Please note: In 2003, the CTF updated its Grades of Recommendations to include an "I Recommendation" for situations where insufficient evidence exists to allow a recommendation to be made.  (Formerly, these situations were captured under a "C Recommendation".)  This change is not retroactive, and all "C Recommendations" made prior to 2003 have not been reevaluated in light of the new "I" recommendation grade.  For a discussion of these recommendation grades, please link to the 2003 article in the Canadian Medical Association Journal here.

Intrapartum Electronic Fetal Monitoring

Objective
To make recommendations for the use of electronic fetal monitoring for Canadian women with normal or high-risk pregnancies to prevent intrapartum asphyxia and its consequences.

Burden of Suffering
The rate of perinatal complications and death in Canada has declined steadily over the last 20 years.  Early and accurate identification of fetal distress with EFR permits medical or obstetric intervention that may reduce the frequency and severity of adverse outcomes due to asphyxia.  The reported incidence of fetal distress has been increasing rapidly in recent years.  In Ontario the recorded incidence of fetal distress increased from 2.4 per 100 deliveries in 1979 to 6.4 per 100 deliveries in 1987.

Options
Electronic fetal monitoring can be done either externally (with sensors on the mothers abdomen) or internally (with an electrode attached to the fetal scalp). Internal monitoring can be supplemented by fetal scalp blood sampling and monitoring of uterine contraction pressure by placement of a sensor in the uterine cavity. External ascultation can also be done.

Outcomes
Rates of hypoxia, perinatal death, cesarean section, and other operative deliveries, neurological signs, Apgar scores, admission to special care nurseries, and maternal infections.

Evidence
MEDLINE was searched for 1988 to October 1993 with the MeSH terms fetal monitoring and randomized controlled trials and the Cochrane Database of Systematic Reviews was also searched.

Values
The 13-member Task Force of experts in family medicine, geriatric medicine, pediatrics, psychiatry and epidemiology used an evidence-based method for evaluating the effectiveness of preventive health care interventions. Recommendations were not based on cost-effectiveness of options. Patient preferences were not discussed.

Background papers providing critical appraisal of the evidence and tentative recommendations prepared by the chapter author were pre-circulated to the members. Evidence for this topic was presented and deliberated upon in 1- to 2-day meetings from October 1993 to March 1994. Consensus was reached on final recommendations.

Benefits, Harms, and Costs
4 randomized controlled trials were done that studied high-risk pregnancies and 4 were done that studied low-risk pregnancies. The studies compared electronic fetal monitoring with active clinical monitoring by nursing and medical staff. Most had small samples of patients. For the 4 studies of high-risk pregnancies, 3 increased the rate of cesarean sections, 2 increased other obstetrical deliveries, and 1 increased blood gas levels and neurological signs in the infants; no other significant differences were found. For the low-risk pregnancies 2 studies found an increase in cesarean section deliveries and 2 found an increase in other operative deliveries.

The Cochrane Database of Systematic Reviews had 4 reviews of electronic fetal monitoring and they showed no benefits of electronic fetal monitoring for Apgar scores, admission to the special care nursery, or perinatal death. Electronic fetal monitoring showed decreased rates of neonatal seizures but increased rates of cesarean section and maternal infection.

Recommendations
Recommendation grade [A, B, C, D, E]  and level of evidence [I, II-1, II-2, II-3, III] are indicated after each recommendation. Citations in support of individual recommendations are identified in the guideline text.

• There is poor evidence to include or exclude electronic fetal monitoring in the PHE of high-risk pregnant women [C, I].
• There is fair evidence to exclude electronic fetal monitoring from routine intrapartum care [D, I].

Sponsors
The Canadian Task Force on Preventive Health Care developed this guideline with funding from Health Canada.

Source Document
Anderson G. Intrapartum electronic fetal monitoring. In: Canadian Task Force on the Periodic Health Examination. Canadian Guide to Clinical Preventive Health Care. Ottawa: Health Canada, 1994; 158-65.