The rapid biophysical profile for early intrapartum fetal well-being assessment

Admission ultrasonography as a means of identifying unrecognized fetal compromise in term singleton pregnancies at the onset of labor - a feasibility study

OBJECTIVES

Apparently uncomplicated low-risk pregnancies, especially first time births, account for a significant proportion of adverse birth outcomes. Improved risk stratification with a simple bedside scan on admission in early labor could potentially reduce adverse intrapartum outcomes. The aim of this feasibility study was to assess a cohort of low-risk subjects with admission ultrasonography at the onset of labor with a view to conducting a future randomized controlled trial (RCT). The objectives were three-fold; i) to determine the logistics of performing a labor admission ultrasound scan ii) to establish whether abnormal ultrasound features can be identified and iii) whether they are associated with emergency delivery and/or poor condition of the neonate at birth.

METHODS

We performed a prospective cohort study of 295 participants with term singleton cephalic pregnancies admitted in early labor or for labor induction with non-fetal indications. The setting was a university teaching hospital in Ireland with almost 8000 births annually. A bedside ultrasound scan was performed to assess fetal biometry, amniotic fluid volume and placental maturity. Patients and their babies were followed up until hospital discharge. The outcomes of interest included image quality, time to perform a scan, oligohydramnios (Single Deepest Pool ≤ 2 cm), small for gestational age (SGA; abdominal circumference <10th centile), mature placenta (Grannum 2 or 3), pathological CTG, emergency cesarean section (CS), fetal acidosis (cord arterial pH <7.10 or base excess <-12.0), low Apgar score <7 at 5 min and neonatal unit admission.

RESULTS

Image quality was optimal in 274 of the 295 scans (93%) and 271 (92%) were completed in less than 10 min. Of this low-risk population, 67 of 294 (23%) had oligohydramnios, 11 (4%) were small for gestational age and 87 (30%) had a mature placenta (Grannum grade 2). The incidence of pathological CTG and emergency CS was higher among patients with oligohydramnios than those with a normal scan but did not reach statistical significance; Odds Ratio 3.40 (95% Confidence Intervals 0.55 to 20.92) and OR 1.43 (95% CI 0.66 to 3.08) respectively. The mean birthweight was significantly lower in those with oligohydramnios -139 g (95% CI -248 to -30) and admission scan detected SGA -357 g (95% CI -557 to -137). Adverse perinatal outcomes were uncommon with a higher incidence of fetal acidosis (pH < 7.10) in the oligohydramnios group. The incidence of neonatal unit admission >24 h was higher in the oligohydramnios group but not statistically significant; OR 3.75 (95% CI 0.61 to 22.97). Results for SGA alone were non-significant and results for oligohydramnios and SGA combined were similar to those for oligohydramnios alone.

CONCLUSIONS

Admission ultrasonography is feasible in a routine clinical setting, but evidence of benefit is weak and does not currently justify a randomized controlled trial.

Associations of History of Displacement, Food Insecurity, and Stress With Maternal-Fetal Health in a Conflict Zone: A Case Study

Background: In populations with a history of conflict, early identification of pregnant women who are at risk of adverse pregnancy outcomes is challenging, especially if sonography is not available. We evaluated the performance of symphysis-fundal height (SFH) for identification of high-risk pregnancies and investigated if food security and diet quality, clinical biomarkers, and stress were associated with SFH and two known indicators of maternal-fetal well-being, sonography-estimated fetal weight and amniotic fluid index (AFI).

Methods: For this cross-sectional study, 61 women with high-risk pregnancies were recruited after referral to the obstetrics and gynecology unit at San José Hospital in Popayán, Colombia. Multiple stepwise linear and ordered logistic regressions were used to identify associations of SFH, sonography-estimated fetal weight and AFI classification with history of displacement, food insecurity, post-traumatic stress symptoms as well as biopsychosocial risk evaluated through the Colombian risk scale.

Results: History of displacement was associated with lower SFH Z-scores, but higher hemoglobin, taking iron supplements and a higher diastolic blood pressure were associated with higher SFH Z-scores. SFH was also associated with AFI but not with sonography-estimated fetal weight. Stress indicators were associated with a higher AFI. In contrast family support, an element of the Colombian biopsychosocial risk assessment, was associated with a higher sonography-estimated fetal weight, whereas more hours of sleep/day were associated with lower sonography-estimated fetal weight.

Conclusion: SFH was not only associated with biological factors known to affect maternal/fetal health but also with history of displacement, thus validating its use in conflict areas for pregnancy assessment. Associations of biopsychosocial stressors with maternal-fetal outcomes highlight the need for a systematic assessment of stress in pregnant women from conflict zones.

Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review

BACKGROUND

The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation.

METHODS AND FINDINGS

The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.

CONCLUSIONS

From the available evidence, the partograph is associated with improved perinatal outcomes and is recommended for use with intermittent auscultation for intrapartum monitoring in low resource settings. CTG is associated with higher caesarean section rates without proven benefits for perinatal outcomes, and should not be recommended in low-resource settings. High-quality evidence considering implementation barriers and enablers is needed to determine the optimal foetal monitoring strategy in low-resource settings.

Applicability of the rapid biophysical profile in antepartum fetal well-being assessment in high-risk pregnancies from a university hospital in são paulo, Brazil: preliminary results

Objective. To evaluate the clinical applicability of the rapid biophysical profile (rBPP), comparing results of the rBPP to umbilical cord pH values and Apgar scores. Methods. A cross-sectional study was conducted with 37 pregnant women from our high-risk service. All of them gave birth at our institution. rBPP was conducted up to 24 h prior to delivery and pH values were obtained from the umbilical vein immediately after birth. The mean and standard deviations for maternal age, gestational age at birth, pH values, and Apgar score in the 1st and 5th minutes after birth were calculated. An unpaired Student's t-test was applied to evaluate the correlation between these variables and rBPP scores of 2 and 4. Results. rBPP score of 2 was observed in 8 patients (21.6%) and score 4 was observed in 29 cases (78.4%). No patients received score zero. The difference between the Apgar scores of the rBPP score 2 and 4 was statistically significant (P < 0.01) while the same was not true with the umbilical cord pH (P = 0.08), even though the values tended to be lower in the rBPP 2 group. Conclusion. The rBPP is a fast and practical method of assessment of antepartum fetal well-being. Further studies, with a larger number of patients, are necessary to evaluate the applicability of the method.

Safe sound exposure in the fetus and preterm infant

Exposure to sound can have beneficial and harmful effects on the developing fetus and preterm infant. Although recommendations for safe exposure to sound have existed for more than three decades, reports indicate that these recommendations are not being followed. Recommendations are made to promote attention to the problem of unsafe exposure to sound in early development, and a multidisciplinary team, including representatives from disciplines beyond medicine and nursing, must redress safe exposure.

Admission tests other than cardiotocography for fetal assessment during labour

BACKGROUND

Evidence on the benefits of admission tests other than cardiotocography in preventing adverse perinatal outcomes has not been established.

OBJECTIVES

To assess the effectiveness of admission tests other than cardiotocography in preventing adverse perinatal outcomes.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2011).

SELECTION CRITERIA

Randomised (individual and cluster) controlled trials, comparing labour admission tests other than CTG for the prevention of adverse perinatal outcomes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility, quality and extracted data.

MAIN RESULTS

We included one study involving 883 women.Comparison of sonographic assessment of amniotic fluid index (AFI) on admission versus no sonographic assessment of AFI on admission. The incidence of cesarean section for fetal distress in the intervention group (29 of 447) was significantly higher than those of controls (14 of 436) (risk ratio (RR) 2.02; 95% confidence interval (CI) 1.08 to 3.77).The incidence of Apgar score less than seven at five minutes in the intervention group (10 of 447) was not significantly different from controls (seven of 436) (RR 1.39, 95% CI 0.54 to 3.63).The incidence of artificial oxytocin for augmentation of labour in the intervention group (213 of 447) was significantly higher than controls (132 of 436) (RR 1.57; 95% CI 1.32 to 1.87).The incidence of neonatal NICU admission in the intervention group (35 of 447) was not significantly different from the controls (33 of 436) (RR 1.03; 95% CI 0.66 to 1.63)

AUTHORS' CONCLUSIONS

There is not enough evidence to support the use of admission tests other than cardiotocography for fetal assessment during labour. Appropriate randomised controlled trials with adequate sample size of admission tests other than cardiotocography for fetal assessment during labour are required.

Reducing stillbirths: screening and monitoring during pregnancy and labour

BACKGROUND

Screening and monitoring in pregnancy are strategies used by healthcare providers to identify high-risk pregnancies so that they can provide more targeted and appropriate treatment and follow-up care, and to monitor fetal well-being in both low- and high-risk pregnancies. The use of many of these techniques is controversial and their ability to detect fetal compromise often unknown. Theoretically, appropriate management of maternal and fetal risk factors and complications that are detected in pregnancy and labour could prevent a large proportion of the world's 3.2 million estimated annual stillbirths, as well as minimise maternal and neonatal morbidity and mortality.

METHODS

The fourth in a series of papers assessing the evidence base for prevention of stillbirths, this paper reviews available published evidence for the impact of 14 screening and monitoring interventions in pregnancy on stillbirth, including identification and management of high-risk pregnancies, advanced monitoring techniques, and monitoring of labour. Using broad and specific strategies to search PubMed and the Cochrane Library, we identified 221 relevant reviews and studies testing screening and monitoring interventions during the antenatal and intrapartum periods and reporting stillbirth or perinatal mortality as an outcome.

RESULTS

We found a dearth of rigorous evidence of direct impact of any of these screening procedures and interventions on stillbirth incidence. Observational studies testing some interventions, including fetal movement monitoring and Doppler monitoring, showed some evidence of impact on stillbirths in selected high-risk populations, but require larger rigourous trials to confirm impact. Other interventions, such as amniotic fluid assessment for oligohydramnios, appear predictive of stillbirth risk, but studies are lacking which assess the impact on perinatal mortality of subsequent intervention based on test findings. Few rigorous studies of cardiotocography have reported stillbirth outcomes, but steep declines in stillbirth rates have been observed in high-income settings such as the U.S., where cardiotocography is used in conjunction with Caesarean section for fetal distress.

CONCLUSION

There are numerous research gaps and large, adequately controlled trials are still needed for most of the interventions we considered. The impact of monitoring interventions on stillbirth relies on use of effective and timely intervention should problems be detected. Numerous studies indicated that positive tests were associated with increased perinatal mortality, but while some tests had good sensitivity in detecting distress, false-positive rates were high for most tests, and questions remain about optimal timing, frequency, and implications of testing. Few studies included assessments of impact of subsequent intervention needed before recommending particular monitoring strategies as a means to decrease stillbirth incidence. In high-income countries such as the US, observational evidence suggests that widespread use of cardiotocography with Caesarean section for fetal distress has led to significant declines in stillbirth rates. Efforts to increase availability of Caesarean section in low-/middle-income countries should be coupled with intrapartum monitoring technologies where resources and provider skills permit.

[Fetal assessment of the labor admission in low risk pregnancies]

The assessment of fetal well-being at the beginning of labor must lead to an appropriate monitoring, adapted to the present risks. Even if some medical events are unforeseeable, three ways of reflexions get clear: abnormal maternofetal signs at the admission indicate the need for an increased monitoring (NP5); the reading of the medical file could reveal a high-risk pregnancy; at least, the realization of electronic fetal heart rate monitoring for any woman at the beginning of the labor is recommended: in case of normality, it remains a good criterion of a fetal good health. In this context of admission, there is no evidence supporting that other techniques (amnioscopy, acoustic test, echography, Doppler, etc.) could be beneficial in low-risk women and be recommended (NP5). Research is to be continued in this field.