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Cited by 19Maternal and Perinatal Health InterventionsNeonatal and fetal brain pathologyHeart Rate Variability and Autonomic Control

The DOI matches its Crossref record; 41 of the 43 references it cites were found in a registry or an index.

Categorization of Fetal Heart Rate Decelerations in American and European Practice: Importance and Imperative of Avoiding Framing and Confirmation Biases

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Sholapurkar, Shashikant L.·2015·Journal of Clinical Medicine Research
DOI 10.14740/jocmr2166wPMC PMC4522983
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Abstract

Interpretation of electronic fetal monitoring (EFM) remains controversial and unsatisfactory. Fetal heart rate (FHR) decelerations are the commonest aberrant feature on cardiotocographs and considered "center-stage" in the interpretation of EFM. A recent American study suggested that the lack of correlation of American three-tier system to neonatal acidemia may be due to the current peculiar nomenclature of FHR decelerations leading to loss of meaning. The pioneers like Hon and Caldeyro-Barcia classified decelerations based primarily on time relationship to contractions and not on etiology per se. This critical analysis debates pros and cons of significant anchoring/framing and confirmation biases in defining different types of decelerations based primarily on the shape (slope) or time of descent. It would be important to identify benign early decelerations correctly to avoid unnecessary intervention as well as to improve the positive predictive value of the other types of decelerations. Currently the vast majority of decelerations are classed as "variable". This review shows that the most common rapid decelerations during contractions with trough corresponding to peak of contraction cannot be explained by "cord-compression" hypothesis but by direct/pure (defined here as not mediated through baro-/chemoreceptors) or non-hypoxic vagal reflex. These decelerations are benign, most likely and mainly a result of head-compression and hence should be called "early" rather than "variable". Standardization is important but should be appropriate and withstand scientific scrutiny. Significant framing and confirmation biases are necessarily unscientific and the succeeding three-tier interpretation systems and structures embodying these biases would be dysfunctional and clinically unhelpful. Clinical/pathophysiological analysis and avoidance of flaws/biases suggest that a more physiological and scientific categorization of decelerations should be based on time relationship to contractions alone irrespective of shape or descent time as indeed proposed by pioneers like Hon and Caldeyro-Barcia. Such meaningful categorization, apart from being a scientific necessity, could improve the practical performance of three-tier FHR interpretation systems and possibly application of dependent complementary techniques like fetal ECG/pulse oximetry/computer-aided analysis, thus facilitating future progress in the field of intrapartum fetal monitoring.

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Figure 1 Hypothesis of cord compression and variable deceleration [25, 27, 29, 30] (thankfully reproduced from OJOG 2013;3:362-370, open access) [23]. This hypothesis has major fallacies. Complete cord compression has been postulated for these most common decelerations (CTG paper speed 3 cm/min). The FHR recovery commencing at the height of contraction (where umbilical arterial and venous occlusion is unrelieved) cannot be explained. Instead the deceleration depicted seems consistent with “direct” or “pure” vagal reflex (head compression).
Figure 1 Hypothesis of cord compression and variable deceleration [25, 27, 29, 30] (thankfully reproduced from OJOG 2013;3:362-370, open access) [23]. This hypothesis has major fallacies. Complete cord compression has been postulated for these most common decelerations (CTG paper speed 3 cm/min). The FHR recovery commencing at the height of contraction (where umbilical arterial and venous occlusion is unrelieved) cannot be explained. Instead the deceleration depicted seems consistent with “direct” or “pure” vagal reflex (head compression).CC BY · PubMed Central
Figure 2 CTG in a case of cord prolapse showing decelerations (mistakenly) classed as “variable” (reproduced with thanks from Westgate et al, AJOG, 2007) [1]. Although these decelerations “look” rapid (paper speed 1 cm/min), the “descent time” is well over 60 s.
Figure 2 CTG in a case of cord prolapse showing decelerations (mistakenly) classed as “variable” (reproduced with thanks from Westgate et al, AJOG, 2007) [1]. Although these decelerations “look” rapid (paper speed 1 cm/min), the “descent time” is well over 60 s.CC BY · PubMed Central
Figure 3 The same CTG from Figure 2 shown with American CTG paper speed of 3 cm/min. Note that the “descent time” is well over 60 s. Hence, based on American definitions [10, 11], these decelerations are “late”, demonstrating that rate/time of descent does not reliably predict etiology.
Figure 3 The same CTG from Figure 2 shown with American CTG paper speed of 3 cm/min. Note that the “descent time” is well over 60 s. Hence, based on American definitions [10, 11], these decelerations are “late”, demonstrating that rate/time of descent does not reliably predict etiology.CC BY · PubMed Central
Figure 4 Diagrammatic representation of early, late and variable decelerations as practiced in British Obstetrics before 2007 (reproduced with kind permission from “Principles of Obstetrics” by Bryan Hibbard, 1988) [20]. Note the apparent rapid descent of early decelerations.
Figure 4 Diagrammatic representation of early, late and variable decelerations as practiced in British Obstetrics before 2007 (reproduced with kind permission from “Principles of Obstetrics” by Bryan Hibbard, 1988) [20]. Note the apparent rapid descent of early decelerations.CC BY · PubMed Central

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Research works printed but not linked: 1

  1. [24]Royal College of Obstetricians and Gynaecologists. Clinical Effectiveness Support Unit. The use of electronic fetal monitoring. The use and interpretation of cardiotocography in intrapartum fetal surveillance Evidence based Clinical Guideline No 8. 2001. London (UK), RCOG Press

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Metadata

Authors
Sholapurkar, S. L.
Affiliations
Royal United Hospital (GB)
Corresponding author
Sholapurkar, Shashikant L.
ORCID
Sholapurkar, Shashikant L.
Venue
Journal of Clinical Medicine Research
Publisher
Elmer Press, Inc.
Published
2015
Volume
7
Issue
9
Pages
672-680
ISSN
  • 1918-3003 (ISSN-L)
  • 1918-3011
DOI
10.14740/jocmr2166w
PMC
PMC4522983
OpenAlex
W1796605382
Cited by
19
References
43
Citations by year
2024: 2 · 2023: 3 · 2022: 1 · 2020: 1 · 2018: 3 · 2017: 5 · 2016: 4
FWCI
0.59
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • Journal of Clinical Medicine Research (publishedVersion, cc-by-nc)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
Topics
  • Health Sciences › Medicine › Obstetrics and Gynecology › Maternal and Perinatal Health Interventions
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Neonatal and fetal brain pathology
  • Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
Keywords
fetal heart rate decelerations, fetal heart rate monitoring, framing bias, confirmation bias, anchoring effect, variable decelerations, vagal reflex, intrapartum fetal monitoring, neonatal acidemia, terminology standardization

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