Advancements in Fetal Heart Rate Monitoring: A Report on Opportunities and Strategic Initiatives for Better Intrapartum Care

Cardiotocography (CTG), introduced in the 1960s, was initially expected to prevent hypoxia-related deaths and neurological injuries. However, more than five decades later, evidence supporting the evidence of intrapartum CTG in preventing neonatal and long-term childhood morbidity and mortality remains inconclusive. At the same time, shortcomings in CTG interpretation have been recognised as important contributory factors to rising caesarean section rates and missed opportunities for timely interventions. An important limitation is its high false-positive rate and poor specificity, which undermines reliably identifying foetuses at risk of hypoxia-related injuries. These shortcomings are compounded by the technology's significant intra- and interobserver variability, as well as the subjective and complex nature of fetal heart rate interpretation. However, human factors and other environmental factors are equally significant. Advancements in fetal heart rate monitoring are crucial to support clinicians in improving health outcomes for newborns and their mothers, while at the same time avoiding unnecessary operative deliveries. These limitations highlight the clinical need to enhance neonatal outcomes while minimising unnecessary interventions, such as instrumental deliveries or caesarean sections. We believe that achieving this requires a paradigm shift from subjective interpretation of complex and nonspecific fetal heart rate patterns to evidence-based, quantifiable solutions that integrate hardware, engineering and clinical perspectives. Such transformation necessitates an international, multidisciplinary effort encompassing the entire continuum of pregnancy care and the broader healthcare ecosystem, with emphasis on well-defined, actionable health outcomes. Achieving this will depend on collaborations between researchers, clinicians, medical device manufacturers and other relevant stakeholders. This expert review paper outlines the most relevant and promising directions for research and strategic initiatives to address current challenges in fetal heart rate monitoring. Key themes include advancements in computerised fetal heart rate monitoring, the application of big data and artificial intelligence, innovations in home and remote monitoring and consideration of human factors.