Ultrasound Probe Pressure on the Maternal Abdominal Wall and the Effect on Fetal Middle Cerebral Artery Doppler Indices

Background and objectives: Doppler ultrasound of umbilical and fetal vessels is useful for monitoring fetal well-being, fetal anemia, intrauterine growth retardation, and other perinatal outcomes. The adverse perinatal outcome and circulatory changes can be reflected in fetal Doppler studies. The aim of this study was to evaluate the effect of increased pressure exerted on the maternal abdominal wall during routine ultrasound on the middle cerebral artery (MCA), resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). Materials and Methods: A prospective study was conducted, in which we included 40 pregnant women between 24 + 0 and 41 + 3 gestational weeks (GW), with singleton pregnancies, without any associated pathologies, undergoing routine US examination. We recorded the flow velocity waveforms in the MCA, and we measured the RI, PI, PSV, and the applied pressure on to the maternal abdominal wall-needed for a proper evaluation of MCA. We then repeated the same measurements at two different higher pressure levels, at the same time having a proper image of the targeted vessel. Results: We found significant differences for the PI and RI levels with an increase in abdominal pressure (median PI 1.46, 1.58, and 1.92, respectively; median RI 0.74, 0.78, and 0.85, respectively; p < 0.05), for both PI and RI. At the same time, we found no significant differences for PSV in the studied group in relationship with increase in abdominal pressure (median PSV 39.56, 40.10, and 39.70, respectively; p > 0.05). Conclusions: The applied abdominal pressure by the examiner's hand, during routine US scan in pregnancy, can modify the MCA parameters of blood flow resistance (PI and RI) when measured by Doppler US, thus influencing the diagnostic accuracy in a series of pregnancy associated pathologies, such as chronic fetal distress (CFD) or intrauterine growth restriction (IUGR).

Beware: the misuse of technology and the law of unintended consequences

Electronic monitoring of the fetal heart rate during labor (EFM), originally designed to assess fetal stress and allow the early detection of the compromised fetus, has instead led to increasing maternal morbidity without decreasing fetal morbidity. The unintended consequences of this technologic advance have led to the creation of a pseudodisease and unwarranted intervention in response to its detection. Is it ethical to introduce a new technology without adequate assessment of its possible consequences? Are we about to repeat this (error resulting from the introduction of EFM?) There is increasing interest in monitoring the function of the newborn brain, to enable the early detection of subclinical seizures. The monitor may also be used for assessing brain function in older children and adults who are comatose or paralyzed and cannot appropriately respond to stimuli. Use of this amplitude-integrated electroencephalography (aEEG) in the newborn for detection of seizures and other brain abnormalities is not dissimilar to the use of electronic fetal heart rate monitoring. Whether seizures or subclinical seizures themselves cause harm to the developing nervous system is unclear. The effectiveness of medications for treatment of seizures in the newborn has not been established. Therefore, the consequences of introducing automated EEG for the detection of subclinical neonatal seizures are likely to be similar to the results of the introduction of EFM: creation of another pseudodisease, followed by unwarranted intervention, and increased legal liability. What are the ethics of continued approval and introduction of unevaluated technology? What is the wisdom of its use? Beware of the unintended consequences.

The effects of different maternal positions on non-stress test: an experimental study

AIMS AND OBJECTIVES

To determine the effects of different maternal positions on non-stress test results and the preferences of mothers for involving positions.

BACKGROUND

The non-stress test (NST) has become a common tool in diagnosing fetal risks. The major problem encountered in the application of the non-stress test has been obtaining erroneous non-reactive non-stress test results when, indeed, the fetus is healthy and oxygenation is sufficient.

STUDY DESIGN

Experiment design with randomly assigned four positions: supine, left lateral, semi-fowler and sitting up. The sample included 408 women in a university hospital in Turkey. Women were randomly assigned to four groups in equal numbers of 102. Data collection and analysis. Data were collected through two instruments: Demographic and Pregnancy History Form and NST tracing. Main outcome measures were percentage of reactive NST and number of minutes for reactivity in each position.

RESULTS

There were significant (P < 0.05) differences among four groups. Supine position showed the least fetal reactivity. In terms of time to reactivity, there were no statistically significant differences. Qualitative data showed that pregnant women were least comfortable in supine position reporting back pain and shortening of breath.

CONCLUSION

Supine position yields the lowest non-reactivity in tandem with physical discomfort such as back pain and difficulty in breathing.

RELEVANCE TO CLINICAL PRACTICE

Sitting up, semi-fowler and left lateral positions are recommended to be used during the non-stress test. In addition, the preferences of the pregnant women should be determined before the test to minimize discomfort which, when it occurs, may signal physiological alterations experienced during the test.

Are Routine Interventions Necessary in Normal Birth?

Routine interventions during labor and birth, such as perineal shaving and enemas before vaginal delivery, continuous intrapartum electronic fetal monitoring (EFM), and episiotomy are prevalent in Taiwan, but they may not always be necessary. Numerous studies investigating these interventions have failed to find absolute benefits for women with uncomplicated and low-risk pregnancies. No evidence-based benefits support routine perineal shaving or enemas during labor for reducing the risk of perineal wound infection or neonatal infection. The use of EFM is associated with an increased rate of operative interventions (vacuum, forceps, cesarean delivery) but does not result in a significant decrease in the incidence of perinatal death or cerebral palsy. Routine episiotomy does not have demonstrable advantages over restrictive episiotomy in the frequency or severity of perineal damage or pelvic relaxation.

Necrotizing Fasciitis of the Scalp in a Newborn

BACKGROUND

Fetal scalp electrode monitoring is usually without complications, but on rare occasions it can serve as a portal of entry for organisms colonizing the maternal genital tract.

CASE

We present a case of neonatal necrotizing fasciitis of the scalp that was associated with intrapartum fetal scalp electrode monitoring. Skin cultures grew Group A Streptococcus M11 T nontypeable serotype, an unusual cause of neonatal necrotizing fasciitis. The neonate's mother had a concurrent perineal infection and the same Group A streptococcal serotype was cultured from maternal blood and vaginal swabs.

CONCLUSION

This case highlights the emergence of life-threatening Group A Streptococcus causing invasive disease in both infants and mothers and the need for careful monitoring of neonates who have had intrapartum electrode monitoring.

Cerebrospinal fluid leak in a premature neonate

Cerebrospinal fluid (CSF) cranial leaks in neonates are rare, and only four case reports have been published previously. Two of the previous cases were also in preterm newborns delivered at 30 weeks gestation. We present a case of CSF leak in a premature neonate delivered at 30 weeks gestation. Our approach to treatment was different from that previously described. After the initial treatment with local packing bandage failed to stop CSF leakage, local exploration with wound suturing was done, with resultant ceasing of leakage within 12 hours of birth. This case presents a rare complication of CSF leakage caused by internal scalp monitoring. This complication seems to be more frequent in premature babies, thus special consideration should be taken in premature infants before applying such monitoring.

Monitoring the fetus in labor: evidence to support the methods

Electronic fetal monitoring (EFM) was implemented across the United States in the 1970s. By 1998, it was used in 84% of all U.S. births, regardless of whether the primary caregiver was a physician or a midwife. Numerous randomized trials have agreed that continuous EFM in labor increases the operative delivery rate, without clear benefit to the baby. Intermittent auscultation (IA) is safe and effective in low-risk pregnancies and may play a role in helping birth remain normal. Clinicians and educators are encouraged to reconsider the use of IA in the care of healthy childbearing women.

Historical controversy in health technology assessment: the case of electronic fetal monitoring

Electronic fetal monitoring (EFM) was introduced in the late 1950s as an alternative to traditional auscultation by stethoscope or fetoscope in the management of labor and delivery. The new technology was seen as a valuable tool in the prevention of cerebral palsy and other adverse fetal outcomes and diffused rapidly into clinical practice. In the late 1970s, some scepticism began to be voiced about the evidence for the effectiveness of EFM. The authors published a systematic review of the evidence in 1979 that concluded that there was insufficient evidence for the effectiveness of the routine use of EFM and a clear rise in the cesarean delivery rate associated with its use. The analysis was based on a thorough review of approximately 600 books and articles, but focused heavily on the evidence of four randomized clinical trials (RCTs) that had been published. An economic analysis further underscored the importance of this issue. The report was met with harsh ad hominem criticism from clinicians both in public venues and in the medical literature. Subsequently, additional RCTs were conducted and other analyzes were published, and in 1987 the American College of Obstetricians and Gynecologists recommended that auscultation was an acceptable alternative to EFM in routine labor and delivery. Yet, today EFM continues to be the standard of practice, used in 80% of labors in this country. The most important conclusion drawn from this experience is the need to evaluate new technologies before their widespread diffusion into clinical practice.

[Problems in fetal monitoring characteristic of risks for malpractice suits]

Medical malpractice suits in obstetrics comprise about 10% of all claims against medical institutions in Israel. A significant proportion are due to failures relating to fetal monitoring. We studied the characteristics of 102 of 4125 obstetrical cases reported to the Medical Risk Management Co. as being at risk for a malpractice suit. The cases were divided into those with medical management failures (misinterpretation of fetal monitor tracing, failure to respond promptly to fetal monitoring indicating distress, etc.) and technical failures (loss of monitor tracings, interruption in the tracing at a critical time, unreadable tracings, etc.). The monetary quantum in fetal monitoring failures exceeded $30,000,000. The majority of these failures could have been avoided by using central electronic fetal monitoring systems with alerting and archival capabilities.

Fetal pulse oximetry: an adjunct to electronic fetal heart rate monitoring

Electronic fetal heart rate monitoring is routinely used as an indirect measure of fetal oxygenation, yet its value continues to be questioned. With a nonreassuring fetal heart rate pattern, the clinician often needs additional information about fetal oxygen status. Fetal pulse oximetry is a new fetal assessment technology. After consideration of the results of a multicenter randomized, controlled, clinical trial on fetal pulse oximetry in the United States, the U.S. Food and Drug Administration approved the technology for clinical use on May 12, 2000. The results of this trial are anticipated to be published in late 2000.

Social and professional influences of the technology of electronic fetal monitoring on obstetrical nursing

Electronic fetal monitoring (EFM) is one example of a biomedical technology that rapidly diffused from an experimental innovation into a standard medical practice. First developed in the 1950s, EFM became commercially available in the early 1970s and quickly transformed intrapartum obstetrical practice. Assessments and interventions, which practitioners had previously based primarily on laboring women's subjective reports of bodily sensations, were now being based on quantifiable objective data from uterine activity and fetal heart rate transducers. Despite concerns of over-medicalization of the natural event of birth, iatrogenesis related to the increased incidence of operative deliveries, and escalating costs, EFM became widely accepted as routine and necessary by both practitioners and patients. By presenting the confident expectations and cautious reservations of various practitioners and patients to EFM, this article explores the rapid diffusion of EFM within the social context of the 1970s. A special focus is given to the perspective of intrapartum obstetrical nurses, because they have been the primary users of this perinatal technology since its introduction.

Intrapartum fetal invasive procedures and perinatal transmission of HIV

OBJECTIVE

To study the effect of intrapartum use of fetal invasive procedures (scalp electrodes or scalp pH sampling) on perinatal transmission rate of HIV.

STUDY DESIGN

We compared the perinatal transmission of 57 HIV pregnancies in which invasive procedures (IP) were performed with a control group of 214 pregnancies without IP. We controlled for potentially risk factors (maternal CD4 level, gestational age, antiretroviral therapy use, duration of rupture of membranes (ROM), length of labor and mode of delivery) by stratification and logistic regression.

RESULTS

Transmission rate in the group with IP was 26.3% (15/57) versus 13.6% (29/214) in the control group, relative risk (RR) 1.9, 95% CI (1.1-3.4). By logistic regression we observed three significant factors involved in transmission of HIV: low maternal CD4 level (odds ratio (OR)=3.3, 95% CI=1.2-9.4), duration of ROM (OR=2.9, 95% CI=1.1-7.9) and IP use (OR=3.5, CI 95%=1.2-9.6). Interaction between duration of ROM and IP are also significant (OR=5.1, CI 95%=1.5-17.5).

CONCLUSIONS

Intrapartum use of fetal scalp electrodes or fetal scalp pH sampling increases the perinatal transmission of HIV and should therefore be avoided in HIV patients.

Penetrating ocular injury with a fetal scalp monitoring spiral electrode

PURPOSE

To report a penetrating ocular injury resulting from inadvertent placement of a fetal scalp monitoring spiral electrode into the right eye of a preterm male with a face presentation.

METHODS

Case report and review of the literature.

RESULTS

A spiral electrode was screwed clockwise into the right eye, tearing the inferior retina and creating two inferior iridotomies. Severe myopic astigmatism resulted from gradual lens dislocation combined with elongation of the eye. Despite persistent occlusive therapy and aggressive optical correction, before and after lensectomy at age 3 years, visual acuity was only 20/200 at age 8 years.

CONCLUSIONS

Although complications from spiral monitoring electrodes are uncommon, this case emphasizes that before inserting a spiral monitoring electrode during labor, face presentation must be excluded to prevent inadvertent ocular injury.

Continuous electronic fetal monitoring: contradictions between practice and research

The reliability, validity, and efficacy of electronic fetal monitoring (EFM) remain matters of controversy. In fact, several professional organizations, including the American College of Obstetricians and Gynecologists, have endorsed the use of intermittent auscultation for low-risk pregnant women. Nevertheless, in 1996, 83% of laboring women in the United States are monitored electronically. Nurses should encourage healthy, low-risk pregnant women to weigh carefully decisions about the use of EFM.

Cesarean delivery. Microbial colonization in amniotic fluid

OBJECTIVE

To determine the frequency, clinical significance and causative factors behind intraamniotic microbial colonization in uninfected parturients at the time of cesarean delivery.

STUDY DESIGN

Amniotic fluid specimens for bacterial and mycoplasmal cultures were obtained by direct aspiration at cesarean section from 251 pregnant women (24-43 completed weeks) who had no clinical infection at the time of the operation. The symptoms of maternal infection were followed postoperatively for the first week of the puerperium.

RESULTS

The prevalence of amniotic fluid microbial invasion was 29% (72/251). In patients not in labor and with intact membranes, it was 13% (20/158); in patients in labor and with intact membranes, 23% (5/22); and in those with ruptured membranes, 66% (47/71). The most common species isolated were Ureaplasma urealyticum, Lactobacillus species and coagulase-negative staphylococci. In the total 251 patients, clinically evident postoperative endometritis was observed in 6 (2%) and wound infection in 10 (4%). In patients operated on and with intact membranes, no risk factors were found as regards amniotic fluid microbial colonization. In patients operated on after rupture of the membranes, the only significant risk factor as regards amniotic fluid microbial invasion was use of an internal monitor before the operation (P < .0003) (relative risk 10.7, 95% confidence limit 2.9-39.4). The relative risk of postoperative endometritis was 2.3 (95% confidence limit 1.3-4.3) in patients with microbial invasion of the amniotic cavity as compared to patients without invasion. The corresponding risk value for post-operative wound infection was 1.4 (95% confidence limit 0.6-3.1).

CONCLUSION

Though the incidence of microbial invasion of the amniotic fluid before surgery was unexpectedly high, its clinical significance as regards maternal puerperal morbidity appeared to be low. The use of internal monitoring during labor was the only significant risk factor as regards amniotic fluid microbial colonization in patients operated on after membrane rupture.

Mortality from early neonatal group B streptococcal sepsis: influence of obstetric factors

Our objective was to determine if the neonatal mortality from early group B streptococcal (GBS) septicemia was associated with obstetric factors other than birthweight. Medical records from our institution for all neonates with positive blood cultures for GBS in the first 7 days of life between January 1981 and December 1992 were reviewed (n = 61). All the neonates had received broad-spectrum intravenous antibiotics within 3 h of birth, and all had cerebrospinal fluid (CSF) cultures obtained. In a multivariate model we found a significant association between neonatal mortality and birthweight (P = .01). The other significant associations were with positive CSF cultures (P = .01) and intrapartum invasive fetal scalp electrode monitoring (P = .03). After controlling for these and other variables in the model, the odds of death for the infants with scalp electrode monitoring was 8 times greater (95% CI = 1.1,56), compared to those who had the GBS septicemia but no intrapartum fetal scalp electrode monitoring. In conclusion, the association we found between neonatal fatality from early GBS septicemia and invasive fetal scalp electrode monitoring is plausible and needs further study.

Efficacy and safety of intrapartum electronic fetal monitoring: an update

OBJECTIVE

To compare the efficacy and safety of routine electronic fetal monitoring (EFM) of labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs).

DATA SOURCES

We identified RCTs by searching the MED-LINE data base for the period 1966-1994, contacting experts, and reviewing published references.

METHODS OF STUDY SELECTION

Our search identified 12 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. The studies included 58,855 pregnant women and their 59,324 infants in both high- and low-risk pregnancies from ten clinical centers in the United States, Europe, Australia, and Africa.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted, and their accuracy was confirmed independently. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of nine outcomes. Overall, a statistically significant decrease was associated with routine EFM for a 1-minute Apgar score less than 4 (relative risk [RR] 0.82, 95% confidence interval [CI] 0.65-0.98) and neonatal seizures (RR 0.5, 95% CI 0.30-0.82). The protective effect of EFM for a 1-minute Apgar score less than 4 was apparent only in the non-United States studies, and the protective effect for neonatal seizures was evident only in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores less than 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.33, 95% CI 1.08-1.59) and total operative delivery (RR 1.23, 95% CI 1.15-1.31). Risk of cesarean delivery was greatest in low-risk pregnancies.

CONCLUSION

The only clinically significant benefit from the use of routine EFM was in the reduction of neonatal seizures. Because of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use EFM or intermittent auscultation during labor.

The psychological effects of counting fetal movements

By identifying a change in fetal activity state, fetal movement counting may help to reduce the possibility of stillbirth. Concern has arisen that such a focus on fetal activity may cause undue maternal anxiety. A prospective, controlled trial was conducted to determine whether fetal movement counting induced anxiety or other deleterious psychological effects in low-risk primigravidas. A sample of 613 healthy pregnant women was randomly assigned at 28 weeks' gestation to fetal movement counting, sleep recording, or a nonrecording control group. State and trait of anxiety, belief in sources of personal control, and attitudes toward pregnancy and infant were assessed at 28 and 37 weeks' gestation. Participation rates were high (91.4%) across all groups. Most women (90%) assigned to count fetal movements did so on a daily basis (95% of days). No significant changes in psychological status occurred in the three groups as a result of self-monitoring conditions. Independent of group assignment, all women showed a slight increase in transient state and decrease in trait of anxiety from 28 to 37 weeks. Internal locus of control and positive attitudes toward the infant increased slightly, and feelings of well-being decreased slightly for all women. It was concluded that women are willing to record fetal activity, and that fetal movement counting does not cause deleterious psychological effects in low-risk pregnant women.

Is the risk of perinatal transmission of human immunodeficiency virus increased by the intrapartum use of spiral electrodes or fetal scalp pH sampling?

OBJECTIVE

Our aim was to determine whether the intrapartum use of fetal scalp electrodes or fetal scalp pH sampling increases the rate of perinatal transmission of human immunodeficiency virus.

STUDY DESIGN

The rate of perinatal transmission of human immunodeficiency virus in 31 monitored pregnancies was determined, and those pregnancies were compared with a control group of 117 pregnancies.

RESULTS

The monitored group was comparable to the control group with respect to maternal age, race, human immunodeficiency virus risk behavior, CD4+ cell count, p24 antigen status, and stage of human immunodeficiency virus disease. The mean gestational age at delivery and the mean birth weight were similar in the monitored group and the control group. The perinatal transmission rate for the monitored group (29.0%) was not statistically different from that of the control group (25.6%).

CONCLUSIONS

If confirmed by larger studies, our findings suggest that the intrapartum use of fetal scalp electrodes or fetal scalp pH sampling does not appear to increase the perinatal transmission of human immunodeficiency virus.

[The influence of internal fetal monitoring on pregnancy outcome and survey of uterine contraction]

Pregnancy outcome of 30 primigravida receiving internal fetal monitoring (IFM) was studied with 52 cases without IFM as control. Intrauterine pressure was measured in IFM patients during active phase and second stage of labor. The occurrence of fetal distress, neonatal morbidity and the positive isolation rate of bacteria in amnionic fluid and aspirate from the throat of newborns was 56.7%, 23.3%, 50.0% and 45.5% respectively in the IFM group. The occurrence of fetal distress and neonatal morbidity were significantly higher than those of the control group. The intrauterine pressure, duration, frequency and intensity of uterine contractions during active phase and second stage of labor were observed. The characters of uterine contraction in IFM and external fetal monitoring were different, and a kind of false fetal heart rate deceleration was described in the paper.

Neonatal labioperineal tear from fetal scalp electrode insertion. A case report

Intrauterine electronic fetal heart monitoring is a widely used tool in diagnosing intrauterine fetal distress. We describe a case of successful conservative treatment for a neonatal labioperineal tear caused by scalp electrode application during breech delivery.

Gonococcal scalp abscess: a risk of intrauterine monitoring

Internal fetal monitoring was introduced into clinical practice in the 1960s.1 Intrauterine fetal scalp electrodes are commonly used to evaluate the condition of the fetus. Fetal scalp abscesses are a well-recognized but uncommon complication of intrauterine electrode monitoring. We report a case of neonatal gonococcal scalp abscess occurring after scalp electrode and pH monitoring were performed. The infant showed no signs of sepsis. The mother was asymptomatic and had a normal pregnancy.

Herpes simplex infection associated with short-term use of a fetal scalp electrode. A case report

A case of localized neonatal herpes simplex virus (HSV) infection involved a prior fetal scalp electrode site. Rupture of the fetal membranes, placement of the fetal scalp electrode and delivery occurred within 30 minutes. The mother had no previous history of genital lesions, and no herpetic lesions were noted at delivery.

Infection of fetal scalp electrode monitoring sites

Complications caused by placement of a fetal scalp electrode include trauma, hemorrhage and infection. Infections are usually localized and self-limited, but they can occasionally lead to serious complications, such as osteomyelitis, sepsis and death. The recommended treatment for a scalp abscess is incision and drainage, followed by appropriate antibiotic therapy. If a serious infection is suspected, the infant should be hospitalized, blood cultures obtained and intravenous antibiotic therapy initiated.

Recommendations for the management of low risk obstetric patients

Specific interventional procedures have enjoyed widespread popularity in the United States in the routine management of low risk obstetric patients without the benefit of clinical studies attesting to their utility. A review of the literature was conducted to survey obstetric practice with regard to amniotomy, intravenous fluids, third stage administration of oxytocics, episiotomy and continuous fetal monitoring.

Scalp electrode associated neonatal Escherichia coli meningitis--a case report

A case of Escherichia coli meningitis in a newborn boy is described which seemed to be related to the use of a screwed top scalp electrode for perinatal monitoring. First a subcutaneous abscess developed at the place of the former electrode and the infant recovered well after surgical incision. 36 hour later the boy became acutely ill because of a purulent meningitis. From both the subcutaneous Abscess as the CSF identical E. coli (K1-strain) were cultured.

Effects of chronic instrumentation on fetal growth

Chronically-instrumented fetal sheep are a commonly used animal model for the study of fetal growth and metabolism. In the current study, we wanted to test the hypothesis that instrumentation alone would alter fetal growth patterns. Thirty-two animals in three groups were used: (i) non-instrumented animals (n = 10); (ii) instrumented with catheters in the maternal and fetal femoral artery and vein and electromagnetic flow probes on the main uterine arteries (n = 10): (iii) animals instrumented as group 2, but with the addition of a doppler flow probe on the common umbilical artery and a common umbilical vein catheter (n = 12). Animals in group 2 and 3 were monitored until 137 to 140 days of gestation, at which time they were sacrificed for fetal morphometric measurements. Instrumentation significantly (P less than 0.05) decreased fetal body weight, length, and thymus weights. Liver-to-body ratios increased (P less than 0.05) in both surgically-instrumented groups. The addition of the umbilical artery doppler flow probe and an umbilical venous catheter did not lead to any further alterations in fetal growth. The current study demonstrates that surgical instrumentation alone can lead to significant alterations in fetal growth.

Fatal Streptococcus viridans septicemia and meningitis: relationship to fetal scalp electrode monitoring

Viridans streptococci have been reported as an increasingly frequent pathogen in neonatal sepsis. These infections have appeared to be less virulent than those associated with other bacteria. The case of an infant is reported who developed a scalp abscess secondary to an internal fetal monitoring electrode caused by viridans streptococci. This infection evolved into a rapidly fatal septicemia and meningitis. Viridans streptococci may be responsible for virulent fatal infections in neonates.

Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

An overview of vibroacoustic stimulation

Vibroacoustic stimulation of the fetus as a test of fetal well-being has become fairly common despite limited research on this tool. A review of the literature reveals that fetal accelerations in response to this stimulus are indicative of fetal health. Vibroacoustic stimulation correlates well with other methods of fetal assessment and is effective in converting nonreactive tracings to reactive tracings in healthy fetuses, saving patients time and expense.