The recognition and management of intrapartum fetal heart rate emergencies: beyond definitions and classification

The ongoing and well-documented debate about the value of electronic fetal monitoring has focused primarily on the fact that most variant fetal heart rate (FHR) patterns are poor predictors of fetal acid-base status. Most recently, much of this attention has been focused on the implications for clinical management of FHR patterns that the National Institute of Child Health and Human Development has classified as indeterminate: neither normal nor abnormal. Given that a majority of fetuses will have an FHR pattern considered indeterminate at some point in labor, this is an important and worthwhile discussion. It is also important, however, for providers to be able to recognize those patterns that signal the presence of developing acidemia and those that signal the potential presence of an acute obstetric complication that can quickly lead to acidemia and fetal asphyxia, such as a placental abruption or uterine rupture. Early identification of these FHR patterns, and immediate intervention to improve oxygenation or expedite birth, may help improve neonatal outcomes. The first part of this article presents descriptions of theses FHR patterns. The route and timing of birth during these emergencies is then discussed. The last part of the article presents an overview of strategies for optimizing the efficiency of providers, particularly teams of providers, in responding to FHR emergencies. The use of simulation-based training is reviewed, with specific focus on its potential application in the context of preparing for these emergencies.