Fetal monitoring in labour: summary and update of NICE guidance

Fetal QRS extraction from single-channel abdominal ECG using adaptive improved permutation entropy

Fetal electrocardiogram (fECG) monitoring is crucial for assessing fetal condition during pregnancy. However, current fECG extraction algorithms are not suitable for wearable devices due to their high computational cost and multi-channel signal requirement. The paper introduces a novel and efficient algorithm called Adaptive Improved Permutation Entropy (AIPE), which can extract fetal QRS from a single-channel abdominal ECG (aECG). The proposed algorithm is robust and computationally efficient, making it a reliable and effective solution for wearable devices. To evaluate the performance of the proposed algorithm, we utilized our clinical data obtained from a pilot study with 10 subjects, each recording lasting 20 min. Additionally, data from the PhysioNet 2013 Challenge bank with labeled QRS complex annotations were simulated. The proposed methodology demonstrates an average positive predictive value ( + P ) of 91.0227%, sensitivity (Se) of 90.4726%, and F1 score of 90.6525% from the PhysioNet 2013 Challenge bank, outperforming other methods. The results suggest that AIPE could enable continuous home-based monitoring of unborn babies, even when mothers are not engaging in any hard physical activities.

Computer Vision for Identification of Increased Fetal Heart Variability in Cardiotocogram

INTRODUCTION

Increased fetal heart rate variability (IFHRV), defined as fetal heart rate (FHR) baseline amplitude changes of >25 beats per minute with a duration of ≥1 min, is an early sign of intrapartum fetal hypoxia. This study evaluated the level of agreement of machine learning (ML) algorithms-based recognition of IFHRV patterns with expert analysis.

METHODS

Cardiotocographic recordings and cardiotocograms from 4,988 singleton term childbirths were evaluated independently by two expert obstetricians blinded to the outcomes. Continuous FHR monitoring with computer vision analysis was compared with visual analysis by the expert obstetricians. FHR signals were graphically processed and measured by the computer vision model labeled SALKA.

RESULTS

In visual analysis, IFHRV pattern occurred in 582 cardiotocograms (11.7%). Compared with visual analysis, SALKA recognized IFHRV patterns with an average Cohen's kappa coefficient of 0.981 (95% CI: 0.972-0.993). The sensitivity of SALKA was 0.981, the positive predictive rate was 0.822 (95% CI: 0.774-0.903), and the false-negative rate was 0.01 (95% CI: 0.00-0.02). The agreement between visual analysis and SALKA in identification of IFHRV was almost perfect (0.993) in cases (N = 146) with neonatal acidemia (i.e., umbilical artery pH <7.10).

CONCLUSIONS

Computer vision analysis by SALKA is a novel ML technique that, with high sensitivity and specificity, identifies IFHRV features in intrapartum cardiotocograms. SALKA recognizes potential early signs of fetal distress close to those of expert obstetricians, particularly in cases of neonatal acidemia.

Effects and mechanisms of acupuncture on women related health

Globally, public health interventions have resulted in a 30-year increase in women's life expectancy. However, women's health has not increased when socioeconomic status is ignored. Women's health has become a major public health concern, for those women from developing countries are still struggling with infectious and labor-related diseases, and their counterparts in developed countries are suffering from physical and psychological disorders. In recent years, complementary and alternative medicine has attracted wide attentions with regards to maintaining women's health. Acupuncture, a crucial component of traditional Chinese medicine, has been used to treat many obstetric and gynecological diseases for thousands of years due to its analgesic and anti-inflammatory effects and its effects on stimulating the sympathetic/parasympathetic nervous system. To fully understand the mechanism through which acupuncture exerts its effects in these diseases would significantly extend the list of available interventions and would allow for more reasonable advice to be given to general practitioners. Therefore, by searching PubMed and CNKI regarding the use of acupuncture in treating obstetric and gynecological diseases, we aimed to summarize the proven evidence of using acupuncture in maintaining women's health by considering both its effectiveness and the underlying mechanisms behind its effects.

Prevention of fetal brain injury in category II tracings

INTRODUCTION

With category II fetal heart rate tracings, the preferred timing of interventions to prevent fetal hypoxic brain damage while limiting operative interventions remains unclear. We aimed to estimate fetal extracellular base deficit (BDecf ) during labor with category II tracings to quantify the timing of potential interventions to prevent severe fetal metabolic acidemia.

MATERIAL AND METHODS

A longitudinal study was conducted using the database of the Recurrence Prevention Committee, Japan Obstetric Compensation System for Cerebral Palsy, including infants with severe cerebral palsy born at ≥34 weeks' gestation between 2009 and 2014. Cases included those presumed to have an intrapartum onset of hypoxic-ischemic insult based on the fetal heart rate pattern evolution from reassuring to an abnormal pattern during delivery, in association with category II tracings marked by recurrent decelerations and an umbilical arterial BDecf  ≥ 12 mEq/L. BDecf changes during labor were estimated based on stages of labor and the frequency/severity of fetal heart rate decelerations using the algorithm of Ross and Gala. The times from the onset of recurrent decelerations to BDecf 8 and 12 mEq/L (Decels-to-BD8, Decels-to-BD12) and to delivery were determined. Cases were divided into two groups (rapid and slow progression) based upon the rate of progression of acidosis from onset of decelerations to BDecf 12 mEq/L, determined by a finite-mixture model.

RESULTS

The median Decels-to-BD8 (28 vs. 144 min, p < 0.01) and Decels-to-BD12 (46 vs. 177 min, p < 0.01) times were significantly shorter in the rapid vs slow progression. In rapid progression cases, physicians' decisions to deliver the fetus occurred at ~BDecf 8 mEq/L, whereas the "decisions" did not occur until BDecf reached 12 mEq/L in slow progression cases.

CONCLUSIONS

Fetal BDecf reached 12 mEq/L within 1 h of recurrent fetal heart rate decelerations in the rapid progression group and within 3 h in the slow progression group. These findings suggest that cases with category II tracings marked by recurrent decelerations (i.e., slow progression) may benefit from operative intervention if persisting for longer than 2 h. In contrast, cases with sudden bradycardia (i.e., rapid progression) represent a challenge to prevent severe acidosis and hypoxic brain injury due to the limited time opportunity for emergent delivery.

Clinical practice guidelines for intrapartum cardiotocography interpretation: A systematic review

BACKGROUND

Clinical practice guidelines on intrapartum cardiotocography (CTG) interpretation provide structured tools to detect fetal hypoxia. Despite frequent use of different guidelines, little is known about their comparable consistency. We sought to appraise guidelines relevant to intrapartum CTG interpretation and summarise consensus and non-consensus recommendations.

AIMS

To compare existing intrapartum CTG interpretation guidelines.

MATERIALS AND METHODS

We searched PubMed, CINAHL, Cochrane, Embase, guideline databases and websites of guideline development institutions using terms 'cardiotocography', 'electronic fetal/foetal monitoring', and 'guideline' or equivalent term. The search was restricted to English-language articles published between January 1980 and January 2023 and excluded animal studies. The initial search yielded 2128 articles with 1253 unique citations. Guidelines were included if they: used English as the reporting language; included CTG interpretation criteria or guidelines as a primary objective; were published or updated since 1980; and were the most recently updated publications when multiple versions were identified.

RESULTS

Nineteen studies were considered for full review, and 13 met inclusion criteria. Two reviewers independently assessed guideline quality using the AGREE II instrument, and synthesised consensus and non-consensus recommendations using the content analysis approach. Most guidelines employed a three-tier interpretation framework. There were significant differences between the guidelines for relative importance of key CTG features such as accelerations, decelerations and variability, with respect to the outcome of fetal hypoxia.

CONCLUSIONS

There are significant differences between key intrapartum CTG interpretation guidelines currently being used. Greater consistency is needed across CTG interpretation guidelines to improve the quality of data, clinical governance, monitoring of outcomes, and to support future developments.