BJA Education, 17 (12): 406–411 (2017)

doi: 10.1093/bjaed/mkx034
Advance Access Publication Date: 27 September 2017
Matrix reference
1A01, 2A04, 3J02

Intrapartum assessment of fetal well-being

Gayani Jayasooriya, MBBS BSc (Hons) FRCA1,* and

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Veronica Djapardy, MA BMBCh MRCOG2
1
Speciality Registrar ST6, Imperial School of Anaesthesia, Queen Charlotte’s and Chelsea Hospital, Imperial
College Healthcare NHS Trust, Du Cane Road, London W12 0HS, UK and 2Consultant Obstetrician and
Gynaecologist, Queen Charlotte’s and Chelsea Hospital, Imperial College Healthcare NHS Trust, Du Cane
Road, London W12 0HS, UK
*To whom correspondence should be addressed. Tel: þ44 7894 829434; Fax: þ44 203313 5373; E-mail: gayani.jayasooriya@gmail.com

Physiology of the fetal heart rate

Key points
• Despite electronic intrapartum monitoring of the
fetal heart rate being firmly established in clinical
practice it is experiencing rising levels of scrutiny
as a sole decision tool in labour.
• Interpretation of the cardiotocograph requires a
systematic approach, with an appreciation of
clinical context.
• The National Institute for Clinical Care Excellence
(NICE) and other institutions worldwide have pro-
duced guidelines to aid classification of the
cardiotocograph.
• Inter and intra-observer variation exists when
interpreting findings of the cardiotocograph.
• Adjunctive techniques to enhance clinical decision
making during labour are constantly evolving.
National guidelines for cardiotocograph (CTG) interpretation
have undergone significant changes in the past decade, and
their role in predicting fetal well-being and outcomes has come
under increasing scrutiny.1,2 Accordingly, a survey endorsed by
the Obstetric Anaesthetists’ Association in 20163 revealed a de-
sire for continued education in interpretation of the CTG. This
article will briefly refresh the physiology of fetal heart rate con-
trol, principles of CTG interpretation, its place in current evi-
dence-based practice, and expand on complementary and
emerging techniques of assessing fetal well-being in labour.
Mechanisms of fetal heart rate control include the sinoatrial and
atrioventricular nodes and cardiac conducting tissue. The fetal
parasympathetic nervous system reaches maturity by term,
whereas sympathetic nervous system development is still on-
going. As pregnancy progresses, this maturation of vagal innerv-
ation manifests as a decline in resting fetal heart rate and an
increase in baseline variability. This has implications for the inter-
pretation of fetal heart rate patterns at varying gestations. Other
factors networked in fetal heart rate control include baroreceptors,
chemoreceptors, circulating catecholamines, and other endocrine
factors.4 Thus, fetal heart rate is predominantly a product of the in-
tricate balance of the autonomic nervous system, with influences
extrinsic to the heart, such as humoral factors, also playing a role.
Relationship of fetal hypoxia and acidosis to fetal heart
rate
The fetus is conditioned to thrive in a mildly hypoxic and acidic
environment. Oxygen exchange between the mother and the
fetus is facilitated by this relative gradient. The insufficient
supply of oxygen leads to changes in fetal pH- which then sub-
sequently results in signs of distress in the fetus. One such sign
is a change in fetal heart rate, caused by the impact of hypoxia
and acidosis on the control mechanisms outlined above.4 Thus,
the premise of electronic fetal monitoring (EFM) rests on the as-
sumption that fetal heart rate is a reflection of fetal oxygenation
status.
Causes of fetal hypoxia and acidosis
Correct functioning of the fetomaternal circulation, utero-
placental exchange, and fetal factors have implications for fetal

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406

oxygenation. Any inadequacy of these factors may cause fetal
compromise, which will be exaggerated in labour, where with
every uterine contraction a period of reduced uteroplacental
perfusion ensues.
History and rationale of intrapartum fetal
assessment
The purpose of intrapartum fetal heart rate monitoring is to de-
tect episodes of hypoxia and prevent neonatal morbidity and
mortality. Intermittent auscultation was used as early as the
1800s for evaluating fetal well-being, and the criteria for fetal
distress were established by the mid-1850s.4
Routine use of EFM began in the 1970s to prevent conse-
quences of hypoxia, such as cerebral palsy or hypoxaemic en-
cephalopathy, despite a paucity of efficacy data.2 Although the
rates of these complications have declined, there is very little
evidence to suggest that this has been as a direct result of EFM.
Does it improve fetal outcome?
A Cochrane review5 concluded that compared with intermittent
auscultation, continuous CTG showed no significant difference
in perinatal death and cerebral palsy rates. There was a reduced
neonatal seizure rate with CTG use, but the relationship of early
neonatal seizures to long-term disability is not well established.
It is worth noting that most studies in the review were con-
ducted before the early 1990s and only two were considered
high quality. The authors also comment on an increased likeli-
hood of intervention with CTG. As surgical delivery is known to
increase risks to mothers in both the short term and the long
term, this raises questions about the risk–benefit equilibrium of
CTG monitoring.
Importantly, no trial to date has compared CTG with no
monitoring. This alludes to the fact that monitoring fetal well
being in labour by some means is now considered standard
practice, which would seem unethical to deny to a parturient.
This disconnect of current ‘best evidence’, with perceived
benefit in observational practice, compounded by costs of negli-
gence claims in maternity care,2,6 perpetuates the ubiquitous
Fig 1 Image of CTG monitor and routinely recorded parameters, including fetal heart rate, maternal heart rate, and strength and frequency of uterine contractions.
Intrapartum assessment of fetal well-being
nature of EFM. The answer to best practice may lie in the meas-
ured use of this technology, a standardized approach to defin-
ition and interpretation, combined with complementary
techniques to provide context–in fact, as some authors suggest, a
complete overhaul of the way CTGs are interpreted1 or, at the
very least, the abandonment of this technique as a root cause of
litigation.2,7
Intrapartum fetal monitoring in low-risk
labour
National Institute for Health and Care Excellence (NICE) guide-
lines8 suggest that with the high false-positive rate of CTG, its
role in low-risk labour is not established. Here, it advocates the
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use of intermittent auscultation (pinard or hand-held Doppler)
at specific intervals, with the aim of escalating monitoring if
concerning features arise.
Intrapartum fetal monitoring in labour with
risk factors
A Doppler ultrasound transducer and pressure transducer are
placed on the maternal abdomen, which monitor fetal heart
rate and the frequency and strength of uterine contractions, re-
spectively. These variables are then plotted against time on
graph paper (Fig. 1).
Indications
NICE has recently updated the list of risk factors that warrant
continuous CTG during labour to include oxytocin use and the
establishment and maintenance of regional anaesthesia.8
Assessment and interpretation
The assessment and interpretation of CTGs require a simple,
systematic approach. The fetal heart rate is assessed for four
features (Table 1) before categorizing the overall impression of
the trace. Various systems exist;9,10 however, here, we will
BJA Education | Volume 17, Number 12, 2017 407
Intrapartum assessment of fetal well-being

Table 1 Description of cardiotocograph features. NICE guideline on intrapartum care for healthy women and babies.8 *Regard the following as
concerning characteristics of variable decelerations: lasting more than 60 s; reduced baseline variability within the deceleration; failure to re-
turn to baseline; biphasic (W) shape; no shouldering (shouldering is a brief increase in fetal heart rate from baseline immediately before and
after a deceleration, thus giving the deceleration the appearance of having ‘shoulders’). †Although a baseline fetal heart rate between 100 and
109 beats min1 is a non-reassuring feature, continue usual care if there is normal baseline variability and no variable or late decelerations

Features Baseline Baseline variability Decelerations

of CTG (beats min1) (beats min1)

Reassuring 110–160 5–25 • None or early

• Variable decelerations with no concerning characteristics*
<90 min
Non-reassuring 100–109† <5 for 30–50 min • Variable decelerations with no concerning characteristics*
OR OR 90 min
161–180 >25 for up to 15–25 min OR
• Variable decelerations with any concerning characteristics* in

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up to 50% of contractions for 30 min
OR
• Variable decelerations with any concerning characteristics* in
over 50% of contractions <30 min
OR
• Late decelerations in over 50% of contractions for <30 min, with
no maternal or fetal clinical risk factors such as vaginal bleed-
ing or significant meconium
Abnormal Below 100 <5 for more than 50 min • Variable decelerations with any concerning characteristics* in
OR OR over 50% of contractions for 30 min (or less if any maternal or
Above 180 >25 for more than 30 min fetal clinical risk factors)
OR OR
Sinusoidal • Late decelerations for 30 min (or less if any maternal or fetal
clinical risk factors)
OR
• Acute bradycardia or a single prolonged deceleration lasting
3 min or more

discuss the classification system in the 2014 NICE Guidance according to their shape, duration, and timing in relation to
(updated 2017).8 contractions.

Baseline rate Early decelerations

Normal fetal heart rate at term is 110–160 beats min1. The base-
line is judged by looking at the mean heart rate over 10 min. A rate
>160 beats min1 is classified as a tachycardia and a rate <110
beats min1 a bradycardia. Differentiating fetal heart rate from
maternal heart rate is considered good practice (Figs 2 and 3).8
Early decelerations are uniform in shape and mirror the con-
traction. Thought to be a result of fetal head compression dur-
ing a contraction, they should recover with relaxation of the
uterus. Early decelerations are considered normal findings in
labour.

Variability
Variability refers to minor fluctuations in baseline fetal heart
rate, which can be irregular in amplitude and frequency (Fig. 2).
A normal variability is 5–25 beats min1 and is measured from
the peak to a trough of a recording during 1 min. A variability <5
beats min1 is reduced variability, whereas >25 beats min1 is
marked variability. Both extremes are associated with fetal hyp-
oxic states and innocuous states, e.g. quiescence/sleep (reduced
variability) or thumb sucking (marked variability).
Persistent absence of variability is considered a pre-terminal
feature and carries with it high probability of a hypoxic fetus.
Sinusoidal variability is an oscillating pattern of three to five
cycles per minute, which may indicate fetal anaemia or severe
fetal hypoxia. However, similar patterns may present transi-
ently in forceful thumb sucking (pseudo-sinusoidal).
Decelerations
These are transient reductions in fetal heart rate (>15 beats min1
reduction for at least 15 s), which can be further subdivided
Late decelerations
Although uniform and gradual in shape, they have a trough
that occurs following the peak of a contraction (Fig. 3). These
are a possible sign of reduced fetal oxygenation.
Variable decelerations
These show a more sudden, steep reduction in fetal heart rate
and are considered a sign of fetal hypoxia. The morphology of
one deceleration may vary from the next, thus giving rise to its
nomenclature. They can be further classified as uncomplicated
(<60 s) or complicated (>60 s).
Prolonged deceleration
Any deceleration lasting more than 3 min falls into this category
and usually prompts urgent delivery of the fetus (Fig. 3).
Updated NICE guidance advises avoiding terminology such
as typical and atypical as it can be confusing. It suggests, as a
general rule of thumb, the longer and later the decelerations,

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 Intrapartum assessment of fetal well-being

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Fig 2 CTG printout. A CTG with reassuring features. Normal baseline, good variability, and presence of accelerations. No decelerations visible. There are regular uterine
contractions recorded by the tocometer and maternal pulse is recorded on the same trace.

Fig 3 Pathological CTG. A period of excess uterine stimulation with syntocinon augmentation of labour (five to six contractions occur within 10 min). The CTG trace has
reduced variability and late decelerations. As a response, the syntocinon infusion rate is reduced (and then stopped); however, the fetal heart rate drops rapidly and re-
mains low for >3 min. Clinical examination reveals a cervix which is 2 cm dilated, and a decision is made to proceed to Caesarean section immediately. Note how re-
cording the maternal pulse helps differentiate fetal and maternal heart rates.

the higher the risk of fetal acidosis, particularly if accompanied
by a tachycardia and/or reduced baseline variability.8
Accelerations
Defined as transient increases in fetal heart rate (>15 beats min1
for at least 15 s) these tend to be associated with fetal activity
(Fig. 2). Although their presence is reassuring, absence in an
otherwise normal CTG should not cause concern.
Categorizing traces
Once an assessment of the four features is made, a CTG can be
classed as normal, suspicious or pathological8 with the purpose
of guiding management (Table 2). Despite this seemingly logical
classification, inter- and intra-observer variability exists when in-
terpreting recordings.11 The range of classification systems have
compounded the situation by introducing variability in definition
of CTG characteristics and classification.12 In addition, technical
difficulties such as loss of contact and inadvertent maternal
pulse recording further hinder accuracy. Several practices have
become commonplace to try to mitigate these inconsistencies,
including a ‘fresh eyes’ or a ‘buddy’ approach to CTG interpret-
ation.13 Aides-mémoire for locally adopted classification systems,
such as standardized CTG stickers, have also become routine.
Electronic interpretation of CTG tracings is sometimes
utilized to supplement clinician analysis with the intention of
a more objective assessment. However, recently published re-
sults of the INFANT study [randomized controlled trial (RCT) of

BJA Education | Volume 17, Number 12, 2017 409

Intrapartum assessment of fetal well-being

Table 2 Management based on interpretation of CTG traces adapted from NICE guideline on intrapartum care for healthy women and babies.
*If there are any concerns about the baby’s well-being, be aware of the possible underlying causes and start one or more of the following con-
servative measures based on an assessment of the most likely cause(s): encourage the woman to mobilize or adopt an alternative position
(and to avoid being supine); offer i.v. fluids if the woman is hypotensive; reduce contraction frequency by reducing or stopping oxytocin if it is
being used and/or offering a tocolytic drug (a suggested regimen is subcutaneous terbutaline 0.25 mg). †Talk to the woman and her birth com-
panion(s) about what is happening

Category Definition Management

Normal All features are reassuring • Continue CTG†

Suspicious 1 Non-reassuring feature • Correct any underlying causes such as hypotension or uterine hyperstimulation
AND • Start one or more conservative measures*
2 Reassuring features • Inform an obstetrician or a senior midwife
• Document a plan for reviewing the whole clinical picture and the CTG findings†
Pathological 1 Abnormal feature • Obtain a review by an obstetrician and a senior midwife
OR • Exclude acute events (e.g. cord prolapse, suspected placental abruption, or sus-

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2 Non-reassuring features
Need for urgent Acute bradycardia or a single
intervention prolonged deceleration
for 3 min or more
pected uterine rupture)
• Correct any underlying causes, such as hypotension or uterine
hyperstimulation
• Start one or more conservative measures*
• If the CTG trace is still pathological after implementing conservative measures:
– obtain a further review by an obstetrician and a senior midwife
– offer digital fetal scalp stimulation and document the outcome
• If the cardiotocograph trace is still pathological after fetal scalp stimulation:
– consider fetal blood sampling
– consider expediting the birth
• Urgently seek obstetric help
• If there has been an acute event (e.g. cord prolapse, suspected placental abrup-
tion, or suspected uterine rupture) expedite the birth
• Correct any underlying causes, such as hypotension or uterine
hyperstimulation
• Start one or more conservative measures*
• Make preparations for an urgent birth
• Expedite the birth if the acute bradycardia persists for 9 min
If the fetal heart rate recovers at any time up to 9 min, reassess any decision to ex-
pedite the birth, in discussion with the woman†

>46 000 women] demonstrated no significant neonatal benefit,
nor did it reveal any difference in mode or urgency of delivery
when employing an electronic decision support tool to supple
ment clinician interpretation.14
Adjunctive tests of fetal well-being
It has become understood that CTG interpretation is an imper-
fect science, and as such, adjuncts have been developed with
the aim of enhancing clinical decision making.
Fetal scalp electrode
Royal College of Obstetricians and Gynaecologists (RCOG) has
advocated measurement of lactate too.15 Although outcomes
have been comparable with either method, there appears to be a
higher chance of successfully obtaining a sample for lactate
measurement, because of the smaller sample size required.
Fetal blood sampling (FBS) should not be performed when
the clinical picture suggests that delivery should be expedited
regardless of the result. However, when uncertainty exists re-
garding the significance of CTG findings, the RCOG 15 and NICE8
recommend its use (Table 2). Digital fetal scalp simulation dur-
ing the procedure can cause fetal heart accelerations, which
may be a reassuring sign.8

The fetal scalp electrode is placed on the fetal scalp. The fetal
heart rate is derived from the R-R interval of the fetal electrocar- Fetal pulse oximetry
diographic (fECG) trace picked up by the device. Although,
This too requires placement of a sensor on the fetal presenting
placement can be difficult, it carries the risk of infection, and
part. The literature suggests that fetal saturations 30% are
has the potential to become displaced, it may allow more reli-
reassuring, whereas <30% should prompt consideration of
able recording of fetal heart rate where trans-abdominal detec-
intervention.16 A Cochrane review of fetal pulse oximetry (FPO)
tion has been substandard.
to supplement CTG concluded that its use did not appear to en-
hance clinical practice16 and in keeping with this the use of FPO
Fetal blood sampling appears to have ceased.
This involves taking fetal scalp blood into capillary tubes for ana-
lysis of fetal pH and/or lactate. Acquiring samples can be time-
consuming, can be difficult, and may fail to yield an adequate
Fetal electrocardiograpy
sample for analysis. Additionally, it can be falsely reassuring in Hypoxaemia alters characteristics of the fECG (P-R interval,
the presence of chorioamnionitis or thick meconium. Historically, T:QRS ratio and ST segment).17 When this technique is used, it
while pH has been the measurement of interest, recently, the is with the aid of automated ST analysis (STANV R ) software

410 BJA Education | Volume 17, Number 12, 2017


which looks at the CTG and fECG concurrently. The analysis of
the fECG using STANV R requires a scalp electrode to be placed.
A Cochrane review17 looked at RCTs analysing the effect of
using fECG to complement CTG interpretation. It concluded
that combining fECG with CTG made no difference to the num-
ber of Caesarean sections, fetal pH, neonatal encephalopathy,
neonatal intubation, or APGAR scores compared with CTG
alone. There was a reduced likelihood of performing FBS and a
marginal reduction in operative vaginal delivery rates with
fECG use. In keeping with this, a subsequent RCT of over 11 000
deliveries demonstrated no impact on operative delivery rates
or perinatal outcomes.18 The current NICE guideline does not
make a recommendation on the use of STANV R .8
Ultrasound
Transabdominal ultrasound scanning is now commonplace in
the setting of fetal distress in labour. The ease of use, combined
with minimal risk profile, makes it a desirable tool, and the abil-
ity to visualize fetal cardiac activity rapidly and directly is use-
ful for timely decision making.
Another emergent setting in which ultrasound is used is deci-
sion making before and during an operative vaginal delivery (e.g.
forceps, vacuum cup). The use of ultrasound to correctly identify
fetal head position and orientation can help select an appropriate
and safe technique for assisted delivery.19 Ultrasound can also
assess fetal cardiac activity during these deliveries.
Evidence is accumulating that ultrasound during labour may
predict the need for Caesarean section. Intrapartum ultrasound
has been the focus of studies evaluating how several measured
parameters affect the likelihood of successful vaginal delivery.20
This technique not only provides objective and quantitative data
but also has shown high inter- and intra-observer reliability.20
Conclusion
Despite the aforementioned limitations of CTG, it continues to
form an established component of the assessment of a fetus
during labour. Litigation, combined with the perceived benefits
of this technique, is likely to perpetuate its use for the foresee-
able future. Abandonment of intrapartum EFM is highly un-
likely without widespread uptake of an acceptable alternative
method of monitoring, which at present seems a distant occur-
rence. It is, therefore, imperative that anaesthetists, as part of a
multidisciplinary team, have an appreciation of the currently
available techniques for assessing intrapartum fetal well-being.
Supplementary material
Supplementary material is available at BJA Education online.
Declaration of interest
None declared.
MCQs
The associated MCQs (to support CME/CPD activity) can
be accessed at http://www.oxforde-learning.com/journals/ by
subscribers to BJA Education.
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