Imperativeforimprovementsandinternationalconvergenceofintrapartumfetalmonitoring:Abirdseyeview

摘要： Intrapartumfetalmonitoringhasbeencriticizedforthelackofevidenceofimprovementinfetaloutcomedespitecausingincreasedoperativeintervention.Paradoxically,cardiotocography(CTG)hasbeenamajordriverforlitigationforneonatalneurologicalinjury.Thisanalyticalreviewtriestoexplorewhyextensiveclinicalstudiesandtrialsover50yearshavefailedtodemonstrateorbringaboutsignificantimprovementinintrapartumfetalmonitoring.Thereseemsaneedforsignificantreform.InternationalcongruenceonmostaspectsofCTGinterpretation[definitionsoffetalheartrate(FHR)parameters,CTGrecordingspeed,3-tiersystems,etc.]ishighlydesirabletofacilitatefuturemeaningfulclinicalstudies,evaluationandprogressinthisfield.TheFHRchangesarenon-specificandpoorsurrogateforfetalwell-being.Asacompromiseformaintaininglowfalse-negativeresultsforfetalacidemia,ahighfalse-positivevaluemayhavetobeaccepted.Theneedforredefiningtheplaceofadjuvanttestsoffetalwell-beinglikefetalbloodsamplingorfetalelectrocardiography(ECG)isdiscussed.TheFHRdecelerationsareoftendeterministic(center-stage)inCTGinterpretationand3-tiercategorization.Itisdiscussediftheirscientificandphysiologicalclassification(avoidingframingandconfirmationbiases)maybebestbasedontimerelationshiptouterinecontractionsalone.Thismayprovideamoresoundfoundationwhichcouldimprovethereliabilityandfurtherevolutionof3-tiersystems.ResultsofseveraltrialsoffetalECG(STAN)havebeeninconclusiveandaneedforafreshapproachorstrategyisconsidered.ItishopedthatthelonganticipatedComputer-aidedanalysisofCTGwillbemoreobjectiveandreliable(overcomehumanfactors)andwilloffervaluablesupportormayeventuallyreplacevisualCTGinterpretation.Inanycase,therecordingandarchivingallCTGsdigitallyandtestingcordbloodgasesroutinelyineverydeliverywouldbehighlydesirableforfutureresearch.Thiswouldfacilitatewelldesignedretrospectivestudieswhichcanbeveryinformativeespeciallywhenprospectiverandomisedcontrolledtrialsareoftendifficultandresource-intensive. ... （共8頁）