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Fetal compromise in labor
Sixty years ago, the purpose of introducing electronic fetal heart rate monitoring (EFM) was to reduce the incidence of intrapartum stillbirth. However, by the early 1980s, with falling stillbirth rates, fetal blood sampling had been widely abandoned, as many considered that EFM was sufficient on its own. Unfortunately, while the sensitivity of EFM for the detection of potential fetal compromise is high, specificity is low, and there is a high false positive rate which has been associated with a rising cesarean section rate. The authors suggest that EFM is considered and analyzed as a classic screening test and not a diagnostic test. Furthermore, it requires contextualization with other risk factors to achieve improved performance. A new proposed metric, the Fetal Reserve Index, takes into account additional risk factors and has demonstrated significantly improved performance metrics. It is going through the phases of further development, evaluation, and wider clinical implementation.
Caesarean section delivery
It is the most common surgical operation performed in the world. Since first described 400 years ago, surgical rates continue to rise globally. Caesarean rates are now reported from South American countries of over 50% and rates of over 32% are currently being reported from the United States, China, England and Scotland. Surgical complications can occur at the time of operation and there are major implications for future pregnancies, including increased rates of placenta previa/accreta, stillbirth and preterm labour. This Element discusses many aspects of CD, including the Robson 10 group classification system, which classifies populations by characteristics such as parity, presentation of the fetus and the history of previous births, an evidencebased approach to surgical techniques, recommendations of the major guidelines and recommendations concerning trial of labour after previous caesarean.
