Recommended Citation
Trenhs S, Pietrzak L, Lamptey M, Kram JJF, Cox Bauer C. Evaluating Adherence to Fetal Heart Rate Monitoring Guidelines as a Decision for Primary Cesarean Deliveries. Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Background/Significance:
Cesarean delivery rates in the United States remain high at ~32% of deliveries. Primary cesarean deliveries or Nulliparous, Term, Singleton, Vertex (NTSV) cesareans are ~26%. National benchmarks focus on reducing NTSV cesareans as a key strategy to addressing the overall cesarean delivery rate. While the NTSV benchmark (NTSV rate 23.6% or lower) is an important benchmark for quality improvement, it does not account for clinical factors that may influence delivery decisions. Non-reassuring fetal status (Category II or III) is a frequent indication for NTSV cesareans, yet it is inconsistently defined and fetal heart rate (FHR) monitoring guidelines (Clark guidelines) are variably applied in clinical practice.
Purpose:
To determine the rate of NTSV cesareans and adherence to FHR guidelines.
Methods:
We conducted a quality improvement project within one urban, teaching hospital among patients ≥ 37 weeks’ gestation who presented with a singleton, vertex pregnancy for their first term live birth between 6/1/2021-6/1/2022. NTSV cesarean maternal/neonatal characteristics and outcomes were further reviewed and collected. For cases citing non-reassuring fetal status, FHR tracings and labor progression data were separately reviewed by two OB/GYN physicians to assess adherence to Clark guidelines. Discrepancies between interpretations were reviewed by a third OB/GYN physician for a final decision on adherence. Basic descriptive statistics were computed.
Results:
There were a total of 528 NTSVs with a cesarean rate of 24.1% (N=127). Patients were of median age 25.0 years, and were predominately Black, non-Hispanic (48.8%) with median gestational age of 39w3d. Overall, 61.3% had >10 prenatal visits at that facility. Pre-pregnancy/pregnancy characteristics include diabetes (4.7%), gestational diabetes (3.9%), chronic hypertension (7.1%), and gestational hypertension (29.9%). Of NTSV cesareans citing non-reassuring fetal heart tones (66.1%, N=84), 61.9% did not meet Clark guidelines; those not meeting criteria had 11.5% and 88.5% decreased and increased time, respectively. Neonates born within this subpopulation had a median 5-min APGAR of 9.0; 14.3% were admitted to the NICU.
Conclusion:
While non-reassuring fetal status was the most common indication for NTSV cesarean delivery, over 50% did not meet Clark guidelines, suggesting inconsistent FHR interpretation. Improving adherence to standardized guidelines may help reduce preventable primary cesareans while maintaining maternal and neonatal safety.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
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Document Type
Oral/Podium Presentation
Evaluating Adherence to Fetal Heart Rate Monitoring Guidelines as a Decision for Primary Cesarean Deliveries
Background/Significance:
Cesarean delivery rates in the United States remain high at ~32% of deliveries. Primary cesarean deliveries or Nulliparous, Term, Singleton, Vertex (NTSV) cesareans are ~26%. National benchmarks focus on reducing NTSV cesareans as a key strategy to addressing the overall cesarean delivery rate. While the NTSV benchmark (NTSV rate 23.6% or lower) is an important benchmark for quality improvement, it does not account for clinical factors that may influence delivery decisions. Non-reassuring fetal status (Category II or III) is a frequent indication for NTSV cesareans, yet it is inconsistently defined and fetal heart rate (FHR) monitoring guidelines (Clark guidelines) are variably applied in clinical practice.
Purpose:
To determine the rate of NTSV cesareans and adherence to FHR guidelines.
Methods:
We conducted a quality improvement project within one urban, teaching hospital among patients ≥ 37 weeks’ gestation who presented with a singleton, vertex pregnancy for their first term live birth between 6/1/2021-6/1/2022. NTSV cesarean maternal/neonatal characteristics and outcomes were further reviewed and collected. For cases citing non-reassuring fetal status, FHR tracings and labor progression data were separately reviewed by two OB/GYN physicians to assess adherence to Clark guidelines. Discrepancies between interpretations were reviewed by a third OB/GYN physician for a final decision on adherence. Basic descriptive statistics were computed.
Results:
There were a total of 528 NTSVs with a cesarean rate of 24.1% (N=127). Patients were of median age 25.0 years, and were predominately Black, non-Hispanic (48.8%) with median gestational age of 39w3d. Overall, 61.3% had >10 prenatal visits at that facility. Pre-pregnancy/pregnancy characteristics include diabetes (4.7%), gestational diabetes (3.9%), chronic hypertension (7.1%), and gestational hypertension (29.9%). Of NTSV cesareans citing non-reassuring fetal heart tones (66.1%, N=84), 61.9% did not meet Clark guidelines; those not meeting criteria had 11.5% and 88.5% decreased and increased time, respectively. Neonates born within this subpopulation had a median 5-min APGAR of 9.0; 14.3% were admitted to the NICU.
Conclusion:
While non-reassuring fetal status was the most common indication for NTSV cesarean delivery, over 50% did not meet Clark guidelines, suggesting inconsistent FHR interpretation. Improving adherence to standardized guidelines may help reduce preventable primary cesareans while maintaining maternal and neonatal safety.
Affiliations
Aurora Sinai Medical Center, Aurora UW Medical Group