Summary of Dr. Chapa’s Clinical Pearls

Episode: New Intrapartum FHT Guidance: Oct 2025 CPG 10

Date: September 21, 2025
Host: Dr. Chapa

Episode Overview

This episode covers the imminent release of ACOG’s new Clinical Practice Guidance (CPG) Number 10, set for October 2025, which focuses on intrapartum fetal heart rate (FHR) monitoring. Dr. Chapa breaks down what’s new (and not so new) in this guideline, with a practical, evidence-based review for clinicians. The core of the episode revolves around three main points in the new guidance: the role of intermittent fetal monitoring, updated recommendations on maternal oxygen administration, and the official stance on artificial intelligence (AI) for FHR interpretation in labor.

Key Discussion Points & Insights

The Ubiquity and Limitations of Fetal Heart Rate Monitoring

Continuous fetal heart monitoring is deeply embedded in labor management, despite not reducing rates of neonatal death or long-term neurological issues.
Some benefit exists for continuous monitoring (notably, in reducing immediate neonatal seizures), but data show increased rates of operative deliveries (both vaginal and cesarean) without decreasing mortality.
“We are stuck with continuous electronic fetal monitoring.” (04:30)
Despite discussions about multi-tier systems, the three-category system (I, II, III) remains the standard.

[07:30] Overview: What’s in CPG 10?

Quote: “In October of 2025, so in about two weeks, ACOG is releasing its new clinical practice guidance on intrapartum fetal heart rate monitoring, interpretation and management.”
— Dr. Chapa (07:30)

ACOG’s CPG 10 doesn’t fundamentally change core definitions, but it gives official direction on:

When intermittent monitoring is appropriate
The role (or lack thereof) of maternal oxygen for rescue
Current evidence on AI in fetal tracing interpretation

1. [13:00] Intermittent Auscultation: When and for Whom?

Intermittent auscultation is acceptable—but only in low-risk patients (no oxytocin, no prior cesarean/TOLAC).
- Quote: “Intermittent auscultation may be used during labor for patients at low risk of fetal acidemia who are not receiving oxytocin.” (14:58)
Continuous monitoring is recommended for TOLAC (trial of labor after cesarean) per previous ACOG guidance (PB 205, Feb 2019) and for patients on oxytocin.
Recommended intervals:
- Active first stage: Every 15–30 minutes
- Second stage: Every 5–15 minutes
- Use a handheld Doppler during the contraction and for at least 30 seconds after.
- Caveat: Optimal frequency is not rigid; guidance is based on consensus from ACNM and AWHONN.
Document recordings for accountability and clarity.
“Most providers are comfortable with continuous […] but in the appropriately selected low risk patient, which means not on Pitocin and not a TOLAC, then intermittent auscultation can be performed with those time guidances.” (24:13)

2. [28:00] Maternal Oxygen as a Rescue Measure: JUST SAY NO

Quote: “ACOG recommends against— that means don’t do it— routine maternal oxygen administration for category 2 or 3 fetal heart rate tracing in the absence of maternal hypoxia.” (28:50)

Supplemental oxygen has been widely used as a ‘rescue’ measure for non-reassuring FHR strips, but new guidance makes it clear: Don’t do it unless the mother is hypoxic or obtunded.
- Risks: For preterm infants, excess oxygen can generate free radicals, possibly causing harm (e.g., to the germinal matrix).
- Evidence: No improvements found in pH, Apgar, or NICU admissions when oxygen is used without maternal hypoxia.
- Correction strategies: Reduce contraction frequency (if tachysystole), IV fluids, maternal repositioning—not oxygen.
“The idea of, well, it can't hurt and it could possibly help is wrong on both counts.” (29:15)

3. [34:15] Artificial Intelligence in FHR Interpretation

Quote: “The ACOG recommends against primary reliance on computerized approaches for the interpretation and management of the fetal heart rate in labor.” (35:12)

AI is promising in medicine (notably in image-based tasks like mammography), but for FHR interpretation, it’s not yet ready to guide clinical management.
- Systematic reviews/meta-analyses (>55,000 patients): No improvement in neonatal outcomes with AI use for intrapartum FHR interpretation.
- Current recommendation: Use AI as an educational/research tool, not as the primary basis for management.
- Vendor warning: No professional endorsements yet for any commercial AI FHR interpretation products.
“Maybe use this as an ancillary […] but it should not be relied on as the primary interpretive tool.” (36:10)
“At this time there are no clinical trials that support the notion that computer based fetal heart rate interpretation improves neonatal outcome.” (36:51)

Note: STAN (ST segment analysis) also not endorsed

Early hope, but not recommended due to lack of reproducible benefit: “We recommend against its use because it’s just not reproducible and doesn’t really change any outcome.” (38:10)

[11:35–13:00] Notable Clinical Stories: “Three Saves”

Dr. Chapa shares three acute cases emphasizing the importance of rapid and accurate FHR interpretation:

Case 1: 29-weeker with severe preeclampsia; classic Category III tracing—OR in 20 minutes, baby saved (cord gas pH 6.9).
- “20 minutes more at the house, this child could have died. That was a save.” (12:24)
Case 2: Abruptio placentae (teenager, primigravida); rapid identification, delivery in 25 minutes, Apgar 1 at 1 min, 8 at 8 min.
Case 3: Anticipated shoulder dystocia avoided by identifying macrosomia (4.5 kg) in diabetic mother—planned cesarean, uncomplicated delivery.

Takeaway: Knowing and promptly responding to FHR categories is literally lifesaving.

“Not today, Satan. Not today. Those are three saves.” (13:12)

[42:10] Memorable Quotes & Moments

“What has been will be again. What has been done will be done again. There is nothing new under the sun. Is there anything of which one can say, look, this is something new? It was here already long ago.” (06:45, quoting Ecclesiastes)
“Even though continuous monitoring has issues, it allows for easier interpretation, it allows for a better record.” (22:49)

[41:00] Episode Wrap-Up

Key Takeaways:

Intermittent auscultation is okay, in select, low-risk cases without oxytocin or TOLAC, at recommended intervals.
Do not use maternal O2 for FHR rescue in the absence of hypoxia.
AI/computerized tools for FHR are not ready or endorsed for primary clinical decision-making.

Dr. Chapa closes with gratitude for his team’s hard work and a preview of continued in-depth, no-spin reviews of new women’s health publications.

For Listeners

For deeply practical, up-to-date, and always entertaining clinical guidance on women’s health, keep tuning in to “Dr. Chapa’s Clinical Pearls”!

Transcript

A (0:00)

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B (1:08)

Do you ever like, drive home or as soon as you get home from labor and delivery and you still hear the baby's heart tracing in your head, does that happen to you or does that only happen to me? I mean, that little gallop, right? It happens to me. I get home, I'm like oh my gosh, I gotta get this thing out of my head. Or I hear my imaginary pager or my phone go off when when I'm home and I don't even have the darn thing with me. Anyway, Fetal heart tracings are ubiquitous in labor and delivery and they're fully integrated into what we do. They're part of our everyday labor management, despite the fact that they really haven't done anything to reduce the rate of neonatal death or long term neurological sequelae. Now, there is some benefit for continuous fetal tracing, like the prevention of immediate neonatal seizures. But we know that outside of that, really all that the external or continuous fetal monitoring does is increase interventions like operative vaginal delivery or operative abdominal delivery. But nonetheless, we are stuck with continuous electronic fetal monitoring. Now there is a place where intermittent fetal monitoring can be done, according to the college, and this is in the otherwise low risk patient. They are not a toe lacquer. In other words, they don't have a previous C section and they don't have pitocin augmentation in that criteria. Low risk, not on pitocin, and they're not a toe lacquer in other words, they're not having a previous C section history. Intermittent fetal auscultation can be okay, but the vast majority of the time, just for ease of use and for reproducibility, most are comfortable with continuous external fetal monitoring, despite its limitations. Okay, so again, going back all the way to the 60s, fetal monitoring, whether external or internal, is here to stay. Since that time, we're now talking about. Oh my goodness, 60 years. Is that 60? 40. Yeah, 60 years since the 1960s when it was first introduced. Yet nonetheless, currently more than 1/4. Guys, that's 27% of primary C sections are done to, due to some non reassuring fetal heart rate tracing precision, category two or category three. And so it's important, it's vital that we all speak the same language. Now if you're thinking, wait, what the heck is this? I mean, we already, we already know the intrapartum category one, two and three designation. Absolutely. And we, we definitely do. Although some have proposed a five tier system. Hasn't really taken off. That's old. It has been for at least a decade where that was introduced to break up category two in its current form into three different categories. So you end up with five categories total. But it's kind of clunky, it's, it's kind of messy. So, so unfortunately, despite its limitations, we're stuck with category one, two and three intrapartum. Now, we're talking about this because in October of 2025, so in about two weeks, ACOG is releasing its new clinical practice guidance on intrapartum fetal heart rate monitoring, interpretation and management. Now, first of all, if you listen to our show for some time, you know that we've covered this topic a variety of times in the past from what to do with the category 2. What does category 3 mean? Why does it look that way? And none of that has changed, by the way. Category one is still good. Category three is still in general, pretty darn bad and actionable. Category two is gray, unfortunately, 70 to 80% based on who you read of intrapartum tracing, that one point or the other will be category two, which means you have to evaluate, do something, don't wait, don't delay. But it doesn't necessarily mean you have to run to section. You have to do something. And if it doesn't correct, then you may progress to C section. Of course, the worst predictor is when you watch intrapartum the, the predictable and progressive deterioration of the strip. So if it starts category one, category two doesn't resolve. You do your maneuvers, you take Away Pitocin, you give terbutaline. If it's tachystole, you give IV fluids reposition. If none of that happens in the progressive category, three, that in vivo real time deterior, that's a big flag for metabolic acidosis. Okay, so we know none of that has changed. As we have said many times before, you know, sometimes things that come out in print are new because it's a new publication. And that's our promise and our commitment on the show is let you know what's fresh and new and hot in print. This is coming out again October of 2025. But at the same time, there's nothing new. Remember, nothing is new under the sun. That's just the way they go sometimes. And we've covered that many times before on this show. What has been will be again. What has been done will be done again. There is nothing new under the sun. Is there anything of which one can say, look, this is something new. It was here already long ago. It was here before our time. There is no remembrance of men of old, and even those who are yet to come will not be remembered by those who follow. The whole idea. Thank you, Solomon, is that nothing is new under the sun. I love that. I love that because it's so absolutely true. But we still have to check this, check the data, check the science, to either verify it or refute it. And that is what is in this. Clinical practice guidance coming out in October, which is number 10, clinical practice guidance or CPG, number 10, intrapartum fetal heart rate monitoring, interpretation and management. Very quickly, I'm just going to tell you the three main points, guys, three. That's it. Three main points here as a reminder, because we've covered this already in the show, but three points here of things that are vital for us to remember. The first has to do with what we've already mentioned. Is there a place for intermittent fetal monitoring? And the short answer is I've already spilled the beans there because it's yes. Otherwise low risk, not being stimulated with oxytocin and not having a previous history of C section. So. So that's the end of that. Even though there have been some gaps there in terms of how frequent you should check, there's some guidance, but that there's no real set de facto protocol. Everyone does it differently. So is there a place for intermittent fetal heart rate tracing interpretation or Doppler assessment? Yes, and we're going to cover that briefly. Second, has to do with maternal oxygenation as a way to rescue category 2 tracings. Now I know if you're part of our podcast community, you, you've heard me talk about this. Cuz the short answer is stop doing that. Unless mom is hypoxic or uptunded, which goes with the cause of her hypoxia. Giving mom additional supplemental oxygen to quote unquote, fix a Category 2 strip, not only is it not evidence based, potentially, according to some limited studies, could be harmful, especially in the extreme preterm child, because that could trigger free radical formation. Fetal hemoglobin is such an avid binder of low partial pressures of O2 that you don't need to give supplemental oxygen. We're going to briefly touch on that, even though it seems that we're touching on it right now. And the number three is has to do with AI. That's right, artificial intelligence, because that is a big deal. Artificial intelligence is definitely in medicine and I've covered this in the past in terms of mammography. It does great to listen for to pick up some small visual cues that that a physician Ms. On first inspection. So AI for mammography or even for brain scans. Phenomenal. There's definitely a benefit for that. The question is, even though there's some companies already having packages of AI for fetal heart rate tracings, what does ACOG say? What is the official stance as of October 2025 regarding AI technology for interpretation of these strips? We're going to talk about that. So those are the three things we're going to do. Okay. We're going to talk about the use of intermittent fetal monitoring when applicable. We're going to talk about maternal O2 and how it really does have some limitations. We've got to be careful with that. And then we're going to talk about AI and fetal heart rate tracing potentially at some point, guys, we're going to get there. I have no doubt that we are going to do AI as an adjuvant, especially on the Category 2 tracings. And there's plenty of published data for that. Plenty. But as of right now, we're just not there. We're not there because there's a lot of questions that remain. So I think I've set it up enough. That's what we're going to talk about. We're going to review ACOG's new Clinical Practice Guidance Number 10 coming out in October 2025. We'll be right back. Tired of all the spin in women's health education? Yeah, so are we. This is Dr. Chapa's OBGYN no Spin podcast. Eczema isn't always obvious, but it's real. And so is the relief from EBGLIS. After an initial dosing phase, about 4 in 10 people taking EVGLIS achieved itch relief and clear or almost clear skin at 16 weeks. And most of those people maintain skin that's still more clear at one year with monthly dosing.