Improving the interpretation of electronic fetal monitoring: the fetal reserve index

Development of a Practical Prediction Model for Adverse Neonatal Outcomes at the Start of the Second Stage of Labor

OBJECTIVE

To develop a prediction model for adverse neonatal outcomes using electronic fetal monitoring (EFM) interpretation data and other relevant clinical information known at the start of the second stage of labor.

METHODS

This was a retrospective cohort study of individuals who labored and delivered at two academic medical centers between July 2016 and June 2020. Individuals were included if they had a singleton gestation at term (more than 37 weeks of gestation), a vertex-presenting, nonanomalous fetus, and planned vaginal delivery and reached the start of the second stage of labor. The primary outcome was a composite of severe adverse neonatal outcomes. We developed and compared three modeling approaches to predict the primary outcome using factors related to EFM data (as interpreted and entered in structured data fields in the electronic health record by the bedside nurse), maternal comorbidities, and labor characteristics: traditional logistic regression, LASSO (least absolute shrinkage and selection operator), and extreme gradient boosting. Model discrimination and calibration were compared. Predicted probabilities were stratified into risk groups to facilitate clinical interpretation, and positive predictive values for adverse neonatal outcomes were calculated for each.

RESULTS

A total of 22,454 patients were included: 14,820 in the training set and 7,634 in the test set. The composite adverse neonatal outcome occurred in 3.2% of deliveries. Of the three modeling methods compared, the logistic regression model had the highest discrimination (0.690, 95% CI, 0.656-0.724) and was well calibrated. When stratified into risk groups (no increased risk, higher risk, and highest risk), the rates of the composite adverse neonatal outcome were 2.6% (95% CI, 2.3-3.1%), 6.7% (95% CI, 4.6-9.6%), and 10.3% (95% CI, 7.6-13.8%), respectively. Factors with the strongest associations with the composite adverse neonatal outcome included the presence of meconium (adjusted odds ratio [aOR] 2.10, 95% CI, 1.68-2.62), fetal tachycardia within the 2 hours preceding the start of the second stage (aOR 1.94, 95% CI, 1.03-3.65), and number of prior deliveries (aOR 0.77, 95% CI, 0.60-0.99).

The Mortality of Politics: An American Paradox

INTRODUCTION

The USA has the poorest health statistics of any high-income country. Political polarization has risen dramatically; newer safety net programs (the Affordable Care Act [ACA]) are unevenly provided because many Republican-leaning states refused expanded Federal coverage. Democratic programs have reduced physician leadership of medicine. Both have been deleterious. Here, we investigated associations among four key health measures two of which directly impact pregnancy outcomes and two that affect all patients by percentage of each state that voted for the Republican versus Democratic candidate in the 2020 presidential election.

METHODS

For each state, we used public, non-partisan databases to assess the incidence of COVID, maternal, and infant mortality per 100,000 population and average life expectancy. Correlations among these four outcome variables and percentage Republican vote were calculated (r), contextualized by measuring associations with related variables including COVID vaccination rates, access to medical care, and incidences of heart disease, obesity, diabetes, gunshot deaths, and automotive fatalities.

RESULTS

COVID mortality, maternal and infant mortality, and life expectancy were highly correlated with percentage Republican ("red") vote per state. If "red" states had vaccination rates equivalent to Democratic-leaning ("blue") states, 72,000 deaths could have been avoided. Overall, "red" states have lower health metrics, reduced access to care, and higher comorbidities.

CONCLUSION

The percent Republican vote was strongly associated, but not the whole answer, with worse health outcomes for multiple key measures of public health including mortality, access to care, and various comorbidities. Overall, the ACA has improved patient access to care but has also led to "maternity care deserts" disproportionately in rural areas in "red" states. Translating insurance coverage into improved care and outcomes requires further analysis and will require multi-pronged approaches including expanding coverage and incentivizing quality care.

Etiology and Ontogeny of Cerebral Palsy: Implications for Practice and Research

Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the incidence of CP for infants born at term in the USA. Litigation alleging that poor obstetrical practice caused CP in most of these affected children has led to contentious arguments regarding the actual etiologies of this condition and often resulted in substantial monetary awards for plaintiffs. Recent advances in genetic testing using whole exome sequencing have revealed that at least one-third of CP cases in term infants are genetic in origin and therefore not labor-related. Here, we will present and discuss previous attempts to sort out contributing etiologies and ontogenies of CP, and how these newer diagnostic techniques are rapidly improving our ability to better detect and understand such cases. In light of these developments, we present our vision for an overarching spectrum for proper categorization of CP cases into that the following groups: (1) those begun at conception from genetic causes (nonpreventable); (2) those stemming from adverse antenatal/pre-labor events (possibly preventable with heightened antepartum assessment); (3) Those arising from intrapartum events (potentially preventable by earlier interventions); (4) Those occurring shortly after birth (possibly preventable with closer neonatal monitoring); (5) Those that appear later in the postnatal period from non-labor-related causes such as untreated infections or postnatal intracranial hemorrhages.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.