Report of the subgroup on fetal monitoring

Abstract

Intrapartum fetal surveillance is still under debate, despite 30 years of clinical experience and numerous clinical trials. Waveform analysis of the fetal electrocardiogram has emerged not as an alternative to cardiotochography but as a support tool to allow more accurate interpretation of intrapartum events. During hypoxia, the healthy fetus is utilizing a series of defense mechanisms. Among these, the increase in sympathetic activity, with an increase in circulating adrenaline, activates the myocardium with an increase in workload (the product of cardiac output, myocardium contractility and blood pressure). If there is an imbalance between myocardial oxygen supply and consumption, determined by the workload, then anaerobic metabolism, with a breakdown of myocardial glycogen stores starts and high T waves emerges. ST depression with negative T waves has recently been observed during hypoxia experiments in experimentally growth retarded guinea pigs whilst their normally grown littermates showed ST elevation. These findings have stimulated the development of a dedicated fetal ECG monitor - STAN - incorporating both standard CTG and ST waveform analysis. The STAN concept has now been taken through the process of recognized validation including several prospective studies and a large randomized trial in Plymouth of 2400 high risk, term deliveries. The T/QRS ratio is only one parameter to be used - equally important is to identify the occurrence of ST depression with biphasic negative T waves and to interrelate the CTG and the ST waveform as outlined in the clinical guidelines (table I). This table contains the clinical experience gained over many years and has formed the basis for the first randomized controlled trial comparing ST waveform + CTG with CTG only. Obviously, when the T/QRS ratio is used as the only component of such a scheme, confusion emerges. The analysis should also contain cases with significant intrapartum hypoxia. Recent findings indicate that only when cord artery pH falls below 7.0 and when there is substantial metabolic acidemia is there a significant risk of intrapartum asphyxia. Metabolic acidemia should be estimated from base deficit in the extracellular fluid and the combination of cord artery and vein data should allow for a more accurate assessment of intrapartum events, including the assessment of the duration of hypoxia. The Plymouth trial has tested the hypothesis that the combination of ST wave form and CTG analysis compared with CTG analysis only would reduce operative interventions for fetal distress without placing the fetus at a risk.(ABSTRACT TRUNCATED AT 400 WORDS)