Rational approach to electronic fetal monitoring during labour in 'all' resource settings

Electronic fetal monitoring (EFM) involves the use of cardiotocograph (CTG) to asses fetal wellbeing during labour in order to detect intrapartum fetal hypoxia early so as to institute timely and appropriate action. Indeed, when CTG was introduced into obstetric practice in the 1960s, it was expected to prevent perinatal brain injury and reduce the incidence of short term (neonatal admissions, seizures and neonatal deaths) and long term (cerebral palsy, learning difficulties) that arise secondary to intrapartum hypoxic insults. Unfortunately, although the rates of caesarean sections have dramatically increased over the last 40 years, there has been virtually no change in cerebral palsy rates. However, increasing caesarean section rates have contributed to maternal morbidity and mortality, including rising incidence of morbidly adherent placentae (placenta accrete, increta and percreta). Apart from a high 'false positive' rate of CTG, failure to appreciate the pathophysiology of fetal heart rate changes by the clinicians have contributed to increased operative deliveries, without any substantial improvements in neonatal outcomes. Hence, a rational approach is warranted in the use and interpretation of CTGs to improve maternal and fetal outcomes, in all settings, irrespective of the availability of additional tests of fetal wellbeing such as fetal blood sampling (FBS), fetal electrocardiograph (ST analyser or STAN), fetal pulse oximetry or scalp lactate.