The future of intrapartum care: navigating the perfect storm--an obstetrician's odyssey.

Fellow officers, members, and guests, it is a humbling privilege to address you as the 71st president of this venerable society. Although I wear size-12 shoes, I am following in the very large footprintsof the eminent presidentswho have preceded me. 2009 Will be a significant year inmy life. Itwillmarkmy 40th year as a physician and my eligibility for Medicare and Social Security. By year’s end, Iwill retire from the full-time practice of obstetrics and will deliver the last of thousands of babies. I have watched the evolution of “modern obstetrics” and the birth and death of technologies intended to make the birth process safer for mothers and infants. The timeliness of this talk is highlighted by a recent review of 41 common practices in labor and delivery. Only 4 had strong evidence based on data from scientific trials to support their recommendation while the vast majority either lacked supportive data or should not be offered based on available trial outcomes. I will now take you on an obstetrician’s odyssey duringwhichwewill encounter the “perfect storm” of current intrapartum care. Themosthazardous journey thatmost of us will take in our lifetimes occurs during parturition. While birth has become less dangerous for the fetus, peripartumdeath rates stilloccur in 4of 1000 deliveries and asphyxial brain injury affects approximately 1.6 of 1000 deliveries. Safe, modern intrapartum care beganwith the institutionalization of birth, largely a 20th century phenomenon. The founding of dedicated maternity hospitals gave mothers and infants access to qualified and professional oversight of parturition. A landmark in modern intrapartum care was the development of electronic fetal monitoring (EFM), largely credited to Drs Edward Hon in the United States and Kurt Hammacher in Germany. I touchedmy first EFM in 1968. Itwas the size of a large refrigerator and was permanently located in adelivery room. The patient could not move from her stretcherwhile beingmonitored, but this machine revealed continuous details of fetal heart rate (FHR), intrauterine pressure, and maternal vital signs that I had never before seen. EFM technology became smaller andmore user-friendly. By the early 1970s, itmigrated into the labor rooms of teaching hospitals. Unfortunately we did not fully understand how to apply these observations to assess fetal status. Consequently, innocent perturbations of FHR often led to operative interventions.Many startled but otherwise healthy infants were, in the words of Shakespeare, ripped untimely from their mothers’ wombs. About 10 years after its introduction, the long armof evidence-basedmedicine reached out in a first critical view of EFM by Banta andThacker. Itwas discouraging to find that, when EFM was compared to standard fetal heart auscultation, it provoked higher cesarean delivery rates but did not improve perinatal outcomes. In the next decade, computerized analytic systems began to focus on evaluation of FHR patterns. One such system, developed by a fetal physiologist, Dr Geoffrey Dawes, and an internist, Dr Christopher Redman, was applied successfully to antenatal assessment.Unfortunately, this system did not perform well in the intrapartum environment. More unfortunately, further efforts in applying computerized analysis of FHR to aid intrapartum carehavebeen slow in coming. Deficiencies in the interpretation of EFM and its role in labor management were considered to be significant contributors to the continued rise in cesarean delivery rates. In the mid-1990s, I participated in an EFM expert panel, convened by the National Institute of Child Health and Human Development (NICHD). This group was charged to develop consensus guidelines for the interpretation of FHR patterns. These new guidelineswere first published 10 years ago, and appeared in an the American College of Obstetricians and Gynecologists (ACOG) practice bulletin 4 years ago. Although these newer FHR interpretative guidelines have been revised subsequently, such guidelines have had little measurable impact on intrapartum care to date. Further randomized controlled trials of EFM against standard FHR auscultation continued to show its inability to improve perinatal outcomes. Appraisals of adjunctivemethods of assessing intrapartum fetal health, such as fetal scalp blood sampling, have been performed. At present, scalp blood sampling has been largely abandoned. More recently, clinical investigators advanced the concept of assessing fetal status by using a reflectance oximetry probe to measure oxygen saturation. An initial randomized trial of fetal oximetry showed that, when added to standard EFM, cesarean birth for nonreassuring FHR patterns was less likely than with EFM alone. However, overall cesarean delivery rates and infant outcomes were similar in From theDepartment ofObstetrics and Gynecology,Medical College of Georgia, Augusta, GA.