Will Improving Fetal Heart Rate Interpretation Lead to Reduction in Long-Term Adverse Neonatal Outcomes?
BACKGROUND AND PURPOSE:
Better use and recognition of fetal heart rate (FHR) patterns during labor would improve neonatal outcomes
There is a useful correlation between FHR patterns and fetal arterial pH
Arterial pH adequately reflects fetal tolerance of hypoxic stress during labor
There is no long-term data correlating FHR patterns with neonatal outcomes
Johnson et al. (Obstetrics & Gynecology, 2021) tested the assumption that the correlation between neonatal acidemia and short-term newborn condition is in fact poor, in which case a key assumption regarding the use of electronic fetal monitoring is incorrect
Retrospective cohort study
Term | Singleton | Nonanomalous fetuses
Availability of complete umbilical artery cord gas values and Apgar scores
Delivered between 2012 and 2020
Umbilical cord gas values
Spearman correlation coefficients and receiver operating characteristic curves were calculated for various levels of umbilical artery pH, base excess, and Apgar scores
Review of records: Medical records of neonates undergoing total body cooling for presumed intrapartum hypoxic injury
Correlation between umbilical artery pH and base excess and Apgar scores
Cesarean delivery: 36% of entire cohort
Base excess >-4: 46%
Base excess <-12: 26%
Base excess between -12 to -4: 21%
The correlation between cord pH and base excess and both 1- and 5-minute Apgar scores was weak to non-existent for all pH range subgroups
Correlation range: 0.064 to 0.213
Receiver operating characteristic curve analysis suggested a cord pH value of 7.22 yields the best discrimination for prediction of a severely depressed newborn (5-minute Apgar score less than 4)
Area under the curve: 0.742 | Sensitivity 62% | Specificity 78% (considered ‘fair’)
There is a weak to non-existent correlation between umbilical cord pH and Apgar score, suggesting that individual fetuses vary widely in their tolerance for the metabolic acidemia of labor
This suggests that there may not be a path to “better” FHR use as a method of predicting fetal tolerance of labor
Cesarean delivery in women with greater base deficit was lower, which may indicate that “ the wrong women often undergo cesarean delivery”
The authors state that the data do not suggest a change in current intrapartum management, however
We believe this variability, rather than shortcomings of, or errors in pattern interpretation, to be the weak link in the chain responsible for the observed increased rate of cesarean delivery with no measurable reduction in long-term adverse outcomes
Under these circumstances, further refinements in pattern interpretation, although potentially improving the prediction of fetal pH, are unlikely to significantly alter these clinical outcomes
As far as our current approach to FHR interpretation, it would appear that this is as good as it gets
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