The contributions of the nurse and the machine in home uterine activity monitoring systems

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with care that does not include home uterine activity monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), CENTRAL (Cochrane Library 2016, Issue 5), MEDLINE (1966 to 28 June 2016), Embase (1974 to 28 June 2016), CINAHL (1982 to 28 June 2016), and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk of preterm birth, compared with care that does not include home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries. We assessed the evidence using the GRADE approach.

MAIN RESULTS

There were 15 included studies (6008 enrolled participants); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; three studies, 1596 women; fixed-effect analysis) (GRADE high). This difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75, 95% CI 0.57 to 1.00; one study, 1292 women). There was no difference in the rate of perinatal mortality (RR 1.22, 95% CI 0.86 to 1.72; two studies, 2589 babies) (GRADE low).There was no difference in the number of preterm births at less than 37 weeks (average RR 0.85, CI 0.72 to 1.01; eight studies, 4834 women; random-effects, Tau2 = 0.03, I2 = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77, 95% CI 0.62 to 0.96; five studies, 2367 babies; random-effects, Tau2 = 0.02, I2 = 32%) (GRADE moderate). This difference was not maintained when we restricted the analysis to studies at low risk of bias (RR 0.86, 95% CI 0.74 to 1.01; one study, 1292 babies). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.48, 95% CI 0.31 to 0.64; two studies, 1994 women) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21, 95% CI 1.01 to 1.45; seven studies, 4316 women; random-effects, Tau2 = 0.03, I2 = 62%), but this difference was no longer evident when we restricted the analysis to studies at low risk of bias (average RR 1.22, 95% CI 0.90 to 1.65; three studies, 3749 women; random-effects, Tau2 = 0.05, I2 = 76%) (GRADE low). The number of antenatal hospital admissions did not differ between home groups (RR 0.91, 95% CI 0.74 to 1.11; three studies, 1494 women (GRADE low)). We found no data on maternal anxiety or acceptability.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with conventional or other care packages that do not include home uterine monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2014), CENTRAL (The Cochrane Library 2014, Issue 8), MEDLINE (1966 to 31 August 2014), EMBASE (1974 to 31 August 2014), CINAHL (1982 to 31 August 2014) and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk for preterm birth, in comparison to the same care package without home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries.

MAIN RESULTS

There were 15 included studies (total number of enrolled participants 6008); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78; 95% confidence interval (CI) 0.62 to 0.99; three studies, n = 1596; fixed-effect analysis) (GRADE high). The significant difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75; 95% CI 0.57 to 1.00, one study, 1292 women). There was no significant difference in the rate of perinatal mortality (RR 1.22; 95% CI 0.86 to 1.72; two studies, n = 2589) (GRADE low)There was no significant difference in the number of preterm births at less than 37 weeks (average RR 0.85; CI 0.72 to 1.01; eight studies, n = 4834; random-effects, T² = 0.03, I² = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77; 95% CI 0.62 to 0.96; five studies, n = 2367; random-effects, T² = 0.02, I² = 32%) (GRADE moderate). The difference was not statistically significant when only high quality studies were included (RR 0.86; 95% CI 0.74 to 1.01; one study, n = 1292). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.49; 95% CI 0.39 to 0.62; two studies, n = 3707) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21; 95% CI 1.01 to 1.45; seven studies, n = 4316; random-effects. T² = 0.03, I² = 62%) but this difference was no longer significant when the analysis was restricted to higher quality studies (average RR 1.22; 95% CI 0.90 to 1.65, three studies, n = 3749,random-effects, T² = 0.05, I² = 76%) (GRADE low). One small study reported that the home uterine monitoring group spent fewer days in hospital antenatally. No data on maternal anxiety or acceptability were found.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but more unscheduled antenatal visits and tocolytic treatment, but the level of evidence is generally low to moderate. Important group differences were not evident when sensitivity analysis was undertaken using only high quality trials. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Home uterine monitoring for detecting preterm labour

BACKGROUND

To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed.

OBJECTIVES

To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with conventional or other care packages that do not include home uterine monitoring.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2011), CENTRAL (The Cochrane Library 2011, Issue 4 of 4), MEDLINE (1966 to 30 November 2011), EMBASE (1974 to 30 November 2011), CINAHL (1982 to 30 November 2011) and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk for preterm birth, in comparison to the same care package without home uterine activity monitoring.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. We did not attempt to contact authors to resolve queries.

MAIN RESULTS

There were 15 included studies (total number of enrolled participants 6008); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78; 95% confidence interval (CI) 0.62 to 0.99; three studies, n = 1596; fixed-effect analysis). However, this significant difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75; 95% CI 0.57 to 1.00, one study, 1292 women). There was no significant difference in the rate of perinatal mortality (RR 1.22; 95% CI 0.86 to 1.72; two studies, n = 2589).There was no significant difference in the number of preterm births at less than 37 weeks (average RR 0.85; CI 0.72 to 1.01; eight studies, n = 4834; random effects, T(2) = 0.03, I(2) = 68%). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77; 95% CI 0.62 to 0.96; five studies, n = 2367; random-effects, T(2) = 0.02, I(2) = 32%). Although this difference was not statistically significant when only high quality studies were included (RR 0.86; 95% CI 0.74 to 1.01; one study, n = 1292). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.49; 95% CI 0.39 to 0.62; two studies, n = 2807). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21; 95% CI 1.01 to 1.45; seven studies, n = 4316; random-effects. T(2) = 0.03, I(2) = 62%) but this difference was no longer significant when the analysis was restricted to high quality studies (average RR 1.22; 95% CI 0.90 to 1.65, three studies, n = 3749,random effects, T(2) = 0.05, I(2) = 76%). One small study reported that the home uterine monitoring group spent fewer days in hospital antenatally. No data on maternal anxiety or acceptability were found.

AUTHORS' CONCLUSIONS

Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but more unscheduled antenatal visits and tocolytic treatment. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.

Randomized, double-blinded, placebo-controlled trial of amoxicillin/clavulanic acid to prevent preterm delivery in twin gestation

Objective: The objective of this study was to determine whether prophylactic treatment with oral broad-spectrum antimicrobial therapy improves pregnancy outcomes in twin gestations.

Methods: Patients with twin gestations between 24 and 32 weeks were randomized to receive amoxicillin/clavulanic acid or placebo. Those patients randomized before 24 weeks received a 1-week course at 24 and at 28 weeks gestation. Those patients entered later than 24 weeks received a 1-week course either at 28 weeks or at enrollment (up to 32 weeks). Other than antibiotic use, the management of the groups was identical and unchanged from the routine care of twin gestations.

Results: Of 149 twin pregnancies enrolled, 76 were randomized to the drug group and 73 to the placebo group. There was no significant difference in mean gestational age at delivery (35.9 vs. 35.7 weeks), birth weight (2,358 vs. 2,344 g), mean neonatal nursery stay (9.9 vs. 11.7 days), or respiratory distress syndrome (6/76 vs. 4/73) in the drug vs. placebo group, respectively.

Conclusions: The addition of prophylactic oral broad-spectrum antimicrobial therapy to the standard antepartum management of twin gestations had no demonstrable effect on the gestational age at delivery, birth weight, or neonatal complications. There did not appear to be any beneficial effect of the prophylactic use of amoxicillin/clavulanic acid in this clinical setting.

South Carolina Partners for Preterm Birth Prevention: a regional perinatal initiative for the reduction of premature birth in a Medicaid population

OBJECTIVE

The objective of the study was to improve the distribution of preterm deliveries in a Medicaid population through a regional perinatal risk assessment and case management initiative.

STUDY DESIGN

An innovative public/private partnership was initiated in the 8 county Lowcountry (LC) perinatal region to reduce preterm birth (PTB) among Medicaid recipient women. Eligible women were identified and underwent telephonic risk assessment, education, and access to a 24 hours, 7 days per week perinatal hotline. Women with predetermined risk factors for PTB were offered patient-centered case management. Medicaid claims and birth certificate data were used to compare obstetric outcomes for 2006 (intervention) and 2004 (control) in both the Lowcountry (LC; program) and Midlands (ML; nonprogram) perinatal regions.

RESULTS

There were 6356 Medicaid deliveries in the LC in 2006. Of these, 2111 were referred for telephonic risk assessment; 317 had identifiable PTB risk factors and consented to case management. Compared with 2004, there was a significant improvement in the distribution of preterm birth (P = .05) in the LC region, primarily confined to deliveries less than 28 weeks (1.6% vs 1.1%; P = .029, relative risk [RR] 0.75, 95% confidence interval [CI], 0.51-0.96). There were also reductions in the frequency (6.7% vs 5.8%; RR 0.86, 95% CI, 0.75-0.98; P = .04) and mean duration (25.0 vs 20.6 days; 95% CI, 1.03-7.77; P = .01) of neonatal intensive care unit (NICU) admissions. No changes were identified in the ML region.

CONCLUSION

A regional initiative of telephonic risk assessment and case management of Medicaid recipient women significantly reduced deliveries less than 28 weeks and NICU care.

Home telehealth--current state and future trends

OBJECTIVE

The purpose of this paper is to give an overview about the state of the art in research on home telehealth in an international perspective.

METHOD

The study is based on a review of the scientific literature published between 1990 and 2003 and retrieved via Medline in January/February 2004. All together, the abstracts of 578 publications have been analyzed.

RESULTS

The majority of publications (44%) comes from the United States, followed by UK and Japan. Most publications deal with vital sign parameter (VSP) measurement and audio/video consultations ("virtual visits"). Publications about IT tools for improved information access and communication as well as decision support for staff, patients and relatives are relatively sparse. Clinical application domains are mainly chronic diseases, the elderly population and paediatrics.

CONCLUSIONS

Internationally, we observe a trend towards tools and services not only for professionals but also for patients and citizens. However, their impact on the patient-provider relationship and their design for special user groups, such as elderly and/or disabled needs to be further explored. In general, evaluation studies are rare and further research is critical to determine the impacts and benefits, and limitations, of potential solutions and to overcome a number of hinders and restrictions, such as - the lack of standards to combine incompatible information systems; - the lack of an evaluation framework considering legal, ethical, organisational, clinical, usability and technical aspects; - the lack of proper guidelines for practical implementation of home telehealth solutions.

Uterine contraction assessment

Few approaches to preterm birth prevention have been as thoroughly studied yet as enigmatic as uterine contraction assessment. Despite multiple randomized clinical trials (level 1 evidence), the effectiveness of home uterine contraction assessment as an adjunct to the clinical management of women at risk for preterm birth remains controversial. This article reviews these trials with particular attention to study design and patient inclusion criteria. The data are absolutely clear that home uterine contraction monitoring with or without frequent perinatal nursing contact can reduce the risk of preterm birth and improve perinatal outcomes and that both are independently superior to standard preterm birth prevention education and care.

Current status of home uterine activity monitoring

A comprehensive evidence-based review of the clinical data leads to the conclusion that if patients at high risk for preterm birth (eg, prior preterm birth because of preterm labor, twins and higher-order multiple gestation, women who have preterm labor during the current pregnancy tocolyzed effectively) use the comprehensive system of HUAM correctly (ie, daily nursing care and twice-daily monitoring) with appropriate alarm rates and sensitive monitors, the incidence of early diagnosis of preterm labor, effective prolongation of pregnancy with fewer preterm births, and a reduction in neonatal morbidity is always demonstrated when the study group is compared with a control group consisting of women receiving standard care available to obstetricians in the United States. The authors expect that there will always be arguments regarding whether the monitor or the nurse contributes most to preterm birth reduction. Even when the alerts of detected contractions or patient-reported symptoms are sounded, the issue of prompt and effective medical intervention will always be hotly debated. The appropriate research design that tests HUAM while allowing various diagnostic and treatment modalities that physicians employ around the United States must be individualized. Physicians must make the decision, based on the evidence, regarding whether or not this system would benefit their patients. While investigators argue about research designs and statistical analyses, physicians simply want the best outcomes for their patients, which is what women and the whole of society also want. Based on the available evidence, it is clear that when the comprehensive system of HUAM is used appropriately in the right patients, everyone benefits.

The nursing management of women experiencing preterm labor: clinical guidelines and why they are needed

Nursing care is a critical component of therapy for women experiencing preterm labor. Diversity exists, however, in the level of comprehensiveness and consistency in guidelines for clinical practice. Nonstandardized care interferes with the ability to achieve consistent, positive patient care outcomes. This article is intended for nurses who seek to organize and standardize their care for women experiencing preterm labor. This article presents a review of the applicable practice and research literature. Clinical guidelines for the nursing management of women experiencing preterm labor are presented in the appendix.

A randomized multicenter trial assessing a home uterine activity monitoring device used in the absence of daily nursing contact

OBJECTIVE

To evaluate the effectiveness of home uterine activity monitoring in the early detection of preterm labor among women with a history of preterm delivery.

STUDY DESIGN

Two hundred eighteen women from four centers were prospectively randomized to routine high-risk prenatal care alone (not monitored) or to the same prenatal care with twice-daily home uterine activity monitoring without daily nursing support (monitored). All women had a history of preterm delivery. The primary study end point was cervical status as measured by cervical dilatation at the time of diagnosis of preterm labor.

RESULTS

The two study group populations at entry into the study were similar in medical and demographic characteristics. Of 187 women completing the trial, 21 (24.4%) of the women in the monitored group (n = 86) and 22 (21.8%) of the women in the unmonitored (control) group (n = 101) experienced preterm labor (not significant). Mean cervical dilatation at the time of diagnosis of preterm labor was 1.7 cm in the monitored group and 2.8 cm in the unmonitored group (p = 0.004). A total of 52.4% of the women in the monitored group had a cervical dilatation of < 2 cm when preterm labor was detected, compared with 18.2% of the women in the unmonitored group (p = 0.019). The median duration of gestation after diagnosis of preterm labor was 21.0 days for the monitored group and 3.0 days for the unmonitored group (p = 0.016).

CONCLUSION

The diagnosis of preterm labor for women using home uterine activity monitoring without daily nursing contact was detected with less cervical dilatation than found in those women not monitored. This earlier detection of preterm labor demonstrates the utility and effectiveness of home uterine activity monitoring devices and may lead to improved neonatal outcomes.

The fetal electrocardiogram: ST waveform analysis during labour

Intrapartum fetal surveillance is still under debate, despite 30 years of clinical experience and numerous clinical trials. Waveform analysis of the fetal electrocardiogram has emerged not as an alternative to cardiotochography but as a support tool to allow more accurate interpretation of intrapartum events. During hypoxia, the healthy fetus is utilizing a series of defense mechanisms. Among these, the increase in sympathetic activity, with an increase in circulating adrenaline, activates the myocardium with an increase in workload (the product of cardiac output, myocardium contractility and blood pressure). If there is an imbalance between myocardial oxygen supply and consumption, determined by the workload, then anaerobic metabolism, with a breakdown of myocardial glycogen stores starts and high T waves emerges. ST depression with negative T waves has recently been observed during hypoxia experiments in experimentally growth retarded guinea pigs whilst their normally grown littermates showed ST elevation. These findings have stimulated the development of a dedicated fetal ECG monitor - STAN - incorporating both standard CTG and ST waveform analysis. The STAN concept has now been taken through the process of recognized validation including several prospective studies and a large randomized trial in Plymouth of 2400 high risk, term deliveries. The T/QRS ratio is only one parameter to be used - equally important is to identify the occurrence of ST depression with biphasic negative T waves and to interrelate the CTG and the ST waveform as outlined in the clinical guidelines (table I). This table contains the clinical experience gained over many years and has formed the basis for the first randomized controlled trial comparing ST waveform + CTG with CTG only. Obviously, when the T/QRS ratio is used as the only component of such a scheme, confusion emerges. The analysis should also contain cases with significant intrapartum hypoxia. Recent findings indicate that only when cord artery pH falls below 7.0 and when there is substantial metabolic acidemia is there a significant risk of intrapartum asphyxia. Metabolic acidemia should be estimated from base deficit in the extracellular fluid and the combination of cord artery and vein data should allow for a more accurate assessment of intrapartum events, including the assessment of the duration of hypoxia. The Plymouth trial has tested the hypothesis that the combination of ST wave form and CTG analysis compared with CTG analysis only would reduce operative interventions for fetal distress without placing the fetus at a risk.(ABSTRACT TRUNCATED AT 400 WORDS)

Home uterine activity monitoring in France: a randomized, controlled trial

OBJECTIVES

We assessed the effectiveness of ambulatory tocodynamometry in reducing the preterm delivery rate in women at risk of preterm delivery such as women with risk factors and women previously hospitalized and discharged.

STUDY DESIGN

In four public maternity units these women were randomly allocated to two groups: 84 had home uterine activity monitoring and daily midwife contact and 84 were given the standard care for high-risk women, which generally includes home visits by community midwives.

RESULTS

The proportion of deliveries before 37 weeks' gestation was slightly higher in the monitored group than in the control group (32% vs 22%). The corresponding odds ratio was 1.7 (95% confidence interval: 0.9 to 3.5).

CONCLUSION

Although the sample was small, these results suggest that home uterine activity monitoring was probably not beneficial to the population studied, or at least that any benefit would have been too small to justify extending this monitoring in this high-risk population.