1. Palmer, Denise Gagnon MS, RN

Article Content

Fetal Heart Rate Monitoring, 3rd ed, by Roger Freeman, Thomas J. Garite, and Michael P. Nageotte. Philadephia: Lippincott Williams & Wilkins; 2003. 268 pages, hard cover.


Fetal Heart Rate Monitoring provides perinatal caregivers a physiologically focused text that describes the function, advantages, and limitations of electronic fetal monitoring. The third edition of the book, previously published in 1981 and 1991, reflects back on the historical expectations that care providers had for the impact of fetal monitoring. The authors note that high expectations that electronic fetal monitoring created on inception, combined with the commonplace occurrence of abnormal fetal heart rate patterns, have "led to a labor and delivery environment that is one of high anxiety both for patients and their caregivers." Their goal is to provide the reader with the understanding that electronic fetal monitoring is a diagnostic tool that offers additional information in the broader context of patient assessment, which will hopefully assist in improving patient outcomes.


The first chapter reviews the history of fetal monitoring, including photographs of the earliest fetal monitors. The second chapter examines the physiologic basis of fetal monitoring, including placental anatomy, factors that impact uterine blood flow, fetal circulation, and intrinsic and extrinsic influences on fetal heart rate. Chapter 3 provides an in-depth review of intrauterine hypoxia and other causes of neonatal encephalopathy and cerebral palsy. This chapter, extensively revised from the second edition, includes a comprehensive review of the earliest research into intrauterine hypoxia, and the etiological factors associated with the development of various forms of neurological damage. Of particular interest is the review of the impact of maternal chorioamnionitis, fetal inflammatory response, and inflammatory cytokines on the development of cerebral palsy. The chapter concludes with a review of the criteria of intrapartum events associated with neonatal brain damage, and the impact of both auscultation and electronic fetal monitoring on intrapartum fetal mortality.


Chapters 4 and 5 review how the technology of electronic fetal monitoring functions, including its limitations and advantages. External and internal electronic fetal monitoring, networking of fetal monitors, are examined in detail. The physics and physiology of uterine contractions, how to calculate quantification of uterine activity, and abnormal labor patterns are reviewed. Sample electronic fetal monitoring case studies offer a valuable visual component, along with the text.


Chapters 6 through 10 focus on fetal heart rate patterns, interpretation, fetal acid-base balance, and clinical management. Chapter 6 addresses basic pattern recognition, including baseline fetal heart rate, variability, decelerations, accelerations, and unusual fetal heart rate patterns. This edition incorporates the National Institutes of Health consensus workshop definitions on intrapartum fetal monitoring, as well as current clinical definitions for each pattern. Definitions, causation, associated conditions, impact on fetal oxygenation, and appropriate interventions are described for each pattern. Chapter 7 reviews the different types of fetal cardiac arrhythmias, their physiology, treatment, and recommendations for monitoring. Chapter 8 discusses the biochemical aspects of fetal acid-base balance, assessment modalities including fetal scalp sampling, umbilical cord gases, fetal scalp stimulation, acoustic stimulation, and clinical interpretation of each of these assessments. While the physiology of this chapter is complex, it prepares the reader for the chapters that follow. Chapter 9 addresses clinical management of nonreassuring fetal heart rate patterns. This chapter synthesizes the previous discussions of deceleration physiology, impact on fetal oxygenation, and acid-base balance, and adds the dimension of clinical intervention and management for each type of deceleration. In addition, 10 case studies that illustrate and highlight management points are presented. Chapter 10 is new in this edition, and highlights fetal pulse oximetry. The chapter reviews the physiologic basis for pulse oximetry, the early difficulties in the development of this technology for fetal assessment, and the research around fetal pulse oximetry in clinical practice. Risks and benefits, safety of the technology, and utility of fetal pulse oximetry in current practice are all discussed. Case studies using this technology are presented as a valuable adjunct to the discussion.


The last 4 chapters describe unique applications of fetal monitoring. Chapter 11 reviews the special considerations of fetal heart rate patterns in premature gestation. Complications of hypoxia on the premature newborn are examined including respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, and long-term complications. Conditions associated with hypoxia, premature birth, and fetal compromise, such as abruption, preeclampsia, preterm premature rupture of membranes, intrauterine growth restriction, infection, and multiple gestation, are also reviewed. Unfortunately, these topics are not reviewed in depth; however, sample tracings for each complication are included. The chapter concludes with a summary of differences noted in premature infants' fetal heart rate patterns. Chapter 12 focuses on antepartum fetal monitoring. Physiology, risk identification, types of antepartum testing, and their limitations are reviewed, including fetal movement counting, assessment of fetal growth, and various methods of antepartum fetal heart rate testing, biophysical profile testing, and Doppler velocimetry. However, this chapter could have benefited from updated references, particularly regarding biophysical profile testing and Doppler velocimetry. Chapter 13 extends the discussion to antepartum management of the high-risk patient, providing a suggested framework for test selection and timing, in relationship to diagnosis and risk for uteroplacental insufficiency. Complications such as postdates pregnancy, preeclampsia, chronic hypertension, diabetes, third-trimester bleeding, multiple gestation, decreased fetal movement among others are reviewed. Decision trees for management of patients with nonreassuring tests for various antepartum testing modalities are reviewed. This chapter as well could have benefited from updated references, the newest of which is 1999. However, it still offers the clinician valuable information in regard to testing parameters. Chapter 14 details fetal heart rate patterns associated with central nervous system abnormalities. This chapter has several case studies that are extremely valuable for review, considering the relative rarity of these tracings. Finally, chapter 15 focuses on areas of increased liability in antepartum and intrapartum fetal monitoring such as oxytocin hyperstimulation, discontinuation of monitoring, misinterpretation of patterns, among others. Recommendations for risk management are included. This review is limited, with only 7 references cited.


Strengths of this text include many diagrams, tables, charts, and case studies throughout the text that enhance the written content. The sample tracings of unusual cases are extremely valuable for practicing clinicians. It is a concise, well-written text that describes the foundation principles of fetal monitoring, including its advantages, limitations, and application to practice. Weaknesses include a lack of depth to some of the topics addressed, and readers looking for an exhaustive review of the literature about fetal monitoring will be disappointed. However, for practioners of all levels of experience, this text remains an excellent resource for the fundamentals of electronic fetal monitoring.