Electronic fetal monitoring as a public health screening program: the arithmetic of failure

Performance of a Maternal Risk Stratification System for Predicting Low Apgar Scores

OBJECTIVE

 Maternal risk stratification systems are increasingly employed in predicting and preventing obstetric complications. These systems focus primarily on maternal morbidity, and few tools exist to stratify neonatal risk. We sought to determine if a maternal risk stratification score was associated with neonatal morbidity.

STUDY DESIGN

 Retrospective cohort study of patients with liveborn infants born at ≥24 weeks at four hospitals in one health system between January 1, 2020, and December 31, 2020. The Expanded Obstetric Comorbidity Score (EOCS) is used as the maternal risk score. The primary neonatal outcome was 5-minute Apgar <7. Logistic regression models determined associations between EOCS and neonatal morbidity. Secondary analyses were performed, including stratifying outcomes by gestational age and limiting analysis to "low-risk" term singletons. Model discrimination assessed using the area under the receiver operating characteristic curves (AUC) and calibration via calibration plots.

RESULTS

 A total of 14,497 maternal-neonatal pairs were included; 236 (1.6%) had 5-minute Apgar <7; EOCS was higher in 5-minute Apgar <7 group (median 41 vs. 11, p < 0.001). AUC for EOCS in predicting Apgar <7 was 0.72 (95% Confidence Interval (CI) 0.68, 0.75), demonstrating relatively good discrimination. Calibration plot revealed that those in the highest EOCS decile had higher risk of neonatal morbidity (7.6 vs. 1.7%, p < 0.001). When stratified by gestational age, discrimination weakened with advancing gestational age: AUC 0.70 for <28 weeks, 0.63 for 28 to 31 weeks, 0.64 for 32 to 36 weeks, and 0.61 for ≥37 weeks. When limited to term low-risk singletons, EOCS had lower discrimination for predicting neonatal morbidity and was not well calibrated.

CONCLUSION

 A maternal morbidity risk stratification system does not perform well in most patients giving birth, at low risk for neonatal complications. The findings suggest that the association between EOCS and 5-minute Apgar <7 likely reflects a relationship with prematurity. This study cautions against intentional or unintentional extrapolation of maternal morbidity risk for neonatal risk, especially for term deliveries.

KEY POINTS

· EOCS had moderate discrimination for Apgar <7.. · Predictive performance declined when limited to low-risk term singletons.. · Relationship between EOCS and Apgar <7 was likely driven by prematurity..

Machine learning: a new era for cardiovascular pregnancy physiology and cardio-obstetrics research

The maternal cardiovascular system undergoes functional and structural adaptations during pregnancy and postpartum to support increased metabolic demands of offspring and placental growth, labor, and delivery, as well as recovery from childbirth. Thus, pregnancy imposes physiological stress upon the maternal cardiovascular system, and in the absence of an appropriate response it imparts potential risks for cardiovascular complications and adverse outcomes. The proportion of pregnancy-related maternal deaths from cardiovascular events has been steadily increasing, contributing to high rates of maternal mortality. Despite advances in cardiovascular physiology research, there is still no comprehensive understanding of maternal cardiovascular adaptations in healthy pregnancies. Furthermore, current approaches for the prognosis of cardiovascular complications during pregnancy are limited. Machine learning (ML) offers new and effective tools for investigating mechanisms involved in pregnancy-related cardiovascular complications as well as the development of potential therapies. The main goal of this review is to summarize existing research that uses ML to understand mechanisms of cardiovascular physiology during pregnancy and develop prediction models for clinical application in pregnant patients. We also provide an overview of ML platforms that can be used to comprehensively understand cardiovascular adaptations to pregnancy and discuss the interpretability of ML outcomes, the consequences of model bias, and the importance of ethical consideration in ML use.

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

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

Machine learning on cardiotocography data to classify fetal outcomes: A scoping review

INTRODUCTION

Uterine contractions during labour constrict maternal blood flow and oxygen delivery to the developing baby, causing transient hypoxia. While most babies are physiologically adapted to withstand such intrapartum hypoxia, those exposed to severe hypoxia or with poor physiological reserves may experience neurological injury or death during labour. Cardiotocography (CTG) monitoring was developed to identify babies at risk of hypoxia by detecting changes in fetal heart rate (FHR) patterns. CTG monitoring is in widespread use in intrapartum care for the detection of fetal hypoxia, but the clinical utility is limited by a relatively poor positive predictive value (PPV) of an abnormal CTG and significant inter and intra observer variability in CTG interpretation. Clinical risk and human factors may impact the quality of CTG interpretation. Misclassification of CTG traces may lead to both under-treatment (with the risk of fetal injury or death) or over-treatment (which may include unnecessary operative interventions that put both mother and baby at risk of complications). Machine learning (ML) has been applied to this problem since early 2000 and has shown potential to predict fetal hypoxia more accurately than visual interpretation of CTG alone. To consider how these tools might be translated for clinical practice, we conducted a review of ML techniques already applied to CTG classification and identified research gaps requiring investigation in order to progress towards clinical implementation.

MATERIALS AND METHOD

We used identified keywords to search databases for relevant publications on PubMed, EMBASE and IEEE Xplore. We used Preferred Reporting Items for Systematic Review and Meta-Analysis for Scoping Reviews (PRISMA-ScR). Title, abstract and full text were screened according to the inclusion criteria.

RESULTS

We included 36 studies that used signal processing and ML techniques to classify CTG. Most studies used an open-access CTG database and predominantly used fetal metabolic acidosis as the benchmark for hypoxia with varying pH levels. Various methods were used to process and extract CTG signals and several ML algorithms were used to classify CTG. We identified significant concerns over the practicality of using varying pH levels as the CTG classification benchmark. Furthermore, studies needed to be more generalised as most used the same database with a low number of subjects for an ML study.

CONCLUSION

ML studies demonstrate potential in predicting fetal hypoxia from CTG. However, more diverse datasets, standardisation of hypoxia benchmarks and enhancement of algorithms and features are needed for future clinical implementation.

Maternal Health Considerations: Highlighting and advancing opportunities for improved maternal health

The special collection on Maternal Health Considerations offers a comprehensive exploration of critical issues surrounding maternal well-being across diverse contexts and disciplines. Recognising that maternal health extends beyond the physiological realm, this collection delves into the multifaceted dimensions of maternal well-being, including physical, mental, and socio-ecological factors. The collection comprises a series of interdisciplinary studies that investigate various facets of maternal health, from conception to postpartum stages. It addresses the complex interplay between biological, psychological, and socio-cultural determinants that influence maternal health outcomes. By adopting a holistic approach, the contributors shed light on the interconnectedness of maternal well-being. Key themes explored within this collection include the impact of prenatal care on maternal and neonatal health outcomes, as well as the role of mental health in shaping maternal experiences. In addition, the collection presents innovative recommendations to enhancing maternal well-being, such as community-based interventions, technological advancements, and future policy considerations. Furthermore, the special collection emphasises the significance of culturally sensitive care in promoting maternal health. It highlights the need for tailored interventions that respect the diversity of maternal experiences across different ethnic, racial, and socioeconomic groups. Contributors to this collection employ a range of methodologies, including qualitative and quantitative research case studies, which provide an intricate overview of the current state of maternal health research. The collection also offers valuable insights for policymakers, healthcare practitioners, researchers, and advocates working towards improving maternal health outcomes worldwide. It serves as a vital resource for contributing to our understanding of the complexities surrounding maternal well-being. It offers a platform for critical dialogue and collaborative efforts aimed at promoting holistic maternal health.

The time has come for a paradigm shift in obstetrics' medico-legal litigations

Cerebral Palsy (CP) represents the most common neuromuscular disability in childhood and it is caused by a multiplicity of factors. Intrapartum fetal surveillance is still a controversial issue: even though intrapartum hypoxia alone plays a minimal role in causing neonatal cerebral damage, obstetricians face a large number of medical malpractice litigations for alleged birth mismanagement. The cardinal driver of CP litigation is Cardiotocography (CTG): despite its suboptimal performance in reducing the occurrence of intrapartum brain injury, its ex post interpretation is widely used to evaluate the liability of the labor ward personnel in trials and, based on this, most caregivers are convicted. This article takes cue from a recent acquittal verdict by the Italian Supreme Court of Cassation to challenge the role of intrapartum CTG as a medico-legal proof of malpractice. Because of its low specificity and poor inter- and intra-observer agreement, intrapartum CTG traces do not meet the Daubert criteria and, lastly, they should be weighed with caution in the context of a courtroom trial.

Resistance to Change

Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how they were introduced, implemented, and opposed. Resistance varies from benign - often happening because of inertia or lack of resources to more active forms, including outright opposition using both appropriate and inappropriate methods to resist/delay changes in care. Today, even public health has become politicized, having nothing to do with the underlying science, but having catastrophic results. Two other corroding influences are marketing pressure from the private sector and vested interests in favor of one outcome or another. This also applies to governmental agencies. There are a number of ways in which papers have been buried including putting the thumb on the scale where reviewers can sabotage new ideas. Unless we learn to harness new technologies earlier in their life course and understand how to maneuver around the pillars of obstruction to their implementation, we will not be able to provide medical care at the forefront of technological capabilities.

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

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.

Comparison of the predictive ability for perinatal acidemia in neonates between the NICHD 3-tier FHR system combined with clinical risk factors and the fetal reserve index

BACKGROUND

Electronic fetal monitoring alone is a poor screening test for detecting fetuses at risk of acidemia or asphyxia. We aimed to evaluation of predictive ability of the National Institute of Child Health and Human Development (NICHD) 3-tier fetal heart rate (FHR) system combined with the maternal, obstetric, and fetal risk factors for predicting perinatal acidemia, and to compare this with the predictive of the NICHD 3-tier system alone, and the Fetal Reserve Index (FRI).

METHODS

A retrospective cohort study was conducted among singleton term pregnant women. Fetal heart rate tracings of the last two hours before delivery were interpreted into the NICHD 3-tier FHR classification system by two experienced obstetricians. Demographic data were compared using the χ2 or Fisher's exact test for categorical variables and the Student's t test for continuous variables. Logistic regression model was used to identify factors associated with perinatal acidemia in neonates. The Odds ratios (OR) and probabilities with 95% confidence intervals (CI) were calculated.

RESULTS

A total of 674 pregnant women were enrolled in this study. Using the NICHD 3-tier FHR categories I and II combined with the selected risk factors (AUC 0.62) had a better performance for perinatal acidemia prediction than the NICHD 3-tier FHR alone (AUC 0.55) and the FRI (AUC 0.52), (P<0.01). Improvement of predicting perinatal acidemia was found when NICHD category I was combined with preeclampsia or arrest disorders of labor (OR 3.2, 95% CI 1.30‒7.82) or combined with abnormal second stage of labor (OR 6.19, 95% CI 1.07‒36.06) and when NICHD category II was combined with meconium-stained amniotic fluid (OR 4.73, 95% CI 2.17‒10.31).

CONCLUSIONS

The NICHD 3-tier FHR categories I or II combined with selected risk factors can improve the predictive ability of perinatal acidemia in neonates compared with the NICHD 3-tier system alone or the FRI.

Changing Perspectives of Electronic Fetal Monitoring

The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.

The impact on obstetric and perinatal outcomes in term infants following the introduction of a colour-coded, hierarchical cardiotocography classification system: A retrospective non-inferiority study

BACKGROUND

Queensland introduced a colour-coded cardiotocograph (CTG) classification system (green, blue, yellow and red) to complement the Royal Australian and New Zealand College of Obstetricians and Gynaecologists prose-based classification system of 'low, unlikely, maybe or likely' fetal compromise.

AIMS

The aim of the study was to determine the clinical impact of the introduction of the colour-coded CTG classification system compared to the prose-based system. We hypothesised there would be no change in the rate of operative delivery for intrapartum fetal compromise (OD-IFC).

MATERIALS AND METHODS

This retrospective non-inferiority study from November 2014 to May 2018 used routinely collected data from the Mater Mother's Hospital. Non-insured women with a singleton, non-anomalous, cephalic fetus at term, attempting a vaginal birth with continuous intrapartum CTG were included. The primary outcome was OD-IFC. Secondary outcomes included various obstetric and perinatal outcomes. Non-inferiority analysis was performed with a pre-specified non-inferiority margin of 2% risk difference.

RESULTS

Eleven thousand seven hundred and twenty-seven participants were included. The OD-IFC rate was similar across the study groups (prose-based 15.1% vs colour-coded 15.3%, adjusted odds ratio (aOR) 1.02, 95% CI 0.93-1.13) with the adjusted risk difference of 0.29% (95% CI -0.98 to 1.56), which did not exceed the inferiority margin. There were more spontaneous (aOR 1.11, 95% CI 1.04-1.19) and fewer instrumental (aOR 0.87, 95% CI 0.80-0.95) vaginal births in the colour-coded cohort. There were no differences in neonatal outcomes.

CONCLUSIONS

Reassuringly, the colour-coded CTG classification system was non-inferior to the prose-based system, did not influence OD-IFC but was associated with more spontaneous vaginal deliveries.

Cerebroplacental ratio for prediction of adverse intrapartum and neonatal outcomes in a term uncomplicated pregnancy

Background

Fetal hypoxia is one of the major causes of high perinatal morbidity and mortality rates. Doppler ultrasound tests such as cerebroplacental ratio (CPR) evaluation are commonly used to assess blood flow disturbances in placento-umbilical and feto-cerebral circulations. A low cerebroplacental ratio has been shown to be associated with an increased risk of stillbirth regardless of the gestation or fetal weight. We conducted this study to assess the fetal cerebroplacental ratio in prediction of adverse intrapartum and neonatal outcomes in a term, uncomplicated pregnancy to reduce fetal and neonatal morbidity and mortality.

Results

It was found that neonates with CPR ≤1.1 had significantly higher frequencies of cesarean delivery (CS) for intrapartum fetal compromise compared to those with CPR >1.1 (p=0.043). Neonates with CPR ≤1.1 had significantly lower Apgar score at 1 min and 5 min than those with CPR >1.1 (p=0.004) and (p=0.003), respectively. Neonates with CPR ≤1.1 had significantly higher rates of NICU admission than those with CPR <1.1 (p=0.004).

Conclusion

The cerebroplacental ratio shows the highest sensitivity in the prediction of fetal heart rate abnormalities and adverse neonatal outcome in uncomplicated pregnancies at term. The cerebroplacental ratio index is useful in clinical practice in antenatal monitoring of these women in order to select those at high risk of intra- and postpartum complications.

Time to reconsider: Have the 2015 FIGO and 2017 Swedish intrapartum cardiotocogram classifications led us from Charybdis to Scylla?

In 2015, FIGO revised the 1987 intrapartum cardiotocography (CTG) classification (FIGO1987). A less radical FIGO2015 version was introduced in Sweden 2017 (SWE2017). Now, post hoc simulation studies show that FIGO2015 and SWE2017 are less reliable than (a modified) FIGO1987. FIGO2015 shows significantly better interobserver agreement for normal CTG traces than FIGO1987, but significantly worse for pathological traces. Agreements between templates are moderate to good, but different classifications of mainly variable decelerations and tachycardia cause significant heterogeneities. FIGO2015 shows insufficient sensitivity to identify fetal acidemia compared with FIGO1987. In connection with fetal electrocardiogram ST analysis, one study showed no template was superior in identifying fetal acidemia, but in a series of only academia, FIGO1987 had significantly higher sensitivity than FIGO2015 (73% vs. 43%) and set of an alarm for fetal acidemia considerably earlier. With SWE2017, operative interventions declined significantly in Sweden but several adverse neonatal outcomes increased significantly. It remains to investigate the development with FIGO2015.

Bayes Theorem and Protopathic Bias: Methodological Concerns When Addressing the Impact of Fetal Heart Rate Patterns on the Cesarean Section Rate

Over the last 30 years, the caesarean section rate has reached global epidemic proportions. This trend is driven by multiple factors, an important one of which is the use and inconsistent interpretation of the electronic fetal monitoring (EFM) system. Despite its introduction in the 1960s, the EFM has not definitively improved neonatal outcomes, yet it has since significantly contributed to a seven-fold increase in the caesarean section rate. As we attempt to reduce the caesarean rates in the developed world, we should consider focusing on areas that have garnered little attention in the literature, such as physician sensitization to the poor predictive power of the EFM and the research method biases that are involved in studying the abnormal heart rate patterns-umbilical cord pH relationship. Herein, we apply Bayes theorem to different clinical scenarios to illustrate the poor predictive power of the EFM, as well as shed light on the principle of protopathic bias, which affects the classification of research outcomes among studies addressing the effects of the EFM on caesarean rates. We propose and discuss potential solutions to the aforementioned considerations, which include the re-examination of guidelines with which we interpret fetal heart rate patterns and the development of noninvasive technologies that evaluate fetal pH in real time.

Electronic Fetal Monitoring Credentialing Examination: The First 4000

Objective  Recognized variability in fetal heart rate interpretation led the Perinatal Quality Foundation (PQF) to develop a credentialing exam. We report an evaluation of the 1st 4000 plus PQF Fetal Monitoring Credentialing (FMC) exams. Study Design  The PQF FMC exam is an online assessment for obstetric providers and nurses. The exam contains two question types: traditional multiple-choice evaluating knowledge and Script Concordance Theory (SCT) evaluating judgment. Reliability was measured through McDonald's Total Omega and Cronbach's Alpha. Pearson's correlations between knowledge and judgment were measured. Results  From February 2014 through September 2018, 4,330 different individuals took the exam. A total of 4,057 records were suitable for reliability analysis: 2,105 (52%) physicians, 1,756 (43%) nurses, and 196 (5%) certified nurse midwives (CNMs). As a measure of test reliability, total Omega was 0.80 for obstetric providers and 0.77 for nurses. There was only moderate correlation between the knowledge scores and judgment scores for obstetric providers (0.38) and for nurses (0.43). Conclusion  The PQF FMC exam is a reliable, valid assessment of both Electronic Fetal Monitoring (EFM) knowledge and judgment. It evaluates essential EFM skills for the establishment of practical credentialing. It also reports modest correlation between knowledge and judgment scores, suggesting that knowledge alone does not assure clinical competency.

Mode of delivery among nulliparous women with single, cephalic, term pregnancies: The WHO global survey on maternal and perinatal health, 2004-2008

OBJECTIVE

To determine risk factors associated with cesarean delivery among nulliparous women in spontaneous labor with a single, cephalic, term pregnancy (Robson group 1).

METHODS

Data were assessed from the WHO Global Survey of Maternal and Perinatal Health conducted in 2004-2008.

RESULTS

Among 82 280 women in Robson group 1, 67 698 (82.3%) had vaginal and 14 578 (17.7%) had cesarean delivery. In adjusted analyses, maternal factors associated with cesarean included age older than 18 years, being overweight or obese, being married or cohabitating, attending four prenatal visits or more, and being medically high risk (P<0.001). Women who were obstetrically high risk, referred during labor, or at 39 gestational weeks or more were also more likely to undergo cesarean (all P<0.001). Facility-level factors associated with cesarean were availability of an anesthesia service 24/7, being a teaching facility, requirement of fees for cesarean, availability of electronic fetal monitoring, and having providers skilled in operative vaginal delivery (all P<0.01).

CONCLUSION

The analysis highlights the importance of maintaining a healthy pre-pregnancy and pregnancy weight, optimizing management of women with medical problems, and ensuring clear referral mechanisms for women with intrapartum complications. The association between fees and cesarean delivery warrants further exploration.

The Fetal Reserve Index Significantly Outperforms ACOG Category System in Predicting Cord Blood Base Excess and pH: A Methodological Failure of the Category System

OBJECTIVE

Electronic fetal monitoring (EFM) has been used extensively for almost 50 years but performs poorly in predicting and preventing adverse neonatal outcome. In recent years, the current "enhanced" classification of patterns (category I-III system [CAT]) were introduced into routine practice without corroborative studies, which has resulted in even EFM experts lamenting its value. Since abnormalities of arterial cord blood parameters correlate reasonably well with risk of fetal injury, here we compare the statistical performance of EFM using the current CAT system with the Fetal Reserve Index (FRI) for predicting derangements in base excess (BE), pH, and pO₂ in arterial cord blood.

METHODS

We utilized a research database of labor data, including umbilical cord blood measurements to assess patients by both worst CAT and last FRI classifications. We compared these approaches for their ability to predict BE, pH, and pO₂ in cord blood.

RESULTS

The FRI showed a clear correlation with cord blood BE and pH with BE being more highly correlated than pH. The CAT was much less predictive than FRI (P < .05). The CAT II cases had FRI scores across the spectrum of severity of FRI designations and as such provide little clinical discrimination. The PO₂ was not discriminatory, in part, because of neonatal interventions.

CONCLUSIONS

The Fetal Reserve Index (FRI) provides superior performance over CAT classification of FHR patterns in predicting the BE and pH in umbilical cord blood. Furthermore, the CAT system fails to satisfy multiple fundamental principles required for successful screening programs. Limitations of CAT are further compounded by assumptions about physiology that are not consistent with clinical observations.

Prelabor screening for intrapartum fetal compromise in low-risk pregnancies at term: cerebroplacental ratio and placental growth factor

OBJECTIVES

To determine the screening performance of low fetal cerebroplacental ratio (CPR), a marker of fetal adaptation to suboptimal growth, and maternal placental growth factor (PlGF) level, both in isolation and in combination, for the prediction of Cesarean section (CS) for intrapartum fetal compromise (IFC) and composite adverse neonatal outcome (CANO).

METHODS

This was a prospective cohort study in low-risk women with uncomplicated singleton pregnancy from 36 weeks' gestation to delivery. CPR and PlGF were assessed fortnightly and intrapartum and neonatal outcomes were recorded. CPR and PlGF values from the final assessment for each woman were corrected for gestational age and assessed for screening performance, firstly as continuous variables and then as binary predictors.

RESULTS

Of the 264 women who consented to participate in the study, 207 were included in the final analysis. Seven pregnancies required CS for IFC and 38 had CANO. Pregnancies delivered by CS for IFC had lower CPR and PlGF centiles than those in all other pregnancies. Pregnancies with CANO had a lower PlGF centile. The greatest areas under the receiver-operating characteristics curves (AUCs) for the prediction of CS for IFC (0.92; 95% CI, 0.86-0.97) and CANO (0.64; 95% CI, 0.54-0.74) were achieved by a combination of CPR 20^th and PlGF 33^rd centile thresholds. This produced sensitivities, specificities and positive likelihood ratios for the prediction of CS for IFC of 100%, 86% and 7.14, respectively, and 34.2%, 87.0% and 2.63, respectively, for the prediction of CANO. There was no statistical difference in the AUC for CS for IFC between the combined model and when CPR was used alone, or for CANO between the combined model and CPR or PlGF in isolation.

CONCLUSIONS

This pilot proof-of-concept study describes the screening performance of CPR and maternal PlGF level for CS for IFC in low-risk women from 36 weeks' gestation. It was found that CPR and maternal PlGF improved the overall predictive utility for CS for IFC, as well as that for CANO. However, given the lack of significant difference between the combined model and its individual components, it is debatable whether the combined model is a superior screening test. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Refining the Prediction and Prevention of Emergency Operative Deliveries with the Fetal Reserve Index

Electronic fetal monitoring (EFM) is a poor predictor of outcomes attributable to delivery problems. Contextualizing EFM by adding maternal, obstetrical, and fetal risk-related information to create an index called the Fetal Reserve Index (FRI) improves the predictive capacity and facilitates the timing of interventions. Here, we test critical assumptions of FRI as a clinical tool. Our conceptualization implies that the earlier one reaches the red zone (FRI ≤25) and the longer one spends in the red zone, the greater the likelihood of emergency operative deliveries (EOD).

METHODS

We analyzed 1,402 patients using logistic regression predicting the probability of EOD and employed qualitative methodology techniques to refine predictive capabilities.

RESULTS

Reaching the red zone early and staying there > 1 h increases the probability of EOD. When these risk factors are paired with intrauterine resuscitation (IR) in Stage 1, the reduction of EOD is substantial.

CONCLUSION

FRI is a capable predictor of EOD because it accurately identifies the level of malleable risk. FRI analysis increases the risk of using IR in Stage 1. Matching risk and resources dramatically reduces the chances of EOD. Earlier IR improves the outcomes if the calculated risk is high.

The Causal Inference Framework: A Primer on Concepts and Methods for Improving the Study of Well-Woman Childbearing Processes

The causal inference framework and related methods have emerged as vital within epidemiology. Scientists in many fields have found that this framework and a variety of designs and analytic approaches facilitate the conduct of strong science. These approaches have proven particularly important for catalyzing knowledge development using existing data and addressing questions for which randomized clinical trials are neither feasible nor ethical. The study of healthy women and normal childbearing processes may benefit from more direct and deliberate engagement with the process of inferring causes and, further, may be strengthened through use of methods appropriate for this undertaking. The purpose of this primer, the first in a series of 3 articles, is to provide the reader an introduction to concepts and methods relevant for causal inference, aimed at the clinician scientist and offer details and references supporting further application of epidemiologic knowledge. The causal inference framework and associated methods hold promise for generating strong, broadly representative, and actionable science to improve the outcomes of healthy women during the childbearing cycle and their children.

Safely lowering the emergency Cesarean and operative vaginal delivery rates using the Fetal Reserve Index

Objective: The cardiotocograph (CTG) or electronic fetal monitoring (EFM) was developed to prevent fetal asphyxia and subsequent neurological injury. From a public health perspective, it has failed these objectives while increasing emergency operative deliveries (emergency operative deliveries (EODs) - emergency cesarean delivery or operative vaginal delivery) for newborns, who in retrospect, actually did not require the assistance. EODs increase the risks of complications and stress for patients, families, and medical personnel. A safe reduction in the need for EOD will likely reduce both the overall Cesarean section rate as well as the risk of fetal neurological injury during labor to which it is related. We have developed the fetal reserve index (FRI), which is more comprehensive than CTG as a new screening method for early identification of the fetus at-risk of both neurological harm and the need to "rescue" by means of an EOD. Here, we compare prospectively the need for EOD in two groups of parturients undergoing a trial of labor at term. One group was managed conventionally, the other by the principles of the FRI.Study design: We compared the need for EOD of 800 parturients with singleton cases undergoing a trial of labor at term entering with normal CTG patterns (ACOG category 1). Patients were either treated routinely (400 - "early cases") or in a second group seen later actively managed using the principles of the FRI (400 - "late cases"). The FRI includes measurements of five components of the CTG: rate, variability, decelerations, accelerations, and abnormal uterine activity combined with the presence of medical, obstetrical, and fetal risk factors. The 8-point metric categorizes cases as "green", "yellow", and "red" with the latter being at risk.Results: All 800 patients delivered babies, who were discharged in the usual time course with no untoward outcomes noted. The incidence of red zone scores was comparable in the two groups (≈25%), but the use of intrauterine resuscitation (IR) when reaching the red zone in the late group (47%) was more than double the incidence in the early group (20%) (p < .001). Despite (or because of) this, EODs were significantly reduced in the late group, from 17.3 to 4.0% (p < .001). Further, the late group spent less time in the red zone without increasing overall time in labor. Overall, EOD cases averaged >1 h in the red zone versus 0.5 h for non-EODs.Conclusions: The FRI may provide a metric to reduce EODs and by extension also reduce the risks of both cesarean delivery and adverse fetal/neonatal outcomes. The safe avoidance of EOD would seem to be an important metric to assess the quality of intrapartum management. This study represents the first attempt to apply the principles of the FRI "live" for the concurrent management of patients during labor. These promising results, if confirmed, in larger sample sizes, set the stage for our computerization of the FRI for widespread study. Benefits appear to come from identification and early, conservative management of fetal deterioration before the need to "rescue" the fetus by EOD.

A half century of electronic fetal monitoring and bioethics: silence speaks louder than words

Bioethics abolished the prevailing Hippocratic tenet instructing physicians to make treatment decisions, replacing it with autonomy through informed consent. Informed consent allows the patient to choose treatment after options are explained by the physician. The appearance of bioethics in 1970 coincided with the introduction of electronic fetal monitoring (EFM), which evolved to become the fetal surveillance modality of choice for virtually all women in labor. Autonomy rapidly pervaded all medical procedures, but there was a clear exemption for EFM. Even today, EFM remains immune to the doctrine of informed consent despite continually mounting evidence which proves the procedure is nothing more than myth, illusion and junk science that subjects mothers and babies alike to increased risks of morbidity and mortality. And ethicists have remained utterly silent through a half century of EFM misuse. Our article explores this egregious ethical failure by reviewing EFM's lack of clinical efficacy, discussing the EFM related harm to mothers and babies, and focusing on the reasons that this obstetrical procedure eluded the revolutionary change from the Hippocratic tradition to autonomy through informed consent.

Electronic Fetal Monitoring and Cesarean Birth: A Scoping Review

BACKGROUND

In many United States hospitals, electronic fetal monitoring (EFM) is used continuously during labor for all patients regardless of risk status. Application of EFM, particularly at labor admission, may trigger a chain of interventions resulting in increased risk for cesarean birth among low-risk women. The goal of this review was to summarize evidence on use of EFM during low-risk labors and identify gaps in research.

METHODS

We conducted a scoping review of studies published in English since 1996 that addressed the relationship between EFM use and cesarean among low-risk women. We screened 57 full-text articles for appropriateness. Seven articles were included in the final review.

RESULTS

The largest study demonstrated an 81 percent increased risk of primary cesarean birth when EFM was used in labor, but did not differentiate between high- and low-risk pregnancies. Four randomized controlled trials examined the association of admission EFM with obstetric outcomes; only one considered cesarean birth as a primary outcome and found a 23 percent increase in operative birth when EFM lasted more than 1 hour. A study examining application of continuous EFM before and after 4 centimeters dilatation found no differences between groups.

CONCLUSIONS

In general, the research on this topic suggests an association between the use of EFM and cesarean birth; however, more well-designed studies are needed to examine benefits of EFM versus auscultation, determine if EFM is associated with use of other technologies that could cumulatively increase risk of cesarean birth, and understand provider motivation to use EFM over auscultation.

Perinatal Asphyxia from the Obstetric Standpoint: Diagnosis and Interventions

Perinatal asphyxia is a general term referring to neonatal encephalopathy related to events during birth. Asphyxia refers to a deprivation of oxygen for a duration sufficient to cause neurologic injury. Most cases of perinatal asphyxia are not necessarily caused by intrapartum events but rather associated with underlying chronic maternal or fetal conditions. Of intrapartum causes, obstetric emergencies are the most common and are not always preventable. Screening high-risk pregnancies with ultrasound, Doppler velocimetry, and antenatal testing can aid in identifying fetuses at risk. Interventions such as intrauterine resuscitation or operative delivery may decrease the risk of severe hypoxia from intrauterine insults and improve long-term neurologic outcomes.

Neurological Fallacies Leading to Malpractice: A Case Studies Approach

A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.

Fetal heart rate monitoring: from Doppler to computerized analysis

The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.

Perpetuating Myths, Fables, and Fairy Tales: A Half Century of Electronic Fetal Monitoring

Electronic fetal monitoring (EFM) entered clinical medical practice at the same time bioethics became reality. Bioethics changed the medical ethics landscape by replacing the traditional Hippocratic benign paternalism with patient autonomy, informed consent, beneficence, and nonmaleficence. But EFM use represents the polar opposite of bioethics' revered principles-it has been documented for half a century to be completely ineffectual, used without informed consent, and harmful to mothers and newborns alike. Despite EFM's ethical misuse, there has been no outcry from the bioethical world. Why? This article answers that question, discussing EFM's history and the reasons it was issued an ethics pass. And it explores the reason that even today mothers are still treated with blatant medical paternalism, deprived of autonomy and informed consent, and subjected to real medical risks under the guise that EFM is an essential safety device when in fact it is used almost solely to protect physicians and hospitals from cerebral palsy lawsuits.

Feature selection for computerized fetal heart rate analysis using genetic algorithms

During birth, timely and accurate diagnosis is needed in order to prevent severe conditions such as birth asphyxia. The fetal heart rate (FHR) is often monitored during labor to assess the condition of fetal health. Computerized FHR analysis is needed to help clinicians identify abnormal patterns and to intervene when necessary. The objective of this study is to apply Genetic Algorithms (GA) as a feature selection method to select a best feature subset from 64 FHR features and to integrate these best features to recognize unfavorable FHR patterns. The GA was trained on 408 cases and tested on 102 cases (both balanced datasets) using a linear SVM as classifier. 100 best feature subsets were selected according to different splits of data; a committee was formed using these best classifiers to test their classification performance. Fair classification performance was shown on the testing set (Cohen's kappa 0.47, proportion of agreement 73.58%). To our knowledge, this is the first time that a feature selection method has been tested for FHR analysis on a database of this size.

Cell free DNA testing-interpretation of results using an online calculator

All pregnant women, regardless of age, should be offered screening or invasive testing for chromosomal abnormalities at <20 weeks' gestation. Noninvasive prenatal screening for fetal aneuploidy with the use of cell-free DNA (cfDNA) is a screening method that offers high sensitivity and specificity in validation studies and has reduced the need for unnecessary invasive procedures. Laboratories often advertise and report a test's sensitivity and specificity as a means to describe the test's accuracy. The positive predictive value (PPV) of a screening test (the proportion of positive results that are truly positive) is a function of the prevalence of the condition in a population and often is not reported in direct-to-patient advertising. False-positive cfDNA screening tests have been reported, and there is evidence that some women are deciding to terminate their pregnancy without confirmatory testing. We believe that laboratories should disclose the patient-specific PPV of cfDNA screening for aneuploidy on result reports. To assist with counseling patients about the benefits, risks, and limitations of aneuploidy screening with the use of cfDNA and to demonstrate the relationship between an a priori risk and PPV, we developed a web-based calculator to estimate the PPV of the 4 commercially available cfDNA testing platforms for which data have been published. Estimates are made with the use of a patient's age and gestational age-related risk of trisomy 21, 18 and 13 or an a priori risk that is based on other findings. This web-based calculator is an aid for providers and genetic counselors to illustrate the relationship between disease prevalence and a test's PPV. It has enhanced our counseling of patients both before they elect noninvasive prenatal screening and after they receive a positive result.

Correlating multidimensional fetal heart rate variability analysis with acid-base balance at birth

Fetal monitoring during labour currently fails to accurately detect acidemia. We developed a method to assess the multidimensional properties of fetal heart rate variability (fHRV) from trans-abdominal fetal electrocardiogram (fECG) during labour. We aimed to assess this novel bioinformatics approach for correlation between fHRV and neonatal pH or base excess (BE) at birth.We enrolled a prospective pilot cohort of uncomplicated singleton pregnancies at 38-42 weeks' gestation in Milan, Italy, and Liverpool, UK. Fetal monitoring was performed by standard cardiotocography. Simultaneously, with fECG (high sampling frequency) was recorded. To ensure clinician blinding, fECG information was not displayed. Data from the last 60 min preceding onset of second-stage labour were analyzed using clinically validated continuous individualized multiorgan variability analysis (CIMVA) software in 5 min overlapping windows. CIMVA allows simultaneous calculation of 101 fHRV measures across five fHRV signal analysis domains. We validated our mathematical prediction model internally with 80:20 cross-validation split, comparing results to cord pH and BE at birth.The cohort consisted of 60 women with neonatal pH values at birth ranging from 7.44 to 6.99 and BE from -0.3 to -18.7 mmol L(-1). Our model predicted pH from 30 fHRV measures (R(2) = 0.90, P < 0.001) and BE from 21 fHRV measures (R(2) = 0.77, P < 0.001).Novel bioinformatics approach (CIMVA) applied to fHRV derived from trans-abdominal fECG during labor correlated well with acid-base balance at birth. Further refinement and validation in larger cohorts are needed. These new measurements of fHRV might offer a new opportunity to predict fetal acid-base balance at birth.

Diagnostic accuracy of fetal heart rate monitoring in the identification of neonatal encephalopathy

OBJECTIVE

To estimate the diagnostic accuracy of electronic fetal heart rate abnormalities in the identification of neonates with encephalopathy treated with whole-body hypothermia.

METHODS

Between January 1, 2007, and July 1, 2013, there were 39 neonates born at two hospitals within our system treated with whole-body hypothermia within 6 hours of birth. Neurologically normal control neonates were matched to each case by gestational age and mode of delivery in a two-to-one fashion. The last hour of electronic fetal heart rate monitoring before delivery was evaluated by three obstetricians blinded to outcome.

RESULTS

The differences in tracing category were not significantly different (neonates in the case group 10.3% I, 76.9% II, 12.8% III; neonates in the control group 9.0% I, 89.7% II, 1.3% III; P=.18). Bivariate analysis showed neonates in the case group had significantly increased late decelerations, total deceleration area 30 (debt 30) and 60 minutes (debt 60) before delivery and were more likely to be nonreactive. Multivariable logistic regression showed neonates in the case group had a significant decrease in early decelerations (P=.03) and a significant increase in debt 30 (.01) and debt 60 (P=.005). The area under the receiver operating characteristic curve, sensitivity, and specificity were 0.72, 23.1%, and 94.9% for early decelerations; 0.66, 33.3%, and 87.2% for debt 30, and 0.68, 35.9%, and 89.7% for debt 60, respectively.

CONCLUSION

Abnormalities during the last hour of fetal heart rate monitoring before delivery are poorly predictive of neonatal hypoxic-ischemic encephalopathy qualifying for whole-body hypothermia treatment within 6 hours of birth. LEVEL OF EVIEDENCE: II.

Intermittent auscultation of the fetal heart rate during labor: an opportunity for shared decision making

Electronic fetal heart rate monitoring is the most common form of intrapartal fetal assessment in the United States. Intermittent auscultation of the fetal heart rate is an acceptable option for low-risk laboring women, yet it is underutilized in the hospital setting. Several expert organizations have proposed the use of intermittent auscultation as a means of promoting physiologic childbirth. Within a shared decision-making model, the low-risk pregnant woman should be presented with current evidence about options for fetal heart rate assessment during labor.

Consumer information on fetal heart rate monitoring during labor: a content analysis: a content analysis

Electronic fetal monitoring (EFM) is used for the majority of births that occur in the United States. While there are indications for use of EFM for women with high-risk pregnancies, its use in low-risk pregnancies is less evidence-based. In low-risk women, the use of EFM is associated with an increased risk for cesarean birth compared with the use of intermittent auscultation of the fetal heart rate. The purpose of this investigation was to evaluate the existence of evidence-based information on fetal heart rate monitoring in popular consumer-focused maternity books and Web sites. Content analysis of information in consumer-oriented Web sites and books was completed using the NVivo software (QRSinternational, Melbourne, Australia). Themes identified included lack of clear terminology when discussing fetal monitoring, use of broad categories such as low risk and high risk, limited presentation of information about intermittent auscultation, and presentation of EFM as the standard of care, particularly upon admission into the labor unit. More than one-third of the sources did not mention auscultation, and conflicting information about monitoring methods was presented. The availability of accurate, publically accessible information offers consumers the opportunity to translate knowledge into the power to seek evidence-based care practices during their maternity care experience.

A risk stratification model to predict adverse neonatal outcome in labor

OBJECTIVE

The development and evaluation of a labor risk model consisting of a combination of antepartum risk factors and intrapartum fetal heart rate (FHR) characteristics that can reliably identify those infants at risk for adverse neonatal outcome in labor.

STUDY DESIGN

A nested case-control study of term singleton deliveries at the nine hospitals between March 2007 and December 2009. Eligibility criteria included: gestational age ≥ 37.0 weeks; singleton pregnancy; documented continuous FHR monitoring for ≥ 2 h before delivery; assessment of FHR tracing at least every 20 min; and, available maternal and neonatal outcomes. Adverse neonatal outcome was defined as nonanomalous infants admitted to the newborn intensive care unit with either a 5 minute Apgar score <7 or an umbilical artery pH<7.1. Initial risk score was determined using data available at 1 h after admission. Patients with an initial risk score between 7 and 15 were considered high risk. Intrapartum risk scores were then created for these patients using FHR tracing data and labor characteristics.

RESULT

A total of 51 244 patients were identified meeting study criteria. Of the antepartum variables evaluated (n=31), 10 were associated with an adverse outcome. The high-risk group made up 28% of the population and accounted for 59.8% of the adverse outcomes. Intrapartum characteristics were then evaluated in this high-risk group. Intrapartum evaluation identified the highest risk group with a C/S rate of 40% and adverse outcome rate of 11.3%.

CONCLUSION

Incorporation of maternal and antepartum risk factors with FHR analysis can improve the ability to identify the fetus at risk in labor.

Women's ability to self-screen for contraindications to combined oral contraceptive pills in Tanzanian drug shops

OBJECTIVE

To estimate the accuracy of self-screening for contraindications to combined oral contraceptive pills (COCs) and to estimate the proportion of women with contraindications to hormonal methods among those using drug shops in Tanzania.

METHODS

Trained nurses interviewed 1651 women aged 18-39 years who self-screened for contraindications to COCs with the help of a poster at drug shops in Tanzania. Nurse assessment of the women served as the gold standard for comparison with self-assessment. Blood pressure was also measured onsite.

RESULTS

Nurses reported that 437 (26.5%) women were not eligible to use COCs, compared with 485 (29.4%) according to self-report. Overall, 133 (8.1%) women who said that they were eligible were deemed ineligible by nurses. The rate of ineligibility was artificially high owing to participant and nurse assessments that were incorrectly based on adverse effects of pill use and cultural reasons, and because of the sampling procedure, which intercepted women regardless of their reasons for visiting the drug shop. Adjusted rates of ineligibility were 8.6% and 12.7%, respectively, according to nurse and participant assessment. Both nurses and women underestimated the prevalence of hypertension in the present group.

CONCLUSION

Self-screening among women in rural and peri-urban Tanzania with regard to contraindications to COC use was comparable to assessment by trained nurses.

The perils of protection: vulnerability and women in clinical research

Subpart B of 45 Code of Federal Regulations Part 46 (CFR) identifies the criteria according to which research involving pregnant women, human fetuses, and neonates can be conducted ethically in the United States. As such, pregnant women and fetuses fall into a category requiring "additional protections," often referred to as "vulnerable populations." The CFR does not define vulnerability, but merely gives examples of vulnerable groups by pointing to different categories of potential research subjects needing additional protections. In this paper, I assess critically the role of this categorization of pregnant women involved in research as "vulnerable," both as separate entities and in combination with the fetuses they carry. In particular, I do three things: (1) demonstrate that pregnant women qua pregnancy are either not "vulnerable" according to any meaningful definition of that term or that such vulnerability is irrelevant to her status as a research participant; (2) argue that while a fetus may be vulnerable in terms of dependency, this categorization does not equate to the vulnerability of the pregnant woman; and (3) suggest that any vulnerability that appends to women is precisely the result of federal regulations and dubious public perceptions about pregnant women. I conclude by demonstrating how this erroneous characterization of pregnant women as "vulnerable" and its associated protections have not only impeded vital research for pregnant women and their fetuses, but have also negatively affected the inclusion of all women in clinical research.

Screening women for oral contraception: can family history identify inherited thrombophilias?

OBJECTIVE

Screening for inherited thrombophilias with laboratory tests is impractical before starting women on combined oral contraceptives. As an alternative, some recommend eliciting a family history of venous thromboembolism. The validity of this approach, however, remains unclear.

DATA SOURCES

We sought all published reports that correlated a family history of venous thromboembolism with any thrombophilia confirmed by laboratory test. We used sequential, overlapping computer searches including MeSH terms used for articles in PubMed, a narrative search phrase in Google Scholar, and then all "related" articles in PubMed for each article included without time or language limitations. This was supplemented by a search of www.clinicaltrials.gov.

METHODS OF STUDY SELECTION

The search yielded 10 reports. Information was sought without success from corresponding authors of four other reports that may have had relevant data. Most reports studied atypical, high-prevalence referral populations.

TABULATION, INTEGRATION, AND RESULTS

Results were presented according to the MOOSE (Meta-analysis of observational studies in epidemiology) guidelines for systematic reviews of observational studies. The patient populations varied widely, definitions of family history included first- or first- and second-degree relatives, and the thrombophilias studied differed among these reports. Hence, aggregation of results was not possible. Despite these differences, all reports consistently documented poor validity of family history for detecting thrombophilias. Sensitivity ranged from 16% to 63% and positive predictive value from 6% to 50% for the various thrombophilias studied. In no study did family history meet the benchmark for a good test (sensitivity plus specificity greater than 150%).

CONCLUSION

Obtaining a family history of venous thromboembolism before starting combined oral contraceptives is not a valid means to detect a woman's risk of thrombophilia. Even in high-prevalence populations, in which the positive predictive value is increased, a positive family history of venous thromboembolism was no better than flipping a coin in predicting thrombophilia.

Caring ethics and a Somali reproductive dilemma

The use of traditional ethical methodologies is inadequate in addressing a constructed maternal–fetal rights conflict in a multicultural obstetrical setting. The use of caring ethics and a relational approach is better suited to address multicultural conceptualizations of autonomy and moral distress. The way power differentials, authoritative knowledge, and informed consent are intertwined in this dilemma will be illuminated by contrasting traditional bioethics and a caring ethics approach. Cultural safety is suggested as a way to develop a relational ontology. Using caring ethics and a relational approach can alleviate moral distress in health-care providers, while promoting collaboration and trust between providers and their patients and ultimately decreasing reproductive disparities. This article examines how a relational approach can be applied to a cross-cultural reproductive dilemma.