What is the best intrapartum surveillance method for a patient with a low-risk and uncomplicated pregnancy to ensure maternal and fetal well-being during labor?

Best Intrapartum Surveillance for Low-Risk Pregnancy

For a patient with low-risk, uncomplicated pregnancy during labor, intermittent fetal heart monitoring (Option D) is the best intrapartum surveillance method to ensure maternal and fetal wellbeing. 1, 2

Why Intermittent Auscultation is Superior for Low-Risk Labor

Structured intermittent auscultation is equivalent to continuous electronic fetal monitoring (EFM) in screening for fetal compromise in low-risk patients, while avoiding the substantial harms associated with continuous monitoring. 1, 2

Evidence Against Continuous EFM in Low-Risk Patients

• Continuous EFM increases cesarean delivery rates with a number needed to harm (NNH) of only 20, meaning for every 20 low-risk patients monitored continuously, one additional unnecessary cesarean occurs 1
• Instrumental vaginal births increase with continuous EFM (NNH = 33) 1
• The only demonstrable benefit of continuous EFM is reduction in neonatal seizures, requiring 661 patients to be monitored to prevent one seizure, while showing no difference in neonatal mortality or cerebral palsy rates 1, 2
• Continuous EFM decreases maternal mobility, reduces physical contact with labor support partners, and diminishes time with nursing staff, adversely affecting the labor process and maternal satisfaction 1, 2

Proper Implementation of Intermittent Auscultation

Critical Requirements for Safety

Structured intermittent auscultation requires a 1:1 nurse-to-patient ratio and an established institutional protocol to be safely implemented. 1, 2

Specific Technique Protocol

• Perform Doppler assessment of fetal heart rate every 15-30 minutes during the active phase of first stage labor 1
• Increase frequency to every 5 minutes during second stage of labor with pushing 1, 2
• Count FHR between contractions for at least 60 seconds to determine average baseline rate 1
• Count FHR after uterine contraction for 60 seconds to identify fetal response to active labor 1
• Palpate for uterine contractions during FHR auscultation to determine the relationship between contractions and heart rate 1

Additional Assessment Points

Assess FHR before and after key events including: 1

• Initiation of labor-enhancing procedures
• Artificial or spontaneous rupture of membranes
• Vaginal examinations
• Administration of medications or analgesia/anesthesia

When to Escalate to Continuous Monitoring

Switch from intermittent auscultation to continuous EFM when abnormal fetal heart rate characteristics are detected and unresponsive to resuscitative measures. 1, 3

Specific indications for escalation include: 2, 3

• Abnormal FHR patterns detected on auscultation
• Meconium-stained amniotic fluid
• Maternal fever or signs of chorioamnionitis
• Development of high-risk conditions during labor

Why Other Options Are Inadequate

Option A (Maternal Pulse and Blood Pressure)

• Maternal vital signs monitoring alone does not assess fetal wellbeing, which is the primary concern for detecting intrapartum hypoxia and preventing adverse neonatal outcomes 2

Option B (Uterine Contractions Monitoring)

• Contraction monitoring must be assessed in conjunction with fetal heart rate patterns to determine fetal response to labor stress; monitoring contractions alone is insufficient 1, 2

Option C (Early Identification of Complications)

• While important, this is too vague and does not specify the actual surveillance method needed; it describes a goal rather than a technique 2

Common Pitfalls to Avoid

• Do not use routine admission EFM tracings in low-risk patients, as they increase interventions (epidural analgesia NNH = 19, continuous EFM NNH = 7, fetal scalp testing NNH = 45) without improving neonatal outcomes 1
• The perception that intermittent auscultation increases medicolegal risk has led to routine continuous EFM use in North American hospitals despite lack of evidence of benefit 1, 2
• Lack of staff training in structured intermittent auscultation and economic factors favoring continuous EFM have created barriers to evidence-based practice 1, 2
• Ensure proper 1:1 nursing ratios are maintained, as inadequate staffing compromises the safety of intermittent auscultation 1, 2