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Wisner K, Holschuh C. Fetal Heart Rate Auscultation, 4th Edition. J Obstet Gynecol Neonatal Nurs 2024; 53:e10-e48. [PMID: 38363241 DOI: 10.1016/j.jogn.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.
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Wisner K, Holschuh C. Fetal Heart Rate Auscultation, 4th Edition. Nurs Womens Health 2024; 28:e1-e39. [PMID: 38363259 DOI: 10.1016/j.nwh.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.
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Mitchell JM, Walsh S, O'Byrne LJ, Conrick V, Burke R, Khashan AS, Higgins J, Greene R, Maher GM, McCarthy FP. Association between intrapartum fetal pulse oximetry and adverse perinatal and long-term outcomes: a systematic review and meta-analysis protocol. HRB Open Res 2024; 6:63. [PMID: 38628596 PMCID: PMC11019289 DOI: 10.12688/hrbopenres.13802.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2024] [Indexed: 04/19/2024] Open
Abstract
Background Current methods of intrapartum fetal monitoring based on heart rate, increase the rates of operative delivery but do not prevent or accurately detect fetal hypoxic brain injury. There is a need for more accurate methods of intrapartum fetal surveillance that will decrease the incidence of adverse perinatal and long-term neurodevelopmental outcomes while maintaining the lowest possible rate of obstetric intervention. Fetal pulse oximetry (FPO) is a technology that may contribute to improved intrapartum fetal wellbeing evaluation by providing a non-invasive measurement of fetal oxygenation status. Objective This systematic review and meta-analysis aims to synthesise the evidence examining the association between intrapartum fetal oxygen saturation levels and adverse perinatal and long-term outcomes in the offspring. Methods We will include randomised control trials (RCTs), cohort, cross-sectional and case-control studies which examine the use of FPO during labour as a means of measuring intrapartum fetal oxygen saturation and assess its effectiveness at detecting adverse perinatal and long-term outcomes compared to existing intrapartum surveillance methods. A detailed systematic search of PubMed, EMBASE, CINAHL, The Cochrane Library, Web of Science, ClinicalTrials.Gov and WHO ICTRP will be conducted following a detailed search strategy until February 2024. Three authors will independently review titles, abstracts and full text of articles. Two reviewers will independently extract data using a pre-defined data extraction form and assess the quality of included studies using the Risk of Bias tool for RCTs and Newcastle-Ottawa Scale for observational studies. The grading of recommendations, assessment, development, and evaluation (GRADE) approach will be used to evaluate the certainty of the evidence. We will use random-effects meta-analysis for each exposure-outcome association to calculate pooled estimates using the generic variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-analyses and MOOSE guidelines. PROSPERO registration CRD42023457368 (04/09/2023).
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Affiliation(s)
- Jill M. Mitchell
- INFANT Research Centre, University College Cork, Cork, County Cork, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
| | - Siobhan Walsh
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
| | - Laura J. O'Byrne
- INFANT Research Centre, University College Cork, Cork, County Cork, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
| | - Virginia Conrick
- UCC Library, University College Cork, Cork, County Cork, Ireland
| | - Ray Burke
- Tyndall National Institute, University College Cork, Cork, County Cork, Ireland
| | - Ali S. Khashan
- INFANT Research Centre, University College Cork, Cork, County Cork, Ireland
- School of Public Health, University College Cork, Cork, County Cork, Ireland
| | - John Higgins
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
| | - Richard Greene
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, County Cork, Ireland
| | - Gillian M. Maher
- INFANT Research Centre, University College Cork, Cork, County Cork, Ireland
- School of Public Health, University College Cork, Cork, County Cork, Ireland
| | - Fergus P. McCarthy
- INFANT Research Centre, University College Cork, Cork, County Cork, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, County Cork, Ireland
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Slaoui A, Cordier C, Lefevre-Morane E, Tessier V, Goffinet F, Le Ray C, Bourgeois-Moine A, Sibiude J, Laurent AC, Azria E. Impact of an e-learning training for interpreting intrapartum fetal heart rate monitoring to avoid perinatal asphyxia: A before-after multicenter observational study. J Gynecol Obstet Hum Reprod 2024; 53:102736. [PMID: 38278214 DOI: 10.1016/j.jogoh.2024.102736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/23/2024] [Accepted: 01/23/2024] [Indexed: 01/28/2024]
Abstract
INTRODUCTION Perinatal asphyxia, a condition that results from compromised placental or pulmonary gas exchange during the birth process, is rare but can lead to serious neonatal and long-term consequences. The visual analysis of cardiotocography (CTG) is designed to avoid perinatal asphyxia, but its interpretation can be difficult. Our aim was to test the impact of an e-learning training program for interpreting CTG on the rate of avoidable perinatal asphyxia at term. METHOD We conducted a retrospective multicenter before-after study comparing two periods, before and after the implementation of e-learning training program from July 1, 2016 to December 31, 2016, in CTG interpretation for midwives and obstetricians in five maternity hospitals in the Paris area, France. The training involved theoretical aspects such as fetal physiology and heart rhythm abnormalities, followed by practical exercises using real case studies to enhance skills in interpreting CTG. We included all term births that occurred between the "before" period (July 1 to December 31, 2014) and the "after period (January 1 to June 30, 2017). We excluded multiple pregnancies, antenatal detection of congenital abnormalities, breech births and all scheduled caesarean sections. Perinatal asphyxia cases were analyzed by a pair of experts consisting of midwives and obstetricians, and avoidability of perinatal asphyxia was estimated. The main criterion was the prevalence of avoidable perinatal asphyxia. RESULTS The e-learning program was performed by 83 % of the obstetrician-gynecologists and 65 % of the midwives working in the delivery rooms of the five centers. The prevalence of perinatal asphyxia was 0.45 % (29/7902 births) before the training and 0.54 % (35/7722) after. The rate of perinatal asphyxia rated as avoidable was 0.30 % of live births before the training and 0.28 % after (p = 0.870). The main causes of perinatal asphyxia deemed avoidable were delay in reactions to severe CTG anomalies and errors in the analysis and interpretation of the CTG. These causes did not differ between the two periods. CONCLUSION One session of e-learning training to analyze CTG was not associated with a reduction in avoidable perinatal asphyxia. Other types of e-learning, repeated and implemented over a longer period should be evaluated.
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Affiliation(s)
- Aziz Slaoui
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, FHU PREMA, Paris 75014, France
| | - Cécile Cordier
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, FHU PREMA, Paris 75014, France
| | - Emilie Lefevre-Morane
- Midwifery school of Baudelocque, Université Paris Cité, Assistance Publique-Hôpitaux de Paris, Paris FR-75006, France; Maternité Port-Royal, AP-HP, APHP Centre, Université Paris Cité, FHU PREMA, Paris 75014, France
| | - Véronique Tessier
- Maternité Port-Royal, AP-HP, APHP Centre, Université Paris Cité, FHU PREMA, Paris 75014, France
| | - François Goffinet
- Maternité Port-Royal, AP-HP, APHP Centre, Université Paris Cité, FHU PREMA, Paris 75014, France; CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France
| | - Camille Le Ray
- Maternité Port-Royal, AP-HP, APHP Centre, Université Paris Cité, FHU PREMA, Paris 75014, France; CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France
| | - Agnès Bourgeois-Moine
- Department of Obstetrics and Gynecology, Bichat-Claude Bernard Hospital, AP-HP, Université de Paris, FHU PREMA, Paris, France
| | - Jeanne Sibiude
- Department of Obstetrics and Gynecology, AP-HP, Louis Mourier Hospital, FHU PREMA, Colombes, France; IAME UMR 1137, INSERM, Université de Paris, Paris, France
| | | | - Elie Azria
- Maternity Unit, Groupe Hospitalier Paris Saint Joseph, FHU PREMA, Paris 75014, France; CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Université de Paris, Paris, France.
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Hussain NM, O'Halloran M, McDermott B, Elahi MA. Fetal monitoring technologies for the detection of intrapartum hypoxia - challenges and opportunities. Biomed Phys Eng Express 2024; 10:022002. [PMID: 38118183 DOI: 10.1088/2057-1976/ad17a6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 12/20/2023] [Indexed: 12/22/2023]
Abstract
Intrapartum fetal hypoxia is related to long-term morbidity and mortality of the fetus and the mother. Fetal surveillance is extremely important to minimize the adverse outcomes arising from fetal hypoxia during labour. Several methods have been used in current clinical practice to monitor fetal well-being. For instance, biophysical technologies including cardiotocography, ST-analysis adjunct to cardiotocography, and Doppler ultrasound are used for intrapartum fetal monitoring. However, these technologies result in a high false-positive rate and increased obstetric interventions during labour. Alternatively, biochemical-based technologies including fetal scalp blood sampling and fetal pulse oximetry are used to identify metabolic acidosis and oxygen deprivation resulting from fetal hypoxia. These technologies neither improve clinical outcomes nor reduce unnecessary interventions during labour. Also, there is a need to link the physiological changes during fetal hypoxia to fetal monitoring technologies. The objective of this article is to assess the clinical background of fetal hypoxia and to review existing monitoring technologies for the detection and monitoring of fetal hypoxia. A comprehensive review has been made to predict fetal hypoxia using computational and machine-learning algorithms. The detection of more specific biomarkers or new sensing technologies is also reviewed which may help in the enhancement of the reliability of continuous fetal monitoring and may result in the accurate detection of intrapartum fetal hypoxia.
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Affiliation(s)
- Nadia Muhammad Hussain
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
| | - Martin O'Halloran
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
| | - Barry McDermott
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
- College of Medicine, Nursing & Health Sciences, University of Galway, Ireland
| | - Muhammad Adnan Elahi
- Discipline of Electrical & Electronic Engineering, University of Galway, Ireland
- Translational Medical Device Lab, Lambe Institute for Translational Research, University Hospital Galway, Ireland
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Wanous AA, Ibrahim J, Vats KR. Neonatal resuscitation. Semin Pediatr Surg 2022; 31:151204. [PMID: 36038213 DOI: 10.1016/j.sempedsurg.2022.151204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Amanda A Wanous
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States
| | - John Ibrahim
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States
| | - Kalyani R Vats
- Division of Newborn Medicine, Department of Pediatrics, Children and Magee Women's Hospital, University of Pittsburgh, 300 Halket Street, PA 12513, United States.
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Stoll K, Wang JJ, Niles P, Wells L, Vedam S. I felt so much conflict instead of joy: an analysis of open-ended comments from people in British Columbia who declined care recommendations during pregnancy and childbirth. Reprod Health 2021; 18:79. [PMID: 33858469 PMCID: PMC8048186 DOI: 10.1186/s12978-021-01134-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 04/02/2021] [Indexed: 12/16/2022] Open
Abstract
Background No Canadian studies to date have examined the experiences of people who decline aspects of care during pregnancy and birth. The current analysis bridges this gap by describing comments from 1123 people in British Columbia (BC) who declined a test or procedure that their care provider recommended. Methods In the Changing Childbirth in BC study, childbearing people designed a mixed-methods study, including a cross-sectional survey on experiences of provider-patient interactions over the course of maternity care. We conducted a descriptive quantitative content analysis of 1540 open ended comments about declining care recommendations. Results More than half of all study participants (n = 2100) declined care at some point during pregnancy, birth, or the postpartum period (53.5%), making this a common phenomenon. Participants most commonly declined genetic or gestational diabetes testing, ultrasounds, induction of labour, pharmaceutical pain management during labour, and eye prophylaxis for the newborn. Some people reported that care providers accepted or supported their decision, and others described pressure and coercion from providers. These negative interactions resulted in childbearing people feeling invisible, disempowered and in some cases traumatized. Loss of trust in healthcare providers were also described by childbearing people whose preferences were not respected whereas those who felt informed about their options and supported to make decisions about their care reported positive birth experiences. Conclusions Declining care is common during pregnancy and birth and care provider reactions and behaviours greatly influence how childbearing people experience these events. Our findings confirm that clinicians need further training in person-centred decision-making, including respectful communication even when choices fall outside of standard care.
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Affiliation(s)
- Kathrin Stoll
- Birth Place Lab, Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada.
| | - Jessie J Wang
- Faculty of Medicine, University of British Columbia, 317-2194 Health Sciences Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Paulomi Niles
- Birth Place Lab, Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada.,New York University Rory Meyers College of Nursing, 433 1st Avenue, New York, NY, 10010, USA
| | - Lindsay Wells
- Midwifery Education Program, Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
| | - Saraswathi Vedam
- Birth Place Lab, Department of Family Practice, University of British Columbia, 304-5950 University Blvd, Vancouver, BC, V6T 1Z3, Canada
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Dall'asta A, Ghi T, Mappa I, Maqina P, Frusca T, Rizzo G. Intrapartum Doppler ultrasound: where are we now? Minerva Obstet Gynecol 2021; 73:94-102. [PMID: 33215908 DOI: 10.23736/s2724-606x.20.04698-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Intrapartum hypoxic events most commonly occur in low-risk pregnancies with appropriately grown fetuses. Continuous intrapartum monitoring by means of cardiotocography has not demonstrated a reduction in the frequency of adverse perinatal outcome but has been linked with an increase in the caesarean section rate, particularly among women considered at low risk. Available data from the literature suggests that abnormalities in the uterine artery Doppler and in the ratio between fetal cerebral and umbilical Doppler (i.e. cerebroplacental ratio [CPR]) are associated with conditions of subclinical placental function occurring in fetuses who have failed to achieve their growth potential regardless of their actual size. In this review we summarize the available evidence on the use of intrapartum Doppler ultrasound for the fetal surveillance during labor and the identification of the fetuses at risk of intrapartum distress.
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Affiliation(s)
- Andrea Dall'asta
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy -
- Department of Metabolism, Digestion and Reproduction, Institute of Reproductive and Developmental Biology, Imperial College London, London, UK -
| | - Tullio Ghi
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Ilenia Mappa
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
| | - Pavjola Maqina
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
| | - Tiziana Frusca
- Unit of Obstetrics and Gynecology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Giuseppe Rizzo
- Division of Maternal and Fetal Medicine, Cristo Re Hospital, Tor Vergata University, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
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Oikonomou M, Chandraharan E. Fetal heart rate monitoring in labor: from pattern recognition to fetal physiology. Minerva Obstet Gynecol 2020; 73:19-33. [PMID: 33238664 DOI: 10.23736/s2724-606x.20.04666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The journey of human labor involves hypoxic and mechanical stresses as a result of progressively increasing frequency, duration and strength of uterine contractions and resultant compression of the umbilical cord. In addition, occlusion of the spiral arteries during myometrial contractions also leads to repetitive interruptions in the utero-placental circulation, predisposing a fetus to progressively worsening hypoxic stress as labor progresses. The vast majority of fetuses are equipped with compensatory mechanisms to withstand these hypoxic and mechanical stresses. They emerge unharmed at birth. However, some fetuses may sustain an antenatal injury or experience a chronic utero-placental insufficiency prior to the onset of labor. These may impair the fetus to compensate for the ongoing hypoxic stress secondary to ongoing uterine contractions. Non-hypoxic pathways of neurological damage such as chorioamnionitis, fetal anemia or an acute fetal hypovolemia may potentiate fetal neurological injury, especially in the presence of a super-imposed, additional hypoxic stress. The use of utero-tonic agents to induce or augment labor may increase the risk of hypoxic-ischemic injury. Clinicians need to move away from "pattern recognition" guidelines ("normal," "suspicious," "pathological"), and apply the knowledge of fetal physiology to differentiate fetal compensation from decompensation. Individualization of care is essential to optimize outcomes.
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Affiliation(s)
- Maria Oikonomou
- Department of Obstetrics and Gynecology, Watford General Hospital, Watford, UK -
| | - Edwin Chandraharan
- Department of Intrapartum Care Obstetrics and Gynecology, Basildon and Thurrock University Hospital, Basildon, UK
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Sharma J, Tiwari S, Padhye SM, Mahato B. Prevalence of Repeat Cesarean Section in a Tertiary Care Hospital. JNMA J Nepal Med Assoc 2020; 58:650-653. [PMID: 33068084 PMCID: PMC7580334 DOI: 10.31729/jnma.5375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Cesarean section is the surgical delivery of a baby through an incision made in the mother's abdomen and uterus. Repeat cesarean section has recently increased, partly because of concern about increased risk of uterine rupture in women attempting vaginal birth after cesarean delivery. Among the women who underwent cesarean section in their first delivery, 80-96% had a second surgical delivery. Therefore, the present study aimed to describe the prevalence of repeat cesarean section among Nepali women presented at Kathmandu Medical College and Teaching Hospital who had a previous cesarean section. METHODS This was a descriptive cross-sectional study conducted in Kathmandu Medical College and Teaching Hospital from 1st of February to 31st of May 2020. Ethical approval was taken from the Institutional Review Committee of the Kathmandu Medical College. Convenient sampling was done. All pregnant patients between gestational ages of 37-40 weeks with previous cesarean section admitted for safe confinement were included in the study. RESULTS Among the 104 women, who had prior cesarean section, 99 (95.19%) had second cesarean section and 5 (4.81%) had vaginal birth after cesarean. The most common indication for the first cesarean section was fetal distress 31 (29.81%) while the indication for the second cesarean section among previously cesarean section women was cephalo pelvic disproportion 39 (39.40%). CONCLUSIONS The proportion of cesarean section in both first and subsequent delivery is quite high. This high rate may compromise the reproductive future of the women who underwent consecutive cesarean section with possible consequent complications.
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Affiliation(s)
- Jyotshna Sharma
- Department of Obstetrics and Gynaecology, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal
| | - Sanjeeb Tiwari
- Department of General Practice and Emergency Medicine, Maharajgunj Medical Campus, Institute of Medicine, T.U., Maharajgunj, Kathmandu, Nepal
| | - Saraswati M Padhye
- Department of Obstetrics and Gynaecology, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal
| | - Bidya Mahato
- Department of Obstetrics and Gynaecology, Kathmandu Medical College, Sinamangal, Kathmandu, Nepal
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Sindiani A, Rawashdeh H, Obeidat N, Zayed F, Alhowary AA. Factors that influenced pregnant women with one previous caesarean section regarding their mode of delivery. Ann Med Surg (Lond) 2020; 55:124-130. [PMID: 32477510 PMCID: PMC7251298 DOI: 10.1016/j.amsu.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 05/01/2020] [Accepted: 05/06/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND During the last decades, the rate of caesarean section is increasing and this can increase the mortality and morbidity. Up to one third of the caesarean sections are attributed to the elective repeat caesarean section (ERCS). This study aims to evaluate attitudes and factors affecting the choice of pregnant women with one previous caesarean section regarding their mode of delivery in their second pregnancy. By assessing these attitudes, this study can help the efforts in developing strategies to increase the rates of vaginal delivery. MATERIAL AND METHODS A cross-sectional design was conducted by a structured questionnaire on 166 pregnant women who had delivered once by caesarean section for their first pregnancy and were in the third trimester of their second pregnancy. Any women with an absolute indication for caesarean section was excluded. The study comprises women who attend the clinic at our center in Northern of Jordan. Proper statistical tests were performed to assess the association between the choice of delivery and selected demographic and clinical factors. RESULTS About 55.4% responded that they would choose ERCS (n = 92) and the remaining participants chose trial of labour after caesarean section (TOLAC) (n = 74). Fear of pain was the most common reason for choosing caesarean section, accounting for 55.4%. Interestingly, our study did not show a significant association between the mode of delivery and demographic factors, such as age, educational level and occupation. The single independent significant factor influencing patients' choice that our study revealed was "being informed about the complications of TOLAC". The choice of TOLAC was almost four times higher for those participants who had been informed about the complications, compared to those who had not been informed. CONCLUSION Proper counselling is a main factor that affected the patients' choice toward the mode of delivery. Proper pain management may encourage patients to choose TOLAC because fear of pain was a main reason that patients requested ERCS instead of TOLAC.
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Affiliation(s)
- Amer Sindiani
- Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Hasan Rawashdeh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Nail Obeidat
- Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Faheem Zayed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 22110, Jordan
| | - Ala”a A. Alhowary
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Jordan University of Science and Technology, Irbid, 21110, Jordan
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12
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Ražem K, Kocijan J, Podbregar M, Lučovnik M. Near-infrared spectroscopy of the placenta for monitoring fetal oxygenation during labour. PLoS One 2020; 15:e0231461. [PMID: 32298307 PMCID: PMC7162483 DOI: 10.1371/journal.pone.0231461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 03/24/2020] [Indexed: 11/18/2022] Open
Abstract
Although being the golden standard for intrapartum fetal surveillance, cardiotocography (CTG) has been shown to have poor specificity for detecting fetal acidosis. Non-invasive near-infrared-spectroscopy (NIRS) monitoring of placental oxygenation during labour has not been studied yet. The objective of the study was to determine whether changes in placental NIRS values during labour could identify intrapartum fetal hypoxia and resulting acidosis. We included 43 healthy women in active stage of labour at term. CTG and NIRS parameters in groups with vs. without neonatal umbilical artery pH ≤ 7.20 were compared using Mann-Whitney-U. Receiver-operating-characteristics (ROC) curves were used to estimate predictive value of CTG and NIRS parameters for neonatal pH ≤ 7.20. A computer-based statistical classification was also performed to further evaluate predictive values of CTG and NIRS for neonatal acidosis. Ten (23%) neonates were born with umbilical artery pH ≤ 7.20. Compared to group with pH > 7.20, fetal acidosis was associated with more episodes of placental NIRS deoxygenation (9 (range 2-37) vs. 2 (range 0-65); p<0.001), higher velocity of placental NIRS deoxygenation (2.31 (range 0-22) vs. 1 (range 0-49) %/s; p = 0.03), more decelerations on CTG (25 (range 3-91) vs. 10 (range 10-60); p = 0.02), and more prolonged decelerations on CTG (2 (range 0-4) vs. 1 (range 0-3); p = 0.04). Number of placental deoxygenations had the highest prognostic value for fetal/neonatal acidosis (area under the ROC curve 0.85 (95% confidence interval 0.70-0.99). Computer-based classification also identified number of placental deoxygenations as the most accurate classifier, with 25% false positive and 93% true positive rate in the training dataset, with 100% accuracy when applied to the testing dataset. Placental deoxygenations during labour measured by NIRS are associated with fetal/neonatal acidosis. Predictive value of placental NIRS for neonatal acidosis was superior to that of CTG.
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Affiliation(s)
- Katja Ražem
- Division of Obstetrics and Gynecology, Department of Perinatology, UniversityMedical Centre Ljubljana, Ljubljana, Slovenia
- * E-mail:
| | - Juš Kocijan
- Department of Systems and Control, Jožef Štefan Institute, Ljubljana, Slovenia
- School of Engineering and Management, University of Nova Gorica, Nova Gorica, Slovenia
| | - Matej Podbregar
- Department of Intensive Internal Medicine, General Hospital Celje, Celje, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Lučovnik
- Division of Obstetrics and Gynecology, Department of Perinatology, UniversityMedical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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13
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Hamelmann P, Vullings R, Kolen AF, Bergmans JWM, van Laar JOEH, Tortoli P, Mischi M. Doppler Ultrasound Technology for Fetal Heart Rate Monitoring: A Review. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2020; 67:226-238. [PMID: 31562079 DOI: 10.1109/tuffc.2019.2943626] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Fetal well-being is commonly assessed by monitoring the fetal heart rate (fHR). In clinical practice, the de facto standard technology for fHR monitoring is based on the Doppler ultrasound (US). Continuous monitoring of the fHR before and during labor is performed using a US transducer fixed on the maternal abdomen. The continuous fHR monitoring, together with simultaneous monitoring of the uterine activity, is referred to as cardiotocography (CTG). In contrast, for intermittent measurements of the fHR, a handheld Doppler US transducer is typically used. In this article, the technology of Doppler US for continuous fHR monitoring and intermittent fHR measurements is described, with emphasis on fHR monitoring for CTG. Special attention is dedicated to the measurement environment, which includes the clinical setting in which fHR monitoring is commonly performed. In addition, to understand the signal content of acquired Doppler US signals, the anatomy and physiology of the fetal heart and the surrounding maternal abdomen are described. The challenges encountered in these measurements have led to different technological strategies, which are presented and critically discussed, with a focus on the US transducer geometry, Doppler signal processing, and fHR extraction methods.
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14
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Chandraharan E. Intrapartum care: An urgent need to question historical practices and ‘non-evidence’-based, illogical foetal monitoring guidelines to avoid patient harm. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519878583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Edwin Chandraharan
- Children & Women's Directorate, St. George’s University Hospitals NHS Foundation Trust, London, UK
- Honorary Senior Lecturer, St. George’s University of London, London, UK
- Tianjin Central Hospital of Gynecology & Obstetrics, Tianjin, China
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15
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Jettestad MC, Schiøtz HA, Yli BM, Kessler J. Fetal monitoring in term breech labor - A review. Eur J Obstet Gynecol Reprod Biol 2019; 239:45-51. [PMID: 31176197 DOI: 10.1016/j.ejogrb.2019.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Marte C Jettestad
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway.
| | - Hjalmar A Schiøtz
- Department of Obstetrics and Gynecology, Vestfold Hospital Trust, Tønsberg, Norway
| | - Branka M Yli
- Department of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - Jørg Kessler
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
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16
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Abstract
The use of intermittent auscultation (IA) for fetal surveillance during labor decreased with the introduction of electronic fetal monitoring (EFM). The increased use of EFM is associated with an increase in cesarean births. IA is an evidence-based method of fetal surveillance during labor for women with low risk pregnancies and considered one component of comprehensive efforts to reduce the primary cesarean rate and promote vaginal birth. Many clinicians are not familiar with IA practice. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues, and strategies to promote implementation of IA into practice.
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17
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Vonkova B, Blahakova I, Hruban L, Janku P, Pospisilova S. MicroRNA-210 expression during childbirth and postpartum as a potential biomarker of acute fetal hypoxia. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2018; 163:259-264. [PMID: 30565568 DOI: 10.5507/bp.2018.075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 12/04/2018] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To explore whether miR-210 expression can be used as a diagnostic and prognostic marker in acute fetal hypoxia. METHODS Whole blood samples of 29 women and their fetuses without hypoxia and 24 women and their fetuses with hypoxia were analysed in this study. Reverse transcription and quantitative real-time PCR were used to measure the expression of miR-210. Expression level differences between the control and hypoxic group in labour time and postpartum change fold were analyzed by standard statistical tests. RESULTS We confirmed that miR-210 is significantly more upregulated in fetal blood with acute hypoxia when compared to maternal blood (P Conclusions: Our study confirmed miR-210 upregulation in the blood of pregnant women with acute fetal hypoxia at the time of labour compared to pregnant women without acute fetal hypoxia. Additional investigation should be done to determine miR-210 clearance and the possibility of using miR-210 as a diagnostic and prognostic marker.
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Affiliation(s)
- Barbara Vonkova
- Center of Molecular Medicine, CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic.,Center of Molecular Biology and Gene Therapy, Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Czech Republic.,Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivona Blahakova
- Center of Molecular Medicine, CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic.,Center of Molecular Biology and Gene Therapy, Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Czech Republic
| | - Lukas Hruban
- Department of Gynaecology and Obstetrics, The University Hospital Brno, Czech Republic
| | - Petr Janku
- Department of Gynaecology and Obstetrics, The University Hospital Brno, Czech Republic
| | - Sarka Pospisilova
- Center of Molecular Medicine, CEITEC - Central European Institute of Technology, Masaryk University, Brno, Czech Republic.,Center of Molecular Biology and Gene Therapy, Department of Internal Medicine - Hematology and Oncology, University Hospital Brno, Czech Republic
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18
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Yuan SM. Fetal arrhythmias: Surveillance and management. Hellenic J Cardiol 2018; 60:72-81. [PMID: 30576831 DOI: 10.1016/j.hjc.2018.12.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 12/04/2018] [Accepted: 12/11/2018] [Indexed: 10/27/2022] Open
Abstract
Fetal arrhythmias warrant sophisticated surveillance and management, especially for the high-risk pregnancies. Clinically, fetal arrhythmias can be categorized into 3 types: premature contractions, tachyarrhythmias, and bradyarrhythmias. Fetal arrhythmias include electrocardiography, cardiotocography, echocardiography and magnetocardiography. Oxygen saturation monitoring can be an effective way of fetal surveillance for congenital complete AV block or SVT during labor. Genetic surveillance of fetal arrhythmias may facilitate the understanding of the mechanisms of the arrhythmias and provide theoretical basis for diagnosis and treatment. For fetal benign arrhythmias, usually no treatment but a close follow-up is need, while persistant fetal arrhythmias with congestive heart dysfunction or hydrops fetalis, intrauterine or postnatal treatments are required. The prognoses of fetal arrhythmias depend on the type and severity of fetal arrhythmias and the associated fetal conditions. Responses of fetal arrhythmias to individual treatments and clinical schemes are heterogeneous, and the prognoses are poor particularly under such circumstances.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, People's Republic of China.
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19
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Kapaya H, Williams R, Elton G, Anumba D. Can Obstetric Risk Factors Predict Fetal Acidaemia at Birth? A Retrospective Case-Control Study. J Pregnancy 2018; 2018:2195965. [PMID: 30245882 PMCID: PMC6139200 DOI: 10.1155/2018/2195965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/19/2018] [Accepted: 07/30/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Despite major advances in perinatal medicine, intrapartum asphyxia remains a leading and potentially preventable cause of perinatal mortality and long-term morbidity. The umbilical cord pH is considered an essential criteria for the diagnosis of acute intrapartum hypoxic events. The purpose of this study was to evaluate whether obstetric risk factors are associated with fetal acidaemia at delivery. METHODOLOGY In a case-control study, 294 women with term singleton pregnancies complicated by an umbilical artery cord pH < 7.20 at birth were individually matched by controls with umbilical artery cord pH > 7.20. Groups were compared for differences in maternal, obstetric, and fetal characteristics using logistic regression models presented as odds ratio (OR) with 95% confidence intervals (CI). RESULTS The study showed pregestational diabetes (PGDM) [OR: 5.31, 95% CI: 1.15- 24.58, P = 0.018], urinary tract infection (UTI) [OR: 3.21, 95% CI: 1.61- 6.43, P < 0.001], and low Apgar scores to be significantly associated with acidaemia, whereas low maternal BMI [OR: 0.19, 95% CI: 0.04-0.87, P = 0.032], pyrexia in labour [OR 0.23; 95% CI 0.12-0.53; P < 0.001], electronic fetal monitoring (EFM) [OR 0.65; 95% CI 0.43-0.99; P = 0.042), and emergency caesarean section [OR 0.42; 95% CI 0.26-0.66; P < 0.001] were found to be protective of acidaemia. CONCLUSION Certain obstetric risk factors before and during labour can identify newborns at risk of developing acidaemia. Further research is needed to gain quantitative insight into the predictive capacity of these risks that can inform obstetric clinical management for improved outcomes.
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Affiliation(s)
- Habiba Kapaya
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Roslyn Williams
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Grace Elton
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
| | - Dilly Anumba
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield S102SF, UK
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20
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Dur-e-shahwar, Ahmed I, Amerjee A, Hoodbhoy Z. Comparison of neonatal outcomes between category-1 and non-category-1 Primary Emergency Cesarean Section: A retrospective record review in a tertiary care hospital. Pak J Med Sci 2018; 34:823-827. [PMID: 30190735 PMCID: PMC6115571 DOI: 10.12669/pjms.344.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 07/03/2018] [Accepted: 07/05/2018] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To compare neonatal outcomes between Category-1 and Non-Category-1 Primary Emergency Cesarean Section. METHODS This was a retrospective analysis, conducted at Aga Khan University Hospital Karachi from January 1st 2016 till December 31st 2016. Non-probability purposive sampling technique was used. A sample size of 375 patients who had primary Emergency Caesarean Section (Em-CS) was identified by keeping CS rate of 41.5% and 5% bond on error. Data was collected from labor ward, operating theatre and neonatal ward records by using structured questionnaire. RESULTS In the current study, out of 375 participants who underwent primary Em-CS; majority (89.3%) were booked cases. Two-hundred-eighty-two (75.2%) were primiparous women. Two hundred and thirty (61.3%) were at term and 145(38.7%) were preterm. The main indication among Category-1 CS was fetal distress (15.7%). For Non-Category-1 CS, non-progress of labour (45.1%) was the leading cause of abdominal delivery. Except for APGAR score at one minute (p value = 0.048), no other variables were statistically significant when neonatal outcomes were compared among Category-1 and Non-Category-1 CS. CONCLUSION In this study, fetal distress and non-progress of labor were the main indications for Category-1 and Non-Category-1 CS respectively. We did not find statistically significant association between indications of Em CS and neonatal outcomes. However further prospective studies are required to confirm this association.
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Affiliation(s)
- Dur-e-shahwar
- Dr. Dur-e-Shahwar, FCPS. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Iffat Ahmed
- Dr. Iffat Ahmed, FCPS. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Azra Amerjee
- Dr. Azra Amerjee, FCPS; MCPS HPE; PGD Bioethics. Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
| | - Zahra Hoodbhoy
- Zahra Hoodbhoy, Department of Obstetrics and Gynaecology, The Aga Khan University Hospital, Karachi, Pakistan
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21
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Minato T, Ito T, Kasahara Y, Ooshio S, Fushima T, Sekimoto A, Takahashi N, Yaegashi N, Kimura Y. Relationship Between Short Term Variability (STV) and Onset of Cerebral Hemorrhage at Ischemia-Reperfusion Load in Fetal Growth Restricted (FGR) Mice. Front Physiol 2018; 9:478. [PMID: 29867536 PMCID: PMC5968166 DOI: 10.3389/fphys.2018.00478] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 04/16/2018] [Indexed: 12/14/2022] Open
Abstract
Fetal growth restriction (FGR) is a risk factor exacerbating a poor neurological prognosis at birth. A disease exacerbating a poor neurological prognosis is cerebral palsy. One of the cause of this disease is cerebral hemorrhage including intraventricular hemorrhage. It is believed to be caused by an inability to autoregulate cerebral blood flow as well as immaturity of cerebral vessels. Therefore, if we can evaluate the function of autonomic nerve, cerebral hemorrhage risk can be predicted beforehand and appropriate delivery management may be possible. Here dysfunction of autonomic nerve in mouse FGR fetuses was evaluated and the relationship with cerebral hemorrhage incidence when applying hypoxic load to resemble the brain condition at the time of delivery was examined. Furthermore, FGR incidence on cerebral nerve development and differentiation was examined at the gene expression level. FGR model fetuses were prepared by ligating uterine arteries to reduce placental blood flow. To compare autonomic nerve function in FGR mice with that in control mice, fetal short term variability (STV) was measured from electrocardiograms. In the FGR group, a significant decrease in the STV was observed and dysfunction of cardiac autonomic control was confirmed. Among genes related to nerve development and differentiation, Ntrk and Neuregulin 1, which are necessary for neural differentiation and plasticity, were expressed at reduced levels in FGR fetuses. Under normal conditions, Neurogenin 1 and Neurogenin 2 are expressed mid-embryogenesis and are related to neural differentiation, but they are not expressed during late embryonic development. The expression of these two genes increased in FGR fetuses, suggesting that neural differentiation is delayed with FGR. Uterine and ovarian arteries were clipped and periodically opened to give a hypoxic load mimicking the time of labor, and the bleeding rate significantly increased in the FGR group. This suggests that FGR deteriorates cardiac autonomic control, which becomes a risk factor for cerebral hemorrhage onset at birth. This study demonstrated that cerebral hemorrhage risk may be evaluated before parturition for FGR management by evaluating the STV. Further, this study suggests that choosing an appropriate delivery timing and delivery method contributes to neurological prognosis improvement.
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Affiliation(s)
- Takahiro Minato
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takuya Ito
- Center for Development of Advanced Medical Technology, Jichi Medical University, Shimotsuke, Japan
| | - Yoshiyuki Kasahara
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sayaka Ooshio
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Tomofumi Fushima
- Division of Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences and Faculty of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Akiyo Sekimoto
- Division of Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences and Faculty of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Nobuyuki Takahashi
- Division of Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences and Faculty of Pharmaceutical Sciences, Tohoku University, Sendai, Japan
| | - Nobuo Yaegashi
- Department of Gynecology and Obstetrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshitaka Kimura
- Advanced Interdisciplinary Biomedical Engineering, Tohoku University Graduate School of Medicine, Sendai, Japan
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22
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A Comprehensive Evaluation of the Predictive Abilities of Fetal Electrocardiogram-Derived Parameters during Labor in Newborn Acidemia: Our Institutional Experience. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3478925. [PMID: 29888259 PMCID: PMC5985095 DOI: 10.1155/2018/3478925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 03/20/2018] [Accepted: 04/17/2018] [Indexed: 11/17/2022]
Abstract
This study aimed to identify cardiotocography patterns that discriminate fetal acidemia newborns by comprehensively evaluating the parameters obtained from Holter monitoring during delivery. Between June 1, 2015, and August 1, 2016, a prospective observational study of 85 patients was conducted using fetal Holter monitoring at the Beijing Obstetrics and Gynecology Hospital, Capital Medical University, China. Umbilical cord blood was sampled immediately after delivery and fetal acidemia was defined as umbilical cord arterial blood pH < 7.20. Fetal electrocardiogram- (FECG-) derived parameters, including basal fetal heart rate (BFHR), short-term variation (STV), large acceleration (LA), deceleration capacity (DC), acceleration capacity (AC), proportion of episodes of high variation (PEHV), and proportion of episodes of low variation (PELV), were compared between 16 fetuses with acidemia and 47 without. The areas under the curve (AUC) of receiver operating characteristics (ROC) were calculated. Although all the computerized parameters showed predictive values for acidemia (all AUC > 0.50), STV (AUC = 0.84, P < 0.001), DC (AUC = 0.84, P < 0.001), AC (AUC = 0.80, P < 0.001), and PELV (AUC = 0.71, P = 0.012) were more strongly associated with fetal acidemia. Our institutional experience suggests that FECG-derived parameters from Holter monitoring are beneficial in reducing the incidence of neonatal acidemia.
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23
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Mdoe PF, Ersdal HL, Mduma ER, Perlman JM, Moshiro R, Wangwe PT, Kidanto H. Intermittent fetal heart rate monitoring using a fetoscope or hand held Doppler in rural Tanzania: a randomized controlled trial. BMC Pregnancy Childbirth 2018; 18:134. [PMID: 29728142 PMCID: PMC5935915 DOI: 10.1186/s12884-018-1746-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 04/15/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neonatal mortality is a global challenge, with an estimated 1.3 million intrapartum stillbirths in 2015. The majority of these were found in low resource settings with limited options to intrapartum fetal heart monitoring devices. This trial compared frequency of abnormal fetal heart rate (FHR) detection and adverse perinatal outcomes (i.e. fresh stillbirths, 24-h neonatal deaths, admission to neonatal care unit) among women intermittently assessed by Doppler or fetoscope in a rural low-resource setting. METHODS This was an open-label randomized controlled trial conducted at Haydom Lutheran Hospital from March 2013 through August 2015. Inclusion criteria were; women in labor, singleton, cephalic presentation, normal FHR on admission (120-160 beats/minute), and cervical dilatation ≤7 cm. Verbal consent was obtained. RESULTS A total of 2684 women were recruited, 1309 in the Doppler and 1375 in the fetoscope arms, respectively. Abnormal FHR was detected in 55 (4.2%) vs 42 (3.1%). (RR = 1.38; 95%CI: 0.93, 2.04) in the Doppler and fetoscope arms, respectively. Bag mask ventilation was performed in 80 (6.1%) vs 82 (6.0%). (RR = 1.03; 95%CI: 0.76, 1.38) of neonates, and adverse perinatal outcome was comparable 32(2.4%) vs 35(2.5%). (RR = 0.9; 95%CI: 0.59, 1.54), in the Doppler and fetoscope arms, respectively. CONCLUSION This trial failed to demonstrate a statistically significant difference in the detection of abnormal FHR between intermittently used Doppler and fetoscope and adverse perinatal outcomes. However, FHR measurements were not performed as often as recommended by international guidelines. Conducting a randomized controlled study in rural settings with limited resources is associated with major challenges. TRIAL REGISTRATION This clinical trial was registered on April 2013 with registration number NCT01869582 .
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Affiliation(s)
- Paschal Francis Mdoe
- Haydom Lutheran Hospital, Mbulu, Tanzania. .,Department of Health Science, University of Stavanger, Stavanger, Norway. .,Obstetrics and Gynaecology, Haydom Lutheran Hospital, PO box 9000, Haydom, Mbulu, Tanzania.
| | - Hege L Ersdal
- Department of Health Science, University of Stavanger, Stavanger, Norway.,Department of Anesthesiology and Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Estomih R Mduma
- Haydom Lutheran Hospital, Mbulu, Tanzania.,Department of Health Science, University of Stavanger, Stavanger, Norway
| | | | - Robert Moshiro
- Department of Health Science, University of Stavanger, Stavanger, Norway.,Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Peter T Wangwe
- Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Hussein Kidanto
- Department of Research, Stavanger University Hospital, Stavanger, Norway.,Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Warmerdam GJJ, Vullings R, Van Laar JOEH, Van der Hout-Van der Jagt MB, Bergmans JWM, Schmitt L, Oei SG. Detection rate of fetal distress using contraction-dependent fetal heart rate variability analysis. Physiol Meas 2018; 39:025008. [PMID: 29350194 DOI: 10.1088/1361-6579/aaa925] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Monitoring of the fetal condition during labor is currently performed by cardiotocograpy (CTG). Despite the use of CTG in clinical practice, CTG interpretation suffers from a high inter- and intra-observer variability and a low specificity. In addition to CTG, analysis of fetal heart rate variability (HRV) has been shown to provide information on fetal distress. However, fetal HRV can be strongly influenced by uterine contractions, particularly during the second stage of labor. Therefore, the aim of this study is to examine if distinguishing contractions from rest periods can improve the detection rate of HRV features for fetal distress during the second stage of labor. APPROACH We used a dataset of 100 recordings, containing 20 cases of fetuses with adverse outcome. The most informative HRV features were selected by a genetic algorithm and classification performance was evaluated using support vector machines. MAIN RESULTS Classification performance of fetal heart rate segments closest to birth improved from a geometric mean of 70% to 79%. If the classifier was used to indicate fetal distress over time, the geometric mean at 15 minutes before birth improved from 60% to 72%. SIGNIFICANCE Our results show that combining contraction-dependent HRV features with HRV features calculated over the entire fetal heart rate signal improves the detection rate of fetal distress.
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Affiliation(s)
- G J J Warmerdam
- Faculty of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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25
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Wehberg S, Guldberg R, Gradel KO, Kesmodel US, Munk L, Andersson CB, Jølving LR, Nielsen J, Nørgård BM. Risk factors and between-hospital variation of caesarean section in Denmark: a cohort study. BMJ Open 2018; 8:e019120. [PMID: 29440158 PMCID: PMC5829888 DOI: 10.1136/bmjopen-2017-019120] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES The aim of this study was to estimate the effects of risk factors on elective and emergency caesarean section (CS) and to estimate the between-hospital variation of risk-adjusted CS proportions. DESIGN Historical registry-based cohort study. SETTINGS AND PARTICIPANTS The study was based on all singleton deliveries in hospital units in Denmark from January 2009 to December 2012. A total of 226 612 births by 198 590 mothers in 29 maternity units were included. PRIMARY AND SECONDARY OUTCOME MEASURES We estimated (1) OR of elective and emergency CS adjusted for several risk factors, for example, body mass index, parity, age and size of maternity unit and (2) risk-adjusted proportions of elective and emergency CS to evaluate between-hospital variation. RESULTS The CS proportion was stable at 20%-21%, but showed wide variation between units, even in adjusted models. Large units performed significantly more elective CSs than smaller units, and the risk of emergency CS was significantly reduced compared with smaller units. Many of the included risk factors were found to influence the risk of CS. The most important risk factors were breech presentation and previous CS. Four units performed more CSs and one unit fewer CSs than expected. CONCLUSION The main risk factors for elective CS were breech presentation and previous CS; for emergency CS they were breech presentation and cephalopelvic disproportion. The proportions of CS were stable during the study period. We found variation in risk-adjusted CS between hospitals in Denmark. Although exhaustive models were applied, the results indicated the presence of systematic variation between hospital units, which was unexpected in a small, well-regulated country such as Denmark.
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Affiliation(s)
- Sonja Wehberg
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rikke Guldberg
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Kim Oren Gradel
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Lis Munk
- Swedish Association for Health Professionals, Stockholm, Sweden
| | | | - Line Riis Jølving
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Jan Nielsen
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Bente Mertz Nørgård
- Center for Clinical Epidemiology, Odense University Hospital, Odense, Denmark
- Research Unit of Clinical Epidemiology, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
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Widdows K, Reid HE, Roberts SA, Camacho EM, Heazell AEP. Saving babies' lives project impact and results evaluation (SPiRE): a mixed methodology study. BMC Pregnancy Childbirth 2018; 18:43. [PMID: 29378526 PMCID: PMC5789707 DOI: 10.1186/s12884-018-1672-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 01/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Reducing stillbirth and early neonatal death is a national priority in the UK. Current evidence indicates this is potentially achievable through application of four key interventions within routine maternity care delivered as the National Health Service (NHS) England’s Saving Babies’ Lives care bundle. However, there is significant variation in the degree of implementation of the care bundle between and within maternity units and the effectiveness in reducing stillbirth and improving service delivery has not yet been evaluated. This study aims to evaluate the impact of implementing the care bundle on UK maternity services and perinatal outcomes. Methods The Saving Babies’ Lives Project Impact and Results Evaluation (SPiRE) study is a multicentre evaluation of maternity care delivered through the Saving Babies’ Lives care bundle using both quantitative and qualitative methodologies. The study will be conducted in twenty NHS Hospital Trusts and will include approximately 100,000 births. It involves participation by both service users and care providers. To determine the impact of the care bundle on pregnancy outcomes, birth data and other clinical measures will be extracted from maternity databases and case-note audit from before and after implementation. Additionally, this study will employ questionnaires with organisational leads and review clinical guidelines to assess how resources, leadership and governance may affect implementation in diverse hospital settings. The cost of implementing the care bundle, and the cost per stillbirth avoided, will also be estimated as part of a health economic analysis. The views and experiences of service users and service providers towards maternity care in relation to the care bundle will be also be sought using questionnaires. Discussion This protocol describes a pragmatic study design which is necessarily limited by the availability of data and limitations of timescales and funding. In particular there was no opportunity to prospectively gather pre-intervention data or design a phased implementation such as a stepped-wedge study. Nevertheless this study will provide useful practice-based evidence which will advance knowledge about the processes that underpin successful implementation of the care bundle so that it can be further developed and refined. Trial registration www.clinicaltrials.gov NCT03231007 (26th July 2017)
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Affiliation(s)
- Kate Widdows
- Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, St Mary's Hospital, Oxford Road, Manchester, UK
| | - Holly E Reid
- Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, St Mary's Hospital, Oxford Road, Manchester, UK
| | - Stephen A Roberts
- Centre for Biostatistics, Institute of Population Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Elizabeth M Camacho
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research, and Primary Care, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, St Mary's Hospital, Oxford Road, Manchester, UK. .,Manchester Academic Health Science Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, M13 9WL, Manchester, UK.
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Frasch MG, Boylan GB, Wu HT, Devane D. Commentary: Computerised interpretation of fetal heart rate during labour (INFANT): a randomised controlled trial. Front Physiol 2017; 8:721. [PMID: 29033845 PMCID: PMC5625115 DOI: 10.3389/fphys.2017.00721] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 09/06/2017] [Indexed: 12/31/2022] Open
Affiliation(s)
- Martin G. Frasch
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, United States
| | - Geraldine B. Boylan
- Irish Centre for Fetal and Neonatal Translational Research, Cork, Ireland
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Hau-tieng Wu
- Department of Mathematics and Department of Statistical Science, Duke University, Durham, NC, United States
| | - Declan Devane
- Irish Centre for Fetal and Neonatal Translational Research, Cork, Ireland
- School of Nursing and Midwifery, NUI Galway, Galway, Ireland
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Altini M, Mullan P, Rooijakkers M, Gradl S, Penders J, Geusens N, Grieten L, Eskofier B. Detection of fetal kicks using body-worn accelerometers during pregnancy: Trade-offs between sensors number and positioning. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:5319-5322. [PMID: 28269461 DOI: 10.1109/embc.2016.7591928] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Monitoring fetal wellbeing is key in modern obstetrics. While fetal movement is routinely used as a proxy to fetal wellbeing, accurate, noninvasive, long-term monitoring of fetal movement is challenging. A few accelerometer-based systems have been developed in the past few years, to tackle common issues in ultrasound measurement and enable remote, self-administrated monitoring of fetal movement during pregnancy. However, many questions remain unanswered to date on the optimal setup in terms of body-worn accelerometers as well as signal processing and machine learning techniques used to detect fetal movement. In this paper, we systematically analyze the trade-offs between sensor number and positioning, the presence of reference accelerometers outside of the abdominal area and provide guidelines on dealing with class imbalance. Using a dataset of 15 measurements collected employing 6 three-axial accelerometers we show that including a reference accelerometer on the back of the participant consistently improves fetal movement detection performance regardless of the number of sensors utilized. We also show that two accelerometers plus a reference accelerometer are sufficient for optimal results.
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Martis R, Emilia O, Nurdiati DS, Brown J. Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being. Cochrane Database Syst Rev 2017; 2:CD008680. [PMID: 28191626 PMCID: PMC6464556 DOI: 10.1002/14651858.cd008680.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The goal of fetal monitoring in labour is the early detection of a hypoxic baby. There are a variety of tools and methods available for intermittent auscultation (IA) of the fetal heart rate (FHR). Low- and middle-income countries usually have only access to a Pinard/Laënnec or the use of a hand-held Doppler device. Currently, there is no robust evidence to guide clinical practice on the most effective IA tool to use, timing intervals and length of listening to the fetal heart for women during established labour. OBJECTIVES To evaluate the effectiveness of different tools for IA of the fetal heart rate during labour including frequency and duration of auscultation. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 September 2016), contacted experts and searched reference lists of retrieved articles. SELECTION CRITERIA All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing different tools and methods used for intermittent fetal auscultation during labour for fetal and maternal well-being. Quasi-RCTs, and cross-over designs were not eligible for inclusion. DATA COLLECTION AND ANALYSIS All review authors independently assessed eligibility, extracted data and assessed risk of bias for each trial. Data were checked for accuracy. MAIN RESULTS We included three studies (6241 women and 6241 babies), but only two studies are included in the meta-analyses (3242 women and 3242 babies). Both were judged as high risk for performance bias due to the inability to blind the participants and healthcare providers to the interventions. Evidence was graded as moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Intermittent Electronic Fetal Monitoring (EFM) using Cardiotocography (CTG) with routine Pinard (one trial)There was no clear difference between groups in low Apgar scores at five minutes (reported as < six at five minutes after birth) (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.24 to 1.83, 633 babies, very low-quality evidence). There were no clear differences for perinatal mortality (RR 0.88, 95% CI 0.34 to 2.25; 633 infants, very low-quality evidence). Neonatal seizures were reduced in the EFM group (RR 0.05, 95% CI 0.00 to 0.89; 633 infants, very low-quality evidence). Other important infant outcomes were not reported: mortality or serious morbidity (composite outcome), cerebral palsy or neurosensory disability. For maternal outcomes, women allocated to intermittent electronic fetal monitoring (EFM) (CTG) had higher rates of caesarean section for fetal distress (RR 2.92, 95% CI 1.78 to 4.80, 633 women, moderate-quality evidence) compared with women allocated to routine Pinard. There was no clear difference between groups in instrumental vaginal births (RR 1.46, 95% CI 0.86 to 2.49, low-quality evidence). Other outcomes were not reported (maternal mortality, instrumental vaginal birth for fetal distress and or acidosis, analgesia in labour, mobility or restriction during labour, and postnatal depression). Doppler ultrasonography with routine Pinard (two trials)There was no clear difference between groups in Apgar scores < seven at five minutes after birth (reported as < six in one of the trials) (average RR 0.76, 95% CI 0.20 to 2.87; two trials, 2598 babies, I2 = 72%, very low-quality evidence); there was high heterogeneity for this outcome. There was no clear difference between groups for perinatal mortality (RR 0.69, 95% CI 0.09 to 5.40; 2597 infants, two studies, very low-quality evidence), or neonatal seizures (RR 0.05, 95% CI 0.00 to 0.91; 627 infants, one study, very low-quality evidence). Other important infant outcomes were not reported (cord blood acidosis, composite of mortality and serious morbidity, cerebral palsy, neurosensory disability). Only one study reported maternal outcomes. Women allocated to Doppler ultrasonography had higher rates of caesarean section for fetal distress compared with those allocated to routine Pinard (RR 2.71, 95% CI 1.64 to 4.48, 627 women, moderate-quality evidence). There was no clear difference in instrumental vaginal births between groups (RR 1.35, 95% CI 0.78 to 2.32, 627 women, low-quality evidence). Other maternal outcomes were not reported. Intensive Pinard versus routine Pinard (one trial)One trial compared intensive Pinard (a research midwife following the protocol in a one-to-one care situation) with routine Pinard (as per protocol but midwife may be caring for more than one woman in labour). There was no clear difference between groups in low Apgar score (reported as < six this trial) (RR 0.90, 95% CI 0.35 to 2.31, 625 babies, very low-quality evidence). There were also no clear differences identified for perinatal mortality (RR 0.56, 95% CI 0.19 to 1.67; 625 infants, very low-quality evidence), or neonatal seizures (RR 0.68, 95% CI 0.24 to 1.88, 625 infants, very low-quality evidence)). Other infant outcomes were not reported. For maternal outcomes, there were no clear differences between groups for caesarean section or instrumental delivery (RR 0.70, 95% CI 0.35 to 1.38, and RR 1.21, 95% CI 0.69 to 2.11, respectively, 625 women, both low-quality evidence)) Other outcomes were not reported. AUTHORS' CONCLUSIONS Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.
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Affiliation(s)
- Ruth Martis
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
| | - Ova Emilia
- Universitas Gadjah MadaDepartment of Obstetrics and Gynaecology, Faculty of MedicineJl. Farmako, SekipYogyakartaDaerah Istimewa YogyakartaIndonesia55281
| | - Detty S Nurdiati
- Universitas Gadjah MadaDepartment of Obstetrics and Gynaecology, Faculty of MedicineJl. Farmako, SekipYogyakartaDaerah Istimewa YogyakartaIndonesia55281
| | - Julie Brown
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
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Alfirevic Z, Gyte GML, Cuthbert A, Devane D. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2017; 2:CD006066. [PMID: 28157275 PMCID: PMC6464257 DOI: 10.1002/14651858.cd006066.pub3] [Citation(s) in RCA: 162] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001. OBJECTIVES To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy. MAIN RESULTS We included 13 trials involving over 37,000 women. No new studies were included in this update.One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision. AUTHORS' CONCLUSIONS CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.
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Affiliation(s)
- Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Gillian ML Gyte
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Anna Cuthbert
- University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Declan Devane
- National University of Ireland GalwaySchool of Nursing and MidwiferyUniversity RoadGalwayIreland
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Chandraharan E. Foetal electrocardiograph (ST-analyser or STAN) for intrapartum foetal heart rate monitoring: a friend or a foe? J Matern Fetal Neonatal Med 2017; 31:123-127. [DOI: 10.1080/14767058.2016.1276559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Edwin Chandraharan
- Labour Ward Lead Consultant and Lead for Clinical Governance, St. George’s University Hospitals NHS Foundation Trust, St George’s University of London, London, UK
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Gravett C, Eckert LO, Gravett MG, Dudley DJ, Stringer EM, Mujobu TBM, Lyabis O, Kochhar S, Swamy GK. Non-reassuring fetal status: Case definition & guidelines for data collection, analysis, and presentation of immunization safety data. Vaccine 2016; 34:6084-6092. [PMID: 27461459 PMCID: PMC5139811 DOI: 10.1016/j.vaccine.2016.03.043] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Courtney Gravett
- Global Alliance to Prevent Prematurity and Stillbirth, Seattle Children's Hospital, Seattle, USA.
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Lowe B, Beckmann M. Involving the consultant before fetal blood sampling. Aust N Z J Obstet Gynaecol 2016; 56:387-90. [DOI: 10.1111/ajo.12480] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/23/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Belinda Lowe
- Department of Obstetrics and Gynaecology; Mater Health Services; South Brisbane Queensland Australia
| | - Michael Beckmann
- Department of Obstetrics and Gynaecology; Mater Health Services; South Brisbane Queensland Australia
- Mater Research; The University of Queensland; South Brisbane Queensland Australia
- School of Medicine; The University of Queensland; Brisbane Queensland Australia
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Spilka J, Frecon J, Leonarduzzi R, Pustelnik N, Abry P, Doret M. Sparse Support Vector Machine for Intrapartum Fetal Heart Rate Classification. IEEE J Biomed Health Inform 2016; 21:664-671. [PMID: 27046884 DOI: 10.1109/jbhi.2016.2546312] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Fetal heart rate (FHR) monitoring is routinely used in clinical practice to help obstetricians assess fetal health status during delivery. However, early detection of fetal acidosis that allows relevant decisions for operative delivery remains a challenging task, receiving considerable attention. This contribution promotes sparse support vector machine classification that permits to select a small number of relevant features and to achieve efficient fetal acidosis detection. A comprehensive set of features is used for FHR description, including enhanced and computerized clinical features, frequency domain, and scaling and multifractal features, all computed on a large (1288 subjects) and well-documented database. The individual performance obtained for each feature independently is discussed first. Then, it is shown that the automatic selection of a sparse subset of features achieves satisfactory classification performance (sensitivity 0.73 and specificity 0.75, outperforming clinical practice). The subset of selected features (average depth of decelerations MADdtrd, baseline level β0 , and variability H) receives simple interpretation in clinical practice. Intrapartum fetal acidosis detection is improved in several respects: A comprehensive set of features combining clinical, spectral, and scale-free dynamics is used; an original multivariate classification targeting both sparse feature selection and high performance is devised; state-of-the-art performance is obtained on a much larger database than that generally studied with description of common pitfalls in supervised classification performance assessments.
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Affiliation(s)
- Jiri Spilka
- CNRS, Laboratoire de Physique, Claude Bernard University Lyon 1, Lyon, France
| | - Jordan Frecon
- CNRS, Laboratoire de Physique, Claude Bernard University Lyon 1, Lyon, France
| | - Roberto Leonarduzzi
- CNRS, Laboratoire de Physique, Claude Bernard University Lyon 1, Lyon, France
| | - Nelly Pustelnik
- CNRS, Laboratoire de Physique, Claude Bernard University Lyon 1, Lyon, France
| | - Patrice Abry
- CNRS, Laboratoire de Physique, Claude Bernard University Lyon 1, Lyon, France
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Andersen MM, Thisted DLA, Amer-Wåhlin I, Krebs L. Can Intrapartum Cardiotocography Predict Uterine Rupture among Women with Prior Caesarean Delivery?: A Population Based Case-Control Study. PLoS One 2016; 11:e0146347. [PMID: 26872018 PMCID: PMC4752316 DOI: 10.1371/journal.pone.0146347] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/16/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To compare cardiotocographic abnormalities recorded during labour in women with prior caesarean delivery (CD) and complete uterine rupture with those recorded in controls with prior CD without uterine rupture. STUDY DESIGN Women with complete uterine rupture during labour between 1997 and 2008 were identified in the Danish Medical Birth Registry (n = 181). Cases were validated by review of medical records and 53 cases with prior CD, trial of labour, available cardiotocogram (CTG) and complete uterine rupture were included and compared with 43 controls with prior CD, trial of labour and available CTG. The CTG tracings were assessed by 19 independent experts divided into groups of three different experts for each tracing. The assessors were blinded to group, outcome and clinical data. They analyzed occurrence of defined abnormalities and classified the traces as normal, suspicious, pathological or pre-terminal according to international guidelines (FIGO). RESULTS A pathological CTG during the first stage of labour was present in 77% of cases and in 53% of the controls (OR 2.58 [CI: 0.96-6.94] P = 0.066). Fetal tachycardia was more frequent in cases with uterine rupture (OR 2.50 [CI: 1.0-6.26] P = 0.053). Significantly more cases showed more than 10 severe variable decelerations compared with controls (OR 22 [CI: 1.54-314.2] P = 0.022). Uterine tachysystole was not correlated with the presence of uterine rupture. CONCLUSION A pathological cardiotocogram should lead to particular attention on threatening uterine rupture but cannot be considered a strong predictor as it is common in all women with trial of labour after caesarean delivery.
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Affiliation(s)
- Malene M. Andersen
- Dept. of Obstetrics and Gynaecology, University of Copenhagen, Holbaek Hospital, Holbaek, Denmark
| | - Dorthe L. A. Thisted
- Dept. of Obstetrics and Gynaecology, University of Copenhagen, Holbaek Hospital, Holbaek, Denmark
- University of Copenhagen, Hvidovre Hospital, Dept. of Obstetric and Gynecology, Hvidovre, Denmark
| | - Isis Amer-Wåhlin
- Dept. of Women and Child Health, Karolinska Institute, Stockholm, Sweden
| | - Lone Krebs
- Dept. of Obstetrics and Gynaecology, University of Copenhagen, Holbaek Hospital, Holbaek, Denmark
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Warmerdam GJJ, Vullings R, Van Laar JOEH, Van der Hout-Van der Jagt MB, Bergmans JWM, Schmitt L, Oei SG. Using uterine activity to improve fetal heart rate variability analysis for detection of asphyxia during labor. Physiol Meas 2016; 37:387-400. [PMID: 26862891 DOI: 10.1088/0967-3334/37/3/387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
During labor, uterine contractions can cause temporary oxygen deficiency for the fetus. In case of severe and prolonged oxygen deficiency this can lead to asphyxia. The currently used technique for detection of asphyxia, cardiotocography (CTG), suffers from a low specificity. Recent studies suggest that analysis of fetal heart rate variability (HRV) in addition to CTG can provide information on fetal distress. However, interpretation of fetal HRV during labor is difficult due to the influence of uterine contractions on fetal HRV. The aim of this study is therefore to investigate whether HRV features differ during contraction and rest periods, and whether these differences can improve the detection of asphyxia. To this end, a case-control study was performed, using 14 cases with asphyxia that were matched with 14 healthy fetuses. We did not find significant differences for individual HRV features when calculated over the fetal heart rate without separating contractions and rest periods (p > 0.30 for all HRV features). Separating contractions from rest periods did result in a significant difference. In particular the ratio between HRV features calculated during and outside contractions can improve discrimination between fetuses with and without asphyxia (p < 0.04 for three out of four ratio HRV features that were studied in this paper).
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Affiliation(s)
- G J J Warmerdam
- Faculty of Electrical Engineering, Eindhoven University of Technology, 5612 AZ Eindhoven, The Netherlands
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Brocklehurst P. A study of an intelligent system to support decision making in the management of labour using the cardiotocograph - the INFANT study protocol. BMC Pregnancy Childbirth 2016; 16:10. [PMID: 26791569 PMCID: PMC4719576 DOI: 10.1186/s12884-015-0780-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 12/08/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Continuous electronic fetal heart rate monitoring in labour is widely used but its potential for improving fetal and neonatal outcomes has not been realised. The most likely reason is the difficulty of interpreting the fetal heart rate trace correctly during labour. Computerised interpretation of the fetal heart rate and intelligent decision-support has the potential to deliver this improvement in care. This trial will test whether the addition of decision support software to aid the interpretation of the cardiotocogram (CTG) during labour will reduce the number of 'poor neonatal outcomes' in those women judged to require continuous electronic fetal heart rate monitoring. METHODS AND DESIGN An individually randomised controlled trial of 46,000 women who are judged to require continuous electronic fetal monitoring in labour. ELIGIBILITY CRITERIA Women admitted to a participating labour ward who are judged to require continuous electronic fetal monitoring, have a singleton or twin pregnancy, are ≥ 35 weeks' gestation, have no known gross fetal abnormality and are ≥ 16 years of age. EXCLUSION CRITERIA Triplets or higher order pregnancy, elective caesarean section prior to the onset of labour, planned admission to NICU. Trial interventions: Computerised interpretation of the CTG with decision-support. PRIMARY OUTCOMES Short term: A composite of 'poor neonatal outcome' including stillbirth after trial entry, early neonatal death except deaths due to congenital anomalies, significant morbidity: neonatal encephalopathy, admissions to the neonatal unit with 48 h for > 48 h with evidence of feeding difficulties, respiratory illness or encephalopathy where there is evidence of compromise at birth. Long term: Developmental assessment at the age of 2 years in a subset of 7000 surviving babies. DATA COLLECTION For all participating women and babies, labour variables and outcomes will be stored automatically and contemporaneously onto the Guardian® system. DISCUSSION The results of this trial will have importance for pregnant women and for health professionals who provide care for them. TRIAL REGISTRATION Current Controlled Trials ISRCTN98680152 assigned 30.09.2008.
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Affiliation(s)
- Peter Brocklehurst
- UCL EGA Institute for Women's Health, 74 Huntley Street, WC1E 6 AU, London, UK.
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Howick J, Cohen BA, McCulloch P, Thompson M, Skinner SA. Foundations for evidence-based intraoperative neurophysiological monitoring. Clin Neurophysiol 2016; 127:81-90. [DOI: 10.1016/j.clinph.2015.05.033] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 04/09/2015] [Accepted: 05/08/2015] [Indexed: 10/23/2022]
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Abstract
BACKGROUND Hypoxaemia during labour can alter the shape of the fetal electrocardiogram (ECG) waveform, notably the relation of the PR to RR intervals, and elevation or depression of the ST segment. Technical systems have therefore been developed to monitor the fetal ECG during labour as an adjunct to continuous electronic fetal heart rate monitoring with the aim of improving fetal outcome and minimising unnecessary obstetric interference. OBJECTIVES To compare the effects of analysis of fetal ECG waveforms during labour with alternative methods of fetal monitoring. SEARCH METHODS The Cochrane Pregnancy and Childbirth Group's Trials Register (latest search 23 September 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised trials comparing fetal ECG waveform analysis with alternative methods of fetal monitoring during labour. DATA COLLECTION AND ANALYSIS One review author independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. One review author assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Seven trials (27,403 women) were included: six trials of ST waveform analysis (26,446 women) and one trial of PR interval analysis (957 women). The trials were generally at low risk of bias for most domains and the quality of evidence for ST waveform analysis trials was graded moderate to high. In comparison to continuous electronic fetal heart rate monitoring alone, the use of adjunctive ST waveform analysis made no obvious difference to primary outcomes: births by caesarean section (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.96 to 1.08; six trials, 26,446 women; high quality evidence); the number of babies with severe metabolic acidosis at birth (cord arterial pH less than 7.05 and base deficit greater than 12 mmol/L) (average RR 0.72, 95% CI 0.43 to 1.20; six trials, 25,682 babies; moderate quality evidence); or babies with neonatal encephalopathy (RR 0.61, 95% CI 0.30 to 1.22; six trials, 26,410 babies; high quality evidence). There were, however, on average fewer fetal scalp samples taken during labour (average RR 0.61, 95% CI 0.41 to 0.91; four trials, 9671 babies; high quality evidence) although the findings were heterogeneous and there were no data from the largest trial (from the USA). There were marginally fewer operative vaginal births (RR 0.92, 95% CI 0.86 to 0.99; six trials, 26,446 women); but no obvious difference in the number of babies with low Apgar scores at five minutes or babies requiring neonatal intubation, or babies requiring admission to the special care unit (RR 0.96, 95% CI 0.89 to 1.04, six trials, 26,410 babies; high quality evidence). There was little evidence that monitoring by PR interval analysis conveyed any benefit of any sort. AUTHORS' CONCLUSIONS The modest benefits of fewer fetal scalp samplings during labour (in settings in which this procedure is performed) and fewer instrumental vaginal births have to be considered against the disadvantages of needing to use an internal scalp electrode, after membrane rupture, for ECG waveform recordings. We found little strong evidence that ST waveform analysis had an effect on the primary outcome measures in this systematic review.There was a lack of evidence showing that PR interval analysis improved any outcomes; and a larger future trial may possibly demonstrate beneficial effects.There is little information about the value of fetal ECG waveform monitoring in preterm fetuses in labour. Information about long-term development of the babies included in the trials would be valuable.
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Affiliation(s)
- James P Neilson
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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Sholapurkar SL. Intermittent Auscultation in Labor: Could It Be Missing Many Pathological (Late) Fetal Heart Rate Decelerations? Analytical Review and Rationale for Improvement Supported by Clinical Cases. J Clin Med Res 2015; 7:919-25. [PMID: 26566404 PMCID: PMC4625811 DOI: 10.14740/jocmr2298w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2015] [Indexed: 12/12/2022] Open
Abstract
Intermittent auscultation (IA) of fetal heart rate (FHR) is recommended/preferred in low risk labors. Its usage even in developed countries is poised to increase because of perceived benefit of reduction in operative intervention and some disillusionment with the cardiotocography (CTG). Many national guidelines have stipulated regimes (frequency/timing) of IA based on level IV evidence. These tend to get faithfully and exactingly followed. It was observed that deliveries of many unexpectedly asphyxiated infants occurred despite rigorously performed and documented IA compliant with the guidelines. This triggered a reappraisal of the robustness of IA leading to this focused review supplemented by two anonymized cases. It concludes that the current methodology of IA may be flawed in that it poses a risk of missing many or most late (pathological) FHR decelerations, one of the foremost goals of IA. This is because many late decelerations reach their nadir before the end of the contraction. Thus the currently recommended auscultation of FHR for 60 seconds after the contraction by all national guidelines seemed to encompass their “recovery” phase and appeared to be misinterpreted as normal FHR or even as a reassuring accelerative pattern in the clinical practice. A recent recommendation of recording of the FHR as a single figure (rather than a range) does not remedy this anomaly and seems even less informative. It would be better to auscultate FHR before and after the contractions (or contraction to contraction) and take the FHR just before the contraction as the baseline FHR and interpret the FHR after contraction in the context of this baseline. This relatively simple improvement would detect most late FHR decelerations thus ameliorating the risk and significantly enhancing the patient safety.
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Warmerdam GJJ, Vullings R, Bergmans JWM, Oei SG. Reliability of spectral analysis of fetal heart rate variability. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2014:2817-20. [PMID: 25570577 DOI: 10.1109/embc.2014.6944209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Spectral analysis of fetal heart rate variability could provide information on fetal wellbeing. Unfortunately, fetal heart rate recordings are often contaminated by artifacts. Correction of these artifacts affects the outcome of spectral analysis, but it is currently unclear what level of artifact correction facilitates reliable spectral analysis. In this study, a method is presented that estimates the error in spectral powers due to artifact correction, based on the properties of the Continuous Wavelet Transformation. The results show that it is possible to estimate the error in spectral powers. The information about this error makes it possible for clinicians to assess the reliability of spectral analysis of fetal heart rate recordings that are contaminated by artifacts.
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Abstract
BACKGROUND Fetal movement counting is a method by which a woman quantifies the movements she feels to assess the condition of her baby. The purpose is to try to reduce perinatal mortality by alerting caregivers when the baby might be compromised. This method may be used routinely, or only in women who are considered at increased risk of complications affecting the baby. Fetal movement counting may allow the clinician to make appropriate interventions in good time to improve outcomes. On the other hand, fetal movement counting may cause unnecessary anxiety to pregnant women, or elicit unnecessary interventions. OBJECTIVES To assess outcomes of pregnancy where fetal movement counting was done routinely, selectively or was not done at all; and to compare different methods of fetal movement counting. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-RCTs where fetal movement counting was assessed as a method of monitoring fetal wellbeing. DATA COLLECTION AND ANALYSIS Two review authors assessed studies for eligibility, assessed the methodological quality of included studies and independently extracted data from studies. Where possible the effects of interventions were compared using risk ratios (RR), and presented with 95% confidence intervals (CI). For some outcomes, the quality of the evidence was assessed using the GRADE approach. MAIN RESULTS Five studies (71,458 women) were included in this review; 68,654 in one cluster-RCT. None of these five trials were assessed as having low risk of bias on all seven risk of bias criteria. All included studies except for one (which included high-risk women as participants) included women with uncomplicated pregnancies.Two studies compared fetal movement counting with standard care, as defined by trial authors. Two included studies compared two types of fetal movement counting; once a day fetal movement counting (Cardiff count-to-10) with more than once a day fetal movement counting methods. One study compared fetal movement counting with hormone assessment.(1) Routine fetal movement counting versus mixed or undefined fetal movement countingNo study reported on the primary outcome 'perinatal death or severe morbidity'. In one large cluster-RCT, there was no difference in mean stillbirth rates per cluster (standard mean difference (SMD) 0.23, 95% CI -0.61 to 1.07; participants = 52 clusters; studies = one, low quality evidence). The other study reported no fetal deaths. There was no difference in caesarean section rate between groups (RR 0.93, 95% CI 0.60 to 1.44; participants = 1076; studies = one,low quality evidence). Maternal anxiety was significantly reduced with routine fetal movement counting (SMD -0.22, 95% CI -0.35 to -0.10; participants = 1013; studies = one, moderate quality evidence). Maternal-fetal attachment was not significantly different (SMD -0.02, 95% CI -0.15 to 0.11; participants = 951; studies = one, low quality evidence). In one study antenatal admission after reporting of decreased fetal movements was increased (RR 2.72, 95% CI 1.34 to 5.52; participants = 123; studies = one). In another there was a trend to more antenatal admissions per cluster in the counting group than in the control group (SMD 0.38, 95% CI -0.17 to 0.93; participants = 52 clusters; studies = one, low quality evidence). Birthweight less than 10th centile was not significantly different between groups (RR 0.98, 95% CI 0.66 to 1.44; participants = 1073; studies = one, low quality evidence). The evidence was of low quality due to imprecise results and because of concerns regarding unclear risk of bias. (2) Formal fetal movement counting (Modified Cardiff method) versus hormone analysisThere was no difference between the groups in the incidence of caesarean section (RR 1.18, 95% CI 0.83 to 1.69; participants = 1191; studies = one). Women in the formal fetal movement counting group had significantly fewer hospital visits than those randomised to hormone analysis (RR 0.26, 95% CI 0.20 to 0.35), whereas there were fewer Apgar scores less than seven at five minutes for women randomised to hormone analysis (RR 1.72, 95% CI 1.01 to 2.93). No other outcomes reported showed statistically significant differences. 'Perinatal death or severe morbidity' was not reported. (3) Formal fetal movement counting once a day (count-to-10) versus formal fetal movement counting method where counting was done more than once a day (after meals)The incidence of caesarean section did not differ between the groups under this comparison (RR 2.33, 95% CI 0.61 to 8.99; participants = 1400; studies = one). Perinatal death or severe morbidity was not reported. Women were more compliant in using the count-to-10 method than they were with other fetal movement counting methods, citing less interruption with daily activities as one of the reasons (non-compliance RR 0.25, 95% CI 0.19 to 0.32).Except for one cluster-RCT, included studies were small and used different comparisons, making it difficult to measure the outcomes using meta-analyses. The nature of the intervention measured also did not allow blinding of participants and clinicians.. AUTHORS' CONCLUSIONS This review does not provide sufficient evidence to influence practice. In particular, no trials compared fetal movement counting with no fetal movement counting. Only two studies compared routine fetal movements with standard antenatal care, as defined by trial authors. Indirect evidence from a large cluster-RCT suggested that more babies at risk of death were identified in the routine fetal monitoring group, but this did not translate to reduced perinatal mortality. Robust research by means of studies comparing particularly routine fetal movement counting with selective fetal movement counting is needed urgently, as it is a common practice to introduce fetal movement counting only when there is already suspected fetal compromise.
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Affiliation(s)
- Lindeka Mangesi
- Eastern Cape Department of HealthEpidemiological Research and Surveillance Management DirectoratePrivate Bag X0038BishoSouth Africa5605
| | - G Justus Hofmeyr
- Walter Sisulu University; Centre for Evidence‐based Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University; and Eastern Cape Department of HealthEast LondonSouth Africa
| | - Valerie Smith
- Trinity College DublinSchool of Nursing and Midwifery24 D'Olier StreetDublinIreland2
| | - Rebecca MD Smyth
- The University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
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Doret M, Spilka J, Chudáček V, Gonçalves P, Abry P. Fractal Analysis and Hurst Parameter for Intrapartum Fetal Heart Rate Variability Analysis: A Versatile Alternative to Frequency Bands and LF/HF Ratio. PLoS One 2015; 10:e0136661. [PMID: 26322889 PMCID: PMC4556442 DOI: 10.1371/journal.pone.0136661] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/06/2015] [Indexed: 11/18/2022] Open
Abstract
Background The fetal heart rate (FHR) is commonly monitored during labor to detect early fetal acidosis. FHR variability is traditionally investigated using Fourier transform, often with adult predefined frequency band powers and the corresponding LF/HF ratio. However, fetal conditions differ from adults and modify spectrum repartition along frequencies. Aims This study questions the arbitrariness definition and relevance of the frequency band splitting procedure, and thus of the calculation of the underlying LF/HF ratio, as efficient tools for characterizing intrapartum FHR variability. Study Design The last 30 minutes before delivery of the intrapartum FHR were analyzed. Subjects Case-control study. A total of 45 singletons divided into two groups based on umbilical cord arterial pH: the Index group with pH ≤ 7.05 (n = 15) and Control group with pH > 7.05 (n = 30). Outcome Measures Frequency band-based LF/HF ratio and Hurst parameter. Results This study shows that the intrapartum FHR is characterized by fractal temporal dynamics and promotes the Hurst parameter as a potential marker of fetal acidosis. This parameter preserves the intuition of a power frequency balance, while avoiding the frequency band splitting procedure and thus the arbitrary choice of a frequency separating bands. The study also shows that extending the frequency range covered by the adult-based bands to higher and lower frequencies permits the Hurst parameter to achieve better performance for identifying fetal acidosis. Conclusions The Hurst parameter provides a robust and versatile tool for quantifying FHR variability, yields better acidosis detection performance compared to the LF/HF ratio, and avoids arbitrariness in spectral band splitting and definitions.
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Affiliation(s)
- Muriel Doret
- Department of Obstetrics and Gynaecology, Hospices Civils de Lyon, Hôpital Femme-Mère-Enfant, Bron, France
- * E-mail:
| | - Jiří Spilka
- Physics Department, CNRS, ENS Lyon, France
- Czech Institute of Informatics, Robotics and Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
| | - Václav Chudáček
- Czech Institute of Informatics, Robotics and Cybernetics, Czech Technical University in Prague, Prague, Czech Republic
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Karmakar C, Kimura Y, Palaniswami M, Khandoker A. Analysis of fetal heart rate asymmetry before and after 35 weeks of gestation. Biomed Signal Process Control 2015. [DOI: 10.1016/j.bspc.2015.05.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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East CE, Leader LR, Sheehan P, Henshall NE, Colditz PB, Lau R. Intrapartum fetal scalp lactate sampling for fetal assessment in the presence of a non-reassuring fetal heart rate trace. Cochrane Database Syst Rev 2015; 2015:CD006174. [PMID: 25929461 PMCID: PMC10823414 DOI: 10.1002/14651858.cd006174.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Fetal scalp blood sampling for lactate estimation may be considered following identification of an abnormal or non-reassuring fetal heart rate pattern. The smaller volume of blood required for this test, compared with the more traditional pH estimation, may improve sampling rates. The appropriate use of this practice mandates systematic review of its safety and clinical effectiveness prior to widespread introduction. OBJECTIVES To evaluate the effectiveness and risks of fetal scalp lactate sampling in the assessment of fetal well-being during labour, compared with no testing or alternative testing. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2015). SELECTION CRITERIA All published and unpublished randomised and quasi-randomised trials that compared fetal scalp lactate testing with no testing or alternative testing to evaluate fetal status in the presence of a non-reassuring cardiotocograph during labour. DATA COLLECTION AND ANALYSIS We used the standard methodological procedures of the Cochrane Pregnancy and Childbirth Group. Two review authors independently assessed the studies. MAIN RESULTS The search identified two completed randomised controlled trials (RCTs) and two ongoing trials. The two published RCTs considered outcomes for 3348 mother-baby pairs allocated to either lactate or pH estimation of fetal blood samples when clinically indicated in labour. Overall, the published RCTs were of low or unclear risk of bias. There was a high risk of performance bias, because it would not have been feasible to blind clinicians or participants.No statistically significant between-group differences were found for neonatal encephalopathy (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.32 to 3.09, one study, 2992 infants) or death. No studies reported neonatal seizures. We had planned to report death with other morbidities, for example, neonatal encephalopathy; however, the data were not available in a format suitable for this, therefore death due to congenital abnormality was considered alone. The three reported neonatal deaths occurred in babies with diaphragmatic hernias (n = 2) or congenital cardiac fibrosis (n = 1). All three babies had been randomised to the pH group and were not acidaemic at birth.There were no statistically significant differences for any of the pre-specified secondary fetal/neonatal/infant outcomes for which data were available. This included low Apgar score at five minutes (RR 1.13, 95% CI 0.76 to 1.68, two studies, 3319 infants) and admission to neonatal intensive care units (RR 1.02, 95% CI 0.83 to 1.25, one study, 2992 infants), or metabolic acidaemia (RR 0.91, 95% CI 0.60 to 1.36, one study, 2675 infants) considered within the studies, either overall or where data were available for those where fetal blood sampling had occurred within 60 minutes of delivery.Similar proportions of fetuses underwent additional tests to further evaluate well-being during labour, including scalp pH if in the lactate group or scalp lactate if in the pH group (RR 0.22, 95% CI 0.04 to 1.30, two studies, 3333 infants;Tau² 1.00, I² = 58%). Fetal blood sampling attempts for lactate and pH estimation were successful in 98.7% and 79.4% of procedures respectively in the one study that reported this outcome.There were no significant between-group differences in mode of birth or operative birth for non-reassuring fetal status, either for all women, or within the group where the fetal blood sample had been taken within 60 minutes of delivery (for example, caesarean section for all enrolled, RR 1.09, 95% CI 0.97 to 1.22, two studies, 3319 women; operative delivery for non-reassuring fetal status for all enrolled RR 1.02, 95% CI 0.93 to 1.11, one study, 2992 women).Neither study reported on adverse effects of fetal scalp lacerations or maternal anxiety. AUTHORS' CONCLUSIONS When further testing to assess fetal well-being in labour is indicated, fetal scalp blood lactate estimation is more likely to be successfully undertaken than pH estimation. Further studies may consider subgroup analysis by gestational age, the stage of labour and sampling within a prolonged second stage of labour. Additionally, we await the findings from the ongoing studies that compare allocation to no fetal blood sample with sampling for lactate and address longer-term neonatal outcomes, maternal satisfaction with intrapartum fetal monitoring and an economic analysis.
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Affiliation(s)
- Christine E East
- Monash University/Monash HealthSchool of Nursing and Midwifery/Maternity Services246 Clayton RoadClaytonVictoriaAustralia3168
| | - Leo R Leader
- University of New South WalesWomen's and Children's HealthRoyal Hospital for WomenBarker StreetRandwickNSWAustralia2031
| | - Penelope Sheehan
- University of MelbourneDepartment of Obstetrics and GynaecologyPregnancy Research Centre, 7th Floor, Royal Women's Hospital20 Flemington Road, ParkvilleMelbourneVictoriaAustralia3052
| | - Naomi E Henshall
- Royal Hospital for WomenDelivery SuiteRandwickNew South WalesAustralia
| | - Paul B Colditz
- The University of Queensland, Royal Brisbane & Women's HospitalPerinatal Research CentreButterfield StreetHerstonQueenslandAustralia4029
| | - Rosalind Lau
- Monash UniversitySchool of Nursing and MidwiferyWellington RoadClaytonVictoriaAustralia3800
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Prior T, Kumar S. Expert review--identification of intra-partum fetal compromise. Eur J Obstet Gynecol Reprod Biol 2015; 190:1-6. [PMID: 25917435 DOI: 10.1016/j.ejogrb.2015.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 01/31/2015] [Accepted: 04/07/2015] [Indexed: 09/30/2022]
Abstract
Whilst most cases of cerebral palsy occur as a consequence of an ante-natal insult, a significant proportion, particularly in the term fetus, are attributable to intra-partum hypoxia. Intra-partum monitoring using continuous fetal heart rate assessment has led to an increased incidence of operative delivery without a concurrent reduction in the incidence of cerebral palsy. Despite this, birth asphyxia remains the strongest and most consistent risk factor for cerebral palsy in term infants. This review evaluates current intra-partum monitoring techniques as well as alternative approaches aimed at better identification of the fetus at risk of compromise in labour.
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Affiliation(s)
- Tomas Prior
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London W12 0HS, UK; Institute for Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK
| | - Sailesh Kumar
- Centre for Fetal Care, Queen Charlotte's and Chelsea Hospital, Du Cane Road, London W12 0HS, UK; Institute for Reproductive and Developmental Biology, Imperial College London, London W12 0HS, UK; Mater Research Institute/University of Queensland, Aubigny Place, Raymond Terrace, South Brisbane, QLD 4101, Australia.
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Lundgren I, Smith V, Nilsson C, Vehvilainen-Julkunen K, Nicoletti J, Devane D, Bernloehr A, van Limbeek E, Lalor J, Begley C. Clinician-centred interventions to increase vaginal birth after caesarean section (VBAC): a systematic review. BMC Pregnancy Childbirth 2015; 15:16. [PMID: 25652550 PMCID: PMC4324420 DOI: 10.1186/s12884-015-0441-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/16/2015] [Indexed: 11/17/2022] Open
Abstract
Background The number of caesarean sections (CS) is increasing globally, and repeat CS after a previous CS is a significant contributor to the overall CS rate. Vaginal birth after caesarean (VBAC) can be seen as a real and viable option for most women with previous CS. To achieve success, however, women need the support of their clinicians (obstetricians and midwives). The aim of this study was to evaluate clinician-centred interventions designed to increase the rate of VBAC. Methods The bibliographic databases of The Cochrane Library, PubMed, PsychINFO and CINAHL were searched for randomised controlled trials, including cluster randomised trials that evaluated the effectiveness of any intervention targeted directly at clinicians aimed at increasing VBAC rates. Included studies were appraised independently by two reviewers. Data were extracted independently by three reviewers. The quality of the included studies was assessed using the quality assessment tool, ‘Effective Public Health Practice Project’. The primary outcome measure was VBAC rates. Results 238 citations were screened, 255 were excluded by title and abstract. 11 full-text papers were reviewed; eight were excluded, resulting in three included papers. One study evaluated the effectiveness of antepartum x-ray pelvimetry (XRP) in 306 women with one previous CS. One study evaluated the effects of external peer review on CS birth in 45 hospitals, and the third evaluated opinion leader education and audit and feedback in 16 hospitals. The use of external peer review, audit and feedback had no significant effect on VBAC rates. An educational strategy delivered by an opinion leader significantly increased VBAC rates. The use of XRP significantly increased CS rates. Conclusions This systematic review indicates that few studies have evaluated the effects of clinician-centred interventions on VBAC rates, and interventions are of varying types which limited the ability to meta-analyse data. A further limitation is that the included studies were performed during the late 1980s-1990s. An opinion leader educational strategy confers benefit for increasing VBAC rates. This strategy should be further studied in different maternity care settings and with professionals other than physicians only. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0441-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingela Lundgren
- Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Box 457, , SE-405 30, Gothenburg, Sweden.
| | - Valerie Smith
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Christina Nilsson
- Institute of Health and Care Sciences, The Sahlgrenska Academy at University of Gothenburg, Box 457, , SE-405 30, Gothenburg, Sweden.
| | - Katri Vehvilainen-Julkunen
- University of Eastern Finland, Faculty of Health Sciences, POB 1627, Kuopio University Hospital, 70211, Kuopio, Finland.
| | - Jane Nicoletti
- Universita Degli Studi di Genova, Via Balbi 5, 16126, Genoa, Italy.
| | - Declan Devane
- School of Nursing and Midwifery, NUI Galway/West North West Hospital Group, University Road, Galway, Ireland.
| | - Annette Bernloehr
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Midwifery Research and Education Unit, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Evelien van Limbeek
- Department of Midwifery Science, Zuyd University, POB 1256, 6201 BG, Maastricht, The Netherlands.
| | - Joan Lalor
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.
| | - Cecily Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin 2, Ireland.
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Karmakar C, Khandoker A, Kimura Y, Palaniswami M. Investigating foetal heart rate asymmetry. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2015; 2014:2261-4. [PMID: 25570438 DOI: 10.1109/embc.2014.6944070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In this study, we have investigated how the asymmetry of beat-to-beat foetal heart rate variability (fHRV) changes during development after 35 weeks and before 32 weeks of gestation. Noninvasive foetal electrocardiogram (fECG) signals from 78 pregnant women at the gestational age from 16 to 41 weeks with normal single pregnancies were analysed. Heart rate asymmetry (HRA) index that measures time asymmetry of RR interval time-series signal was used to understand the dynamics of fHRV. Results indicate that foetal HRA measured by Guzik's Index (GI) and Porta's Index (PI) changes after 35 weeks gestation compared to foetus before 32 weeks of gestation. It might be due to significant amount of maturation of the autonomic nervous system done after 35 and could potentially help identify the pathological autonomic nervous system development.
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Meroz MR, Gesser-Edelsburg A. Institutional and Cultural Perspectives on Home Birth in Israel. J Perinat Educ 2015; 24:25-36. [PMID: 26937159 PMCID: PMC4720861 DOI: 10.1891/1058-1243.24.1.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This study exposes doctors' and midwives' perceptions and misperceptions regarding home birth by examining their views on childbirth in general and on risk associated with home births in particular. It relies on an approach of risk communication and an anthropological framework. In a qualitative-constructive study, 19 in-depth interviews were conducted with hospital doctors, hospital midwives, home-birth midwives, and a home-birth obstetrician. Our findings reveal that hospital midwives and doctors suffer from lack of exposure to home births, leading to disagreement regarding norms and risk; it also revealed sexist or patriarchal worldviews. Recommendations include improving communication between home-birth midwives and hospital counterparts; increased exposure of hospital doctors to home birth, creating new protocols in collaboration with home-birth midwives; and establishing a national database of home births.
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