What is the best intrapartum surveillance method for a primigravida (first-time pregnant woman) at 39 weeks gestation with a fetus at the 8th percentile for health promotion and complications prevention?

Continuous Electronic Fetal Monitoring (Option C)

For a primigravida at 39 weeks with a fetus at the 8th percentile, continuous electronic fetal monitoring during labor is the best intrapartum surveillance method because this represents fetal growth restriction requiring high-risk monitoring protocols. 1, 2

Why This Fetus Qualifies as High-Risk

• A fetus at the 8th percentile falls within the definition of fetal growth restriction (FGR), specifically between the 3rd-10th percentile range that requires enhanced surveillance 1
• The Society for Maternal-Fetal Medicine recommends delivery at 38-39 weeks gestation for FGR when estimated fetal weight is between the 3rd and 10th percentile with normal umbilical artery Doppler 1
• Growth restriction represents a chronic hypoxic state that increases the fetus's vulnerability to labor stress, making continuous assessment essential rather than intermittent checks 2

Why Continuous Monitoring is Superior in This Case

• Continuous electronic fetal monitoring can detect patterns of fetal compromise that intermittent auscultation may miss, particularly in fetuses already compromised by growth restriction 2
• Intrauterine growth restriction is specifically identified as a high-risk condition requiring enhanced surveillance due to increased risk of uteroplacental insufficiency and intrapartum hypoxia 2
• The only demonstrable benefit of continuous EFM—reduction in neonatal seizures (NNT = 661)—becomes more clinically relevant in high-risk populations where the baseline risk of hypoxic injury is already elevated 2

Why Other Options Are Inadequate

• Maternal vital signs monitoring alone (Option A) is insufficient because it does not assess fetal wellbeing and cannot detect intrapartum hypoxia or fetal compromise 2
• Intermittent auscultation (Option B) is appropriate only for low-risk pregnancies and requires a 1:1 nurse-to-patient ratio with checks every 15-30 minutes in active labor—this level of surveillance is inadequate for a growth-restricted fetus 2, 3
• Intermittent auscultation checks every 15-30 minutes can miss critical periods of fetal decompensation in a fetus with limited physiologic reserve 2

Accepting the Trade-Offs

• Continuous EFM does increase cesarean delivery rates (NNH = 20) and instrumental vaginal births (NNH = 33) compared to intermittent auscultation 2, 4
• However, this trade-off is acceptable and appropriate in high-risk situations like fetal growth restriction where the fetus is already compromised and the risk of intrapartum hypoxic injury is substantially elevated 2
• The increased intervention rate in low-risk populations is a harm, but in growth-restricted fetuses, these interventions may be life-saving 2

Implementation Strategy

• Use systematic interpretation with the DR C BRAVADO mnemonic (Determine Risk, Contractions, Baseline Rate, Variability, Accelerations, Decelerations, Overall assessment) to guide clinical decision-making 1, 2
• Be prepared for operative delivery if non-reassuring fetal heart rate patterns develop, as growth-restricted fetuses have limited physiologic reserve to tolerate labor stress 2
• Ensure adequate documentation and regular review of tracings by physicians and labor nurses throughout labor 1

Critical Pitfall to Avoid

• Do not treat this as a low-risk pregnancy simply because the Doppler studies may be normal—the 8th percentile growth alone qualifies this fetus as high-risk and mandates continuous monitoring during labor 1, 2