocardiogram (ECG) is a method of monitoring the electrical activity produced by the heart. The extraction of the fetal ECG (FECG) from the abdominal ECG (AECG) is challenging since both ECGs of the mother and the baby share similar frequency components, adding to the fact that the signals are corrupted by white noise. This paper presents a method of FECG extraction by eliminating all other signals using AECG. The algorithm is based on attenuating the maternal ECG (MECG) by filtering and wavelet analysis to find the locations of the FECG, and thus isolating them based on their locations. Two signals of AECG collected at different locations on the abdomens are used. The ECG data used contains MECG of a power of five to ten times that of the FECG. Results The FECG signals were successfully isolated from the AECG using the proposed method through which the QRS complex of the heartbeat was conserved, and heart rate was calculated. The fetal heart rate was 135 bpm and the instantaneous heart rate was 131.58 bpm. The heart rate of the mother was at 90 bpm with an instantaneous heart rate of 81.9 bpm. Conclusion The proposed method is promising for FECG extraction since it relies on filtering and wavelet analysis of two abdominal signals for the algorithm. The method implemented is easily adjusted based on the power levels of signals, giving it great ease of adaptation to changing signals in different biosignals applications.

Objective Previous studies evaluating the situation-background-assessment-recommendation (SBAR) have been shown to increase effective nurse–physician communication and collaboration. The purpose of this study is to evaluate the impact of the SBAR technique on safety attitudes in the obstetrics department. Materials and Methods This study implemented the SBAR Collaborative Communication Education course and was conducted in a medical center from February 2012 to March 2015, which included an educational session on fetal heart rate monitoring, a case-based discussion, and a video demonstration on traditional and SBAR communication. The nurses in the obstetrics department were requested to report their clinical findings and recommendations using a novel SBAR list when abnormal fetal heart beat tracings occurred. All obstetric nurses were requested to complete the Chinese-version of the Safety Attitudes Questionnaire before and after the SBAR educational course. The primary outcome was to evaluate the effect of the SBAR technique on the safety attitudes of the obstetrics department. The secondary outcome was to evaluate the effect of the SBAR technique on the 5-minute Apgar score for neonates. Results Most values, including teamwork climate, safety climate, job satisfaction, and working conditions, significantly improved at both postintervention surveys compared with the preintervention survey. There were no significant differences in the number of the neonates with less than seven 5-minute Apgar scores between the pre- and postintervention periods. Conclusion The SBAR technique, which uses a novel structured handover list, is a feasible tool for nurse–obstetrician communication, and it may improve most dimensions of safety attitudes in the obstetrics department.

OBJECTIVE: To compare interpretability of two intrapartum abdominal fetal heart rate monitoring strategies. We hypothesized that an external fetal electrocardiography monitoring system, a newer technology using wireless abdominal pads, would generate more interpretable fetal heart rate data compared to standard external Doppler fetal heart rate monitoring (standard external monitoring). STUDY DESIGN: We conducted a randomized controlled trial at four Utah hospitals. Patients were enrolled at labor admission and randomized in blocks based on body mass index to fetal electrocardiography or standard external monitoring. Two reviewers, blinded to study allocation, reviewed each fetal heart rate tracing. The primary outcome was the percentage of interpretable minutes of fetal heart rate tracing. An interpretable minute was defined as >25% fetal heart rate data present and no more than 25% continuous missing fetal heart rate data or artifact present. Secondary outcomes included the percentage of interpretable minutes of fetal heart rate tracing obtained while on study device only, the number of device adjustments required intrapartum, clinical outcomes, and patient/provider device satisfaction. We determined that 100 patients per arm (200 total) would be needed to detect a 5% difference in interpretability with 95% power. RESULTS: 218 women were randomized, 108 to fetal electrocardiography and 110 to standard external monitoring. Device set up failure occurred more often in the fetal electrocardiography group (7.5% (8/107) versus 0% (0/109) for standard external monitoring). There were no differences in the percent of interpretable tracing between the two groups. However, fetal electrocardiography produced more interpretable fetal heart rate tracing in subjects with body mass index ≥30. When considering the percentage of interpretable minutes of fetal heart rate tracing while on study device only, fetal electrocardiography outperformed standard external monitoring for all subjects, regardless of maternal body mass index. Maternal demographics and clinical outcomes were similar between arms. In the fetal electrocardiography group, more device changes occurred compared to standard external monitoring (51% vs. 39%), but there were fewer nursing device adjustments (2.9 vs. 6.2 mean adjustments intrapartum, p

Since its inception, many have questioned the utility of electronic fetal heart rate (FHR) monitoring. However, it arrived without the benefit of clear, standard nomenclature, leading to difficulty interpreting studies regarding its benefit. In 2008, the National Institute of Child Health and Human Development (NICHD) developed standard nomenclature for interpreting eFHR tracings. Understanding what drives the tracings is key to managing them. Category II FHR patterns are by far the most common and most diverse patterns, leading to broad variation in care. Presented here is an algorithm for standardization of management of category II FHR tracings, based on the pathophysiology of decelerations, that can be followed in any labor unit.

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented.

The main goals of fetal surveillance are to avoid fetal death and to recognize the fetus that will benefit from early intervention with resuscitation or delivery. Surveillance can occur in the antepartum or intrapartum period. Continuous fetal heart rate monitoring is the most common form of surveillance in the intrapartum period. Several techniques are used in the antepartum period, including nonstress test, biophysical profile, and contraction stress test. Multiple techniques are used once distress is noted in the fetus, with the ultimate resuscitation effort being delivery.

The goal of this review is to synthesize the available information regarding factors leading to the first cesarean, especially as it relates to the role of electronic fetal heart rate monitoring (EFM) in the prevention of the first cesarean. The widespread use of EFM did not reduce perinatal or neonatal adverse outcomes. Coupled with its inherent problems, such as poor sensitivity and reliability, this has led to a dramatic increase in cesarean delivery rates. To be realistic in any attempt to lower the current cesarean rate, we must address the inherent limitations in our current EFM methods.

In 1999, a highly publicized report from the Institute of Medicine identified major deficiencies in the United States health care system, which fueled the rapid growth of the modern patient safety movement. One of the greatest risks to patient safety in obstetrics is poor communication of electronic fetal heart rate monitoring findings. Standardization and elimination of unnecessary complexity are 2 of the cornerstones of improved patient safety. This article describes a standardized, simplified approach to the definition, interpretation, and management of electronic fetal heart rate monitoring that is evidence-based and reflects consensus in the literature.

The perinatal results of the widespread adoption of the continuous electronic fetal heart rate monitoring during labor remain rather disappointing. This is due in part to a lack of consistent interpretation of the fetal heart tracings. Despite efforts by referral agencies over the past decade the situation has not improved. In defense of practitioners the heterogeneity and complexity of definitions and classifications patterns especially morphological currently proposed should be noted. Whereas with the recent advances in the field of neuroscience, it is now possible to visualize the chain of pathophysiological events that lead from the hypoxemic stimulus of the glomus cell to changes in the morphology of the fetal heart rate tracing. Thus by taking some examples of real situations, we propose a method of analysis that dissects the fetal heart tracing and take into account the functional specifications of the chemoreceptor when exposed to a hypoxic environment. Furthermore we can identify tracings with a "threshold effect" and also "sensitization and desensitization effects" according to the intensity, duration and recurrence of hypoxaemic episodes. This new approach based upon specific research into the mechanism behind the fetal heart rate abnormalities may be useful to complement the morphological study of the fetal heart tracing, to provide a better idea of the fetal status and to better define the indications of fetal blood sampling procedures.

Background To quantify changes in fetal heart rate (FHR) parameters after vibroacoustic stimulation (VAS) and to evaluate the usefulness of VAS testing (VAST) in anencephalic fetuses. Our findings may also help to clarify the route(s) of vibration and sound transmission during VAST. Study design and subjects We obtained the antepartum FHR tracings of 16 anencephalic fetuses, including both the nonstress test (NST) and VAST. Using a computerized monitoring system, HYFM, we determined all FHR parameters from data collected for 10min before and 10min after VAS, at successive gestational stages. Results We observed three false reactive responses at term. The false reactive rate for VAST (3/16) was higher than that for NST (1/16). No FHR parameters increased significantly after VAS except for the number of fetal movements (FM), which increased significantly in all gestational groups (25th–32nd and 33rd–40th weeks). Conclusions These findings call attention to an increased probability of a false reactive response in VAST analysis, when the fetus is affected by a CNS disorder. Increased numbers of FM after VAS suggest that the vibratory pathway is more likely to elicit fetal response than the auditory pathway in this setting, and that the vibratory stimulation travels by subcortical rather than by cortical pathways.

In this paper, an algorithm based on independent component analysis (ICA) for extracting the fetal heart rate (FHR) from maternal abdominal electrodes is presented. Three abdominal ECG channels are used to extract the FHR in three steps: first preprocessing procedures such as DC cancellation and low-pass filtering are applied to remove noise. Then the algorithm for multiple unknown source extraction (AMUSE) algorithm is fed to extract the sources from the observation signals include fetal ECG (FECG). Finally, FHR is extracted from FECG. The method is shown to be capable of completely revealing FECG R-peaks from observation leads even with a SNR=-200dB using semi-synthetic data.

The risk of fetal hypoxia during labour and delivery is far higher than in a similar period in the third trimester of pregnancy. Especially during the second stage of labour the fetus has an increased risk of suffering from hypoxia/asphyxia/acidosis. Particularly the development of neonatal seizures in the first 1–2 days following birth is an unfavourable sign for functioning in later life. Absence of accelerations and minimal or absent variability are prominent signs in infants who develop acidosis, followed by seizures in the neonatal period. A number of societies have provided guidelines on who, when and how to monitor the condition of the fetus during the process of labour and delivery. The choice mostly is between intermittent auscultation and electronic FHR monitoring. In some guidelines, electronic FHR monitoring is not a required standard, even for high-risk patients. Nevertheless few practitioners or hospitals have removed cardiotocographs from their labour and delivery units. The recommendation to leave the choice between intermittent auscultation and electronic FHR monitoring to the labouring woman and her attending clinician is based on the conclusions from meta-analyses summarizing outcomes and interventions in randomized controlled trials. Most randomized controlled trials (RCTs) were performed during the 1970s and 1980s. They comprise a mixture of low- and high-risk patients, and preterm and term labours. The studies lack information on how electronic FHR monitoring was performed. Allocation to either intermittent auscultation or electronic FHR monitoring has been variable. The outcome parameters varied likewise. Nearly all RCTs would not fulfil current standards for the quality of a randomised controlled trial. It is a general belief that the FHR tracings obtained with the external mode of FHR monitoring are of a quality comparable to the internal mode. Rupture of the membranes is considered unnecessary to generate a good quality trace. These opinions leading to false trust and the neglect of obtaining good quality traces are not supported by data from our own hospital. In singletons and especially in twins, internal FHR monitoring provides far better data than the external mode.

A PIC17C44 microcontroller development board and a real-time algorithm were developed with the capability of monitoring the fetal heart rate (FHR) as well as recording both the FHR and maternal heart rate for long-term. This paper describes the development of the microcontroller board and implementation of a real-time algorithm which were used to develop the portable recorder. Two set-up were developed. One setup was used to implement the algorithm in the PIC17C44 microcontroller board. Second set-up was developed for the assessment of the reliability of processed heart rates. A large number of clinical tests have shown the very good performance of the developed monitor in comparison with FHR curves simultaneously recorded with IFM-500 Doppler ultrasound fetal monitor. Statistical comparison was done and showed nonsignificant difference in mean ( p =0.05), correlation coefficient ( r =0.8–0.92) and low PRD (5–15).

Background Despite intensive efforts directed at initial training in fetal heart rate interpretation, continuing medical education, board certification/recertification, team training, and the development of specific protocols for the management of abnormal fetal heart rate patterns, the goals of consistently preventing hypoxia-induced fetal metabolic acidemia and neurologic injury remain elusive. Objective The purpose of this study was to validate a recently published algorithm for the management of category II fetal heart rate tracings, to examine reasons for the birth of infants with significant metabolic acidemia despite the use of electronic fetal heart rate monitoring, and to examine critically the limits of electronic fetal heart rate monitoring in the prevention of neonatal metabolic acidemia. Study Design The potential performance of electronic fetal heart rate monitoring under ideal circumstances was evaluated in an outcomes-blinded examination fetal heart rate tracing of infants with metabolic acidemia at birth (base deficit, >12) and matched control infants (base deficit, Results During the study period, 120 infants were identified with an arterial cord blood base deficit of >12 mM/L. Matched control infants were not demographically different from subjects. In actual practice, operative intervention on the basis of an abnormal fetal heart rate tracings occurred in 36 of 120 fetuses (30.0%) with metabolic acidemia. Based on expert, algorithm-assisted reviews, 55 of 120 patients with acidemia (45.8%) were judged to need operative intervention for abnormal fetal heart rate tracings. This difference was significant ( P =.016). In infants who were born with a base deficit of >12 mM/L in which blinded, algorithm-assisted expert review indicated the need for operative delivery, the decision for delivery would have been made an average of 131 minutes before the actual delivery. The rate of expert intervention for fetal heart rate concerns in the nonacidemic control group (22/120; 18.3%) was similar to the actual intervention rate (23/120; 19.2%; P =1.0) Expert review did not mandate earlier delivery in 65 of 120 patients with metabolic acidemia. The primary features of these 65 cases included the occurrence of sentinel events with prolonged deceleration just before delivery, the rapid deterioration of nonemergent category II fetal heart rate tracings before realistic time frames for recognition and intervention, and the failure of recognized fetal heart rate patterns such as variability to identify metabolic acidemia. Conclusions Expert, algorithm-assisted fetal heart rate interpretation has the potential to improve standard clinical performance by facilitating significantly earlier recognition of some tracings that are associated with metabolic acidemia without increasing the rate of operative intervention. However, this improvement is modest. Of infants who are born with metabolic acidemia, only approximately one-half potentially could be identified and have delivery expedited even under ideal circumstances, which are probably not realistic in current US practice. This represents the limits of electronic fetal heart rate monitoring performance. Additional technologies will be necessary if the goal of the prevention of neonatal metabolic acidemia is to be realized.

This paper presents a novel method for the determination of the fetal heart rate by the means of phonocardiography. The two-channel acoustic recording method measures simultaneously the fetal heart sounds on the maternal abdominal surface with the environmental noises. The recorded signals are sampled and analysed by a personal computer. The proposed measurement and signal processing methods provide an accuracy which is comparable to that of ultrasound technology has. The introduced system is viable as a fully non-invasive and inexpensive portable fetal heart rate monitoring device, especially in the field of home care and telemedicine applications.

Objective : Evidence Based Medicine has shown that the results of continuous electronic fetal heart rate (FHR) monitoring are equivalent to those of intermittent auscultation. We were interested in the method midwives preferred to use to monitor FHR during labour and the factors which influenced their choice of method. Study Design : A questionnaire with Likert scaled questions was sent to 500 German speaking Swiss midwives. Data analysis was performed by using SPSS for Windows. Results : The majority of the midwives were confident monitoring FHR using intermittent auscultation as their main method during low risk delivery. The essential factors influencing the choice of method of FHR monitoring were their own personal experience and hospital guidelines. Less important were factors such as risk category, litigation, the mother’s preferences, research results, time and staffing levels. Conclusions : Although the skills necessary to implement evidence into obstetrical practice are still available, evidence based research results do not seem to be of great importance, when midwives decide which method to use for intrapartum FHR monitoring. Hospital policies and the professional training received were more important factors. Programs designed to implement evidence in care should reflect the identification and use of these factors in order to facilitate the process of realisation.

Objectives: The aim of this study was to compare the visual analyses of fetal heart rate tracings by observers according to recent National Institute of Child Health and Human Development interpretative guidelines both with each other and with those of a computerized fetal heart rate analysis and alerting system. Study Design: One-hour sections of intrapartum fetal heart rate records were analyzed by a computerized monitoring system (Hewlett-Packard TraceVue; HP GmbH, Boblingen, Germany) and by 4 observers (a registered obstetric nurse, a certified nurse-midwife, an obstetrics resident physician, and a physician maternal-fetal medicine faculty member) instructed to use the new National Institute of Child Health and Human Development guidelines. We compared specific alerts, baseline rates, frequencies of accelerations and decelerations, and signal quality assessments generated by the TraceVue system and the observers. Power analysis indicated that 50 tracings were required to detect interobserver and observer-computer agreement levels of 80% ± 10%. Statistical comparisons used κ coefficient, χ 2 test, and analysis of variance with repeated measures as appropriate. Results: Levels of agreement between observer pairs and the computer did not vary significantly across successive 10-minute intervals. Overall levels of interobserver agreement for baseline rate, tracing quality assessment, frequencies of accelerations and decelerations, and alerts ranged from 45% to 99% and were highest for baseline rate and signal loss and lowest for acceleration and deceleration counts. Interobserver agreement for alerts was relatively high (range, 72%-84%), with virtually no difference between any of the observers and the computer (range, 76.9%-79.2%; κ = 0.25). Conclusion: Use of the National Institute of Child Health and Human Development guidelines for visual fetal heart rate interpretation did not increase agreements on most fetal heart rate features beyond those expected by chance or noted in previous reports. These guidelines did appear to blunt some interpretive differences, possibly as a result of observer background. Although levels of agreement on fetal heart rate features differed, agreements on clinical alerts were similar among all observers and a computerized fetal heart rate monitoring system. Computer analysis of fetal heart rate tracings could eliminate interobserver variation that results from visual analysis and could produce more consistent clinical responses to normal and abnormal fetal heart rate patterns. (Am J Obstet Gynecol 2000;183:361-6.)

~'ETAL HEART RATE monitoring (FHRM) has become a mainstay of current obstetric practice. After its development in the 1970s as a screening tool for severe intrapartum asphyxia resulting in neurological impairment or death, it was hoped that fetal and neonatal deaths due to intrapartum asphyxia would decrease drastically. Although many well-designed studies have not shown FHRM to be beneficial in reducing these outcomes, the technique is widely used. FHRM, in part, has been blamed for the increase in the rate of cesarean deliveries. The services of an anesthesiologist may be required to provide anesthesia for pregnant women in labor or for obstetric and nonobstetric surgery. In labor, operative vaginal or abdominal delivery may be performed for abnormalities of the fetal heart rate (FHR). Knowledge of FHRM will assist the anesthesiologist in providing optimum care without unnecessarily compromising mother or fetus.

The use of fetal blood sampling has been advocated widely to improve the specificity of fetal heart rate monitoring, but it remains a clinically unpopular procedure. This article considers its physiologic rationale and evidence base. It includes descriptions of the technique with suggestions for improved clinical interpretation and discusses the efficacy of fetal blood sampling with some consideration of possible alternatives.

Intrapartum fetal heart rate monitoring is commonly used to evaluate fetal status in labor, despite a lack of convincing randomized studies to support its use. The National Institutes of Health have helped standardize fetal heart rate monitoring terminology with their 1997 task force report, which will aid clinicians and scientists in their goal of providing quality care and research. The American College of Obstetricians and Gynecologists has recommended the term nonreassuring fetal status for electronic fetal monitor patterns that are not normal; however, Vanderbilt continues to use the terms fetal stress and fetal distress, using specific criteria for each. The approximately 30% of fetal heart rate tracings labeled as fetal stress (or nonreassuring fetal status) can be evaluated further by the use of fetal pulse oximetry, a new technology currently under evaluation in this country.

Objective : This study was designed to assess the changes in fetal oxygen saturation (FSp o 2 ) using fetal pulse oximetry when the fetal heart rate (FHR) monitoring became abnormal during stage II of labour. Study design : FSp o 2 was recorded with the Nellcor N400 Oximeter (FS-14 sensor) and was averaged over the last 10 min of the second stage of labour. Second stage FHR patterns were assessed according to Melchior's classification. Results : In terms of FHR patterns, FSp o 2 -10″ measured 41.4% in type 0 ( n =5), 42.4% in type 1 ( n =19), 43.3% in type 2 ( n =6), 34.0% in type 3 ( n =4) and 27.6% in type 4 ( n =7) ( P =0.03). Conclusions : FSp o 2 -10″ decreases in cases of severe FHR abnormality during the second stage of labour and could help to decide whether to perform an instrumental extraction. © 1997 Elsevier Science Ireland Ltd.

This study identifies cases of unexpected intrapartum fetal deaths over 20 years in a Canadian tertiary hospital. Of 121,659 births, 82 were intrapartum deaths. Eleven fetuses were considered viable and nonanomalous. Six deaths were deemed ideally preventable. Application of electronic fetal heart rate monitoring and rapid operative delivery may reduce the already low rate of intrapartum fetal deaths.

Objective : To compare the opinions of obstetricians who currently use fetal heart rate monitoring (FHRM) by telephone with the opinions of obstetricians in favour of this technique, but who do not use it. Study design : A mail questionnaire was sent to the 612 members of a professional organization of obstetricians. The response rate was 76%. Results : Fourteen percent of the respondents used FHRM by telephone and 43% did not use it, but were in favour of it. Compared with current users, non-users who were in favour of this technique indicated a wider range of clinical indications for monitoring, considered a greater proportion of women to be eligible, and wanted more frequent monitoring. These differences cannot be explained by the characteristics of the obstetricians (age, type of practice or attitude towards FHRM performed in maternity unit). Conclusion : Our survey shows a risk of extensive use of FHRM by telephone if this technique becomes easily accessible.

Optimal interpretation of the events of labor requires integration of information about cervical changes, fetal descent, uterine contractions, fetal position and attitude, as well as fetal heart rate monitoring and maternal condition. The use and understanding of labor curves is a vital part of this process. The complexity and diversity of labor data lend itself to computer storage and analysis.

Fetal heart rate monitoring, uterine contraction monitoring, and amnioinfusion are procedures used commonly during labor that have also improved our understanding of intrapartum physiology, although there are limitations to the ability of these procedures to improve pregnancy outcome. The current status of intrapartum fetal heart rate monitoring, uterine contraction monitoring, and amnioinfusion is reviewed.

Summary It is essential for an obstetric anesthesiologist to be aware of the fetal status before undertaking care of the laboring mother. In the last 20 years electronic fetal monitoring has been the most widely used technique of evaluating the fetus in labor. Recently however, the ability to predict or improve fetal outcome using traditional interpretation has been questioned. This review presents a summary of the current technology and interpretation of intrapartum electronic fetal monitoring, as well as a discussion of its limitations and some of the developments in this field which may help improve the accuracy of fetal assessment. The new developments in fetal monitoring discussed in this article are computerized assessment of fetal heart tracings, heart rate variability analysis, fetal electrocardiogram waveform analysis, abdominal detection of fetal ECG, fetal scalp oxygen saturation, fetal pH sampling and transcutaneous oxygen and carbon dioxide measurement.

The clinical use of intrapartum fetal heart rate monitoring remains controversial. Because of its widespread use in this country, interpretation skills must be maintained. Clear and concise criteria for the diagnosis of fetal stress and distress are presented in this article, and the management of fetal distress is discussed.

Although fetal monitoring is a common clinical procedure, there is little quantitative evidence that it can detect changes occurring during labour. We present quantitative data comparing the first and second stage of labour, from 21 labours resulting in a normal fetal outcome. A range of fetal heart rate variables was calculated from the output of a fetal heart rate monitor. Significant changes were detected in baseline fetal heart rate (P less than 0.005), heart rate variability (P less than 0.05), number of dips (P less than 0.01) and their depth (P less than 0.01). The results encourage confidence in the sensitivity of fetal monitoring for the detection of changes in a number of fetal heart rate variables during the course of labour.

The aim of the study was to evaluate the effect of the introduction of fetal heart rate monitoring on perinatal mortality rates in high-risk pregnancies. Results were compared with the perinatal mortality rates published previously from our clinics. The study group consisted of 2165 high-risk pregnant patients. The perinatal mortality rate in the study group was 28.6%, and the corrected rate 15.9%. The rates were significantly lower in comparison with the total perinatal mortality rates in former years. We are convinced that fetal heart-rate monitoring resulted in a significant decrease in the perinatal mortality rate. Although the increased use of fetal monitoring cannot reduce perinatal mortality resulting from problems such as genetic disorders, this study shows improved outcomes for many high-risk conditions, in particular postmature pregnancies.

Fetal heart rate and fetal movements were recorded in 16 uncomplicated near-term pregnancies. The recordings were used to evaluate a system for automated fetal heart rate analysis (Sonicaid System 8000). Fetal rest-activity patterns were considered in the analysis. The mean duration of C2F periods “active sleep," 33 minutes) was significantly greater than that of C1F periods ("quiet sleep," 19 minutes) ( p p Key words

This study was designed to investigate the range of beat-to-beat changes in fetal inter-beat (RR) intervals during routine clinical monitoring in labour. Fetal RR intervals were automatically measured and collected from 10 fetuses. Intervals which were incorrectly measured were excluded, and the remaining 23510 intervals were used to compile the distribution of beat-to-beat changes. The inter-quartile range of this distribution was 23 ms and the 99th centile fell at approximately 50 ms. No relationship could be established between beat-to-beat changes and the absolute RR interval. These findings differ from the results published by other workers on the basis of data obtained antenatally or during early labour. In addition, the results suggest possibilities for improving algorithms designed to enhance data quality in fetal heart rate monitoring.

Determination of fetal acid-base status, either at birth, intrapartum, or antepartum, is the gold standard for the diagnosis of fetal asphyxia. Indirect methods such as Apgar scores and fetal heart rate monitoring show at best only minimal correlation. It is evident that intrauterine hypoxia is a rare cause of central nervous system injury, and the finding of a normal acid-base status at birth should lead the clinician to search for other causes of central nervous system injury or birth depression. A combination of techniques including fetal acid-base assessment, electronic fetal heart rate monitoring, and thorough neonatal evaluation probably provides the best predictor of long-term outcome. Newer methods of umbilical cord sampling and acid-base determinations in the intrauterine growth retarded fetus hold some hope for the future.

The search for an adequate back-up test for intrapartum fetal heart rate (FHR) monitoring has spanned the entire history of this technology. Although randomized controlled trials (RCTs) of electronic FHR monitoring (EFM) have been disappointing, the expectations may have been unrealistic. The hope that this technology would lower the rate of cerebral palsy from intrapartum asphyxia has not materialized. There is, however, reasonable good evidence that EFM does decreasetherateofperinatalmortality,particularlyearlyinfant death because of hypoxia. Two analyses, 1 a large population analysis 1 and 1 metaanalysis of 9 RCTs 2 and at least 1 RCT 3 have confirmed this reduction in death rates. Clearly, before EFM, intrapartum deaths were relatively common, occurring inapproximately2-3per1000laboringpatients,andnowsuch deaths are rare. Nevertheless, the price we pay for this technology is high. It is a very difficult and hard task to master technology. All studies that have evaluated EFM have shown an increase in cesarean delivery rates in the electronically monitored patients. EFM has created a malpractice nightmare for obstetriciansbecauseoftheunrealisticexpectationthatwecan prevent all cases of neonatal encephalopathy with early operative intervention in hypoxic babies. Perhaps if we examine whatthetechnologycanandcannotdo,theseresultswithEFM