Frequency of Fetal Heart Rate Categories and Short-Term Neonatal Outcome

Marc Jackson, MD, Calla M. Holmgren, and Michael W. Varner, MD

MD,

M. Sean Esplin,

MD,

Erick Henry,

MPH,

OBJECTIVE: To estimate the time spent in each fetal heart rate category during labor and during the last 2 hours before delivery in term singleton pregnancy and to estimate the relationship between the time spent in each category and short-term neonatal outcomes. METHODS: This study reviewed fetal heart rate data and newborn outcomes of women in term labor in 10 hospitals over 28 months. Fetal heart rate characteristics were assessed by labor and delivery nurses, and categories were assigned by computer using definitions from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The duration of time in each category was calculated and correlated with newborn outcome. RESULTS: Forty-eight thousand four hundred forty-four patients were identified. Considering all of labor, category I was present 77.9% of the time, category II was present 22.1% of the time, and category III was present 0.004% of the time. In the last 2 hours before delivery, category I decreased to 60.9% of the duration, category II increased to 39.1%, and category III increased to 0.006%. Newborns of women whose last 2 hours were exclusively category I did well; only 0.6% had 5-minute Apgar scores less than 7, and 0.2% had low Apgar scores with neonatal intensive care unit (NICU) admission. When more than 75% of the last 2 hours was category II, low 5-minute Apgar score increased to 1.3% of patients, and low
From the Department of Maternal-Fetal Medicine and Women and Newborn Clinical Programs, Intermountain Healthcare, and the Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah. Presented in part at the 2010 Annual Meeting of the Society for Maternal-Fetal Medicine, February 1 6, 2010, Chicago, Illinois, and at the 2010 Annual Meeting of the Society for Gynecologic Investigation, March 24 27, 2010, Orlando, Florida. Corresponding author: Marc Jackson, MD, Maternal-Fetal Medicine, Intermountain Medical Center, 5121 South Cottonwood Drive, Salt Lake City, UT 84157; e-mail: marc.jackson@imail.org. Financial Disclosure The authors did not report any potential conflicts of interest. 2011 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/11

5-minute Apgar score with NICU admission increased to 0.7% (both P<.001). CONCLUSION: Category I and category II fetal heart rate patterns are common in labor, and category III patterns are rare. Increasing time in category II in the last 2 hours of labor is associated with increased short-term newborn morbidity.
(Obstet Gynecol 2011;118:8038) DOI: 10.1097/AOG.0b013e31822f1b50

LEVEL OF EVIDENCE: III

t its introduction, it was hoped that continuous observation and analysis of fetal heart rate patterns would guide labor management so that the hypoxic fetus could be identified and delivered promptly, thereby reducing intrapartum stillbirth, neonatal neurologic injury, and subsequent neurodevelopmental delay. Unfortunately, this promise has never been realized,1 perhaps in part because of the lack of an ideal framework for analysis and interpretation of fetal heart rate patterns. Recently, the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) in collaboration with the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine convened a consensus workshop that proposed an updated classification system and definitions for fetal heart rate tracings (Box 1).2 In this classification scheme, category I fetal heart rate patterns are normal and thought to predict a normal fetal acid-base status at the time of observation; category II fetal heart rate patterns are indeterminate; and category III patterns are abnormal and are considered to be most predictive of abnormal fetal acid-base status.2 One of the goals of the NICHD workshop was to suggest research priorities for electronic fetal heart rate monitoring, two of which were a estimation of the relative frequency of the fetal heart rate categories,

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Box 1. Three-Tier Fetal Heart Rate Classification System

Category I Category I fetal heart rate patterns include all of the following: Baseline rate of 110 160 beats per minute Moderate baseline fetal heart rate variability Late or variable decelerations are absent Early decelerations may be present or absent Accelerations may be present or absent Category II Category II fetal heart rate tracings include all patterns not categorized as category I or category III Category III Category III fetal heart rate patterns include: Absent baseline fetal heart rate variability with any of the following: Recurrent late decelerations Recurrent variable decelerations Bradycardia Sinusoidal pattern
Modified from Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. 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;112:661 6.

and validation of the assumptions regarding fetal status with the new fetal heart rate categories. To date, few descriptive data are available to address these questions. The objectives of this study were to estimate the amount of time spent in each of the NICHD fetal heart rate categories during labor and during the last 2 hours of labor in term singleton pregnancy and to estimate the relationship between the duration of time spent in each category and short-term neonatal outcomes.

and delivery during the monitoring period. Patients whose fetus or newborn had a structural or genetic abnormality were excluded. Patients admitted for scheduled cesarean delivery were excluded, even if they were monitored for more than 2 hours before surgery. All study hospitals used electronic fetal monitoring in labor, and all labor and delivery nurses were specifically trained using standardized protocols in the reading of fetal heart rate monitor tracings. Before beginning work on an Intermountain Hospital labor and delivery suite, nurses complete a 4-hour classroom session in basic fetal heart rate monitoring. Within the first year, they must then successfully complete a 2-day course in fetal heart rate monitoring that was developed and is sponsored by the Association of Womens Health, Obstetric and Neonatal Nurses; this course includes a day of lecture materials and a day of skills demonstration and testing. Thereafter, each nurse must document continuing education in fetal heart rate interpretation. This ongoing training consists of attending at least two fetal heart rate Strip Review classroom presentations and completing at least 10 online self-study sessions using Intermountains Strip of the Month each year. All intrapartum fetal heart rate monitor tracings were read by a labor and delivery nurse at least every 20 minutes and the fetal heart rate characteristics (Box 2) entered into a bedside computer workstation. Whenever a change in fetal heart rate patterns developed (eg, onset of variable decelerations or change in fetal heart rate baseline), the nurse entered the new characteristics into the workstation, even if fewer than 20 minutes had passed since the last entry. If there were no further changes, the next assessment and data entry was 20 minutes later. If there were additional fetal heart rate changes observed sooner, the new characteristics were entered at the time of change. Thus, the duration of time of each characteristic and, therefore, each fetal heart rate category was tracked in real time rather than in blocks of time. The fetal heart

Box 2. Fetal Heart Rate Characteristics Assessed

Baseline fetal heart rate Fetal heart rate variability Presence of accelerations Presence of variable decelerations Isolated Recurrent Presence of late decelerations Presence of bradycardia Presence of tachycardia

MATERIALS AND METHODS

We performed a review of the intrapartum fetal heart rate characteristics of all patients with a singleton, nonanomalous fetus in term labor at 10 Intermountain Healthcare hospitals between March 1, 2007, and June 30, 2009. Patient inclusion criteria included: singleton pregnancy; gestational age 37.0 weeks or greater; in labor (either spontaneous or induced) with fetal heart rate monitoring for at least 120 minutes;

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rate tracing and the entered data were then stored in a systemwide enterprise data warehouse and linked to maternal and short-term neonatal data. Fetal heart rate characteristics on all patients were retrieved from the data warehouse, and software was developed to convert the data on fetal heart rate characteristics into the appropriate NICHD fetal heart rate category at each reading. Because nursing entries were timed, the duration of time in fetal heart rate category could then be calculated. Descriptive statistics were performed on fetal heart rate category data for all patients from the entire monitoring period and from the last 2 hours of monitoring before delivery. Proportions were compared using chi-square testing with Yates correction. P .01 was considered statistically significant. The investigation was approved by the Intermountain Healthcare institutional review board.

RESULTS
A total of 48,444 women met criteria for inclusion. The number of study patients from the 10 hospitals ranged from 1,982 to 7,239 during the 28-month sampling period. The majority of the patients were white, married, and parous. The mean maternal age was 27.0 years, the mean time monitored was 513.1 minutes, the median time monitored was 432.4 minutes, and the range of monitoring time was 120.0 5,578.3 minutes. The demographics of the entire group are detailed in Table 1.

Table 1. Demographics of the Study Population

Mean age (y) Ethnicity White Hispanic Pacific Islander Asian African American Other or unknown Parity Nulliparous Multiparous Married Medical or obstetric complication* Tobacco use Mean time monitored (min) All patients Nulliparas Multiparas 27.0 81.4 12.1 0.9 1.1 0.6 3.9 39.7 60.3 82.6 10.2 3.2 513.1 675.0 406.6

Data are % unless otherwise specified. * Includes chronic hypertension, gestational hypertension, pregestational diabetes, gestational diabetes, preeclampsia, suspected intrauterine growth restriction, oligohydramnios, placental abruption, or all.

Labor was spontaneous in 25,590 (52.8%) patients, induced for a medical or obstetric indication in 10,704 (22.1%), and electively induced in 12,150 (25.1%). Oxytocin was used, either for induction or augmentation of labor, in 24,825 (51.2%) patients. Overall, category I fetal heart rate patterns were observed at some point in 48,191 (99.5%) of tracings, category II patterns were found in 40,758 (84.1%) of tracings, and category III patterns were seen in 54 (0.1%) of tracings. A large majority, 83.6%, of patients had a mix of categories during their labor. Only 7,686 (15.9%) patients had monitor strips with category I fetal heart rate patterns exclusively, 253 (0.5%) had only category II patterns, and no patients (0.0%) had only category III fetal heart rate. Examining the entire duration of monitoring in all patients, the fetal heart rate pattern was classified as category I 77.9% of the time, as category II 22.1% of the time, and as category III 0.004% of the time. Segmenting the study population by parity, nulliparas spent a slightly smaller proportion of time in category I and slightly greater time in category II during their labors compared with multiparas (Table 2). In the 2 hours before delivery, category I tracings became less common, and category II and category III tracings became more common. Among all patients in the last 2 hours of monitoring, category I tracings were present 60.9% of the time, category II tracings were present 39.1% of the time, and category III tracings were seen 0.006% of the time (Table 2). The group whose entire labor was spent in fetal heart rate category I had good outcomes. Only 290 (3.8%) had 1-minute Apgar scores less than 7, and 46 (0.6%) had 5-minute Apgar scores less than 7. There were 249 (3.2%) neonatal intensive care unit (NICU) admissions in this group. Only 14 (0.2%) neonates had low 5-minute Apgar scores and NICU admission. Outcomes were similar in the group whose last 2 hours of labor was solely in fetal heart rate category I with an increased incidence of low 1-minute Apgar score but no difference in the other neonatal outcomes (Table 3). To assess whether the amount of time spent in category II was related to short-term neonatal outcome, patients were divided into subgroups based on the amount of time that was spent in category II during the last 2 hours before delivery. Patients who spent the entire last 2 hours of labor in category I were compared with those who spent increasing time in category II, divided into quartiles of 125%, 26 50%, 5175%, and 76 100% of the last 2 hours in fetal heart rate category II. There was no difference between these subgroups with respect to maternal age, race, marital status, or

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Table 2. Distribution of Fetal Heart Rate Category Time in Labor

Overall Labor Monitoring Category I
All patients Mean minutes Percentage of total Median minutes Range Nulliparous Mean minutes Percentage of total Median minutes Range Multiparous Mean minutes Percentage of total Median minutes Range 399.6 77.9 339.4 04,924.3 514.5 76.2 441.2 03,962.5 324.0 79.7 287.9 04,924.3

Last 2 h of Labor Category I

73.1 60.9 80.0 0120.0 66.1 55.1 69.3 0120.0 77.7 64.8 86.5 0120.0

Category II
113.5 22.1 74.8 01,740.9 160.4 23.8 121.0 01,691.6 82.7 20.3 54.0 01,740.9

Category III
0.02 0.004 0.0 069.0 0.03 0.004 0 066.2 0.01 0.003 0.0 069.0

Category II
46.9 39.1 40.0 0120.0 53.9 44.9 50.7 0120.0 42.2 35.2 33.5 0120.0

Category III
0.01 0.006 0.0 037.0 0.01 0.009 0.0 037.0 0.01 0.005 0.0 028.0

tobacco use. However, with increasing time in category II above 25% of the last 2 hours of labor, nulliparity and medical obstetric complications were more common (both P .01; Table 4). Increasing time in category II in the last 2 hours of labor also was associated with increased likelihood of NICU admission or Apgar score less than 7 but not until more than 50% of the time was spent in fetal heart rate category II. In the 5175% category II quartile, only the likelihood of a low 1-minute Apgar score and the likelihood of NICU admission were increased (both P .01). However, in the 76 100% category II quartile, there was an increased likelihood of 1-minute Apgar score less than 7, 5-minute Apgar score less than 7, NICU admission, and the combination of NICU admission and 5-minute Apgar score less than 7 (all P .001; Table 4).

DISCUSSION
There is a broad consensus as to the definition of a normal intrapartum fetal heart rate pattern: normal baseline, moderate variability, and absence of variable or late decelerations.3,4 Category I fetal heart rate patterns are assumed to be reflective of normal fetal oxygenation status, and bad outcomes are uncommon. Our data confirm this notion. Among patients whose fetal heart rate patterns in the last 2 hours before delivery were exclusively category I, only 0.2% (one in every 531) had low 5-minute Apgar scores and admission to the NICU. Similarly, there is accord on abnormal fetal heart rate characteristics: absent variability, recurrent late or variable decelerations, prolonged bradycardia, and sinusoidal patterns.3,4 Fortunately, category III fetal heart rate patterns are a very rare event. In our population of patients in term labor, category III was identified in only 0.1% of patients (one in every 897). Between the extremes, category II fetal heart rate patterns are very common, occurring in 84% of labors. The proportion of time spent in category II increases in the 2 hours before delivery. There is an increased likelihood of adverse short-term outcomes with increasing time in category II fetal heart rate patterns. Despite the association between increasing time in category II and low Apgar scores and NICU admission, the huge majority of newborns who had predominantly category II tracings experienced no short-term morbidity. Thus, describing category II as indeterminate is appropriate. However, its high frequency and broad range of outcomes diminish the

Table 3. Newborn Outcomes in Patients With Category I Tracings

All FHR Category I Entire Labor
No. of patients 1-min Apgar score less than 7 5-min Apgar score less than 7 NICU admission 5-min Apgar score less than 7 and NICU admittance 7,686 290 (3.8) 46 (0.6) 249 (3.2) 14 (0.2)

Last 2 h of Labor
11,677 566 (4.8)* 71 (0.6) 459 (3.9) 22 (0.2)

FHR, fetal heart rate; NICU, neonatal intensive care unit. Data are n (%) unless otherwise specified. * P .001 compared with entire labor FHR category I.

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Table 4. Maternal Variables and Short-Term Neonatal Outcomes With Increasing Time in Fetal Heart Rate Category II
Time in Category, Last 2 h of Labor All FHR Category I
No. of patients Percentage of total Nulliparity (%) Medical or obstetric complication (%) 1-min Apgar score less than 7 5-min Apgar score less than 7 NICU admission 5-min Apgar score less than 7 and NICU admittance 11,676 24.1 34.8 8.1 566 (4.8) 71 (0.6) 459 (3.9) 22 (0.2)

125% Category II
9,313 19.2 33.8 8.7 451 (4.8) 56 (0.6) 363 (3.9) 22 (0.2)

2650% Category II
9,846 20.3 36.5* 9.2* 536 (5.4) 61 (0.6) 424 (4.3) 27 (0.3)

5175% Category II
8,115 16.8 42.9* 10.4* 545 (6.7)* 69 (0.9) 395 (4.9)* 24 (0.3)

76100% Category II
9,494 19.6 52.6* 11.7* 922 (9.7)* 119 (1.3)* 691 (7.3)* 67 (0.7)*

FHR, fetal heart rate; NICU, neonatal intensive care unit. Data are n (%) unless otherwise specified. * P .001 compared with all FHR category I.

usefulness of category II fetal heart rate patterns as an indicator of fetal condition. This is reflected in the recommendations for management of category II tracings, which stress evaluation, continued surveillance, initiation of appropriate corrective measures when indicated, and reevaluation.5 Others have addressed the diversity found in the indeterminate category of fetal heart rate tracings. Larma and colleagues examined fetal heart rate characteristics in the last hour before delivery of 107 neonates with documented umbilical cord acidosis and compared them with those of a control group with normal blood gas results. They found differences in baseline rate, bradycardia, variability, and reactivity between acidotic newborns with and without hypoxicischemic encephalopathy. However, the fetal heart rate characteristics discriminated poorly between acidotic and nonacidotic newborns, because the frequency of accelerations, decelerations, variable decelerations, and severe variable decelerations were not different between the two groups.6 Parer and Ikeda have recognized that broad fetal heart rate categories will necessarily include a wider range of outcome severities. Basing their classification system on published outcome risks related to specific fetal heart rate characteristics, they proposed a colorcoded, five-category scheme, essentially dividing the indeterminate category into three additional risk levels.7 Although their system is rather complex, a study of tracing reviews found good agreement between blinded, expert readers.8 Also noting that such a system lends itself well to computer-based interpretation, they showed that a software-based fetal heart rate assessment system correlated well with the human experts.8

The large number of patients, managed in both tertiary and community hospitals, is a strength of our study. The ongoing training in fetal heart rate monitoring provided to all labor and delivery clinical staff is an additional strength. Also, our data set links to specific patient outcomes rather than to literaturebased risks. Our study has several disadvantages. One is the retrospective nature of the data. There is a possibility of distortion of our results through censoring by intervention, because there may have been expedited delivery in some cases with more prolonged nonreassuring category II patterns. This would likely decrease morbidity in the category II group but reflects a real-world assessment of the associations between fetal heart rate and outcome. More significantly, there is a lack of umbilical cord blood gas data; cord gas sampling is not required in routine deliveries in the Intermountain Healthcare system, and Apgar scores and NICU admission are used as functional markers for neonatal hypoxia. The use of intrapartum fetal heart rate monitoring as a screening test has been rightly questioned.9 In our data set, there are more than 40 combinations of fetal heart rate characteristics that qualify a fetal heart rate pattern as category II. Combining so many different fetal heart rate patterns into a single indeterminate category surely detracts from the use of fetal heart rate monitoring as an indicator of fetal condition. Future research should focus on the subcharacterization of category II fetal heart rate tracings, the cumulative effect of the duration of unfavorable fetal heart rate characteristics, and the effects of other risk factors to differentiate those at highest risk from those at low risk for neonatal compromise and so to improve the predictive value of fetal heart rate monitoring.

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REFERENCES
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5. Management of intrapartum fetal heart rate tracings. ACOG Practice Bulletin No. 116. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:1232 40. 6. Larma JD, Silva AM, Holcroft CJ, Thompson RE, Donohue PK, Graham EM. Intrapartum electronic fetal heart rate monitoring and the identification of metabolic acidosis and hypoxic-ischemic encephalopathy. Am J Obstet Gynecol 2007;197: 301.e1 8. 7. Parer JT, Ikeda T. A framework for standardized management of intrapartum fetal heart rate patterns. Am J Obstet Gynecol 2007;197:26.e1 6. 8. Parer JT, Hamilton EF. Comparison of 5 experts and computer analysis in rule-based fetal heart rate interpretation. Am J Obstet Gynecol 2010;203:451.e17. 9. Grimes DA, Peipert JF. Electronic fetal monitoring as a public health screening program: the arithmetic of failure. Obstet Gynecol 2010;116:1397 400.

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