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Fetal monitoring in labour.

The prevention, early diagnosis, and treatment of intrapartum asphyxia-with its attendant risks of stillbirth, neonatal death, or long term handicap-remain objectives of the highest priority. The discovery of the relation between fetal acidosis and changes in the fetal heart rate led to the introduction in the 1970s of electronic fetal monitoring to reduce the hazards of fetal asphyxia.' Nevertheless, its use has been the subject of deep controversy, particularly in mothers with pregnancies at low risk. Some studies reported falls in perinatal mortality after the introduction of electronic fetal monitoring,2 3 but the extent to which the improvement could be attributed to the monitoring itself was difficult to define. Doubts about the routine use of monitoring for all mothers increased when only one4 of five randomised trials58 reported improved fetal outcome with electronic fetal monitoring as compared with intermittent auscultation. These randomised trials were, however, too small to be conclusive, and an analysis of pooled data from the first four studies showed that neonatal convulsions were less common in babies who had had electronic fetal monitoring provided that it had been used in conjunction with assessments of fetal acid base balance.9 This finding was important-because about half of infants with neonatal convulsions either die in early infancy or survive with serious developmental abnormalities.'0 A much larger randomised trial on 12964 women at the National Maternity Hospital in Dublin has recently been completed. Electronic fetal monitoring was compared with intermittent auscultation, both policies including an option to measure the pH in the fetal scalp." Though there was no difference in perinatal mortality between the two groups, the diagnosis of fetal asphyxia (pH<7-20) was increased by 83% and the number of neonatal convulsions reduced by 55% in the group who had electronic fetal monitoring. Stratified analysis, however, showed that the reduction in neonatal convulsions occurred very largely in those women whose labours had lasted for over five hours. Regular intermittent auscultation may prove to be sufficient in low risk mothers who have a normal short term trace obtained by an external monitor in early labour and who progress to delivery within five hours. Anxieties remain, however: one is that most of the randomised studies have reported that electronic fetal monitoring induces a twofold to threefold increase in the rate of