Vibroacoustic and scalp stimulation

Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up?

BACKGROUND

Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.

OBJECTIVE

We reviewed the content, impact, risk-benefit, and feasibility of interventions for obstetric complications with high population attributable risk of intrapartum-related hypoxic injury, as well as human resource, skill development, and technological innovations to improve obstetric care quality and availability.

RESULTS

Despite ecological associations of obstetric care with improved perinatal outcomes, there is limited evidence that intrapartum interventions reduce intrapartum-related neonatal mortality or morbidity. No interventions had high-quality evidence of impact on intrapartum-related outcomes in low-resource settings. While data from high-resource settings support planned cesarean for breech presentation and post-term induction, these interventions may be unavailable or less safe in low-resource settings and require risk-benefit assessment. Promising interventions include use of the partograph, symphysiotomy, amnioinfusion, therapeutic maneuvers for shoulder dystocia, improved management of intra-amniotic infections, and continuous labor support. Obstetric drills, checklists, and innovative low-cost devices could improve care quality. Task-shifting to alternative cadres may increase coverage of care.

CONCLUSIONS

While intrapartum care aims to avert intrapartum-related hypoxic injury, rigorous evidence is lacking, especially in the settings where most deaths occur. Effective care at birth could save hundreds of thousands of lives a year, with investment in health infrastructure, personnel, and research--both for innovation and to improve implementation.

Vibroacoustic stimulation in abnormal biophysical profile: verification of facilitation of fetal well-being

OBJECTIVES

To verify the effect of vibroacoustic stimulation on biophysical profile score, with a prospective randomised study.

STUDY DESIGN

All women with singleton pregnancy, gestational age >or=30 weeks, intact membranes and biophysical profile score <or=8/10 entered the study, after giving written consent, and were randomised to two groups. In group A, a 3-s stimulus with an artificial larynx was applied; if biophysical profile remained abnormal for 30 min, a second stimulus was applied and it was assessed again. In group B, the observation time was extended for 60 min to match the time periods of group A. Pregnancies were managed by final test score and patients delivering more than 24 h apart from last examination were disregarded from the study. Outcome criteria were intrauterine deaths, caesarean sections for fetal distress, Apgar score <7 at 5 min postpartum, meconium-stained amniotic fluid and neonatal intensive care unit admissions. Our null hypothesis was that application of vibroacoustic stimulation does not alter test's statistical parameters.

RESULTS

1349 patients were randomised in group A and 1484 in group B (2833 in total). When comparing group A to B, application of vibroacoustic stimulation significantly decreased the number of positive tests (4.74% vs. 6.67%, p<0.05) and increased the prevalence of outcome criteria in this subgroup (positive likelihood ratio: 24.1 95% CI: 11.12-52.46 vs. 7.52 95% CI: 4.93-11.46), without altering perinatal outcome. Furthermore, specificity, positive predictive value and test accuracy were significantly improved, as well as negative predictive value for intrauterine death.

CONCLUSION

Vibroacoustic stimulation improves the efficiency of biophysical profile score by decreasing false positive tests and improving test accuracy and should be considered as a means of a more thorough fetal evaluation when fetal compromise is suspected.

Intrauterine asphyxia: clinical implications for providers of intrapartum care

Advances in science and technology have allowed researchers to gain a better understanding of the pathophysiology leading to long-term neurologic damage in newborns. Intrapartum events are now known to be an infrequent cause of adverse neurologic outcome. Clinicians caring for women during labor must have an understanding of the pathophysiology of intrauterine asphyxia as well as an awareness of the capabilities and limitations of available intrapartum fetal assessment tools to diagnose intrauterine fetal asphyxia or predict neurologic outcome. This article reviews the physiology of acid-base balance and fetal gas exchange as well as the current scientific understanding of the role of intrauterine asphyxia in the pathophysiology of neonatal encephalopathy and cerebral palsy. Recommendations for care and documentation are included.

[Intrapartum uterine rupture, causes and treatment]

During 3 year period there were over 20000 deliveries at the Institute for Gynecology and Obstetrics. Considering the fact that our clinic's maternity hospital is the largest in the Balkans and that we are at the top of medical practice, the largest number of deliveries in Serbia and Monte Negro is performed in our institution. For the number of uterus ruptures dramatically increased, we analyzed the way of their repair and possible measures for preventing postpartum hysterectomies. We compared patients with performed hysterectomies or uterus sutures. We analyzed the possibility to approach more conservatively to such complications. 30 patients were subjected to interventions. In the group A there were 25 women subjected to more conservative therapy. In the group B there were 5 patients with total hysterectomy with conservation of one or both adnexes.

Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace

BACKGROUND

Fetal vibroacoustic stimulation is a simple, non-invasive technique where a device is placed on the maternal abdomen over the region of the fetal head and sound is emitted at a predetermined level for several seconds. It is hypothesized that the resultant startle reflex in the fetus and subsequent fetal heart rate acceleration or transient tachycardia following vibroacoustic stimulation provide reassurance of fetal well-being. This technique has been proposed as a tool to assess fetal well-being in the presence of a non-reassuring cardiotocographic trace during the first and second stages of labour.

OBJECTIVES

To evaluate the clinical effectiveness and safety of vibroacoustic stimulation in the assessment of fetal well-being during labour, compared with mock or no stimulation for women with a singleton pregnancy exhibiting a non-reassuring fetal heart rate pattern.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 September 2004), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2004), MEDLINE (January 1966 to January 2005), EMBASE (January 1966 to January 2005) and reference lists of all retrieved articles. We sought unpublished trials and abstracts submitted to major international congresses and contacted expert informants.

SELECTION CRITERIA

All published and unpublished randomised trials that compared maternal and fetal/neonatal/infant outcomes when vibroacoustic stimulation was used to evaluate fetal status in the presence of a non-reassuring cardiotocographic trace during labour, compared with mock or no stimulation.

DATA COLLECTION AND ANALYSIS

Two independent review authors identified potential studies from the literature search and assessed them for methodological quality and appropriateness of inclusion, using a data extraction form. Attempts to contact study authors for additional information were unsuccessful.

MAIN RESULTS

The search strategies yielded six studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review.

AUTHORS' CONCLUSIONS

There are currently no randomised controlled trials that address the safety and efficacy of vibroacoustic stimulation used to assess fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace. Although vibroacoustic stimulation has been proposed as a simple, non-invasive tool for assessment of fetal well-being, there is insufficient evidence from randomised trials on which to base recommendations for use of vibroacoustic stimulation in the evaluation of fetal well-being in labour in the presence of a non-reassuring cardiotocographic trace.

Fetal pulse oximetry: a critical appraisal

Despite 40 years of cumulative clinical experience, and a number of randomized clinical trials, electronic fetal heart rate monitoring is perceived by many obstetrical caregivers as a suboptimal method of intrapartum fetal assessment. Fetal pulse oximetry emerged 15 years ago as a promising new technology intended to improve assessment of fetal condition during labor. A large amount of physiologic data and one large randomized clinical trial have brought this technology into clinical practice. We know that fetal acidemia is rare when the arterial oxygen saturation is >30% but fetal pulse oximetry as currently understood and applied does not reduce the overall cesarean rate. Thus, many clinicians remain unconvinced of the benefit of this technology and its utilization has stalled in the US and Europe. We need to further understand if there is a way to use fetal pulse oximetry in the setting of labor dystocia and a non-reassuring fetal heart rate pattern. Although hypoxemia is an accepted mechanism of fetal brain injury, other potential mechanisms should be explored. Current controversies and fertile areas of research are presented.

Evaluation of non-reassuring fetal heart rate patterns with fetal pulse oximetry combined with vibratory acoustic stimulation

OBJECTIVE

To determine the value of fetal pulse oximetry and vibratory acoustic stimulation in the presence of non-reassuring fetal heart rate patterns during labor.

DESIGN

Prospective study in women monitored by cardiotocography and fetal pulse oximetry during labor.

MATERIALS AND METHODS

During a period of 18 months, 907 consecutive parturients in labor were monitored by cardiotocography. Out of these women, 63 were selected on the basis of a non-reassuring fetal heart rate tracing during the first stage of labor. In these cases, fetal pulse oximetry was applied. Vibratory acoustic stimulation was applied in fetuses without spontaneous reactivity in order to evaluate the fetal status.

RESULTS

Our cases were classified into three groups, according to the lower fetal oxygen saturation levels, from the time of oximetry application until delivery. Group A consisted of 29 cases where fetal oxygen saturation levels were > or = 41%, group B (20 cases) with fetal oxygen saturation of 31-40% and group C (14 cases) with levels of < 30%. Spontaneous reactivity was observed in 15 fetuses of group A and seven of group B, while no case of reactivity was noted in group C. Vibratory acoustic-induced reactivity was associated with low fetal oxygen saturation levels. The mean umbilical artery pH levels were 7.29 +/- 0.051 in group A, 7.21 +/- 0.057 in group B and 7.04 +/- 0.05 in group C.

CONCLUSION

Fetal pulse oximetry should be indicated not only in fetuses without any reactivity but also in those with induced reactivity, after the application of vibratory acoustic stimulation.