Problems with intrapartum fetal heart rate monitoring interpretation and patient management

Fetal heart rate (FHR) monitoring was introduced over 3 decades ago into clinical use and patient management. It continues to be the predominant method for intrapartum fetal surveillance despite questions about its efficacy and outcomes associated with its use. Currently, there appears to be a consensus regarding the reassuring value of a normal reactive pattern without decelerations. Patterns containing absent variability associated with persistent late decelerations, severe variable decelerations, and prolonged decelerations are generally believed to be ominous and may correlate with hypoxia of such severity that fetal central nervous system (CNS) damage may already have occurred. The clinician, however, is faced with FHR patterns between these extremes, and there appears to be a lack of consensus about their management. Furthermore, there is recent evidence that a fetal inflammatory response may lead to CNS damage, and the FHR patterns associated with this condition are not yet understood nor are there any intervention strategies that have been shown to benefit such fetuses. This article is an attempt to illustrate these situations and offer an approach useful to the clinician faced with such FHR patterns.