Associate Professor, Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences


Christian M. Pettker, MD

Language evolves, and perhaps nowhere is that more apparent than in clinical settings. Some would argue that perhaps nowhere is any evolution more important, especially when it comes to using inclusive language that encompasses the totality of the human experience. It can impact everything from how one is treated within a medical facility to research.

Sarah J. Kilpatrick, MD, PhD, and Christian Pettker, MD—sat down with Senior Editor Angie DeRosa to discuss the topic. Kilpatrick is the Helping Hand of Los Angeles Chair in obstetrics and gynecology, chair of the department of obstetrics and gynecology and professor, and associated dean of faculty development at Cedars-Sinai Medical Center in Los Angeles. Pettker is professor of obstetrics, gynecology, and reproductive sciences; associate chief quality officer; and chief of the Department of Obstetrics, Gynecology and Reproductive Sciences at Yale School of Medicine in New Haven, Connecticut.

For print purposes, this content has been edited for clarity and to fit within the pages of the magazine. The full video interview is accessible online at: www.contemporaryobgyn.net/view/board-members-debate-noun-use-pregnant-woman-or-pregnant-person-.

What is the purpose of this change in language?

I think this change in language, which is specifically the change of pregnant women to pregnant persons that we’re talking about, to me, the purpose of this is twofold. The first is to increase the belief in inclusion and decrease discrimination toward transgender people and, specifically in the realm of pregnancy, transgender men. And that is an incredibly important purpose. The second purpose, though, which I think is equally important, is to be able to create more education and learn more about transgender men and pregnancy so that, ultimately, we can even take care of them better because we don’t know that much about transgender male pregnancy. So I think, ultimately, the purpose of this change is to facilitate both of those aims.

I would just echo those comments and add that pregnant people who do not identify as women and don’t accept the term or don’t use the term pregnant women face a lot of bias and exclusion and discrimination, and they’re a very small proportion of the population. And we are acknowledging their presence in our population, the existence of the bias and discrimination against them, and we’re trying to reduce the barriers of them getting really exceptionally good care and trying to include them in our policies and our institutions that take care of pregnant patients.

I agree with that. However, I don’t think changing the name from pregnant women to pregnant persons will, in and of itself, do that. I think that what we need to do, frankly, instead of going more general, we need to be more specific. So I think we need to talk about pregnant transgender men, for example.

And as you pointed out, Chris, if you look at the best data, the percent of US people who are transgender is about 1%. Let’s say half of those are transgender men, so half a percent of the entire US is a transgender man. So that number who are pregnant, obviously, is much smaller than that. So it’s a very small proportion of people. Nonetheless, we want to create an inclusive environment for anyone who needs pregnancy care.

But just changing the names to persons doesn’t help. We actually need to identify those transgender men so that we can learn from them and study what they need to make their care smooth. What do we need to do in the health care systems, not just us, the doctors, but the health care systems, so that they’re not surprised if they see a man who’s coming to a pregnancy clinic.

I personally think we need to do much more in terms of education of health care people and systems within the health care environment that a transgender man might encounter so that they are more accepting. We need to do things like change the pictures in our offices. We need to do things like use symbols, use pictures of flags. I mean, there’s actually a trans pride flag, for example, that could be along the name of a women’s health clinic. That’s a whole other topic of change of name. But, you know, women learned this.

Why do we have women’s health? Because untilwomen named their healthneeds, they weren’t studied. And even now, we don’t have enough research on women’s health. So I think of transgender men in the pregnancy world in the same fashion. Until we name them, we can’t study them, we can’t learn about them, and we can’t talk about them—and just saying a pregnant person doesn’t help that.

I think it’s a really useful distinction to make. And I think you’re right. That is such an important point. And I am happy that we’re doing so much more research, although it’s a small amount of research, and we do need to advocate more for it on this special population and what their health care outcomes are and what their barriers are. It’s a terrific point. But I do think on a global level, our education and our institutions showing an openness to see pregnancies of all types is still helpful.

No, I agree with that. And I think again, it comes down to vocabulary. I think educating people about gender diversity, meaning the concept that gender is not necessarily binary, is what we’re talking about. And one of the very first things we have to do is when any patient comes into the health care system, they need to be asked, “What’s your race/ethnicity? Self-identify. What is your gender?” And that should be part of it. And you and I know, Chris, that every EMR [electronic medical record] can’t accommodate that. We are doing better. Epic is doing better. But right now, at Cedars-[Sinai], we do that, and people don’t have to answer if they don’t want to. But that’s the very first thing we need to know—how do they want to be, and what are their pronouns? How do they want to be referred to? Until we can do that and teach our compatriots that this is important, to provide the best care, we need to recognize the individuality of the person and then design our care around that as we learn more information about their gender identity [and] how their gender identity affects their health and their health outcomes.

That’s such an important point. You know, I think we are talking about the same thing, even though we might disagree on whether or not the term pregnant person achieves the goal that we’re each specifically talking about. The electronic health record example is so important because a few years ago, we had a pregnant man in our office and I couldn’t assign him a pregnancy. I couldn’t use the pregnancy calculator.

And this is actually what opened my mind to using a broader and more inclusive term because I wondered what that patient faced when he called our office—and what did our office say when they heard that it was a man registering for an appointment for a pregnancy—and all the barriers that that person might have faced. So we did create something in the electronic health record that would allow a man to be pregnant.

But just recently, in our hospital, a region of our hospital that’s a bit more open but is limited to admitting women, we had a pregnant man that we needed to admit to that area. And we had to go to do some bed reconciliation and work on that. And it does point to your point of keeping that person within our administrative database as a “pregnant man” so that we can trace that person’s health outcomes, include them in research. It does speak to your point on maintaining that specificity of how we talk about gender on an individual level while we’re also trying to be inclusive.

Those are great points too. And I think about the current trend now in research and journals requiring this change. And I just think we’ve been too quick to adopt this. For example, if you have a paper—and you’ve done your research, and it’s on pregnant women—and now you’re calling them pregnant persons when every single person in that study was a woman, it becomes a little odd. And I think does a little bit [of a] disservice to the women who were in your study that the name “woman” is now lost from pregnancy.

And going back to the fact that women in general need more research and have fought hard to get research about them done in other specialties, now in the one area that we consider, let’s say, needs a woman’s body at the moment—maybe there’s going to be male uterine transplants at some point, but we’re not there yet—and all of a sudden, we’re taking the term away from that. So I think we need to be more inclusive. Absolutely. But we need to think of ways that will really make us more inclusive and not by just changing this name because it’s become politically correct to do. We haven’t thought through the impact of this.

Well, it’s interesting, Sarah, because you talk about the research [for which] the studies might have researched pregnant women. But how sure are we that the study did not include a pregnant man if we’re not asking it at our registration? We are making assumptions in the research that...everybody who had a pregnancy was a pregnant woman. The statistics would say, most of the time, yes. But if we’re not asking those questions right at the front, our research actually might be based on some assumptions that aren’t correct. So you know, again, we’re still talking about the same thing. We’re supporting each other’s argument.

No, that’s a fair point. You’re absolutely right. I think in this arena of health care, [to reach] our goal of best health outcomes and best acceptance and respect for all patients that we see, the more specific we are in categorizing them in a way that they want to be categorized, the more able we are to be both more inclusive and to provide better care.

You know, I read some articles for this. And there’s one article—there are not many out there—[but] there is one article [about] 41 transgender male pregnancies, men with pregnancies.1 [It provides] interesting data, but [for] one of the [questions asked], “What [is your] gender identity?” you would expect that 100% of them would say, male or trans male—and actually 25% did not. So even in that population of men who were transgender men and pregnant, 25% of them...said they still identified as something else and not male or transgender male. So again, it shows the complexity. Like all humans, you know, we all have trouble fitting into categories sometimes.

But for us to provide the best care, we need to know, directly from research with transgender men, about their pregnancies. And we need to categorize all people correctly, if they’re comfortable being categorized. We can make the same argument for race and ethnicity, right? That we say you’re Hispanic. Well, there’s a whole lot of different Hispanics. I mean, categories that...say you’re Black....It’s interesting, we want to be more inclusive, but to do that, I think we actually have to be more specific [for better patient outcomes]. It’s part of the African American/Blackdiscussion we’re having now. To better understand what Black women want in their pregnancy, we have to listen to them and not make assumptions.

Dr Kilpatrick, have you seen in your own practice, as Dr Pettker talked about, any trans individuals who are pregnant?

We’ve had one transgender man pregnant, and we faced many of the things that Dr Pettker just mentioned. It was after that person that we changed some things in our EMR, but even with that man, and with what we thought was correct preparation of people that were going to interact with him, we still had issues. We could have done a better job. And his experience could have been better if we had more discussion. I think what we need to do here in our field is just have more general discussion of transgender people—men, for us mostly, but maybe not always—because their care is complex. It’s not just about pregnancy. What about contraception? What’s the effect of transgender men being on testosterone? Plus, do they still need contraception? Well, the answer is yes. What kind of contraception are they comfortable with? What do they want to call their body parts?

There are a lot of things that we need to educate everyone about, and it shouldn’t be education in the closet. It should be education out there. In 

®, that’s a forum for education. And just the language here, many people couldn’t even give you the maybe 6 or 7 categories that now are in the gender diversity list....You can categorize yourself as A-gender or gender fluid.So on Wednesdays, you’re female, and on Thursdays, you’re male—and that’s a category. So there’s a lot that everyone needs to learn, and [they need to] be comfortable with the language to provide the best care and inclusion for patients who are transgender.

So Sarah, I’m curious...if you’ve made any changes with the language [that you use in different circumstances], and it sounds like maybe you haven’t, but I won’t make any assumptions....For instance, I’ve changed my language a lot when I write guidelines. And when we were working on our [COVID-19] vaccine strategy at Yale New Haven Health and the recommendations given related to pregnancy in the vaccine, we just decided we were going to be all in and say pregnant people who wanted the vaccine or pregnant people should be offered the vaccine. And we made that intentional flip to be inclusive. I actually did not face any organizational restrictions or get any feedback. The CEO didn’t call me and say, “What are you thinking?” They were all very supportive, and I’m glad for that

I’m wondering what your thoughts are on using language like that because we did want to make sure that everybody came for a vaccine and [that] everybody thought they were part of these guidelines and recommendations.

No, we haven’t made any, and frankly, this is where we disagree. I don’t think that’s a useful change. I think removing the term “woman” is fraught with [risk of] taking attention away from women....And this is nothing about not being inclusive to transgender men. I just think this is a trend that has happened way too quickly, and I think it needed to be coupled with much better education.

I think there will be women who will think, “What is it pregnant person? What does that mean? Why are they taking ‘woman’ out of there?” And “What are they trying to do?” I mean, now should we take “men”—if we could take this to the extreme, every single person could be categorized as a pregnant person or a nonpregnant person. That would cover everyone, 100%. We could do away with “men” and “women” altogether. So why this is focused on removing “woman,” but what’s happening in all the other specialties?

What if we said a “pregnant patient” instead? Which we use all the time on the floors. I used it 20 years ago, “This is a pregnant patient.” What if we use that kind of word?

That’s better than a “pregnant person,” I think. But I do think it’s ironic that, where’s this inclusivity coming on the nonpregnancy world? Right? Nobody else is picking this up. Like, how are the nonpregnancy, male specialties dealing with transgender women? You know, I just feel like [this specialty is] a little bit of an easy target. Again, nothing to do with [needing] better inclusivity. But as we say, language is everything. And I go back to my question: Why do we have women’s health? I mean, people are talking about maybe we need to get rid of the word “gynecology.”

Why would that be? What is the argument for that?

Well, it’s a female, right? That is insight for, OK, this is how extreme this is going. And so we’re going to get rid of every term that means “female”?

Well, yeah, I am afraid to tell you that I’ve incorporated the use of the word “they” as a singular pronoun a lot more into my practice and my writing. And that change is probably something you might frown upon.

I think the interesting thing is, I think “they” is an appropriate pronoun for people who want to be called “they,” right? If you’re going to get rid of “she,” you have to also get rid of “he,” [and] then everybody becomes a “they.” But I think asking people what their pronouns are is important. He, she, they. And we all know people, I'm sure, who have a “they” pronoun, and it is awkward to use it. It really makes your mind sort of skip a beat when you’re trying to use it appropriately. But to change all of our language to “they”? I don’t know that it is helpful.

It begs the question, going back to what I think Dr Kilpatrick’s point is, in the rush for political correction and inclusiveness, are we not being thoughtful in areas such as this specialty? I mean, you look at the UN, where they had broadly attempted to make this change and any of the associations or societies that either of you deal with, what are the implications then for language evolution and what that means for categorizing all the different variants of a human being

Right. It’s amazing how quickly this has all happened. I mean, 2 major journals, 

 are both, [as well as] Diana Bianchi [MD, director of the Eunice Kennedy Shriver National Institute of Child Health and Human Development], [using] this now, this new language. And it’s like, really?

Let’s just think through the implications of all this and get focused on what we really want to do—which is, we want to show inclusivity. This is where I think symbols can be really helpful. I mean, churches do this, right? Churches, the Episcopal Church underneath, you’ll see the gay pride flag. They don’t have to write out all the words. There’s a symbol that “We welcome difference.” And I think that’s an easier place to go as we do the educational steps that we really need to do and as we make the medical system able to categorize people so they get the care they want and get called what they want, before you actually change all of the language. Because that’s a huge, huge, huge step. It’s really sort of, it’s very surprising, how quickly [it is happening].

There’s no doubt that trans people are facing discrimination all the time and violence, etc. But you know, so do women, all around the world. And when you think about that, and you’re taking away the term “woman” to replace with a term that’s friendly for trans—and you think about the difference in the proportion of people who fall into those groups—women face no less violence than trans people. So I think it’s just interesting how quickly this has all happened. Then it’s a train that looks like it’s going to be very impossible to stop.

And yet, we haven’t improved trans care. We haven’t improved inclusivity. Yet. Because we haven’t done the work that really needs to be done, [which is the granular work]. It’s really granular, and it’s really focused on our structural systems and on educating people.

I think the pendulum will keep swinging. The more we can have discussions like this, and get this out in the open, and have interested listeners in these conversations, the more we’re going to get it right—the more that it’s not going to be one group leading the discussion....We’re going to have the differences of opinion all get aired so we can get this right so that our patients can be well taken care of, so that we can reduce the barriers and biases and the things that all of our patients face to create barriers to good care.

So I’m just very thankful that we can have these open conversations, and I hope that people can listen to this with an open mind and a respectful heart and really try to understand all the intricacies with using language like this so that they can work to get it right. I know I learned a lot from having this discussion. And [it’s] helpful for me to chart the course and [how] our organization, and my own work, and how the various societies and professional organizations that I work with can do a good job at this.

I agree with all that, Chris. And as we started, I think we basically agree we just have a difference of opinion about the strategy to get there.

It’s interesting, too, to think about from the perspective of a medical office level. You don’t want those patients walking in—or not walking in at all—and not get the care that they deserve.

In this study of 41 patients, 17% delivered at home.1 That’s definitely understandable if you are afraid. This is a group of patients, even before pregnancy, even before they might be pregnant, who are cautious or afraid of the health care system already, so we definitely want to create an environment where they feel comfortable. And the other thing is, I think this is really a subspecialty group. A transgender man who’s pregnant brings complicated issues to the pregnancy, including how this may challenge their own mental health if they think of themselves as a man and yet they decided to stay pregnant or get pregnant. That is contradicting, I’m sure, in their mind [regarding] how they feel about themselves. So that whole aspect of their care really takes a care provider who is an expert in this

Chris, you and I have taken care of a pregnant patient who has got bad maternal cardiac disease. That’s rare, [but] we wouldn’t expect a general ob/gyn to be able to manage that patient fully. And in this context, there are not going to be that many people around the country because there are not that many pregnant transgender men. But you would expect that there would kind of be centers of excellence that people could contact to help them. Otherwise, that person won’t have all of their needs met as they come in, even if it’s a friendly office. They may be friendly—in that they don’t get shocked that a man walked in and he’s pregnant—but they may not understand the issues that are going on with respect to the rest of his life and how he feels about himself in this time. I think it’s also simplistic to think that by changing the name, we’re going to make every OB-GYN comfortable managing a patient [such as this].

The care has to be so individualized, and generalities aren’t going to take good care of the patients. Absolutely.

Light AD, Obedin-Maliver J, Sevelius JM, Kerns JL. Transgender men who experienced pregnancy after female-to-male gender transitioning. 

. 2014;124(6):1120-1127. doi: 10.1097/AOG.0000000000000540

Articles

The use of “pregnant woman” or “pregnant person” and their respective plurals is being debated within many levels of the medical world, including major journals, societies, and associations. When it comes to pregnancy, what noun should prevail, or should any? 

The meaning of a noun

Intrahepatic cholestasis of pregnancy (ICP) occurs in the second and third trimesters of pregnancy and is characterized by pruritus and elevated serum bile acid concentrations. Its incidence has been estimated to range from 0.3% to 15% in various populations, with most estimates from 0.3% to 0.5%.

 While ICP poses little risk for women, it does confer risk to the fetus. The persistence and intensity of associated pruritis are uncomfortable, and the increased risk of stillbirth is a significant concern to both patients and health care professionals.

What is the differential diagnosis of pruritis in pregnancy?

Pruritis is a common complaint in pregnancy.

 In ICP, itching is often generalized but predominantly affects the palms of the hands and the soles of the feet, is worse at night, and is generally not associated with a rash.

 The most frequent pathologic causes of pruritus specific to pregnancy include atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestationis, and ICP.

Q|How should a woman with pruritus in pregnancy be evaluated?

A detailed history and physical examination are imperative in making the diagnosis of ICP. In the process of taking the history and performing the physical examination, it is appropriate to consider and assess for other causes of pruritus without a rash 

. ICP should be considered in a woman who develops new-onset pruritus without a rash in the second half of pregnancy.

In evaluating a patient for other potential causes for pruritus, one should assess the onset, extent, severity, aggravating and alleviating factors, timing, medical history, medications (eg, narcotics), allergies, past medical/family history of atopy (eg, eczema, allergic rhinitis, asthma), amount of bathing, household contacts, pets, and travel history. Sexual history and any history of intravenous drug use should be assessed to ascertain the patient’s risk of hepatitis and HIV. A history of ICP in any prior pregnancies should be assessed as well.

Other significant signs and symptoms to assess include recent changes in weight, appetite, skin or eye color (jaundice), and sleep habits. Excessive fatigue, insomnia, malaise, and abdominal pain and colic are not common with ICP. If present, evaluation for other causes of pruritis and hepatic disease may be warranted.

The physical examination should assess for the presence of rashes, excoriations, papules, plaques, or bullae. Although ICP is not associated with a rash, the intensity of the pruritus can lead to the development of excoriations or prurigo nodularis, which may be mistaken for a rash.

 Dark urine and jaundice are not common with ICP and suggest other hepatic diseases.

Q|What laboratory evaluation is recommended for a pregnant woman with pruritis in whom ICP is suspected?

We recommend measurement of serum bile acid levels and liver transaminases in patients with suspected ICP (GRADE 1B).

 Mass spectrometry and liquid chromatography can evaluate for total and fractionated (cholic, chenodeoxycholic, and deoxycholic acid) bile acids. Total bile acids also can be assessed by enzymatic assay. Although the enzymatic assay does not provide fractionated bile acid levels, fractionated levels have limited utility, and the most clinically useful value is the total bile acid level.

The clinical diagnosis of ICP is based on pruritus symptoms and supported by the presence of elevated total serum bile acid levels and the absence of diseases associated with similar laboratory findings and symptoms. A serum total bile acid concentration of greater than 10 micromol/L often is used to diagnose ICP, although the data are limited and the diagnostic accuracy has been questioned.

 Increases in transaminases (eg, alanine aminotransferase and aspartate aminotransferase) can also sometimes be seen in ICP, although elevated transaminases are not necessary for the diagnosis. 

Although bile acid levels can be affected by a postprandial state, random bile acids can be used to diagnose ICP and are typically more convenient for the patient and practitioner than fasting bile acids. 

 lists other causes of ICP and elevated bile acid concentrations. Particularly in women with elevated bile acids before the second trimester of pregnancy, other etiologies should be considered.

Q|Are particular women or populations at risk for ICP?

Women with preexisting hepatobiliary disease are reported to be at higher risk for ICP. Patients with a history of ICP are at risk for recurrence. ICP has been associated with multiple gestations and advanced maternal age, and familial clustering of cases of ICP also suggests a genetic component.

 ICP likely results from both environmental and hormonal influences in women who are genetically susceptible.

Q|What are the complications of cholestasis of pregnancy?

ICP is associated with several adverse perinatal outcomes, including stillbirth, meconium-stained amniotic fluid, and preterm birth (both spontaneous and iatrogenic). Data suggest that the risk of stillbirth with ICP is associated with the total bile acid concentration,

 although some level of risk may still be present even with low bile acid concentrations.

Women with ICP and bile acid levels ≥40 micromol/L have been reported to have increased risks of adverse perinatal outcomes, including preterm birth, asphyxia or respiratory distress syndrome, and meconium-stained amniotic fluid.

 Increased rates of both indicated and spontaneous preterm birth are reported with ICP, with the incidence of prematurity varying greatly among studies. Pregnancies complicated by spontaneous preterm birth have been reported to have an earlier onset of pruritus, and the prevalence of spontaneous preterm birth increases with higher total bile acid concentrations.

 There also is evidence that patients with ICP are at increased risk for preeclampsia.

Q|What is the recommended treatment for cholestasis of pregnancy?

We recommend that ursodeoxycholic acid (UDCA) be used as the first-line agent for the treatment of maternal symptoms of ICP (GRADE

Three meta-analyses have summarized the data from randomized trials and have reported benefits in improving maternal symptoms.

 Compared with placebo or alternative agents (eg, cholestyramine or S-adenosyl methionine), UDCA is more effective in relieving pruritus and improving laboratory abnormalities and has no known adverse fetal effects. The typical starting dose for UDCA is 10 to 15 mg/kg per day, which can be divided into doses taken 2 or 3 times daily. Typical regimens are 300 mg taken 2 or 3 times daily or 500 mg twice daily. A decrease in pruritus usually is seen within 1 to 2 weeks. If pruritis is not relieved, the dose can be titrated to a maximum of 21 mg/kg per day. Biochemical improvement is usually seen within 3 to 4 weeks.

Alternative drugs, such as S-adenosyl methionine and cholestyramine, can be considered for patients who cannot take UDCA or have continued symptoms on the maximum dosage. It has been reported that rifampin can be combined with UDCA for refractory cases of ICP with improvement in pruritis.16 Antihistamines such as diphenhydramine or hydroxyzine also have been used for pruritis, although these may have limited benefit. Topical antipruritics (eg, menthol creams, calamine lotion) are also of limited use, given that itching is typically widespread. To date, none of these alternative treatments have been evaluated in randomized controlled trials.

Q|Is serial serum bile acid testing beneficial?

In patients with ICP, bile acid levels can increase during pregnancy and may increase rapidly near term. Given that higher serum total bile acid concentrations have been associated with adverse perinatal outcomes in some studies, repeat bile acid measurement has been suggested as potentially useful in guiding management. Follow-up laboratory testing may help guide delivery timing, especially in severe cases, but serial testing (eg, weekly) is not recommended.

Q|How should a pregnant woman with itching and normal bile acids be managed?

The pruritus in ICP can precede the rise in serum bile acids by several weeks. Therefore, if symptoms persist and no other explanation for pruritis exists, measurement of the total bile acid concentration and serum transaminases should be repeated. If UDCA is started empirically at the time testing is performed and before results are available, it is possible that elevated bile acid or transaminase levels may never be detected.

Q|Is antepartum testing indicated for patients with ICP?

We suggest that patients with a diagnosis of ICP begin antenatal fetal surveillance at a gestational age when delivery would be performed in response to abnormal fetal testing or at the time of diagnosis if the diagnosis is made later in gestation (GRADE 2C).

 The observed increased risk of stillbirth with ICP has prompted most practitioners to perform antenatal testing in this setting. However, the efficacy of antepartum fetal testing to prevent stillbirth in the setting of ICP is unknown. Several studies and case reports have reported stillbirth occurring within a few days of a reactive nonstress test.

 Antepartum fetal testing in ICP may not be useful because the mechanism of stillbirth is thought to be a sudden event rather than a chronic placental vascular process.

Recent clinical trials and meta-analyses support fetal surveillance with substantially lower rates of adverse perinatal outcomes compared with earlier reports, potentially due to more intensive monitoring with fetal surveillance and late-preterm or early-term delivery.

 The optimal frequency of testing is unknown and may be determined by criteria such as comorbidities or bile acid levels (eg, more frequent for total bile acid levels of 100 micromol/L or more). Due to the higher risk of stillbirth, patients with ICP should be placed on continuous fetal monitoring in labor.

Q| When should women with a diagnosis of cholestasis be delivered?

While the risk for late stillbirth is avoided with an early planned delivery, this must be weighed against risks to the neonate related to prematurity. The timing of delivery should be approached using risk stratification based on patient-specific factors, including total bile acid levels, in a shared decision-making model. 

We recommend that patients with total bile acid levels ≥100 micromol/L be offered delivery at 36 0/7 weeks of gestation, given that the risk for stillbirth increases substantially around this gestational age (GRADE 1B). We recommend delivery between 36 0/7 and 39 0/7 weeks of gestation for patients with intrahepatic cholestasis of pregnancy and total bile acid levels <100 micromol/L (GRADE 1C). 

Delivery timing for women with total bile acid levels <100 micromol/L should be individualized; it is reasonable for patients with bile acid levels of <40 micromol/L to be managed toward the later end of this time range, given the low risk for stillbirth seen in the studies referenced above, while women with total bile acid levels of ≥40 micromol/L should be considered for earlier delivery.

Delivery between 34 and 36 weeks of gestation can be considered in women with ICP, total bile acid levels of ≥100 micromol/L, and any of the following:

excruciating and unremitting maternal pruritus not relieved with pharmacotherapy;

a prior history of stillbirth before 36 weeks of gestation due to ICP with recurring ICP in the current pregnancy; or

preexisting or acute hepatic disease with clinical or laboratory evidence of worsening hepatic function.

Any patient delivered for ICP prior to 36 weeks of gestation should be extensively counseled about the absence of definitive evidence that the maternal and fetal benefits of delivery outweigh the potential morbidity of prematurity. 

We recommend antenatal corticosteroids for fetal lung maturity for patients delivered before 37 0/7 weeks of gestation if not previously treated (GRADE 1A).

For patients with early-term pregnancies (37 to 38 weeks of gestation) with pruritis suggestive of ICP, no rash, and no bile acid results yet available to confirm the diagnosis, management should be based on shared decision-making that involves a discussion of the uncertainty of the diagnosis, the risks of ICP vs early-term delivery, and the values and preferences of the patient. 

Diagnostic certainty, and thus advice about delivery management, is improved if there are elevated transaminases or a history of ICP in prior pregnancies, and it may be reasonable to deliver in the absence of bile acid results in these situations. 

We recommend against preterm delivery at <37 weeks of gestation in patients with a clinical diagnosis of ICP without laboratory confirmation of elevated bile acids (GRADE 1B).

The risk of recurrence of ICP in subsequent pregnancies may be as high as 90%, although data are insufficient to counsel patients on specific ranges.

 Some data also suggest that patients with a history of ICP are at higher risk for developing later hepatobiliary disease, particularly within the first year after the diagnosis of ICP. Given the risk for hepatitis C in these patients and the availability of an effective treatment, some experts advocate for routine testing for hepatitis C in patients with ICP.

It is important to consider reevaluation of liver function test results after delivery in patients with persistent pruritis or other signs or symptoms of a hepatobiliary disease, such as right upper quadrant pain or jaundice. If serologic study results remain abnormal, the patient should be referred to a liver specialist for evaluation for another underlying condition. 

1.Wikström Shemer E, Marschall HU, Ludvigsson JF, Stephansson O. Intrahepatic cholestasis of pregnancy and associated adverse pregnancy and fetal outcomes: a 12-year population-based cohort study. BJOG 2013;120:717-23.

2.Kenyon AP, Tribe RM, Nelson-Piercy C, et al. Pruritus in pregnancy: a study of anatomical distribution and prevalence in relation to the development of obstetric cholestasis. Obstet Med 2010;3:25-9.

3.Bechtel MA, Plotner A. Dermatoses of pregnancy. Clin Obstet Gynecol 2015;58:104-11.

4.Ambros-Rudolph CM, Glatz M, Trauner M, Kerl H, Müllegger RR. The importance of serum bile acid level analysis and treatment with ursodeoxycholic acid in intrahepatic cholestasis of pregnancy: A case series from central europe. Arch Dermatol 2007;143:757-62.

5.Egan N, Bartels A, Khashan AS, et al. Reference standard for serum bile acids in pregnancy. BJOG : 2012;119:493-8.

6.Manzotti C, Casazza G, Stimac T, Nikolova D, Gluud C. Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev 2019;7:Cd012546.

7.Pataia V, Dixon PH, Williamson C. Pregnancy and bile acid disorders. Am J Physiol Gastrointest Liver Physiol 2017;313:G1-g6.

8.Brouwers L, Koster MP, Page-Christiaens GC, et al. Intrahepatic cholestasis of pregnancy: maternal and fetal outcomes associated with elevated bile acid levels. Am J Obstet Gynecol 2015;212:100 e1-7.

9.Kawakita T, Parikh LI, Ramsey PS, et al. Predictors of adverse neonatal outcomes in intrahepatic cholestasis of pregnancy. Am J Obstet Gynecol 2015;213:570 e1-8.

10.Cui D, Zhong Y, Zhang L, Du H. Bile acid levels and risk of adverse perinatal outcomes in intrahepatic cholestasis of pregnancy: A meta-analysis. J Obstet Gynaecol Res 2017;43:1411-20.

11.Ovadia C, Seed PT, Sklavounos A, et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet 2019;393:899-909.

12.Williamson C, Hems LM, Goulis DG, et al. Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group. BJOG 2004;111:676-81.

13.Bacq Y, Sentilhes L, Reyes HB, et al. Efficacy of ursodeoxycholic acid in treating intrahepatic cholestasis of pregnancy: a meta-analysis. Gastroenterology 2012;143:1492-501.

14.Gurung V, Middleton P, Milan SJ, Hague W, Thornton JG. Interventions for treating cholestasis in pregnancy. Cochrane Database Syst Rev 2013;2013:Cd000493.

15.Kong X, Kong Y, Zhang F, Wang T, Yan J. Evaluating the effectiveness and safety of ursodeoxycholic acid in treatment of intrahepatic cholestasis of pregnancy: A meta-analysis (a prisma-compliant study). Medicine (Baltimore) 2016;95:e4949.

16.Liu J, Murray AM, Mankus EB, Ireland KE, Acosta OM, Ramsey PS. Adjuvant Use of Rifampin for Refractory Intrahepatic Cholestasis of Pregnancy. Obstet Gynecol 2018;132:678-81.

17.Alsulyman OM, Ouzounian JG, Ames-Castro M, Goodwin TM. Intrahepatic cholestasis of pregnancy: perinatal outcome associated with expectant management. Am J Obstet Gynecol 1996;175:957-60.

18.Herrera CA, Manuck TA, Stoddard GJ, et al. Perinatal outcomes associated with intrahepatic cholestasis of pregnancy. The Journal of Maternal-Fetal & Neonatal Medicine 2018;31:1913-20.

19.Lee RH, Incerpi MH, Miller DA, Pathak B, Goodwin TM. Sudden fetal death in intrahepatic cholestasis of pregnancy. Obstet Gynecol 2009;113:528-31.

20.Sentilhes L, Verspyck E, Pia P, Marpeau L. Fetal death in a patient with intrahepatic cholestasis of pregnancy. Obstet Gynecol 2006;107:458-60.

21.Chappell LC, Bell JL, Smith A, et al. Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet 2019;394:849-60.

22.Wijarnpreecha K, Thongprayoon C, Sanguankeo A, Upala S, Ungprasert P, Cheungpasitporn W. Hepatitis C infection and intrahepatic cholestasis of pregnancy: A systematic review and meta-analysis. Clin Res Hepatol Gastroenterol 2017;41:39-45.

Intrahepatic cholestasis of pregnancy (ICP) occurs in the second and third trimesters of pregnancy and is characterized by pruritus and elevated serum bile acid concentrations.

Society for Maternal-Fetal Medicine Consult Series #53: Intrahepatic Cholestasis of Pregnancy

Experts debate the use of "pregnant women" and "pregnant persons." 

Listen Now: Building and Sustaining a Gender-Affirming Medical Care Environment

Videos

Join Senior Editor Angie DeRosa as Sarah J. Kilpatrick, MD, PhD; and Christian M. Pettker, MD debate noun use. 

Board Members Debate Noun Use: Pregnant Woman or Pregnant Person? 

As obstetricians we commit ourselves to a job that consists mostly of bringing life to the world. These celebrations offer such joy in our work. Less often we are shepherds of loss. We help a couple through miscarriage or stillbirth and support families with the loss of a newborn, for example. These moments are most devastating for patients and their families, but they are also full of grief for us. We are never prepared for, nor do we completely recover from, the loss of a mother. Mothers are young. Mothers are the foundations of a family. Most of the time, the loss of a mother is sudden and unexpected. It leaves an empty space unlike any other. Most obstetricians can recite the names of every mother we helped take care of, but lost.

’s maternal mortality series and to share our experiences. When we were asked to write, we accepted without a second thought; it is easy to write about people we think about on most days. We hope that reflecting on these lives and how we have been changed by them can help our colleagues reflect on their own experiences. We also aim to help motivate a movement to improve efforts to prevent maternal mortality. Our reflection on these cases cannot dwell purely on the profound sadness of it all or how we might have wanted it to go differently. From each case we need to grow and change and get better for the next woman that comes through our door.

During a low point in training, during a time of loss, one of our mentors offered important words of encouragement in this context: “You will be changed by this event. You will either be better from it, or worse from it. But you are the one who chooses which it will be.” In trying to make things better, and in a spirit of fellowship for our colleagues reading this, we are sharing our stories. 


We paused in the hallway halfway between triage and the operating room (OR), so she could kiss her kids. “We will take good care of her,” I remember saying to the two scared, sleepy looking faces. They were in pajamas and attached to their dad. One was about a year younger than my daughter and one was about a year older. 

“She lost a lot of blood,” her husband said again. I nodded, said “I know” and tried to sound reassuring. “We have blood on the way, but the most important thing right now is that we get her into the operating room.” And off we went. It was 5:45 am.

By the time the case started, I had two chiefs operating with me. Thank goodness for change of shift. We worked quickly to get in, acutely aware of how quickly blood was coming out from below. The woman was scheduled to be seen for the first time the next day by maternal-fetal medicine (MFM), but I knew at minimum she had a bleeding previa and two prior cesareans. Anesthesia was transfusing, the cell saver was being assembled, oncology was on their way, my back-up was coming. I was supported. This was the way it was supposed to work. 

Yet despite my amazing team, a very prepared hospital, and my years of training, 90 minutes later I was giving chest compressions. And despite a trauma surgeon, two gynecologic oncologists, and a critical care boarded MFM all by my side, a few minutes after 8 am, I was telling that scared man, now father of three, that he was a single parent. 

Six hours later, after debriefing with the many residents, nurses, and specialists who shared in this tragedy with me, I was back home. My family was the same, my house was the same, but nothing would ever be quite the same. I took a healthy young woman into the OR to deliver her baby and she died on my OR table in my care. 

As I learned more about my patient in the days that followed her death, from the neonatal intensive care unit doctors who took care of her 32-weeker, from hospital staff who knew her as a friend, and from her family who spoke at her funeral, I was bothered most by the fact that we did not have the chance to know one another. I hated that our entire patient-doctor relationship was defined by that night. I wanted her to know the kind of doctor I was. I wanted the opportunity to answer her questions and concerns. I wanted to reassure her that even in the brief moments we had together, I understood how much she loved her children, and I would have done anything to have her case end differently. I wanted then and now to be able to reach out to her family, to see her kids, to tell them in person how sorry I was.  And yet because of the Health Insurance Portability and Accountability Act, the medical legal system, and perhaps most importantly because of a brief moment of eye contact between her husband and me at the funeral, I have stayed away. I am a caregiver but I continue to care in this instance in silence. 

Now almost a decade out from this tragedy, I continue to think about this woman, her daughter, and her family almost every day. In the early years, what used to surprise me most was that I barely knew this woman or her family and yet I thought about them not only at work when I was counseling, operating, and teaching, but at home when I was tucking my kids in, laughing with my husband, or admiring a sunrise. As the years have passed, I have become more comfortable with how frequently my thoughts drift to her and her family. Her story has become part of my story even though our endings were so different. 

For my part, I have been exceptionally lucky. This tragedy could have led to self-doubt and a disdain for the uncertainty and powerlessness of obstetrical care. Perhaps because of the amazing team who got me through that night, I continue to believe that I kept my promise and that we took good care of this mom. I continue to love obstetrics, especially the most challenging deliveries, which push us all to be better. I will forever feel vulnerable because of that night, but I feel honored to be with families at these most dangerous and intimate moments.


She came to our practice after finding out the worst and best information a woman can hear. A neurologist told her the bad news that she had suspected: Her symptoms indeed were signs that the disease that took her mother would also slowly but soon take her life, too. At the same time, she found out she was pregnant. The neurologist and our MFM team were uncertain if she would live through her pregnancy. She was certain she would try. She wanted to be a mother, she wanted her husband to be a father, and she wanted to give life to her child.

With her first visit to our practice she set into motion a transformation of our service. We spent weeks coordinating her care and planning her admission. We assembled all of the specialists and all of the nursing units for regularly scheduled morning meetings planning for her pregnancy. At a certain point she and her husband wanted to join the meetings. Despite our trepidation at this request, based on a paternalistic fear that we would have trouble discussing openly some of the scarier parts of her care, we accepted this challenge. And together we planned for the joy of birth but also for all of the frightening moments she might encounter to get there.  

We took care of the woman for four months in the hospital-she was in the ICU all of those days-progressively losing her strength to move, talk, and breathe. With each week we added another specialty to our meetings, to support her feeding or to plan her tracheostomy and ventilator management. But at the same time, we tried to commit to all of the normal aspects of childbirth, too. Our lactation team visited her in the third trimester to discuss her plans for breastfeeding.  The labor and maternity nurses threw her a baby shower in the intensive care unit. One of my highest honors as an obstetrician was to be invited; it remains, and will probably always be, the only baby shower I have attended. She was committed to becoming well again and having as normal an experience as possible. She believed there would be a cure for her disease in her lifetime.

Her plan was for a vaginal birth and despite her weakness we believed it was medically possible. At term, when we found out that her baby was in breech presentation, she requested an external cephalic version. We tried, but failed, and she ended up with a cesarean that included skin-to-skin, breastfeeding, and rooming-in, even in the ICU.  She left the hospital with her husband and her baby, to go live and die at home.

She was able to see her child’s first birthday. As a result, she avoided becoming a “maternal mortality” “pregnancy-related death” statistic. Admittedly, when we talk about efforts to reduce maternal mortality we are not talking about preventing cases like this.  But despite all we were able to do for her, those who took care of this family experienced profound loss because she did not live long enough. For me and my colleagues, years later even, this still has all of the sadness of a maternal loss.

All the way through the end, she felt blessed and had no regrets. I think she knew how much she touched and influenced each of her caregivers.  Her courage and strength were something that built strength in our hospital’s service and made us so much better at taking care of complicated patients. Our introspection on her care and her life was important for our thinking about how to build a patient-centered destination hospital for the highest-risk pregnancies. Realizing how often complex patients at our hospital could be helped by this level of coordination, this work became a regularly occurring meeting that continues monthly to this day. What she started for us continues to amaze me. New specialties join our meetings all the time, though this is hardly challenging in a tertiary care center. It is when a family member, a church leader, an attorney, a conservator, or a patient joins us for these meetings that I am convinced we would not be meeting our patients’ true needs if our patient had not blessed us with her experience.

I think about her regularly. Certainly, each meeting of the Proactive Care group generates memories of our first meetings working together. But I also think about her every time I work harder to support a vaginal birth or the breastfeeding goals of a woman who faces smaller but still important challenges related to her medical problems or social issues. Most of all, I think of her strength and courage and her commitment to getting better in the face of her inevitable death. This makes me stronger, too.

Two physicians recount their experiences of losing a patient.

Memorials to two mothers

Obstetricians have been trying to link the fetal heart rate (FHR) with fetal health since the invention of the modified stethoscope by Pinard in the 1870s. Practical application of intrapartum FHR assessment, however, required the development of an electronic fetal monitoring (EFM) system based on the fetal ECG by Drs. Edward Hon and Orvan Hess at Yale in the late 1950s. Their discovery allowed for precise estimations of FHR baselines and periodic changes in a continuous fashion. Within a decade, clinicians throughout the United States had adopted EFM.

Unfortunately, the inconvenient truth about EFM is that it was introduced before its efficacy could be confirmed by hard-core research. Developed primarily to reduce the occurrence of cerebral palsy (CP) and intrapartum stillbirth, its value in preventing these outcomes has never been proven. In fact, it’s the secondary benefit of fetal monitoring-providing a convenient way to supervise several patients at one time-and our fear of litigation that are the primary reasons it survives. So EFM remains perhaps the most prominent example of universal adoption of a medical technology before its verification.

The shortcomings of electronic FHR monitoring 

The available data suggest that continuous intrapartum EFM does not perform much better than the intermittent auscultation of Pinard. A Cochrane meta-analysis that included over 37,000 patients, for instance, concluded that while its application cut neonatal seizures in half (RR 0.50; 95% CI, 0.31–0.80), it failed to affect perinatal mortality or CP rates. The same meta-analysis also revealed that continuous EFM increased cesarean (RR 1.16; 95% CI, 1.01–1.32) and operative vaginal (RR 1.16; 95% CI, 1.01–1.32) deliveries. In fact, as ACOG reports, the false-positive rate of EFM for CP exceeds 99%, with as few as 1 to 2/1,000 fetuses with nonreassuring patterns developing CP.

The specificity of EFM may be improved with fetal scalp stimulation and scalp pH. A heart rate acceleration stimulated by digital pressure on the fetal scalp is highly correlated with a normal fetal pH (negative likelihood ratio 0.08; 95% CI, 0.02–0.41), although its absence is not always associated with acidosis in the setting of a worrisome tracing. Scalp pH testing can be employed at this point with a value of <7.20 (mixed venous) typically used as an indication for delivery, although its use appears to be rapidly decreasing across the country. 

Because of the false-positive rates of these approaches, additional methods of assessing fetal status in labor have been introduced under more rigorous testing, with mixed results. Fetal pulse oximetry has been compared to EFM in several clinical trials but the research to date shows no difference in overall cesarean delivery rates, although fewer of them were performed for nonreassuring fetal status (RR 0.68; 95% CI, 0.68–0.99). These studies also didn’t show differences in any maternal or neonatal outcomes. More promising is the STAN fetal heart monitor, an FDA-approved device that takes Dr. Hon’s original technology of monitoring the fetal ECG and uses specialized software to examine specific changes in the ECG related to fetal hypoxemia. Its use is suggested only in higher-risk patients who are likely to develop metabolic acidosis, rather than as a substitute for standard EFM. The most recent Cochrane review of STAN, which incorporated nearly 10,000 patients, showed reduced rates of metabolic acidosis and neonatal encephalopathy as well as operative vaginal deliveries without influencing cesarean rates.

Unfortunately, none of these tests has proven to be universally applicable and traditional EFM is here to stay. With this in mind, we are pressed to improve EFM interpretation to increase its usefulness and accuracy. The NIH/NICHD recognized this in 1997 and convened a workshop to provide a consensus on definitions related to EFM interpretation.This publication standardized terms for baseline rates (normal, tachycardia, bradycardia), variability, accelerations, decelerations, and contraction patterns. In our opinion, these guidelines provided a common interpretation paradigm-a way to speak a common language. Many institutions, including our own, mandated the use of the NICHD criteria on their L&D floors and through credentialing examinations for all providers involved in inpatient care of pregnant patients. However, the 1997 criteria had its limitations; for instance, it did not clarify the terms “reassuring” or “nonreassuring” or clearly explain the appropriate management for abnormal patterns. 

In April 2008, the NICHD directed a second workshop to revisit its 1997 recommendations; updated definitions and interpretation standards were published in September 2008.Here are some of the key points: 

 GENERAL CONSIDERATIONS included highlighting the dynamic and contextual nature of EFM interpretation. The authors stressed that a particular assessment is only limited to its specific time period. The workshop also emphasized the poor positive predictive value of EFM: While the presence of accelerations and/or variability reliably predicts the absence of fetal metabolic acidemia, the absence of accelerations and/or variability does not predict acidemia. 

UTERINE CONTRACTIONS are now quantified as the number of contractions present in a 10-minute window, averaged over 30 minutes, with normal representing five or fewer contractions in 10 minutes and tachysystole meaning five or more contractions in 10 minutes. The terms hyperstimulation and hypertonus, which are referred to in ACOG Practice Bulletin No. 70, are discouraged. 

 if they occur with 50% or more of uterine contractions in any 20-minute window and as 

 if they occur with less than 50% of uterine contractions in any 20-minute window. Otherwise the same definitions for early, late, and variable decelerations as well as normal FHR baseline and variability remain. 

A THREE-TIER INTERPRETATION SYSTEM was introduced in 2008 to aid in reading, communicating, and managing FHR tracings:

 a. CATEGORY I (NORMAL): Strongly predictive of normal fetal acid-base status; may be followed in a routine manner. These tracings include 

▶ baseline rate 110–160 bpm ▶ moderate variability ▶ absent, late, or variable decelerations ▶ early decelerations may or may not be present ▶accelerations may or may not be present   b. CATEGORY II (INDETERMINATE): Not predictive of abnormal fetal acid-base status but require evaluation, continued surveillance, and reevaluation, taking into account the clinical context.

 c. CATEGORY III (ABNORMAL): Predictive of abnormal fetal acid-base status; require prompt evaluation and management. Include either: 

▶ absent baseline FHR variability with: 

The best way to learn these categories is to learn the definitions of I and III; all other tracing types fall into category II’s grey zone. In reality, a large proportion of tracings are neither ‘reassuring’ nor ‘nonreassuring.’ In fact, the time may have arrived for us to abandon these terms. In the first place, using two systems and five terms can only make interpretation and communication confusing. Moreover, the new tripartite system allows more ‘wiggle room’ by creating a category that neither connotes normality nor mandates immediate delivery. 

It is left to the caregiver to decide upon appropriate management of category II tracings but category III tracings warrant prompt delivery. It is also unclear how the legal profession will view the change in language given their frequent misuse of the terms ‘reassuring’ and ‘nonreassuring.’ 

We hope that these new guidelines will improve communication on L&D and applaud the efforts of the workshop to continue the discourse on EFM. We encourage you to learn these new definitions and incorporate them into your practice as they become a standard of care. It’s clear, however, that we need more technology and research to improve our assessments of fetal health in labor. While improving the way we talk about fetal assessment is good, finding a better tool for such assessment would be better. ◀

DR. PETTKER is Assistant Professor, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, and Medical Director of the Labor and Birth Unit, Yale-New Haven. DR. LOCKWOOD, Editor in chief, is Anita O’Keefe Young Professor and Chair, Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, CT. 

Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev. 2006;(3):CD006066. doi:10.1002/14651858.CD006066. 

American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 70. Intrapartum fetal heart rate monitoring. Obstet Gynecol. 2005;106:1453-1460. 

Skupski DW, Eglinton GS. Intrapartum fetal stimuluation tests: a meta-analysis. Obstet Gynecol. 2002;100:830. 

East CE, Chan FY, Colditz PB, et al. Fetal pulse oximetry for fetal assessment in labour. Cochrane Database Syst Rev. 2007;(2): CD004075. doi:10.1002/14651858.CD004075. 

Neilson JP. Fetal electrocardiogram (ECG) for fetal monitoring during labour. Cochrane Database Syst Rev. 2006;(3):CD000116. doi:10.1002/14651858.CD000116. 

Electronic fetal heart rate monitoring: research guidelines for inter-pretation. National Institute of Child Health and Human Development Research Planning Workshop. Am J Obstet Gynecol. 1997;177:13851390. 

Macones GA, Hankins GD, Spong CY, et al. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring: update on definitions, interpretation, and research guidelines. Obstet Gynecol. 2008;112:661-666. 

The NIH/NICHD has released new guidelines on electronic fetal heart rate assessment. Two experts summarize the new standards and explain their value.

Opinion: New FHR monitoring standards: Something old and something new

The shortcomings of electronic FHR monitoring							

The specificity of EFM may be improved with fetal scalp stimulation and scalp pH. A heart rate acceleration stimulated by digital pressure on the fetal scalp is highly correlated with a normal fetal pH (negative likelihood ratio 0.08; 95% CI, 0.02–0.41), although its absence is not always associated with acidosis in the setting of a worrisome tracing.

  Scalp pH testing can be employed at this point with a value of <7.20 (mixed venous) typically used as an indication for delivery, although its use appears to be rapidly decreasing across the country. 

Because of the false-positive rates of these approaches, additional methods of assessing fetal status in labor have been introduced under more rigorous testing, with mixed results. Fetal pulse oximetry has been compared to EFM in several clinical trials but the research to date shows no difference in overall cesarean delivery rates, although fewer of them were performed for nonreassuring fetal status (RR 0.68; 95% CI, 0.68–0.99).

  These studies also didn't show differences in any maternal or neonatal outcomes. More promising is the STAN fetal heart monitor, an FDA-approved device that takes Dr. Hon's original technology of monitoring the fetal ECG and uses specialized software to examine specific changes in the ECG related to fetal hypoxemia. Its use is suggested only in higher-risk patients who are likely to develop metabolic acidosis, rather than as a substitute for standard EFM. The most recent Cochrane review of STAN, which incorporated nearly 10,000 patients, showed reduced rates of metabolic acidosis and neonatal encephalopathy as well as operative vaginal deliveries without influencing cesarean rates.