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NOMENCLATURE

A Review of the Proceedings

from the 2008 NICHD Workshop
on Standardized Nomenclature
for Cardiotocography
Update on Definitions, Interpretative Systems
With Management Strategies, and Research
Priorities in Relation to Intrapartum
Electronic Fetal Monitoring
Barrett Robinson, MD, MPH, Latasha Nelson, MD
Maternal Fetal Medicine, Northwestern Memorial Hospital, Chicago, IL

Despite evidence demonstrating no neonatal benefit, the medicolegal

climate in the United States requires obstetricians to integrate continuous
intrapartum surveillance into their care of the pregnant laboring patient.
The intent of this article is to familiarize the reader with the most recent,
standardized, quantitative nomenclature recommended to describe intra-
partum CTG in order to reduce miscommunication among providers caring
for the laboring patient, propagate consistent, evidence-based responses
to CTG patterns, and systematize the terminology used by researchers
investigating intrapartum CTG.
[Rev Obstet Gynecol. 2008;1(4):186-192]

© 2008 MedReviews®, LLC

Key words: Intrapartum cardiotocography • Electronic fetal monitoring • NICHD

nomenclature

I
n 2002, approximately 3.4 million fetuses (85% of approximately 4 million
live births) in the United States were assessed with continuous cardiotocogra-
phy (CTG), making it the most commonly performed obstetric procedure.1
Although CTG, also known as electronic fetal monitoring, is widespread in devel-
oped nations, its ability to identify the fetus that may be becoming asphyxiated
This article provides an update for the review of NICHD nomenclature published in
Reviews in Obstetrics & Gynecology, Volume 1, Number 2, Spring 2008, on pages 56-60.

186 VOL. 1 NO. 4 2008 REVIEWS IN OBSTETRICS & GYNECOLOGY

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Update: NICHD Standardized Nomenclature for Cardiotocography
and therefore may benefit from inter-
vention is limited, and has failed to
lead to reduced rates of cerebral palsy
and neurologic injury. There are no
studies comparing CTG with an ab-
sence of intrapartum monitoring, but
trials comparing CTG with intermit-
tent auscultation show no reduction
in the overall risk of perinatal death
(relative risk [RR] 0.85; 95% confi-
dence interval [95% CI], 0.59-1.23) or
cerebral palsy (RR 1.74; 95% CI, 0.97-
3.11).2 What studies have demon-
strated is that CTG versus intermittent
auscultation leads to higher operative
delivery rates by cesarean or assisted
vaginal delivery (RR 1.66; 95% CI,
Despite compelling evidence demonstrating no neonatal benefit, the medicole-
gal climate in the United States requires obstetricians to integrate continuous
intrapartum surveillance into their care of the pregnant laboring patient.
1.30-2.13 and RR 1.16; 95% CI, 1.01-
1.32, respectively).2
Despite compelling evidence
demonstrating no neonatal benefit,
the medicolegal climate in the United
States requires obstetricians to inte-
grate continuous intrapartum surveil-
lance into their care of the pregnant
laboring patient. Due to the setup of
labor and delivery units and the
team-oriented approach that exists in
most facilities, nurses, residents,
nurse midwives, and physicians may
all be regularly involved in assessing
the CTG. To communicate effectively
in the event that an abnormal CTG
exists and invoke an appropriate level
of concern, standardized terminology
is necessary.3,4
In 1997, the National Institutes of
Child Health and Human Develop-
ment (NICHD) sponsored a Research
Planning Workshop that addressed
this issue. The workshop’s express
purpose was to develop “a standard-
ized and rigorously, unambiguously
described set of definitions that can
be quantitated” for electronic fetal
heart monitoring, with the ultimate
goal of producing a common lan-
guage that would facilitate further in-
vestigational research examining the
predictive value of electronic fetal
monitoring and management strate-
gies to recognize and reduce intra-
partum fetal compromise.5 The Amer-
ican College of Obstetricians and
Gynecologists (ACOG); the Associa-
tion of Women’s Health, Obstetric and
Neonatal Nurses; the Royal College
of Obstetricians and Gynaecologists;
and the Society of Obstetricians and
Gynaecologists of Canada not only
endorsed the definitions, but recom-
mended new interpretations, defini-
tions, and particular intrapartum
management actions for some situa-
tions.
In April 2008, the NICHD, ACOG,
and the Society for Maternal-Fetal
Medicine (SMFM) jointly sponsored a
workshop on CTG, or fetal heart rate
(FHR) patterns. The goals of this
workshop6 were (1) to review and up-
date the definitions for CTG pattern
categorization as compared with the
prior workshop, (2) to assess existing
classification systems for interpreta-
tion of particular CTG patterns and
make new recommendations for a
system to be employed in the United
States, and (3) to make recommenda-
tions for research priorities as they re-
late to CTG. The intent of this article
is to familiarize the reader with the
resulting standardized, quantitative
nomenclature that is recommended to
describe intrapartum CTG to reduce
miscommunication among providers
caring for the laboring patient, as well
as systematize the terminology used
by researchers investigating intra-
partum CTG. A new emphasis on in-
VOL. 1 NO. 4 2008
terpretative systems and recom-
mended management strategies, as set
forth by the recent 2008 joint work-
shop, is also included and reviewed in
detail.
Fundamental Principles When
Using NICHD Terminology6
A set of overarching operational
principles was outlined prior to pre-
senting the actual definitions of terms
integral to the interpretation of car-
diotocography. The most germane
principles are:
• Although the development of com-
puterized interpretation programs is
underway, the definitions are to be
used for visual interpretation of
CTG.
• The definitions apply to patterns
produced from either an external
Doppler ultrasound device or a di-
rect transcervical fetal electrode de-
tecting the fetal electrocardiogram.
• The documentation of both CTG
and tocodynamometry should be of
adequate quality for visual interpre-
tation.
• The chief emphasis is on intra-
partum patterns, although the defi-
nitions are applicable to antepar-
tum observations.
• The patterns to be defined are cate-
gorized as either baseline, periodic,
or episodic. Periodic patterns are as-
sociated with contractions, whereas
episodic patterns are independent
of uterine contractions.
• Periodic patterns are distinguished
based on waveform, with accelera-
tions or decelerations defined as
abrupt versus gradual onset in rela-
tion to the adjacent baseline CTG.
• No differentiation is made between
short-term variability (or beat-to-
beat variability or R-R wave period
differences in the electrocardio-
gram) and long-term variability be-
cause in practice, they are visually
determined as a unit. The definition
of variability is based visually on
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Update: NICHD Standardized Nomenclature for Cardiotocography continued

the amplitude of the complexes,
with exclusion of the regular,
smooth sinusoidal pattern.
• CTG patterns are gestational
age–dependent and can differ based
on fetal physiologic status and ma-
ternal physiologic status, making
each of these critical interpretive
factors in the evaluation of a CTG
pattern. Maternal medical status,
prior fetal assessments, use of med-
ications, and other factors also war-
rant consideration.
• The individual components of CTG
that are defined do not occur in iso-
lation and generally evolve over
time. A full description of a CTG re-
quires a qualitative and quantita-
tive description of uterine contrac-
tions, baseline fetal heart rate,
A full description of a cardiotocography (CTG) requires a qualitative and
quantitative description of uterine contractions, baseline fetal heart rate,
baseline CTG variability, presence of accelerations, periodic or episodic de-
celerations, and changes or trends of CTG patterns over time.
baseline CTG variability, presence
of accelerations, periodic or
episodic decelerations, and changes
or trends of CTG patterns over time.
Uterine Contractions6
The number of contractions present in
a 10-minute window, averaged over
30 minutes, is the manner by which
uterine contractions are quantified.
When assessing uterine activity, equal
importance should be given to con-
traction frequency, duration, inten-
sity, and relaxation time between
contractions. Normal uterine contrac-
tions are 5 contractions or less in 10 min-
utes, averaged over a 30-minute
window. Tachysystole is defined as
more than 5 contractions in 10 min-
utes, averaged over a 30-minute win-
dow. When using the term tachysys-
tole, several key points should be kept
in mind, including: (1) the presence or
absence of associated CTG decelera-
tions, (2) tachysystole can occur irre-
spective of whether labor is sponta-
neous or stimulated, although the
clinical responses may differ based on
whether contractions are spontaneous
or stimulated, and (3) the usage of
such terms as hyperstimulation and
hypercontractility are without mean-
ing and should be abandoned.
Definitions of Fetal Heart
Rate Patterns6
Essential to the definitions of FHR
patterns are the characteristics of
baseline, variability, acceleration, and
deceleration.
Baseline fetal heart rate is the aver-
age fetal heart rate rounded to incre-
ments of 5 beats per minute during a
10-minute segment, excluding accel-
erations and decelerations and peri-
ods of marked variability ( 25
beats/min).
In any given 10-minute window,
the minimum baseline duration must
be at least 2 minutes (not necessarily
contiguous), or else the baseline is
considered indeterminate. In cases
where the baseline is indeterminate,
the previous 10-minute window
should be reviewed and utilized to de-
termine the baseline.
A normal FHR baseline rate ranges
from 110 to160 beats per minute. If
the baseline FHR is less than 110 beats
per minute, it is termed bradycardia. If
the baseline FHR is more than 160
beats per minute, it is termed tachy-
cardia.
Baseline FHR variability is deter-
mined in a 10-minute window and
excludes accelerations and decelera-
tions. A sinusoidal fetal heart rate
pattern is defined as a visually appar-
ent, smooth, sine-wave–like undulat-
ing pattern in FHR baseline with a
cycle frequency of 3 to 5 per minute
that persists for 20 minutes or more.
A sinusoidal fetal heart rate pattern is
incompatible with the definition of
variability.
Variability is defined as fluctuations
in the FHR baseline with irregular am-
plitude and inconstant frequency.
These fluctuations are visually quanti-
tated as the amplitude of the peak to
trough in beats per minute, shown in
Table 1.
Based on visual assessment, an ac-
celeration is defined as an apparent
abrupt increase in FHR above base-
line, with the time from the onset of
the acceleration to its acme less than
30 seconds. The increase is measured
from the most recently determined
portion of the baseline. The peak is
15 beats per minute or more above the
baseline, and the acceleration lasts
15 seconds or more, but less than
2 minutes from the onset to the return
to the previously determined baseline.
In pregnancies of fewer than 32 weeks
of gestation, accelerations are defined
as having a peak 10 beats per minute
or more above the baseline and dura-
tion of 10 seconds or longer.
Prolonged acceleration is 2 minutes
or longer and less than 10 minutes
in duration, with any acceleration
Table 1
Baseline Fetal Heart Rate Variability
Fluctuation Classification
Amplitude Range Classification
Undetectable Absent
Undetectable to Minimal
 5 beats/min
6 to 25 beats/min Moderate
More than
25 beats/min Marked

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lasting 10 minutes or longer consti-
tuting a change in baseline.
FHR decelerations are classified as
late, early, or variable. The character-
istics of each type of deceleration are
described in the following paragraphs.
Based on visual assessment, late
deceleration is defined as an apparent
gradual decrease and return to the
baseline FHR in association with a
uterine contraction, with the time
from onset of the deceleration to its
nadir as 30 seconds or longer. The de-
crease is typically symmetrical in
shape and is measured from the most
recently determined portion of the
baseline to the nadir of the decelera-
tion. The deceleration’s timing is de-
layed, with the nadir of the decelera-
tion occurring after the peak of the
uterine contraction. In general, the
onset, nadir, and recovery of a late
deceleration occur after the begin-
ning, acme, and end of the associated
contraction, respectively.
Based on visual assessment, early
deceleration is defined as an apparent
gradual decrease and return to the
baseline FHR in association with a
uterine contraction, with the time
from onset of the deceleration to its
nadir as 30 seconds or longer. The de-
crease is typically symmetrical in
shape and is measured from the most
recently determined portion of the
baseline to the nadir of the decelera-
tion. Early decelerations are coinci-
dent in timing with uterine con-
tractions, with the nadir of the
deceleration occurring simultaneously
with the peak of the uterine contrac-
tion. In general, the onset, nadir, and
recovery of a late deceleration occur
in a coincident fashion with the be-
ginning, acme, and end of the associ-
ated contraction, respectively.
Based on visual assessment, vari-
able deceleration is defined as an ap-
parent abrupt decrease in FHR below
the baseline, with the time from the
onset of the deceleration to the nadir
of the deceleration as fewer than
30 seconds. The decrease is measured
from the most recently determined
portion of the baseline to the nadir of
the deceleration. Variable decelera-
tions may or may not be associated
with uterine contractions. The de-
crease from baseline is 15 beats per
minute or greater and lasts 15 seconds
or longer, but lasts less than 2 min-
utes from onset to return to baseline.
When variable decelerations occur in
conjunction with uterine contrac-
tions, their onset, depth, and duration
may vary with each successive uter-
ine contraction. Variable decelera-
tions may occur in conjunction with
other findings, the clinical signifi-
cance of which requires further
investigational research. Some exam-
ples include a slow return of the FHR
after the end of the contraction,
biphasic decelerations, tachycardia
after variable deceleration(s), acceler-
ations preceding and/or following
(often referred to as “shoulders” or
“overshoots”), and fluctuations in the
trough of the deceleration.
Based on visual assessment, pro-
longed deceleration is defined as an
apparent decrease in FHR below the
baseline, measured from the most re-
cently determined portion of the
baseline. The decrease in the FHR is
15 beats per minute or more and
lasts at least 2 minutes but less than
10 minutes from onset to return to
baseline. A deceleration that is sus-
tained for 10 minutes constitutes a
change in baseline.
Deceleration Quantification
Guidelines6
The quantification of deceleration
magnitude is based on the depth of
the deceleration’s nadir in beats per
minute below the baseline, excluding
any transient spikes or electronic arti-
fact. The duration of the deceleration
is quantitated in minutes and seconds
from the start of the deceleration to
VOL. 1 NO. 4 2008
the deceleration end. Accelerations
are likewise quantitated.
Although some authors have sug-
gested grading decelerations based on
such factors as the depth or absolute
nadir in beats per minutes and dura-
tion, the predictive value of these
grading systems has not been suffi-
ciently established and requires fur-
ther investigation.
Decelerations are classified as re-
current if they occur with 50% or
more of uterine contractions in any
20-minute segment. Decelerations oc-
curring with less than 50% of uterine
contractions in any 20-minute seg-
ment are defined as intermittent.
Interpretative Systems for
Classification of Fetal Heart
Rate Patterns6
Although many interpretative systems
exist for FHR tracings, the selected
system must be evidence based, sim-
ple, and applicable to clinical prac-
tice. As the FHR response is a dy-
namic process that requires frequent
reassessment, categorization of a
tracing is limited to the time period
being assessed. Over time it is not un-
common for FHR tracings to migrate
from one category to another. FHR
tracing patterns provide information
on the current acid-base status of the
fetus and cannot predict the develop-
ment of cerebral palsy.
Two FHR findings reliably predict
the absence of acidemia: (1) the
presence of FHR accelerations, either
spontaneous or stimulated, or (2)
moderate FHR variability. It must be
emphasized, however, that although
either fetal accelerations or moderate
FHR variability reliably predict the
absence of acidemia, the absence of
accelerations, the presence of minimal
variability, or the presence of absent
variability does not reliably predict
the presence of fetal hypoxemia or
metabolic acidemia. The significance
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Update: NICHD Standardized Nomenclature for Cardiotocography continued

of marked variability (formerly de- cal circumstances must always be tion and interpretation of FHR trac-
scribed as saltatory) remains unclear. taken into account, the 2008 NICHD ings into a 3-tier system, described in
Although the entire associated clini- workshop has simplified categoriza- Table 2.

Table 2
3-Tier Fetal Heart Rate Interpretation System6

Category I
Normal tracings, which are strongly predictive of normal fetal acid-base status at the time of observation and can be followed in a
routine manner without any specific action required, include all of the following:
• Baseline rate: 110-160 beats/min
• Moderate variability
• Absence of any late or variable decelerations
• Early decelerations may or may not be present
• Accelerations may or may not be present

Category II
Indeterminate tracings, although not predictive of abnormal fetal acid-base status, cannot be classified as Category I or III and thus
require evaluation and continued surveillance and reevaluation. These tracings are not infrequently encountered in clinical care, and
include any of the following:
• Baseline rate
 Tachycardia
 Bradycardia not accompanied by absent baseline variability
• Baseline FHR variability
 Minimal baseline variability
 Absent baseline variability not accompanied by recurrent decelerations
 Marked baseline variability
• Absence of induced accelerations after fetal stimulation (eg, scalp stimulation, vibroacoustic stimulation, direct fetal scalp sam-
pling, transabdominal halogen light)
• Periodic or episodic decelerations
 Recurrent variable decelerations accompanied by minimal or moderate baseline variability
 Prolonged deceleration 2 min but 10 min
 Recurrent late decelerations with moderate baseline variability
 Variable decelerations with other characteristics, such as slow return to baseline, “overshoots,” or “shoulders”

Category III
Abnormal tracings, which are predictive of abnormal fetal acid-base status at the time of observation, require prompt evaluation and
initiation of expeditious attempts to resolve the abnormal FHR pattern, such as provision of maternal oxygen, change in maternal
position, discontinuation of labor stimulation, treatment of maternal hypotension, or additional efforts. These tracings include either:
• Absent baseline FHR variability along with any of the following:
 Recurrent late decelerations
 Recurrent variable decelerations
 Bradycardia
• Sinusoidal pattern
FHR, fetal heart rate.

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Update: NICHD Standardized Nomenclature for Cardiotocography

Research Recommendations6
CTG is nearly ubiquitous in obstetric
practice in the United States, and well-
designed studies are needed to fill
gaps in knowledge. Areas of highest
priority include observational studies
focused on indeterminate CTG pat-
terns, including descriptive epidemiol-
ogy, frequency of specific patterns,
changes over time, relationships to
clinically relevant outcomes, and the
effect of the patterns’ durations (eg,
recurrent late decelerations with min-
imal variability) on clinical outcomes.
Additional areas with a paucity of re-
search include the effect of uterine
contractile characteristics on clinical
outcomes, the effectiveness of CTG ed-
ucational programs that include all
relevant stakeholders, potential com-
parisons between computerized inter-
pretation and provider interpretation,
digitally addressable formatted com-
prehensive data sets that integrate
CTG outcomes, and techniques that
may serve to supplement CTG, such as
ST segment analysis.
Commentary and Conclusions
Cardiotocography has become an ac-
cepted component of most intra-
partum monitoring in the United
States, despite the lack of demon-
strated fetal or neonatal benefit in the
literature. In order to continue to
safely and consistently apply this
technology to the care of obstetrical
patients, agreed-upon guidelines for
description of CTG patterns, interpre-
tation and categorization of CTG
patterns, and appropriate provider
responses to CTG patterns must be
systematically introduced into prac-
tice and adhered to by all members of
the obstetrical team. The recent joint
workshop on continuous fetal CTG
sponsored by the NICHD, ACOG, and
SMFM in April 2008 and the resulting
update published by Macones and
colleagues6 substantially advanced the
cause of clarifying the current, recom-
mended nomenclature and establish-
ing a simple, evidence-based, clinically
applicable interpretative system.
Standardization of terminology and
subsequent categorization into 1 of 3
tiers should aid providers who are de-
ciding whether the patterns are sug-
gestive of a lack of fetal acidemia or
alternately require intervention. De-
spite numerous studies demonstrating
that inter- and intraobserver variabil-
ity is high when CTG tracings are re-
viewed,7,8 there is consensus that
normal tracings classified as Category
I indicate an absence of fetal
acidemia.6,9,10,11 On the other hand,
acidemia may be present in up to 1 of
4 fetuses with abnormal or Category
III CTG tracings.12 Although expedi-
tious action is indicated to either re-
solve the concerning aspects of the
abnormal tracing or to move towards
delivery, due to the low prevalence of
intrapartum fetal asphyxia, even ab-
normal tracings have a well-recog-
nized false-positive rate that in some
instances can be greater than 90%.13
Patients with indeterminate trac-
ings, classified as Category II, may
ultimately be the most difficult to
manage in clinical practice. A main-
stay of the recommended strategy is
close, continuous evaluation and
assessment. These tracings may ulti-
mately fit criteria for normal, Category
I tracings as time passes or after subse-
quent evaluative strategies, at which
point confidence in the nonacidemic
status of the fetus may be gained. Al-
ternately, indeterminate tracings may
ultimately meet the criteria for abnor-
mal, Category III tracings, in which
case the imperative to resolve concern-
ing aspects or move expeditiously to-
wards delivery will become clear. Due
to the potential uncertainty inherent in
these nonpredictive tracings, a call has
been issued for investigational research
focusing on the relationship between
such tracings and clinical outcomes.
This document attempts to famil-
iarize the reader with recently pro-
posed NICHD language in an effort to
further advance the cause of utilizing
common terminology and employing
consistent, evidence-based, and sim-
ple interpretative systems among
providers who use continuous CTG in
their clinical practice. Personal review
of the original NICHD workshop doc-
ument cited below, along with any or
all of the additional sources for this
article, is strongly encouraged.
References
1. Martin JA, Hamilton BE, Sutton PD, et al. Births:
final data for 2002. Natl Vital Stat Rep.
2003;52(10):1-113.
2. Alfirevic Z, Devane D, Gyte GM, et al. Continuous
tocography (CTG) as a form of electronic fetal

Main Points
• Continuous cardiotocography (CTG) is the most commonly performed obstetric procedure in the United States.
• Usage of the standardized terminology developed by the National Institute of Child Health and Human Development (NICHD) to
describe intrapartum CTG can help reduce miscommunication among providers caring for the laboring patient and systematize
the terminology used by researchers investigating intrapartum CTG.
• Utilization of the recent interpretative systems and corresponding management strategies result in consistent, evidence-based
responses to CTG patterns that are normal (Category I), abnormal (Category III), or indeterminate (Category II).
• Personal review of the original NICHD document is strongly encouraged.

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