Intrapartum electronic fetal monitoring (EFM) is used for most women who give birth in the United States. As such, clinicians are faced daily with the management of fetal heart rate (FHR) tracings. The purpose of this document is to provide obstetric care providers with a framework for evaluation and management of intrapartum EFM patterns based on the new three-tiered categorization.

This American College of Obstetricians and Gynecologists practice bulletin was published following a 2008 workshop that updated electronic fetal monitoring (EFM) nomenclature and recommended the use of a 3-tiered system for evaluation and management of intrapartum EFM patterns.¹ The new terminology includes the use of the term tachysystole in patients with more than 5 contractions in 10 minutes, averaged over 30 minutes. Fetal heart rate (FHR) tracings with tachysystole should be categorized by the presence or absence of FHR decelerations. The terms hyperstimulation and hypercontractility were abandoned.¹ The 3 categories of FHR tracings may be defined as follows: Category I FHR tracings are normal and are not associated with fetal acidemia (Box 1 in the original article). Category II FHR tracings include all FHR patterns that are not classified as category I or category III (Box 1). Category II tracings “require evaluation, continued surveillance, initiation of appropriate corrective measures when indicated, and reevaluation.” Category III tracings are abnormal and signal “an increased risk for fetal acidemia at the time of observation”; these tracings have been associated with an increased risk for neonatal encephalopathy, cerebral palsy, and neonatal acidosis. Category III tracings are defined in Box 1. Persistent category III tracings “most often require prompt delivery.”