The Validity of Fetal Heart Rate Monitoring During the Second Stage of Labor F. PIQUARD, PhD, R. HSIUNG, MD, M. METTAUER, MD, A. SCHAEFER, PhD, P. HABEREY, MD, AND P. DELLENBACH, MD Fetal blood pH, pCOz, and lactic acid were measured before and after the final period of the second stage of labor in an attempt to better understand the validity of fetal heart rate (HR) monitoring at this time. Following a classification derived from Melchior, six FHR patterns were recognized: 0, 1, 2a, 2b, 3, and 4. In the second stage of labor, until bearing-down efforts began, the fetal acid-base status did rot change regardless of the type of tracing. At the time of delivery, a5 compared with values measured before the beginning of the final stage, the highest shift of lactic acid, ‘coupled with the lowest pH shift, was associated with the type 3 patlern. The most rapid increases of lactic acid and PCO; and decreases in pH were associated with type 2b patterns. Both type 3 and 2b patterns were ominous, but low ‘Apgar scores were more frequent in type 3 because the duration of the final stage of labor was longer. Working. from the mean slopes of the shifts of biologic parameters as a function of time, theoretical limits were derived and discussed for safe duration of the final stage of labor. (Obstet Gynecol 72:746, 1988) The validity of continuous electronic fetal heart rate (FHR) monitoring during the first stage of labor is now well established, and patterns of normal and abnormal FHRs, allowing early diagnosis of fetal distress, have been described.’ At present, continuous FHR monitor- ing in the second stage of labor is not universally accepted, and during the last decades, few authors have taken an interest in FHR tracings during this part of labor.-* The optimal length of the second stage is also a matter of speculation. The quality of tracings is, often poor because of patient movements and bearing- down efforts. Melchior and Bernard? have approached the problem, but even with good tracings, clear-cut, Front the Groupe de Recherche on Natron Fostale, Departnent of Physiology, Louis Pasteur University, Strasbourg: and the Deprtient of Obstetrics and Gynecology, Centre Médico-Chirurgical et Obstetrics, ‘Schiltighein, France. Supported. by grants of the ULE.R. of Biomedical Sciences of Strasbourg. 746 0020-784s798/59.50 specific patterns that will allow identification and quantitation of fetal distress remain to be accepted. The present study was undertaken to assess the value of FHR monitoring during the end of the second stage of labor. To accomplish this, FHR tracings ini- tially categorized according to the classification of Melchior and Bernard? were compared with the status of the fetus, as determined by both classic clinical parameters and by those biologic parameters that mea- sure the degree of fetal hypoxia (pH, pCO2, and lactic acid). We hypothesized that by using this comparative method, we could identify specific FHR patterns that would allow an early diagnosis of fetal asphyxia during the second stage of labor, enabling the clinician to wait for spontaneous delivery or indicating operative deliv- ery. Materials and Methods ‘The study population consisted of 234 patients from a homogeneous local population of white women. The mean maternal age of the study patients was 25.3 + 4.3 years; 145 were primiparous and 189 delivered spon- taneously (Table 1). All these women had a normal term pregnancy with a fetus in cephalic presentation and an uneventful first stage of labor (normal Friedmann cervical dilatation curve). The FHR was recorded from the beginning of labor and had been deemed normal according to accepted standards! up to the moment of full dilatation, when the patients en- tered the study. Although the second stage of labor traditionally begins at full cervical dilatation and ends at the mo- ment of delivery, for this study we focused on the “final period’ of the second stage of labor, as docu- mented on the cardiotocographic tracing. AS reported by Roemer et al,” this final period begins with the first voluntary bearing-down efforts and ends at the mo- ment of delivery, without any limitations in the num- Otstetrics & GynecologyTable 1. Clinical Data of Patients in Study Toe of Final wage of abr Se ee sect Sa Parity: livery Pe Maternal = S08 _ Duration zat Group Nem ——Mulips age) See tin) Tin Typeo rr Borda en 2 es a % OMAr3B MS 2 ye ls eee ee ? tye ot Mo Mosae we 1 Typed OB 3 3e2l ot 7 ne 5 Typed 2 4 8 2222 wer i Toul ats asa ws 8 ‘Primip. = paimiparocss mullip, = multiparous; 5 = spontaneous vaginal delivery: V Data are presented as mean = SD or N. * See text for explanation * Significant diference with all other Rrowps ( = Significant difference with all other groups ( test, P< 001). test, P= 05) ‘gum extraction: F = forceps * Significant difference with all other Rroups (one-way’ analy of variance, P< 01) ber of contractions. Restricting the study to this shorter period is justified because its duration can be precisely located on the tracings, whereas the traditional length, of the second stage often cannot be measured precisely because of possible error in determining the exact moment of full cervical dilatation. Moreover, FHR scoring was made precisely at this period. Fetal heart rate tracings were obtained and recorded directly using a scalp electrode and a Hewlett-Packard monitor (Model 8040 A; Boeblingen, West Germany). The frequency and duration of the uterine contractions were obtained by external tocography. All FHR trac- ings were interpreted blindly at a later date by the same person (RH), without any previous knowledge of the biologic values, the method of delivery, or its outcome. We initially used the classification of Mel- chior and Bernard? (Figure 1, part A). However, it rapidly became apparent that group 2 was not homo- geneous and, taking into account the depth of brady- cardia, we divided this group into two subgroups (Figure 1, part B). This revised classification was there- fore adopted and six types of FHR pattern were ob- tained, corresponding to the following definitions: type 0—stable heart rate; type I—decelerations at each contraction and_maintenance of a normal baseline between the contractions; type 2a—decreased baseline between 90-120 beats per minute, with decelerations often occurring during the contractions; type 2b— decreased baseline under 90 beats per minute, with frequent decreased variability; type 3—severe fall of the baseline associated with marked accelerations dur- ing the contractions; and type 4—fall of the baseline under 90 beats per minute, but occurring much later, practically at the extreme end of labor. Two fetal blood samples were obtained in all cases. VOL. 72, NO. 5, NOVEMBER 1588 ‘The first (approximately 100 jzL) was taken from the fetal scalp as close as possible to the beginning of the final stage. The second (obtained from the umbilical artery) was collected from the clamped cord immedi- ately after birth and before the first cry. Arterial blood was sampled in all cases because it reflects fetal condi- tions better.” Half the specimen was analyzed for pH and pCO; with a blood gas and pH analyzer (Model 168; Corning Medical, Halstead, England). Metabolic acidosis is usually evaluated by indirect methods such as base deficit of the extracellular fluid. Previous stud- ies have demonstrated that to assess fetal hypoxia, actual pH and lactate have a higher reliability than base deficit.”°-"" For this reason, we immediately analyzed the remaining sample (60 jL) for plasma lactate con- tre 1 [i rrne 20 rez [pore : A 8 Figure 1. Classification of FHR tracings obtained inthe final stage of labor. A) Original classification of Melchior and Bernard? with five type pattems. B) Modification of the type 2 pattern introduced by Piquard etal (present study). Piquard et al FHR During Final Stage 747‘Table 2. pH, Lactate, and pCO: Shifts" and Correlation With the Time Length of the Final Stage of Labor PH Lactate (mmol) PCO: (mtg) N Shite r Shite 7 Shite 7 Typeo 2 0.051" 0328 13 = 092 ons 0.035. Type 10 0.058 05e2! 186 = 1.09 0538" 0.255" ‘Type 22 46 073 0.53! 2M = 128 1.67 oar Type 2 2 “0.111 = 0.046 0." 244 = 109 ata) osu’ Type 18 0.147 = 0.088 0.595" 3.98 = 1.9) ore 0382 Typed R ~0.087 2 0.082 0518 1162 = 080 o5i0 0503 e <1 ‘=001 NS = not significant. Data are presented as mean = SD. * For each biologie parameter, shift is the diference between the value measured inthe umbilical artery blood and the value determined in scalp blood taken before the beginning ofthe final stage. "For each type of FHR pattern and for each pH, lactate, or pCOs, shits are significant at the 01 level (paired # test) * Pe 001 spe os. Peo * Ditference between all types of FHR pattern was tested by analysis of variance centration by means of an amperometric method (Lac tate Analyzer, Model 640; Roche-Kontron, Basel, Swit- zerland), in accordance with the technique described by Piquard et al.'? Apgar scores were determined in the first minute after birth. Statistical analysis was performed using ? test (for categorical variables) and analysis of variance or paired t test (for continuous variables). The differences among, several means were assessed by Duncan’s multiple range test, corrected for unequal sample sizes." Sig- nificance was defined at the .05 level. Results Table 1 presents the clinical data and distribution of the 234 cases among the six types of tracings. Type 1 was the most frequent type (N = 104), and the rarest was type 4 (N = 12). The maternal age distribution was the same in all groups. The duration of the final stage of labor and the number of contractions during this stage were not significantly different except for group 2b, in which both the duration and the number of contrac- tions were markedly lower (P < .01). Operative deliv- cries were more frequent (7 test, P <.05) in group 2b, and also in group 3, in which 15 of 18 were primiparas. Low Apgar scores (7 or lower) were more numerous in groups 3 (N = 5) and 2a (N = 7) (¥ test, P < .001), Whereas types 0 and 1 were associated with the best ‘Apgar scores. Among patients with low Apgar scores, four of type 3 but only three of type 2a had operative deliveries. Before the final stage, pH, pCO> , and lactate levels did not differ significantly regardless of the type of tracing (mean values: 7.33 + 0.06 for pH, 39.9 = 7.4 748 Piquard et al FHR During Final Stage mmHg for pCO», and 2.32 + 1.13 mmol/L for lactate). ‘At the moment of delivery, the same parameters were significantly different among all the groups. A reduc- tion in pH values and a rise in lactate and pCO, values occurred and increased in magnitude as one pro- gresses from type 0 to type 3 (Table 2). For each type of FHR pattern and for each parameter, shifts were si nificant (P < .001 for all comparisons, paired t tes). The difference of these shifts between each type of FHR pattern was established by analysis of variance (P <.001 for lactate; P< .01 for pH). Moreover, analysis of these data by Duncan's test showed that, for lactate, type 3 was significantly different (P < .001) from all the other types, and type 0 different from types 2a and 2b (P < .01). For pH, type 3 differed from types 0 and 4 (P <.01), and type 2a differed from type 0 (P < .05). Toassess the clinical significance of these results, we determined correlation coefficients between the shift of acid-base parameters and the length of the final stage for each tracing type (Table 2). In type 4, no significant correlations were established, partly because of the small number of patients (N = 12). For pCO>, correla- tions were poor in all cases, with low r coefficients. In all groups for which correlations were estab- lished, we plotted the shifts of lactate concentrations (Figure 2) and pH values (Figure 3) in relation to the duration of the final stage. Regression lines and the 99% confidence limits of the mean estimated values of time duration were drawn. As pH drops and lactate values rise as a function of time, the theoretical time limits necessary to reach what can be considered pathologic levels of lactate and pH could be deter- mined. Previous studies”®° have shown that for lac- tate, an umbilical artery concentration of 6 mmol/L Obstetrics & Gynecologylactate Type 1 Type 20 Figure 3. pH shift as related to duration of the final stage of labor. Slopes with 99% confidence limits for calculated values of time have been drawn for each pattern where correlation is significant (see Table 2), Dotted line indicates the lower normal limit of pH (7.20) enerally accepted in the umbilical artery VOL. 72, NO. 5, NOVEMBER 1988 Figure 2. Lactate shift as related to duration ‘of the final stage of labor. Slopes with 99% confidence limits for calculated values of time have been drawn for each pattern where cor relation is significant (see Table 2) Dotted line indicates the upper normal level of lactate (6 ‘mmolL) generally accepted in the umbilical artery should be the upper normal limit, whereas 7.20 is the generally accepted lower normal limit for pH!" to define fetal acidosis. Taking these values into account, we calculated the following time limits: for lactate, 35.7 = 23.0, 21.4 # 13.4, 16.6 = 7.3, 10.0 + 4.9, and 13.5 = 4.9 minutes, respectively, for types 0, 1, 2a, 2b, and for pH, 16.4 + 7.6, 14.1 = 5.2, 8.9 * 3.4, and 12.3 + 4.9 minutes, respectively, for types 1, 2a, 2b, and 3. These values were significantly different for each type of tracing (variance analysis, P < .001). Duncan's analysis showed that for lactate, the theoretical time limits of type 0 differed from all the other types (P < .01), and type 1 differed from types 2a and 2b (P < .05). For pH, type 1 differed from type 2b (P < 01) and from type 3 (P< .05), and type 2a differed from type 2b (P < .01). Discussion ‘The second stage of labor is now considered to be a time of risk for the fetus*!®"® it has been observed that a longer duration of the second stage is associated with ‘an increase of perinatal morbidity and mortality." We have therefore attempted in this study to classify FHR patterns in the final period of the second stage in terms of fetal hypoxic stress, as measured by the parameters of pH, pCOz, lactate, and Apgar score at the moment of delivery. Type 0 and type 1 FHR patterns were associated Piquard et al FHR During Final Stage 749with the highest Apgar scores, and type 3 with the lowest. The degree of fetal hypoxia as judged by shifts in pH and lactate increased from type 0 to 3. In type 3, a clear-cut metabolic acidosis rapidly developed. This group, of whom 15 of 18 (83%) were primiparas, showed the longest duration for the final stage, the highest rate of operative delivery, and the lowest ‘Apgar scores. From a purely biologic point of view, especially when considering the steeper slopes, type 2b is worse than 2a and, in our opinion, must be considered more dangerous. When looking at clinical, results, there is a discrepancy between Apgar scores, which were lower in group 2a than in group 2. This can be explained by the fact that type 2b intuitively was, considered more ominous by the obstetricians present in the delivery room. This recognition led them to shorten the final moments of labor by using operative delivery more frequently, thus obtaining better Apgar scores. Fetal heart rate patterns classed by Melchior and Bernard? as group 4 are in fact difficult to classify. This pattern begins as a type 0, but at the end of the final stage is identical to group 2b. Because the dura- tion of bradycardia is short, the acid-base shift is limited, and this could explain why the mean meta- bolic results were closer to type 0 or 1 than to type 2b. Because there were few patients in this group and most of them were multiparas, type 4 could also be considered a transient type, without any precise char- acteristics. In our opinion, it would be better to con- sider this as a type 2b from the moment bradycardia occurs; if bradycardia persists, operative delivery should be considered. Can an optimal length be proposed for the second stage? Roemer et al!? contend that the second stage should not exceed 45 minutes for optimal fetal and neonatal well-being. Katz et al? have shown that the ‘mean umbilical artery pH decreases significantly when, the second stage lasts more than 30 minutes, but concluded that other studies are needed to assess accurately the safe time limits of the second stage. The mean theoretical durations of the final stage of labor calculated from our acid-base data are consistent with the above values. Close observation of the final part of the second stage is mandatory. If the FHR pattern is type 0 or 1, no fetal or neonatal distress is observed even if the duration of this stage is more than 35 minutes. Type 2b or 3 FHR patterns are associated with rapidly developing hypoxia and acidosis. Lactate will rise and pH will fall in minutes to what may be considered dangerous levels, and rapid operative de- livery should be seriously considered. It is beyond the scope of this study to conclude, for all cases, what the optimal duration of the final stage of labor should be In our department, managing patients with the time 750 Piquard et al FHR During Final Stage limits that we derived has not increased the rate of operative delivery (17% for the last 3000 deliveries). ‘These clinical and biologic data are applicable to a population of normal fetuses and normal deliveries. Whether extrapolation can be proposed for other more or less pathologic deliveries remains to be proved. However, if some degree of hypoxia has developed during the first part of labor, as diagnosed by patho- logic FHR patterns and acid-base balance, these time limits might be reduced. In conclusion, we believe that FHR monitoring, should certainly be done during the whole length of the second stage. The use of FHR-patterns classifica- tion in the final period of the second stage of labor will enable the obstetrician to identify the fetus that is likely to develop acidosis at a more rapid rate than normal. This could lead to more timely operative delivery. References 1. Goodlin RC. History of fetal monitoring. Am J Obstet Gynecol 1979:1333923-82 2, Melchior J, Bernaed N. Incidence and pattern of fetal heat rate alterations during labor. In: Konzel W, ed. Fetal heatt rate monitoring. Heidelberg: Springer-Verlag, 1985:73-81 3, Gaziano EP, Freemann DW, Bendel RP, FHR variability and other heart rate observations during second stage labor. Obstet Gynecol 1980563127. 4. Herbert CM, Boehm FH. Prolonged end-stage fetal heart rate deceleration: A reanalysis. Obstet Gynecol 1981,57:589-93, 5. Katz M, Lunenfeld E, Metzner l, Bashan N, Gross J. 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Obstet Gynecol 1967,70:196-201. Alexander, Cantraine F, Schwers J. Apgar score and cord pH in relation to length of second stage. In: Rolfe P, ed. Fetal physio logical measurements. London: Butterworth, 1986 59-64. Hellman LM, Prystowsky H. The duration of the second stage of labour. Am J Obstet Gynecol 1952/68:1223-33 VOL. 72, NO. 5, NOVEMBER 1988 ‘Address reprint requests to: P. Dellentach, MD Centre Médico-Chirurgical et Obstetrical de Ia Sécurité Sociale 19, rue Louis Pasteur, C.P. 83 F-67042 Strasbourg Cedex France Received February 29, 1988, Receined in revised form Mey 10, 1988. “Accepted May 11, 1988 ‘Copyright © 1968 by The American College of Obstetriians and Gynecologist. Piquard et al FHR During Final Stage 751