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Kebede TN, Abebe KA, Chekol MS, Moltot Kitaw T, Mihret MS, Fentie BM, Sibhat YA, Tizazu MA, Beshah SH, Taye BT. The effect of continuous electronic fetal monitoring on mode of delivery and neonatal outcome among low-risk laboring mothers at Debre Markos comprehensive specialized hospital, Northwest Ethiopia. Front Glob Womens Health 2024; 5:1385343. [PMID: 38979032 PMCID: PMC11228245 DOI: 10.3389/fgwh.2024.1385343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 06/07/2024] [Indexed: 07/10/2024] Open
Abstract
Background Electronic fetal heart rate monitoring (EFM) has been widely used in obstetric practice for over 40 years to improve perinatal outcomes. Its popularity is growing in Ethiopia and other sub-Saharan African countries to reduce high perinatal morbidity and mortality rates. However, its impact on delivery mode and perinatal outcomes in low-risk pregnancies remains controversial. This study aimed to assess the effect of continuous EFM on delivery mode and neonatal outcomes among low-risk laboring mothers at Debre Markos Comprehensive Specialized Hospital, Northwest Ethiopia. Methods A prospective follow-up study was conducted from November 20, 2023, to January 10, 2024. All low-risk laboring mothers meeting the inclusion criteria were included. Data were collected via pretested structured questionnaires and observation, then analyzed using Epi-data 4.6 and SPSS. The incidences of cesarean delivery and continuous EFM were compared using the chi-squared test and Fisher's exact test. Results The study found higher rates of instrumental-assisted vaginal delivery (7% vs. 2.4%) and cesarean sections (16% vs. 2%) due to unsettling fetal heart rate patterns in the continuous EFM group compared to the intermittent auscultation group. However, there were no differences in immediate neonatal outcomes between the groups. Conclusion When compared to intermittent auscultation with a Pinard fetoscope, the routine use of continuous EFM among low-risk laboring mothers was associated with an increased risk of cesarean sections and instrumental vaginal deliveries, without significantly improving immediate newborn outcomes. However, it is important to note that our study faced significant logistical constraints due to the limited availability of EFM devices, which influenced our ability to use EFM comprehensively. Given these limitations, we recommend avoiding the routine use of continuous EFM for low-risk laboring mothers to help reduce the rising number of operative deliveries, particularly cesarean sections. Our findings should be interpreted with caution, and further research with adequate resources is needed to draw definitive conclusions.
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Affiliation(s)
- Tirusew Nigussie Kebede
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Kidist Ayalew Abebe
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Moges Sisay Chekol
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Tebabere Moltot Kitaw
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Muhabaw Shumye Mihret
- Department of Clinical Midwifery, School of Midwifery, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Bezawit Melak Fentie
- Department of General Midwifery, School of Midwifery, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Yared Alem Sibhat
- Department Obstetrics and Gynecology, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Michael Amera Tizazu
- Department Public Health, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Solomon Hailemeskel Beshah
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
| | - Birhan Tsegaw Taye
- Department of Midwifery, Asrat Woldeyes Health Science Campus, Debre Berhan University, Debre Berhan, Ethiopia
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Tsikouras P, Oikonomou E, Bothou A, Kyriakou D, Nalbanti T, Andreou S, Daniilidis A, Peitsidis P, Nikolettos K, Iatrakis G, Nikolettos N. Labor management and neonatal outcomes in cardiotocography categories II and III (Review). MEDICINE INTERNATIONAL 2024; 4:27. [PMID: 38628383 PMCID: PMC11019468 DOI: 10.3892/mi.2024.151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
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.
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Affiliation(s)
- Panagiotis Tsikouras
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Efthimios Oikonomou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Anastasia Bothou
- Midwifery Department of Neonatology, University Hospital Alexandra, 11528 Athens, Greece
| | - Dimimitrios Kyriakou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Theopi Nalbanti
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Sotirios Andreou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Angelos Daniilidis
- 1st Department of Obstetrics and Gynecology, Papageorgiou Hospital, Aristotle University of Thessaloniki, 56429 Thessaloniki, Greece
| | - Panagiotis Peitsidis
- Department of Obstetrics and Gynecology, Helena Venizelou Maternity Hospital, 11521 Athens, Greece
| | - Konstantinos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
| | - Georgios Iatrakis
- Midwifery Department, University of West Attica, 12243 Athens, Greece
| | - Nikolaos Nikolettos
- Department of Obstetrics and Gynecology, Democritus University of Thrace, 68100 Alexandroupolis, Greece
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Girault A, Le Ray C, Garabedian C, Goffinet F, Tannier X. Re-evaluating fetal scalp pH thresholds: An examination of fetal pH variations during labor. Acta Obstet Gynecol Scand 2024; 103:479-487. [PMID: 38059396 PMCID: PMC10867374 DOI: 10.1111/aogs.14739] [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: 10/03/2023] [Revised: 11/09/2023] [Accepted: 11/14/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Since the 1970s, fetal scalp blood sampling (FSBS) has been used as a second-line test of the acid-base status of the fetus to evaluate fetal well-being during labor. The commonly employed thresholds that delineate normal pH (>7.25), subnormal (7.20-7.25), and pathological pH (<7.20) guide clinical decisions. However, these experienced-based thresholds, based on observations and common sense, have yet to be confirmed. The aim of the study was to investigate if pH drop rate accelerates at the common thresholds (7.25 and 7.20) and to explore the possibility of identifying more accurate thresholds. MATERIAL AND METHODS A retrospective study was conducted at a tertiary maternity hospital between June 2017 and July 2021. Patients with at least one FSBS during labor for category II fetal heart rate and delivery of a singleton cephalic infant were included. The rate of change in pH value between consecutive samples for each patient was calculated and plotted as a function of pH value. Linear regression models were used to model the evolution of the pH drop rate estimating slope and standard errors across predefined pH intervals. Exploration of alternative pH action thresholds was conducted. To explore the independence of the association between pH value and pH drop rate, multiple linear regression adjusted on age, body mass index, parity, oxytocin stimulation and suspected small for gestational age was performed. RESULTS We included 2047 patients with at least one FSBS (total FSBS 3467); with 2047 umbilical cord blood pH, and a total of 5514 pH samples. Median pH values were 7.29 1 h before delivery, 7.26 30 min before delivery. The pH drop was slow between 7.40 and 7.30, then became more pronounced, with median rates of 0.0005 units/min at 7.25 and 0.0013 units/min at 7.20. Out of the alternative pH thresholds, 7.26 and 7.20 demonstrated the best alignment with our dataset. Multiple linear regression revealed that only pH value was significantly associated to the rate of pH change. CONCLUSIONS Our study confirms the validity and reliability of current guideline thresholds for fetal scalp pH in category II fetal heart rate.
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Affiliation(s)
- Aude Girault
- Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM U 1153Université Paris CitéParisFrance
- Cochin Hospital, Assistance Publique‐Hôpitaux de Paris, Université Paris CitéPort Royal Maternity UnitParisFrance
- Laboratoire d'Informatique Médicale et d'Ingénierie des Connaissances pour la e‐Santé, LIMICSSorbonne Université, Inserm, Université Sorbonne Paris‐NordParisFrance
| | - Camille Le Ray
- Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM U 1153Université Paris CitéParisFrance
- Cochin Hospital, Assistance Publique‐Hôpitaux de Paris, Université Paris CitéPort Royal Maternity UnitParisFrance
| | - Charles Garabedian
- Department of obstetrics, Univ. Lille, ULR 2694—MetricsCHU LilleLilleFrance
| | - François Goffinet
- Center of Research in Epidemiology and StatisticS/CRESS/Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), INSERM U 1153Université Paris CitéParisFrance
- Cochin Hospital, Assistance Publique‐Hôpitaux de Paris, Université Paris CitéPort Royal Maternity UnitParisFrance
| | - Xavier Tannier
- Laboratoire d'Informatique Médicale et d'Ingénierie des Connaissances pour la e‐Santé, LIMICSSorbonne Université, Inserm, Université Sorbonne Paris‐NordParisFrance
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Crouch C, Seeho S, Morris J. Intrapartum fetal heart rate monitoring: Rationalise, refine or replace? Aust N Z J Obstet Gynaecol 2024; 64:77-79. [PMID: 37702257 DOI: 10.1111/ajo.13752] [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: 04/17/2023] [Accepted: 09/03/2023] [Indexed: 09/14/2023]
Abstract
Monitoring the fetal heartbeat underpins assessment of fetal wellbeing in labour. Although commonly employed in clinical practice, shortcomings remain. A recent review of clinical practice guidelines highlights the variation in definitions of the fetal heart rate that will lead to differences in interpretation. Will intrapartum care be improved by greater consensus around clinical practice guidelines through rationalisation or refinement of guidelines, or will the future see this technique replaced by more accurate forms of fetal monitoring?
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Affiliation(s)
- Catherine Crouch
- Department of Obstetrics and Gynaecology Royal North Shore Hospital, Sydney, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney Medical School Northern, Sydney, New South Wales, Australia
| | - Sean Seeho
- Department of Obstetrics and Gynaecology Royal North Shore Hospital, Sydney, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney Medical School Northern, Sydney, New South Wales, Australia
- Kolling Institute of Medical Research, Women and Babies Research, Sydney, New South Wales, Australia
| | - Jonathan Morris
- Department of Obstetrics and Gynaecology Royal North Shore Hospital, Sydney, New South Wales, Australia
- The University of Sydney Faculty of Medicine and Health, Sydney Medical School Northern, Sydney, New South Wales, Australia
- Kolling Institute of Medical Research, Women and Babies Research, Sydney, New South Wales, Australia
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Kuah S, Simpson B, Salter A, Matthews G, Louise J, Bednarz J, Chandraharan E, Symonds I, McPhee A, Mol BW, Turnbull D, Wilkinson C. Comparison of effect of CTG + STan with CTG alone on emergency Cesarean section rate: STan Australian Randomized controlled Trial (START). ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:462-470. [PMID: 37289946 PMCID: PMC10946943 DOI: 10.1002/uog.26279] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/11/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate whether use of ST analysis of the fetal electrocardiogram (STan) as an adjunct to continuous cardiotocography (CTG) reduces the rate of emergency Cesarean section (EmCS) compared with CTG alone. METHODS This was a randomized controlled trial of patients with a singleton fetus in cephalic presentation at ≥ 36 weeks' gestation, requiring continuous electronic fetal monitoring during labor at a tertiary maternity hospital in Adelaide, Australia, between January 2018 and July 2021. Participants were randomized to undergo CTG + STan or CTG alone. The calculated sample size was 1818 participants. The primary outcome was EmCS. Secondary outcomes included metabolic acidosis, a composite adverse perinatal outcome, and other maternal and neonatal morbidity and safety outcomes. RESULTS The present study enrolled 970 women, of whom 967 were included in the primary analysis. EmCS occurred in 107/482 (22.2%) deliveries in the CTG + STan arm and in 107/485 (22.1%) in the CTG arm (adjusted relative risk, 1.02 (95% CI, 0.81-1.27); P = 0.89). There was no difference in the rate of adverse maternal or neonatal outcomes between arms. CONCLUSIONS The addition of STan as an adjunct to continuous CTG did not reduce the EmCS rate. The smaller-than-anticipated sample size meant that this study was underpowered to detect absolute differences of ≤ 5% and, therefore, this negative finding could be due to a Type-2 error. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- S. Kuah
- Women's and Children's HospitalNorth AdelaideSAAustralia
| | - B. Simpson
- Women's and Children's HospitalNorth AdelaideSAAustralia
- Women's and Children's Health, Adelaide Medical SchoolUniversity of AdelaideNorth AdelaideSAAustralia
| | - A. Salter
- School of Public Health, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - G. Matthews
- Women's and Children's HospitalNorth AdelaideSAAustralia
| | - J. Louise
- Women's and Children's Hospital, Faculty of Health and Medical SciencesUniversity of AdelaideNorth AdelaideSAAustralia
| | - J. Bednarz
- School of Public Health, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
- South Australian Health and Medical Research InstituteSAHMRI Women and KidsNorth AdelaideSAAustralia
| | - E. Chandraharan
- Global Academy of Medical Education and Training LtdLondonUK
| | - I. Symonds
- Adelaide Medical School, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - A. McPhee
- South Australian Health and Medical Research InstituteSAHMRI Women and KidsNorth AdelaideSAAustralia
| | - B. W. Mol
- Department of Obstetrics and GynaecologyMonash UniversityClaytonVICAustralia
- Aberdeen Centre for Women's Health Research, School of Medicine, Medical Sciences and NutritionUniversity of AberdeenAberdeenUK
| | - D. Turnbull
- School of Psychology, Faculty of Health and Medical SciencesUniversity of AdelaideAdelaideSAAustralia
| | - C. Wilkinson
- Women's and Children's HospitalNorth AdelaideSAAustralia
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Magawa S, Maki S, Nii M, Yamaguchi M, Tamaishi Y, Enomoto N, Takakura S, Toriyabe K, Kondo E, Ikeda T. Evaluation of fetal acidemia during delivery using the conventional 5-tier classification and Rainbow systems. PLoS One 2023; 18:e0287535. [PMID: 37352197 PMCID: PMC10289380 DOI: 10.1371/journal.pone.0287535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 06/07/2023] [Indexed: 06/25/2023] Open
Abstract
The association between prepartum time-series fetal heart rate pattern changes and cord blood gas data at delivery was examined using the conventional 5-tier classification and the Rainbow system for 229 female patients who delivered vaginally. They were classified into three groups based on the results of umbilical cord blood gas analysis at delivery. The fetal heart rate pattern classifications were based on analysis of measurement taken at 10-min intervals, beginning at 120 min pre-delivery. The relationship between fetal heart rate pattern classification and cord blood pH at delivery changed over time. The 5-tier classification at each interval increased before delivery in the Mild and Severe groups compared with the Normal group. No significant differences were observed between acidemia groups. The Rainbow classification showed a significant differences between the acidemia groups at each interval, particularly during the prepartum period. A relationship between classification and outcome was evident before delivery for both the 5-tier classification and Rainbow system.
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Affiliation(s)
- Shoichi Magawa
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Shintaro Maki
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Masafumi Nii
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Mizuki Yamaguchi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Yuya Tamaishi
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Naosuke Enomoto
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Sho Takakura
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Kuniaki Toriyabe
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Eiji Kondo
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Faculty of Medicine, Mie, Japan
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Ghesquière L, Moreeuw M, Drumez E, Gilbert M, Hanssens S, Védé M, Garabedian C. [Is it possible to safely reduce the use of in utero pH in the delivery room? Analysis of practices]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2023; 51:270-274. [PMID: 36931599 DOI: 10.1016/j.gofs.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 05/05/2023]
Abstract
OBJECTIVE To evaluate our clinical practices since the implementation of different tools to reduce the use of pH in utero (pHiu) in the delivery room. METHODS A single-centre retrospective study was conducted in our university maternity hospital of Lille from October 2016 to March 2021. All patients in labour with a vaginal delivery agreement, a fetus in cephalic presentation and no contraindication to perform a pHiu were included. Since 2019, team training in fetal heart rate interpretation and a change in birth room practices with the introduction of fetal scalp pacing have been implemented to reduce the use of pH in utero. In order to evaluate the impact on clinical practices, the rate of pHiu, the number of pHiu performed per patient, the rates of instrumental deliveries, caesarean sections and pH at birth below 7.0 were studied and compared over time. RESULTS In total, 1515 patients had one or more pHiu during our study period, i.e. 7.3% (1515/20,562). The rate of pHiu decreased significantly from 2016 to 2021: in 2016, 12.1% (142/1171) of our sample had a pHiu during their labour, compared to 3.4% (33/963) in 2021. pH < 7.0 remained stable, ranging from 1.6 to 2.2%. Similarly, the rates of instrumental deliveries and caesarean sections remained stable, ranging from 17.7% to 21% and from 9.8% to 11.6%, respectively. CONCLUSION Improved knowledge of fetal physiology, awareness of teams of the limits of pHiu and introduction of fetal scalp stimulation have led to a decrease in the number of pHiu, without an increase in the rates of neonatal acidosis, instrumental deliveries and caesarean sections.
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Affiliation(s)
- Louise Ghesquière
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France.
| | - Marine Moreeuw
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Elodie Drumez
- ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France; Department of Biostatistics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Mélissa Gilbert
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Sandy Hanssens
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Morgane Védé
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France
| | - Charles Garabedian
- Department of Gynecology and Obstetrics, CHU de Lille, Lille University Hospital, 59000 Lille, France; ULR 2694 - METRICS : évaluation des technologies de santé et des pratiques médicales, CHU de Lille, University of Lille, 59000 Lille, France
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8
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Improving the interpretation of electronic fetal monitoring: the fetal reserve index. Am J Obstet Gynecol 2023; 228:S1129-S1143. [PMID: 37164491 DOI: 10.1016/j.ajog.2022.11.1275] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/03/2022] [Accepted: 11/03/2022] [Indexed: 03/19/2023]
Abstract
Electronic fetal monitoring, particularly in the form of cardiotocography, forms the centerpiece of labor management. Initially successfully designed for stillbirth prevention, there was hope to also include prediction and prevention of fetal acidosis and its sequelae. With the routine use of electronic fetal monitoring, the cesarean delivery rate increased from <5% in the 1970s to >30% at present. Most at-risk cases produced healthy babies, resulting in part from considerable confusion as to the differences between diagnostic and screening tests. Electronic fetal monitoring is clearly a screening test. Multiple attempts have aimed at enhancing its ability to accurately distinguish babies at risk of in utero injury from those who are not and to do this in a timely manner so that appropriate intervention can be performed. Even key electronic fetal monitoring opinion leaders admit that this goal has yet to be achieved. Our group has developed a modified approach called the "Fetal Reserve Index" that contextualizes the findings of electronic fetal monitoring by formally including the presence of maternal, fetal, and obstetrical risk factors and increased uterine contraction frequencies and breaking up the tracing into 4 quantifiable components (heart rate, variability, decelerations, and accelerations). The result is a quantitative 8-point metric, with each variable being weighted equally in version 1.0. In multiple previously published refereed papers, we have shown that in head-to-head studies comparing the fetal reserve index with the American College of Obstetricians and Gynecologists' fetal heart rate categories, the fetal reserve index more accurately identifies babies born with cerebral palsy and could also reduce the rates of emergency cesarean delivery and vaginal operative deliveries. We found that the fetal reserve index scores and fetal pH and base excess actually begin to fall earlier in the first stage of labor than was commonly appreciated, and the fetal reserve index provides a good surrogate for pH and base excess values. Finally, the last fetal reserve index score before delivery combined with early analysis of neonatal heart rate and acid/base balance shows that the period of risk for neonatal neurologic impairment can continue for the first 30 minutes of life and requires much closer neonatal observation than is currently being done.
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Ugwumadu A, Arulkumaran S. A second look at intrapartum fetal surveillance and future directions. J Perinat Med 2023; 51:135-144. [PMID: 36054840 DOI: 10.1515/jpm-2022-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/25/2022] [Indexed: 01/17/2023]
Abstract
Intrapartum fetal surveillance aims to predict significant fetal hypoxia and institute timely intervention to avoid fetal injury, and do so without unnecessary operative delivery of fetuses at no risk of intrapartum hypoxia. However, the configuration and application of current clinical guidelines inadvertently undermine these aims because of persistent failure to incorporate increased understanding of fetal cardiovascular physiology and adaptations to oxygen deprivation, advances in signal acquisition/processing, and related technologies. Consequently, the field on intrapartum fetal surveillance is stuck in rudimentary counts of the fetal R-R intervals and visual assessment of very common, but nonspecific fetal heart decelerations and fetal heart rate variability. The present authors argue that the time has come to move away from classifications of static morphological appearances of FHR decelerations, which do not assist the thinking clinician in understanding how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults or the patterns that suggest progressive loss of compensation. We also reappraise some of the controversial aspects of intrapartum fetal surveillance in modern obstetric practice, the current state of flux in training and certification, and contemplate the future of the field particularly in the context of the emerging role of artificial intelligence.
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Affiliation(s)
- Austin Ugwumadu
- Department of Obstetrics & Gynaecology, St George's, University of London, London SW17 0RE, UK
| | - Sabaratnam Arulkumaran
- Department of Obstetrics & Gynaecology, St George's, University of London, London SW17 0RE, UK
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10
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Schifrin BS, Koos BJ, Cohen WR, Soliman M. Approaches to Preventing Intrapartum Fetal Injury. Front Pediatr 2022; 10:915344. [PMID: 36210941 PMCID: PMC9537758 DOI: 10.3389/fped.2022.915344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022] Open
Abstract
Electronic fetal monitoring (EFM) was introduced into obstetric practice in 1970 as a test to identify early deterioration of fetal acid-base balance in the expectation that prompt intervention ("rescue") would reduce neonatal morbidity and mortality. Clinical trials using a variety of visual or computer-based classifications and algorithms for intervention have failed repeatedly to demonstrate improved immediate or long-term outcomes with this technique, which has, however, contributed to an increased rate of operative deliveries (deemed "unnecessary"). In this review, we discuss the limitations of current classifications of FHR patterns and management guidelines based on them. We argue that these clinical and computer-based formulations pay too much attention to the detection of systemic fetal acidosis/hypoxia and too little attention not only to the pathophysiology of FHR patterns but to the provenance of fetal neurological injury and to the relationship of intrapartum injury to the condition of the newborn. Although they do not reliably predict fetal acidosis, FHR patterns, properly interpreted in the context of the clinical circumstances, do reliably identify fetal neurological integrity (behavior) and are a biomarker of fetal neurological injury (separate from asphyxia). They provide insight into the mechanisms and trajectory (evolution) of any hypoxic or ischemic threat to the fetus and have particular promise in signaling preventive measures (1) to enhance the outcome, (2) to reduce the frequency of "abnormal" FHR patterns that require urgent intervention, and (3) to inform the decision to provide neuroprotection to the newborn.
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Affiliation(s)
- Barry S. Schifrin
- Department of Obstetrics and Gynecology, Western University of Health Sciences, Pomona, CA, United States
| | - Brian J. Koos
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, United States
| | - Wayne R. Cohen
- Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Tucson, AZ, United States
| | - Mohamed Soliman
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Microbiology, Immunology, and Molecular Genetics, University of California, Los Angeles, Los Angeles, CA, United States
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11
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Victor SF, Bach DBB, Hvelplund AC, Nickelsen C, Lyndrup J, Wilken-Jensen C, Scharff LJ, Weber T, Secher NJ, Krebs L. Cardiotocography combined with ST analysis versus cardiotocography combined with fetal blood sampling in deliveries with abnormal CTG: a randomized trial. Arch Gynecol Obstet 2022; 307:1771-1780. [PMID: 35701639 DOI: 10.1007/s00404-022-06649-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 05/25/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE The aim was to investigate if intrapartum monitoring with cardiotocography (CTG) in combination with ST analysis (STAN) results in an improved perinatal outcome. METHODS We performed a two-center randomized trial. 1013 women with term fetuses in cephalic presentation entered the trial. If a CTG showed intermediate or pathological abnormalities, they were offered fetal blood sampling (FBS) and inclusion if the pH value was above 7.25. They were randomized to either CTG + FBS or CTG + STAN. The primary outcome was neonatal metabolic acidosis, defined as umbilical cord arterial blood pH below 7.05, and base excess equal to or below -10. The secondary outcomes included operative vaginal delivery for fetal distress. RESULTS The rate of metabolic acidosis was 0.8% in the CTG + FBS group and 1.5% in women in the CTG + STAN (P = 0.338). More women in the CTG + STAN group delivered by operative vaginal delivery (25.6% vs 33.5%, P = 0.006). Significantly fewer women in the CTG + STAN group had three to five (28.8% vs 11.0%, P = < 0.001) and six to ten fetal blood samples taken (3.4% vs 0.4%, P = < 0.001). CONCLUSION CTG + STAN did not reduce the incidence of neonatal metabolic acidosis compared to CTG + FBS. CTG + STAN was, however, associated with an increased risk of operative vaginal delivery and a reduced use of FBS. If STAN is used for fetal surveillance, we recommend that it is combined with other methods, such as FBS, for confirmation of the need for operative delivery. CLINICALTRIALS gov ID: NCT01699646. Date of registration: October 4, 2012 (retrospectively registered). https://clinicaltrials.gov/ct2/show/NCT01699646?id=NCT01699646&draw=2&rank=1.
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Affiliation(s)
- Simon Foged Victor
- Department of Obstetrics and Gynecology, Zealand University Hospital, Holbæk, Denmark.
| | - Diana Bøttcher Brøndum Bach
- Department of Gynecology and Obstetrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Anna Carolina Hvelplund
- Department of Pediatrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Carsten Nickelsen
- Department of Gynecology and Obstetrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Jens Lyndrup
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark
| | | | - Lise Jul Scharff
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark
| | - Tom Weber
- Department of Gynecology and Obstetrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Niels Jørgen Secher
- Department of Gynecology and Obstetrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark
| | - Lone Krebs
- Department of Gynecology and Obstetrics, Copenhagen University Hospital, Amager and Hvidovre Hospital, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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12
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Mosnino E, Michel AS, Messedi E, Kayem G, Pinton A. [Comparison of the measurement of lactate at the cord by hand-held devices approved for use during labor with a reference device]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2022; 50:481-485. [PMID: 35288368 DOI: 10.1016/j.gofs.2022.02.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/12/2022] [Accepted: 02/13/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To compare two portable lactate devices, Lactate Scout and StatStrip Xpress, to a laboratory reference device by assessing the concordance of cord blood lactate values at birth. METHODS We conducted a single-center prospective validation study in a level 3 maternity hospital. For all cord samples taken at birth, we analyzed lactates on the reference device (GEM4000®) and on two portable devices Lactate Scout and StatStrip Xpress. We compared the lactate values from each of the two handheld devices to the reference device. RESULTS A total of 101 samples were collected. Each was analyzed by all three machines. The average lactate value obtained by the different machines was 3.7mmol/L. The mean difference between the Lactate Scout and GEM4000® apparatus was 0.0mmol/L±0.8mmol/L. Between these two devices at lactate threshold of 4.8mmol/L, the negative predictive value was 96,2% (76/79) and the area under the curve was 0.98 (95% CI 0.96-1]. The mean difference between StatStrip Xpress and GEM4000® was 0.1mmol/L±0.7mmol/L. Between these two devices at the lactate threshold of 4.8mmol/L, the negative predictive value was 97,4% (76/78) and the area under the curve was 0.95 (95% CI 0.86-1). CONCLUSION There is a good correlation between the lactates obtained by the reference device and the two portable devices Lactate Scout and StatStrip Xpress.
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Affiliation(s)
- E Mosnino
- Service de gynécologie obstétrique, hôpital Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne Université, AP-HP, 91, boulevard de l'Hôpital, Paris, France
| | - A-S Michel
- Service de gynécologie obstétrique, hôpital Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne Université, AP-HP, 91, boulevard de l'Hôpital, Paris, France
| | - E Messedi
- Sorbonne Université, AP-HP, 91, boulevard de l'Hôpital, Paris, France; Service de biochimie, hôpital Trousseau, DMU biologie et génomique Médicales, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - G Kayem
- Service de gynécologie obstétrique, hôpital Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne Université, AP-HP, 91, boulevard de l'Hôpital, Paris, France
| | - A Pinton
- Service de gynécologie obstétrique, hôpital Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Sorbonne Université, AP-HP, 91, boulevard de l'Hôpital, Paris, France.
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13
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Evolving Frameworks for the Foundation and Practice of Electronic Fetal Monitoring. MATERNAL-FETAL MEDICINE 2022. [DOI: 10.1097/fm9.0000000000000148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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14
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Zamora Del Pozo C, Chóliz Ezquerro M, Mejía I, Díaz de Terán Martínez-Berganza E, Esteban LM, Rivero Alonso A, Castán Larraz B, Andeyro García M, Savirón Cornudella R. Diagnostic capacity and interobserver variability in FIGO, ACOG, NICE and Chandraharan cardiotocographic guidelines to predict neonatal acidemia. J Matern Fetal Neonatal Med 2021; 35:8498-8506. [PMID: 34652249 DOI: 10.1080/14767058.2021.1986479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Despite its routine use in intrapartum care, the technique of fetal cardiotocography has some limitations. The aim of this study is to analyze the predictive capacity and interobserver agreement in the latest versions of four international cardiotocography guidelines: Federation of Gynecology and Obstetrics (FIGO), American College of Obstetrics and Gynecology (ACOG), the National Institute for Health and Care Excellence (NICE) and Chandraharan, used to predict neonatal acidemia. STUDY DESIGN The last 30 min of 150 cardiotocographic records were analyzed over all the pH ranges and were blindly evaluated by three independent reviewers. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) were calculated to assess the predictive capacity of each fetal cardiotocographic guideline. The degree of interobserver agreement was evaluated with the Fleiss Kappa coefficient. RESULTS Observers found fetal cardiotocography guidelines to have a variable sensitivity and specificity. The Chandraharan classification reached the highest sensitivity (78.79%), while ACOG had the highest specificity (95.73%). On average for the three observers, Chandraharan had the highest discrimination capacity for neonatal acidemia, although this was only moderate (AUC 0.66; 95%CI, 0.55-0.77) and did not differ significantly from the remaining guidelines. The degree of agreement among the three observers, assessed according to the Fleiss Kappa coefficient, was generally acceptable or moderate for all items and classifications, being highest with the FIGO classification (ĸ = 0.35; 95%CI, 0.28-0.41) and lowest with the ACOG (ĸ = 0.23; 95%CI, 0.16-0.30). CONCLUSION Although all the guidelines have a moderate capacity to predict neonatal acidemia, the Chandraharan guideline has the highest capacity. This follows a different approach from the others in that it relies on interpretations of cardiotocographic traces based on fetal physiology. The degree of interobserver agreement is, in general, acceptable for the four guidelines, and is the highest for FIGO.
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Affiliation(s)
| | | | - Inmaculada Mejía
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Luis Mariano Esteban
- Universidad de Zaragoza, Escuela Universitaria Politécnica de la Almunia, C/Mayor s/n, La Almunia de Doña Godina, Spain
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15
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Iorizzo L, Carlsson Y, Johansson C, Berggren R, Herbst A, Wang M, Leiding M, Isberg PE, Kristensen K, Wiberg-Itzel E, McGee T, Wiberg N. Proposed cutoff for fetal scalp blood lactate in intrapartum fetal surveillance based on neonatal outcomes: a large prospective observational study. BJOG 2021; 129:636-646. [PMID: 34555249 DOI: 10.1111/1471-0528.16924] [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: 07/10/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Determination of lactate in fetal scalp blood (FBS) during labour has been recognised since the 1970s. The internationally accepted cutoff of >4.8 mmol/l indicating fetal acidosis is exclusive for the point-of-care device (POC) LactatePro™, which is no longer in production. The aim of this study was to establish a new cutoff for scalp lactate based on neonatal outcomes with the use of the StatstripLactate® /StatstripXpress® Lactate system, the only POC designed for hospital use. DESIGN Observational study. SETTING January 2016 to March 2020 labouring women with indication for FBS were prospectively included from seven Swedish and one Australian delivery unit. POPULATION Inclusion criteria: singleton pregnancy, vertex presentation, ≥35+0 weeks of gestation. METHOD Based on the optimal correlation between FBS lactate and cord pH/lactate, only cases with ≤25 minutes from FBS to delivery were included in the final calculations. MAIN OUTCOME MEASURES Metabolic acidosis in cord blood defined as pH <7.05 plus BDecf >10 mmol/l and/or lactate >10 mmol/l. RESULTS A total of 3334 women were enrolled of whom 799 were delivered within 25 minutes. The areas under the receiver operating characteristics curves (AUC) and corresponding optimal cutoff values were as follows; metabolic acidosis AUC 0.87 (95% CI 0.77-0.97), cutoff 5.7 mmol/l; pH <7.0 AUC 0.83 (95% CI 0.68-0.97), cutoff 4.6 mmol/l; pH <7.05 plus BDecf ≥12 mmol/l AUC 0.97 (95% CI 0.92-1), cutoff 5.8 mmol/l; Apgar score <7 at 5 minutes AUC 0.74 (95% CI 0.63-0.86), cutoff 5.2 mmol/l; and pH <7.10 plus composite neonatal outcome AUC 0.76 (95% CI 0.67-0.85), cutoff 4.8 mmol/l. CONCLUSION A scalp lactate level <5.2 mmol/l using the StatstripLactate® /StatstripXpress® system will safely rule out fetal metabolic acidosis. TWEETABLE ABSTRACT Scalp blood lactate <5.2 mmol/l using the StatstripLactate® /StatstripXpress system has an excellent ability to rule out fetal acidosis.
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Affiliation(s)
- L Iorizzo
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Obstetrics and Gynaecology, Helsingborg Hospital, Helsingborg, Sweden
| | - Y Carlsson
- Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden.,Centre of Perinatal Medicine and Health, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg, Sweden
| | - C Johansson
- Department of Obstetrics and Gynaecology, Ystad lasarett, Ystad, Sweden
| | - R Berggren
- Department of Obstetrics and Gynaecology, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - A Herbst
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Obstetrics and Gynaecology, Skåne University Hospital, Skåne, Sweden
| | - M Wang
- Department of Obstetrics and Gynaecology, Westmead Hospital, Sydney, NSW, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - M Leiding
- Department of Obstetrics and Gynaecology, Skåne University Hospital, Skåne, Sweden
| | - P-E Isberg
- Department of Statistics, Lund University, Lund, Sweden
| | - K Kristensen
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden.,Department of Obstetrics and Gynaecology, Gold Coast University Hospital, Gold Coast, Qld, Australia
| | - E Wiberg-Itzel
- Department of Obstetrics and Gynaecology, Söder Hospital, Stockholm, Sweden.,Institute of Karolinska, Stockholm, Sweden
| | - T McGee
- Department of Obstetrics and Gynaecology, Westmead Hospital, Sydney, NSW, Australia.,The University of Sydney, Sydney, NSW, Australia
| | - N Wiberg
- Department of Obstetrics and Gynaecology, Ystad lasarett, Ystad, Sweden.,Department of Clinical Sciences Malmö, Lund University, Lund, Sweden
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16
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Gilbert M, Ghesquiere L, Drumez E, Subtil D, Fague V, Berveiller P, Garabedian C. How to reduce fetal scalp blood sampling? A retrospective study evaluating the diagnostic value of scalp stimulation to predict fetal wellbeing assessed by scalp blood sampling. Eur J Obstet Gynecol Reprod Biol 2021; 263:153-158. [PMID: 34216939 DOI: 10.1016/j.ejogrb.2021.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The Fetal Blood Sample (FBS) is used as an indicator of fetal acidosis during labor. Its place is discussed through the lack of randomized trials, as well as the limitations related to the technical procedure. An alternative could be the Fetal Scalp Stimulation (FSS). AIM Our objective was to describe the FSS diagnostic value to predict fetal wellbeing defined from FBS. METHODS The FSS consisted in a digital scalp stimulation for 15 s. Test was negative when an acceleration and/or a normal variability were elicited in the 2 min following. FSS was performed before each FBS which was classified as normal when pH was > 7.25. The diagnostic value was assessed by sensibility, specificity, positive and negative predictive values. FINDINGS 148 women were included in our center from February to December 2019. Of the 191 FBS procedures, when accelerations were elicited sensibility was 58,3 (36.8-77.1), specificity was 67,5 (59.3-75), positive predictive value was 20,9 (12.5-32.9) and negative predictive value was 91.7 % (95 %CI, 85-95.5). DISCUSSION FBS is considered as the gold standard in our study which could be discussed as it is abandoned in some countries because of its questioned reliability and the lack of controlled randomized trials. CONCLUSION This study suggests that FSS could be an interesting alternative adjunctive test to perform in the first instance as it seems to be reliable, non-invasive and easy to perform in order to limit FBS only to absence of acceleration after FSS.
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Affiliation(s)
- M Gilbert
- CHU Lille, Department of Obstetrics, F-59000, Lille, France.
| | - L Ghesquiere
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
| | - E Drumez
- Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France; CHU Lille, Department of Biostatistics, F-59000, Lille, France
| | - D Subtil
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
| | - V Fague
- CH Valenciennes, Department of Obstetrics, F-59300, Valenciennes, France
| | - P Berveiller
- CH Poissy, Department of Obstetrics, F-78300, Poissy, France
| | - C Garabedian
- CHU Lille, Department of Obstetrics, F-59000, Lille, France; Univ. Lille, ULR 2694 METRICS, Évaluation des Technologies de Santé et des Pratiques Médicales, F-59000, Lille, France
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17
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East CE, Davey MA, Kamlin COF, Davis PG, Sheehan PM, Kane SC, Brennecke SP. The addition of fetal scalp blood lactate measurement as an adjunct to cardiotocography to reduce caesarean sections during labour: The Flamingo randomised controlled trial. Aust N Z J Obstet Gynaecol 2021; 61:684-692. [PMID: 33754338 DOI: 10.1111/ajo.13327] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Fetal scalp blood sampling for lactate measurement (FBSLM) is sometimes used to assist in identification of the need for expedited birth in the presence of an abnormal cardiotocograph (CTG). However, there is no randomised controlled trial evidence to support this. AIM To determine whether adding FBSLM reduces the risk of birth by emergency caesarean section in labours complicated by an abnormal CTG, compared with CTG without FBS. MATERIAL AND METHODS Labouring women at a tertiary maternity hospital in Melbourne, Australia with a singleton, cephalic presentation, at ≥37 weeks gestation with an abnormal CTG pattern were randomised to the intervention (n = 61), with intermittent FBSLM in addition to CTG monitoring, or control (CTG without FBS, n = 62). The primary outcome was rate of birth by caesarean section. Secondary outcomes included overall operative birth and fetal and neonatal safety endpoints. TRIAL REGISTRATION ACTRN12611000172909. RESULTS The smaller than anticipated sample was unable to demonstrate an effect from adding FBSLM to CTG monitoring on birth by caesarean section vs monitoring by CTG without FBS (25/61 and 28/62 respectively, P = 0.64, risk ratio 0.91, 95% confidence intervals 0.60-1.36). One newborn infant in the CTG group met the criteria for the composite neonatal outcome of death or serious outcome, neonatal encephalopathy, five-minute Apgar score < 4, neonatal resuscitation, admission to neonatal intensive care unit for 96 h or more. CONCLUSION We were unable to provide robust evidence of the effectiveness of FBSLM to improve the specificity of the CTG in the assessment of fetal wellbeing.
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Affiliation(s)
- Christine E East
- Judith Lumley Centre & School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.,Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Mary-Ann Davey
- Judith Lumley Centre & School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia
| | - C Omar F Kamlin
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Peter G Davis
- Neonatal Services, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Penelope M Sheehan
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stefan C Kane
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Shaun P Brennecke
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Victoria, Australia
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18
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Ito A, Hayata E, Nakata M, Oji A, Furukawa T, Nakakuma M, Morita M. iPREFACE score: Integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring. J Obstet Gynaecol Res 2021; 47:1305-1311. [PMID: 33438340 PMCID: PMC8048540 DOI: 10.1111/jog.14652] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/10/2020] [Accepted: 12/26/2020] [Indexed: 11/27/2022]
Abstract
AIM Cardiotocography is used worldwide to evaluate fetal well-being during pregnancy and labor. In past guidelines, the management plan was determined based on the assessment of the most severe waveform. There are no guidelines for evaluating the integrated recurrent decelerations; however, we believe their assessment to be essential for predicting the status of the fetus. The objective of this study was to propose an indicator for performing medical interventions during labor by creating a scoring system that reflects integrated recurrent decelerations. METHODS In this retrospective cohort study, we included data for only full-term single fetus births from vaginal deliveries. The score named the iPREFACE score (integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring) was calculated using cardiotocography findings from continuing 30 min before delivery. We examined the iPREFACE score and fetal acidemia association and calculated the cut-off iPREFACE scores for acidemia using receiver operating characteristic curves. RESULTS The study included 469 delivery cases. Their iPREFACE scores exhibited a significant negative correlation with the umbilical artery blood pH (correlation coefficient; -0.43). The cut-off iPREFACE scores for the umbilical artery blood with pH <7.20, <7.10 and <7.0 were 44, 46 and 67, respectively (the areas under the curve were 0.776, 0.962 and 0.996, respectively). CONCLUSION The iPREFACE score may predict fetal acidemia and could be used as an indicator for timely medical interventions during labor. Because assessments using a cardiotocography are quick and easy to perform, the iPREFACE score could be a valuable tool in clinical practice.
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Affiliation(s)
- Ayumu Ito
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan.,Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Eijiro Hayata
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Masahiko Nakata
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Ayako Oji
- Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
| | - Takamasa Furukawa
- Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Masahito Nakakuma
- Department of Obstetrics and Gynecology, Ageo Central General Hospital, Ageo-shi, Japan
| | - Mineto Morita
- Department of Obstetrics and Gynecology, Toho University Graduate School of Medicine, Tokyo, Japan.,Department of Obstetrics and Gynecology, Toho University Omori Medical Center, Tokyo, Japan
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19
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Tagliaferri S, Cepparulo P, Vinciguerra A, Campanile M, Esposito G, Maruotti GM, Zullo F, Annunziato L, Pignataro G. miR-16-5p, miR-103-3p, and miR-27b-3p as Early Peripheral Biomarkers of Fetal Growth Restriction. Front Pediatr 2021; 9:611112. [PMID: 33777862 PMCID: PMC7991078 DOI: 10.3389/fped.2021.611112] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 02/15/2021] [Indexed: 12/14/2022] Open
Abstract
Current tests available to diagnose fetal hypoxia in-utero lack sensitivity thus failing to identify many fetuses at risk. Emerging evidence suggests that microRNAs derived from the placenta circulate in the maternal blood during pregnancy and may be used as non-invasive biomarkers for pregnancy complications. With the intent to identify putative markers of fetal growth restriction (FGR) and new therapeutic druggable targets, we examined, in maternal blood samples, the expression of a group of microRNAs, known to be regulated by hypoxia. The expression of microRNAs was evaluated in maternal plasma samples collected from (1) women carrying a preterm FGR fetus (FGR group) or (2) women with an appropriately grown fetus matched at the same gestational age (Control group). To discriminate between early- and late-onset FGR, the study population was divided into two subgroups according to the gestational age at delivery. Four microRNAs were identified as possible candidates for the diagnosis of FGR: miR-16-5p, miR-103-3p, miR-107-3p, and miR-27b-3p. All four selected miRNAs, measured by RT-PCR, resulted upregulated in FGR blood samples before the 32nd week of gestation. By contrast, miRNA103-3p and miRNA107-3p, analyzed between the 32nd and 37th week of gestation, showed lower expression in the FGR group compared to aged matched controls. Our results showed that measurement of miRNAs in maternal blood may form the basis for a future diagnostic test to determine the degree of fetal hypoxia in FGR, thus allowing the start of appropriate therapeutic interventions to alleviate the burden of this disease.
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Affiliation(s)
- Salvatore Tagliaferri
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Pasquale Cepparulo
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Antonio Vinciguerra
- Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Marta Campanile
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Giuseppina Esposito
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Giuseppe Maria Maruotti
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | - Fulvio Zullo
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
| | | | - Giuseppe Pignataro
- Division of Obstetrics and Gynecology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy.,Division of Pharmacology, Department of Neuroscience, Reproductive and Dentistry Sciences, School of Medicine, University of Naples "Federico II", Naples, Italy
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20
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Castro L, Loureiro M, Henriques TS, Nunes I. Systematic Review of Intrapartum Fetal Heart Rate Spectral Analysis and an Application in the Detection of Fetal Acidemia. Front Pediatr 2021; 9:661400. [PMID: 34408993 PMCID: PMC8364976 DOI: 10.3389/fped.2021.661400] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/01/2021] [Indexed: 11/13/2022] Open
Abstract
It is fundamental to diagnose fetal acidemia as early as possible, allowing adequate obstetrical interventions to prevent brain damage or perinatal death. The visual analysis of cardiotocography traces has been complemented by computerized methods in order to overcome some of its limitations in the screening of fetal hypoxia/acidemia. Spectral analysis has been proposed by several studies exploring fetal heart rate recordings while referring to a great variety of frequency bands for integrating the power spectrum. In this paper, the main goal was to systematically review the spectral bands reported in intrapartum fetal heart rate studies and to evaluate their performance in detecting fetal acidemia/hypoxia. A total of 176 articles were reviewed, from MEDLINE, and 26 were included for the extraction of frequency bands and other relevant methodological information. An open-access fetal heart rate database was used, with recordings of the last half an hour of labor of 246 fetuses. Four different umbilical artery pH cutoffs were considered for fetuses' classification into acidemic or non-acidemic: 7.05, 7.10, 7.15, and 7.20. The area under the receiver operating characteristic curve (AUROC) was used to quantify the frequency bands' ability to distinguish acidemic fetuses. Bands referring to low frequencies, mainly associated with neural sympathetic activity, were the best at detecting acidemic fetuses, with the more severe definition (pH ≤ 7.05) attaining the highest values for the AUROC. This study shows that the power spectrum analysis of the fetal heart rate is a simple and powerful tool that may become an adjunctive method to CTG, helping healthcare professionals to accurately identify fetuses at risk of intrapartum hypoxia and to implement timely obstetrical interventions to reduce the incidence of related adverse perinatal outcomes.
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Affiliation(s)
- Luísa Castro
- Faculty of Medicine, Centre for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal.,Health Information and Decision Sciences Department - MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,School of Health of the Polytechnic of Porto, Porto, Portugal
| | - Maria Loureiro
- Faculty of Engineering, University of Porto, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal
| | - Teresa S Henriques
- Faculty of Medicine, Centre for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal.,Health Information and Decision Sciences Department - MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Inês Nunes
- Faculty of Medicine, Centre for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal.,Institute of Biomedical Sciences Abel Salazar, University of Porto, Porto, Portugal.,Centro Materno-Infantil do Norte - Centro Hospitalar e Universitário do Porto, Porto, Portugal
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21
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Prouhèze A, Girault A, Barrois M, Lepercq J, Goffinet F, Le Ray C. Fetal scalp blood sampling: Do pH and lactates provide the same information? J Gynecol Obstet Hum Reprod 2020; 50:101964. [PMID: 33130281 DOI: 10.1016/j.jogoh.2020.101964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 10/20/2020] [Accepted: 10/22/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Assess the discordance between scalp pH and lactates performed from the same sample during labor. METHOD This single-center retrospective study included all women with a singleton fetus who had at least one fetal blood sample taken during labor. Some of them had up to seven samples. Scalp pH was the reference parameter for obstetric decision-making. The correlation between the pH and lactates was studied using Pearson coefficient. By categorizing the values as normal, pre-acidosis and acidosis, we were able to estimate agreement with Cohen's kappa coefficient. The frequency of discordance in the categorization and the factors related to it were studied with univariate and multivariable analyses. Cases of severe acidosis at birth (cord pH < 7.00) and cases with acidosis scalp lactates but normal scalp pH were analyzed. RESULTS We analyzed 480 samples from 268 fetuses among the 2644 deliveries during the study periode. Fetal blood sampling represented 10 % of deliveries. The scalp pH and lactates results were strongly correlated (r=-0.83), but their agreement was only fair (K = 0.36). In 29.4 % of cases, pH and lactates were discordant. Factors related to discordance were meconium-stained fluid, sampling at full dilation and multiple sampling. Six infants (2.2 %) had severe acidosis at birth. Cases' analyses did not allow to conclude severe acidosis could have been avoided using scalp lactates for obstetric decision-making. CONCLUSION For more than a quarter of the samples, results were discordant between scalp pH and lactates, especially when cervix was full dilated and when the amniotic fluid was meconium-stained. A randomized controlled trial comparing the relevance of each parameter according to the obstetrical situation would be necessary.
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Affiliation(s)
- Audrey Prouhèze
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France.
| | - Aude Girault
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France; Paris University, INSERM U1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center of Research on Epidemiology and Statisctics Sorbonne Paris Cité (CRESS), Paris, France
| | - Mathilde Barrois
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France
| | - Jacques Lepercq
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France
| | - François Goffinet
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France; Paris University, INSERM U1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center of Research on Epidemiology and Statisctics Sorbonne Paris Cité (CRESS), Paris, France
| | - Camille Le Ray
- Maternity of Port-Royal, AP-HP. APHP., Paris University Center, FHU PREMA, Paris, France; Paris University, INSERM U1153, Obstetrical Perinatal and Pediatric Epidemiology Research Team (EPOPé), Center of Research on Epidemiology and Statisctics Sorbonne Paris Cité (CRESS), Paris, France
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22
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Shakouri F, Iorizzo L, Edwards HMK, Vinter CA, Kristensen K, Isberg PE, Wiberg N. Effectiveness of fetal scalp stimulation test in assessing fetal wellbeing during labor, a retrospective cohort study. BMC Pregnancy Childbirth 2020; 20:347. [PMID: 32503518 PMCID: PMC7275571 DOI: 10.1186/s12884-020-03030-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/22/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is discussed whether fetal scalp stimulation (FSS) test is a reliable complimentary tool to cardiotocography (CTG) to assess fetal wellbeing during labor. The test is based on the assumption that a well-oxygenated fetus, in contrast to the depressed fetus, will respond to a certain stimulus. The aim of this study was to investigate the effectiveness of the FSS-test. METHODS A retrospective observational study carried out Copenhagen University Hospital, Herlev, Denmark. Laboring women with singleton pregnancies in cephalic presentation after gestation week 33 and indication for fetal blood sampling (FBS) were eligible for inclusion. The FSS-test was classified as positive when an acceleration was absent at the time of FBS and negative when an acceleration was present. Lactate in scalp blood was measured by the point-of-care device LactatePro™ and pH in artery umbilical cord blood by the stationary blood gas analyzer ABL800. Lactate level < 4.2 mmol/L in scalp blood and arterial cord pH > 7.1 were cut-offs for normality. RESULTS Three hundred eighty-five women were included. The cohort was divided by the FBS-to-delivery time: Group 1 (n = 128) ≤ 20 min, Group 2 (n = 117) 21-59 min and Group 3 (n = 140) ≥ 60 min. The proportion of FSS-positive tests differed significantly between the groups (p < 0.000). In Group 1 the sensitivity, specificity and likelihoods for scalp lactate ≥4.2 mmol/L were 81.5 (95% CI 67-90.1), 13.3 18.5 (95% CI 5.9-24.6), LHR+ 0.94 (95% CI 0.8-1.1) and LHR - 1.4 (95% CI 0.6-3.2) and for umbilical artery pH ≤ 7.10 the values were 82.6% (95% CI 61.2-95.1), 16% (95% CI 9.4-24.7), 1.0 (95% CI 0.8-1.2) and 1.1 (95% CI 0.4-3) respectively. Regardless of the FBS-to-delivery time the LHR+ for lactate ≥4.2 mmol/L increased to 1.38 (95% CI 1.2-1.6). CONCLUSION The effectiveness of scalp stimulation test was poor for both ruling in and out fetal hypoxia during labor. Absence of a provoked acceleration seems to be a normal phenomenon in the second stage of labor.
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Affiliation(s)
- Farzaneh Shakouri
- Department of Gynecology and Obstetrics, Sjælland University Hospital, Roskilde, Denmark
| | - Linda Iorizzo
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden. .,Department of Gynecology and Obstetrics, Helsingborg Hospital, Helsingborg, Sweden.
| | - Hellen Mc Kinnon Edwards
- Department of Gynecology and Obstetrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Christina Anne Vinter
- Department of Gynecology and Obstetrics, Odense University Hospital, Odense, Denmark.,Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Karl Kristensen
- Department of Clinical Sciences Lund, Gynecology and Obstetrics, Lund University, Faculty of Medicine, Lund, Sweden
| | | | - Nana Wiberg
- Department of Clinical Sciences Lund, Gynecology and Obstetrics, Lund University, Faculty of Medicine, Lund, Sweden.,Department of Gynecology and Obstetrics, Skåne University Hospital, Ystad, Sweden
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23
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Stål I, Wennerholm UB, Nordstrom L, Ladfors L, Wiberg-Itzel E. Fetal scalp blood sampling during second stage of labor - analyzing lactate or pH? A secondary analysis of a randomized controlled trial. J Matern Fetal Neonatal Med 2020; 35:1100-1107. [PMID: 32233704 DOI: 10.1080/14767058.2020.1743656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Cardiotocography (CTG) is a widely used method for assessing fetal wellbeing during labor. It is well-known that CTG has high sensitivity but low specificity. To avoid unnecessary operative interventions, adjunctive methods such as fetal blood sampling (FBS) are used. Few studies have looked into whether FBS can be used during second stage of labor, and in that case, which of the methods (lactate or pH) are preferred.Objective: To evaluate clinical effectiveness of measuring lactate versus pH in preventing birth acidemia when FBS was performed during second stage of labor.Methods: Secondary analysis of a randomized controlled trial . Thousand three hundred and thirty-eight women with a singleton pregnancy, cephalic presentation, gestational age ≥34 weeks, and indication for FBS during second stage of labor were included.Main outcome measures: Metabolic acidemia (pH <7.05 and base deficit >12 mmol/l) or pH < 7.00 in cord arterial blood at birth.Secondary outcomes: A composite outcome (metabolic acidemia, pH <7 or Apgar score <4), and rates of operative deliveries.Results: Metabolic acidemia occurred in 4.1% in the lactate versus 5.1% in the pH group (relative risk (RR): 0.80; 95% confidence interval (CI): 0.48-1.35) and pH <7 in 1.4% versus 2.8% (RR: 0.51, 95% CI: 0.23-1.13). Composite outcome was found in 3.8 versus 4.9%, respectively (RR: 0.76; 95% CI: 0.46-1.26). No difference in total operative interventions was found. More cesarean deliveries were performed in the lactate group (16.5 vs. 12.4%; RR: 1.33; 95% CI: 1.02-1.74).Conclusion: When analyzing lactate or pH in fetal scalp blood during second stage of labor neonatal outcomes were comparable. The frequency of total operative interventions was similar but more cesarean deliveries were performed in the lactate group.
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Affiliation(s)
- Ingrid Stål
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Ulla-Britt Wennerholm
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Lennart Nordstrom
- Department of Women and Children's Health, Karolinska Institute, Stockholm, Sweden.,Department of Pregnancy and Delivery, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Ladfors
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital East, Gothenburg, Sweden
| | - Eva Wiberg-Itzel
- Department of Clinical Science and Education, Section of Obstetrics and Gynecology, Karolinska Institute, Womens clinic Sodersjukhuset, Stockholm, Sweden
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24
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Amer-Wåhlin I, Ugwumadu A, Yli BM, Kwee A, Timonen S, Cole V, Ayres-de-Campos D, Roth GE, Schwarz C, Ramenghi LA, Todros T, Ehlinger V, Vayssiere C. Fetal electrocardiography ST-segment analysis for intrapartum monitoring: a critical appraisal of conflicting evidence and a way forward. Am J Obstet Gynecol 2019; 221:577-601.e11. [PMID: 30980794 DOI: 10.1016/j.ajog.2019.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND In the past century, some areas of obstetric including intrapartum care have been slow to benefit from the dramatic advances in technology and medical care. Although fetal heart rate monitoring (cardiotocography) became available a half century ago, its interpretation often differs between institutions and countries, its diagnostic accuracy needs improvement, and a technology to help reduce the unnecessary obstetric interventions that have accompanied the cardiotocography is urgently needed. STUDY DESIGN During the second half of the 20th century, key findings in animal experiments captured the close relationship between myocardial glycogenolysis, myocardial workload, and ST changes, thus demonstrating that ST waveform analysis of the fetal electrocardiogram can provide information on oxygenation of the fetal myocardium and establishing the physiological basis for the use of electrocardiogram in intrapartum fetal surveillance. RESULTS Six randomized controlled trials, 10 meta-analyses, and more than 20 observational studies have evaluated the technology developed based on this principle. Nonetheless, despite this intensive assessment, differences in study protocols, inclusion criteria, enrollment rates, clinical guidelines, use of fetal blood sampling, and definitions of key outcome parameters, as well as inconsistencies in randomized controlled trial data handling and statistical methodology, have made this voluminous evidence difficult to interpret. Enormous resources spent on randomized controlled trials have failed to guarantee the generalizability of their results to other settings or their ability to reflect everyday clinical practice. CONCLUSION The latest meta-analysis used revised data from primary randomized controlled trials and data from the largest randomized controlled trials from the United States to demonstrate a significant reduction of metabolic acidosis rates by 36% (odds ratio, 0.64; 95% confidence interval, 0.46-0.88) and operative vaginal delivery rates by 8% (relative risk, 0.92; 95% confidence interval, 0.86-0.99), compared with cardiotocography alone.
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25
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ACOG Committee Opinion No. 766: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol 2019; 133:e164-e173. [PMID: 30575638 DOI: 10.1097/aog.0000000000003074] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Obstetrician-gynecologists, in collaboration with midwives, nurses, patients, and those who support them in labor, can help women meet their goals for labor and birth by using techniques that require minimal interventions and have high rates of patient satisfaction. Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. For women who are in latent labor and are not admitted to the labor unit, a process of shared decision making is recommended to create a plan for self-care activities and coping techniques. Admission during the latent phase of labor may be necessary for a variety of reasons, including pain management or maternal fatigue. Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support provided by support personnel, such as a doula, is associated with improved outcomes for women in labor. Data suggest that for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring. The widespread use of continuous electronic fetal monitoring has not been shown to significantly affect such outcomes as perinatal death and cerebral palsy when used for women with low-risk pregnancies. Multiple nonpharmacologic and pharmacologic techniques can be used to help women cope with labor pain. Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. For most women, no one position needs to be mandated or proscribed. Obstetrician-gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor. Birthing units should carefully consider adding family-centric interventions that are otherwise not already considered routine care and that can be safely offered, given available environmental resources and staffing models. These family-centric interventions should be provided in recognition of the value of inclusion in the birthing process for many women and their families, irrespective of delivery mode. This Committee Opinion has been revised to incorporate new evidence for risks and benefits of several of these techniques and, given the growing interest on the topic, to incorporate information on a family-centered approach to cesarean birth.
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26
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Iorizzo L, Persson KEM, Kristensen KH, Wiberg N. Reliability of the point-of care analyzer "StatStrip® Xpress™" for measurement of fetal blood lactate. Clin Chim Acta 2019; 495:88-93. [PMID: 30953612 DOI: 10.1016/j.cca.2019.04.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 03/04/2019] [Accepted: 04/02/2019] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Measurement of lactate in fetal blood is used to assess the degree of anaerobic metabolism. The technical difficulties in obtaining enough scalp blood for analysis by a bloodgas-analyzer advocates for the use of a point-of-care device. StatStrip®Xpress™ (SSX) has shown promising properties but needs further evaluation before implementation into fetal surveillance. METHODS Arterial/venous umbilical cord blood from 112 newborns were analyzed simultaneously with SSX and the reference method ABL800™. From 321 fetuses with abnormal heart rate scalp blood was sampled and analyzed repeatedly with SSX. RESULTS ABL800™ -lactate ranged from 1.9-13.3 mmol/L in arterial to 1.5-10.2 mmol/L in venous cord blood with excellent correlation to SSX (R2 = 0.95). SSX-values were lower compared to the reference method ranging from -0.79 mmol/L for low values to -1.68 mmol/L for high values. The mean CV for SSX-values in cord respectively scalp blood was: lactate ≤3 mmol/L 7.1% respectively 8.4%; lactate >3 mmol/L 3.8% respectively 6.8%. Repeated measurements of the same sample with SSX where without significant difference in cord/scalp blood (p = 0.11). CONCLUSION SSX-lactate values were constantly lower but correlated excellent to the reference method. The reproducibility was good for cord and scalp blood. We suggest SSX as an attractive device for measurement of fetal lactate.
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Affiliation(s)
- Linda Iorizzo
- Department of Obstetrics and Gynecology, Skåne University Hospital, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Kristina E M Persson
- Department of Laboratory Medicine, Lund University, Skåne University Hospital, Sweden
| | | | - Nana Wiberg
- Department of Obstetrics and Gynecology, Skåne University Hospital, Sweden; Department of Clinical Sciences, Lund University, Malmö, Sweden.
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Hulsenboom ADJ, Verdurmen KMJ, Vullings R, van der Hout–van der Jagt MB, Kwee A, van Laar JOEH, Oei SG. Relative versus absolute rises in T/QRS ratio by ST analysis of fetal electrocardiograms in labour: A case-control pilot study. PLoS One 2019; 14:e0214357. [PMID: 30913253 PMCID: PMC6435156 DOI: 10.1371/journal.pone.0214357] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 03/12/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction The additional value of ST analysis during labour is uncertain. In ST analysis, a T/QRS baseline value is calculated from the fetal electrocardiogram and successive T/QRS ratios are compared to this baseline. However, variation in the orientation of the electrical heart axis between fetuses may yield different T/QRS baseline values. In case of a higher T/QRS baseline value more ST events are encountered, although not always related to perinatal outcome. We hypothesised that we can partly correct for this effect by analysing T/QRS rises as a percentage from baseline (relative ST analysis). This study aimed to explore whether relative ST analysis has better diagnostic value for cord acidaemia compared to conventional ST analysis, where predefined fixed T/QRS ratios are used. Methods and materials A case-control study was performed in 20 term human fetuses during labour; 10 cases (umbilical cord artery pH <7.05 at birth, defining acidaemia) and 10 controls (pH >7.20) were included. The fetal electrocardiogram was recorded using a STAN monitor. We electronically extracted all T/QRS values, baseline and episodic ST events from the STAN monitor and calculated the relative T/QRS changes. The cut-off for relative ST events was determined in a receiver operator characteristic (ROC) curve at optimal specificity for cord acidaemia. Parameters of interest were area under the curve (AUC) of the ROC curve for relative ST events and test performance of both conventional and relative ST analysis. Results Relative ST analysis showed an AUC of 0.99. The optimal cut-off value for relative T/QRS rise was determined at 0.70. Relative vs conventional (absolute) ST analysis showed a specificity of 100% vs 40% (p = 0.031); sensitivity 90% vs 90%; positive likelihood ratio infinity vs 1.5; negative likelihood ratio 0.10 vs 0.25, respectively. Conclusion Relative ST analysis seems to be a promising method to detect impending fetal acidaemia during labour. Further studies are required to determine the diagnostic accuracy.
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Affiliation(s)
| | - Kim M. J. Verdurmen
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
| | - Rik Vullings
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | | | - Anneke Kwee
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - S. Guid Oei
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, Veldhoven, the Netherlands
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
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28
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Lopes-Pereira J, Costa A, Ayres-De-Campos D, Costa-Santos C, Amaral J, Bernardes J. Computerized analysis of cardiotocograms and ST signals is associated with significant reductions in hypoxic-ischemic encephalopathy and cesarean delivery: an observational study in 38,466 deliveries. Am J Obstet Gynecol 2019; 220:269.e1-269.e8. [PMID: 30594567 DOI: 10.1016/j.ajog.2018.12.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Revised: 11/29/2018] [Accepted: 12/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intrapartum cardiotocography is widely used in high-resource countries and remains at the center of fetal monitoring and the decision to intervene, but there is ample evidence of poor reliability in visual interpretation as well as limited accuracy in identifying fetal hypoxia. Combined monitoring of intrapartum cardiotocography and ST segment signals was developed to increase specificity, but analysis relies heavily on intrapartum cardiotocography interpretation and is therefore also affected by the previously referred problems. Computerized analysis was developed to overcome these limitations, aiding in the quantification of parameters that are difficult to evaluate visually, such as variability, integrating the complex guidelines of combined intrapartum cardiotocography and ST analysis, and using visual and sound alerts to prompt health care professionals to reevaluate features associated with fetal hypoxia. OBJECTIVE The objective of the study was to evaluate the effect of introducing a central fetal monitoring system with computerized analysis of intrapartum cardiotocography and ST signals into the labor ward of a tertiary care university hospital in which all women are continuously monitored with intrapartum cardiotocography. The incidence of adverse perinatal outcomes and intervention rates was evaluated over time. STUDY DESIGN In this retrospective cohort study, yearly rates of hypoxic-ischemic encephalopathy, instrumental vaginal delivery, overall cesarean delivery, and urgent cesarean delivery were obtained from the hospital's clinical databases. The rates occurring in the period from January 2001 to December 2003, before the introduction of the central monitoring system with computerized analysis of intrapartum cardiotocography and ST signals (Omniview-SisPorto), were compared with those occurring from January 2004 to December 2014, after the introduction of the system. All rates were calculated with 95% confidence intervals. RESULTS A total of 38,466 deliveries occurred during this period. After introduction of the system, there was a significant decrease in the number of hypoxic-ischemic encephalopathy cases per 1000 births (5.3%, 95% confidence interval [4.0-7.0] vs 2.2%, 95% confidence interval [1.7-2.8]; relative risk, 0.42, 95% confidence interval [0.29-0.61]), overall cesarean delivery rates (29.9%, 95% confidence interval [28.9-30.8] vs 28.3%, 95% confidence interval [27.8-28.8]; relative risk, 0.96, 95% confidence interval [0.92-0.99]), and urgent cesarean deliveries (21.6%, 95% confidence interval [20.7-22.4] vs 19.2%, 95% confidence interval [18.8-19.7]; relative risk, 0.91, 95% confidence interval [0.87-0.95]). The instrumental vaginal delivery rate increased (19.5%, 95% confidence interval [18.7-20.3] vs 21.4%, 95% confidence interval [21.0-21.9; relative risk, 1.07, 95% confidence interval 1.02-1.13]. CONCLUSION Introduction of computerized analysis of intrapartum cardiotocography and ST signals in a tertiary care hospital was associated with a significant reduction in the incidence of hypoxic-ischemic encephalopathy and a modest reduction in cesarean deliveries.
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Affiliation(s)
- Joana Lopes-Pereira
- Department of Obstetrics and Gynecology, University of Porto School of Medicine, and Centro Hospitalar, S. João, Portugal.
| | - Antónia Costa
- Department of Obstetrics and Gynecology, University of Porto School of Medicine, and Centro Hospitalar, S. João, Portugal; Institute of Biomedical Engineering, University of Porto School of Medicine, Porto, Portugal.
| | - Diogo Ayres-De-Campos
- Institute of Biomedical Engineering, University of Porto School of Medicine, Porto, Portugal; Department of Health Information and Decision Sciences and Center for Research in Health Technology and Services, University of Porto School of Medicine, Porto, Portugal; Department of Obstetrics, Gynecology, and Reproductive Medicine, Santa Maria Hospital, University of Lisbon School of Medicine, Lisbon, Portugal
| | - Cristina Costa-Santos
- Department of Health Information and Decision Sciences and Center for Research in Health Technology and Services, University of Porto School of Medicine, Porto, Portugal
| | - Joana Amaral
- Department of Obstetrics and Gynecology, University of Porto School of Medicine, and Centro Hospitalar, S. João, Portugal
| | - João Bernardes
- Department of Obstetrics and Gynecology, University of Porto School of Medicine, and Centro Hospitalar, S. João, Portugal; Institute of Biomedical Engineering, University of Porto School of Medicine, Porto, Portugal
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29
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Goodman DM, Mlay P, Thielman N, Small MJ, Schmitt JW. Using fetal scalp stimulation with Doppler ultrasonography to enhance intermittent auscultation in low-resource settings: a diagnostic trial from Tanzania. BMC Pregnancy Childbirth 2019; 19:71. [PMID: 30760224 PMCID: PMC6374908 DOI: 10.1186/s12884-019-2212-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 02/01/2019] [Indexed: 11/12/2022] Open
Abstract
Background Hypoxia during labor contributes to 2.2 million intrapartum and early neonatal deaths each year. An additional 0.6–1.0 million cases of life-long disability occur because of fetal hypoxia during labor. It is known that fetal heart rate changes in labor correspond to hypoxia and neurologic compromise, but a reliable, low-cost method for detecting these changes is not available. In this study we sought to compare the ability of a handheld Doppler device to detect accelerations as part of the fetal scalp stimulation test and to compare the diagnostic performance of routine intermittent auscultation with auscultation that is augmented with fetal scalp stimulation. Methods This non-randomized, pre- and post-diagnostic trial was conducted with 568 maternal-fetus pairs at Kilimanjaro Christian Medical Center in Moshi, Tanzania. The first objective was to determine whether a handheld Doppler device could detect fetal accelerations in labor with reasonable accuracy as compared with a cardiotocography machine. We performed the fetal scalp stimulation test on 50 fetuses during labor using both a handheld Doppler and a cardiotocography machine and compared the outcomes for correlation using the kappa correlation coefficient. During the second objective, two groups of laboring women were monitored either with intermittent auscultation alone per routine protocol (N = 251) or with intermittent auscultation augmented with fetal scalp stimulation per study protocol(N = 267). Diagnostic accuracy of the monitoring method was determined by comparing umbilical cord blood gases immediately after birth with the predicted state of the baby based on monitoring. The analyses included sensitivity, specificity, and positive and negative predictive values. Results The prevalence of fetal acidemia ranged from 15 to 20%. Adding the fetal scalp stimulation test to intermittent auscultation protocols improved the performance of intermittent auscultation for detecting severe acidemia (pH < 7.0) from 27 to 70% (p = 0.032). The negative predictive value of intermittent auscultation augmented with the fetal scalp stimulation test ranged from 88 to 99% for mild (pH < 7.2) to severe fetal acidemia. Conclusions The fetal scalp stimulation test, conducted with a handheld Doppler, is feasible and accurate in a limited resource setting. It is a low-cost solution that merits further evaluation to reduce intrapartum stillbirth and neonatal death in low-income countries. Trial registration ClinicalTrials.gov (NCT02862925).
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Affiliation(s)
- David M Goodman
- Hubert-Yeargan Center for Global Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA. .,Department of Obstetrics and Gynecology, Orlando Health, Winnie Palmer Hospital for Women and Babies, 83 West Miller Street, Orlando, FL, 32806, USA.
| | - Pendo Mlay
- Kilimanjaro Christian Medical Centre, Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Nathan Thielman
- Hubert-Yeargan Center for Global Health, Department of Internal Medicine: Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Maria J Small
- Hubert-Yeargan Center for Global Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - John W Schmitt
- Hubert-Yeargan Center for Global Health, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
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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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Housseine N, Punt MC, Browne JL, Meguid T, Klipstein-Grobusch K, Kwast BE, Franx A, Grobbee DE, Rijken MJ. Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review. PLoS One 2018; 13:e0206295. [PMID: 30365564 PMCID: PMC6203373 DOI: 10.1371/journal.pone.0206295] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Natasha Housseine
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Marieke C. Punt
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joyce L. Browne
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tarek Meguid
- Department of Obstetrics and Gynaecology, Mnazi Mmoja Hospital, Zanzibar, Tanzania
- School of Health and Medical Science, State University of Zanzibar (SUZA), Zanzibar, Tanzania
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Barbara E. Kwast
- International Consultant Maternal Health and Safe Motherhood, Leusden, The Netherlands
| | - Arie Franx
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Diederick E. Grobbee
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marcus J. Rijken
- Department of Obstetrics and Gynaecology, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
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Cummins G, Kremer J, Bernassau A, Brown A, Bridle HL, Schulze H, Bachmann TT, Crichton M, Denison FC, Desmulliez MPY. Sensors for Fetal Hypoxia and Metabolic Acidosis: A Review. SENSORS (BASEL, SWITZERLAND) 2018; 18:E2648. [PMID: 30104478 PMCID: PMC6111374 DOI: 10.3390/s18082648] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 07/30/2018] [Accepted: 08/02/2018] [Indexed: 12/11/2022]
Abstract
This article reviews existing clinical practices and sensor research undertaken to monitor fetal well-being during labour. Current clinical practices that include fetal heart rate monitoring and fetal scalp blood sampling are shown to be either inadequate or time-consuming. Monitoring of lactate in blood is identified as a potential alternative for intrapartum fetal monitoring due to its ability to distinguish between different types of acidosis. A literature review from a medical and technical perspective is presented to identify the current advancements in the field of lactate sensors for this application. It is concluded that a less invasive and a more continuous monitoring device is required to fulfill the clinical needs of intrapartum fetal monitoring. Potential specifications for such a system are also presented in this paper.
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Affiliation(s)
- Gerard Cummins
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Jessica Kremer
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Anne Bernassau
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Andrew Brown
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK.
| | - Helen L Bridle
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Holger Schulze
- Division of Infection and Pathway Medicine, Edinburgh Medical School, The Chancellor's Building, The University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.
| | - Till T Bachmann
- Division of Infection and Pathway Medicine, Edinburgh Medical School, The Chancellor's Building, The University of Edinburgh, Edinburgh EH16 4SB, Scotland, UK.
| | - Michael Crichton
- Institute of Mechanical, Processing and Energy Engineering, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
| | - Fiona C Denison
- MRC Centre for Reproductive Health, Queen's Medical Research Institute, University of Edinburgh, Edinburgh EH16 4TJ, Scotland, UK.
| | - Marc P Y Desmulliez
- Institute of Sensors, Signals and Systems, Heriot-Watt University, Riccarton EH14 4AS, Scotland, UK.
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Garabedian C, Clermont-Hama Y, Sharma D, Aubry E, Butruille L, Deruelle P, Storme L, De Jonckheere J, Houfflin-Debarge V. Correlation of a new index reflecting the fluctuation of parasympathetic tone and fetal acidosis in an experimental study in a sheep model. PLoS One 2018; 13:e0190463. [PMID: 29320537 PMCID: PMC5761865 DOI: 10.1371/journal.pone.0190463] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 11/20/2017] [Indexed: 12/21/2022] Open
Abstract
The autonomic nervous system plays a leading role in the control of fetal homeostasis. Fetal heart rate variability (HRV) analysis is a reflection of its activity. We developed a new index (the Fetal Stress Index, FSI) reflecting parasympathetic tone. The objective of this study was to evaluate this index as a predictor of fetal acid-base status. This was an experimental study on chronically instrumented fetal lambs (n = 11, surgery at 128 +/- 2 days gestational age, term = 145 days). The model was based on 75% occlusion of the umbilical cord for a maximum of 120 minutes or until an arterial pH ≤ 7.20 was reached. Hemodynamic, gasometric and FSI parameters were recorded throughout the experimentation. We studied the FSI during the 10 minutes prior to pH samplings and compared values for pH>7.20 and pH≤ 7.20. In order to analyze the FSI evolution during the 10 minutes periods, we analyzed the minimum, maximum and mean values of the FSI (respectively FSImin, FSImax and FSImean) over the periods. 11 experimentations were performed. During occlusion, the heart rate dropped with an increase in blood pressure (respectively 160(155-182) vs 106(101-120) bpm and 42(41-45) vs 58(55-62) mmHg after occlusion). The FSImin was 38.6 (35.2-43.3) in the group pH>7.20 and was higher in the group pH less than 7.20 (46.5 (43.3-52.0), p = 0.012). The correlation of FSImin was significant for arterial pH (coefficient of -0.671; p = 0.004) and for base excess (coefficient of -0.632; p = 0.009). The correlations were not significant for the other parameters. In conclusion, our new index seems well correlated with the fetal acid-base status. Other studies must be carried out in a situation close to the physiology of labor by sequential occlusion of the cord.
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Affiliation(s)
- C. Garabedian
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics, Lille, France
- * E-mail:
| | - Y. Clermont-Hama
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics, Lille, France
| | - D. Sharma
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Pediatric Surgery, Lille, France
| | - E. Aubry
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Pediatric Surgery, Lille, France
| | - L. Butruille
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
| | - P. Deruelle
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics, Lille, France
| | - L. Storme
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Neonatology, Lille, France
| | - J. De Jonckheere
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, CIC-IT 1403, Lille, France
| | - V. Houfflin-Debarge
- Univ. Lille, EA 4489 –Perinatal Environment and Health, Lille, France
- CHU Lille, Department of Obstetrics, Lille, France
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Wang M, Chua SC, Bouhadir L, Treadwell EL, Gibbs E, McGee TM. Point-of-care measurement of fetal blood lactate - Time to trust a new device. Aust N Z J Obstet Gynaecol 2017; 58:72-78. [DOI: 10.1111/ajo.12671] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 06/14/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Mandy Wang
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School Westmead; University of Sydney; Sydney New South Wales Australia
| | - Seng C. Chua
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School Westmead; University of Sydney; Sydney New South Wales Australia
| | - Lilain Bouhadir
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School Westmead; University of Sydney; Sydney New South Wales Australia
| | - Erin L. Treadwell
- Sydney Medical School Westmead; University of Sydney; Sydney New South Wales Australia
| | - Emma Gibbs
- NHMRC Clinical Trials Centre; University of Sydney; Sydney New South Wales Australia
| | - Therese M. McGee
- Department of Obstetrics and Gynaecology; Westmead Hospital; Sydney New South Wales Australia
- Sydney Medical School Westmead; University of Sydney; Sydney New South Wales Australia
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Bhatia M, Mahtani KR, Nunan D, Reddy A. A cross-sectional comparison of three guidelines for intrapartum cardiotocography. Int J Gynaecol Obstet 2017; 138:89-93. [PMID: 28346664 DOI: 10.1002/ijgo.12161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 02/22/2017] [Accepted: 03/23/2017] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the cardiotocography classification systems outlined by the International Federation of Gynecology and Obstetrics (FIGO) in 2015 and the UK National Institute for Health and Care Excellence (NICE) in 2007 and 2014. METHODS A cross-sectional observational study of cardiotocography practices at a UK hospital was conducted among labor ward staff (n=21) from November 1 to November 31, 2015. All observers classified ten cardiotocography traces according to the three guidelines using a bespoke form. Outcome measures included interobserver agreement (κ values), percentage agreement, intervention rate, and perceived ease of use. RESULTS The κ values were 0.38 (FIGO 2015), 0.37 (NICE 2007), and 0.34 (NICE 2014). The percentage agreement was identical across the three systems for both normal cardiotocography results (100.0%) and for intermediate or suspicious results (80.9%). By contrast, the percentage agreement for abnormal or pathological findings was 47.6% for NICE 2014, 76.2% for FIGO 2015, and 91.0% for NICE 2007 guidelines. Among 210 observations, intervention was deemed necessary for 48 (22.9%) for FIGO 2015, 29 (13.8%) for NICE 2014, and 56 (26.7%) for NICE 2007 guidelines. The FIGO 2015 system was considered the easiest to use by 13 (61.9%) observers. CONCLUSION Interobserver agreement of cardiotocography classification is suboptimal. The FIGO 2015 system offered favorable agreement scores, perceived ease of use, and a moderate intervention rate.
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Affiliation(s)
- Meena Bhatia
- Department of Obstetrics and Gynaecology, Buckinghamshire National Health Service Trust, Aylesbury, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - David Nunan
- Nuffield Department of Primary Care Health Science, University of Oxford, Oxford, UK
| | - Aparna Reddy
- Department of Obstetrics and Gynaecology, Buckinghamshire National Health Service Trust, Aylesbury, UK.,Department of Obstetrics and Gynaecology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Martinek R, Nedoma J, Fajkus M, Kahankova R, Konecny J, Janku P, Kepak S, Bilik P, Nazeran H. A Phonocardiographic-Based Fiber-Optic Sensor and Adaptive Filtering System for Noninvasive Continuous Fetal Heart Rate Monitoring. SENSORS 2017; 17:s17040890. [PMID: 28420215 PMCID: PMC5426540 DOI: 10.3390/s17040890] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 03/28/2017] [Accepted: 04/12/2017] [Indexed: 11/21/2022]
Abstract
This paper focuses on the design, realization, and verification of a novel phonocardiographic- based fiber-optic sensor and adaptive signal processing system for noninvasive continuous fetal heart rate (fHR) monitoring. Our proposed system utilizes two Mach-Zehnder interferometeric sensors. Based on the analysis of real measurement data, we developed a simplified dynamic model for the generation and distribution of heart sounds throughout the human body. Building on this signal model, we then designed, implemented, and verified our adaptive signal processing system by implementing two stochastic gradient-based algorithms: the Least Mean Square Algorithm (LMS), and the Normalized Least Mean Square (NLMS) Algorithm. With this system we were able to extract the fHR information from high quality fetal phonocardiograms (fPCGs), filtered from abdominal maternal phonocardiograms (mPCGs) by performing fPCG signal peak detection. Common signal processing methods such as linear filtering, signal subtraction, and others could not be used for this purpose as fPCG and mPCG signals share overlapping frequency spectra. The performance of the adaptive system was evaluated by using both qualitative (gynecological studies) and quantitative measures such as: Signal-to-Noise Ratio—SNR, Root Mean Square Error—RMSE, Sensitivity—S+, and Positive Predictive Value—PPV.
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Affiliation(s)
- Radek Martinek
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Jan Nedoma
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Marcel Fajkus
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Radana Kahankova
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Jaromir Konecny
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Petr Janku
- Department of Obstetrics and Gynecology, Masaryk University and University Hospital Brno, Jihlavska 20, 625 00 Brno, Czech Republic.
| | - Stanislav Kepak
- Department of Telecommunications, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Petr Bilik
- Department of Cybernetics and Biomedical Engineering, Faculty of Electrical Engineering and Computer Science, VSB-Technical University of Ostrava, 17 Listopadu 15, Ostrava 70833, Czech Republic.
| | - Homer Nazeran
- Department of Electrical and Computer Engineering, University of Texas El Paso, 500 W University Ave, El Paso, TX 79968, USA.
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Birgisdottir BT, Holzmann M, Varli IH, Graner S, Saltvedt S, Nordström L. Reference values for Lactate Pro 2™ in fetal blood sampling during labor: a cross-sectional study. J Perinat Med 2017; 45:321-325. [PMID: 27089399 DOI: 10.1515/jpm-2016-0027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/08/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Lactate Pro™ (LP1) is the only lactate meter evaluated for fetal scalp blood sampling (FBS) in intrapartum use. The reference values for this meter are: normal value <4.2 mmol/L, preacidemia 4.2-4.8 mmol/L, and acidemia >4.8 mmol/L. The production of this meter has been discontinued. An updated version, Lactate Pro 2TM (LP2), has been launched and is shown to be differently calibrated. The aims of the study were to retrieve a conversion equation to convert lactate values in FBS measured with LP2 to an estimated value if using LP1 and to define reference values for clinical management when using LP2. STUDY DESIGN A cross-sectional study was conducted at a university hospital in Sweden. A total of 113 laboring women with fetal heart rate abnormalities on cardiotocography (CTG) had FBS carried out. Lactate concentration was measured bedside with both LP1 and LP2 from the same blood sample capillary. A linear regression model was constructed to retrieve a conversion equation to convert LP2 values to LP1 values. RESULTS LP2 measured higher values than LP1 in all analyses. We found that 4.2 mmol/L with LP1 corresponded to 6.4 mmol/L with LP2. Likewise, 4.8 mmol/L with LP1 corresponded to 7.3 mmol/L with LP2. The correlation between the analyses was excellent (Spearman's rank correlation, r=0.97). CONCLUSION We recommend the following guidelines when interpreting lactate concentration in FBS with LP2: <6.4 mmol/L to be interpreted as normal, 6.4-7.3 mmol/L as preacidemia indicating a follow-up FBS within 20-30 min, and >7.3 mmol/L as acidemia indicating intervention.
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Affiliation(s)
| | - Malin Holzmann
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm
| | - Ingela Hulthén Varli
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm
| | - Sofie Graner
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm
| | - Sissel Saltvedt
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm
| | - Lennart Nordström
- Department of Obstetrics and Gynecology, Karolinska University Hospital, Stockholm
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Committee Opinion No. 687: Approaches to Limit Intervention During Labor and Birth. Obstet Gynecol 2017; 129:e20-e28. [DOI: 10.1097/aog.0000000000001905] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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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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Ayres-de-Campos D, Spong CY, Chandraharan E. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet 2016; 131:13-24. [PMID: 26433401 DOI: 10.1016/j.ijgo.2015.06.020] [Citation(s) in RCA: 420] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Diogo Ayres-de-Campos
- Medical School, Institute of Biomedical Engineering, S. Joao Hospital, University of Porto, Portugal
| | - Catherine Y Spong
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
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Ayres-de-Campos D. Introduction: Why is intrapartum foetal monitoring necessary – Impact on outcomes and interventions. Best Pract Res Clin Obstet Gynaecol 2016; 30:3-8. [DOI: 10.1016/j.bpobgyn.2015.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 06/11/2015] [Indexed: 10/23/2022]
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