The "fetal Reserve Index": Re-Engineering the Interpretation and Responses to Fetal Heart Rate Patterns

Robert D. Eden, Mark I. Evans, Shara M. Evans, Barry S. Schifrin

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


Objective: Electronic fetal monitoring (EFM) correlates poorly with neonatal outcome. We present a new metric: the "Fetal Reserve Index" (FRI), formally incorporating EFM with maternal, obstetrical, fetal risk factors, and excessive uterine activity for assessment of risk for cerebral palsy (CP). Methods: We performed a retrospective, case-control series of 50 term CP cases with apparent intrapartum neurological injury and 200 controls. All were deemed neurologically normal on admission. We compared the FRI against ACOG Category (I-III) system and long-term outcome parameters against ACOG monograph (NEACP) requirements for labor-induced fetal neurological injury. Results: Abnormal FRI's identified 100% of CP cases and did so hours before injury. ACOG Category III identified only 44% and much later. Retrospective ACOG monograph criteria were found in at most 30% of intrapartum-acquired CP patients; only 27% had umbilical or neonatal pH <7.0. Conclusions: In this initial, retrospective trial, an abnormal FRI identified all cases of labor-related neurological injury more reliably and earlier than Category III, which may allow fetal therapy by intrauterine resuscitation. The combination of traditional EFM with maternal, obstetrical, and fetal risk factors creating the FRI performed much better as a screening test than EFM alone. Our quantified screening system needs further evaluation in prospective trials.

Original languageEnglish
Pages (from-to)90-104
Number of pages15
JournalFetal Diagnosis and Therapy
Issue number2
StatePublished - 1 Feb 2018


  • ACOG monitoring classification system
  • Cerebral palsy
  • Electronic fetal monitoring
  • Fetal Reserve Index
  • Intrauterine resuscitation
  • Neonatal encephalopathy


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