The Fetal Reserve Index Significantly Outperforms ACOG Category System in Predicting Cord Blood Base Excess and pH: A Methodological Failure of the Category System.

Abstract

Electronic fetal monitoring (EFM) has been used extensively for almost 50 years but performs poorly in predicting and preventing adverse neonatal outcome. In recent years, the current "enhanced" classification of patterns (category I-III system [CAT]) were introduced into routine practice without corroborative studies, which has resulted in even EFM experts lamenting its value. Since abnormalities of arterial cord blood parameters correlate reasonably well with risk of fetal injury, here we compare the statistical performance of EFM using the current CAT system with the Fetal Reserve Index (FRI) for predicting derangements in base excess (BE), pH, and pO2 in arterial cord blood. We utilized a research database of labor data, including umbilical cord blood measurements to assess patients by both worst CAT and last FRI classifications. We compared these approaches for their ability to predict BE, pH, and pO2 in cord blood. The FRI showed a clear correlation with cord blood BE and pH with BE being more highly correlated than pH. The CAT was much less predictive than FRI (P < .05). The CAT II cases had FRI scores across the spectrum of severity of FRI designations and as such provide little clinical discrimination. The PO2 was not discriminatory, in part, because of neonatal interventions. The Fetal Reserve Index (FRI) provides superior performance over CAT classification of FHR patterns in predicting the BE and pH in umbilical cord blood. Furthermore, the CAT system fails to satisfy multiple fundamental principles required for successful screening programs. Limitations of CAT are further compounded by assumptions about physiology that are not consistent with clinical observations.