Feasibility and reliability of fetal two dimensional speckle tracking echocardiography at 16 weeks gestational age: A pilot study

BACKGROUND

Fetal two-dimensional speckle tracking echocardiography (2D-STE) is an emerging technique for assessing fetal cardiac function by measuring global longitudinal strain. Alterations in global longitudinal strain may serve as early indicator of pregnancy complications, making 2D-STE a potentially valuable tool for early detection. Early detection can facilitate timely interventions to reduce fetal and maternal morbidity and mortality. Therefore, the aim of this study was to investigate the feasibility of performing 2D-STE at 16 weeks gestational age.

METHODS

This pilot study utilized 50 ultrasound clips of the fetal four-chamber view recorded between 15+5 and 16+2 weeks gestational age from a prospective cohort study. A strict protocol assessed three parameters essential for 2D-STE analysis: fetal four-chamber view ultrasound clip quality, region of interest, and frame rates. Two independent researchers measured global longitudinal strain in all adequate fetal four-chamber view ultrasound clips to determine inter- and intra-operator reliability.

RESULTS

Out of the 50 ultrasound clips, 37 (74%) were feasible for 2D-STE analysis. The inter-operator reliability for global longitudinal strain measurements of the left and right ventricles was moderate (ICC of 0.64 and 0.74, respectively), while the intra-operator reliability was good (ICC of 0.76 and 0.79, respectively).

CONCLUSIONS

Our findings demonstrate that fetal 2D-STE analysis at 16 weeks gestational age is feasible when adhering to a strict protocol. However, further improvements are necessary to enhance the inter- and intra-operator reliability of 2D-STE at this gestational age.

Early prediction of gestational diabetes mellitus using maternal demographic and clinical risk factors

OBJECTIVE

To build and validate an early risk prediction model for gestational diabetes mellitus (GDM) based on first-trimester electronic medical records including maternal demographic and clinical risk factors.

METHODS

To develop and validate a GDM prediction model, two datasets were used in this retrospective study. One included data of 14,015 pregnant women from Máxima Medical Center (MMC) in the Netherlands. The other was from an open-source database nuMoM2b including data of 10,038 nulliparous pregnant women, collected in the USA. Widely used maternal demographic and clinical risk factors were considered for modeling. A GDM prediction model based on elastic net logistic regression was trained from a subset of the MMC data. Internal validation was performed on the remaining MMC data to evaluate the model performance. For external validation, the prediction model was tested on an external test set from the nuMoM2b dataset.

RESULTS

An area under the receiver-operating-characteristic curve (AUC) of 0.81 was achieved for early prediction of GDM on the MMC test data, comparable to the performance reported in previous studies. While the performance markedly decreased to an AUC of 0.69 when testing the MMC-based model on the external nuMoM2b test data, close to the performance trained and tested on the nuMoM2b dataset only (AUC = 0.70).

Artificial intelligence based cardiotocogram assessment during labor

OBJECTIVE

To assess whether artificial intelligence, inspired by clinical decision-making procedures in delivery rooms, can correctly interpret cardiotocographic tracings and distinguish between normal and pathological events.

STUDY DESIGN

A method based on artificial intelligence was developed to determine whether a cardiotocogram shows a normal response of the fetal heart rate to uterine activity (UA). For a given fetus and given the UA and previous FHR, the method predicts a fetal heart rate response, under the assumption that the fetus is still in good condition and based on how that specific fetus has responded so far. We hypothesize that this method, when having only learned from fetuses born in good condition, is incapable of predicting the response of a compromised fetus or an episode of transient fetal distress. The (in)capability of the method to predict the fetal heart rate response would then yield a method that can help to assess fetal condition when the obstetrician is in doubt. Cardiotocographic data of 678 deliveries during labor were selected based on a healthy outcome just after birth. The method was trained on the cardiotocographic data of 548 fetuses of this group to learn their heart rate response. Subsequently it was evaluated on 87 fetuses, by assessing whether the method was able to predict their heart rate responses. The remaining 43 cardiotocograms were segment-by-segment annotated by three experienced gynecologists, indicating normal, suspicious, and pathological segments, while having access to the full recording and neonatal outcome. This future knowledge makes the expert annotations of a quality that is unachievable during live interpretation.

RESULTS

The comparison between abnormalities detected by the method (only using past and present input) and the annotated CTG segments by gynecologists (also looking at future input) yields an area under the curve of 0.96 for the distinction between normal and pathological events in majority-voted annotations.

CONCLUSION

The developed method can distinguish between normal and pathological events in near real-time, with a performance close to the agreement between three gynecologists with access to the entire CTG tracing and fetal outcome. The method has a strong potential to support clinicians in assessing fetal condition in clinical practice.

Transferring an extremely premature infant to an extra-uterine life support system: a prospective view on the obstetric procedure

To improve care for extremely premature infants, the development of an extrauterine environment for newborn development is being researched, known as Artificial Placenta and Artificial Womb (APAW) technology. APAW facilitates extended development in a liquid-filled incubator with oxygen and nutrient supply through an oxygenator connected to the umbilical vessels. This setup is intended to provide the optimal environment for further development, allowing further lung maturation by delaying gas exposure to oxygen. This innovative treatment necessitates interventions in obstetric procedures to transfer an infant from the native to an artificial womb, while preventing fetal-to-neonatal transition. In this narrative review we analyze relevant fetal physiology literature, provide an overview of insights from APAW studies, and identify considerations for the obstetric procedure from the native uterus to an APAW system. Lastly, this review provides suggestions to improve sterility, fetal and maternal well-being, and the prevention of neonatal transition.

Simulation-based development: shaping clinical procedures for extra-uterine life support technology

BACKGROUND

Research into Artificial Placenta and Artificial Womb (APAW) technology for extremely premature infants (born < 28 weeks of gestation) is currently being conducted in animal studies and shows promising results. Because of the unprecedented nature of a potential treatment and the high-risk and low incidence of occurrence, translation to the human condition is a complex task. Consequently, the obstetric procedure, the act of transferring the infant from the pregnant woman to the APAW system, has not yet been established for human patients. The use of simulation-based user-centered development allows for a safe environment in which protocols and devices can be conceptualized and tested. Our aim is to use participatory design principles in a simulation context, to gain and integrate the user perspectives in the early design phase of a protocol for this novel procedure.

METHODS

Simulation protocols and prototypes were developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from participants with clinical expertise from a range of disciplines. The procedure made use of fetal and maternal manikins and included animations and protocol task cards.

RESULTS

Physical simulation with the active participation of clinicians led to the diffusion of tacit knowledge and an iteratively formed shared understanding of the requirements and values that needed to be implemented in the procedure. At each sequel, participant input was translated into simulation protocols and design adjustments.

CONCLUSION

This work demonstrates that simulation-based participatory design can aid in shaping the future of clinical procedure and product development and rehearsing future implementation with healthcare professionals.

Detection of postpartum uterine activity with electrohysterography

OBJECTIVE

Uterine contractions are essential for childbirth, but also for expulsion of the placenta and for limiting postpartum blood loss. Postpartum hemorrhage is associated with almost 25% of the maternal deaths worldwide and the leading cause of maternal death in most low-income countries. Little is known about the physiology of the uterus postpartum, particularly due to the lack of an accurate measurement tool. The primary objective of this pilot study is to explore the potential of using electrohysterography to detect postpartum uterine contractions. If postpartum uterine activity can be objectified, this could contribute to understanding the physiology of the uterus and improve diagnosis and treatment of postpartum hemorrhage.

STUDY DESIGN

In this observational study we included women aiming for a vaginal birth in two large maternity clinics in the Netherlands, Amphia Hospital Breda (group A, N2018-0161) and Máxima Medical Center Veldhoven (group B, N17.149). An electrode patch was placed on the maternal abdomen to record real-time electrical uterine activity until one hour postpartum continuously. In group A, the placement of the patch was lower than in group B. For analysis, tracings were divided into five different phases (1: dilatation until start pushing, 2: from start pushing until childbirth, 3: from childbirth until placental expulsion, 4: first hour after placental expulsion and 5: after one hour postpartum). Readability, signal quality and contraction frequency per hour were assessed. Additionally, patient satisfaction was evaluated through a survey.

RESULTS

In total 91 pregnant women were included of whom 45 in group A and 46 women in group B. Complete registrations were obtained throughout the five labor phases with very little artefacts or signal loss. The readability of the tracings decreased after childbirth. A significantly better readability was found in tracings where the patch placement was lower on the abdomen for phases 4 and 5. Contraction frequency was highest during phase 2 and decreased towards phase 5. Women rated the satisfaction with electrohysterography as high and mostly did not notice the patch.

CONCLUSION

It is possible to detect uterine activity postpartum with electrohysterography. Further investigation is recommended to improve diagnosis and treatment of postpartum hemorrhage.

Accidental rupture of membranes and neonatal infection after labor induction with silicone or latex balloon catheters: A retrospective cohort study

OBJECTIVE(S)

Accidental rupture of membranes (acROM), an insertion-related complication of the balloon catheter for labor induction, may prolong the duration of ruptured membranes. Prolonged rupture of membranes is associated with an increased risk of intra-uterine infection with possibly neonatal infection as result. Little is known about safety profiles of different catheters regarding the occurrence of these complications. This study compares the incidence of neonatal early-onset sepsis (EOS) and acROM in women receiving either silicone or latex balloon catheters.

STUDY DESIGN

A retrospective cohort study was performed including 2200 women (silicone balloon catheter, n = 1100 vs. latex balloon catheter, n = 1100). The primary outcomes were the incidence of acROM, and suspected and proven neonatal EOS. Secondary outcomes were: prolonged rupture of membranes, intrapartum fever, pre- or postnatal neonatal exposure to antibiotics, and perinatal outcomes. A subgroup analysis was performed between women with and without acROM.

RESULTS

No statistically significant difference with regard to suspected or proven EOS was seen between the silicone and latex groups. The acROM rate was significantly higher in the silicone group compared to the latex group (2.9 % and 0.3 %, p < 0.01). Prolonged rupture of membranes was significantly more common in the silicone group compared to the latex group (5.0 % and 2.4 %, p < 0.01), as was the use of intrapartum antibiotics (12.7 % and 9.6 %, p = 0.02). Neonates were significantly more often exposed to pre- or postnatal antibiotics in the silicone group compared to the latex group (17.6 % and 13.6 %, p = 0.01). Subgroup analysis showed significantly more suspected and proven neonatal EOS when catheter-insertion was complicated with acROM (11.4 % and 20.0 %), compared to cases without acROM (3.8 % and 2.5 %), irrespective of the type of catheter used.

CONCLUSION(S)

The use of silicone balloon catheters for labor induction results in higher rates of acROM, prolonged rupture of membranes and use of intrapartum antibiotics, compared to latex balloon catheters. No statistically significant differences were found in the occurrence of suspected or proven neonatal EOS, however neonates from the silicone group were more often exposed to pre- or postnatal antibiotics. When acROM occurs, irrespective of type of catheter used, suspected and proven neonatal EOS was seen more often.

Visualization of contractions: Evaluation of a new experience design concept to enhance the childbirth experience

BACKGROUND

The purpose of this study was to develop and evaluate an innovative design proposition intended to help enhance the childbirth experience. The innovation consists of a smartphone application for birth preparation during pregnancy with information and coaching, in addition to a wall projection at the labor ward that visualizes the progress of labor based on uterine monitoring data.

METHODS

We conducted a randomized controlled clinical pilot study. Singleton pregnant people pursuing a vaginal birth were recruited between 28 and 32 weeks of gestation and allocated to the intervention group (mobile application during the third trimester and wall projection at the labor ward) or to care as usual. Childbirth expectations and experiences were measured with validated questionnaires, which were completed at 32 and 36 weeks of gestation, immediately after birth, and at 4 weeks postpartum. Quantitative outcomes were analyzed and feedback about the proposition was evaluated using qualitative methods.

RESULTS

The qualitative feedback from patients was largely positive; however, we could not detect any significant differences between the intervention and control groups about fear of childbirth and other outcome measures.

CONCLUSION

In this pilot study, we evaluated a new experience design proposition for pregnancy and childbirth. This study generated data that will help to further improve and evaluate similar innovations in the future. This application may facilitate participatory care, promoting active involvement of parents in the healthcare processes of pregnancy and childbirth.

Simulation-Based Training in Emergency Obstetric Care in Sub-Saharan and Central Africa: A Scoping Review

Background

Every day approximately 810 women die from complications related to pregnancy and childbirth worldwide. Around two thirds of these deaths happen in sub-Saharan Africa. One of the strategies to decrease these numbers is improving the quality of care by emergency obstetric simulation-based training. The effectiveness of such training programs depends on the program's instructional design.

Objective

This review gives an overview of studies about emergency obstetric simulation-based training and examines the applied instructional design of the training programs in sub-Saharan and Central Africa.

Methods

We searched Medline, Embase and Cochrane Library from inception to May 2021. Peer-reviewed articles on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa were included. Outcome measures were categorized based on Kirkpatrick's levels of training evaluation. The instructional design was evaluated by using the ID-SIM questionnaire.

Findings

In total, 47 studies met the inclusion criteria. Evaluation on Kirkpatrick level 1 showed positive reactions in 18 studies. Challenges and recommendations were considered. Results on knowledge, skills, and predictors for these results (Kirkpatrick level 2) were described in 29 studies. Retention as well as decay of knowledge and skills over time were presented. Results at Kirkpatrick level 3 were measured in 12 studies of which seven studies demonstrated improvements of skills on-the-job. Improvements of maternal and neonatal outcomes were described in fifteen studies and three studies reported on cost-estimations for training rollout (Kirkpatrick level 4). Instructional design items were heterogeneously applied and described.

Conclusions

Results of 47 studies indicate evidence that simulation-based training in sub-Saharan and Central Africa can have a positive impact across all four levels of Kirkpatrick's training evaluation model. However, results were not consistent across all studies and the effects vary over time. A detailed description of instructional design features in future publications on simulation-based training will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other.

Evidence and clinical relevance of maternal-fetal cardiac coupling: A scoping review

BACKGROUND

Researchers have long suspected a mutual interaction between maternal and fetal heart rhythms, referred to as maternal-fetal cardiac coupling (MFCC). While several studies have been published on this phenomenon, they vary in terms of methodologies, populations assessed, and definitions of coupling. Moreover, a clear discussion of the potential clinical implications is often lacking. Subsequently, we perform a scoping review to map the current state of the research in this field and, by doing so, form a foundation for future clinically oriented research on this topic.

METHODS

A literature search was performed in PubMed, Embase, and Cochrane. Filters were only set for language (English, Dutch, and German literature were included) and not for year of publication. After screening for the title and the abstract, a full-text evaluation of eligibility followed. All studies on MFCC were included which described coupling between heart rate measurements in both the mother and fetus, regardless of the coupling method used, gestational age, or the maternal or fetal health condition.

RESULTS

23 studies remained after a systematic evaluation of 6,672 studies. Of these, 21 studies found at least occasional instances of MFCC. Methods used to capture MFCC are synchrograms and corresponding phase coherence indices, cross-correlation, joint symbolic dynamics, transfer entropy, bivariate phase rectified signal averaging, and deep coherence. Physiological pathways regulating MFCC are suggested to exist either via the autonomic nervous system or due to the vibroacoustic effect, though neither of these suggested pathways has been verified. The strength and direction of MFCC are found to change with gestational age and with the rate of maternal breathing, while also being further altered in fetuses with cardiac abnormalities and during labor.

CONCLUSION

From the synthesis of the available literature on MFCC presented in this scoping review, it seems evident that MFCC does indeed exist and may have clinical relevance in tracking fetal well-being and development during pregnancy.

The impact of angles of insonation on left and right ventricular global longitudinal strain estimation in fetal speckle tracking echocardiography

OBJECTIVES

Two-dimensional speckle tracking echocardiography has been considered an angle-independent modality. However, current literature is limited and inconclusive on the actual impact of angle of insonation on strain values. Therefore, the primary objective of this study was to assess the impact of angles of insonation on the estimation of fetal left ventricular and right ventricular global longitudinal strain. Secondarily, the impact of different definitions for angles of insonation was investigated in a sensitivity analysis.

METHODS

This is a retrospective analysis of a prospective longitudinal cohort study with 124 healthy subjects. The analyses were based on the four-chamber view ultrasound clips taken between 18+0 and 21+6 weeks of gestation. Angles of insonation were categorized into three groups: up/down, oblique and perpendicular. The mean fetal left and right ventricular and global longitudinal strain values corresponding to these three groups were compared by an ANOVA test corrected for heteroscedasticity.

RESULTS

Fetal left and right ventricular global longitudinal strain values were not statistically different between the three angles of insonation (p-value >0.062 and >0.149, respectively). When applying another definition for angles of insonation in the sensitivity analysis, the mean left ventricular global longitudinal strain value was significantly decreased for the oblique compared to the up/down angle of insonation (p-value 0.041).

CONCLUSIONS

There is no evidence of a difference in fetal left and right ventricular global longitudinal strain between the different angles of insonation in fetal two-dimensional speckle tracking echocardiography.

Association between high levels of comorbid anxiety and depressive symptoms and decreased likelihood of birth without intervention: A longitudinal prospective cohort study

OBJECTIVE

To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed in each pregnancy trimester and physiological birth.

DESIGN

Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014.

SETTING

Primary care, in the Netherlands.

POPULATION

Dutch-speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder or chronic disease history.

METHODS

Pregnancy-specific anxiety and depressive symptoms were measured prospectively in each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modelling was performed in MPLUS to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth.

MAIN OUTCOME MEASURES

Trajectories of CAD symptoms and physiological birth.

RESULTS

Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1-persistently low levels of symptoms (reference class 1; 79.0%), group 2-intermittently high levels of symptoms (classes 3, 6 and 7; 11.2%), and group 3-persistently high levels of symptoms (classes 2, 4 and 5; 9.8%). Persistently high levels of CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (odds ratio 0.67, 95% confidence interval 0.47-0.95, P = 0.027) compared with the reference group (persistently low levels of symptoms), after adjusting for confounders.

CONCLUSIONS

This study is the first showing evidence that persistently high CAD levels, assessed in each pregnancy trimester, are associated with a lower likelihood of physiological birth.

Two-year neurodevelopmental outcome in children born extremely preterm: the EPI-DAF study

OBJECTIVE

In 2010, the Dutch practice regarding initiation of active treatment in extremely preterm infants was lowered from 25 completed weeks' to 24 completed weeks' gestation. The nationwide Extremely Preterm Infants - Dutch Analysis on Follow-up Study was set up to provide up-to-date data on neurodevelopmental outcome at 2 years' corrected age (CA) after this guideline change. Design: National cohort study.

PATIENTS

All live born infants between 24^0/7 weeks' and 26^6/7 weeks' gestational age who were 2 years' CA in 2018-2020.

MAIN OUTCOME MEASURE

Impairment at 2 years' CA, based on cognitive score (Bayley-III-NL), neurological examination and neurosensory function.

RESULTS

651 of 991 live born infants (66%) survived to 2 years' CA, with data available for 554 (85%). Overall, 62% had no impairment, 29% mild impairment and 9% moderate-to-severe impairment (further defined as neurodevelopmental impairment, NDI). The percentage of survivors with NDI was comparable for infants born at 24 weeks', 25 weeks' and 26 weeks' gestation. After multivariable analysis, severe brain injury and low maternal education were associated with higher odds on NDI. NDI-free survival was 48%, 67% and 75% in neonatal intensive care unit (NICU)-admitted infants at 24, 25 and 26 weeks' gestation, respectively.

CONCLUSIONS

Lowering the threshold has not been accompanied by a large increase in moderate-to-severely impaired infants. Among live-born and NICU-admitted infants, an increase in NDI-free survival was observed from 24 weeks' to 26 weeks' gestation. This description of a national cohort with high follow-up rates gives an accurate description of the range of outcomes that may occur after extremely preterm birth.

New possibilities for ST analysis - A post-hoc analysis on the Dutch STAN RCT

BACKGROUND

The diagnostic value of ST analysis of the fetal electrocardiogram (fECG) during labor is uncertain. False alarms (ST events) may be explained by physiological variation of the fetal electrical heart axis. Adjusted ST events, based on a relative rather than an absolute rise from baseline, correct for this variation and may improve the diagnostic accuracy of ST analysis.

AIMS

Determine the optimal cut-off for relative ST events in fECG to detect fetal metabolic acidosis.

STUDY DESIGN

Post-hoc analysis on fECG tracings from the Dutch STAN trial (STAN+CTG branch).

SUBJECTS

1328 term singleton fetuses with scalp ECG tracing during labor, including 10 cases of metabolic acidosis.

OUTCOME MEASURES

Cut-off value for relative ST events at the point closest to (0,1) in the receiver operating characteristic (ROC) curve with corresponding sensitivity and specificity.

RESULTS

Relative baseline ST events had an optimal cut-off at an increment of 85% from baseline. Relative ST events had a sensitivity of 90% and specificity of 80%.

CONCLUSIONS

Adjusting the current definition of ST events may improve ST analysis, making it independent of CTG interpretation.

Interprofessional Consensus Regarding Design Requirements for Liquid-Based Perinatal Life Support (PLS) Technology

Liquid-based perinatal life support (PLS) technology will probably be applied in a first-in-human study within the next decade. Research and development of PLS technology should not only address technical issues, but also consider socio-ethical and legal aspects, its application area, and the corresponding design implications. This paper represents the consensus opinion of a group of healthcare professionals, designers, ethicists, researchers and patient representatives, who have expertise in tertiary obstetric and neonatal care, bio-ethics, experimental perinatal animal models for physiologic research, biomedical modeling, monitoring, and design. The aim of this paper is to provide a framework for research and development of PLS technology. These requirements are considering the possible respective user perspectives, with the aim to co-create a PLS system that facilitates physiological growth and development for extremely preterm born infants.

The electrical heart axis of the fetus between 18 and 24 weeks of gestation: A cohort study

Introduction

A fetal anomaly scan in mid-pregnancy is performed, to check for the presence of congenital anomalies, including congenital heart disease (CHD). Unfortunately, 40% of CHD is still missed. The combined use of ultrasound and electrocardiography might boost detection rates. The electrical heart axis is one of the characteristics which can be deduced from an electrocardiogram (ECG). The aim of this study was to determine reference values for the electrical heart axis in healthy fetuses around 20 weeks of gestation.

Material and methods

Non-invasive fetal electrocardiography was performed subsequent to the fetal anomaly scan in pregnant women carrying a healthy singleton fetus between 18 and 24 weeks of gestation. Eight adhesive electrodes were applied on the maternal abdomen including one ground and one reference electrode, yielding six channels of bipolar electrophysiological measurements. After removal of interferences, a fetal vectorcardiogram was calculated and then corrected for fetal orientation. The orientation of the electrical heart axis was determined from this normalized fetal vectorcardiogram. Descriptive statistics were used on normalized cartesian coordinates to determine the average electrical heart axis in the frontal plane. Furthermore, 90% prediction intervals (PI) for abnormality were calculated.

Results

Of the 328 fetal ECGs performed, 281 were included in the analysis. The average electrical heart axis in the frontal plane was determined at 122.7° (90% PI: -25.6°; 270.9°).

Discussion

The average electrical heart axis of healthy fetuses around mid-gestation is oriented to the right, which is, due to the unique fetal circulation, in line with muscle distribution in the fetal heart.

Non-invasive fetal electrocardiography, electrohysterography and speckle-tracking echocardiography in the second trimester: study protocol of a longitudinal prospective cohort study (BEATS-study)

Background

Worldwide, hypertensive disorders of pregnancy (HDP), fetal growth restriction (FGR) and preterm birth remain the leading causes of maternal and fetal pregnancy-related mortality and (long-term) morbidity. Fetal cardiac deformation changes can be the first sign of placental dysfunction, which is associated with HDP, FGR and preterm birth. In addition, preterm birth is likely associated with changes in electrical activity across the uterine muscle. Therefore, fetal cardiac function and uterine activity can be used for the early detection of these complications in pregnancy. Fetal cardiac function and uterine activity can be assessed by two-dimensional speckle-tracking echocardiography (2D-STE), non-invasive fetal electrocardiography (NI-fECG), and electrohysterography (EHG). This study aims to generate reference values for 2D-STE, NI-fECG and EHG parameters during the second trimester of pregnancy and to investigate the diagnostic potential of these parameters in the early detection of HDP, FGR and preterm birth.

Methods

In this longitudinal prospective cohort study, eligible women will be recruited from a tertiary care hospital and a primary midwifery practice. In total, 594 initially healthy pregnant women with an uncomplicated singleton pregnancy will be included. Recordings of NI-fECG and EHG will be made weekly from 22 until 28 weeks of gestation and 2D-STE measurements will be performed 4-weekly at 16, 20, 24 and 28 weeks gestational age. Retrospectively, pregnancies complicated with pregnancy-related diseases will be excluded from the cohort. Reference values for 2D-STE, NI-fECG and EHG parameters will be assessed in uncomplicated pregnancies. After, 2D-STE, NI-fCG and EHG parameters measured during gestation in complicated pregnancies will be compared with these reference values.

Discussion

This will be the a large prospective study investigating new technologies that could potentially have a high impact on antepartum fetal monitoring.

Trial registration

Registered on 26 March 2020 in the Dutch Trial Register (NL8769) via https://www.trialregister.nl/trials and registered on 21 October 2020 to the Central Committee on Research Involving Human Subjects (NL73607.015.20) via https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm.

[Electrohysterography, a promising alternative for uterine monitoring: 5 years later]

Electrohysterography monitors the electrical activity of the uterine muscle through electrodes on the maternal abdominal wall. It is a non-invasive method for uterine contraction monitoring and has a strong correlation with the invasive intra-uterine pressure catheter. A prospective validation study showed a significant higher sensitivity of electrohysterography compared to external tocodynamometry for uterine contraction detection (p-value < 0.001). Moreover, the sensitivity of electrohysterography appears to be less affected by maternal obesity compared to external tocodynamometry. A clinical pilotstudy comparing electrohysterography and external tocodynamometry during labor, showed no negative effect of electrohysterography on labor outcomes. Recently, technical improvements have been made and electrohysterography has become available in an adhesive electrode patch together with fetal and maternal electrocardiography. Therefore, we expect a successful implementation of electrohysterography in the near future.

Adapted ST analysis during labor: relative versus absolute ST events, a case-control study

BACKGROUND

The value of ST analysis of the fetal electrocardiogram during labor to lower asphyxia and cesarean section rates is uncertain. Physiological variation of the electrical heart axis between fetuses may explain false alarms in conventional ST analysis (absolute ST analysis). ST events (alarms) based on relative T/QRS rises (relative ST analysis) correct for this variation and may improve diagnostic accuracy of ST analysis.

AIMS

To compare the diagnostic accuracy of absolute and relative ST analysis with regard to fetal acidemia.

STUDY DESIGN

Retrospective case-control study.

SUBJECTS

20 healthy women with an uncomplicated pregnancy monitored with ST analysis during labor: 10 cases (umbilical cord artery pH < 7.05) and 10 controls (pH > 7.20).

OUTCOME MEASURES

Sensitivity, specificity, positive and negative likelihood ratio.

RESULTS

In 16 of the 20 patients a total of 54 absolute ST events were reported. Two reviewers classified the cardiotocograms; in cases 29% of the absolute ST events were significant, in the controls it was 19%. Relative ST analysis versus absolute ST analysis showed a sensitivity of 90% (55-100%) vs. 70% (35-93%), a specificity of 100% (69-100%) vs. 70% (35-93%), a positive likelihood ratio of infinity vs. 2.3 (0.8-6.5), a negative likelihood ratio of 0.1 (0.0-0.6) vs. 0.4 (0.2-1.2), and diagnostic odds ratio of infinity vs. 5.4 (0.8-36.9). McNemar showed no statistical significant difference between the sensitivity and specificity of the methods.

CONCLUSIONS

We observed higher positive and lower negative likelihood ratios for relative ST analysis in comparison to absolute ST analysis. In this small study we found no statistical difference. Relative ST analysis should be studied in a larger study.

Clinical evaluation of electrohysterography as method of monitoring uterine contractions during labor: A propensity score matched study

OBJECTIVE

Electrohysterography is a non-invasive technique to monitor uterine activity and has a significantly higher sensitivity compared to conventional external tocodynamometry. Whether this technique could lead to improved obstetrical outcomes is still unknown. In this propensity score matched study, clinical results of the first pilot implementing electrohysterography during labor were evaluated. The hypothesis tested is that electrohysterography will help to optimize uterine activity and thereby lead to fewer obstetric interventions. Secondary outcomes were Apgar score, arterial umbilical pH values, first stage labor duration, episiotomy rate and postpartum vaginal blood loss.

STUDY DESIGN

From November 2017 until October 2018, electrohysterography was introduced as a standard alternative for monitoring uterine activity in high-risk deliveries. It could be applied in case of induced labor, previous cesarean delivery, body mass index ≥30 kg/m² or an inadequate external tocodynamometry monitoring. Outcomes were compared to a matched group of women in which external tocodynamometry was applied for uterine activity monitoring during labor. These women were identified using propensity scores.

RESULTS

A total of 348 women received electrohysterography as standard method of uterine monitoring during labor. A match (1:1 ratio) was found for 317 women, resulting in a total population of 634 women. No significant differences were seen in obstetric interventions (i.e. cesarean deliveries and assisted vaginal deliveries) between the electrohysterography and tocodynamometry group (P = 0.80). No statistically significant differences were seen regarding the secondary outcomes.

CONCLUSIONS

This first pilot study implementing electrohysterography as monitoring method during labor in a high-risk population did not result in statistically significant differences regarding obstetric interventions, low Apgar scores or low umbilical artery pH values. Therefore, we suggest that electrohysterography causes no harm and we recommend further implementation and evaluation in clinical practice.

Evaluating the Instructional Design and Effect on Knowledge, Teamwork, and Skills of Technology-Enhanced Simulation-Based Training in Obstetrics in Uganda: Stepped-Wedge Cluster Randomized Trial

BACKGROUND

Simulation-based training is a common strategy for improving the quality of facility-based maternity services and is often evaluated using Kirkpatrick's theoretical model. The results on the Kirkpatrick levels are closely related to the quality of the instructional design of a training program. The instructional design is generally defined as the "set of prescriptions for teaching methods to improve the quality of instruction with a goal of optimizing learning outcomes."

OBJECTIVE

The aim of this study is to evaluate the instructional design of a technology-enhanced simulation-based training in obstetrics, the reaction of participants, and the effect on knowledge, teamwork, and skills in a low-income country.

METHODS

A stepped-wedge cluster randomized trial was performed in a university hospital in Kampala, Uganda, with an annual delivery volume of over 31,000. In November 2014, a medical simulation center was installed with a full-body birthing simulator (Noelle S550, Gaumard Scientific), an interactive neonate (Simon S102 Newborn CPR Simulator, Gaumard Scientific), and an audio and video recording system. Twelve local obstetricians were trained and certified as medical simulation trainers. From 2014 to 2016, training was provided to 57 residents in groups of 6 to 9 students. Descriptive statistics were calculated for ten instructional design features of the training course measured by the 42-item ID-SIM (Instructional Design of a Simulation Improved by Monitoring). The Wilcoxon signed rank test was conducted to investigate the differences in scores on knowledge, the Clinical Teamwork Scale, and medical technical skills.

RESULTS

The mean scores on the ten instructional design features ranged from 54.9 (95% CI 48.5-61.3) to 84.3 (95% CI 80.9-87.6) out of 100. The highest mean score was given on the feature feedback and the lowest scores on repetitive practice and controlled environment. The overall score for the training day was 92.8 out of 100 (95% CI 89.5-96.1). Knowledge improved significantly, with a test score of 63.4% (95% CI 60.7-66.1) before and 78.9% (95% CI 76.8-81.1) after the training (P<.001). The overall score on the 10-point Clinical Teamwork Scale was 6.0 (95% CI 4.4-7.6) before and 5.9 (95% CI 4.5-7.2) after the training (P=.78). Medical technical skills were scored at 55.5% (95% CI 47.2-63.8) before and 65.6% (95% CI 56.5-74.7) after training (P=.08).

CONCLUSIONS

Most instructional design features of a technology-enhanced simulation-based training in obstetrics in a low-income country were scored high, although intervals were large. The overall score for the training day was high, and knowledge did improve after the training program, but no changes in teamwork and (most) medical technical skills were found. The lowest-scored instructional design features may be improved to achieve further learning aims.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN98617255; http://www.isrctn.com/ISRCTN98617255.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12884-020-03050-3.

Changes in Maternal Heart Rate Variability in Response to the Administration of Routine Obstetric Medication in Hospitalized Patients: Study Protocol for a Cohort Study (MAMA-Heart Study)

Pregnancy is a period of continuous change in the maternal cardiovascular system, partly mediated by the autonomic nervous system. Insufficient autonomic adaptation to increasing gestation is associated with pregnancy complications, such as hypertensive disorders of pregnancy and preterm birth (both major causes of perinatal morbidity and mortality). Consequently, maternal heart rate variability (mHRV), which is a proxy measure for autonomic activity, is increasingly assessed in these cohorts to investigate the pathophysiology of their complications. A better pathophysiological understanding could facilitate the early detection of these complications, which remains challenging. However, such studies (typically performed in pregnancies leading to hospitalization) have generated conflicting findings. A probable reason for these conflicting findings is that these study cohorts were likely administered routine obstetric medications during the study period of which the effects on mHRV are largely unknown. Subsequently, we design a longitudinal, observational study to quantifying the effect of these medications-particularly corticosteroids, which are known to affect fetal HRV-on mHRV to improve the interpretation of past and future studies. We will enroll 61 women admitted to a tertiary obstetric unit with an indication to receive corticosteroids antenatally. Participants' mHRV will be continuously acquired throughout their hospitalization with wrist-worn photoplethysmography to facilitate a within-patient comparison of the effect of corticosteroids on mHRV.

Storage conditions of oxytocin in a tropical climate in a low-income country

OBJECTIVE

To establish the storage conditions of oxytocin in a health facility in a low-income country with a tropical climate, as suboptimal storage may lead to ineffectiveness of drugs essential to prevent and treat postpartum hemorrhage.

METHODS

At Mulago National Referral Hospital (28 000-33 000 deliveries/year) in Kampala, Uganda, temperature logging Safe-Rx cards were placed in boxes of oxytocin and in every known storage location. The route of the boxes through the hospital was tracked for 54 days, and storage conditions were observed.

RESULTS

Oxytocin was stored within the recommended temperature range (2°C-8°C) 24% of the time. The average temperature measured within the oxytocin boxes was 18.2°C, with a minimum of -2.3°C and maximum of 30.4°C. Six out of twelve known storage places had a refrigerator, but not one location stored medication at the recommended temperature constantly. The average temperature in the storage places ranged from 9.5°C to 27.6°C, with a minimum temperature of 2.3°C and maximum of 30.9°C.

CONCLUSION

Oxytocin is not stored in the recommended temperature range for the majority of time. The presence of refrigerators does not ensure adherence to advised temperature storage conditions.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance

BACKGROUND

Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care.

OBJECTIVES

To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience.

SEARCH METHODS

The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes.

MAIN RESULTS

We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions).

AUTHORS' CONCLUSIONS

Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

A randomized controlled trial studying the effect of maternal hyperoxygenation on fetal heart rate in suspected fetal distress

OBJECTIVE

To investigate the effect of maternal hyperoxygenation on fetal heart rate (FHR) when applied for suspected fetal distress during the second stage of term labor.

APPROACH

A single-center randomized controlled trial was conducted in a tertiary care hospital in The Netherlands. Participants were included during the second stage of labor in case of an intermediary or abnormal FHR pattern. Patients were randomized to receive either 100% oxygen at 10 l/min until delivery, or conventional care without additional oxygen. The primary outcome was the change in FHR pattern before and after the onset of the study, measured as the change in depth and duration of FHR decelerations. Secondary outcome measures were features based on phase-rectified signal averaging (PRSA), baseline assignability, and deceleration characteristics of the FHR pattern.

MAIN RESULTS

Between March 2016 and April 2018, 117 women were included. The FHR pattern could be analyzed for 71 participants, the other 46 women delivered before the end of the post time-frame. A 2.3% reduction in depth and duration of FHR decelerations was found after maternal hyperoxygenation, compared to a 10% increase in the control group (p = 0.24). Maternal hyperoxygenation had a significantly positive effect on PRSA metrics, with a decrease in PRSA-acceleration capacity (p = 0.03) and PRSA-deceleration capacity (p = 0.02) in the intervention group compared to the control group.

SIGNIFICANCE

The difference in depth and duration of decelerations after the start of the study was not significantly different between both study groups. A statistically significant positive effect on PRSA-deceleration capacity and PRSA-acceleration capacity was found after maternal hyperoxygenation, which might be associated with a positive effect on neonatal outcome.

Qualitative assessment of interpretability and observer agreement of three uterine monitoring techniques

OBJECTIVE

The aim of this research was to assess the quality and inter- and intra-observer agreement of tracings obtained by three different techniques for uterine contraction monitoring: the external tocodynamometer (TOCO), the intrauterine pressure catheter (IUPC) and a recently introduced method based on electrohysterography (EHG).

STUDY DESIGN

We included 150 uterine activity registrations from a previous prospective observational study (W3 study), conducted at Máxima Medical Centre in Veldhoven, the Netherlands. Term singleton pregnant women were simultaneously monitored with TOCO, IUPC and EHG during labor. Six clinicians, blinded to the source (TOCO, IUPC, or EHG) and subject, evaluated all tracings that were subsequently presented in random order. They annotated contractions and assigned each tracing a score for interpretability of 2 (good), 1 (moderate) or 0 (poor). To evaluate inter-observer agreement, we calculated kappa values for the qualitative assessment, and intraclass correlation coefficients (ICC) for the number of contractions annotated by clinicians. Four clinicians repeated this procedure to evaluate intra-observer agreement.

RESULTS

IUPC tracings received the highest quality rating, with a mean score of 1.95, followed by a mean score of 1.60 for EHG and 0.80 for TOCO (p < 0.05). Mean weighted kappa values were 0.63 for TOCO and 0.45 for EHG. The average number of contractions that was picked up by clinicians was 59.8 for the intrauterine pressure catheter, 49.8 for EHG and 26.4 for TOCO. The ICC of the intrauterine pressure catheter was significantly higher than the external methods, regarding both inter- and intra-observer agreement (0.98 and 0.99 respectively).

CONCLUSION

IUPC recordings scored best regarding quality, inter- and intra-observer agreement. However, due to safety issues, in many countries this technique is not used anymore. The quality of TOCO was rated as poor and many contractions were missed as compared to the gold standard. From a clinical interpretational point of view, EHG is favorable to TOCO. EHG recordings were assigned higher quality scores, but with less agreement between clinicians. An explanation could be that EHG is a relatively new technique, while IUPC and the TOCO are being used for decades. Building experience with EHG (training) is therefore recommended.

Two-dimensional Speckle tracking echocardiography in Fetal Growth Restriction: a systematic review

Background Fetal growth restriction (FGR), defined as an estimated fetal weight (EFW)<10th percentile, is associated with an increased risk for adverse fetal and neonatal outcome. Early antenatal diagnosis is important and remains challenging. Deformation changes in the fetal myocardium are early signs of myocardial dysfunction. These changes can be measured using two-dimensional speckle tracking echocardiography (2D-STE) to predict impaired placental function in the growth restricted fetus. Aim To review the literature on fetal heart deformation values measured with 2D-STE, in fetuses with an EFW< 10th centile and appropriate for gestational age (AGA) fetuses, and to compare the results in both groups. Methods The EMBASE, Medline, and Cochrane databases were searched from inception until April 2020. Observational studies on evaluating the cardiac deformation values longitudinal strain, strain rate, and/or global dyssynchrony of both ventricles in FGR, using 2D-STE, were included. Methodological quality was assessed using the Newcastle-Ottowa risk of bias scale. Results Four studies met the inclusion criteria. The mean gestational age (GA) varied from 30 to 38 weeks in the FGR group and 20 to 40 weeks in AGA fetuses. The number of included FGR fetuses (with or without Doppler abnormalities), varied from 30 to 50. Longitudinal strain in FGR fetuses was described as comparable (n = 2), increased (n = 1) and>95th percentile (n = 1) compared to AGA fetuses. Strain rate was measured in two studies. One reported an increased strain rate, another showed comparable strain rate. Two studies addressed global left ventricle (LV) and right ventricle (RV) dyssynchrony. Dyssynchrony was increased in FGR compared to AGA fetuses. Conclusion The currently published data is limited and heterogeneous concerning GA and Doppler profiles. The data presentation and the interpretation thereof make qualitative comparisons impossible. Large prospective longitudinal cohort studies looking at the value of deformation measurements of the fetal heart in FGR and AGA fetuses are needed to assess the clinical significance of deformation values measured with 2D-STE.

The use of a stronger instructional design by implementing repetitive practice in simulation-based obstetric team training: trainees’ satisfaction

Objective

This study compares satisfaction levels from multiprofessional obstetric care teams about simulation-based obstetric team training courses with and without the instructional design feature repetitive practice.

Methods

The present study is part of a multicentre cluster-randomised controlled trial (TOSTI trial) that investigated the effectiveness of a 1 day, multiprofessional, simulation-based obstetric team training. The initial training group received a training which was designed based on best practice. After 1 year, the control group received a training course in which the instructional design was changed by providing repetitive practice. All participants were asked to fill in a 29-item evaluation form with seven questions about baseline characteristics and 22 questions about training features. The questions about training features could be rated on a scale of 1 to 5. Finally, all participants were asked to rate the total training day on a scale of 1–10.

Results

The best practice group consisted of 471 trainees and the repetitive practice group of 549, including gynaecologists, residents, midwives and nurses. The best practice group rated the total training day significantly higher than the repetitive practice group (mean 8.8, SD 0.6 and mean 8.7, SD 0.6; p<0.003, Cohen’s d=0.19). Several training features were also scored higher in the best practice group.

Conclusion

This study showed that obstetric healthcare professionals rated a simulation-based obstetric team training course, with and without repetition of scenarios, both high. The training without the repetitive elements gained higher scores for the total training dayand several, and several training features were scored higher. The difference between the mean scores and the effect sizes for the training features were small. This implies that repetitive practice can be integrated in simulation-based team training to optimise learning effects, with small effects on trainees satisfaction.

Right ventricular dysfunction identified by abnormal strain values precedes evident growth restriction in small for gestational age fetuses

OBJECTIVES

Small for gestational age (SGA) fetuses have an increased risk for adverse outcome. Placental insufficiency leads to changes in the circulation, with secondary adaptation of the fetal heart resulting in changed cardiac deformation. This deformation can be measured with 2D speckle tracking echocardiography (2D-STE). SGA is antenatally often undiagnosed. The measurement of deformation changes in the fetal heart might help in the prediction of SGA and identify fetuses in need of more intensive surveillance.

METHODS

In this longitudinal prospective cohort study, global longitudinal strain (GLS) and strain rate (GLSR), measured before 23 weeks gestational age were compared between SGA and appropriate for gestational age (AGA) fetuses, based on birthweight corrected for gestational age at birth.

RESULTS

The fetal heart rate was significantly increased in SGA; 158 beats per minute (146-163) vs 148 (134-156); P = 0.035 in AGA. Right ventricle GLS (RV-GLS) values were significantly increased in SGA; -15.87% (-11.69% to -20.55%) vs -20.24% (-16.29% to -24.28%); p = 0.024, respectively.

CONCLUSION

RV-GLS values, measured with 2D-STE, were significantly increased in SGA, indicating systolic RV dysfunction before 23 weeks gestational age in fetuses who will become SGA later in pregnancy. A large longitudinal prospective cohort study is needed to confirm these findings.

Study protocol training for life: a stepped wedge cluster randomized trial about emergency obstetric simulation-based training in a low-income country

BACKGROUND

Globally perinatal and maternal mortality rates remain unacceptably high. There is increasing evidence that simulation-based training in obstetric emergencies is associated with improvement in clinical outcomes. However, the results are not entirely consistent. The need for continued research in a wide variety of clinical settings to establish what works, where and why was recommended. The aim of this study is to investigate the effectiveness of an emergency obstetric simulation-based training program with medical technical and teamwork skills on maternal and perinatal mortality in a low-income country.

METHODS

A stepped wedge cluster randomized trial will be conducted at the medium to high-risk labour ward at Mulago Hospital, Kampala, Uganda, with an annual delivery rate of over 23,000. The training will be performed using a train-the-trainers model in which training is cascaded down from master trainers to local facilitators (gynaecologists) to learners (senior house officers). Local facilitators will be trained during a four-day train-the-trainers course with an annual repetition. The senior house officers will be naturally divided in seven clusters and randomized for the moment of training. The training consists of a one-day, monodisciplinary, simulation-based training followed by repetition training sessions. Scenarios are based on the main local causes of maternal and neonatal mortality and focus on both medical technical and crew resource management skills. Kirkpatrick's classification will be used to evaluate the training program. Primary outcome will be the composite of maternal and neonatal mortality ratios. Secondary outcome will comprise course perception, evaluation of the instructional design of the training, knowledge, technical skills, team performance, percentage of ventouse deliveries, percentage of caesarean sections, and a Weighted Adverse Outcome Score.

DISCUSSION

This stepped wedge cluster randomized trial will investigate the effect of a monodisciplinary simulation-based obstetric training in a low-income country, focusing on both medical technical skills and crew resource management skills, on patient outcome at one of the largest labour wards worldwide. We will use a robust study design which will allow us to better understand the training effects, and difficulties in evaluating training programs in low-income countries.

TRIAL REGISTRATION

ISRCTN98617255 , retrospectively registered July 23, 2018.

Simulation-based training of vaginal twin delivery for experienced gynaecologists: Useful or not?

OBJECTIVE

It is important to train clinicians to maintain and optimise maternal and neonatal outcomes after vaginal twin delivery. Simulation-based training provides opportunities for training in a realistic way without harming patients. The aim of this study is to evaluate the effect of simulation-based training concerning twin vaginal delivery on knowledge and comfort of obstetrician-gynaecologists.

STUDY DESIGN

Obstetrician-gynaecologists participated in a twin vaginal delivery simulation between March 2018 and May 2019. Simulation-based training consisted of standardized patient interviews, didactic sessions and three different simulation-based scenarios: internal podalic version and breech extraction, assisted vaginal delivery and vaginal breech delivery with problems of aftercoming head. Pre- and posttraining, participants were asked to fill out questionnaires exploring knowledge concerning vertex-vertex twin deliveries and vertex-nonvertex twin deliveries, level of comfort performing various obstetric manoeuvres and counselling on mode of delivery for women pregnant with twins. Our primary outcome of interest was a change in knowledge or comfort surrounding vaginal twin delivery after completion of the simulation-based training.

RESULTS

The estimated median number of vaginal twin deliveries performed by the participating thirty-four obstetrician-gynaecologists was 50 (IQR 20-100). Significant improvements were seen in knowledge regarding twin deliveries with vertex-nonvertex presentation (p < 0.01). In two of three questions regarding twin delivery with vertex-vertex presentation significant improvements were seen as well (p < 0.01). Before training, 40.6% of participants felt comfortable to perform internal podalic version compared to 91.2% afterwards (p < 0.01). Comfort with breech extraction increased from 69.7% to 97.1% pre- and posttraining, respectively (p < 0.01). Before training only 55.9% would strongly counsel patients towards vaginal twin delivery as opposed to 73.5% after training (p = 0.07).

CONCLUSIONS

Simulation-based training results in beneficial effects on knowledge and comfort concerning vaginal twin deliveries for obstetrician-gynaecologists. This training suggested a potential impact on provider practice with a more favourable attitude towards twin vaginal birth.

Fetal strain and strain rate during pregnancy measured with speckle tracking echocardiography: A systematic review

Establishment of the maturational patterns of the fetal left and right ventricle strain and strain rate by two-dimensional speckle tracking echocardiography is a prerequisite for its routine clinical adaptation in pregnancy. The aim of this study is to review systematically current literature on the development of left and right ventricle strain and strain rate derived by speckle tracking during gestation. EMBASE, Medline and Central were searched, from inception to October 2019, for observational studies of singletons in uncomplicated, non-anomalous pregnancies, measuring global longitudinal strain and strain rate with 2D speckle tracking echocardiography in the fetal heart during gestation. 23 Studies met the inclusion criteria. The gestational age of the included fetuses varied from 12 to 42 weeks. Four studies used a longitudinal study design, with few consecutive measurements at varying gestational ages. 19 Studies performed either cross sectional or both longitudinal and cross sectional measurements. The ultrasound devices and speckle tracking algorithm software used, varied. Strain and strain rate during gestation increased, decreased or remained stable in the left and right fetal ventricle with increasing gestation. Due to considerable variation in the included gestational ages measured and inconsistency in the direction of strain and strain rate development, a meta-analysis could not be performed. Contradictory results concerning the development of strain and strain rate during gestation were shown, probably due to suboptimal study designs and varying algorithms and ultrasound devices used. A large longitudinal cohort study is needed to obtain reference values for fetal cardiac deformation in the uncomplicated, singleton pregnancy.

The standardized 12-lead fetal electrocardiogram of the healthy fetus in mid-pregnancy: A cross-sectional study

Introduction

The examination of the fetal heart in mid-pregnancy is by ultrasound examination. The quality of the examination is highly dependent on the skill of the sonographer, fetal position and maternal body mass index. An additional tool that is less dependent on human experience and interpretation is desirable. The fetal electrocardiogram (ECG) could fulfill this purpose. We aimed to show the feasibility of recording a standardized fetal ECG in mid-pregnancy and explored its possibility to detect congenital heart disease (CHD).

Materials and methods

Women older than 18 years of age with an uneventful pregnancy, carrying a healthy singleton fetus with a gestational age between 18 and 24 weeks were included. A fetal ECG was performed via electrodes on the maternal abdomen. After removal of interferences, a vectorcardiogram was constructed. Based on the ultrasound assessment of the fetal orientation, the vectorcardiogram was rotated to standardize for fetal orientation and converted into a 12-lead ECG. Median ECG waveforms for each lead were calculated.

Results

328 fetal ECGs were recorded. 281 were available for analysis. The calculated median ECG waveform showed the electrical heart axis oriented to the right and inferiorly i.e. a negative QRS deflection in lead I and a positive deflection in lead aVF. The two CHD cases show ECG abnormalities when compared to the mean ECG of the healthy cohort.

Discussion

We have presented a method for estimating a standardized 12-lead fetal ECG. In mid-pregnancy, the median electrical heart axis is right inferiorly oriented in healthy fetuses. Future research should focus on fetuses with congenital heart disease.

Feasibility of non-invasive Foetal electrocardiography in a twin pregnancy

Background

Twin pregnancy is associated with increased perinatal mortality. Close foetal monitoring is therefore warranted. Doppler Ultrasound cardiotocography is currently the only available method to monitor both individual foetuses. Unfortunately, the performance measures of this method are poor and erroneous monitoring of the same twin with both transducers may occur, leaving the second twin unmonitored. In this study we aimed to determine the feasibility of monitoring both foetuses simultaneously in twin gestation by means of non-invasive foetal electrocardiography (NI-fECG), using an electrode patch on the maternal abdomen.

Methods

A NI-fECG recording was performed at 25 + 3 weeks of gestation on a multiparous woman pregnant with dichorionic diamniotic twins. An electrode patch consisting of eight adhesive electrodes was applied on the maternal abdomen, yielding six channels of bipolar electrophysiological measurements. The output was digitized and stored for offline processing. The recorded signals were preprocessed by suppression of high-frequency noise, baseline wander, and powerline interference. Secondly, the maternal ECG was subtracted and segmentation into individual ECG complexes was performed. Finally, ensemble averaging of these individual ECG complexes was performed to suppress interferences.

Results

Six different recordings were obtained from each of the six recording channels. Depending on the orientation and distance of the fetal heart with respect to each electrode, a distinction could be made between each fetus based on the morphology of the signals. Yielding of the fetal ECGs was performed manually based on the QRS complexes of each fetus.

Conclusion

NI-fECG with multiple electrodes allows for monitoring of the fetal heart rate and ECG of both individual fetuses in twin pregnancies.

Critical analysis of electrohysterographic methods for continuous monitoring of intrauterine pressure

Monitoring the progression of uterine activity provides important prognostic information during pregnancy and delivery. Currently, uterine activity monitoring relies on direct or indirect mechanical measurements of intrauterine pressure (IUP), which are unsuitable for continuous long-term observation. The electrohysterogram (EHG) provides a non-invasive alternative to the existing methods and is suitable for long-term ambulatory use. Several published state-of-the-art methods for EHG-based IUP estimation are here discussed, analyzed, optimized, and compared. By means of parameter space exploration, key parameters of the methods are evaluated for their relevance and optimal values. We have optimized all methods towards higher IUP estimation accuracy and lower computational complexity. Their accuracy was compared with the gold standard accuracy of internally measured IUP. Their computational complexity was compared based on the required number of multiplications per second (MPS). Significant reductions in computational complexity have been obtained for all published algorithms, while improving IUP estimation accuracy. A correlation coefficient of 0.72 can be obtained using fewer than 120 MPS. We conclude that long-term ambulatory monitoring of uterine activity is possible using EHG-based methods. Furthermore, the choice of a base method for IUP estimation is less important than the correct selection of electrode positions, filter parameters, and postprocessing methods. The presented review of state-of-the-art methods and applied optimizations show that long-term ambulatory IUP monitoring is feasible using EHG measurements.

The effect of intrauterine resuscitation by maternal hyperoxygenation on perinatal and maternal outcome: a randomized controlled trial

BACKGROUND

Maternal hyperoxygenation is widely used during labor as an intrauterine resuscitation technique. However, robust evidence regarding its beneficial effect and potential side effects is scarce, and previous studies show conflicting results.

OBJECTIVE

To assess the effect of maternal hyperoxygenation upon suspected fetal distress during the second stage of term labor on fetal heart rate, neonatal outcome, maternal side effects, and mode of delivery.

MATERIALS AND METHODS

In a single-center randomized controlled trial in a tertiary hospital in The Netherlands, participants were randomized in case of an intermediary or abnormal fetal heart rate pattern during the second stage of term labor, to receive either conventional care or 100% oxygen at 10 L/min until delivery. The primary outcome was the change in fetal heart rate pattern. Prespecified secondary outcomes were Apgar score, umbilical cord blood gas analysis, neonatal intensive care unit admission, perinatal death, free oxygen radical activity, maternal side effects, and mode of delivery. We performed subgroup analyses for intermediary and abnormal fetal heart rate, and for small for gestational age fetuses.

RESULTS

From March 2016 through April 2018, a total of 117 women were included. Fetal heart rate patterns could be analyzed in 71 women. Changes in fetal heart rate (defined as improvement, equal, or deterioration) in favor of maternal hyperoxygenation were significant (odds ratio, 5.7; 95% confidence interval, 1.7-19.1) using ordinal logistic regression. Apgar score, umbilical cord blood gas analysis, free oxygen radicals, and mode of delivery showed no significant differences between the intervention and control group. Among women with an abnormal fetal heart rate, there were fewer episiotomies on fetal indication in the intervention group (25%) than in the control group (65%, P < .01).

CONCLUSION

Maternal hyperoxygenation has a positive effect on the fetal heart rate in the presence of suspected fetal distress during the second stage of labor. There was no significant difference in the mode of delivery or neonatal outcome; however, significantly fewer episiotomies on fetal indication were performed following maternal hyperoxygenation in the subgroup with abnormal fetal heart rate pattern.

Heart rate variability in hypertensive pregnancy disorders: A systematic review

BACKGROUND

Hypertensive pregnancy disorders (HPD) are associated with dysfunction of the autonomic nervous system. Cardiac autonomic functions can be assessed by heart rate variability (HRV) measurements.

OBJECTIVE

To study whether HRV detects differences in the function of the autonomic nervous system between pregnant women with HPD compared to normotensive pregnant women and between women with a history of a pregnancy complicated by HPD compared to women with a history of an uncomplicated pregnancy.

METHODS

A systematic search was performed in Medline, EMBASE, and CENTRAL to identify studies comparing HRV between pregnant women with HPD or women with a history of HPD to women with (a history of) normotensive pregnancies.

RESULTS

The search identified 523 articles of which 24 were included in this review, including 850 women with (a history of) HPD and 1205 normotensive controls. The included studies showed a large heterogenicity. A decrease in overall HRV was found in preeclampsia (PE), compared to normotensive pregnant controls. A trend is seen towards increased low frequency/high frequency-ratio in women with PE compared to normotensive pregnant controls.

CONCLUSION

Our systematic review supports the hypothesis a sympathetic overdrive is found in HPD which is associated with a parasympathetic withdrawal. However, the included studies in our review showed a large diversity in the methods applied and their results.

The diagnostic value of fetal fibronectin testing in clinical practice

AIM

To evaluate the clinical management to withhold treatment for preterm labor in symptomatic women with an intermediate cervical length and negative fetal fibronectin (fFN) testing.

METHODS

A retrospective cohort study was performed in a tertiary care teaching hospital in the Netherlands. Pregnant women with a gestational age between 23⁺⁵ to 34⁺⁰ weeks, with the presence of regular uterine contractions accompanied by a cervical length between 15 and 30 mm and intact membranes, who underwent fFN testing were included to obtain the diagnostic value of fFN testing for preterm delivery within 7 days.

RESULTS

Fetal fibronectin testing has an extremely high negative predictive value (100%) and sensitivity (100%) for delivery within 7 days, in singleton and multiple pregnancies. However, specificity (64%) and positive predictive value (10%) of fFN testing in singleton pregnancies are low. Blood present on the fFN sample does not affect the reliability of the fFN test; the negative predictive value remains 100%.

CONCLUSION

Women with symptoms of early preterm labor, intact membranes, a cervical length between 15 and 30 mm and negative fFN testing do not deliver within 7 days. Administration of corticosteroids and tocolytics can safely be withhold. Furthermore, blood on the fFN sample does not change the reliability of the fFN test.

Head orientation and electrode placement potentially influence fetal scalp ECG waveform

BACKGROUND

Fetal monitoring based on electrocardiographic (ECG) morphology is obtained from a single unipolar fetal scalp electrode. Ideally, it should be obtained from multiple leads, as ECG waveform depends on alignment between electrode and electrical heart axis. This alignment is unknown in fetuses. Besides, fetuses are surrounded by conductive media, which may influence ECG waveform. We explored the influence of electrode position and head orientation on ECG waveforms of unipolar and bipolar scalp ECGs recorded in air and in conductive medium.

METHODS

We recorded ECGs in one adult subject at five different scalp positions in five different head orientations both in dry and immersed conditions. The ratio between T-amplitude and QRS-amplitude (T/QRS ratio) of unipolar and bipolar scalp ECGs was determined and compared between all conditions.

RESULTS

In the dry condition, we observed in the unipolar leads little to no difference between different electrode positions (maximal T/QRS difference 0.00-0.01) and minor differences between head orientations (0.02-0.03), whereas bipolar leads showed no recognizable ECG signal at all. During the immersed condition, we found variation in the unipolar leads, both between electrode positions (maximal T/QRS difference 0.02-0.05) and between head orientations (0.03-0.06). Bipolar leads showed different ECG signals in contrasting head orientations.

CONCLUSIONS

Both unipolar and bipolar scalp lead-derived ECG waveforms are influenced by electrode position and head orientation when the subject is submerged in a conductive medium. Fetal monitoring based on single scalp lead ECG waveform might be suboptimal, as it lacks correction for fetal head orientation and electrode position.

[Breech delivery 'on all fours']

Since the publication of the results of the Term Breech Trial (TBT) in 2000 the number of planned Caesarean sections for breech presentation has increased dramatically, at the expense of vaginal breech deliveries. The favourable effect of a planned Caesarean section for breech presentation on perinatal outcomes described in the TBT could not, however, be reproduced in later trials. A planned Caesarean section does carry an increased risk of maternal complications; furthermore, a previous Caesarean section leads to higher risks for both mother and child in any subsequent pregnancy. A recent prospective study advocates vaginal breech delivery 'on all fours', a position in which the mother leans on her hands and knees during delivery. A vaginal breech delivery in this position seems to be just as safe for the child as a planned Caesarean section, while a vaginal delivery is safer for the mother than a Caesarean section. This article describes two uncomplicated vaginal breech deliveries in the all fours position.

Comparison of the psychological and physiological effects on students of a video-assisted or text introduction to a simulated task

Introduction

The use of different methods for introducing the scenario in simulation-based medical education has not been investigated before and may be a useful element to optimise the effectiveness of learning. The aim of this study was to compare an immersive video-assisted introduction to a minimal text-based one, with regard to emotional assessment of the situation.

Methods

In this pilot study, 39 students participated in a medical simulated scenario. The students were randomly assigned to an experimental group (video-assisted introduction) or a control group (minimal textual introduction) and both were followed by performing surgery on LapSim (Surgical Science, Gothenburg, Sweden). The emotional assessment of the situation, cognitive appraisal, was defined as the ratio of the demands placed by an individual’s environment (primary appraisal) to that person’s resources to meet the demands (secondary appraisal). Secondary outcomes were anxiety (State-Trait Anxiety Inventory), physiological parameters (heart rate, heart rate variability, skin conductance, salivary cortisol), engagement (Game Engagement Questionnaire), motivation (Intrinsic Motivation Inventory) and performance (mean score in percentage calculated by LapSim of predefined levels).

Results

Participants in the immersive video group (n=17) were overloaded in terms of their perceived demands (a ratio of 1.17, IQR 0.30) compared with those in the control group (a ratio of 1.00, IQR 0.42, n=22) (P=0.01). No significant differences were found between the groups in secondary outcomes. Both groups showed an increase of anxiety after the introduction method. In the experimental group, this score increased from 9.0 to 11.0, and in the textual group from 7.5 to 10.5, both P<0.01.

Discussion

This study shows that the method of introducing a simulated scenario may influence the emotional assessment of the situation. It may be possible to make your simulation introduction too immersive or stimulating, which may interfere with learning. Further research will be necessary to investigate the impact and usefulness of these findings on learning in simulation-based medical education.

Relative versus absolute rises in T/QRS ratio by ST analysis of fetal electrocardiograms in labour: A case-control pilot study

Introduction

The additional value of ST analysis during labour is uncertain. In ST analysis, a T/QRS baseline value is calculated from the fetal electrocardiogram and successive T/QRS ratios are compared to this baseline. However, variation in the orientation of the electrical heart axis between fetuses may yield different T/QRS baseline values. In case of a higher T/QRS baseline value more ST events are encountered, although not always related to perinatal outcome. We hypothesised that we can partly correct for this effect by analysing T/QRS rises as a percentage from baseline (relative ST analysis). This study aimed to explore whether relative ST analysis has better diagnostic value for cord acidaemia compared to conventional ST analysis, where predefined fixed T/QRS ratios are used.

Methods and materials

A case-control study was performed in 20 term human fetuses during labour; 10 cases (umbilical cord artery pH <7.05 at birth, defining acidaemia) and 10 controls (pH >7.20) were included. The fetal electrocardiogram was recorded using a STAN monitor. We electronically extracted all T/QRS values, baseline and episodic ST events from the STAN monitor and calculated the relative T/QRS changes. The cut-off for relative ST events was determined in a receiver operator characteristic (ROC) curve at optimal specificity for cord acidaemia. Parameters of interest were area under the curve (AUC) of the ROC curve for relative ST events and test performance of both conventional and relative ST analysis.

Results

Relative ST analysis showed an AUC of 0.99. The optimal cut-off value for relative T/QRS rise was determined at 0.70. Relative vs conventional (absolute) ST analysis showed a specificity of 100% vs 40% (p = 0.031); sensitivity 90% vs 90%; positive likelihood ratio infinity vs 1.5; negative likelihood ratio 0.10 vs 0.25, respectively.

Conclusion

Relative ST analysis seems to be a promising method to detect impending fetal acidaemia during labour. Further studies are required to determine the diagnostic accuracy.

The fetal electrocardiogram to detect the effects of betamethasone on fetal heart rate variability

BACKGROUND

Betamethasone is widely used to enhance fetal lung maturation in case of threatened preterm birth. Antenatal corticosteroids are known to reduce fetal heart rate variability (fHRV) in the days following administration. Since decreased fHRV is a marker for fetal distress, this transient decrease of fHRV can cause unnecessary medical intervention.

AIM

To describe the effect of betamethasone on fHRV, by applying spectral analysis on non-invasive fetal electrocardiogram (fECG) recordings.

STUDY DESIGN

Secondary analysis of a prospective cohort study.

SUBJECTS

Women with a singleton pregnancy, at risk for preterm delivery and receiving betamethasone, admitted to the obstetric high care unit in the period from March 2013 until July 2016.

OUTCOME MEASURES

The primary outcome measure was fHRV in both time- and frequency-domain. Secondary outcome measures included basal fetal heart rate (fHR) and fHR variance. FHRV parameters were then calculated separately for the quiet and active state.

RESULTS

Following 68 inclusions, 22 patients remained with complete series of measurements and sufficient data quality. FHRV parameters and fHR showed a decrease on day 2 compared to day 1, significant for short-term variability and high-frequency power. Similar results were found when analyzing for separate behavioral states. The number of segments in quiet state increased during days 1 and 2. Normalized values showed no difference for all behavioral states.

CONCLUSION

FHRV decreases on day 2 after betamethasone administration, while periods of fetal quiescence increase. No changes were found in the normalized values, indicating that the influence of autonomic modulation is minor. Clinical trial registration number NL43294.015.13.

Clinical Use of Electrohysterography During Term Labor: A Systematic Review on Diagnostic Value, Advantages, and Limitations

Importance

Real-time electrohysterography (EHG)-based technologies have recently become available for uterine monitoring during term labor. Therefore, obstetricians need to be familiar with the diagnostic value, advantages, and limitations of using EHG.

Objective

The aims of this study were to determine the diagnostic value of EHG in comparison to (1) the intrauterine pressure catheter (IUPC), (2) the external tocodynamometer (TOCO), and (3) in case of maternal obesity; (4) to evaluate EHG from users' and patients' perspectives; and (5) to assess whether EHG can predict labor outcome.

Evidence Acquisition

A systematic review was performed in the MEDLINE, EMBASE, and Cochrane library in October 2017 resulting in 209 eligible records, of which 20 were included.

Results

A high sensitivity for contraction detection was achieved by EHG (range, 86.0%-98.0%), which was significantly better than TOCO (range, 46.0%-73.6%). Electrohysterography also enhanced external monitoring in case of maternal obesity. The contraction frequency detected by EHG was on average 0.3 to 0.9 per 10 minutes higher compared with IUPC, which resulted in a positive predictive value of 78.7% to 92.0%. When comparing EHG tocograms with IUPC traces, an underestimation of the amplitude existed despite that patient-specific EHG amplitudes have been mitigated by amplitude normalization. Obstetricians evaluated EHG tocograms as better interpretable and more adequate than TOCO. Finally, potential EHG parameters that could predict a vaginal delivery were a predominant fundal direction and a lower peak frequency.

Conclusions and Relevance

Electrohysterography enhances external uterine monitoring of both nonobese and obese women. Obstetricians consider EHG as better interpretable; however, they need to be aware of the higher contraction frequency detected by EHG and of the amplitude mismatch with intrauterine pressure measurements.