Last week, the American College of Obstetricians and Gynecologists (ACOG) released new guidance outlining an evidence-based framework for the evaluation and management of fetal heart rate patterns. Clinical Practice Guideline No. 10: Intrapartum Fetal Heart Rate Monitoring: Interpretation and Management is a cumulative practice guideline, replacing multiple practice bulletins and advisories dating back to 2009.
The guidance reaffirms the 2008 National Institute of Child Health and Human Development (NICHD) nomenclature and definitions surrounding electronic fetal monitoring and recommends the continued use of the three-tired system of fetal heart rate interpretation, with a few significant takeaways:
- Consistent use of the same classification system and terminology is crucial for all nurses and obstetric clinicians within an institution.
- Classification systems may be helpful in rapid communication about fetal heart rate tracings, but can overlook the subtle complexities of individual FHR tracing characteristics, including baseline, variability, and decelerations, as well as the tracing’s evolution over time and response to interventions.
- Categorization provides a snapshot in time; FHR tracing patterns are dynamic and will frequently shift between categories depending on the clinical situation and management.
A summary of recommendations leads the clinical practice guidelines. These recommendations are classified by strength and evidence quality, and are summarized below.
- In the setting of a category I fetal heart rate tracing, routine intrapartum care should be provided.
- Initial intrauterine resuscitation attempts should include one or more of the following: maternal position changes, amnioinfusion, material IV fluid bolus, decreasing or discontinuing augmentation or induction agents (i.e. oxytocin, misoprostol or dinoprostone), correction of maternal pathophysiology that may be contributing to FHR tracing changes. Resuscitation attempts should be made prior to cesarean delivery for a category II FHR tracing.
- Maternal oxygen administration should not be used for category II or III tracings in the absence of maternal hypoxia.
- In the setting of a category III tracing not responsive to resuscitation attempts, an expedited delivery is recommended.
- Uterine tachysystole associated with a category II or III FHR tracing should be treated with a rapid-acting uterine relaxation agent if it persists despite pausing oxytocin.
- ACOG recommends against the routine use of ST-segment analysis or primary reliance on computerized approaches for interpretation and management of the fetal heart rate in labor, and against the routine use of fetal pulse oximetry as an assessment of fetal well-being.
It is no surprise that the electronic fetal heart monitoring guidelines, perspectives, and education provided by the Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) closely align with those newly published by ACOG. This strong correlation stands as a testament to the powerful collaboration and shared dedication to evidence-based practice among all professionals caring for birthing individuals.
Future posts will outline the standard nomenclature for discussing fetal heart rate tracings, as well as break down the three-tiered system of categorization.
Have you reviewed this new clinical practice guideline? Any thoughts or surprises? Let us know!
Please reach out to Brennan Lee Consultants if you would like to attend a Fetal Monitoring course or to arrange an educational program at your hospital. We also provide Fetal Monitoring education and expert consultation to attorneys and legal professionals involved in Birth Injury cases.
