Johns Hopkins clinicians and engineers are developing a new tool for noninvasive intrapartum fetal brain monitoring.

For more than 50 years, obstetricians relied on electronic fetal heart rate monitors during delivery to watch for signs of insufficient oxygen flow to the brain of the fetus during labor and delivery.

Now, Johns Hopkins clinicians and engineers are working to develop a better system, one that could radically improve the safety of the fetus during labor and delivery at Johns Hopkins and around the world.

The team includes Ernie Graham, professor of gynecology and obstetrics, Ray Koehler, professor of anesthesiology and critical care medicine, Jeeun Kang, assistant professor in the Department of Anesthesiology and Critical Care Medicine, and Emad Boctor, associate professor in the Johns Hopkins Whiting School of Engineering.

Graham, director of the obstetric outreach program, says the current system is deeply flawed, generating an extremely high rate of false positives and unnecessary cesarean deliveries.

“Monitoring the fetus during labor is one of the most consequential decisions we make in obstetrics,” says Graham. “And right now, we’re relying on a tool that simply doesn’t tell us what we need to know. Fetal heart rate alone cannot reliably distinguish a baby who is truly in distress from one who is not.”

He says some studies put the rate of false positives at 99.8%. The rate of cesarean deliveries rose from about 5% in 1970 when fetal heart rate monitoring was still new, to roughly a third of deliveries today because obstetricians perform them prophylactically early in the course of deceleration.

Graham and other Johns Hopkins clinicians collaborated with engineers from the Whiting School to develop an entirely new fetal monitoring tool, which he says is far more accurate in determining the oxygen status of a fetal brain during labor and delivery. They published an analysis of the concept in Experimental Neurology in January 2022.

The FOCUS (fetal oxygenation and continuous ultrasound surveillance) tool, which uses photoacoustic assessments of oxygen levels in the fetus’s brain and mother’s placenta, needs approval from the Food and Drug Administration before clinical trials can begin, he says.

The device uses near-infrared light, which excites the hemoglobin in the fetus’s brain, sending back a sound wave that can be measured through the abdominal wall.

The wearable, wireless device is easy for clinicians to use, Graham says, and provides continuous monitoring during labor and delivery. “For the first time, we would have a real-time window into the baby’s brain during labor — something we’ve never had before,” he says. “That has the potential to fundamentally change how we make decisions in the delivery room.”

Graham says the innovation is possible because of the cross-disciplinary collaboration at Johns Hopkins. “As clinicians, we understand the stakes at the bedside, but solving a problem this complex requires deep engineering expertise,” he says. “What makes Johns Hopkins unique is the ability to bring those worlds together in a meaningful, translational way.”

Graham says he, like other obstetricians, has been aware of the problem for a long time.

He began working with Koehler, an expert in perinatal physiology, who had been using near-infrared light waves to measure oxygen levels in the neonatal brain. They thought they could use a related approach in the fetus.

With engineers Boctor and Kang, they developed FOCUS.

“We owe mothers and babies better than the status quo,” Graham says. “If validated in clinical trials, this technology could represent a paradigm shift in how we monitor fetal well-being and prevent unnecessary interventions.”

Medically reviewed by: Ernie Graham, MD