Current status and recommendations for intrapartum monitoring of fetal heart rate

Authors: A. Měchurová 1;  P. Velebil 1;  L. Hruban 2;  P. Janků 2
Authors‘ workplace: Ústav pro péči o matku a dítě, Praha, doc. MUDr. J. Feyereisl, CSc. 1;  Gynekologicko-porodnická klinika LF MU a FN, Brno, přednosta prof. MUDr. P. Ventruba, DrSc. 2
Published in: Čes. Gynek.2016, 81, č. 2 s. 112-124


Monitoring of fetal heart rate is one of the basic components of obstetrical care, in which the cardiotocography remains the gold standard and screening method in early diagnosis of fetal hypoxia, even after introduction of other selective methods of intrauterine monitoring of fetal well-being. The review article is divided into several parts: pathophysiology of fetal oxygenation, fetal heart rate and changes of fetal hemodynamics, and rules for fetal heart rate auscultation. The main principles of cardiotocographic monitoring and evaluation of ante- and intrapartrum recordings according to the FIGO criteria from 1986 and evaluation of intrapartum recordings according to the 2015 FIGO recommendations are mentioned. At the end a comparative table of 1986 FIGO and 2015 FIGO criteria is presented.


cardiotocography (CTG), CTG classification – FIGO 1986, FIGO 2015, diagnosis of fetal hypoxia, auscultation of fetal heart, fetal monitoring in utero


1. ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 348, November 2006: Umbilical cord blood gas and acid-base analysis. Obstet Gynecol, 2006, 108(5), p. 1319–1322.

2. Alfirevic, Z., Devane, D., Gyte, GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev, 2013,5:CD006066.

3. Ayres-de-Campos, D., Arulkumaran, S., FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Physiology of fetal oxygenation and the main goals of intrapartum fetal monitoring. Int J Gynecol Obstet, 2015, 131, p. 5–8.

4 Ayres-de-Campos, D., Bernardes, J., Costa-Pereira, A., Pereira-Leite, L. Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision. BJOG, 1999, 106(12), p. 1307–1310.

5. Ayres-de-Campos, D., Spong, CY., Chandraharan, E., FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynecol Obstet, 2015, 131(1), p. 13–24.

6. Ayres-de-Campos, D., Spong, CY., Chandraharan, E. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynecol Obstet, 131, 2015, p. 13–24.

7. Bakker, JJ., Janssen, PF., van Halem, K., et al. Internal versus external tocodynamometry during induced or augmented labour. Cochrane Database Syst Rev, 2013;8:CD006947.

8. Bakker, PC., Colenbrander, GJ., Verstraeten. AA., Van Geijn, HP. Quality of intrapartum cardiotocography in twin deliveries. Am J Obstet Gynecol 2004, 191(6), p. 2114–2119.

9. Ball, RH., Parer, JT. The physiologic mechanisms of variable decelerations. Am J Obstet Gynecol, 1992, 166(6 Pt 1), p. 1683–1689.

10. Blackwell, SC., Grobman, WA., Antoniewicz, L., et al. Interobserver and intraobserver reliability of the NICH 3-tier fetal heart rate interpretation system. Am J Obstet Gynecol, 2011, 205(4), p. 378.e1–5.

11. Boutroy, MJ. Fetal and neonatal effects of the beta-adrenoreceptor blocking agents. Dev Pharmacol Ther, 1987, 10(3), p. 224–231.

12. Briozzo, L., Martinez, A., Nozar, M., et al. Tocolysis and delayed delivery versus emergency delivery in cases of non-reassuring fetal status during labor. J Obstet Gynaecol Res, 2007, 33(3), p. 266–273.

13. Cahill, AG., Roehl, KA., Odibo, AO., Macones, GA. Association and prediction of neonatal acidemia. Am J Obstet Gynecol, 2012, 207(3), p. 206.e1–8.

14. Caldeyro-Barcia, R., Noriega-Guerra, L., Cibils, LA., et al. Effect of position changes on the intensity and frequency of uterine contractions during labor. Am J Obstet Gynecol, 1960, 80, p. 284–290.

15. Carbonne, B., Benachi, A., Leveque, ML., et al. Maternal position during labor: effects on fetal oxygen saturation measured by pulse oximetry. Obstet Gynecol, 1996, 88(5), p. 797–800.

16. Carter, MC. Signal processing and display-cardiotocographs. Br J Obstet Gynaecol, 1993, 100(Suppl. 9), p. 21–23.

17. Clark, SL., Paul, RH. Intrapartum fetal surveillance: the role of fetal scalp blood sampling. Am J Obstet Gynecol, 1985, 153(7), p. 717–720.

18. Court, DJ., Parer, JT. Experimental studies of fetal asphyxia and fetal heart rate interpretation. In: Nathanielsz PW, Parer JT, editors. Research in Perinatal Medicine (I). New York: Perinatalogy Press, 1984. p. 113–169.

19. Di Renzo, GC., Luzi, G., Caserta, G., et al. The role of telemetry in perinatal monitoring. J Perinat Med, 1994, 22(6), p. 517–522.

20. Devane, D., Lalor, JG., Daly, S., et al. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev, 2012, 2:CD005122.

21. Elimian, A., Figueroa, R., Tejani, N. Intrapartum assessment of fetal well-being: a comparison of scalp stimulation with scalp blood pH sampling. Obstet Gynecol, 1997, 89(3), p. 373–376.

22. Fawole, G., Hofmeyr, GJ. Maternal oxygen administration for fetal distress. Cochrane Database Syst Rev, 2012, 12:CD000136.

23. Freeman, RK., Anderson, G., Dorchester, W. A prospective multi-institutional study of antepartum fetal heart rate monitoring. I. Risk of perinatal mortality and morbidity according to antepartum fetal heart rate test results. Am J Obstet Gynecol, 1982, 143, p. 771.

24. Graça, LM., Cardoso, CG., Calhaz-Jorge, C. An approach to interpretation and classification of sinusoidal fetal heart rate patterns. Eur J Obstet Gynecol Reprod Biol, 1988, 27(3), p. 203–212.

25. Hamilton, E., Warrick, P., O‘Keeffe, D. Variable decelerations: do size and shape matter? J Matern Fetal Neonatal Med, 2012, 25(6), p. 648–653.

26. Herbst, A., Ingemarsson, I. Intermittent versus continuous electronic fetal monitoring in labour: a randomized study. Br J Obstet Gynaecol, 1994, 101(8), p. 663–668.

27. Heus, R., Mulder, EJ., Derks, JB., Visser, GH. Acute tocolysis for uterine activity reduction in term labor: a review. Obstet Gynecol Surv, 2008, 63(6), p. 383–388.

28. Heus, R., Mulder, EJ., Derks, JB., et al. A prospective randomized trial of acute tocolysis in term labour with atosiban or ritodrine. Eur J Obstet Gynecol Reprod Biol, 2008, 139(2), p. 139–145.

29. Heuser, CC., Knight, S., Esplin, S., et al. Tachysystole in term labor: incidence, risk factors, outcomes, and effect on fetal heart tracings. Am J Obstet Gynecol, 2013, 209(1), p. 32.e 1–6.

30. Hofmeyr, GJ., Lawrie, TA. Amnioinfusion for potential or suspected umbilical cord compression in labour. Cochrane Database Syst Rev, 2012, 1:CD000013.

31. Holzmann, M., Wretler, S., Cnattingius, S., Nordstrom, L. Cardiotocography patterns and risk of intrapartum fetal acidemia. J Perinat Med, 2015, 43(4), p. 473–479.

32. Choserot, M., Lamy, C., Perdriolle-Galet, E., et al. Correlation between fetal scalp samples and umbilical cord samples. [in Fench] J Gynecol Obstet Biol Reprod (Paris), 2014, 43(4), p. 300–306.

33. Interpretace fetálního kardiotokogramu. Čes Gynek, 2013, 78, Suppl., s. 26–27.

34. Itskovitz, J., Goetzman, BW., Rudolph, AM. The mechanism of late deceleration of the heart rate and its relationship to oxygenation in normoxemic and chronically hypoxemic fetal lambs. Am J Obstet Gynecol, 1982, 142, p. 66.

35. Kaye, EM., Dooling, EC. Neonatal herpes simplex meningoencephalitis associated with fetal monitor scalp electrodes. Neurology, 1981, 31(8), p. 1045–1047.

36. Kessler, J., Moster, D., Albrechtsen, S. Intrapartum monitoring of high-risk deliveries with ST analysis of the fetal electrocardiogram: an observational study of 6010 deliveries. Acta Obstet Gynecol Scand, 2013, 92(1), p. 75–84.

37. Lewis, D., Downe, S. FIGO consensus guidelines on intrapartum fetal monitoring: Intermittent auscultation. Inter J Gynec Obstet, 2015, 131, p. 9–12.

38. Low, J., Lindsay, BG., Derrick, EJ. Threshold of metabolic acidosis associated with newborn complications. Am J Obstet Gynecol, 1997, 177(6), p. 1391–1394.

39. MacLennan, A. A template for defining a causal relation between acute intrapartum events and cerebral palsy: international consensus statement. BMJ, 1999, 319(7216), p. 1054–1059.

40. Macones, GA., Hankins, GD., Spong, CY., et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol, 2008, 112, p. 661.

41. Maiques, V., Garcia-Tejedor, A., et al. Intrapartum fetal invasive procedures and perinatal transmission of HIV. Eur J Obstet Gynecol Reprod Biol, 1999, 87(1), p. 63–67.

42. Měchurová, A. Kardiotokografie, minimum pro praxi, 2. rozšířené vyd. Maxdorf, 2014, 198 s., s. 10–13.

43. Modanlou, HD., Murata, Y. Sinusoidal fetal heart rate pattern: reappraisal of its definition and clinical significance. J Obstet Gynaecol Res, 2004, 30(3), p. 169–180.

44. National Institute for Health and Clinical Excellence. Caesarean section. NICE clinical guideline 13. April 2004 Accessed August 1, 2014.

45. Nelson, KB., Dambrosia, JM., Ting, TY., Grether, JK. Uncertain value of electronic fetal monitoring in predicting cerebral palsy. N Engl J Med, 1996, 334(10), p. 613–618.

46. Norén, H., Carlsson, A. Reduced prevalence of metabolic acidosis at birth: an analysis of established STAN usage in the total population of deliveries in a Swedish distrikt hospital. Am J Obstet Gynecol, 2010, 202(6), p. 546.e1–7.

47. Nunes, I., Ayres-de-Campos, D., Figueiredo, C., Bernardes, J. An overview of central fetal monitoring systems in labour. J Perinat Med, 2013, 41(1), p. 93–99.

48. Nunes, I., Ayres-de-Campos, D., Kwee, A., Rosen, KG. Prolonged saltatory fetal heart rate pattern leading to newborn metabolic acidosis. Clin Exp Obstet Gynecol, 2014, 41(5), p. 507–511.

49. Nurani, R., Chandraharan, E., Lowe, V., et al. Misidentification of maternal heart rate as fetal on cardiotocography during the second stage of labour: the role of the fetal electrocardiograph. Acta Obstet Gynecol Scand, 2012, 91(12), p. 1428–1432.

50. Olofsson, P., Ayres-de-Campos, D., Kessler, J., et al. A critical appraisal of the evidence for using cardiotocography plus ECG ST interval analysis for fetal surveillance in labor. Part II: the meta-analyses. Acta Obstet Gynecol Scand, 2014, 93(6), p. 571–586.

51. O‘Mahony, F., Hofmeyr, GJ., Menon, V. Choice of instruments for assisted vaginal delivery. Cochrane Database Syst Rev, 2010;11:CD005455.

52. Paneth, N., Bommarito, M., Stricker, J. Electronic fetal monitoring and later outcome. Clin Invest Med, 1993, 16(2), p. 159–165.

53. Pullen, KM., Riley, ET., Waller, SA., et al. Randomized comparison of intravenous terbutaline vs nitroglycerin for acute intrapartum fetal resuscitation. Am J Obstet Gynecol, 2007, 197(4), p. 414.e1–6.

54. Rosen, KG., Dagbjartsson, A., Henriksson, BA., et al. The relationship between circulating catecholamines and ST waveform in the fetal lamb electrocardiogram during hypoxia. Am J Obstet Gynecol, 1984, 149(2), p. 190–195.

55. Rosen, KG., Kjellmer, I. Changes in the fetal heart rate and ECG during hypoxia. Acta Physiol Scand, 1975, 93(1), p. 59–66.

56. Rouse, DJ., Owen, J., Goldenberg, RL., Cliver, SP. Determinants of the optimal time in gestation to initiate antenatal fetal testing: a decision-analytic approach. Am J Obstet Gynecol, 1995, 173, p. 1357.

57. Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring. Evidence-based clinical guideline, number 8. London: RCOG Press, 2001.

58. Segal, S. Labor epidural analgesia and maternal fever. Anesth Analg, 2010, 111(6), p. 1467–1475.

59. Simmons, SW., Taghizadeh, N., Dennis, AT., et al. Combined spinalepidural versus epidural analgesia in labour. Cochrane Database Syst Rev, 2012, 10: CD003401.

60. Simpson, KR., James, DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstet Gynecol, 2005, 105(6), p. 1362–1368.

61. Spencer, JA. Clinical overview of cardiotocography. Br J Obstet Gynaecol, 1993, 100, Suppl. 9, p. 4–7.

62. Takano, Y., Furukawa, S., Ohashi, M., et al. Fetal heart rate patterns related to neonatal brain damage and neonatal death in placental abruption. J Obstet Gynaecol Res, 2013, 39(1), p. 61–66.

63. Vintzileos, AM., Nochimson, DJ., Guzman, ER., et al. Intermittent electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis. Obstet Gynecol, 1995, 85(1), p. 149–155.

64. Visser, GH., Ayres-de-Campos, D., FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Adjunctive technologies. Int J Gynecol Obstet, 2015, 131, p. 25–29 [in this issue].

65. Wayenberg, JL. Threshold of metabolic acidosis associated with neonatal encephalopathy in the term newborn. J Matern Fetal Neonatal Med, 2005, 18(6), p. 381–385.

66. Westgate, JA., Wibbens, B., Bennet, L., et al. The intrapartum deceleration in center stage: a physiologic approach to the interpretation of fetal heart rate changes in labor. Am J Obstet Gynecol, 2007, 197(3), p. 236.e1–236.e11.

67. Westgren, M., Kruger, K., Ek, S., et al. Lactate compared with pH analysis at fetal scalp blood sampling: a prospective randomised study. Br J Obstet Gynaecol, 1998, 105(1), p. 29–33.

68. Westerhuis, ME., Visser, GH., Moons, KG., et al. Cardiotocography plus ST analysis of fetal electrocardiogram compared with cardiotocography only for intrapartum monitoring: a randomized controlled trial. Obstet Gynecol, 2011, 117(2 Pt 1), p. 406–407.

69. Wiberg, N., Kallen, K., Herbst, A., Olofsson, P. Relation between umbilical cord pH, base deficit, lactate, 5-minute Apgar score and development of hypoxic-ischemic encephalopathy. Acta Obstet Gynecol Scand, 2010, 89(10), p. 1263–1269.

70. Williams, EA. Abnormal uterine action during labour. J Obstet Gynaecol Br Emp, 1952, 59, p. 635–641.

Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine
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