Effectiveness of intrapartum fetal surveillance to improve maternal and neonatal outcomes: a systematic review and network meta-analysis

Intrapartum fetal monitoring practices in Norway: A population-based study

OBJECTIVE

To describe intrapartum fetal monitoring methods used in all births in Norway in 2019-2020, assess adherence to national guidelines, investigate variation by women's risk status, and explore associations influencing monitoring practices.

METHODS

A nationwide population-based study. We collected data about all pregnancies with a gestational age ≥ 22 weeks during 2019-2020 from the Medical Birth Registry of Norway. We used descriptive analyses, stratified for risk status, to examine fetal monitoring methods used in all deliveries. Univariable and multivariable logistic regression models were used to determine factors associated with monitoring with cardiotocography (CTG) in low-risk, straightforward births.

RESULTS

In total, 14 285 (14%) deliveries were monitored with only intermittent auscultation (IA), 46214 (46%) with only CTG, and 33417 (34%) with IA and CTG combined. Four percent (2 067/50 533) of women with risk factors were monitored with IA only. Half (10589/21 282) of the low-risk women with straightforward births were monitored with CTG. Maternal and fetal characteristics, size of the birth unit and regional practices influenced use of CTG monitoring in this group.

CONCLUSIONS

Most births are monitored with CTG only, or combined with IA. Half the women with low-risk pregnancies and straightforward births were monitored with CTG although national guidelines recommending IA.

Cardiotocography use for fetal assessment during labor in low- and middle-income countries: A scoping review

BACKGROUND

The use of cardiotocography (CTG) to improve neonatal outcomes is controversial. The medical settings, subjects, utilizations, and interpretation guidelines of CTG are unclear for low- and middle-income countries (LMICs).

OBJECTIVES

To assess and review CTG use for studies identified in LMICs and provide insights on the potential for effective use of CTG to improve maternal and neonatal outcomes.

SEARCH STRATEGY

The databases Medline, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published and unpublished literature through September 2023.

SELECTION CRITERIA

Publications were identified which were conducted in LMICs, based on the World Bank list of economies for 2019; targeting pregnant women in childbirth; and focusing on the utilization of CTG and neonatal outcomes.

DATA COLLECTION AND ANALYSIS

Publications were screened, and duplicates were removed. A scoping review was conducted using PRISMA-ScR guidelines.

RESULTS

The searches generated 1157 hits, of which 67 studies were included in the review. In the studies there was considerable variation and ambiguity regarding the study settings, target populations, utilizations, timing, frequency, and duration of CTG. While cesarean section rates were extensively investigated as an outcome of studies of CTG itself and the effect of additional techniques on CTG, other clinically significant outcomes, including neonatal mortality, were not well reported.

CONCLUSIONS

Variations and ambiguities were found in the use of CTG in LMICs. Due to the limited amount of evidence, studies are needed to examine CTG availability in the context of LMICs.

Timing of cesarean delivery for fetal heart rate abnormalities in hypertensive pregnancies induced with oral misoprostol or Foley catheter: Secondary analysis of a randomized clinical trial

OBJECTIVE

The study aims to assess how oral misoprostol for cervical ripening affects the time of cesarean delivery (CD) for fetal heart rate (FHR) abnormalities in pre-eclampsia patients. Secondary goals include determining the role of uterine hyperstimulation, comparing misoprostol with Foley catheter, and identifying risk factors for FHR abnormalities associated with CD.

METHODS

A previously published randomized clinical trial was subjected to a secondary analysis (NCT01801410). We conducted a time-dependent analysis, stratifying the population based on the final mode of induction used (low-dose oral misoprostol vs Foley catheter).

RESULTS

There was no CD for FHR abnormalities within 2 h of starting misoprostol. At 5 h, the cumulative incidence of CD for FHR abnormalities in the misoprostol group was 2.10%, while it was 1.00% in the Foley group (P = 0.565). After 25 h, the CD risk for FHR abnormalities remained constant in both groups at 21.00% (95% confidence interval [CI] 15.00%-28.00%). Within 5 h of misoprostol induction, the risk of uterine hyperstimulation was similar in both groups (0.33% in misoprostol vs 0.34% in Foley group, P = 0.161). The risk of CD for FHR abnormalities was unaffected by newborn weight centiles.

CONCLUSION

There was no significant difference in CD risk for FHR abnormalities between misoprostol and Foley catheter induction. Nonetheless, the cumulative incidence of CD for FHR abnormalities increased faster in the misoprostol group, indicating that FHR monitoring timing should be tailored to the induction method.

Improving management of first and second stages of labour in low- and middle-income countries

Labour care must balance aspirations of parents with vigilance for unanticipated calamities. The 'on-site midwife-led primary care birth unit' facilitates this. The World Health Organization have replaced the traditional partograph with the 'Labour Care Guide'. An implementation project in Botswana included the mnemonic COPE: Companion, Oral fluids, Pain relief and Eliminate the supine position. The Parto-Ma project in Tanzania used guidelines, training and support to improve childbirth outcomes. We list labour practices supported by recent evidence, and highlight new developments. Foetal macrosomia increases risk but mistaken diagnosis increases caesarean births. Obstructed labour is a complex clinical diagnosis, and is difficult to predict. For shoulder dystocia prioritise delivery of the posterior shoulder, facilitated if needed by posterior axilla sling traction. 'Extended balloon labour induction' with two or three Foley catheters side by side, may reduce risks associated with uterine stimulants. Bedside ultrasound may facilitate the diagnosis of cephalic malpositions and malpresentations.

Efficacy of nonpharmacological interventions for severe radiation-induced oral mucositis among head and neck cancer patients: A network meta-analysis of randomised controlled trials

AIMS AND OBJECTIVES

To assess the effectiveness of different nonpharmacological treatments for severe radiation-induced oral mucositis in patients with head and neck cancer.

BACKGROUND

Radiation-induced oral mucositis is highly prevalent in patients with head and neck cancer. Current medications for radiation-induced oral mucositis are limited in effectiveness and susceptible to side effects, and while there is an increasing adoption of nonpharmacological interventions, the optimal one remains unclear.

DESIGN

Systematic review and network meta-analysis based on the PRISMA-NMA guidelines.

METHODS

Six databases were searched. Two authors independently performed the literature screening, data extraction and methodological quality assessment of the included studies. Traditional pairwise meta-analysis was performed by R Studio. A network meta-analysis was then conducted to assess the effects of nonpharmacological interventions for severe radiation-induced oral mucositis in patients with head and neck cancer.

RESULTS

Fifty-two studies involving seven types of nonpharmacological interventions were enrolled. The network meta-analysis indicated that natural plant-based therapies might be the most effective, health education interventions might be the second most effective, and honey might be the third most effective interventions for reducing the incidence of severe radiation-induced oral mucositis. For reducing the incidence of severe oral mucositis-related pain, the pairwise meta-analysis showed that only natural plant-based therapies and health education interventions were effective.

CONCLUSIONS

Nonpharmacological interventions are effective in the management of severe radiation-induced oral mucositis among patients with head and neck cancer.

RELEVANCE TO CLINICAL PRACTICE

Nonpharmacological interventions are a category of safe and effective adjunctive therapies that should be encouraged in clinical practice.

TRIAL REGISTRATION DETAILS

CRD42023400745.

Tending to the machine: The impact of intrapartum fetal surveillance on women in Australia

Qualitative research about women and birthing people's experiences of fetal monitoring during labour and birth is scant. Labour and birth is often impacted by wearable or invasive monitoring devices, however, most published research about fetal monitoring is focused on the wellbeing of the fetus. This manuscript is derived from a larger mixed methods study, 'WOmen's Experiences of Monitoring Baby (The WOMB Study)', aiming to increase understanding of the experiences of women and birthing people in Australia, of being monitored; and about the information they received about fetal monitoring devices during pregnancy. We constructed a national cross-sectional survey that was distributed via social media in May and June, 2022. Responses were received from 861 participants. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia. This paper comprises the analysis of the free text survey responses, using qualitative and inductive content analysis. Two categories were constructed, Tending to the machine, which explores participants' perceptions of the way in which clinicians interacted with fetal monitoring technologies; and Impressions of the machine, which explores the direct impact of fetal monitoring devices upon the labour and birth experience of women and birthing people. The findings suggest that some clinicians need to reflect upon the information they provide to women and birthing people about monitoring. For example, freedom of movement is an important aspect of supporting the physiology of labour and managing pain. If freedom of movement is important, the physical restriction created by a wired cardiotocograph is inappropriate. Many participants noticed that clinicians focused their attention primarily on the technology. Prioritising the individual needs of the woman or birthing person is key to providing high quality woman-centred intrapartum care. Women should be provided with adequate information regarding the risks and benefits of different forms of fetal monitoring including how the form of monitoring might impact her labour experience.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Intrapartum cardiotocography with simultaneous maternal heart rate registration improves neonatal outcome

BACKGROUND

Intrapartum cardiotocographic monitoring of fetal heart rate by abdominal external ultrasound transducer without simultaneous maternal heart rate recording has been associated with increased risk of early neonatal death and other asphyxia-related neonatal outcomes. It is unclear, however, whether this increase in risk is independently associated with fetal surveillance method or is attributable to other factors.

OBJECTIVE

This study aimed to compare different fetal surveillance methods and their association with adverse short- and long-term fetal and neonatal outcomes in a large retrospective cohort of spontaneous term deliveries.

STUDY DESIGN

Fetal heart rate and maternal heart rate patterns were recorded by cardiotocography during labor in spontaneous term singleton cephalic vaginal deliveries in the Hospital District of Helsinki and Uusimaa, Finland between October 1, 2005, and September 30, 2023. According to the method of cardiotocography monitoring at birth, the cohort was divided into the following 3 groups: women with ultrasound transducer, women with both ultrasound transducer and maternal heart rate transducer, and women with internal fetal scalp electrode. Umbilical artery pH and base excess values, low 1- and 5-minute Apgar scores, need for intubation and resuscitation, neonatal intensive care unit admission for asphyxia, neonatal encephalopathy, and early neonatal death were used as outcome variables.

RESULTS

Among the 213,798 deliveries that met the inclusion criteria, the monitoring type was external ultrasound transducer in 81,559 (38.1%), both external ultrasound transducer and maternal heart rate recording in 62,268 (29.1%), and fetal scalp electrode in 69,971 (32.7%) cases, respectively. The rates of both neonatal encephalopathy (odds ratio, 1.48; 95% confidence interval, 1.08-2.02) and severe acidemia (umbilical artery pH <7.00 and/or umbilical artery base excess ≤-12.0 mmol/L) (odds ratio, 2.03; 95% confidence interval, 1.65-2.50) were higher in fetuses of women with ultrasound transducer alone compared with those of women with concurrent external fetal and maternal heart rate recording. Monitoring with ultrasound transducer alone was also associated with increased risk of neonatal intubation for resuscitation (odds ratio, 1.22; 95% confidence interval, 1.03-1.44). A greater risk of severe neonatal acidemia was observed both in the ultrasound transducer (odds ratio, 2.78; 95% confidence interval, 2.23-3.48) and concurrent ultrasound transducer and maternal heart rate recording (odds ratio, 1.37; 95% confidence interval, 1.05-1.78) groups compared with those monitored with fetal scalp electrodes. No difference in risk of neonatal encephalopathy was found between newborns monitored with concurrent ultrasound transducer and maternal heart rate recording and those monitored with fetal scalp electrodes.

CONCLUSION

The use of external ultrasound transducer monitoring of fetal heart rate without simultaneous maternal heart rate recording is associated with higher rates of neonatal encephalopathy and severe neonatal acidemia. We suggest that either external fetal heart rate monitoring with concurrent maternal heart rate recording or internal fetal scalp electrode be used routinely as a fetal surveillance tool in term deliveries.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Assessment of fetal resistance to hypoxia using the Stange test as an adjunct to Apgar scale assessment of neonatal health status

It has been established that the cause of biological death of fetuses in stillbirths and the cause of neonatal encephalopathies in live births is hypoxic brain cell damage in fetuses. Timely cesarean section remains the most effective way to preserve fetal life and health in the face of lethal intrauterine hypoxia. However, there is no universally recognized methodology for assessing fetal adaptation reserves to hypoxia and no methodology for selecting the type of delivery in order to perform a timely cesarean section if necessary. The Apgar score, which has been used since 1952, allows assessment of neonatal health at 1 and 5 minutes after birth, but this assessment is made without taking into account the health of the fetus before delivery. In recent years, it has been established that the outcome of fetal hypoxia is determined not only by its duration, but also by the amount of adaptive reserves available in the fetus to hypoxia. It was found that the duration of fetal immobility during apnea of a pregnant woman is an indicator of fetal resistance to hypoxia. In 2011, a method of assessing fetal resistance to intrauterine hypoxia based on the Stange test was developed in Russia. It has been found that the maximum duration of fetal immobility during maternal apnea is normally more than 30 seconds, while in the presence of fetal signs of fetoplacental insufficiency it does not reach 30 seconds, and in the presence of signs of severe fetoplacental insufficiency it does not reach 10 seconds. Therefore, it was proposed to consider good fetal resistance to hypoxia as an indication for vaginal delivery, and poor fetal resistance to hypoxia as an indication for cesarean section. A technique for assessing fetal resistance to hypoxia is described that has been developed for independent use by every pregnant woman. It is shown that it is sufficient for her to have a stopwatch and to be able to record the maximum period of fetal immobility during voluntary apnea. It is hoped that a measure of fetal resistance to hypoxia could be a meaningful complement to the Apgar score of neonatal health. It is envisioned that the use of a modified Stange test could help physicians prevent stillbirths and neonatal encephalopathies.

ST waveform analysis vs cardiotocography alone for intrapartum fetal monitoring: An updated systematic review and meta-analysis of randomized trials

INTRODUCTION

ST waveform analysis (STAN) was introduced as an adjunct to cardiotocography (CTG) to improve neonatal and maternal outcomes. The aim of the present study was to quantify the efficacy of STAN vs CTG and assess the quality of the evidence using GRADE.

MATERIAL AND METHODS

We performed systematic literature searches to identify randomized controlled trials and assessed included studies for risk of bias. We performed meta-analyses, calculating pooled risk ratio (RR) or Peto odds ratio (OR). We also performed post hoc trial sequential analyses for selected outcomes to assess the risk of false-positive results and the need for additional studies.

RESULTS

Nine randomized controlled trials including 28 729 women were included in the meta-analysis. There were no differences between the groups in operative deliveries for fetal distress (10.9 vs 11.1%; RR 0.96; 95% confidence interval [CI] 0.82-1.11). STAN was associated with a significantly lower rate of metabolic acidosis (0.45% vs 0.68%; Peto OR 0.66; 95% CI 0.48-0.90). Accordingly, 441 women need to be monitored with STAN instead of CTG alone to prevent one case of metabolic acidosis. Women allocated to STAN had a reduced risk of fetal blood sampling compared with women allocated to conventional CTG monitoring (12.5% vs 19.6%; RR 0.62; 95% CI 0.49-0.80). The quality of the evidence was high to moderate.

CONCLUSIONS

Absolute effects of STAN were minor and the clinical significance of the observed reduction in metabolic acidosis is questioned. There is insufficient evidence to state that STAN as an adjunct to CTG leads to important clinical benefits compared with CTG alone.

Umbilical cord blood gases sampling in low-risk vaginal deliveries as a predictor of adverse neonatal outcome

INTRODUCTION

There is no clear correlation between abnormal umbilical cord blood gas studies (UCGS) and adverse neonatal outcome in low-risk deliveries. We investigated the need for its routine use in low-risk deliveries.

METHODS

We retrospectively compared maternal, neonatal, and obstetrical characteristics among low-risk deliveries (2014-2022) between "normal" and "abnormal" pH groups: A:normal pH ≥ 7.15; abnormal pH < 7.15; B: normal pH ≥ 7.15 and base excess (BE) > - 12 mmol/L; abnormal pH < 7.15 and BE ≤ We retrospectively compared 12 mmol/L; C: normal pH ≥ 7.1; abnormal pH < 7.1; D: normal pH > 7.1 and BE > - 12 mmol/L; abnormal pH < 7.1 and BE ≤ - 12 mmol/L.

RESULTS

Of 14,338 deliveries, the rates of UCGS were: A-0.3% (n = 43); B-0.07% (n = 10); C-0.11% (n = 17); D-0.03% (n = 4). The primary outcome, composite adverse neonatal outcome (CANO) occurred in 178 neonates with normal UCGS (1.2%) and in only one case with UCGS (2.6%). The sensitivity and specificity of UCGS as a predictor of CANO were high (99.7-99.9%) and low (0.56-0.59%), respectively.

CONCLUSION

UCGS were an uncommon finding in low-risk deliveries and its association with CANO was not clinically relevant. Consequently, its routine use should be considered.

Perinatal and Neonatal Outcomes Using Cardiotocography Versus STAN and Cardiotocography: a Systematic Review

Objective:ST waveform analysis (STAN) was introduced to improve the interpretation of cardiotocography (CTG) resulting in reduction of unnecessary interventions and metabolic acidosis. A systematic review was conducted with the aim to evaluate the effect of STAN method compared with isolated CTG on perinatal and neonatal outcomes. Materials and methods:A search of electronic databases (PubMed, Cochrane, Scopus) was conducted to identify randomized controlled trials (RCTs) in English language. Outcomes considered operative deliveries, fetal blood sampling (FBS), metabolic acidosis, perinatal and neonatal death, neonatal seizures, neonatal encephalopathy, transfer to the neonatal intensive care unit (NICU) and Apgar score. Results:Seven RCTs were included in the present review. The first two RCTs showed that the combination of STAN and CTG was a better option than using CTG alone, because there was a documented reduction in the rate of operative deliveries due to fetal distress and metabolic acidosis. The following studies showed no statistically significant changes with the combination of methods, except from a reduction in FBS. Conclusions:The findings from the RCTs were inconclusive. Most studies did not demonstrate a superiority of the combination regarding operative deliveries and neonatal outcomes but there were many methodological differences between the trials.

Accuracy of intrapartum cardiotocography in identifying acidemia at birth by umbilical cord blood gasometry in high-risk pregnancies

OBJECTIVE

The aim of this study was to evaluate the accuracy of intrapartum cardiotocography in identifying acidemia at birth by umbilical cord blood gasometry in high-risk pregnancies.

METHODS

This was a retrospective cohort study of singleton high-risk parturients using intrapartum cardiotocography categories I, II, and III. The presence of fetal acidemia at birth was identified by the analysis of umbilical cord arterial blood pH (<7.1). Associations between variables were determined using the chi-square test and Kruskal-Wallis tests.

RESULTS

We included 105 cases of cardiotocography category I, 20 cases of cardiotocography category II, and 10 cases of cardiotocography category III. cardiotocography category III had a higher prevalence of cesarean sections compared to cardiotocography category I (90.0 vs. 42.9%, p<0.006). Venous pH was higher in patients with cardiotocography category I compared to cardiotocography category III (7.32 vs. 7.23, p=0.036). Prevalence of neonatal intensive care unit (NICU) admission was lower in neonates of patients with cardiotocography category I compared to cardiotocography category III (3.8 vs. 30.0%, p=0.014). Prevalence of composite adverse outcomes was lower in neonates of patients with cardiotocography category I compared to cardiotocography category II (9.5 vs. 30.0%, p=0.022) and cardiotocography category III (9.5 vs. 60.0%, p=0.0004). cardiotocography categories II and III had low sensitivity (0.05 and 0.00, respectively) and high negative predictive value (NPV) (0.84 and 0.91, respectively) for identifying fetal acidemia at birth. The three categories of intrapartum cardiotocography showed high specificities (96.0, 99.0, and 99.0%, respectively).

CONCLUSION

All three categories of intrapartum cardiotocography showed low sensitivity and high specificity for identifying acidemia at birth.

Continuous fetal cerebral blood flow monitoring during labor: A feasibility study

BACKGROUND

Current methods for fetal surveillance during labor have significant limitations. Since continuous fetal cerebral blood flow velocity (CBFV) monitoring during labor may add valuable information about fetal well-being, we developed a new ultrasound system called VisiBeam. VisiBeam consists of a flat probe (diameter 11 mm) with a cylindric plane wave beam, a vacuum attachment (diameter 40 mm), a scanner, and a display.

AIMS

To assess the feasibility of VisiBeam for continuous fetal CBFV monitoring during labor, and to study changes in CBFV during uterine contractions.

STUDY DESIGN

Descriptive observational study.

SUBJECTS

Twenty-five healthy women in labor with a singleton fetus in cephalic presentation at term. A transducer was placed over a fontanelle and attached to the fetal head with vacuum suction.

OUTCOME MEASURES

Achievement of continuous good quality fetal CBFV measures, such as peak systolic velocity, time averaged maximum velocity and end diastolic velocity. Trend plots of velocity measures display changes in CBFV between and during uterine contractions.

RESULTS

Good quality recordings during and between contractions were achieved in 16/25 fetuses. In twelve fetuses, CBFV measures were stable during uterine contractions. Four fetuses showed patterns of reduced CBFV velocity measures during contractions.

CONCLUSIONS

Continuous fetal CBFV monitoring by VisiBeam was feasible in 64 % of the subjects during labor. The system displayed variations of fetal CBFV not available by today's monitoring techniques and motivates for further studies. However, improvement of the probe attachment is required to ensure good quality signal in a higher proportion of fetuses during labor.

Computerized cardiotocography analysis during labor - A state-of-the-art review

Cardiotocography is defined as the recording of fetal heart rate and uterine contractions and is widely used during labor as a screening tool to determine fetal wellbeing. The visual interpretation of the cardiotocography signals by the practitioners, following common guidelines, is subject to a high interobserver variability, and the efficiency of cardiotocography monitoring is still debated. Since the 1990s, researchers and practitioners work on designing reliable computer-aided systems to assist practitioners in cardiotocography interpretation during labor. Several systems are integrated in the monitoring devices, mostly based on the guidelines, but they have not clearly demonstrated yet their usefulness. In the last decade, the availability of large clinical databases as well as the emergence of machine learning and deep learning methods in healthcare has led to a surge of studies applying those methods to cardiotocography signals analysis. The state-of-the-art systems perform well to detect fetal hypoxia when evaluated on retrospective cohorts, but several challenges remain to be tackled before they can be used in clinical practice. First, the development and sharing of large, open and anonymized multicentric databases of perinatal and cardiotocography data during labor is required to build more accurate systems. Also, the systems must produce interpretable indicators along with the prediction of the risk of fetal hypoxia in order to be appropriated and trusted by practitioners. Finally, common standards should be built and agreed on to evaluate and compare those systems on retrospective cohorts and to validate their use in clinical practice.

The social organisation of decision-making about intrapartum fetal monitoring: An Institutional Ethnography

BACKGROUND

International guidelines recommend intrapartum cardiotocograph (CTG) monitoring for women at risk for poor perinatal outcome. Research has not previously addressed how midwives and obstetricians enable or hinder women's decision-making regarding intrapartum fetal monitoring and how this work is structured by external organising factors.

AIM

To examine impacts of policy and research texts on midwives' and obstetricians' work with labouring women related to intrapartum fetal monitoring decision-making.

METHODS

We used a critical feminist qualitative methodology known as Institutional Ethnography (IE). The research was conducted in an Australian tertiary maternity service. Data collection included interviews, observation, and texts relating to midwives' and obstetricians' work with the fetal monitoring system. Textual mapping was used to explain how midwives' and obstetricians' work was organised to happen the way it was.

FINDINGS

CTG monitoring was initiated predominantly by midwives applying mandatory policy. Midwives described reluctance to inform labouring women that they had a choice of fetal monitoring method. Discursive approaches used in a national fetal surveillance guideline, a Cochrane systematic review, and the largest randomised controlled trial regarding CTG monitoring in labour generated and reproduced assumptions that clinicians, not labouring women, were the appropriate decision-maker regarding fetal monitoring in labour.

DISCUSSION AND CONCLUSION

Guidelines structured midwives' and obstetricians' work in a manner that undermined women's participation in decisions about fetal monitoring method. Intrapartum fetal monitoring guidelines should be critically reviewed to ensure they encourage and enable midwives and obstetricians to support women to make decisions about intrapartum care.

Wanting to be 'with woman', not with machine: Midwives' experiences of caring for women being continuously monitored in labour

PROBLEM

Some continuous electronic fetal monitoring (CEFM) devices restrict women's bodily autonomy by limiting their mobility in labour and birth.

BACKGROUND

Little is known about how midwives perceive the impact of CEFM technologies on their practice.

AIM

This paper explores the way different fetal monitoring technologies influence the work of midwives.

METHODS

Wireless and beltless 'non-invasive fetal electrocardiogram' (NIFECG) was trialled on 110 labouring women in an Australian maternity hospital. A focus group pertaining to midwives' experiences of using CTG was conducted prior to the trial. After the trial, midwives were asked about their experiences of using NIFECG. All data were analysed using thematic analysis.

FINDINGS

Midwives felt that wired CTG creates barriers to physiological processes. Whilst wireless CTG enables greater freedom of movement for women, it requires constant 'fiddling' from midwives, drawing their attention away from the woman. Midwives felt the NIFECG better enabled them to be 'with woman'.

DISCUSSION

Midwives play a pivotal role in mediating the influence of CEFM on women's experiences in labour. Exploring the way in which different forms of CEFM impact on midwives' practice may assist us to better understand how to prioritise the woman in order to facilitate safe and satisfying birth experiences.

CONCLUSION

The presence of CEFM technology in the birth space impacts midwives' ways of working and their capacity to be woman-centred. Current CTG technology may impede midwives' capacity to be 'with woman'. Compared to the CTG, the NIFECG has the potential to enable midwives to provide more woman-centred care for those experiencing complex pregnancies.

What Do Women Want? Consent for the Use of Electronic Fetal Monitoring

BACKGROUND

Guidelines published by professional associations of midwives, obstetricians, and nurses in the United States recommend against using continuous cardiotocography (CTG) in low-risk patients. In the United States, CTG or electronic fetal/uterine monitoring (EFM) rather than auscultation with a fetoscope or Pinard horn is the norm. Interpretation of the fetal heart rate (FHR) and uterine activity (UA) tracings provided by continuous EFM may be associated with the decision for a cesarean birth. Typically, consent is not sought in the decision about type of monitoring. No studies were identified where women's attitudes about the need to consent to the type of fetal monitoring used during labor have been explored. Therefore, the purpose of this research was to examine women's attitudes about the use of EFM in a healthcare setting.

METHODS

We asked a sample of women aged 18–50 years to respond to one of three monitoringscenarios. The scenarios were used to distinguish between attitudes about monitoring in general, monitoring the health of a mother in labor, and monitoring the health of the fetus during labor. Wemeasured their level of interest in being monitored and their opinions about whether healthcare providers should be required to obtain consent for the monitoring described in the scenario.

RESULTS

Interest in receiving monitoring (across all three scenarios) was moderate, with the highest level of interest in monitoring the fetus during labor and the least interest in monitoring a general health context. Across all scenarios, 82% of respondents believed that practitioners should obtain consent for monitoring, 14% were unsure, and 4% said there should not be a requirement for consent. While low (6%), the percentage responding that consent was not needed was highest in monitoring a fetus in labor.

CONCLUSIONS

Women in our study expressed a strong preference for the opportunity to consent to the use of monitoring regardless of the healthcare scenario. There is findings suggest the need for further research exploring what women do and do not know about CTG and what their informed performance are a pressing need to rethink the role of a pressing need to rethink the role of shared decision-making and informed consent about the type of monitoring use during labor.

Intermittent Auscultation Reduces Risk of Emergency Cesarean Delivery

According to this study: Compared with other fetal surveillance methods, intermittent auscultation seems to reduce the risk of emergency cesarean delivery without increasing that of adverse neonatal and maternal outcomes.Newer methods of fetal surveillance didn't improve neonatal outcomes or reduce the risk of unnecessary maternal interventions.

Current Resources for Evidence-Based Practice, July 2021

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of how fetal monitoring may lead to overuse of birth-related interventions, commentaries on reviews focused on bedsharing, and women's lifetime estrogen exposure and risk of cardiovascular mortality.

Midwives must, obstetricians may: An ethnographic exploration of how policy documents organise intrapartum fetal monitoring practice

BACKGROUND

The capacity for midwifery to improve maternity care is under-utilised. Midwives have expressed limits on their autonomy to provide quality care in relation to intrapartum fetal heart rate monitoring.

AIM

To explore how the work of midwives and obstetricians was textually structured by policy documents related to intrapartum fetal heart rate monitoring.

METHODS

Institutional Ethnography, a critical qualitative approach was used. Data were collected in an Australian hospital with a central fetal monitoring system. Midwives (n=34) and obstetricians (n=16) with experience working with the central fetal monitoring system were interviewed and observed. Policy documents were collected and analysed.

FINDINGS

Midwives' work was strongly structured by policy documents that required escalation of care for any CTG abnormality. Prior to being able to escalate care, midwives were often interrupted by other clinicians uninvited entry into the room in response to the CTG seen at the central monitoring station. While the same collection of documents guided the work of both obstetricians and midwives, they generated the expectation that midwives must perform certain tasks while obstetricians may perform others. Midwifery work was textually invisible.

DISCUSSION AND CONCLUSION

Our findings provide a concrete example of the way policy documents both reflect and generate power imbalances in maternity care. Obstetric ways of knowing and doing are reinforced within these documents and continue to diminish the visibility and autonomy of midwifery. Midwifery organisations are well placed to co-lead policy development and reform in collaboration with maternity consumer and obstetric organisations.