Abstract
Fetal heart rate (FHR) decelerations are the commonest aberrant feature on cardiotocograph (CTG) thus having a major influence on classification ofFHRpatterns into the three tier system. The unexplained paradox of early decelerations (head compression—an invariable phenomenon in labor) being extremely rare [1] should prompt a debate about scientific validity of current categorization. This paper demonstrates that there appear to be major fallacies in the pathophysiological hypothesis (cord compression—baroreceptor mechanism) underpinning of vast majority of (variable?) decelerations. Rapid decelerations during contractions with nadir matching peak of contractions are consistent with “pure” vagal reflex (head compression) rather than result of fetal blood pressure or oxygenation changes from cord compression. Hence, many American authors have reported that the abrupt FHR decelerations attributed to cord compression are actually due to head compression [2-6]. The paper debates if there are major fundamental fallacies in current categorization of FHR decelerations based concomitantly on rate of descent (reflecting putative aetiology?) and time relationship to contractions. Decelerations with consistently early timing (constituting majority) seem to get classed as “variable” because of rapid descent. A distorted unscientific categorization of FHR decelerations could lead to clinically unhelpful three tier classification system. Hence, the current unphysiological classification needs a fresh debate with consideration of alternative models and re-evaluation of clinical studies to test these. Open debate improves patient care and safety. The clue to benign reflex versus hypoxic nature of decelerations seems to be in the timing rather than the rate of descent. Although the likelihood of fetal hypxemia is related to depth and duration ofFHRdecelerations, the cut-offs are likely to be different for early/late/variable decelerations and it seems to be of paramount importance to get this discrimination right for useful visual or computerized system of CTG interpretation.
Highlights
American Congress of Obstetricians and Gynecologists (ACOG) commented that a standardized approach to nomenclature, systems of interpretation and management algorithms of fetal heart rate (FHR) abnormalities has remained problematic [7]
As an unintended but direct consequence, ACOG definitions mandate “early” and “late” decelerations to be always more than 60 - 65 seconds, making early decelerations very rare which is unphysiological and unexplained [14]
It needs to be debated whether the current categorization of Fetal heart rate (FHR) decelerations contains any flawed hypotheses, significant contradictions or anomalies undermining basic tenets of scientific practice
Summary
American Congress of Obstetricians and Gynecologists (ACOG) commented that a standardized approach to nomenclature, systems of interpretation and management algorithms of fetal heart rate (FHR) abnormalities has remained problematic [7]. L Sholapurkar / Open Journal of Obstetrics and Gynecology 3 (2013) 362-370 make or break CTG interpretation This clinical opinion paper has a limited scope with focus on decelerations only and other less controversial FHR changes like baseline rate and accelerations are not the subject. The clinician can “continue to observe”, “evaluate further” or “deliver” on individualized basis as no management algorithm can be prescribed for Category 2, which has been a major criticism [8]. This apparent lack of discriminatory potential may not be due to the three tier system itself but could be because of how different types of FHR decelerations are interpreted or categorized. Open debate facilitates scientific progress and enhances patient care and safety
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