The relationship between maternal anemia and electronic fetal monitoring patterns

Shannon E. Beermann, Virginia Y. Watkins, Antonina I. Frolova, Nandini Raghuraman, Alison Cahill

Research output: Contribution to journalArticlepeer-review


Background: Anemia is a commonly diagnosed comorbidity in pregnancy that is associated with increased risk of maternal and neonatal complications. Recent data demonstrate that maternal anemia is associated with higher umbilical artery and umbilical vein O2 content at the time of delivery. Objective: This study aimed to examine the relationship between maternal anemia and electronic fetal monitoring patterns associated with fetal hypoxia. Study Design: This is a secondary analysis of a prospective cohort study of singleton term deliveries with cord gases and universal complete blood count collected on admission between 2010 and 2014. Maternal anemia was defined as hemoglobin ≤11.0 g/dL on admission. The primary outcome was a composite of high-risk category 2 electronic fetal monitoring features in the last 60 minutes before delivery (recurrent late and/or variable decelerations, minimal variability, tachycardia, or >1 prolonged deceleration); secondary outcomes were total deceleration area and total deceleration area >90th percentile. Of the 8580 patients in the original study, 8196 were included in the analysis. Outcomes were compared between patients with and without anemia. Multivariable logistic regression was used to adjust for potentially confounding factors, including hypertensive disorders of pregnancy and induction of labor. Results: Of the 8196 patients with complete blood count on admission and fetal monitoring data, 2672 (32.6%; 2672/8196) were anemic and 5524 (67.4%; 5524/8196) were not. Patients with anemia were significantly less likely to have composite high-risk category 2 features on electronic fetal monitoring (34.2% vs 32.0%; adjusted risk ratio, 0.93; 95% confidence interval, 0.86–0.99). Women with anemia also had decreased total deceleration area and were less likely to have total deceleration area >90th percentile (18.7% vs 16.2%; adjusted risk ratio, 0.85; 95% confidence interval, 0.77–0.94). Conclusion: Patients with anemia are less likely to have high-risk category 2 electronic fetal monitoring features associated with fetal hypoxia. This finding is consistent with the association between maternal anemia and increased umbilical cord O2 content, and suggests that maternal anemia may be protective against intrapartum fetal hypoxia.

Original languageEnglish
Pages (from-to)449.e1-449.e6
JournalAmerican journal of obstetrics and gynecology
Issue number4
StatePublished - Oct 2023


  • anemia
  • anemia in pregnancy
  • category 2 fetal monitoring
  • composite category 2 patterns
  • electronic fetal monitoring
  • fetal tolerance of labor
  • high-risk category 2 features
  • intrapartum anemia
  • maternal anemia
  • total deceleration area


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