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Intrapartum fetal monitoring is commonly performed in labor on the basis that changes in the fetal heart rate pattern may correlate with the fetal oxygenation status, thereby providing additional information to obstetric clinicians who must decide whether or not any intervention is necessary. This activity reviews the methods for fetal monitoring as well as its indications and physiologic basis. It will highlight the role of the interprofessional care team in implementing and interpreting its results. Objectives: Review specific fetal heart tracings associated with a certain pathology. Describe the fetal heart patterns on the tracing. Identify the pathophysiology of fetal heart tracings. Summarize how interprofessional can improve diagnostic results when patients require a fetal heart tracing. Access free multiple choice questions on this topic.

Continuous fetal monitoring, or cardiotocography, is a method of tracking the fetal heart rate (FHR) along with the occurrence of uterine contractions. The relationship between these two variables is widely accepted to correlate with the oxygenation status of the fetus. This is intended to benefit the mother and fetus by providing obstetric clinicians with additional real-time information that they may use to determine if any intervention is necessary. In many areas of the United States, continuous intrapartum fetal monitoring has been used routinely for most women undergoing labor and delivery. However, the evidence basis for this is controversial as research has demonstrated that routine FHR monitoring is associated with increases in the rates of both operative vaginal deliveries and Cesarean sections without significantly improving most newborn or childhood outcomes.[1] Evidence is mixed on the effect of FHR monitoring on neonatal mortality, and a small reduction in the incidence of neonatal seizures has been observed when fetal monitoring is used. However, no benefit has been demonstrated from the use of fetal monitoring in most other perinatal outcomes, including Apgar scores, the incidence of neurologic injury, cerebral palsy, developmental delay, and NICU admission. Outside of the immediate intrapartum period, fetal monitoring may be used to evaluate for placental abruption, commonly when an obstetric patient presents following abdominal trauma. It may also be used to help differentiate true versus false labor. The ability to implement and interpret FHR monitoring is largely expected of obstetric care teams and is believed to serve a more important role in high-risk pregnancies and evaluation of fetal well-being outside of labor.[2]

A 2017 meta-analysis demonstrated that women undergoing intrapartum FHR monitoring were more likely to have cesarean sections or instrumental vaginal deliveries than those assessed with intermittent auscultation.[1] Methods of internal monitoring are associated with additional complications. For example, methods invasive to the fetus such as fetal scalp electrode placement and fetal scalp pH sampling have been associated with vertical transmission of pathogens such as HSV and HIV.[9][10] They are also associated with an increased risk of scalp trauma, cephalohematoma, subdural hematoma, asphyxiation, and sepsis.[8] Intrauterine pressure catheter placement is most commonly associated with placental laceration or abruption due to malposition. However, other serious complications, including uterine perforation and cord entanglement, have been observed.[11]

Fetal monitoring is an interdisciplinary task that may improve maternal and fetal outcomes in certain settings. For optimal use, nurses and nurse-midwives should be familiar with all involved equipment and contribute by placing and troubleshooting external transducers. FHR tracings do not represent the entire clinical scenario for the mother nor the newborn, and nurses have an important role in monitoring mothers throughout labor for vital sign abnormalities, excessive discomfort, or other clinical changes that they may need to bring to the attention of a physician, nurse-midwife or another clinician on the obstetric team. These clinicians should regularly assess the FHR tracings and should initiate further diagnostic evaluation, internal monitoring, resuscitation, and/or operative delivery as appropriate. All team members should communicate effectively with the shared goal of a safe delivery for both the mother and newborn.