Original Research

Intrapartum Resuscitation Interventions for

Category II Fetal Heart Rate Tracings and
Improvement to Category I
Uma M. Reddy, MD, MPH, Steven J. Weiner, MS, George R. Saade, MD, Michael W. Varner, MD,
Sean C. Blackwell, MD, John M. Thorp Jr, MD, Alan T.N. Tita, MD, PhD, Russell S. Miller, MD,
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Alan M. Peaceman, MD, David S. McKenna, MD, Edward K. S. Chien, MD, MBA, Dwight J. Rouse, MD,
Yasser Y. El-Sayed, MD, Yoram Sorokin, MD, and Steve N. Caritis, MD, for the Eunice Kennedy
Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal
Medicine Units (MFMU) Network*

OBJECTIVE: To evaluate intrapartum resuscitation inter-
ventions and improvement in category II fetal heart rate
(FHR) tracings.
METHODS: This secondary analysis of a randomized
trial of intrapartum fetal electrocardiographic ST-
segment analysis included all participants with category
II FHR tracings undergoing intrauterine resuscitation:
maternal oxygen, intravenous fluid bolus, amnioinfusion,
or tocolytic administration. Fetal heart rate pattern-
recognition software was used to confirm category II
FHR tracings 30 minutes before intervention and to
analyze the subsequent 60 minutes. The primary out-
come was improvement to category I within 60 minutes.
Secondary outcomes included FHR tracing improvement
to category I 30–60 minutes after the intervention and
composite neonatal outcome.

*See Appendix 1, available online at http://links.lww.com/AOG/C385, for a list of other members of the NICHD MFMU Network.
From the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD; the Departments of Obstetrics and Gynecology, the
University of Texas Medical Branch at Galveston, Galveston, Texas, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of Texas
McGovern Medical School at UT Health, Houston, Texas, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Alabama at
Birmingham, Birmingham, Alabama, Columbia University, New York, New York, Northwestern University, Chicago, Illinois, The Ohio State University, Columbus,
Ohio, MetroHealth Medical Center-Case Western Reserve University, Cleveland, Ohio, Brown University, Providence, Rhode Island, Stanford University, Stanford,
California, Wayne State University, Detroit, Michigan, and the University of Pittsburgh, Pittsburgh, Pennsylvania; and the George Washington University Biostatistics
Center, Washington, DC.
This work is supported by grants HD34208, HD53097, HD40545, HD40560, HD27869, HD40485, HD40512, HD27915, HD40544, HD40500, HD68282,
HD68268, HD27917, HD21410, and U10 HD36801 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
and by funding from Neoventa Medical. Comments and views expressed in this article are those of the authors and do not necessarily represent views of the National
Institutes of Health. Neoventa Medical did not participate in the monitoring of the study; data collection, management, or analysis; or manuscript preparation. Funded in
part by Neoventa Medical.
Presented at the Society for Maternal-Fetal Medicine’s 37th Annual Pregnancy Meeting, January 23–28, 2017, Las Vegas, Nevada.
Dr. Rouse, Editor-in-Chief of Obstetrics & Gynecology, was not involved in the review or decision to publish this article.
The authors thank Ashley Salazar, RN, MSN, WHNP, for assistance with protocol development and coordination between clinical research centers; Elizabeth Thom, PhD
and Michael A. Belfort, MB, BCh, MD, PhD for protocol development and oversight; and Catherine Y. Spong, MD for protocol development, oversight and outcome
review.
Each author has confirmed compliance with the journal’s requirements for authorship.
Corresponding author: Uma M. Reddy, MD, MPH, Yale University School of Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, New Haven,
CT; email: Uma.Reddy@yale.edu.
Financial Disclosure
Alan Tita reports his institution received funds from Pfizer. Russell Miller reports money was paid to him from Janssen Research & Development, LLC, for serving on
their Advisory Board service (unrelated to this manuscript topic). He also received funds from UpToDate (chapter author unrelated to this manuscript topic). David
McKenna’s institution is a satellite site for The Ohio State University for the NICHD MFMU, which pays his institution for patients enrolled in MFMU studies. Edward
Chien reports that money was paid to his institution from MetroHealth. The other authors did not report any potential conflicts of interest.
© 2021 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0029-7844/21

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RESULTS: Of 11,108 randomized participants, 2,251
(20.3%) had at least one qualifying intervention for category
II FHR tracings: 63.7% improved to category I within
60 minutes and 50.5% improved at 30–60 minutes. Only
3.4% underwent cesarean delivery and 4.1% an operative
vaginal delivery for nonreassuring fetal status within
60 minutes after the intervention. Oxygen administration
was the most common intervention (75.4%). Among
American College of Obstetricians and Gynecologists-
defined subgroups that received oxygen, the absent FHR
accelerations and absent–minimal FHR variability subgroup
(n5332) was more likely to convert to category I within
60 minutes than the FHR accelerations or “moderate FHR
variability” subgroup (n51,919) (77.0% vs 63.0%, odds ratio
[OR] 2.0, 95% CI 1.4–2.7). The incidence of composite
neonatal adverse outcome for category II tracings was 2.9%
(95% CI 2.2–3.7%) overall; 2.8% (95% CI 2.0–3.8%) for
improvement to category I within 60 minutes (n51,433);
and 3.2% (95% CI 2.1–4.6%) for no improvement within
60 minutes (n5818). However, the group with improvement
had 29% lower odds for higher level neonatal care (11.8% vs
15.9%, OR 0.71, 95% CI 0.55–0.91).
CONCLUSION: Nearly two thirds of category II FHR
tracings improved to category I within 60 minutes of
intervention with a relatively low overall rate of the
composite neonatal adverse outcome.
FUNDING SOURCE: Funded in part by Neoventa Medical.
(Obstet Gynecol 2021;138:409–16)
DOI: 10.1097/AOG.0000000000004508
O f the almost 4 million patients delivering each year
in the United States, approximately 75% undergo
labor.1 Intrauterine resuscitation is commonly attempted
to improve fetal oxygenation in response to concerning
fetal heart rate (FHR) tracings by improving maternal
blood flow to the placenta, increasing blood oxygen con-
tent, or ameliorating umbilical cord compression. For
FHR tracings characterized by absent variability and
recurrent late or deep variable decelerations (Eunice Ken-
nedy Shriver National Institute of Child Health and
Human Development category III), there is an increased
association with neonatal hypoxia and metabolic acido-
sis.2 However, category III tracings are relatively infre-
quent, occurring in about 0.09% of fetuses within
30 minutes of delivery.3 The majority of fetuses are well
oxygenated, and therefore not acidotic in labor, but will
have FHR changes that fall into category II, which is
defined as any FHR tracing that is not category I or
III. The efficacy of intrauterine resuscitation procedures
to improve the fetal condition when there is a category II
FHR tracing is based on limited data.2
Commonly performed intrauterine resuscitation
techniques include maternal oxygen, intravenous (IV)
410 Reddy et al Outcomes of Intrapartum Resuscitation Interventions
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Unauthorized reproduction of this article is prohibited.
hydration, tocolytic administration, and amnioinfu-
sion.2 Given the paucity of data, we evaluated how
often these standard intrapartum resuscitation inter-
ventions lead to an improvement in category II
FHR tracings within the recommended time frame
of 60 minutes.4 The primary outcome was objective
improvement to category I at any point in the first
60 minutes after the intervention. Secondary out-
comes that were evaluated included an improvement
of the FHR tracing to category I in the period between
30 and 60 minutes after the intervention to allow time
for the intervention to have an effect and composite
neonatal morbidity rates in the group that improved
to category I compared with the group that remained
category II after 60 minutes.
ROLE OF THE FUNDING SOURCE
The authors had access to relevant aggregated study
data and other information (such as study protocol,
analytic plan and report, validated data table, and
clinical study report) required to understand and report
research findings. The authors take responsibility for
the presentation and publication of the research find-
ings, have been fully involved at all stages of publica-
tion and presentation development, and are willing to
take public responsibility for all aspects of the work. All
individuals included as authors and contributors who
made substantial intellectual contributions to the
research, data analysis, and publication or presentation
development are listed appropriately. The role of the
sponsor in the design, execution, analysis, reporting,
and funding is fully disclosed. The authors’ personal
interests, financial or nonfinancial, relating to this
research and its publication have been disclosed.
METHODS
We conducted a secondary analysis of data from the
Eunice Kennedy Shriver National Institute of Child
Health and Human Development Maternal-Fetal Med-
icine Units Network STAN trial, a large, multicenter
randomized controlled trial of fetal ECG ST-segment
analysis used as an adjunct to conventional electronic
fetal monitoring in laboring patients with singleton
pregnancies at more than 36 weeks of gestation. A total
of 11,108 participants underwent randomization at 26
hospitals in the United States between 2010 and 2014.
The methodology of STAN has been previously re-
ported.5 Inclusion criteria for this analysis was a partic-
ipant with intrauterine resuscitation interventions of
interest performed for a category II FHR tracing in
either the first or second stage of labor. Participants
were excluded if they had less than 60 minutes of inter-
pretable FHR tracing postintervention, unless a
OBSTETRICS & GYNECOLOGY
decision to deliver for nonreassuring fetal status was
made before 60 minutes. Fetal heart rate pattern-
recognition software was used to confirm category II
FHR tracing 30 minutes before the intervention and to
analyze the FHR tracing 60 minutes after the interven-
tion as previously described.6,7
Interventions were defined as any of the following:
maternal oxygen, IV fluid bolus, amnioinfusion, or
tocolytic administration. If more than one intervention
was performed at the same time, each intervention was
included in the analysis. If the patient had more than
one episode of intervention for a category II FHR
tracing, the analysis was limited to the first set of
interventions for each patient. The primary outcome
was improvement to category I at any point in the first
60 minutes after the intervention. Improvement of the
FHR tracing to category I in the period between 30 and
60 minutes after the intervention was a secondary
outcome. Secondary neonatal outcomes selected a
priori were compared between groups with an improve-
ment to category I within 60 minutes and the group
without evidence of improvement and included a
composite of intrapartum fetal death, neonatal death,
5-minute Apgar score 3 or lower, neonatal seizure,
umbilical artery blood pH of 7.05 or less with a base
deficit of 12 mmol/L or more, intubation for ventilation
at delivery, or neonatal encephalopathy5; individual Fig. 1. Flow diagram of participant exclusion and inclu-
components of the composite outcome, 5-minute Apgar sion. *None of the four interventions of interest for a cate-
gory II tracing. †No category II tracing in 30 minutes before
score, umbilical-artery blood gas results, and admission intervention, per the PeriGen interpretation. ‡Did not have
to the intermediate care nursery or neonatal intensive at least 60 minutes of tracing after the intervention and did
care unit. not have a decision for cesarean delivery or operative
In a post hoc analysis, we further analyzed category vaginal delivery for nonreassuring fetal status before
II tracings according to American College of Obstetri- 60 minutes. STAN, fetal electrocardiographic ST-segment
analysis.
cians and Gynecologists’ Practice Bulletin No. 116 (Fig.
Reddy. Outcomes of Intrapartum Resuscitation Interventions. Ob-
1), which provides two different approaches for the stet Gynecol 2021.
management of a category II tracing. For patients with
category II tracings characterized by “absent FHR
accelerations and absent/minimal FHR variability,” using SAS 9.4. P,.05 was chosen to denote signifi-
delivery should be considered if there is no improve- cance. No adjustments were made for multiple compar-
ment with resuscitation efforts; those with tracings that isons. No imputation for missing data was performed.
are characterized by the presence of “FHR accelerations
or moderate FHR variability” can continue surveillance RESULTS
and intrauterine resuscitative measures.2 We compared Of 11,108 randomized participants, 20.3% (n52,251)
these two subcategories of category II tracing for the had one or more interventions for a category II FHR
rate of improvement to category I after each interven- tracing meeting the criteria for duration of FHR trac-
tion, except for tocolytic administration due to its small ing preintervention and postintervention (Fig. 1). The
numbers. overall characteristics of the participants included in
Institutional review board approval was obtained this analysis are shown in Table 1 and compari-
from all participating centers. Categorical variables son with those excluded in the analysis cohort in
were compared with the use of the x2 test or Fisher Table 2. Description of the labor and intervention
exact test, as appropriate; continuous variables used characteristics of the cohort including the number of
the Wilcoxon rank-sum test. Odds ratios (ORs) and patients receiving more than one intervention are
95% CIs were calculated. Analyses were performed described in Table 3. Overall, 89.4% of interventions

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Table 1. Characteristics of the Study Population Table 2. Characteristics of Analyzed Cohort
(N52,251) Compared With Participants Not Included
in the Analysis
Characteristic Value
Insufficient
Age (y) 27.166.0 FHR
Gestational age at time of randomization (wk) 39.561.2 Tracing
Self-identified race and ethnicity Included Before
Non-Hispanic Black 526 (23.4) Participants Intervention
Non-Hispanic White 810 (36.0) (N52,251) (n5806) P
Asian 70 (3.1)
Hispanic 797 (35.4) Age (y) 27.166.0 27.466.0 .31
Other or not recorded* 48 (2.1) Gestational age 39.561.2 39.361.2 .001
BMI (kg/m2) 33.567.0 at time of
Education level (y) 12.862.5 randomization
Nulliparous 1,336 (59.4) (wk)
Cervical dilation at randomization (cm) 4.661.3 Self-identified race .008
Induced labor 1,363 (60.6) and ethnicity
BMI, body mass index. Non-Hispanic 23.4 24.8
Data are mean6SD or n (%). Black
* Includes the following: Native Hawaiian or Pacific Islander, Non-Hispanic 36.0 34.4
Native American or Alaskan Native, other (not specified), not White
recorded. Asian 3.1 1.6
Hispanic 35.4 38.5
Other or not 2.1 0.7
occurred in the first stage of labor. Eighty-three per- recorded
cent had one intervention, 16% had two, and 0.7% BMI (kg/m2) 33.567.0 32.566.9 ,.001
had three administered in combination. Of those with Education level (y) 12.862.5 12.762.7 .29
Nulliparous 59.4 45.4 ,.001
more than one intervention, 89.1% involved both Cervical dilation at 4.661.3 5.161.2 ,.001
oxygen administration and IV fluid bolus (with or randomization
without amnioinfusion or tocolytic administration). (cm)
Of the participants with an intervention for a category Induced labor 60.6 58.4 .29
II FHR tracing, 63.7% improved postintervention to FHR, fetal heart rate; BMI, body mass index.
category I at some point within 60 minutes and 50.5% Data are mean6SD or % unless otherwise specified.
improved to category I between 30 and 60 minutes
(Table 4). Oxygen administration was the most fre- FHR accelerations and absent/minimal FHR variabil-
quently performed intrauterine resuscitation interven- ity” subgroup was more likely to convert to category I
tion for category II FHR tracings (75.4%, n51,698), tracing within 60 minutes than the FHR accelerations
followed by IV fluid bolus (29.3%, n5659), amnioin- or moderate FHR variability subgroup (77.0% vs
fusion (10.7%, n5240), and tocolytic administration 63.0%, OR 2.0, 95% CI 1.4–2.7), due to improvement
(2.0%, n545). Improvement to category I tracing in variability. After IV fluid bolus the “absent FHR
within 60 minutes was observed in the majority of accelerations and absent/minimal FHR variability”
participants for each intervention (range 52.1–67.1%) subgroup was also more likely to convert to a category
(Table 4). Only 3.4% (77 participants) had a decision I tracing within 60 minutes than the “FHR accelera-
to undergo cesarean delivery and 4.1% (92 partici- tions or moderate FHR variability subgroup” (77% vs
pants) had an operative vaginal delivery for nonreas- 65.4%, OR 1.8, 95% CI 1.1–2.9). Amnioinfusion was
suring fetal status within 60 minutes after the not associated with a difference in conversion to a
intervention. When excluding those 169 participants, category I tracing within 60 minutes for the two cate-
cesarean delivery occurred in 30.8% (441/1,433) of gory II FHR tracing subgroups.
those that improved to category I within 60 minutes The incidence of composite neonatal adverse
and 28.5% (185/649) that did not improve and were outcome for category II tracing was low overall,
still at risk of cesarean delivery. 2.9% (95% CI 2.2–3.7%); 2.8% (95% CI 2.0–3.8%)
In the post hoc analysis, of the 2,251 participants, for those with improvement to category I within
14.7% (n5332) were in the absent FHR accelerations 60 minutes (n51,433) and 3.2% (95% CI 2.1–4.6%)
and absent–minimal FHR variability subgroup; oxy- for those with no improvement within 60 minutes
gen was administered in 75.9% of these cases (252/332) (n5818). However, compared with the group with-
(Table 5). After oxygen administration, the “absent out evidence of improvement, the odds of needing

412 Reddy et al Outcomes of Intrapartum Resuscitation Interventions OBSTETRICS & GYNECOLOGY

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Table 3. Labor and Intervention Characteristics*

Any Intervention Oxygen IV Fluid Bolus Amnioinfusion Tocolysis

Characteristic (N52,251) (n51,698) (n5659) (n5240) (n545)

Stage of labor at intervention

1st 2,012 (89.4) 1,496 (88.1) 602 (91.4) 237 (98.8) 42 (93)
2nd 239 (10.6) 202 (11.9) 57 (8.7) 3 (1.3) 3 (7)
Study assignment
ST analysis 1,043 (46.3) 792 (46.6) 313 (47.5) 117 (48.8) 18 (40)
CTG only 1,208 (53.7) 906 (53.4) 346 (52.5) 123 (51.3) 27 (60)
Given in combination with another 376 (16.7) 370 (21.8) 340 (51.6) 37 (15.4) 20 (44)
intervention†
IV, intravenous; CTG, cardiotocography.
Data are n (%).
* If more than one type of intervention was performed at the same time, the case will appear in multiple columns.
†
Number of patients receiving more than one intervention listed in table. For specific intervention, refer to number receiving intervention in
addition to another listed intervention in table.

higher level neonatal care (intermediate or intensive DISCUSSION

care unit) was 29% lower in the group with an
improvement to category I within 60 minutes
(11.8% vs 15.9%, OR 0.71, 95% CI 0.55–0.91). The
group with an improvement to category I within
60 minutes had a slightly higher umbilical cord pH
than those without improvement (7.2460.06 vs
7.2360.08, P5.007) (Table 6).
About 20% of low-risk participants in labor at more
than 36 weeks of gestation underwent intervention for
a category II FHR tracing, as determined by objective
pattern-recognition software for FHR tracing interpre-
tation. The majority of patients improved from cate-
gory II FHR tracing to category I within 60 minutes,
but 7.5% of the participants underwent either cesarean

Table 4. Intervention Characteristics and Improvement of Fetal Heart Rate Tracing to Category I

Any Intervention Oxygen IV Fluid Bolus Amnioinfusion Tocolytic

Characteristic (N52,251) (n51,698) (n5659) (n5240) (n545)

Improvement to category I
At any point within 60 min 1,433 (63.7) 1,105 (65.1) 442 (67.1) 125 (52.1) 27 (60)
Between 30 and 60 min 1,136 (50.5) 872 (51.4) 357 (54.2) 105 (43.8) 22 (49)
Cesarean delivery decision 77 (3.4) 51 (3.0) 26 (4.0) 11 (4.6) 7 (16)
within 60 min*
Operative vaginal delivery 92 (4.1) 78 (4.6) 29 (4.4) 3 (1.3) 1 (2)
within 60 min†
1st stage only n52,012 n51,496 n5602 n5237 n542
Improvement to category I
At any point within 60 min 1,362 (67.7) 1,046 (69.9) 425 (70.6) 125 (52.7) 25 (60)
Between 30 and 60 min 1,090 (54.2) 835 (55.8) 344 (57.1) 105 (44.3) 21 (50)
Cesarean delivery decision 67 (3.3) 45 (3.0) 19 (3.2) 11 (4.6) 7 (17)
within 60 min*
Operative vaginal delivery 24 (1.2) 19 (1.3) 12 (2.0) 2 (0.8) 1 (2)
within 60 min†
2nd stage only n5239 n5202 n557 n53 n53
Improvement to category I
At any point within 60 min 71 (29.7) 59 (29.2) 17 (30) 0 (0) 2 (67)
Between 30 and 60 min 46 (19.3) 37 (18.3) 13 (23) 0 (0) 1 (33)
Cesarean delivery decision 10 (4.2) 6 (3.0) 7 (12) 0 (0) 0 (0)
within 60 min*
Operative vaginal delivery 68 (28.5) 59 (29.2) 17 (30) 1 (33) 0 (0)
within 60 min†
IV, intravenous.
Data are n (%).
* Decision for cesarean delivery for nonreassuring fetal status made within 60 minutes of the intervention.
†
Vacuum- or forceps-assisted delivery for nonreassuring fetal status within 60 minutes of the intervention.

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Table 5. Intervention Characteristics and Improvement of Fetal Heart Rate Tracing to Category I Within 60
Minutes by American College of Obstetricians and Gynecologists Category II Tracing Type

Accelerations or Absent Accelerations and

Characteristic n Moderate Variability* Absent or Minimal Variability* P

Any intervention 2,251 1,189/1,919 (62.0) 244/332 (73.5) ,.001

Oxygen 1,698 911/1,446 (63.0) 194/252 (77.0) ,.001
IV fluid bolus 659 366/560 (65.4) 76/99 (77) .03
Amnioinfusion 240 108/207 (52.2) 17/33 (52) .94
IV, intravenous.
Data are n/N (%) unless otherwise specified.
* American College of Obstetricians and Gynecologists category II tracing type in the 30 minutes immediately before the intervention.

delivery or operative vaginal delivery for nonreassur-
ing fetal status within 60 minutes after the intervention.
Maternal oxygen supplementation was the most
frequently performed intrauterine resuscitation inter-
vention (75%). We observed that after oxygen admin-
istration for a category II FHR tracing, the “absent
FHR accelerations and absent/minimal FHR variabil-
ity” group was more likely to convert to a category I
tracing within 60 minutes than the “FHR accelerations
or moderate FHR variability” group due to improve-
ment in variability. Because we do not have a control
group without oxygen administration, we are not able
to determine if this improvement in the FHR tracing
was due to oxygen administration itself or would have
occurred even without oxygen administration. The
same limitation applies to all the other interventions.
Under normal physiologic conditions in sheep, the
supply of oxygen to the fetus is twice the metabolic
demand; thus, fetal oxygen uptake is not affected until
oxygen delivery is reduced by more than half.8 Fur-
thermore, sheep studies suggest that when fetal hyp-
oxia is not due to maternal hypoxia, maternal oxygen
administration results in increased free radical
markers in the fetus.9 Primate research demonstrates
that, although maternal oxygen supplementation may
correct fetal hypoxia, it will not correct acidosis.10 In
the only three randomized trials investigating the use
of maternal oxygen supplementation in laboring
patients11–13 as well as the Cochrane Database of Sys-
tematic Reviews,14 oxygen supplementation was not
demonstrated to be of benefit to the fetus. The most
recent study was a nonblinded trial in which 114 par-
ticipants with category II tracings were randomized to
room air without a facemask compared with 10 L of
oxygen per minute by nonrebreather facemask until
delivery combined with additional resuscitation meth-
ods after randomization; the study found that room air
was noninferior to maternal oxygen supplementation
for the improvement of umbilical artery lactate, a
marker of fetal metabolic acidosis.13 There was no

Table 6. Neonatal Outcomes by Fetal Heart Rate Tracing Category Postintervention

No Improvement to
Improvement to Category Category I Within
Outcome I Within 60 min (n51,433) 60 min (n5818) OR (95% CI) P

Composite adverse outcome* 38/1,377 (2.8) 25/790 (3.2) 0.87 (0.52–1.45)

Intrapartum fetal death 0 0
Neonatal death 1 (0.1) 0 (0.0)
5-min Apgar score 3 or lower 8 (0.6) 5 (0.6)
Neonatal seizure 2 (0.1) 1 (0.1)
Umbilical artery blood pH 7.05 or less 17/1,376 (1.2) 17/790 (2.2)
Intubation for ventilation at delivery 19 (1.3) 11 (1.3)
Neonatal encephalopathy 2 (0.1) 2 (0.2)
5-min Apgar score 9 (9–9) 9 (9–9) .24
Umbilical artery pH 7.2460.06 7.2360.08 .007
Intermediate care nursery or NICU 169 (11.8) 130 (15.9) 0.71 (0.55–0.91)
OR, odds ratio; NICU, neonatal intensive care unit.
Data are n/N (%), n (%), median (interquartile range), or mean6SD unless otherwise specified.
*Composite adverse outcome is composed of any one of the following occurrences: intrapartum fetal death, neonatal death, 5-minute Apgar
score 3 or lower, neonatal seizure, an umbilical artery blood pH of 7.05 or less with a base deficit of 12 mmol per liter or more,
intubation for ventilation at delivery, or neonatal encephalopathy.

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difference in resolution of recurrent decelerations
within 60 minutes between the O2 (n557) and room
air groups (75.4% vs 86.0%; P5.15), but the sample
size was underpowered to detect a significant differ-
ence.15 Based on a review of the available literature,
Hamel et al16 concluded that maternal oxygen supple-
mentation in labor should be reserved for maternal
hypoxia and is not supported by current evidence as
an intervention for nonreassuring fetal status. There
are currently at least three trials identified in Clinical-
Trials.gov comparing supplemental oxygen to room
air in participants with category II fetal heart tracings.
17
In 63% of participants receiving IV hydration,
amnioinfusion, or tocolytics as intrauterine resuscita-
tion for a category II FHR tracing, there was an
improvement of the FHR tracing to category I within
60 minutes. The underlying mechanisms for the
potential benefits of these interventions are plausible.
Most patients are restricted from taking oral fluids in
labor and typically receive 125 mL/h of IV fluids,
which is inadequate to maintain fluid balance during
labor under typical circumstances. Adequate placenta
perfusion and therefore optimal oxygenation of the
fetus depend on optimal maternal intravascular vol-
ume.18 Randomized controlled trials have demon-
strated the clearest benefit of amnioinfusion for cord
compression patterns most likely associated with oligo-
hydramnios, such as those occurring early in labor or
in a growth-restricted or postdates fetus.19 Tocolysis
with subcutaneous terbutaline 0.25 mg was the least
frequently used intervention, accounting for only 2%
of the intrauterine resuscitation techniques performed.
Excessive contractions can lead to nonreassuring fetal
heart patterns; use of beta-2-sympathomimetic agents
may improve placental blood flow and therefore fetal
oxygenation.18
There are numerous strengths of this study. The
use of data from patients participating in the STAN
trial with availability of the entire fetal heart tracing
available for analysis and careful prospective collection
of intrauterine interventions performed by study staff
limits bias. Furthermore, the use of objective comput-
erized FHR pattern-recognition software preinterven-
tion and postintervention, avoids the bias of health care
professional interpretation by knowledge of an inter-
vention being instituted to improve the FHR pattern.
Additional study design strengths include the large
sample size and the prospective and rigorous data
collection by trained, certified study staff.
A limitation of this study is that improvement in
the FHR pattern cannot be directly ascribed to the
intrauterine intervention because of lack of a control
VOL. 138, NO. 3, SEPTEMBER 2021 Reddy et al
© 2021 by the American College of Obstetricians
and Gynecologists. Published by Wolters Kluwer Health, Inc.
Unauthorized reproduction of this article is prohibited.
group of category II tracings without intervention; the
FHR pattern may have improved within 60 minutes
without any intervention. However, the feasibility of
having a control group without intervention for a
category II tracing is unlikely given the prevailing
clinical practice of intrauterine resuscitation.2 The
cohort in this analysis may not be representative of
the entire population in labor given individuals who
were already receiving interventions were excluded
from the STAN trial. Furthermore, category II FHR
tracings were considered as a single group when, in
fact, there is heterogeneity in patterns, which may
have differing underlying mechanism and progression
rates to category III tracings. Lastly, because the inci-
dences of the composite neonatal morbidity were rel-
atively low in the subgroups of category II tracings,
this study is likely underpowered to detect a difference
in this low-frequency outcome.
In the majority of cases, an intervention for a
category II FHR tracing was followed by an improve-
ment in the FHR tracing to category I. The overall
incidence of composite neonatal adverse outcome was
relatively low for category II tracings in this study.
The participants without improvement of the FHR
tracing pattern after intrapartum interventions did
have an increased need for higher level of neonatal
care. The results of ongoing controlled trials should
help us understand better the magnitude and limita-
tions of the benefits of these widely used interven-
tions, particularly oxygen administration.
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PEER REVIEW HISTORY
Received February 6, 2021. Received in revised form April 29,
2021. Accepted May 6, 2021. Peer reviews and author correspon-
dence are available at http://links.lww.com/AOG/C386.
OBSTETRICS & GYNECOLOGY