The recent article by Blackwell et al evidenced that the reliability of visual analysis of fetal heart rate (FHR) tracings when performed according to the latest version of the American guidelines was limited and no better than chance in the most severe class. The authors also reported that an important number of tracings could not be classified.

For more than 30 years, researchers have been exposing the poor reliability of FHR interpretation according to different interpretation guidelines. The impact of poor reliability on the accuracy and on the effectiveness of FHR analysis has been well demonstrated, and the limited value of the latter 2 aspects has been well established, but the problem of poor reliability seems to be largely looked on as something disagreeable that comes up from time to time, but life afterward carries on as usual.

But can anything be done to improve the reliability of FHR analysis?

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  One possible direction is to simplify existing guidelines. A recent comparison of the 3 major sets of interpretation guidelines suggested that they remain complex, somewhat subjective, and prone to memory decay. A simpler and more objective set of guidelines could provide better reliability.

  
  
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  Given the limitations of FHR analysis, use of ancillary tests, such as fetal blood sampling or fetal electrocardiogram analysis is suggested. The latter may still be improved because it relies on FHR analysis to decide intervention and the classification system proposed has also been shown to be poorly reliable.

  
  
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  Regular training in FHR interpretation was shown to result in higher reliability in a systematic review that evaluated computer-based programs, lectures, case studies, audits, and simulated clinical scenarios. It has now to be determined which is the most efficient training method or how often does training need to be repeated.

  
  
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  Finally, there is evidence that computer analysis of FHR tracings can accurately identify cases of newborn metabolic acidosis. Several programs have been developed for this purpose and some are already undergoing evaluation in randomized clinical trials.

FHR monitoring remains widely used in clinical practice and there can be devastating consequences to an inadequate FHR interpretation, leading to an incorrect clinical decision. Therefore, we believe that it is time that increased efforts are put into the development of solutions to overcome the limited reliability of the method.