What is the recommended intrapartum fetal surveillance for a multi-gravida (multiple pregnancy) patient at 38 or 39 weeks of gestation with controlled hypertension (HTN) and a fetus in the 8th percentile?

Intrapartum Fetal Surveillance Recommendation

This patient requires continuous electronic fetal monitoring throughout labor due to multiple high-risk factors including controlled hypertension and fetal growth restriction (8th percentile). 1, 2

Rationale for Continuous Monitoring

This case presents a high-risk pregnancy with two critical factors that mandate enhanced surveillance:

• Controlled hypertension on medication places this patient at risk for superimposed preeclampsia, placental insufficiency, and acute hypertensive crises during labor 1
• Fetal growth restriction (8th percentile) indicates uteroplacental insufficiency and increased risk of intrapartum hypoxia and fetal compromise 1

The International Society for the Study of Hypertension in Pregnancy (ISSHP) specifically emphasizes that monitoring for adequate fetal growth is critical in hypertensive disorders, and fetal monitoring should include assessment of fetal biometry, amniotic fluid, and umbilical artery Doppler 1

Evidence Supporting Continuous Monitoring

Continuous electronic fetal monitoring is appropriate and recommended for high-risk labor, which this patient clearly represents 2. While structured intermittent auscultation may be acceptable for low-risk pregnancies, it is not appropriate when maternal hypertension and fetal growth restriction are present 2.

The American College of Radiology guidelines state that antepartum fetal testing in multiple gestations (and by extension, other high-risk conditions) is recommended in all situations where surveillance would ordinarily be performed, including suspected growth restriction 1.

Complete Intrapartum Surveillance Protocol

Fetal Monitoring Components:

• Continuous electronic fetal heart rate monitoring to detect Category II or III patterns indicating developing fetal acidosis 2
• Assessment for moderate fetal heart rate variability and accelerations as reassurance against acidosis 2
• Immediate intervention if Category III tracings develop (absent variability with recurrent late/variable decelerations or bradycardia) 2

Maternal Monitoring Components:

• Continuous blood pressure monitoring given her hypertensive disorder 1, 3
• Assessment for severe hypertension (≥160/110 mmHg) requiring urgent treatment 1, 4
• Evaluation for signs of preeclampsia progression including neurological symptoms, right upper quadrant pain, or visual changes 1, 4

Laboratory Surveillance:

• Baseline labs at admission: complete blood count (hemoglobin, platelets), liver enzymes, creatinine, uric acid 3
• Repeat labs if clinical deterioration or signs of preeclampsia develop 1

Critical Management Points

Severe hypertension (≥160/110 mmHg) requires urgent treatment within minutes using oral nifedipine, intravenous labetalol, or intravenous hydralazine to prevent maternal stroke 1, 4, 3

Magnesium sulfate for seizure prophylaxis should be administered if severe hypertension develops or if any neurological signs/symptoms appear 1, 4, 3

Intrauterine resuscitation should be initiated for Category II tracings with concerning features: stop oxytocin if being used, maternal repositioning, intravenous fluids, oxygen administration, and fetal scalp stimulation 2

Common Pitfalls to Avoid

• Do not rely on intermittent auscultation in this high-risk patient—the combination of hypertension and growth restriction mandates continuous monitoring 2
• Do not assume controlled hypertension is benign—at least 25% of gestational hypertension cases progress to preeclampsia, and this can occur rapidly during labor 1
• Do not delay intervention for Category III tracings—expedited delivery should occur if immediate intrauterine resuscitation does not improve the pattern 2
• Blood pressure alone is not a reliable indicator of disease severity; serious organ dysfunction can develop at relatively mild levels of hypertension 3

Answer to Multiple Choice Question

The correct answer is B: continuous monitoring for fetal as high risk patient. While maternal vitals monitoring (C) and early identification of complications (D) are also essential components of care, the specific question about intrapartum fetal surveillance is best answered by continuous electronic fetal monitoring given the high-risk nature of this pregnancy 1, 2.