Correlation of the five tier color coded category during intrapartum

cardiotocographic monitoring with the neonatal outcome in

MCU FDTMF Hospital: a Prospective Study
By: Paula Patricia P. Perez, M.D.
ABSTRACT
Introduction: Category II FHR tracings of the three tiered classification system are indeterminate and include a
wide variety of possible tracings that do not fit in either Category I (normal) or Category III(abnormal) tracings.
To further categorize the indeterminate pattern, the 5-tier color coded system was introduced by Parer and Ikeda.
Objective: To correlate the five tier color coded category for intrapartum electronic fetal monitoring with the
neonatal outcome.
Methodology: A prospective cohort study was done on patients 15- 44 years old with singleton pregnancies who delivered
vaginally or by primary cesarean section due to fetal distress, and with cardiotocographic (CTG) tracing obtained within 2 hours
prior to delivery. Subjects were included during their prenatal check-ups at the outpatient department or during emergency
room admission. They were monitored using the electronic fetal monitor during labor their room/delivery room/operating stay.
After the delivery, arterial cord blood was submitted to the laboratory for umbilical cord ph analysis. APGAR scores
(5, 10 minutes) were assessed. The single investigator correlated the five tier color coded category using the color coded
chart of Parer and Ikeda. Primary neonatal outcomes of umbilical cord ph and APGAR score and the secondary
outcomes of NICU admission, need for ventilator support, neonatal sepsis and length of hospital stay were determined.
Results: One Among the 91 subjects, hypertensive disorders, maternal cardiac problems and babies
with IUGR were significantly correlated with the five tier color coded category (p=0.05, 0.007 and 0.003, respectively).
It was also correlated with primary outcomes of APGAR score and umbilical cord pH.
Conclusion: The five tier color coded system is correlated with acidemia, poor APGAR score and the
development of an adverse neonatal outcome thus, it becomes a stepwise approach for an obstetrician
knowing when to intervene and when to do an expectant management.
Key Words: 5-tier color coded system, intrapartum electronic fetal monitoring, neonatal outcomes, APGAR score, acidemia

From the Department of Obstetrics and Gynecology, Manila Central University, Filemon D. Tanchoco Medical Foundation and Hospital
1st Prize: 40th Resident Physicians’ Trainee Research Ppaer Oral Contests, July 20, 2017, Tanchoco Auditorium
Correspondence: Paula Patricia P. Perez, MD ● Email address: mcu_obgyn@yahoo.com● Department of Obstetrics and Gynecology,
MCU-FDTMF Hospital, Samson Road, EDSA, Caloocan City Tel: 3672031 loc. 1219

INTRODUCTION

The fetus depends on the mother for placental
exchange of oxygen and carbon dioxide. This in turn
relies on adequate maternal blood gas concentrations,
uterine blood supply, placental transfer and fetal gas
transport. Disruption of any of these can cause fetal
hypoxia, which, despite compensatory mechanisms,
may lead to acidosis 1.
is due to reduced placental transfer, umbilical artery and
vein values will both be abnormal and similar, whereas in
acute cord compression or fetal bradycardia, the hypoxia
and acidosis will be predominantly in the umbilical artery,
leading to a large arteriovenous difference. This is because a
slow passage of blood through the placenta allows time for
maximum gas exchange despite reduced total blood flow 2.

As in labor, neonates from pregnancies with Injury to the brain sustained during the perinatal
antenatal (growth retardation) or intrapartum (meconium period was one of the most common causes of death or
staining) complications, are more likely to be hypoxic and severe long term neurologic deficits in children. The data
acidotic at birth. In placental dysfunction where hypoxia showed that 10% of brain injury is related to perinatal

Philippine Scientific Journal Vol. 50 • No. 2 9

Correlation of the five tier color coded category during intrapartum cardiotocographic monitoring with the neonatal outcome
in MCU FDTMF Hospital: a Prospective Study
or intrapartum events3,4. The brain injury referred as
hypoxic-ischemic encephalopathy occurs due to impaired
cerebral blood flow likely as a consequence of interrupted
placental blood flow leading to impaired gas exchange5.
If gas exchange is persistently impaired, hypoxemia
and hypercapnia develop with resultant fetal acidosis
or what has been referred to as asyphyxia. Severe fetal
acidemia defined as umbilical arterial pH of less than
7.00 is associated with increased risk of adverse
neurologic outcome 6,7.
Continuous intrapartum electronic fetal heart
rate monitoring (EFM) to monitor fetal status was
introduced in the 1960s and was used in 89% of
singleton pregnancies in 20048. However, despite
previous attempts, developing a standardized approach
to interpretation and management has been problematic.
EFM is often criticized for having a high false positive
rate as it is unable to predict cerebral palsy, this is not the
intended goal 9. The primary goal is to identify fetuses
with hypoxemia or acidemia and intervene before an
adverse outcome because persistent fetal acidemia
can result in permanent neurologic sequelae.
Intermittent auscultation of Fetal Heart
Rate (FHR) and electronic fetal monitoring such as
cardiotocography (CTG) are the most popular methods
for intrapartum fetal surveillance. Whereas the former
focuses only on estimation of basal heart rate, the latter
also reflects upon other qualities of fetal heart rate such
as variability, accelerations and decelerations10. With
reduction in the cost of the equipment, EFM has become
a routine in many labor wards and especially at tertiary
level hospitals. A normal trace with a normal acid base
status at birth has an accuracy of 98 %11. The most ominous
fetal heart patterns are often associated with only 80%
accuracy for low APGAR score and fetal acidosis
at birth12.
Initial studies demonstrated the significance of
EFM in reducing intrapartum mortality and detecting
fetal acidemia when compared with intermittent
auscultation. It also showed an increase in cesarean and
operative vaginal deliveries 13,14. The aim of intrapartum
fetal monitoring is to identify fetuses that are being
inadequately oxygenated, enabling appropriate action
before the occurrence of injury 15. It also provides
reassurance of adequate fetal oxygenation to avoid
unnecessary intervention. It should be emphasized that
in order to avoid adverse outcome related to hypoxia and
10 Philippine Scientific Journal Vol. 50 • No. 2
acidosis, an appropriate and timely clinical response is
required to revert the situation or to expedite delivery 15.
The American College of Obstetricians and
Gynecologists (ACOG), the National Institute of Child
Health and Human Development, and the Society for
Maternal-Fetal Medicine developed the three-tiered
classification of fetal heart rate abnormalities and a
system for interpreting these abnormalities16. Category I
fetal heart rate (FHR) tracings are normal tracings which
are not associated with fetal asphyxia while Category III
FHR tracings are abnormal and indicative of hypoxic
risk to the fetus and possible acidemia16,17.
Category II FHR tracings are indeterminate and
include a wide variety of possible tracings that do not
fit in either Category I or Category III16,17. To further
categorize the indeterminate pattern, the 5-tier color coded
system was introduced by Parer and Ikeda.22 The 5-tier
color coded scheme categorizes CTG patterns thru colors
green, blue, yellow, orange and red. Green is for the normal
features and red for the most abnormal features. The
Indeterminate category is further subdivided into 3
categories in the 5-tier system. This research is conducted
to evaluate the use of the 5-tier color coded system in
the interpretation of our intrapartum CTG monitoring.
Review of review
In a study done by Gyamfi-Bannerman, et
al (2008)18, each Maternal-Fetal Medicine examiner
reviewed 120 fetal heart rate segments. There was strong
concordance noted between category 1 and “green” as
well as category 3 and “red” tracings. The 3-tier and 5-tier
systems were similar in fetal heart rate interpretations
for tracings that were either very normal or very abnormal.
Whether one system is superior to the others in
predicting fetal acidemia remains unknown.
A case control study was done by Jaclyn Coletta,
et al (2012)19 on patients with a fetal arterial pH <7
matched to the next birth that resulted in a pH >7.2.
Tracings were categorized into 3- and 5-tier systems
by a single reviewer. Sensitivities and specificities
were calculated for each. Twenty-four cases and 24 controls
were identified. They noted that the 5-tier system
had a better sensitivity than the 3-tier system.
In a study done by Ikeda (2014), the database at
one tertiary hospital in Nagoya, Japan, was retrospectively
reviewed for women with singleton fetuses in cephalic
 Correlation of the five tier color coded category during intrapartum cardiotocographic monitoring with the neonatal outcome
presentation and in active labor at ≥37 gestational weeks
between 1 June 2011 and 30 April 2012. Continuous FHR
tracings in the second stage of labor were subdivided into
15-min intervals were assessed according to the five-tier
classification. A total of 777 parturient women were
eligible for the study protocol in which level 1 is normal,
level 2 is subnormal, and levels 3-5 are abnormal patterns.
No cases of severe fetal acidosis were recorded when
the maximal levels were below 3. Both the pH and base
excess of the umbilical artery decreased with higher
levels of FHR tracings interpretation (p<0.001). Both
the summations of level-4 windows and level-3 and
level-4 windows were significantly higher in women with
severe fetal acidosis than in women without (P < 0.001),
indicating that the duration of abnormal levels is
associated with severe fetal acidosis. Both the degree and
duration of FHR tracing abnormalities correlate with
severe fetal acidosis.
OBJECTIVES
The study aimed to correlate the five tier color
coded category for intrapartum electronic fetal
monitoring with the neonatal outcomes of APGAR
score and umbilical cord pH.
Specific Objectives:
1. To correlate the five tier color coded category with
the baseline demographic characteristics as to the
maternal age, parity, age of gestation, obstetric
comorbidities and the route of deliveries due fetal
distress.
2. To determine the median APGAR scores at 5 and
10 minute period for each five tier color coded
category green, blue, yellow, orange and red.
3. To correlate each color coded category green, blue,
yellow, orange and red with the primary neonatal
outcomes such as the APGAR score and umbilical
cord pH.
4. To correlate the five tier color coded category green,
blue, yellow, orange and red with the adverse
secondary outcomes such as the need for Neonatal
ICU (NICU) admission, need for a ventilator
support, development of early onset neonatal
sepsis and the mean length of hospital stay.
in MCU FDTMF Hospital: a Prospective Study
METHODOLOGY
A prospective cohort study was done among
patients admitted at the clinical division who were aged
15 - 44 years old with singleton pregnancies who delivered
by normal vaginal delivery either spontaneously or by
instrumental delivery either by a vacuum extraction or
by outlet forceps extraction and women who delivered
by primary cesarean section due to fetal distress who
has a cardiotocographic (CTG) tracing obtained at the
late first stage of labor within 2 hours prior to delivery.
Excluded were cases of preterm gestation less
than 34 weeks, fetus with congenital anomalies, multifetal
gestation, sedatives given within 4 hours prior to delivery,
presence of maternal fever (Temperature more than
or equal to 38C), CTG tracing of less than 15 minutes,
patients who did not give their consent or withdraw from
the study and patients who are in imminent delivery.
An informed consent was obtained to the subjects
who were eligible to be included in the study during their
prenatal check-ups at the outpatient department (OPD)
or during admission at the emergency room (ER). The
sample size of 15 for each color category was computed
based on confidence level of 95%, level of error of 7%
and an accuracy of 98%. There will be a total of 75
sample population for the five tier color coded charts.
Eligible subjects were monitored using the
electronic fetal monitor (EFM) available in the labor
room/delivery room/operating room (LR/DR/OR)
complex. All CTG tracings were printed and were obtained
within the late first stage of labor and were reviewed at
the time of analysis. CTG tracings were categorized by
the investigator according to the five tier color coded
classification as to green, blue, yellow orange and red
based on Parer and Ikeda’s illustration (Figure 1).
The intra-observer variability was by the following:
1) the tracing was categorized by a single reviewer and
that was the investigator, 2) the investigator classified
the CTG tracing according to the five tier color coded
category by Parer and Ikeda which is a standard diagnostic
criteria, 3) the investigator is trained to do the interpretation,
and 4) the EFM machine that was used is simple, calibrated
and operator friendly. This was not a blinded study.
Immediately after the delivery of the baby, while the
Philippine Scientific Journal Vol. 50 • No. 2 11
 Correlation of the five tier color coded category during intrapartum cardiotocographic monitoring with the neonatal outcome
in MCU FDTMF Hospital: a Prospective Study

placenta still in situ, 4 Kelly forceps were placed on the ± SD were generated. Analyses of the different variables
cord and isolated a 10 centimeter segment of umbilical were done using the following test statistics: ANOVA
cord in the middle then cut between the 2 sets of clamps or Kruskal Wallis to compare more than two groups
so that the isolated segment was independent and both the with numerical data, Chi-square test or Fisher Exact test
baby and placenta will still have a clamp in place (Figure to compare and associate nominal (categorical) data.
Figure 1. The five tier fetal heart rate interpretation system by Parer and Ikeda
2). One milliliter of arterial cord blood was collected
from the middle segment and the collected arterial blood
was placed in a pre-heparinized syringe. After the arterial
cord blood collection, the safe cap was placed and
have a clamppositioned the2).syringe
in place (Figure upright.
One milliliter Allcord
of arterial theblood
air was
bubbles
collectedwere
from the middle
segment andremoved
the collectedfrom
arterialthe
bloodsample
was placedbyingently rolling syringe.
a pre-heparinized the syringe
After thein
arterial cord
blood collection, the safe cap was placed and positioned the syringe upright. All the air bubbles were
between the hands. The specimen was sent to the
removed from the sample by gently rolling the syringe in between the hands. The specimen was sent to
the laboratorylaboratory within
within 10 minutes 10 minutes
for the assessment forcord
of umbilical thebloodassessment
pH 15. of
umbilical cord blood pH . 15

Figure 2. Collection of umbilical cord blood pH

APGAR scores at 5 and 10 minutes were assessed

APGARby scores
the atpediatric resident
5 and 10 minutes were on duty.
assessed The
by the investigator
pediatric resident on duty. The
investigator correlated the five tier color coded category with the primary and secondary neonatal
correlated the five tier color coded category with
outcomes. Primary outcomes were monitored: 1. Normal cord blood pH (ph> or = 7.20), 2. Fetal
the
acidemia (pHprimary and APGAR
<7.20), 3. Normal secondary neonatal
score (AS=7 outcomes.
and above), and 4. AbnormalPrimary
APGAR scores (AS<
7 at 5 and 10 outcomes were monitored:
minutes). Secondary 1. Normal
outcomes included 1. Neonatalcord blood pH
ICU Admission, 2. Ventilatory
support, 3.Early onset neonatal sepsis, and 4. Length of hospital stay were secondary outcomes. Early
(ph> or = 7.20), 2. Fetal acidemia (pH <7.20), 3. Normal
onset neonatal sepsis was defined as any systemic bacterial infection confirmed by a positive blood From Parer JT, Ikeda T.A.;Am J Obstet Gynecol 2007 Jul: 197 (1):26 23
Figure 1. The five tier fetal heart rate interpretation system by Parer and Ikeda
culture in theAPGAR score
first seven days of life .(AS=7 and above), and 4. Abnormal From Parer JT, Ikeda T.A.;Am J Obstet Gynecol 2007 Jul: 197 (1):26 23
_________________________________________________________________________________

APGAR scores (AS< 7 at 5 and 10 minutes). Secondary RESULTS

After reviewing the CTG tracings, baseline demographic information such as the maternal age,
outcomes included 1. Neonatal ICU Admission, 2. A total of 91 subjects were included in the study. The study was conducted from the clinical
parity, gestational age at delivery and the route of delivery secondary to fetal distress were collecteddivision
first admissions of September 2015 to September 2016 in the LR/DR/OR complex of MCU FDTMF
Ventilatory
hand by the investigator. support, 3. Early onset neonatal sepsis, and Hospital.

4. Length of hospital stay were secondary outcomes.

DataEarly
RESULTS 5

onset and
were encoded neonatal
tallied in sepsis was 10
SPSS version defined as any
for windows. systemic
Descriptive statistics were
generated for all variables. For nominal data, frequencies and percentages were computed. For numerical
data, mean ±bacterial infection
SD were generated. confirmed
Analyses by avariables
of the different positive
wereblood culture
done using the following test A total of 91 subjects were included in the study.
in theorfirst
statistics: ANOVA Kruskalseven
Wallisdays of life
to compare more. than two groups with numerical data, Chi-square
test or Fisher Exact test to compare and associate nominal (categorical) data. The study was conducted from the clinical division
admissions of September 2015 to September 2016 in
After reviewing the CTG tracings, baseline
the LR/DR/OR complex of MCU FDTMF Hospital.
demographic information such as the maternal age,
parity, gestational age at delivery and the route of
Table 1 shows the correlation of the five tier color
delivery secondary to fetal distress were collected first
coded category with the demographic characteristics.
hand by the investigator.
Maternal age of the subjects, age of gestation, parity and
subjects without comorbidity were not correlated with
Data were encoded and tallied in SPSS version
the five tier color coded category. On the other hand,
10 for windows. Descriptive statistics were generated
hypertensive disorders, maternal cardiac problems and
for all variables. For nominal data, frequencies and
babies with IUGR were significantly correlated with the
percentages were computed. For numerical data, mean

12 Philippine Scientific Journal Vol. 50 • No. 2

 minute period appeared similar for all categories with a slight decrease in median APGAR score (AS=7)
in the Red category.
Table 2. Median APGAR scores at 5 and 10 minute period for five tier color coded category
Correlation of the five tier color coded category during intrapartum cardiotocographic
Green Blue monitoring
yellow with the neonatal
Orange Redoutcome
Table 2. Median APGAR scores at 5 and 10 minute
in MCU period Hospital:
FDTMF for five tier color coded category
a Prospective Study
Median 9
Green 9
Blue 8
yellow Orange 6 Red 2
APGAR score at 5
Median
minutes 9 9 8 6 2
five tier color coded category (p=0.05, 0.007 and 0.003, APGAR Table
score at35 and 4 show the correlation of the five tier
Median APGARminutesscore 9 9 9 9 7
respectively). The routes of delivery were also significantly color coded
at 10 minutes category with the primary neonatal outcome.
correlated to the
Table 1 shows five tier
the correlation of thecolor
five tier coded
color coded charts,
category withhowever the
the demographic TheMedian
resultsAPGAR score 9
were significant
at 10 minutes
9 9
(p <0.0001) 9
thus, the7 five tier
characteristics. Maternal age of the subjects, age of gestation, parity and subjects without comorbidity
proportion
were not correlatedof
withsubjects tocoded
the five tier color the category.
five tierOn thecolor coded
other hand, charts
hypertensive has
disorders, color coded category was correlated with APGAR score
no significant difference to fetal distress (p-value 0.38).
maternal cardiac problems and babies with IUGR were significantly correlated with the five tier color
and umbilical cord pH. There were more patients with poor
coded category (p=0.05, 0.007 and 0.003, respectively). The routes of delivery were also significantly Table 3 and 4 show the correlation of the five tier color coded category with the primary neonatal
correlated to the five tier color coded charts, however the proportion of subjects to the five tier color
Table 1. Correlation of the Demographic Characteristics with the five tier AS andresultsumbilical
outcome. TheTable were
cord(p <0.0001)
significant
acidosis at 5fiveminutes
thus,tierthecolor tier color
among
coded
those
coded charts has no significant difference to fetal distress (p-value 0.38). 3 and 4 show the correlation of the five coded category withcategory wasneonatal
the primary correlated
color
Table coded category
1. Correlation of the Demographic Characteristics with the five tier color coded category in Orange
with APGAR
outcome. The and
scoreresults Red
and umbilical category
cord pH.
were significant There were
(p <0.0001) as compared
more
thus, the fivepatients
tier colorwith to
coded the
poor AS and
category others.
wasumbilical
correlatedcord
Maternal Age Green Blue yellow Orange Red P value* acidosis
withatAPGAR
5 minutes
scoreamong those incord
and umbilical Orange and Red
pH. There werecategory as compared
more patients with poortoASthe
andothers.
umbilical cord
(n =60) (n=13) (n=7) (n=10) (n=1) Table
acidosis3.
at 5Correlation
minutes among those of the FiveandTier
in Orange ColorasCoded
Red category comparedCategory
to the others. with
15-19 y/o 8 3 1 0 0 the 3.Primary
Table Correlation Neonatal
of the FiveOutcomes
Tier Color Coded Category with the Primary Neonatal Outcomes
20-35 y/o 49 8 3 9 1 0.21 Table 3. Correlation of the
Normal APGAR Five Tier Color Coded
Poor Category with the
APGAR Primary Neonatal
Total Outcomes
P value*
36-44 y/o 7 2 3 1 0 (NS) score at 5 minute
Normal APGAR score PooratAPGAR
5 minute (n=91) P value*
Total
Age of Gestation score at 5 minute score at 5 minute (n=91)
in weeks Green 60 0 60
34 1/7 to 36 6/7 4 0 0 0 0 Green 60 0 60
Blue 13 0 13
37-40 55 10 7 8 1 0.23 Blue 13 0 13
40 1/7 to 42 3 3 0 2 0 (NS) yellow 7 0 7 <0.0001 (S)
yellow 7 0 7 <0.0001 (S)
Parity Orange 4 6 10
Orange 4 6 10
Primi 36 7 2 6 0 Red 0 1 1
Red 0 1 1
*p-value ≤0.05-Significant
Multi 27 6 5 4 1 0.53 (NS) *p-value ≤0.05-Significant
Route of
Deliveries due to Table 4. Correlation of the Five Tier Color Coded Category with
TableTable
4. Correlation of the
4. Correlation Five
of the FiveTier
TierColor
ColorCoded Categorywith
Coded Category withthethe Primary
Primary Neonatal
Neonatal Outcomes
Outcomes
fetal distress the Primary Neonatal Outcomes
NSVD 0 0 0 2 1 <0.001 (S)
pHpH
>/=>/=7.20
7.20 pH <7.20
pH <7.20 Total
Total P value*
P value*
Operative 0 0 0 1 0 <0.001 (S) (n=82)
(n=82) (n= 9)
(n= 9) (n=91)
(n=91)
Vaginal delivery
Cesarean 0 1 2 4 0 <0.001 (S) Green
Green 6060 00 6060
Section
Maternal BlueBlue 1313 00 1313
Obstetric
Complications† yellow
yellow 66 11 7 7 <0.0001 (S) (S)
<0.0001
Diabetes 26 4 3 4 0 0.24 (NS) Orange
Mellitus Orange 33 77 1010
Hypertensive 13 2 3 0 0 0.05 (S) Red Red 00 11 1 1
Disorder
* p-value
* p-value ≤0.05-Significant
≤0.05-Significant
Thyroid 6 1 2 1 0 0.11 (NS)
Problems
Cardiac 3 0 2 0 0 0.007 (S) TableTable
4 shows 4theshows
correlation the
of thecorrelation
five tier color codedofcategory
the five
with thetier color
secondary neonatal
Table 4 shows the correlation of the five tier color coded category with the secondary neonatal
Problems
coded
outcomes: category
outcomes: NICU
NICU admission,with
admission, the
CPAP/Intubated,
CPAP/Intubated, secondary
and occurrence ofneonatal
and occurrence of early onset outcomes:
early onset neonatal sepsis. The length
neonatal sepsis. The length
IUGR^ 1 0 1 0 0 0.003 (S) of hospital stay was significantly longer among the Orange and Red category (Mean duration: 9.5 days
NICU
of hospital admission,
and 12 stay
days, was CPAP/Intubated,
significantly
respectively). longer among the Orangeand and occurrence
Red category (Mean of duration:
early 9.5 days
None 18 6 0 5 1 0.09 (NS) and onset
12 days, respectively).
neonatal sepsis. The length of hospital stay was
* p-value>0.05- Not significant; p-value ≤0.05-Significant
†-with multiple response
significantly longer among the Orange and Red category
^Intrauterine growth restriction
NSVD- Normal spontaneous vaginal delivery (Mean duration: 9.5 days and 12 days, respectively).
Table 2 shows the that median APGAR score at Table 4. Correlation of the Five Tier Color Coded Category with
5 minute period was normal for green, blue and yellow 6
the
TableSecondary
4. Correlation ofNeonatal
the Five Tier Outcomes
Color coded Category with the Secondary Neonatal Outcomes
categories while
Table 2 shows poor
the that APGAR
median APGAR scorescores for orange
at 5 minute period wasand
normalred.
for green, blue and Green Blue yellow Orange Red
yellow
Whilecategories
thewhile poor APGAR
median APGAR scores forscore
orange and
at red.
10While the median
minute APGAR score at 10
period (n=60) (n=13) (n=7) (n=10) (n=1) P value*
7
minute period appeared similar for all categories with a slight
appeared similar for all categories with a slight decrease decrease in median APGAR score (AS=7)
Mean Length of 0 0 0 9.5 12 <0.0001 (S) 7
in the Red category. hospital stay (days)
in median APGAR score (AS=7) in the Red category.
NICU admission <0.0001 (S)
Table 2. Median APGAR scores at 5 and 10 minutes period for five tier yes 3 (5%) 0 2 (28.6%) 8 (80%) 1 (100%)
No 57 (95%) 13 (100%) 5 (71.4%) 2 (20%) 0
Table 2. Median
color APGAR scores at 5 and 10 minute period for five tier color coded category
coded category
CPAP/Intubated <0.0001 (S)
Green Blue yellow Orange Red yes 0 0 0 7 (70%) 1 (100%)
No 60 (100%) 13 (100%) 7 (100%) 3 (30%) 0
Median 9 9 8 6 2
APGAR score at 5 Early onset
minutes neonatal Sepsis <0.0001(S)
yes 3 (5%) 0 2 (28.6%) 7 (70%) 1 (100%)
No 57 (95%) 13 (100%) 5 3 (30%) 0
Median APGAR score 9 9 9 9 7 (71.4%)
at 10 minutes * p-value ≤0.05-Significant

Philippine Scientific Journal Vol. 50 • No. 2 13

Table 3 and 4 show the correlation of the five tier color coded category with the primary neonatal
DISCUSSION
outcome. The results were significant (p <0.0001) thus, the five tier color coded category was correlated
Correlation of the five tier color coded category during intrapartum cardiotocographic monitoring with the neonatal outcome
in MCU FDTMF Hospital: a Prospective Study
DISCUSSION
This is the first study in our country that correlates
the five tier color coded chart by Parer and Ikeda to the
neonatal outcomes. Majority of the subjects included in
this study were primiparous, 20 to 35 years of age and
at 37 – 40 weeks age of gestation at the time of delivery.
These demographic characterisics were not associated
with the five tier color coded category by Parer and Ikeda.
Diabetes mellitus (DM) is the most common maternal
\comorbidity followed by subjects without any
comorbidity. Pregnancy induced hypertension, mothers
with cardiac diseases (gravidocardiac) and IUGR babies
were associated with the five tier color coded category
because exposed fetuses developed compensatory
mechanism to live in these vaso-occlusive environment
for survival.
Results from this study showed that the five tier
color coded chart of Parer and Ikeda were correlated
with acidemia and evolution to a worsening pattern thus
the development of fetal compromise. Tracings that fall
on the orange tracing should prompt the obstetrician
for an aggressive resuscitative intervention and to expedite
the delivery right away because it is correlated with
fetal acidosis, poor APGAR score and eventually
the development of fetal hypoxia and hypoxemia.
Results of this study were in accordance with
the study done by Eric H. Dellinger, et al (2000) wherein
women with singleton pregnancies ≥32 weeks of
gestation electronically monitored at 2 institutions were
examined. Tracings in the final hour before delivery were
defined as normal, fetal stress, or fetal distress. After
delivery, Apgar scores, cord blood gas values, and
admission to the neonatal intensive care unit were
examined as measures of early neonatal outcome. Among
the 898 patients, 627 (70%) had tracings classified as
normal, 263 (29%) had tracings classified as fetal stress,
and 8 (1%) had tracings classified as fetal distress. There
was a significant worsening of neonatal outcome across
these 3 groups with regard to depressed Apgar scores 1
minute (5.1%, 18.3%, and 75.0%; P < .05), depressed
Apgar scores at 5 minutes (1.0%, 3.8%, and 37.5%;
P < .05), and admission to the neonatal intensive care
unit (5.6%, 10.6%, and 37.5%; P < .05). There was also
a progressive worsening of cord blood pH, a progressive
increase in PCO2, and a progressive decline in base
excess. This simple classification system for interpret-
14 Philippine Scientific Journal Vol. 50 • No. 2
ing fetal heart rate tracings accurately predicts normal
outcomes for fetuses as well discriminating fetuses
in true distress.
In 2008, the National Institute of Child Health
and Human Development (NICHHD) along with the
Society for Maternal-Fetal Medicine and the American
College of Obstetrician and Gynecologist (ACOG)
convened a workshop to revise the accepted definitions
EFM and assist in its interpretation and management.
The key elements are assessment of the baseline fetal
heart rate, presence and absence of variability and
interpretation of periodic changes. At this workshop,
several EFM were reviewed including the work of Parer
and Ikeda who constructed a grid of all possible fetal heart
rate patterns and classified each into 1 of 5 categories
using the color code green as to low risk and red for severe
risk of acidemia and evolution to a more serious pattern.
In a study done by Di Tommaso et.al (2013)22, 97
cardiotocography traces were retrospectively interpreted
according to five classification systems for EFM:
Dublin Fetal Heart Rate Monitoring Trial (DFHRMT),
Royal College of Obstetricians and Gynecologists
(RCOG), Society of Obstetricians and Gynecologists
of Canada (SOGC), National Institute of Child Health
and Human Development (NICHD) and Parer & Ikeda.
For each classification system, sensitivity, specificity,
positive and negative predictive values and receiver-
operating characteristic (ROC) curves were calculated.
Parer & Ikeda and NICHD classifications had the highest
specificity in detecting umbilical cord arterial pH ≤7.15.
The high specificity of the NICHD classification is
hindered by a high percentage of “intermediate” trac-
es (80%). Parer & Ikeda classification is the one that
best classify as pathological only the traces of fetuses
that are truly at risk of acidemia, thus avoiding
unnecessary intervention. It also showed the best trade-off
between sensitivity and specificity and the lowest rate
of traces considered “intermediate”.
In October 2015, the International Federation
of Gynecology and Obstetrics (FIGO) intrapartum fetal
monitoring expert consensus panel presented their new
CTG intrapartum classification system. The new
CTG patterns are classified as normal, suspicious and
pathological, and it is seemingly a 3-tier classification.
However, it is equivalent to the five tier color coded
system as green being the normal tracing, yellow
for suspicious and red for pathological tracing,
 Correlation of the five tier color coded category during intrapartum cardiotocographic monitoring with the neonatal outcome
eliminating the intermediate traces of blue and orange.
The 2015 revised FIGO guidelines is simpler
than the five tier color coded chart by Parer and Ikeda
because the drawback of the latter is that it is more
tedious in the analysis of the different fetal heart rates
using the chart (refer to figure 1) and may be more
wearisome for the obstetrician. Its advantage is that it is
the best that identifies fetuses truly at risk for fetal
acidemia and poor neonatal outcome thus avoiding
unnecessary intervention. The 2015 revised FIGO
guideline is presently recommend by the Philippine
OB GYN Society (POGS). Research using the FIGO
guideline and the five tier color coded chart by Parer
and Ikeda is recommended to allow comparison
on correlation with the neonatal outcomes.
The small sample size of the of the blue, yellow,
orange and red is reflective of the low frequency of the
said colors and the resuscitative intervention done by
the obstetrician to prevent the development of fetal
acidemia, thus prevention of conversion of the tracing
to orange and eventually red color category.
CONCLUSION/RECOMMENDATIONS
Maternal demographic characteristics such as
the age, gestational age in weeks and parity were not
correlated with the five tier color coded category. The
route of delivery due to fetal distress was significantly
correlated with the orange and red categories however
the proportion of the subjects to the different color coded
charts is not associated with fetal distress due to the small
sample size of the orange and red category. Subjects with
hypertension, cardiac problems and fetuses with IUGR
were correlated with the five tier color coded category
and they were associated with a good neonatal outcome.
The observed median APGAR score at 5 minute period
is normal for green, blue and yellow, and poor APGAR
score was observed for orange and red. A normal APGAR
score was observed at 10 minute period for all the five
color coded categories. Tracings that fall on the orange
and red categories are correlated with fetal acidosis and
poor APGAR scores thus resuscitative measures and
aggressive termination of pregnancy should be done
immediately by the obstetrician. The five tier color coded
category of Parer and Ikeda is correlated in identifying
fetuses at risk for acidemia, poor APGAR score and the
in MCU FDTMF Hospital: a Prospective Study
development of an adverse neonatal outcome thus it
becomes a stepwise approach for an obstetrician knowing
when to intervene and when to do an expectant
management.
Future researches on the following are
recommended: 1) inclusion of the characteristic of amniotic
fluid (clear or meconium stained) as this has a large effect
on the intrapartum monitoring and it can predict if the
fetus is at risk for asphyxia; 2) Inclusion of other common
maternal comorbidities such as anemia and asthma;
3) include the other obstetric indication for primary
cesarean section (e.g. dystocia) and operative vaginal
delivery and correlate them with the five tier color
category and its neonatal outcome; 4) follow up the future
neonatal outcomes of the fetuses with acidemia
on the orange and red color coded chart to predict the
development of cerebral palsy.
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