Vol. 68, No. 3
Fetal Monitoring in Labor* C. FLEET, Ph.D., E. HOPKINS, M.D., D. CHRISOLM, B.S., G. ROSE, R.N., F. BEPKO, M.D., J. GEORGE, M.D. and S. SINKFORD, M.D., Departments of Obstetrics and Gynecology and of Pediatrics, Howard University and District of Columbia General Hospitals, Washington, D.C.
DURING the period June 30, 1974 to June 30, 1975, electronic surveillance of fetal heart rate and maternal intrauterine pressure during labor was conducted at the District of Columbia General Hospital on 936 obstetrical patients. To determine the impact of this procedure upon perinatal and neonatal outcome, departmental statistics were reviewed for five years prior to electronic surveillance and one year after its implementation. The specific aim of our project was to provide a structured program of improved prenatal and intrapartum health care delivery at the District of Columbia General Hospital. An overall goal was the reduction of the perinatal mortality at D.C. General Hospital. We sought to provide irrefutable evidence of the positive value of maternal fetal electronic surveillance during labor by comparing the maternal and fetal morbidity and mortality statistics at D.C. General Hospital before and after the introduction of the program. Since the major health care procedure during the first year of operation was the implementation of electronic surveillance during labor, this study provided a unique evaluation of maternal fetal electronic surveillance alone in the improvement of perinatal outcome. Unlike any previous published study, no parallel improvement of pedicatric services was provided. MATERIAL AND METHODS
The obstetrical population at the District of Columbia General Hospital is primarily indigent. They are all classified as high risk *Supported by a grant from the National Foundation-March of Dimes.
patients. From this population, there were 2,224 obstetrical deliveries during fiscal year 1974-1975. A sample of 936 obstetrical patients-were electronically monitored. During the initial six months, only the highest rated of the patients at risk were monitored. These patients were classified according to the high risk index used by the District of Columbia Department of Human Resources. This was primarily due to the availability of only two monitors. Later, with the acquisition of two additional monitors, we were able to monitor nearly every patient in labor. The most common reason for not monitoring patients was the imminence of delivery and/or the unavailability of a monitor. The instruments utilized in electronic surveillance were the Corometric models 101 and 111. Upon admission to labor and delivery, the indirect method of measurement of fetal heart rate and uterine contractions were initiated by the nurse who applied the tocotransducer and the ultrasonic transducer to the patient. With the occurrence of ominous patterns and/or other indications conceived by the physician, the mode of measurement was changed to the direct method. The physician introduced a transcervical intrauterine catheter to monitor uterine activity and an internal spiral electrode to monitor the fetal heart rate. The tracings were recorded at a speed of 3 cm/minute. Interpretation of patterns was performed by the physician in accordance with the Hon classification. RESULTS
In an effort to determine the effect of electronic surveillance on the obstetrical service, data were compiled from fiscal year 1969 through fiscal year 1975. These data are re-
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flected in Table 1. The terminology used is standard nonmenclature except for the term 'fetal deaths'. At the District of Columbia General Hospital, fetal deaths are used interchangeably with stillbirths which is defined as death of a fetus whose weight is greater than or equal to one pound. Table 1. MATERNAL AND PERINATAL MORTALITY STATISTICS, D.C. GENERAL HOSPITAL
1969 1970 1971 Live births Fetal deaths (stillbirth) Fetal death ratio rate Neonatal deaths Neonatal death rate Perinatal deaths Perinatal death rate Maternal deaths Maternal death rate OB Admissions Outpatient Visits Babies Born Deliveries Cesarean sections
1973 1974 1975
4,919 4,793 3,568 3,650 2,779 2,200 1,972 107 21.8 129 26.2
6,686 7,044 7,931 7,265 4,761
9,426 9,883 10,691 9,772 7,882 7,834 9,633 5,026 5,205 4,659 3,715 2,842 2,246 2,012 4,954 5,154 4,612 3,676 2,807 2,224 1,986 211
An overview of statistics for the past six years (1969 to 1975) revealed a steady decrease in the number of admissions to the department. This reduction was reflected in a decline in live births, fetal deaths, (stillbi4ths) and neonatal deaths. Perinatal deaths reached their maximum increase in 1970, followed by a continuous decrease through 1975. Maternal deaths reached their maximum in 1970 followed by a gradual decrease to zero in 1973 and 1974 and an increase to two in 1975. The Cesarean section rate increased gradually to its maximum in 1971 followed by a continual decrease through 1975. Alterations in these statistics may also be due to the initiation of a birth control clinic in April 1964 and an abortion clinic in 1966.
June 1974 (near the end of the fiscal year 1974), electronic maternal fetal monitoring was initiated within the department. To determine the impact of this parameter, we looked closely at the statistics of 1974 and 1975. Like the years prior to 1974, there continued to be a decrease in admissions, deliveries, and babies born from 1974 to 1975. This is probably still influenced by the presence of an abortion clinic which increased its numbers from 718 in 1974 to 1,038 in 1975. For the same period, the birth control clinic admissions decreased from 6,965 in 1974 to 6,328 in 1975. Live births dropped by 228. Fetal deaths (stillbirths) dropped by 10. While this parameter continues to reflect the trend established in 1969, it should be noted that there was a reasonably significant drop in fetal deaths. During the same period, the neonatal deaths reversed its downward trend and increased by an insignificant five. The perinatal deaths increased by an insignificant three. Maternal deaths reversed its downward trend from zero in 1973-1974 to two in 1975. The cause of these two deaths were intraabdominal hemorrhage with ruptured uterus and hemorrhage with traumatic induced abortion. The Cesarean sections continued its downward trend from 254 to 250 in 1975. This represents a -1.6% decrease during the year. DISCUSSION
With such a small base for our statistics, it is difficult to differentiate the exact impact of maternal fetal monitoring. Overall, for the six year period, there has been a significant downward spiral for admissions, deliveries, and babies born. This may be partially due to medicare and medicaid, as well as, implementation of birth control and abortions clinics. During the same period, there has been a continued decline in the Cesarean section rate. This statistic was surprising since we anticipated a higher Cesarean rate due to greater detection of fetal distress. Support for these data were provided by Shenker et al., who reported no increase in Cesarean sections due to fetal distress among 2,411 electronically monitored patients at Booth Mem-
Vol. 68, No. 3
orial Medical Center.1 Inconsistent with our findings, were two studies conducted by Gabert and Stenchever at the University of Utah Medical Center from 1970 through 1972.2.3 In their studies, there was a definite increase in the Cesarean section rate which they attributed to greater detection of fetal distress due to electronic monitoring. Since our patient population consisted almost exclusively of patients who were rated at high levels of risk, we did anticipate some variations in our statistics. This was reflected in an increase in the perinatal rate from 51.8 in 1974 to 55.3 in 1975. This is probably not significant and the perinatal rate for this period was essentially unchanged. It was noted that fetal deaths dropped from 49 in 1974 to 39 in 1975. During this same period, the neonatal rate increased from 29.5 to 35.5. While the cause of the increase remains to be researched, we probably delivered more stressful babies who were managed in a nursery system which had not been appreciably changed since our only innovation was electronic surveillance of mother and baby during labor. The obstetrical population has become, during the 1974-75 period, an increasingly-high risk group. Those indigent patients eligible for medicaid have sought private care. The maternal infant care program has provided private type obstetrical care in other hospitals. The patient population left at D.C. General has been the highest of the high risk patients. As can be expected, these statistics are inconsistent with other studies conducted where improved nursery facilities coincided with the implementation of electronic monitoring. One such study was conducted by Paul and Hon at the Los Angeles County Medical Center, during 1970-1972.4 These investigators reported a lower neonatal mortality rate among the monitored patients than among the nonmonitored patients. In a similar study, Shenker et al. reported a decline in fetal deaths from 11/1000 deliveries for fetuses over 1000 grams during the years 1967
to 1972 to 3.1/1000 deliveries in 1973, when maternal fetal monitoring was initiated. Gabert reported a decline in fetal deaths from 15 in 1969 to 6 in 1971 when maternal fetal monitoring was prevalent.2 For the same periods, Skenker and Paul reported a decline in fetal deaths.' However, it should be noted that their calculations for fetal deaths were based only on intrapartum deaths. During the fiscal years 1974-1975, there was a decline in fetal deaths from 49 to 39. However, because of the fairly substantial increase in neonatal deaths, our overall perinatal increased or remain stable rather than declined as did the previously mentioned studies. SUMMARY
The above statistics have indicated that a single procedure such as electronic surveillance has a positive effect in reducing fetal deaths. This change alone may not reduce perinatal mortality. If the significance of such care is to make a substantial effect on perinatal outcome, there must be multiple innovations in obstetrical and pediatric care. As a result, we have implemented structured programs for the management of high risk patients to include a well staffed and equipped neonatal intensive care unit. These variables coupled with electronic surveillance will be evaluated at a later date. LITERATURE CITED
1. SHENKER, L. et al. Routine Electronic Monitor-
ing of Fetal Heart Rate and Uterine Activity During Labor. Obstet. & Gynecol., 46:185-189, 1975. 2. GABERT, H. and M. STENCHEVER. Electronic Fetal Monitoring as a Routine Practice in an Obstetric Service: A Progress Report. Am. J. Obstet. & Gynecol., 118:534-537, 1974. 3. GABERT, H. and M. STENCHEVER. Continuous Electronic Monitoring of Fetal Heart Rate During Labor. Am. J. Obstet. & Gynecol., 115:919923, 1973. 4. PAUL, R. and E. HON. Clinical Fetal Monitoring vs. Effect on Perinatal Outcome. Am. J. Obstet. & Gynecol., 118:529-533, 1974.
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