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Intrapartum Management of Category II Fetal

Heart Rate Tracings- Towards Standardization
of Care.

Article in American journal of obstetrics and gynecology April 2013

DOI: 10.1016/j.ajog.2013.04.030 Source: PubMed


39 1,439

18 authors, including:

David A Miller Gary Dildy

University of Southern California Baylor College of Medicine


Anthony M Vintzileos Gary Dv Hankins

Winthrop University Hospital University of Texas Medical Branch at Galves


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Optoacoustic measurement of blood oxygenation in human placenta View project

NICHD Fetal Growth Studies View project

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Clinical Opinion
www.AJOG .org

Intrapartum management of category II fetal heart rate
tracings: towards standardization of care
Steven L. Clark, MD; Michael P. Nageotte, MD; Thomas J. Garite, MD; Roger K. Freeman, MD; David A. Miller, MD;
Kathleen R. Simpson, RN, PhD; Michael A. Belfort, MD, PhD; Gary A. Dildy, MD; Julian T. Parer, MD;
Richard L. Berkowitz, MD; Mary DAlton, MD; Dwight J. Rouse, MD; Larry C. Gilstrap, MD; Anthony M. Vintzileos, MD;
J. Peter van Dorsten, MD; Frank H. Boehm, MD; Lisa A. Miller, CNM, JD; Gary D. V. Hankins, MD

I nterpretation and management of

fetal heart rate (FHR) patterns during
labor remains one of the most prob-
There is currently no standard national approach to the management of category II fetal
heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under
lematic issues in obstetrics. Multiple such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR
basic science investigations and clinical monitoring even if this technique had immense intrinsic value, since there has never
trials have been published since the been a standard hypothesis to test dealing with interpretation and management of these
introduction of this technique in the late abnormal patterns. We present an algorithm for the management of category II FHR
1950s.1-7 Unfortunately, this body of patterns that reflects a synthesis of available evidence and current scientific thought. Use
work has primarily served to raise more of this algorithm represents one way for the clinician to comply with the standard of care,
questions than it has answeredeas a and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.
medical community, we seem to know
Key words: fetal heart rate monitoring, neonatal encephalopathy, patient safety
less than we thought we did 30 years ago
regarding the utility of this ubiquitous
In recent years, several specic issues patterns in fact prevents cerebral challenging patterns. In a very real sense,
relating to the interpretation and man- palsy or other types of neurologic the FHR monitor is a medical device that
agement of FHR patterns have received impairment.8-12 was introduced into clinical practice
considerable attention in the medical Against this background, however, without an instruction manual, without
literature. These include the lack of there remains in many of us suspicion the now common premarket testing to
agreement in interpretation even among (albeit based primarily upon anecdotal support the unrealistic expectations
recognized experts, the role of FHR experience and the original basic science of efcacy, and without clearly dened
patterns as a primary driver of a rising investigations) that at least a portion parameters for use. Under such cir-
cesarean rate, and the explosion of of the conicting evidence regarding cumstances, it would be difcult to
litigation involving FHR patterns, de- the clinical utility of intrapartum FHR demonstrate clinical efcacy even of a
spite the consistent absence of scien- monitoring results from ad hoc inter- device with immense intrinsic value,
tic evidence to support the contention pretation of terminology, and the lack of since there has never been a standard
that intervention based on any single standardized protocols for management hypothesis to test dealing with interpre-
FHR pattern or combination of FHR and intervention based on what are often tation and management of abnormal
patterns. With respect to the assessment
of the clinical value of FHR monitoring,
From the Hospital Corporation of America (Dr Clark) and Vanderbilt University (Dr Boehm), Nashville,
TN; Long Beach Memorial Hospital, Long Beach (Dr Nageotte), University of California, Irvine
an evolving consensus exists in the
(Drs Garite and Freeman), University of Southern California, Los Angeles (Dr Miller), and University maternal-fetal medicine community that
of California, San Francisco (Dr Parer), CA; Mercy Hospital, St. Louis, MO (Dr Simpson); Baylor College it is time to start over and establish some
of Medicine and Texas Childrens Hospital (Drs Belfort and Dildy) and University of Texas (Dr Gilstrap), common language, standard interpreta-
Houston, TX, and University of Texas Medical Branch, Galveston (Dr Hankins), TX; New York tion, and reasonable management prin-
Presbyterian/Columbia University, New York (Drs Berkowitz and DAlton) and Winthrop University
Hospital, Mineola (Dr Vintzileos), NY; Brown University and Women and Infants Hospital of Rhode
ciples and guidelines.13-19
Island, Providence, RI (Dr Rouse); Medical University of South Carolina, Charleston, SC (Dr van A Eunice Kennedy Shriver National
Dorsten); and Perinatal Risk Management and Consultation Services, Portland, OR (Ms Miller). Institute of Child Health and Human
Received Jan. 21, 2013; revised March 27, 2013; accepted April 24, 2013. Development (NICHD) consensus panel
Management recommendations discussed in this document reect the opinions of the authors. They in 2008 proposed a uniform system of
do not necessarily reect endorsement by afliated institutions or organizations. terminology in which any FHR pattern is
The authors report no conict of interest. classied as category I, II, or III, based on
Reprints not available from the authors. the presence or absence of well-dened
0002-9378/$36.00  2013 Mosby, Inc. All rights reserved. aspects of the FHR.20 Once univer-
sally adopted in clinical practice, these

AUGUST 2013 American Journal of Obstetrics & Gynecology 89

Clinical Opinion Obstetrics

Algorithm for management of category II fetal heart rate tracings
Moderate variability or accelerations

Yes No

Significant decelerations with 50% of contractions for 1 hour Significant decelerations with 50% of contractions for 30 minutes

Yes No Yes No

Latent Phase Active Phase Second Stage Observe for 1 hour

Normal labor progress Normal progress Persistent pattern

No Yes No Yes Yes No

Cesarean Observe Cesarean or OVD Observe Cesarean or OVD Manage per algorithm

OVD, operative vaginal delivery.

That have not resolved with appropriate conservative corrective measures, which may include supplemental oxygen, maternal position changes, intravenous fluid administration, correction of hypotension,
reduction or discontinuation of uterine stimulation, administration of uterine relaxant, amnioinfusion, and/or changes in second stage breathing and pushing techniques.
Clark. Category II FHRT. Am J Obstet Gynecol 2013.

denitions should serve as an important only to preterm birth as the most category II FHR patterns (Figure 1)
rst step in both the investigation of the pressing issue in clinical obstetrics. In along with several important specic
signicance of various FHR patterns, addition, the overall cesarean delivery clarications (Table). As outlined in
and the development of a uniform rate exceeded 32% in the United States in Figure 1, it is reasonable to initiate
standard of care in the interpretation 2011, and exceeds 50% of all births in management of a category II FHR
and management of such patterns. With some US hospitals.23 While dystocia and pattern with an assessment of variability
this in mind, subsequent recommenda- prior cesarean delivery remain the lead- and accelerations, thus allowing the
tions have been developed by the ing indicators for such surgical inter- clinician to immediately rule out the
American Congress of Obstetricians and vention, the presence of a category II or presence of clinically signicant meta-
Gynecologists (ACOG) for the manage- III FHR in labor is a frequent indication bolic acidemia. For nonacidemic fetuses,
ment of category I (normal) and cate- as well.11,24 For cesarean deliveries, there the focus then shifts to assessing the
gory III (pathologically abnormal) FHR is a wide variance in the reported likelihood of developing signicant
patterns.20,21 Although useful, these indications and their frequency, both acidemia prior to delivery. While no al-
recommendations remain insufcient between hospitals and among members gorithm can predict all cases of sudden
since 80% of fetuses in labor demon- of the medical staff practicing obstet- deterioration due to sentinel events, even
strate FHR patterns that fall into cate- rics.24 Concern regarding FHR patterns with category I FHR patterns, analysis of
gory II, patterns for which no specic is perhaps the indication that has the the frequency and nature of de-
ACOG management recommendations greatest such variance; we believe this celerations and the progress in labor
exist.21,22 observation is directly related to the provides the clinician with a reasonable
The management of category II FHR absence of dened management pro- approach to such decision making
patterns remains the most important tocols for category II patterns. (Figure 1).
and challenging issue in the eld of Accordingly, we present a suggested With category II FHR tracings that
FHR monitoring, and is arguably second algorithm for the management of do not exhibit moderate variability or

90 American Journal of Obstetrics & Gynecology AUGUST 2013

FOR CLASSROOM USE ONLY Obstetrics Clinical Opinion

Management of category II fetal heart rate patterns: clarifications for use in algorithm

1. Variability refers to predominant baseline FHR pattern (marked, moderate, minimal, absent) during a 30-minute evaluation period, as defined
2. Marked variability is considered same as moderate variability for purposes of this algorithm.
3. Significant decelerations are defined as any of the following:
 Variable decelerations lasting longer than 60 seconds and reaching a nadir more than 60 bpm below baseline.
 Variable decelerations lasting longer than 60 seconds and reaching a nadir less than 60 bpm regardless of the baseline.
 Any late decelerations of any depth.
 Any prolonged deceleration, as defined by the NICHD. Due to the broad heterogeneity inherent in this definition, identification of a prolonged
deceleration should prompt discontinuation of the algorithm until the deceleration is resolved.
4. Application of algorithm may be initially delayed for up to 30 minutes while attempts are made to alleviate category II pattern with conservative
therapeutic interventions (eg, correction of hypotension, position change, amnioinfusion, tocolysis, reduction or discontinuation of oxytocin).
5. Once a category II FHR pattern is identified, FHR is evaluated and algorithm applied every 30 minutes.
6. Any significant change in FHR parameters should result in reapplication of algorithm.
7. For category II FHR patterns in which algorithm suggests delivery is indicated, such delivery should ideally be initiated within 30 minutes of
decision for cesarean.
8. If at any time tracing reverts to category I status, or deteriorates for even a short time to category III status, the algorithm no longer applies.
However, algorithm should be reinstituted if category I pattern again reverts to category II.
9. In fetus with extreme prematurity, neither significance of certain FHR patterns of concern in more mature fetus (eg, minimal variability) or
ability of such fetuses to tolerate intrapartum events leading to certain types of category II patterns are well defined. This algorithm is not
intended as guide to management of fetus with extreme prematurity.
10. Algorithm may be overridden at any time if, after evaluation of patient, physician believes it is in best interest of the fetus to intervene sooner.

FHR, fetal heart rate; NICHD, Eunice Kennedy Shriver National Institute of Child Health and Human Development.
Clark. Category II FHRT. Am J Obstet Gynecol 2013.

accelerations, but do exhibit patterns of development of management rec- algorithm must also avoid unnec-
persistent late or signicant variable ommendations for category II FHR essary intervention, and encourage
decelerations, as dened in the Table, patterns. The effectiveness and vaginal delivery in women whose
signicant metabolic acidemia cannot associated intervention rates of this FHR patterns suggest minimal risk
be excluded. Further, these deceleration algorithm may be further dened of signicant deterioration prior to
patterns signify the presence of physio- and rened in future studies. delivery. We designed this algo-
logic stresses that increase the risk 3. Category II patterns identify fetuses rithm with both goals in mind, but
of developing such acidemia. In such that may potentially be in some with a primary focus on the
cases, we recommend expeditious de- degree of jeopardy but are either not avoidance of preventable injury.
livery. Examples of the application of acidemic, or have not yet developed a 4. The appropriateness of select con-
this algorithm are demonstrated in degree of hypoxia/acidemia that servative attempts to relieve certain
Figures 2-5. These examples assume that would result in neonatal encepha- category II patterns is well estab-
the 20-minute period shown in the lopathy.12,20,21 However, we believe lished.25-29 However, valid scientic
gures is representative of the 30-60 one important goal of intrapartum evidence afrming the effectiveness
minute observation period referred to care is delivery of the fetus, when of such measures varies widely. For
in the algorithm. Should the pattern possible, prior to the development of example, while amnioinfusion for
either improve or deteriorate during this damaging degrees of hypoxia/acid- relief of oligohydramnios-associated
time frame, management should be emia. We offer this algorithm to variable decelerations is well sup-
changed accordingly. assist the attending physician in ported in the literature, no evidence
In assessing and implementing this accomplishing this goal. We recog- exists to support the efcacy of
algorithm, we wish to bring specic nize that adherence to the algorithm maternal oxygen administration
attention to a number of considerations cannot alter the course for an already in commonly achievable concen-
which we consider to be particularly injured fetus, or one that experiences trations in increasing fetal tissue
germane. an unexpected catastrophic event oxygenation, or in improving new-
1. This algorithm follows the foun- during labor. born outcomes regardless of oxygen
dational NICHD denitions and However, since any algorithm concentration.28,29 Nevertheless, any
recommendations.20,21 for the management of category II of the commonly accepted ap-
2. This algorithm should be un- patterns will apply to the majority proaches to relief of abnormal FHR
derstood as a next step in the of fetuses during labor, the patterns may be appropriately

AUGUST 2013 American Journal of Obstetrics & Gynecology 91

Clinical Opinion Obstetrics

Tracing exhibits minimal to absent variability without decelerations, despite regular contractions

Medication effect has been excluded clinically as part of the initial period of intrauterine resuscitation attempts. While the fetus may have experienced
prelabor central nervous system injury, absence of late decelerations excludes ongoing hypoxia in a neurologically intact fetus. However, since such
fetuses may not tolerate labor without sudden deterioration and demise, cesarean delivery would be appropriate, per algorithm, if pattern persists for
1 hour.
Clark. Category II FHRT. Am J Obstet Gynecol 2013.

attempted in specic situations. II FHR pattern.21 Acceptable ap- presence of moderate baseline vari-
Their effect should be apparent proaches to monitoring of uterine ability or accelerations. In contrast,
within 30 minutes of application activity are well described in available conicting data exist regarding
(Figure 1). If the FHR tracing remains literature.30,31 the signicance of variability within
category II following these efforts, the 5. Recent data suggest that no single deceleration nadirs.35,36 Variability
algorithm is applied to the pattern quantitative value of fetal arterial within decelerations alone cannot
observed following these attempts at pH serves to dene a point of be reliably used to exclude fetal
therapeutic intervention. hypoxia-induced damage applicable acidemia and accordingly is not
Attention should be given to the to all fetuses.32 However, the litera- addressed in this algorithm.
prompt elimination of excessive ture is consistent in its demonstra- 6. FHR patterns cannot be inter-
uterine activity including tachysystole tion that for any individual fetus, preted in isolation. Accordingly,
or prolonged contractions, especially baseline variability and accelera- we have incorporated labor prog-
when uterine stimulants (oxytocin or tions will reliably be depressed ress as described in traditional
prostaglandin-containing agents) are before the pH has reached a level of terms (stage I latent phase, stage I
being applied.30,31 Oxytocin infusion acidemia associated with neurologic active phase and second stage) into
should be reduced or discontinued injury for that fetus, regardless of this algorithm. This is of signi-
in the presence of excessive uterine its quantitative value.33,34 Hence cance since the expected remaining
activity and a persistent category this algorithm relies strongly on the length of labor may inuence

Tracing exhibits minimal to absent variability and late decelerations occurring with >50% of contractions

Per algorithm, expedited delivery is indicated regardless of labor progress.

Clark. Category II FHRT. Am J Obstet Gynecol 2013.

92 American Journal of Obstetrics & Gynecology AUGUST 2013

FOR CLASSROOM USE ONLY Obstetrics Clinical Opinion

Tracing exhibits moderate variability and accelerations, thus excluding clinically significant acidemia

Late decelerations represent protective cardiovascular response to contraction-induced reductions in fetal oxygenation. Per algorithm, if labor is
progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from delivery, delivery would be
Clark. Category II FHRT. Am J Obstet Gynecol 2013.

the likelihood of, and response conservative approaches in the deceleration pattern (Figure 1).
to, deterioration of category II presence of persistent category II However, intervention in patients
patterns. A category II pattern FHR patterns are lacking. For with certain category II patterns
may have a different indicated example, we hesitate to recommend and slow, but technically adequate
management when presenting in nonintervention for an arrest of labor progression may also be an
early rst-stage labor than an active phase dilatation of 4 hours in appropriate option.
identical pattern presenting in the the presence of recurrent late de- 7. Some well-dened features of
late second stage. We acknowledge celerations, even in the presence of category II patterns (eg, fetal tachy-
recent data suggesting that cesarean moderate variability. The superb cardia or marked variability) are
delivery based on classic denitions reliability of accelerations and not included in the algorithm-
of protracted active phase, arrest of moderate variability in excluding based decision tree for interven-
dilatation, or arrest of second-stage any degree of hypoxia-related cen- tion. This does not signify that such
descent alone may not be necessary, tral nervous system depression or patterns are innocuouseindeed, it
and that longer periods of obser- risk of ongoing hypoxic injury may be exactly these features of a
vation may yield lower intervention would allow observation of patterns tracing that mandate consideration
rates.10,37 However, data demon- with these features and adequate as a category II pattern, and the use
strating the safety of these more labor progress regardless of the of this algorithm. However, in such

Tracing exhibits moderate variability and acceleration, thus excluding clinically significant acidemia

Significant variable decelerations seen here suggest umbilical cord compression during contraction, which could, over time, lead to significant acidemia.
Per algorithm, if labor is progressing normally in active phase or second stage, careful observation would be appropriate. If the fetus is remote from
delivery, delivery would be appropriate.
Clark. Category II FHRT. Am J Obstet Gynecol 2013.

AUGUST 2013 American Journal of Obstetrics & Gynecology 93

Clinical Opinion Obstetrics

cases, it is our expectation that uterus.40,42,43 Such variations are operator expertise in use of these
other concerning patterns included legion and cannot be adequately techniques.44,45 Because delivery
in the algorithm will appear prior to addressed with a single algorithme based on this algorithm will be
the need for intervention. indeed, their rarity and physiologic principally driven by concern for
8. This algorithm is intended to heterogeneity probably preclude fetal well-being, and because vari-
address the challenge of progressive meaningful study as a group. We can able levels of expertise in operative
intrapartum hypoxia/acidemia due only comment that tolerance for vaginal delivery exist among prac-
to the effects of labor contractions such recurrent patterns remote titioners, we anticipate that cesarean
on a susceptible fetus. Neither this, from delivery ought to be small delivery will be the most common
nor any other management ap- unless the etiology is apparent and procedure elected in many situa-
proach to labor, will ever predict, can be promptly ameliorated. tions. In contrast to some types of
or prevent, unexpected sentinel 10. The current NICHD classication category III tracings in which the
events that may occur without system uses the classic descriptions urgency of intervention may occa-
warning and rapidly change a FHR of deceleration patterns initially sionally justify acceptance of some
pattern from category II to category developed by Kulbi and colleagues.1 degree of risk for trauma, the vast
III. In such situations, even the However, because different types of majority of category II tracings in
most expeditious response may be decelerations have unique etiol- which delivery is indicated only
insufcient to avoid neonatal en- ogies, a given fetus may have >1 warrant initiation of delivery within
cephalopathy and its sequelae.38,39 pathologic process ongoing during 30 minutes of the decision for
However, 2 clinical situations exist labor. One example would be a delivery. A limited attempt at oper-
in which category II patterns, while growth-restricted fetus with oligo- ative vaginal delivery by an ex-
excluding ongoing hypoxia/acid- hydramnios demonstrating both perienced clinician may represent
emia, may be harbingers of sentinel variable decelerations secondary to optimal care in some circumstances.
events that may rapidly lead to cord compression and late de- However, the physician with limited
profound hypoxia. These condi- celerations due to hypoxia during experience in operative vaginal de-
tions are vaginal bleeding sufcient contractions based on uteropla- livery should not delay preparations
to suggest possible placental ab- cental insufciency. This may give for cesarean, nor persist in attempts
ruption, and any woman undergo- rise to a less well-dened, hybrid at operative vaginal delivery without
ing a trial of labor after a previous pattern of decelerationsefor exam- progressive descent with each con-
cesarean.40-42 In both cases, this ple, late decelerations superim- traction. Without real expertise in
algorithm does not apply, as expe- posed upon variable decelerations. operative vaginal delivery, a deteri-
ditious cesarean delivery is often Because relatively benign variable orating category II FHRT will often
indicated based on the sudden decelerations are visually more be best managed by prompt cesar-
appearance of decelerations in a dramatic than the subtle, yet more ean delivery.
context (moderate variability and concerning, late decelerations, the 12. The most vexing issue in the devel-
accelerations) that would be other- latter may be easily overlooked. opment of this algorithm was the
wise reassuring. In such cases, the patient should issue of decreased vs absent vari-
9. This algorithm does not address the be managed with a focus on the ability. We accept the accuracy of
issue of prolonged deceleration, late, rather than the variable de- data concluding that FHR vari-
as dened by the NICHD. This celerations. Such hybrid decelera- ability must be absent to reliably
denition is too broad to be clini- tion patterns differ from the more reect a high degree of correla-
cally useful in isolation.20,21 A 121- commonly seen atypical variable tion with severe fetal acidemia.20,21
second deceleration to 90 beats/min decelerations that have no correla- However, we caution against delay-
and a 9-minute and 59-second tion with fetal acidemia.35 It is ing delivery of a deteriorating FHR
deceleration to 50 beats/min are, important for clinicians to carefully pattern because criteria indicating
from a clinical standpoint, very evaluate any atypical-appearing probable severe metabolic acidemia
different, yet both are, by denition, variable decelerations in this light. have not yet been met. We have
prolonged decelerations. The situa- 11. The algorithm presented authorizes chosen to treat persistent minimal
tions associated with prolonged judgment in some situations be- and absent variability as one for the
decelerations also greatly impact tween cesarean delivery and opera- following reasons.
the decision makingea prolonged tive vaginal delivery. We wish to a. Variability cannot be considered
deceleration following an epidural emphasize that operative vaginal to be a strictly binary feature of
should give rise to a completely delivery is not universally appli- a FHR pattern. It is evident that
different set of management con- cable, but rather depends on the a fetus with moderate vari-
siderations than an identical pattern patient meeting appropriate criteria ability (thus excluding concur-
in a woman laboring with a scarred for vacuum or forceps, as well as rent fetal metabolic acidemia)

94 American Journal of Obstetrics & Gynecology AUGUST 2013

FOR CLASSROOM USE ONLY Obstetrics Clinical Opinion

that devolves to a state of frank expertise is not universal among prac- observation is appropriate, and is
asphyxia and severe metabolic ticing obstetricians. Indeed, even among embraced in the algorithm.
academia with absent variability recognized experts there is signicant 14. The algorithm presented here rep-
as a result of episodes of intra- interobserver variation in the differen- resents a consensus of the best
partum hypoxia must rst pass tiation of FHR patterns with minimal vs thoughts of 18 authors regard-
through a stage of minimal absent variability.9 A basic principle of ing one reasonable approach to
variability, unless the deteriora- any safety protocol is the direction of category II FHR patterns given our
tion is abrupt and catastrophic as such guidelines to the least, not the present scientic understanding.
seen in a sentinel event. greatest expected level of user compe- All authors are highly experienced
b. While it is possible for apparent tence. Thus, we have used moderate clinicians with signicant peer-
variability to be exaggerated rather than moderate or minimal vari- reviewed research experience and
with the use of a rst-genera- ability as a dening reassuring feature of publications in the area of fetal
tion external, ultrasound-based our algorithm. While we acknowledge evaluation. They also represent a
heart rate monitoring device, that such a decision will lead to inter- broad geographic spectrum and
autocorrelation techniques em- vention in cases that, in hindsight, might experience in both the academic
ployed with most current be proven to be unnecessary, we believe and private practice worlds and
monitoring systems have mini- that following the algorithm as written represent the disciplines of medi-
mized this tendency.46 Unfortu- will avoid preventable neurologic injury cine, nursing, and midwifery. As
nately erratic signal detection or due to lack of intervention for a category such, it is reasonable for clinicians
transient artifact may give rise to II FHR pattern, and will be associated to utilize this algorithm in the
periods of apparent minimal with an appropriate intervention rate. management of category II FHR
variability that could be falsely Cases of fetal hypoxia/acidemia during patterns; compliance with this pro-
reassuring to some clinicians labor due to unexpected sentinel events tocol is one way to meet the
and lead to delay in delivery. If remain largely unpreventable.38,39 standard of care in the United
technically feasible, the fetus States. Importantly, as with most
with a category II pattern and 13. A fetus presenting with persistent other areas of medicine, the estab-
poor FHR signal quality should minimal to absent FHR variability lishment of this algorithm as one
be monitored with a fetal scalp and absent accelerations but way to comply with the standard
electrode. without signicant decelerations of care does not exclude the exis-
c. An external FHR monitor that poses a signicant diagnostic and tence of other equally acceptable
yields a consistent high-quality management dilemma. In many of approaches. While the authors uni-
tracing, or a continuous fetal these cases, such a pattern repre- formly agree on the appropriateness
scalp lead tracing, will generally sents preexisting central nervous of this model for any laboring
allow the qualied clinician to system injury with marked meta- patient, each of us can think of
distinguish different degrees of bolic acidemia. In other cases, in- numerous situations in which al-
variability, even in the presence trauterine events leading to the ternative approaches to any branch
of classic late or variable de- injury may have resolved (eg, um- of the algorithm would be equally
celerations. Unfortunately, such bilical cord compression) and the acceptable.
a determination may be ren- fetus will have recovered metaboli- 15. This algorithm is supported by
dered more difcult by many of cally, but not neurologically. Devel- available clinical experience, a sub-
the category II patterns actually opmental anomalies unrelated to stantial body of basic science evi-
encountered in clinical practice. hypoxia/acidemia may give rise dence, and indirect clinical data.
Such difculties are especially to a similar picture. Although the Given the current state of obstetric
common in the presence of benet of cesarean delivery in knowledge, we do not believe it is
atypical variable decelerations, improving neurologic outcome in possible to simultaneously eliminate
in which determination of re- such fetuses has never been preventable fetal neurologic injury
turn to baseline may be difcult. demonstrated, these fetuses may be and signicantly reduce the cesar-
In such cases, a baseline less likely to tolerate the additional ean delivery rate for abnormal FHR
apparently exhibiting some de- hypoxia and acidemia that accom- patternseseveral decades of such
gree of variability may in fact panies even normal labor without attempts have resulted in the cur-
still be a part of a recovering intrapartum demise. In the absence rent state of Brownian motion
deceleration. of signicant decelerations however, in which neither goal has been
the clinician may be assured that measurably achieved. Our goal in
With exceptional expertise, most of while the fetus may be damaged, it is developing this algorithm has been
these situations can be appropriately not being damaged. Under these to x one variable in this equation
delineated. However, that level of circumstances, a limited period of by presenting an algorithm, which if

AUGUST 2013 American Journal of Obstetrics & Gynecology 95

Clinical Opinion Obstetrics

implemented as one component of demonstrated to be superior to all 79-3245. Hyattsville, MD: National Center for
good obstetrical care, will assist the others in randomized clinical tri- Health Services Research, US Department of
Health, Education, and Welfare; 1979.
clinician in avoiding preventable als.51 Yet the near universal adop- 7. Freeman R. Intrapartum fetal monitoringea
intrapartum fetal hypoxia, meta- tion of these standard approaches disappointing story. N Engl J Med 1990;322:
bolic acidemia, and hypoxic injury has resulted in improved outcomes 624-6.
based on failure to deliver in the face for cardiac arrest patients. Such al- 8. Chauhan SP, Klauser CK, Woodring TC, et al.
of certain persistent category II FHR gorithms have, over time, also un- Intrapartum nonreassuring fetal heart rate
tracing and prediction of adverse outcome:
patterns. Of course, as with any dergone modication due to interobserver variation. Am J Obstet Gynecol
set of recommendations, clinical advances in clinical understanding 2008;198:623.
studies directly applying this algo- based on new data. It is also 9. Blackwell SC, Grobman WA, Antoniewitz L,
rithm both retrospectively to large important to note that in this et al. Interobserver and intraobserver reliability
series of category II patterns, and instance, our algorithm does not of the NICHD 3-tier fetal heart rate inter-
pretation system. Am J Obstet Gynecol 2011;
prospectively to large populations, seek to replace any established 205:375.
are needed to potentially improve methodical approach to the man- 10. Spong KY, Berghella V, Wenstrom KD,
the efcacy of the algorithm, and to agement of category II patterns. Mercer BM, Saade GR. Preventing the rst ce-
better ascertain the actual inter- Rather, we suggest that this algo- sarean delivery. Obstet Gynecol 2012;120:
vention rate associated with its rithm will be helpful in the current 1181-93.
11. Clark SL, Hankins GDV. Temporal and
application. It is anticipated that clinical setting in the United States demographic trends in cerebral palsy: fact
such studies may facilitate rene- in which a lack of clear direction has and ction. Am J Obstet Gynecol 2003;188:
ment of this basic algorithm to led to divergent decision making 628-33.
reduce the intervention rate without regarding cesarean section for FHR 12. American College of Obstetricians and
incurring preventable morbidity or abnormalities.24 Gynecologists and American Academy of
Pediatrics. Neonatal encephalopathy and cere-
mortality. Adoption of this algorithm for the bral palsy: dening the pathogenesis and
16. We make no claim of the superiority management of category II FHR patterns pathophysiology. Washington, DC: American
of this algorithm over other ap- by the clinician is one approach to College of Obstetricians and Gynecologists;
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