The future of electronic fetal monitoring

Cooling treatment on the reduction of category II fetal tracings

OBJECTIVES

Epidural-related maternal fever increases the incidence of Category II fetal tracings. To compare the effectiveness of low-flow oxygen inhalation and cooling treatment for parturients with Category II fetal tracings caused by epidural-related maternal fever.

METHODS

We investigated 200 pregnant women who accepted epidural analgesia during labor and had body temperature exceeding 38 °C during labor. Among the patients, 99 and 101 were randomly allocated to receive cooling treatment group (control group) and oxygen inhalation (oxygen group), respectively. The primary outcome was the incidence of Category II fetal heart rate tracings.

RESULTS

The incidence of Category II fetal heart rate tracings in the control group was significantly higher than that in the oxygen group. However, no significant differences were noted between the two groups in terms of the Apgar scores; amniotic fluid turbidity; or maternal outcomes, including cesarean section rate, forceps delivery rate, lateral resection rate, manual removal of placenta rate, the amount of intrapartum hemorrhage, and hemorrhage at postpartum 2 h. Oxygen inhalation therapy was more effective than cooling treatment in reducing the incidence of Category II tracings.

CONCLUSION

Low-flow and short-term oxygen inhalation for parturients with epidural-related maternal fever reduces the incidence of Category II fetal heart rate tracings, but had no significant influence on the mode of delivery or neonatal outcomes.

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 effect of acupressure and halogen light stimulation on nonstress testing and antenatal anxiety: A randomized controlled trial

CONTEXT

Acupressure and halogen light stimulation, are used to reduce false non-reactive nonstress test results related to fetal sleep.

OBJECTIVE

This study was conducted to determine the effect of acupressure and halogen light stimulation on nonstress testing and anxiety during pregnancy.

DESIGN

Randomized controlled experimental study.

SETTING

The population of the study consisted of pregnant women who were requested to have a nonstress test.

PARTICIPANTS

The sample of the study included 132 pregnant women (acupressure group:44; halogen light group:45, and control group:43).

METHODS

The acupressure group was applied acupressure on the Zhiyin acupuncture point three times, the halogen light group was applied halogen light stimulation twice on the fetal head from the mother's abdomen. In the interpretation of the results, the level of statistical significance was taken as P < 0.05.

MAIN OUTCOME PARTICIPANTS

In our study, there was no difference between the acupressure and halogen light groups in terms of the mean number of fetal movements, the number of accelerations, the time to the first acceleration, and the time to reach the reactive result in the nonstress test (P > 0.05), while the mean number of fetal movements and accelerations of these two groups were higher, and the mean time to the first acceleration and the mean time to reach the reactive result in the nonstress test were shorter than those of the control group (P < 0.05). In addition, no statistically significant difference was found between the groups in terms of mean state anxiety inventory scores (P > 0.05).

RESULTS

Acupressure and halogen light stimulation increased the rates of reactive nonstress tests.

Intelligent classification of cardiotocography based on a support vector machine and convolutional neural network: Multiscene research

OBJECTIVE

To propose a computerized system utilizing multiscene analysis based on a support vector machine (SVM) and convolutional neural network (CNN) to assess cardiotocography (CTG) intelligently.

METHODS

We retrospectively collected 2542 CTG records of singleton pregnancies delivered at the maternity ward of the First Affiliated Hospital of Xi'an Jiaotong University from October 10, 2020, to August 7, 2021. CTG records were divided into five categories (baseline, variability, acceleration, deceleration, and normality). Apart from the category of normality, the other four different categories of abnormal data correspond to four scenes. Each scene was divided into training and testing sets at 9:1 or 7:3. We used three computer algorithms (dynamic threshold, SVM, and CNN) to learn and optimize the system. Accuracy, sensitivity, and specificity were performed to evaluate performance.

RESULTS

The global accuracy, sensitivity, and specificity of the system were 93.88%, 93.06%, and 94.33%, respectively. In acceleration and deceleration scenes, when the convolution kernel was 3, the test data set reached the highest performance.

CONCLUSION

The multiscene research model using SVM and CNN is a potential effective tool to assist obstetricians in classifying CTG intelligently.

Labor management and neonatal outcomes in cardiotocography categories II and III (Review)

The safe care of both mothers and fetuses during labor is a primary goal of all health professionals. The assessment of fetal oxygenation and well-being is a key aspect of perinatal care provided. Fetal heart rate (FHR) auscultation became part of daily obstetric practice in a number of countries during the 20th century and remains a key method of fetal monitoring, particularly in low-risk pregnancies. Cardiotocography (CTG) is the continuous monitoring and recording of the FHR and uterine myometrial activity, making it possible to assess the fetal condition. It therefore plays a critical role in the detection of fetal hypoxia during labor, a condition directly related to short- and long-term complications in the newborn. Herein, particular reference is made to the management of CTG category II and III standards, as well as to the handling of childbirth. In addition, specific FHR patterns are associated with immediate neonatal outcomes based on updated studies conducted worldwide. Finally, the prognostic significance of CTG and its potential as a prospective avenue for further investigation are also highlighted herein. Given that the misinterpretation of CTG findings is the most common cause of medical-legal responsibility, this knowledge field requires more emphasis and attention. The aim of the present review was to further deepen the knowledge on issues that mainly concern the safety and monitoring of pregnant women and fetuses during childbirth.

Fetal and Maternal Monitoring

Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.

Effect of maternal cortisol levels on fetal heart rate patterns in primiparous pregnant women in the third trimester

OBJECTIVE

This study aimed to determine whether maternal cortisol levels affect fetal heart rate patterns in primiparous pregnant women in the third trimester.

METHODS

This cross-sectional descriptive study included 400 primiparous pregnant women with uncomplicated pregnancies between November and December 2022. The study included primiparous pregnant women over 18 years old in the third trimester who had not exercised for at least 2 h before the fetal heart rate monitoring and had a healthy pregnancy without consuming any food or drink. Fetuses with decelerating heartbeats and pregnant women who showed uterine contraction and cervical dilation during the fetal heart rate monitoring were excluded from the study. Research data were collected with the data collection form. The fetal heart rate data were collected using a cardiotocograph. At least two accelerations during the 20-min nonstress test period were the basis for diagnosing a reactive nonstress test. About 5 mL of maternal saliva for cortisol measurements was collected before fetal heart rate monitoring. Research data were analyzed with IBM SPSS Statistics for Macintosh, Version 28.0. A p-value of <0.05 was considered significant.

RESULTS

There were no significant differences in the comparison of the groups in terms of education and income status, family type, fetal gender, pregnancy planning status, BMI and age averages, or gestational week averages (p>0.05). The number of at least two accelerations required for the diagnosis of reactive NST was also higher in Group 1 (maternal salivary cortisol level ≤24.20). A moderately positive relationship between fetal heart rate and maternal salivary cortisol was observed (r=0.448, p=0.000). In total, 11.9% of the total change in fetal heart rate level is explained by maternal cortisol (R2=0.119). Maternal cortisol increases fetal heart rate level (ß=0.349).

CONCLUSION

These findings suggest that stress in primiparous pregnant women with high cortisol levels may influence fetal heart rate patterns. It was revealed that the increase in cortisol level, considered a stress hormone, may be a harbinger of fetal tachycardia.

Analysis of the effect of an artificial intelligence chatbot educational program on non-face-to-face classes: a quasi-experimental study

BACKGROUND

Education and training are needed for nursing students using artificial intelligence-based educational programs. However, few studies have assessed the effect of using chatbots in nursing education.

OBJECTIVES

This study aimed to develop and examine the effect of an artificial intelligence chatbot educational program for promoting nursing skills related to electronic fetal monitoring in nursing college students during non-face-to-face classes during the COVID-19 pandemic.

DESIGN

This quasi-experimental study used a nonequivalent control group non-synchronized pretest-posttest design.

METHODS

The participants were 61 junior students from a nursing college located in G province of South Korea. Data were collected between November 3 and 16, 2021, and analyzed using independent t-tests.

RESULTS

The experimental group-in which the artificial intelligence chatbot program was applied-did not show statistically significant differences in knowledge (t = -0.58, p = .567), clinical reasoning competency (t = 0.75, p = .455), confidence (t = 1.13, p = .264), and feedback satisfaction (t = 1.72, p = .090), compared with the control group; however, its participants' interest in education (t = 2.38, p = .020) and self-directed learning (t = 2.72, p = .006) were significantly higher than those in the control group.

CONCLUSION

The findings of our study highlighted the potential of artificial intelligence chatbot programs as an educational assistance tool to promote nursing college students' interest in education and self-directed learning. Moreover, such programs can be effective in enhancing nursing students' skills in non-face-to face-situations caused by the ongoing COVID-19 pandemic.

Current Innovative Methods of Fetal pH Monitoring-A Brief Review

In this study, we explore the "why?", and "how?", monitoring the pH of the fetal scalp is used, and show its limitations. In addition, we review the development of new devices based on the modern physics and nanomaterials serving this topic. Most of the works we found in our search have focused on improving the prognostic of fetal heart rate monitoring, because it is the "golden standard" in determining fetal distress. Although the best-known screening method, it can only provide limited information about the actual status of the fetus. The best predictive assessment, with the highest reproducibility, states that a normal fetal heart rate is indicative of a healthy baby. However, its excellent sensitivity is much reduced when identifying the actual "distress". This is when second-line monitoring methods come into play to guide the diagnostics and direct the obstetrician towards an action plan. Although a historic method, fetal scalp pH sampling is still under review as to its efficiency and place in the current obstetrics. Continuous surveillance of the fetal parameters is important, especially for the fetuses undergoing intrauterine growth restricted (IUGR). Since fetal scalp blood sampling is still under research and is a randomized controlled trial, which compares the relevance of pH and lactates to the obstetrical situation, the maternal-fetal medicine could greatly benefit from the introduction of engineered nanomedicines to the field.

Time and Effort by Labor Nurses to Achieve and Maintain a Continuous Recording of the Fetal Heart Rate via External Monitoring

OBJECTIVE

To describe the time and effort of labor and delivery (L&D) nurses working to achieve a continuous recording of the fetal heart rate via external fetal monitoring, as well as the types of aids involved in that process.

DESIGN

Descriptive study using a cross-sectional survey methodology.

PARTICIPANTS

L&D nurses practicing in New Jersey.

INTERVENTION/MEASUREMENTS

An online survey was used to collect data from labor nurses to identify if they used aids and what types of aids they used in their practice to achieve and maintain a continuous recording of the fetal heart rate via external fetal monitoring, as well as the amount of time that they spent doing so at the bedside.

RESULTS

Of the 134 nurses who participated in the survey, 50% reported spending 1 to 2 hours repositioning an individual, and 48.9% reported spending 1 to 2 hours per 12-hour shift manipulating the ultrasound transducer. Thus, up to one third of the shift was spent working to achieve a continuous recording of the fetal heart rate via external fetal monitoring. More than 99% (n = 133) of participants reported the use of aids. The most popular aids included supplemental monitoring equipment such as extra fetal monitor straps or improvised aids such as washcloths.

CONCLUSION

L&D nurses spend at least some time at the bedside manipulating the ultrasound transducer to achieve and maintain a continuous recording of the fetal heart rate via external fetal monitoring. Various aids are used to do so. Understanding the amount of time nurses spend at the bedside and the aids used for this purpose may provide a better understanding of the work of L&D nurses.

"My whole room went into chaos because of that thing in the corner": Unintended consequences of a central fetal monitoring system

OBJECTIVE

Technologies for fetal heart rate monitoring have been widely introduced despite evidence of no improvement in perinatal outcomes. A significant body of research has raised concerns that healthcare information technologies can have unintended consequences. We sought to describe an unintended consequence of central fetal monitoring technology.

DESIGN

The research was conducted as an Institutional Ethnography. Data generated from interviews, focus groups, and observations were analysed to generate an account of midwives' experiences with the central fetal monitoring system.

SETTING

The birthing unit of one Australian maternity service with a central fetal monitoring system.

INFORMANTS

34 midwives and midwifery students who worked with the central fetal monitoring system.

FINDINGS

Midwives described a disruptive social event they named being K2ed. Clinicians responded to perceived cardiotocograph abnormalities by entering the birth room despite the midwife not having requested assistance. Being K2ed disrupted midwives' clinical work and generated anxiety. Clinical communication was undermined, and midwives altered their clinical practice. Midwives performed additional documentation work to attempt to avoid being K2ed.

KEY CONCLUSIONS

This is the first report of an unintended consequence relating to central fetal monitoring, demonstrating how central fetal monitoring technology potentially undermines safety by impacting on clinical and relational processes and outcomes in maternity care.

IMPLICATIONS FOR PRACTICE

Current evidence does not support implementation or ongoing use of central fetal monitoring systems. Further research is needed to inform scaling down central fetal monitoring systems in a safe and supported way.