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Labor and Delivery, St. John’s Mercy Medical Center, St. Louis, MO, USA
KEYWORDS Summary Intrauterine resuscitation techniques are often used during labor when the fetal
Intrauterine heart rate pattern is nonreassuring. These techniques have not been well studied; common
resuscitation; practices are based on classic studies many years old. Models of intrauterine resuscitation
Maternal oxygen using one (or more) technique as a first-line intervention and adding others in a specific series
administration; or clinical algorithm based on fetal response have not been tested. Maternal oxygen therapy is
Nonreassuring fetal often used; however, recent evidence suggests potential risks to the mother and fetus or
heart rate pattern; newborn. Even small increases in maternal and fetal pO2 as a result of maternal oxygen admin-
Oxygen free radicals istration can produce oxygen free radical activity in mothers and fetuses. The potential long-
term effects are unknown. Caution should be exercised when considering maternal oxygen
administration as a first-line intrauterine resuscitation measure until more data are available,
reserving its use after other measures have been unsuccessful in resolving the nonreassuring
fetal heart rate pattern.
ª 2008 Elsevier Ltd. All rights reserved.
1744-165X/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.siny.2008.04.016
Intrauterine resuscitation during labor 363
on multiple physiologic parameters, whereas the obstetri- Therefore, a diagnosis of nonreassuring fetal status can
cian, midwife, and labor nurse are limited to the assess- be consistent with birth of a vigorous baby.5
ment of the heart rate pattern of a patient who is unseen.
These inherent challenges of EFM make interpretation and Intrauterine resuscitation
decision making less than precise.
Approximately 30% of fetuses will demonstrate a nonreas- Choice of intervention(s) when fetal compromise is
suring FHR pattern at some time during labor1; however, in suspected is based on the individual clinical situation and
many of these cases, the fetus remains well oxygenated. specific characteristics of the nonreassuring FHR pattern.
EFM sensitivity (the ability to detect a healthy fetus when it The clinical context in which the nonreassuring FHR pattern
is indeed healthy) is high, whereas specificity (the ability to occurs and success in resolving the pattern serve as the
detect a compromised fetus when it is compromised and not basis for the clinician’s judgment in selecting which initial
include healthy fetuses in the criteria) is low.2 and subsequent methods might work best. No standardized
Further confounding factors include a lack of consensus or systematic approach to intrauterine resuscitation is
among clinicians regarding characteristics of FHR patterns found in the literature or offered by the American College
that indicate fetal compromise as well as a lack of universal of Obstetricians and Gynecologists or the Association of
adoption of standardized definitions to describe FHR Women’s Health, Obstetric and Neonatal Nurses; however,
patterns. Findings from the Joint Commission3 analysis of some techniques are commonly used for specific non-
sentinel event data related to perinatal harm during labor reassuring FHR patterns. For example, interventions for
and birth emphasized the role of accurate communication a woman experiencing a hypotensive episode following
in promoting patient safety. As a result of these data, the a medication dose for regional anesthesia with an accom-
Joint Commission recommended use of standard definitions panying FHR demonstrating recurrent late decelerations
to describe FHR patterns and interdisciplinary education to and moderate variability could include repositioning, an
enhance the likelihood that all members of the perinatal intravenous (IV) fluid bolus, and, if no resolution, ephed-
team would be speaking and understanding the same rine. Recurrent variable decelerations during the first stage
language when communicating FHR data.3 Although stan- of labor can be treated with repositioning, and, if no
dardized definitions were offered by the National Institute resolution, an amnioinfusion. During the second stage of
of Child Health and Human Development (NICHD) Research labor, the same FHR pattern could be treated with
Planning Workshop in 1997,4 all clinicians and institutions repositioning and modification of instructions to the woman
have not incorporated them into clinical practice. The regarding her pushing efforts. The key issues are timely
terms reassuring and nonreassuring are often used to identification and minimization or elimination of the
convey the clinician’s interpretation of the FHR pattern factors thought to be causing physiologic stress to the fetus
and to acknowledge the inherent imprecision of EFM. as suggested by the nonreassuring FHR pattern.
364 K.R. Simpson
Although a nonreassuring FHR pattern might be idio- administer oxygen whereas others do so routinely for
pathic, in some cases, the physiologic stress imposed on the prolonged periods during labor, in some cases concurrent
fetus is iatrogenic. Examples of iatrogenic stress include with oxytocin while the FHR remains nonreassuring and in
oxytocin-induced uterine hyperstimulation, supine or li- other cases long after the nonreassuring FHR pattern has
thotomy maternal positioning, regional anesthesia, and resolved. The most common delivery method is 10 L/min
clinician-coached maternal pushing efforts during second administered via a nonrebreather mask, which results in
stage labor. Attention to clinical conditions with the an FiO2 of 80% to 100%.7,8 Other devices are less efficient
potential for fetal compromise and prompt treatment are (nasal cannula at 10 L/min: FiO2 31%, simple facemask at
indicated to promote fetal wellbeing. 10 L/min: FiO2 27% to 40%).2
Recent evidence suggests that fetal deterioration A search of the electronic databases Medline, the
evolves over time within an approximate 1-hour time Cumulative Index to Nursing and Allied Health Literature
frame.6 Thus, barring any acute adverse clinical event (CINAHL), and the Cochrane Database of Systematic
such as placental abruption, uterine rupture, or prolapsed Reviews from 1966 to January 2008 using the key words or
umbilical cord, generally there is enough time to rescue phrases ‘maternal oxygen administration/therapy’, ‘intra-
a fetus whose wellbeing is in question based on the FHR uterine resuscitation’, ‘in-utero resuscitation’, ‘treatment
pattern. In the context of adequate staffing and with a fetal for fetal distress’, and ‘nonreassuring FHR patterns’
assessment frequency of every 15 to 30 minutes based on revealed numerous studies regarding the effects of mater-
risk status, it is reasonable to expect that a nonreassuring nal oxygen therapy on the fetus during the antepartum and
FHR pattern during labor will be identified and treated in intrapartum periods. Additional studies not identified in the
a timely manner before fetal harm occurs. electronic database search were located in the reference
Despite routine use, intrauterine resuscitation techniques lists of articles reviewed.
have not been well studied; common practices are based in During the antepartum period, three studies considered
part on classic studies many years old. Models of intrauterine the effects of maternal oxygen administration on fetuses
resuscitation using one or more techniques as first-line in- with suspected intrauterine growth restriction,10e12 and
terventions and adding others in a specific series or clinical one study was conducted using healthy fetuses.13 Labor
algorithm based on the fetal response have not been tested. was the clinical setting of 13 studies in which mothers
Yet many clinicians use a step-wise method when intervening were given oxygen.7,8,14e24 However, only six of those
during a nonreassuring FHR pattern. Theoretically, the in- studies7,15,16,18,19,24 included fetuses with nonreassuring
terventions listed in Table 1 are selected on a continuum be- FHR patterns. The number of patients with nonreassuring
ginning with the least invasive and moving forward until FHR patterns in each of those studies was quite small;
there is resolution of the nonreassuring FHR pattern or plans ranging from 1 to 35; up to a total of 98 when combining
are underway for expeditious birth. Therefore, lateral posi- all six studies. Some of the studies did not specifically
tioning is often the first intervention, followed by discontinu- mention whether subjects had a nonreassuring FHR pat-
ation of oxytocin (if infusing), modification of maternal tern, instead noting that the mothers had maternal com-
pushing efforts, and/or an IV fluid bolus; while medications plications such as diabetes or preeclampsia that could
such as oxygen, terbutaline, or ephedrine and procedures increase the risk of fetal compromise. None used random-
such as amnioinfusion are used if the pattern does not resolve ization as a design method. Various amounts of oxygen
with first-line measures. A review of the evidence for each of ranging from 27% to 100% FiO2 were administered. An ad-
these intrauterine resuscitation techniques has been pub- ditional 16 studies were conducted to evaluate the poten-
lished elsewhere.2 tial benefits of routinely giving the mother oxygen to
Recently, several studies have provided more evidence hyperoxygenate the fetus immediately prior to cesarean
concerning common intrauterine resuscitation techniques. birth25e40 with FiO2 levels ranging from 28% to 100%; in
Maternal oxygen administration at 10 L/min administered some studies, comparison groups receiving 21% FiO2
via a nonrebreather facemask may be useful in improving (room air) were used.
fetal oxygen status when the FHR is nonreassuring during Results of all of the studies indicated that maternal
labor.7 Individually, maternal oxygen administration, an IV oxygen administration increases fetal oxygenation regard-
fluid bolus of 500 mL of lactated Ringer’s solution, and less of the method used to measure fetal oxygen status,
lateral positioning have been shown to increase fetal oxy- including FHR patterns, fetal scalp blood sampling, trans-
gen saturation (FSpO2) during labor.8 Reduction of uterine cutaneous oxygen saturation, near-infrared spectroscopy,
activity can be accomplished by maternal repositioning, fetal oxygen saturation (FSpO2), and umbilical blood
an IV fluid bolus of at least 500 mL of lactated Ringer’s sampling. However, although these results might be en-
solution, and discontinuation of oxytocin.9 When used con- couraging in suggesting therapeutic effects of maternal
currently, these three interventions have been found to be oxygen administration for the fetus, this body of evidence
more successful in resolving oxytocin-induced uterine suffers from lack of inclusion of fetuses with nonreassur-
hyperstimulation when compared to discontinuing oxytocin ing FHR patterns in most studies, small sample size, and
alone or with an IV fluid bolus.9 lack of randomly selected comparison groups who did
not receive oxygen except for the studies concerning rou-
Maternal oxygen administration as an tine oxygen use immediately prior to cesarean birth. Con-
intrauterine resuscitation technique ducting a randomized controlled trial allocating patients
with a nonreassuring FHR pattern during labor to a group
Use of maternal oxygen therapy as an intrauterine re- in which oxygen was withheld as an intervention would
suscitation technique varies widely. Some clinicians rarely likely be difficult.
Intrauterine resuscitation during labor 365
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