In September 2008, updated NICHD consensus guidelines on electronic fetal heart rate monitoring were published jointly in Obstetrics and Gynecology and in JOGNN.
Background:
In 1997, a group of FHR monitoring experts met under the auspices of the National Institute of Child Health and Human Development (NICHD) to develop guidelines for interpreting and managing intrapartum fetal heart rate (FHR) patterns. The group quantified and named every FHR characteristic using mutually exclusive definitions but did not address interpretation or management. That document was published jointly in the American Journal of Obstetrics and Gynecology and in JOGNN (1). Over the last few years, that terminology was formally adopted by ACOG (2), ACNM (3) and AWHONN (4).
In April of 2008, another group of FHR monitoring experts reconvened under the auspices of ACOG and NICHD to expand the FHR monitoring guidelines to include interpretive categories. Tekoa King CNM, MPH was ACNM’s official representative at that meeting, and this month the consensus from the meeting participants was published as updated guidelines, again jointly in Obstetrics and Gynecology and in JOGNN (5).
What is new?
None of the previously defined FHR terms were changed but new terms for defining uterine activity were added. The primary change is the categorization of FHR patterns into three categories (I, II, and III) based on the association between each FHR pattern and fetal acidemia. Management of specific FHR patterns is not addressed in this document.
How does this affect midwifery practice?
There has been a great deal of research in the past decade about the relationship between specific FHR patterns and fetal acidemia and that research is reflected in the new guidelines. The FHR patterns that are 99% predictive that a newborn will not have acidemia are specified, and those FHR patterns that reflect a significant risk for fetal acidemia are also delineated. The first lends support for managing women independently and the second will help midwives work out collaborative practice agreements. Unfortunately, there is a huge middle group of FHR patterns that is not consistently a reflection of fetal status and these FHR patterns will continue to be managed as is appropriate in individual settings.
Finally, the new guidelines do not address intermittent auscultation. The ACNM Clinical Practice Committee is currently reviewing the Intermittent Auscultation Clinical Practice Bulletin (6)to determine if terminology changes to that document are warranted in light of the new NICHD guidelines. Stay tuned for more on that later this fall. (Clinical Bulletins are available to ACNM members only.)
1. National Institute of Child Health and Human Development Research Planning Workshop. Electronic fetal heart rate monitoring; Research guidelines for interpretation. Am J Obstet Gynecol 1997;177:1385-90; JOGNN 1997;26:635-640.
2. American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring. Practice Bulletin Number 62, 2005.
3. American College of Nurse-Midwives. Standard Nomenclature for Electronic Fetal Monitoring. Position Statement 2006. ACNM. Silver Spring MD. 2006.
4. Association of Women’s Health, Obstetric and Neonatal Nurses. Fetal Heart Monitoring Principles & Practices.3nd ed. Philadelphia PA Lippincott 2007.
5. Macones GA, Hankins GD, Spong CY, Hauth J, Moore T. The 2008. National Institute of Child Health and Human Development Research Workshop Report on Electronic fetal heart rate monitoring. Obsetet Gyneocl 2008;112:661-6, JOGNN 2008 August 29, Epub ahead of print.
6. American College of Nurse-Midwives. Intermittent Auscultation for Intrapartum Fetal Heart Rate surveillance no. 9. J Midwifery Womens Health 2007;52:314-9.
