Interpretation of intrapartum fetal heart rate tracings
1998; Elsevier BV; Volume: 179; Issue: 4 Linguagem: Inglês
10.1016/s0002-9378(98)70225-x
ISSN1097-6868
Autores Tópico(s)Neuroscience of respiration and sleep
ResumoTo the Editors:To scream “Hallelujah!” was my first reaction when I read the title and introductory remark of the “Clinical Opinion” article of the December 1997 issue (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). When I finished reading it, my enthusiasm was somewhat tempered but still I am extremely happy because the leaders of fetal-maternal medicine subspecialty in this country finally began the difficult road to correct the misuse and attempt the proper use of this important tool. The anxious appeal made last year1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar is partially answered with this public recognition of the drawbacks as currently used. But there are still very important conceptual errors to adjust.First, the good things: (1) In III.G it is recognized that the baseline variability “in practice” should not be broken down into “short term” and “long term,” a concept postulated >16 years ago.2Cibils LA Electronic fetal monitoring. Wright PSG, Boston1981Google Scholar (2) A most important concept is clearly stated in III.I where unequivocally is indicated the importance of age of gestation, as well as clinical condition of the mother, for interpretation and correct decision making. (3) In III.J it is recognized that the tracing must be analyzed in toto rather than in separate components, thus recognizing that changes are associated (when clinically important) and interrelated. The application of this very critical concept, which has been postulated for a long time,3Cibils LA Intrapartum fetal monitoring.in: The high risk fetus. Springer-Verlag, New York1993Crossref Google Scholar replaces the popular “pattern recognition.” (4) A most welcome decision is stated in IV. Definitions. All the garbage of cloudy verbiage is thrown away, and concise, clear descriptions were instead selected to describe the normal and abnormal tracings.Second, the no good things. A most distressing statement is contained in the second paragraph of III. Purpose: “. . . set of definitions . . . to develop . . . interpretation of intrapartum FHR [fetal heart rate] tracings so that predictive value of monitoring can be assessed” (italics mine). FHR monitoring is a diagnostic tool, not a predictor. It is not different from taking the blood pressure, which, when it is high in a hypertensive subject, cannot predict whether the subject will have a stroke, a cerebral vascular accident, a myocardial infarction, a burst aneurysm, or none of the above.As stated before, “ . . . the recording of one fetal pathophysiologic response to labor cannot predict what will happen to that fetus later in life when even a most meticulous neonatal examination by neurologists within the first month of life cannot do it. It follows that one cannot ask from a test more than what it can give . . .”1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The day this concept is clearly understood by those who use and evaluate FHR monitoring will be the day when those patients on whom it is applied will be better served. It is very likely that VI.C will eventually be demonstrated if, and when, the technique is used in well-staffed hospitals by well-trained individuals. I hope that some member of the panel will care to comment about the second part of this letter. To the Editors:To scream “Hallelujah!” was my first reaction when I read the title and introductory remark of the “Clinical Opinion” article of the December 1997 issue (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). When I finished reading it, my enthusiasm was somewhat tempered but still I am extremely happy because the leaders of fetal-maternal medicine subspecialty in this country finally began the difficult road to correct the misuse and attempt the proper use of this important tool. The anxious appeal made last year1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar is partially answered with this public recognition of the drawbacks as currently used. But there are still very important conceptual errors to adjust.First, the good things: (1) In III.G it is recognized that the baseline variability “in practice” should not be broken down into “short term” and “long term,” a concept postulated >16 years ago.2Cibils LA Electronic fetal monitoring. Wright PSG, Boston1981Google Scholar (2) A most important concept is clearly stated in III.I where unequivocally is indicated the importance of age of gestation, as well as clinical condition of the mother, for interpretation and correct decision making. (3) In III.J it is recognized that the tracing must be analyzed in toto rather than in separate components, thus recognizing that changes are associated (when clinically important) and interrelated. The application of this very critical concept, which has been postulated for a long time,3Cibils LA Intrapartum fetal monitoring.in: The high risk fetus. Springer-Verlag, New York1993Crossref Google Scholar replaces the popular “pattern recognition.” (4) A most welcome decision is stated in IV. Definitions. All the garbage of cloudy verbiage is thrown away, and concise, clear descriptions were instead selected to describe the normal and abnormal tracings.Second, the no good things. A most distressing statement is contained in the second paragraph of III. Purpose: “. . . set of definitions . . . to develop . . . interpretation of intrapartum FHR [fetal heart rate] tracings so that predictive value of monitoring can be assessed” (italics mine). FHR monitoring is a diagnostic tool, not a predictor. It is not different from taking the blood pressure, which, when it is high in a hypertensive subject, cannot predict whether the subject will have a stroke, a cerebral vascular accident, a myocardial infarction, a burst aneurysm, or none of the above.As stated before, “ . . . the recording of one fetal pathophysiologic response to labor cannot predict what will happen to that fetus later in life when even a most meticulous neonatal examination by neurologists within the first month of life cannot do it. It follows that one cannot ask from a test more than what it can give . . .”1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The day this concept is clearly understood by those who use and evaluate FHR monitoring will be the day when those patients on whom it is applied will be better served. It is very likely that VI.C will eventually be demonstrated if, and when, the technique is used in well-staffed hospitals by well-trained individuals. I hope that some member of the panel will care to comment about the second part of this letter. To scream “Hallelujah!” was my first reaction when I read the title and introductory remark of the “Clinical Opinion” article of the December 1997 issue (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). When I finished reading it, my enthusiasm was somewhat tempered but still I am extremely happy because the leaders of fetal-maternal medicine subspecialty in this country finally began the difficult road to correct the misuse and attempt the proper use of this important tool. The anxious appeal made last year1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar is partially answered with this public recognition of the drawbacks as currently used. But there are still very important conceptual errors to adjust. First, the good things: (1) In III.G it is recognized that the baseline variability “in practice” should not be broken down into “short term” and “long term,” a concept postulated >16 years ago.2Cibils LA Electronic fetal monitoring. Wright PSG, Boston1981Google Scholar (2) A most important concept is clearly stated in III.I where unequivocally is indicated the importance of age of gestation, as well as clinical condition of the mother, for interpretation and correct decision making. (3) In III.J it is recognized that the tracing must be analyzed in toto rather than in separate components, thus recognizing that changes are associated (when clinically important) and interrelated. The application of this very critical concept, which has been postulated for a long time,3Cibils LA Intrapartum fetal monitoring.in: The high risk fetus. Springer-Verlag, New York1993Crossref Google Scholar replaces the popular “pattern recognition.” (4) A most welcome decision is stated in IV. Definitions. All the garbage of cloudy verbiage is thrown away, and concise, clear descriptions were instead selected to describe the normal and abnormal tracings. Second, the no good things. A most distressing statement is contained in the second paragraph of III. Purpose: “. . . set of definitions . . . to develop . . . interpretation of intrapartum FHR [fetal heart rate] tracings so that predictive value of monitoring can be assessed” (italics mine). FHR monitoring is a diagnostic tool, not a predictor. It is not different from taking the blood pressure, which, when it is high in a hypertensive subject, cannot predict whether the subject will have a stroke, a cerebral vascular accident, a myocardial infarction, a burst aneurysm, or none of the above. As stated before, “ . . . the recording of one fetal pathophysiologic response to labor cannot predict what will happen to that fetus later in life when even a most meticulous neonatal examination by neurologists within the first month of life cannot do it. It follows that one cannot ask from a test more than what it can give . . .”1Cibils LA On intrapartum fetal monitoring.Am J Obstet Gynecol. 1996; 174: 1382-1389Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar The day this concept is clearly understood by those who use and evaluate FHR monitoring will be the day when those patients on whom it is applied will be better served. It is very likely that VI.C will eventually be demonstrated if, and when, the technique is used in well-staffed hospitals by well-trained individuals. I hope that some member of the panel will care to comment about the second part of this letter.
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