Fetal Assessment

Foreword
The Challenge of Monitoring
a Fe t us

Lucky Jain, MD, MBA

Consulting Editor

The daunting challenge of monitoring a fetus and ensuring its safe passage to normal
spontaneous birth is foremost in the minds of all who work in this field. The task would
be somewhat simpler if we knew which fetus was at high risk for morbidity and in utero
demise; we could then deploy our best technology and resources to keep a tight vigil
and intervene when the risk became too high.1 Yet, a substantial number of fetal acci-
dents occur in low-risk or no-risk pregnancies.2 The story doesn’t end here; the wide
range of fetal physiologic measures—and the overlapping circles of normal and
abnormal—make the challenge all the more difficult. It is not surprising, therefore,
that several reviews of the published literature have come to pretty much the same
conclusion: nearly forty years after its introduction, there is no clear evidence that ante-
natal electronic fetal monitoring improves perinatal outcome. Experts recommend
further studies focusing on the use of a battery of monitoring techniques in specific
populations of women with increased risk of complications. Here, too, there are logis-
tical problems in stepping up the pace.
Yet, we have shining examples of advances in our ability to image the fetus.3 High-
resolution ultrasounds and MRIs have allowed accurate diagnosis of even the tiniest
aberrations in fetal anatomy. These, coupled with cutting edge genetic testing
methods, have allowed for better informed decision-making on the part of parents
and providers. It has also allowed for coordinated multidisciplinary care of newborns
with multi-organ involvement. These and a broad spectrum of issues related to fetal
monitoring have been covered in this issue of Clinics in Perinatology. Drs Macones
and Odibo are to be congratulated for the superb set of articles in this issue. These arti-
cles highlight the challenges faced by practitioners and opportunities for refining our
approach to fetal monitoring. In particular, our biggest challenge may lie not in the
technology we use, but in our own super cautious interpretation of the tests and the
fear of the unknown. This is especially true when even the best tests are applied to

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doi:10.1016/j.clp.2011.01.001 perinatology.theclinics.com
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low-risk populations where the prevalence of the disease is very low. For detecting the
one to three per thousand risk of serious fetal injury or death, the positive predictive
value of a test with 99% sensitivity and 99% specificity can be as low as 10–30%.
It is no wonder that interventions like cesarean sections, which are often triggered
by an abnormal test, have gone up dramatically.
Finally, for many of the resource-poor nations that are clamoring to acquire the
latest technology, lessons learned from the experience of the wealthiest nations
should direct their attention to the basics. A recent study reported a remarkable
30% drop in stillbirth rate in developing countries after a low-cost educational inter-
vention to train providers in early newborn care.4 Another cautionary tale is emerging
from the rapid adoption of interventions such as inductions and cesarean sections in
emerging economies; the higher morbidity and mortality in the mother and baby after
surgical delivery are cause for real concern and need to be monitored closely.
It is our hope that publications like this will help direct clinical practice and improve
quality of care. I am particularly thankful to Kerry Holland at Elsevier for committing an
issue of the Clinics to this important topic and to the authors and editors for their
superb contributions.

Lucky Jain, MD, MBA

Department of Pediatrics
Emory University School of Medicine
2015 Uppergate Drive
Atlanta, GA 30322, USA
E-mail address:
ljain@emory.edu

REFERENCES

1. Wolfberg AJ, Norwitz ER. Probing the fetal cardiac signal for antecedents of brain
injury. Clin Perinatol 2009;36(3):673–84.
2. Graham EM, Petersen SM, Christo DK, et al. Intrapartum electronic fetal heart
rate monitoring and the prevention of perinatal brain injury. Obstet Gynecol 2006;
108(3 Pt 1):656–66.
3. Farley D, Dudley DJ. Fetal assessment during pregnancy. Pediatr Clin North Am
2009;56(3):489–504.
4. Carlo WA, Goudar SS, Jehan I, et al. Newborn-care training and perinatal mortality
in developing countries. N Engl J Med 2010;362(7):614–23.