Continuous Electronic Fetal Monitoring

Aka: Continuous Electronic Fetal Monitoring, CEFM, Continuous External Fetal Heart Rate Monitoring, Continuous Internal Fetal Heart Rate Monitoring

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II. Indications : High risk pregnancy (see efficacy below)

  1. See Peripartum Risk to the Fetus
  2. Antepartum factors
    1. Conditions affecting placental insufficiency
    2. Known fetal anomaly
    3. Maternal Preeclampsia or Gestational Hypertension
    4. Maternal Type 1 Diabetes Mellitus
    5. Fetal Growth Retardation suspected
    6. Uterine scar from prior cesarean delivery (in Trial of Labor after Cesarean or TOLAC)
  3. Intrapartum factors
    1. Meconium present
    2. Tachysystole
    3. Intrauterine Infection
    4. Vaginal Bleeding
    5. Uterine stimulant (i.e. Oxytocin) use for Labor Induction or augmentation
    6. Low risk patient with concerning findings on Structured Intermittent Auscultation (SIA)
      1. Irregular Fetal Heart Rate
      2. Fetal Tachycardia (>160 bpm for >10 minutes)
      3. Fetal Bradycardia (<110 bpm for >10 minutes)
      4. Recurrent fetal decelerations after contractions (>50% of contractions)
      5. Prolonged deceleration (2-10 minutes)

III. Adverse Effects

  1. See Efficacy below (including False Positive Rate)

IV. Types: Fetal Heart Rate Monitoring

  1. Structured Intermittent Auscultation
    1. Preferred in most low risk patients
  2. Continuous External Fetal Heart Rate Monitoring
  3. Continuous Internal Fetal Heart Rate Monitoring
    1. Intrauterine fetal scalp electrode placement
    2. Indicated when external monitoring is not possible or unreliable
      1. Maternal body habitus
      2. Fetal Position interferes with monitoring
    3. May be combined with other monitors
      1. Intrauterine pressure catheter placement
    4. Adverse Effects
      1. Requires Amniotomy and increased risk of Chorioamnionitis, vertical transmission HSV and Viral Hepatitis

V. Efficacy: Continuous Electronic Fetal Monitoring (CEFM)

  1. CEFM does not significantly improve fetal outcome
    1. Only measurable benefits
      1. Fewer Neonatal Seizures
      2. Good tracing is reassuring for good outcome
    2. No benefit in APGAR Scores
    3. No decrease in NICU admissions
    4. No change in perinatal death rate
    5. No reduction in Cerebral Palsy
      1. Non-reassuring tracing does not predict bad outcome
      2. False Positive Rate 99.8% if ominous tracing
        1. Late Decelerations
        2. Decreased variability
  2. CEFM increases the risk of surgical intervention (False Positive for fetal acidosis in two thirds of cases)
    1. Increases ceserean rate by 20%
    2. Increases operative Vaginal Delivery rate
  3. Consider Informed Consent for CEFM
    1. CEFM may be indicated in high risk pregnancies
    2. Consider intermittent monitoring if low risk

VI. References

  1. Alfirevic (2017) Cochrane Database Syst Rev (1):CD006066 [PubMed]
  2. Arnold (2020) Am Fam Physician 102(3): 158-67 [PubMed]
  3. Devane (2017) Cochrane Database Syst Rev (1):CD005122 [PubMed]
  4. Luthy (1987) Obstet Gynecol 69(5):687-95 [PubMed]
  5. Leveno (1986) N Engl J Med 315(10):615-19 [PubMed]

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