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Shema N, Weintraub AY, Rotem R, Salem SY. The Correlation Between the Total Decelerations and Accelerations Areas and Cord Blood pH in Women with Low-Risk Pregnancies. Reprod Sci 2024; 31:1401-1407. [PMID: 38253982 DOI: 10.1007/s43032-024-01455-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024]
Abstract
Fetal acidosis among low-risk pregnancies is not common; however, identifying those at risk for this complication antenatally is of great interest. We aimed to assess the correlation between the total decelerations area during the last 120 min of fetal monitoring prior to delivery and neonatal acidemia in low-risk pregnancies and whether the total acceleration area has a protective effect in the presence of decelerations. A retrospective cohort study was conducted among women with term low-risk pregnancies. A researcher blinded to fetal outcomes interpreted electronic fetal monitor patterns during the 120 min prior to delivery. The primary outcome was fetal acidemia, defined as umbilical artery pH below 7.10. The correlation between the total decelerations and accelerations areas and cord blood pH was tested using the Spearman correlation coefficient. A total of 109 women were included and of these, six (5.5%) delivered infants with cord blood pH < 7.10. A significant correlation was demonstrated between the total decelerations area and cord blood pH (p = 0.01). No correlation was found between the total accelerations area and cord blood pH. Among low-risk pregnancies, a correlation was found between the total decelerations area but not the total accelerations area during the final 120 min of labor and cord blood pH.
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Affiliation(s)
- Noam Shema
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel.
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Shimrit Yaniv Salem
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Ben-Gurion University of the Negev, Soroka University Medical Center, Beer Sheva, Israel
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Evans MI, Britt DW, Devoe LD. Etiology and Ontogeny of Cerebral Palsy: Implications for Practice and Research. Reprod Sci 2024; 31:1179-1189. [PMID: 38133768 DOI: 10.1007/s43032-023-01422-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the incidence of CP for infants born at term in the USA. Litigation alleging that poor obstetrical practice caused CP in most of these affected children has led to contentious arguments regarding the actual etiologies of this condition and often resulted in substantial monetary awards for plaintiffs. Recent advances in genetic testing using whole exome sequencing have revealed that at least one-third of CP cases in term infants are genetic in origin and therefore not labor-related. Here, we will present and discuss previous attempts to sort out contributing etiologies and ontogenies of CP, and how these newer diagnostic techniques are rapidly improving our ability to better detect and understand such cases. In light of these developments, we present our vision for an overarching spectrum for proper categorization of CP cases into that the following groups: (1) those begun at conception from genetic causes (nonpreventable); (2) those stemming from adverse antenatal/pre-labor events (possibly preventable with heightened antepartum assessment); (3) Those arising from intrapartum events (potentially preventable by earlier interventions); (4) Those occurring shortly after birth (possibly preventable with closer neonatal monitoring); (5) Those that appear later in the postnatal period from non-labor-related causes such as untreated infections or postnatal intracranial hemorrhages.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, NY, USA.
- Comprehensive Genetics, PLLC, New York, NY, USA.
- Departments of Obstetrics, Gynecology, and Reproductive Sciences, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
| | - David W Britt
- Fetal Medicine Foundation of America, New York, NY, USA
| | - Lawrence D Devoe
- Department of Obstetrics & Gynecology, The Medical College of Georgia at Augusta University, Augusta, GA, USA
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Steyde G, Spairani E, Magenes G, Signorini MG. Fetal heart rate spectral analysis in raw signals and PRSA-derived curve: normal and pathological fetuses discrimination. Med Biol Eng Comput 2024; 62:437-447. [PMID: 37889432 PMCID: PMC10794317 DOI: 10.1007/s11517-023-02953-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
Cardiotocography (CTG) is the most common technique for electronic fetal monitoring and consists of the simultaneous recording of fetal heart rate (FHR) and uterine contractions. In analogy with the adult case, spectral analysis of the FHR signal can be used to assess the functionality of the autonomic nervous system. To do so, several methods can be employed, each of which has its strengths and limitations. This paper aims at performing a methodological investigation on FHR spectral analysis adopting 4 different spectrum estimators and a novel PRSA-based spectral method. The performances have been evaluated in terms of the ability of the various methods to detect changes in the FHR in two common pregnancy complications: intrauterine growth restriction (IUGR) and gestational diabetes. A balanced dataset containing 2178 recordings distributed between the 32nd and 38th week of gestation was used. The results show that the spectral method derived from the PRSA better differentiates high-risk pregnancies vs. controls compared to the others. Specifically, it more robustly detects an increase in power percentage within the movement frequency band and a decrease in high frequency between pregnancies at high risk in comparison to those at low risk.
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Affiliation(s)
- Giulio Steyde
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy.
| | - Edoardo Spairani
- Electrical, Computer and Biomedical Engineering Department, Università di Pavia, 27100, Pavia, Italy
| | - Giovanni Magenes
- Electrical, Computer and Biomedical Engineering Department, Università di Pavia, 27100, Pavia, Italy
| | - Maria G Signorini
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Piazza Leonardo da Vinci 32, 20133, Milano, Italy
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Geva N, Geva Y, Katz L, Binyamin Y, Rotem R, Weintraub AY, Yaniv Salem S. Correlation between total deceleration area in CTG records and cord blood pH in pregnancies with IUGR. Arch Gynecol Obstet 2024:10.1007/s00404-023-07240-0. [PMID: 38225432 DOI: 10.1007/s00404-023-07240-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 09/14/2023] [Indexed: 01/17/2024]
Abstract
PURPOSE Fetal cardiotocography is the most common method to assess fetal well-being during labor. Nevertheless, its predictive ability for acidemia is limited, both in low-risk and high-risk pregnancies (Nelson et al. in N Engl J Med 334: 613-9, 1996; Rinciples P et al. in Health and Human Development Workshop Report on Electronic Fetal Monitoring : Update on Definitions. no. 2007, 510-515, 2008), especially in high-risk pregnancies, such as those complicated by growth restriction. In this study we aim examine the association between deceleration and acceleration areas and other measure of fetal heart rate in intrapartum fetal monitoring and neonatal arterial cord blood pH in pregnancies complicated by growth restriction. MATERIALS AND METHODS A retrospective cohort study of 100 deliveries complicated by growth restriction, delivered during 2018, was conducted. Known major fetal anomalies, non-vertex presentation and elective cesarean deliveries were excluded. Total deceleration and acceleration areas were calculated as the sum of the areas within the deceleration and acceleration, respectively. RESULTS In deliveries complicated by growth restriction, cord blood pH is significantly associated with total deceleration area (p = 0.05) and correlates with cumulative duration of the decelerations (Spearman's rank -0.363, p < 0.05), and total acceleration area (-0.358, p < 0.05). By comparing the cord blood pH in deliveries with a total deceleration area that was above and below the median total deceleration area, we demonstrated a significant difference between the categories. CONCLUSIONS Cord blood pH significantly correlates with total deceleration area and other fetal monitoring characteristics in neonates with growth restriction. Future studies using real-time, machine-learning based techniques of fetal heart rate monitoring, may provide population specific threshold values that will support bedside clinical decision making and perhaps achieve better outcomes.
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Affiliation(s)
- Neta Geva
- Department of Neonatology, Ben-Gurion University of the Negev Faculty of Health Sciences, Sheril and Hain Saban Children Hospital, Soroka Medical Center, Beer-Sheva, Israel.
| | - Yael Geva
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Lior Katz
- Pediatric Division, Rambam Health Care Campus, Haifa, Israel
| | - Yair Binyamin
- Department of Anesthesiology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Reut Rotem
- Division of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University Medical School, Jerusalem, Israel
| | - Adi Yehuda Weintraub
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Shimrit Yaniv Salem
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Shapira R, Kedar R, Yaniv Y, Keidar N. Double-sided asymmetric method for automated fetal heart rate baseline calculation. Phys Eng Sci Med 2023; 46:1779-1790. [PMID: 37770779 DOI: 10.1007/s13246-023-01337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 09/12/2023] [Indexed: 09/30/2023]
Abstract
The fetal heart rate (FHR) signal is used to assess the well-being of a fetus during labor. Manual interpretation of the FHR is subject to high inter- and intra-observer variability, leading to inconsistent clinical decision-making. The baseline of the FHR signal is crucial for its interpretation. An automated method for baseline determination may reduce interpretation variability. Based on this claim, we present the Auto-Regressed Double-Sided Improved Asymmetric Least Squares (ARDSIAsLS) method as a baseline calculation algorithm designed to imitate expert obstetrician baseline determination. As the FHR signal is prone to a high rate of missing data, a step of gap interpolation in a physiological manner was implemented in the algorithm. The baseline of the interpolated signal was determined using a weighted algorithm of two improved asymmetric least squares smoothing models and an improved symmetric least squares smoothing model. The algorithm was validated against a ground truth determined from annotations of six expert obstetricians. FHR baseline calculation performance of the ARDSIAsLS method yielded a mean absolute error of 2.54 bpm, a max absolute error of 5.22 bpm, and a root mean square error of 2.89 bpm. In a comparison between the algorithm and 11 previously published methods, the algorithm outperformed them all. Notably, the algorithm was non-inferior to expert annotations. Automating the baseline FHR determination process may help reduce practitioner discordance and aid decision-making in the delivery room.
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Affiliation(s)
- Rotem Shapira
- Laboratory of Bioenergetic and Bioelectric Systems, Biomedical Engineering Faculty, Technion-IIT, Haifa, Israel
| | - Reuven Kedar
- Department of Obstetrics & Gynecology, Carmel Medical Center, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Yael Yaniv
- Laboratory of Bioenergetic and Bioelectric Systems, Biomedical Engineering Faculty, Technion-IIT, Haifa, Israel.
| | - Noam Keidar
- Laboratory of Bioenergetic and Bioelectric Systems, Biomedical Engineering Faculty, Technion-IIT, Haifa, Israel.
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Al-yousif S, Najm IA, Talab HS, Hasan Al Qahtani N, Alfiras M, Al-Rawi OYM, Subhi Al-Dayyeni W, Amer Ahmed Alrawi A, Jabbar Mnati M, Jarrar M, Ghabban F, Al-Shareefi NA, Musa Jaber M, H. Saleh A, Md Tahir N, Najim HT, Taher M. Intrapartum cardiotocography trace pattern pre-processing, features extraction and fetal health condition diagnoses based on RCOG guideline. PeerJ Comput Sci 2022; 8:e1050. [PMID: 36092005 PMCID: PMC9454876 DOI: 10.7717/peerj-cs.1050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
CONTEXT The computerization of both fetal heart rate (FHR) and intelligent classification modeling of the cardiotocograph (CTG) is one of the approaches that are utilized in assisting obstetricians in conducting initial interpretation based on (CTG) analysis. CTG tracing interpretation is crucial for the monitoring of the fetal status during weeks into the pregnancy and childbirth. Most contemporary studies rely on computer-assisted fetal heart rate (FHR) feature extraction and CTG categorization to determine the best precise diagnosis for tracking fetal health during pregnancy. Furthermore, through the utilization of a computer-assisted fetal monitoring system, the FHR patterns can be precisely detected and categorized. OBJECTIVE The goal of this project is to create a reliable feature extraction algorithm for the FHR as well as a systematic and viable classifier for the CTG through the utilization of the MATLAB platform, all the while adhering to the recognized Royal College of Obstetricians and Gynecologists (RCOG) recommendations. METHOD The compiled CTG data from spiky artifacts were cleaned by a specifically created application and compensated for missing data using the guidelines provided by RCOG and the MATLAB toolbox after the implemented data has been processed and the FHR fundamental features have been extracted, for example, the baseline, acceleration, deceleration, and baseline variability. This is followed by the classification phase based on the MATLAB environment. Next, using the guideline provided by the RCOG, the signals patterns of CTG were classified into three categories specifically as normal, abnormal (suspicious), or pathological. Furthermore, to ensure the effectiveness of the created computerized procedure and confirm the robustness of the method, the visual interpretation performed by five obstetricians is compared with the results utilizing the computerized version for the 150 CTG signals. RESULTS The attained CTG signal categorization results revealed that there is variability, particularly a trivial dissimilarity of approximately (+/-4 and 6) beats per minute (b.p.m.). It was demonstrated that obstetricians' observations coincide with algorithms based on deceleration type and number, except for acceleration values that differ by up to (+/-4). DISCUSSION The results obtained based on CTG interpretation showed that the utilization of the computerized approach employed in infirmaries and home care services for pregnant women is indeed suitable. CONCLUSIONS The classification based on CTG that was used for the interpretation of the FHR attribute as discussed in this study is based on the RCOG guidelines. The system is evaluated and validated by experts based on their expert opinions and was compared with the CTG feature extraction and classification algorithms developed using MATLAB.
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Affiliation(s)
- Shahad Al-yousif
- Research Centre, The University of Almashreq, Baghdad, Iraq
- College of Engineering, Department of Electrical & Electronic Engineering, Gulf University, Almasnad, Kingdom of Bahrain
- Department of Medical Instrumentation Engineering Techniques, Dijlah University College, Baghdad, Iraq
| | - Ihab A. Najm
- College of Engineering, Tikrit University, Tikrit, Iraq
| | - Hossam Subhi Talab
- Children Welfare Teaching Hospital, Medical City, (MD, CABP, CAB Neonatology), Baghdad, Iraq
| | - Nourah Hasan Al Qahtani
- Department of Obstetrics and Gynecology, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Dammam, Saudi Arabia
| | - M. Alfiras
- College of Engineering, Department of Electrical & Electronic Engineering, Gulf University, Almasnad, Kingdom of Bahrain
| | - Osama YM Al-Rawi
- College of Engineering, Department of Electrical & Electronic Engineering, Gulf University, Almasnad, Kingdom of Bahrain
| | | | | | - Mohannad Jabbar Mnati
- Department of Electronic Technology, Institute of Technology Baghdad, Middle Technical University, Baghdad, Iraq
| | - Mu’taman Jarrar
- College of Medicine, Imam Abdulrahman Bin Faisal University, Al Dammam, Saudi Arabia
| | - Fahad Ghabban
- Department of Information Systems College of Computer Science and Engineering, Taibah University, Al Madinah Al Munawwarah, Saudi Arabia
| | - Nael A. Al-Shareefi
- College of Biomedical Informatics, University of Information Technology and Communications (UOITC), Baghdad, Iraq
| | - Mustafa Musa Jaber
- Al-Turath University College, Department of Computer Engineering, Baghdad, Iraq
- Department of Medical Instruments Engineering Techniques, Al-Farahidi University, Baghdad, Iraq
| | | | - Nooritawati Md Tahir
- Electrical Engineering Department, College of Engineering, Universiti Teknologi MARA, Shah Alam, Malaysia
- Integrative Pharmacogenomics Institute (iPROMISE), Universiti Teknologi MARA, Shah Alam, Malaysia
- Institute of Big Data Analytics and Artificial Intelligence (IBDAAI), Universiti Teknologi MARA, Shah Alam, Malaysia
| | - Huda T. Najim
- Department of Biomedical Engineering, University of Technology, Baghdad, Iraq
| | - Mayada Taher
- Department of Laser and Optoelectronics Engineering, University of Technology, Baghdad, Iraq
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Gyllencreutz E, Varli IH, Lindqvist PG, Holzmann M. Variable deceleration features and intrapartum fetal acidemia - The role of deceleration area. Eur J Obstet Gynecol Reprod Biol 2021; 267:192-197. [PMID: 34826666 DOI: 10.1016/j.ejogrb.2021.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 11/02/2021] [Accepted: 11/05/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE In recent years deceleration area has received increasing attention as a potential predictor of intrapartum fetal hypoxia. In several studies, the area has been manually esteemed as triangular in shape, which might introduce bias. In addition, the commonly used outcome acidemia in umbilical artery is affected by mode of delivery. We wanted to investigate the association between the variable deceleration features area, duration, depth and cumulative deceleration area (30 and 60 min) and intrapartum fetal acidemia measured as lactate concentration at fetal scalp blood sampling (FBS) in immediate connection to the decelerations. STUDY DESIGN In the source population of 1070 labors at Karolinska University Hospital, Sweden, with FBS performed on indication, we found 507 fetuses with predominantly variable decelerations as the indication for FBS. We examined the last 60- and 30-minutes of fetal monitoring preceding the FBS with focus on deceleration area, duration and depth. The contours of the decelerations were outlined manually but the area was calculated with a computer software program. We assessed area, duration and depth both as mean values per deceleration and as cumulative values during the time period of interest. We analyzed Pearson correlations and area under receiver operating characteristics curves (AUC). We also performed an adjusted analysis, with baseline frequency, variability, and accelerations as covariates. RESULTS Deceleration area and duration were the best predictors of intrapartum fetal acidemia (fetal lactate concentration >4.8 mmol/L measured with Lactate Pro™) with AUCs of 0.671 (0.682) and 0.678 (0.683) for cumulative measures during 30 (60) minutes prior to FBS, compared to deceleration depth with AUC of 0.632 (0.631). Corresponding Pearson correlations in 30-min (60-min) groups were 0.329 (0.335) and 0.358 (0.354) for deceleration area and duration and 0.212 (0.204) for deceleration depth. Using 250 beats cumulative cut-off for deceleration area during last 30 min, 71% vs. 43% were acidemic and non-acidemic, odds ratio = 3.2 (95% CI 1.7-6.1). CONCLUSIONS Deceleration area and duration were better predictors of intrapartum fetal acidemia than deceleration depth. Cumulative deceleration area >250 beats during 30 min was associated with three-fold higher odds of intrapartum acidemia compared to <250 beats.
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Affiliation(s)
- Erika Gyllencreutz
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology, Östersund Hospital, Region Jämtland Härjedalen, Sweden
| | - Ingela Hulthén Varli
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Medical Unit Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden
| | - Pelle G Lindqvist
- Department of Clinical Sciences and Education, Sodersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Malin Holzmann
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Medical Unit Pregnancy and Childbirth, Karolinska University Hospital, Stockholm, Sweden.
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Abstract
The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, NY, USA.
- Comprehensive Genetics, PLLC, New York, NY, USA.
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA.
| | - David W Britt
- Fetal Medicine Foundation of America, New York, NY, USA
| | - Shara M Evans
- Department of Maternal Child Health, Gillings School of Public Health, University of North Carolina, Chapel Hill, USA
| | - Lawrence D Devoe
- Department of Obstetrics and Gynecology, Medical College of Georgia, Augusta University, Augusta, GA, USA
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Zamora Del Pozo C, Chóliz Ezquerro M, Mejía I, Díaz de Terán Martínez-Berganza E, Esteban LM, Rivero Alonso A, Castán Larraz B, Andeyro García M, Savirón Cornudella R. Diagnostic capacity and interobserver variability in FIGO, ACOG, NICE and Chandraharan cardiotocographic guidelines to predict neonatal acidemia. J Matern Fetal Neonatal Med 2021; 35:8498-8506. [PMID: 34652249 DOI: 10.1080/14767058.2021.1986479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Despite its routine use in intrapartum care, the technique of fetal cardiotocography has some limitations. The aim of this study is to analyze the predictive capacity and interobserver agreement in the latest versions of four international cardiotocography guidelines: Federation of Gynecology and Obstetrics (FIGO), American College of Obstetrics and Gynecology (ACOG), the National Institute for Health and Care Excellence (NICE) and Chandraharan, used to predict neonatal acidemia. STUDY DESIGN The last 30 min of 150 cardiotocographic records were analyzed over all the pH ranges and were blindly evaluated by three independent reviewers. The sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating characteristic curve (AUC) were calculated to assess the predictive capacity of each fetal cardiotocographic guideline. The degree of interobserver agreement was evaluated with the Fleiss Kappa coefficient. RESULTS Observers found fetal cardiotocography guidelines to have a variable sensitivity and specificity. The Chandraharan classification reached the highest sensitivity (78.79%), while ACOG had the highest specificity (95.73%). On average for the three observers, Chandraharan had the highest discrimination capacity for neonatal acidemia, although this was only moderate (AUC 0.66; 95%CI, 0.55-0.77) and did not differ significantly from the remaining guidelines. The degree of agreement among the three observers, assessed according to the Fleiss Kappa coefficient, was generally acceptable or moderate for all items and classifications, being highest with the FIGO classification (ĸ = 0.35; 95%CI, 0.28-0.41) and lowest with the ACOG (ĸ = 0.23; 95%CI, 0.16-0.30). CONCLUSION Although all the guidelines have a moderate capacity to predict neonatal acidemia, the Chandraharan guideline has the highest capacity. This follows a different approach from the others in that it relies on interpretations of cardiotocographic traces based on fetal physiology. The degree of interobserver agreement is, in general, acceptable for the four guidelines, and is the highest for FIGO.
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Affiliation(s)
| | | | - Inmaculada Mejía
- Department of Obstetrics and Gynecology, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Luis Mariano Esteban
- Universidad de Zaragoza, Escuela Universitaria Politécnica de la Almunia, C/Mayor s/n, La Almunia de Doña Godina, Spain
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Small KA, Sidebotham M, Fenwick J, Gamble J. "I'm not doing what I should be doing as a midwife": An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women Birth 2021; 35:193-200. [PMID: 34092530 DOI: 10.1016/j.wombi.2021.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/18/2021] [Accepted: 05/20/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central fetal monitoring systems transmit cardiotocograph data to a central site in a maternity service. Despite a paucity of evidence of safety, the installation of central fetal monitoring systems is common. AIM This qualitative research sought to explore whether, and how, clinicians modified their clinical safety related behaviours following the introduction of a central monitoring system. METHODS An Institutional Ethnographic enquiry was conducted at an Australian hospital where a central fetal monitoring system had been installed in 2016. Informants (n=50) were midwifery and obstetric staff. Data collection consisted of interviews and observations that were analysed to understand whether and how clinicians modified their clinical safety related behaviours. FINDINGS The introduction of the central monitoring system was associated with clinical decision making without complete clinical information. Midwives' work was disrupted. Higher levels of anxiety were described for midwives and birthing women. Midwives reported higher rates of intervention in response to the visibility of the cardiotocograph at the central monitoring station. Midwives described a shift in focus away from the birthing woman towards documenting in the central monitoring system. DISCUSSION The introduction of central fetal monitoring prompted new behaviours among midwifery and obstetric staff that may potentially undermine clinical safety. CONCLUSION This research raises concerns that central fetal monitoring systems may not promote safe intrapartum care. We argue that research examining the safety of central fetal monitoring systems is required.
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Affiliation(s)
- Kirsten A Small
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Mary Sidebotham
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Jennifer Fenwick
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
| | - Jenny Gamble
- Transforming Maternity Care Collaborative, School of Nursing & Midwifery, Griffith University, Australia.
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Li SF, Zhao YY, Li GF, Wang N, Zhang S, Chen L, Wang Y. Computerized analysis of fetal heart rate pattern in the third trimester of low-risk pregnancy by long-range electronic fetal monitoring. J Matern Fetal Neonatal Med 2021; 35:5506-5512. [PMID: 33596763 DOI: 10.1080/14767058.2021.1887120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND With computerized analysis of fetal heart rate(FHR) data from long-range monitoring, we aimed to comprehensively clarify the characteristics of FHR with increasing gestational age in low-risk pregnant women during the third trimester of pregnancy. METHODS This was an observational study. 85 fetuses of low-risk pregnant women were included. The data covered 28 ∼ 40 weeks of gestation, and 125 cases of FHR monitoring from 85 fetuses were totally collected. The FHR baseline rate, variability, and acceleration were computationally calculated, analyzed and compared. RESULTS The average effective monitoring time for each case was 13.9 ± 4.3 h. FHR baseline gradually decreased as the gestational age progressed, and the maximum FHR baseline appeared at 28-29 weeks, which was 137.5 (133.0, 141.3) bpm, whereas the minimum FHR baseline appeared at 38-39 weeks, that was 132.8 (128.1, 138.4) bpm. FHR variability fluctuated in (4-12)bpm. It gradually increased from 28 to 33 weeks of gestation, reached the maximum of 7.6 (6.0-9.4) bpm, and then decreased until full-term pregnancy. The moderate variability proportion of FHR gradually increased from 28 weeks of gestation, peaked at 32-33 weeks as 65.8%, and then gradually decreased to 56.2% at 37 weeks, which was maintained at this level until 39 weeks. The variation tendency of minimal variability proportion was opposite to moderate variability proportion. When it reached 40 weeks, the minimal and moderate variability proportions were 50.0% and 49.0%, respectively. The FHR acceleration area showed no trend change during the third trimester, while fluctuated in (29.5-42.4) lattices/h. CONCLUSION This study revealed that the characteristics of FHR gradually changed with increasing gestational age, and the most obvious change was observed at 32-33 weeks, demonstrating that the specific gestational weeks may be an important period for the physiological bias of FHR tends to mature.
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Affiliation(s)
- Shu-Fang Li
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Peking University, Beijing, China.,Department of Gynecology and Obstetrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang-Yu Zhao
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Peking University, Beijing, China
| | - Guang-Fei Li
- Biomedical Engineering, School of Life Science, Beijing Institute of Technology, Beijing, China
| | - Nan Wang
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Peking University, Beijing, China
| | - Song Zhang
- College of Life Science and Bio-engineering, Beijing University of Technology, Beijing, China
| | - Lian Chen
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Peking University, Beijing, China
| | - Yan Wang
- Department of Gynecology and Obstetrics, Peking University Third Hospital, Peking University, Beijing, China
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Ekengård F, Cardell M, Herbst A. Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor. J Matern Fetal Neonatal Med 2021; 35:4853-4860. [PMID: 33406946 DOI: 10.1080/14767058.2020.1869931] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Cardiotocography (CTG) is the main method of intrapartum fetal surveillance. In 2015 a new guideline was introduced by the International Federation of Gynecology and Obstetrics (FIGO), FIGO-15. In Sweden it was adjusted to SWE-17, replacing the previous national template, SWE-09. This study, conducted at one university hospital and one regional hospital in southern Sweden, evaluated the diagnostic validity of these three templates to detect fetal acidosis during the first stage of labor. MATERIAL AND METHODS A total of 73 neonates with pH <7.1 in umbilical cord artery or vein at cesarean delivery during the first stage of labor were identified retrospectively. For each acidotic neonate, three non-acidemic neonates, with a pH ≥7.2 in cord artery and vein, and Apgar scores ≥9 at five and ten minutes, in all 219 neonates, were selected. The CTG tracings before birth in acidemic neonates, and tracings at the same cervical dilatation in the non-acidemic neonates, were independently assessed by three professionals from the obstetric staff, blinded to group and clinical data. Based on their categorizations of the included variables (baseline, variability, accelerations, decelerations and contraction rate), each CTG tracing was systematically classified according to the three templates. The sensitivity and specificity to identify acidemia by the classification pathological were determined for each template. Interobserver agreement in the assessments of tracings as pathological or not was analyzed, using free-marginal Kappa index. RESULTS The sensitivity for patterns classified as pathological to identify acidemia was similar for FIGO-15 (71%) and SWE-17 (77%, p = .13), and the specificity was 97% for both. SWE-09 had a significantly higher sensitivity (95%, p < .001) albeit with a lower specificity (90%, p < .001) than the other two templates. Among acidemic neonates, the fraction of tracings classified as normal was higher with SWE-17 (9.6%) than with SWE-09 (0%; p = .01) and FIGO-15 (1.4%; p = .06). For tracings from neonates with acidemia, agreement for three independent assessors was strong (κ 0.85) with SWE-09, and weak for FIGO-15 (κ 0.47), and SWE-17 (κ 0.51). For tracings from neonates without acidemia, the agreement was almost perfect for FIGO-15 (κ 0.91), strong withSWE-17 (κ 0.90) and moderate with SWE-09 (κ 0.78). CONCLUSIONS The ability of FIGO-15 and SWE-17 to identify fetal acidosis is considered insufficient. The combination of a high sensitivity and a high specificity makes SWE-09 the most discriminatory template during the first stage of labor.
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Affiliation(s)
- Frida Ekengård
- Department of Obstetrics, and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
| | - Monika Cardell
- Department of Obstetrics, and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
| | - Andreas Herbst
- Department of Obstetrics, and Gynecology, Skåne University Hospital, Institution of Clinical Sciences Lund University, Lund, Sweden
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Morgan JA, Hankins ME, Wang Y, Hutchinson D, Sams HL, Voltz JH, McCathran CE, Kaye AD, Lewis DF. Prolonged Fetal Heart Rate Decelerations in Labor: Can We Reduce Unplanned Primary Cesarean Sections in This Group? Adv Ther 2020; 37:4325-4335. [PMID: 32839938 DOI: 10.1007/s12325-020-01468-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Non-reassuring fetal tracing is the second leading cause of primary cesarean delivery in the United States. Prolonged fetal heart rate decelerations are non-reassuring fetal heart rate characteristics, which do not uniformly predict poor fetal outcome but can prompt obstetricians to proceed with cesarean delivery. The objective of this manuscript is to identify a strategy to reduce the primary cesarean section rate in patients with prolonged fetal heart rate decelerations in labor. METHODS This is a retrospective cohort study over a 5-year period at an academic medical center, including patients undergoing primary cesarean section following labor induction, augmentation, or spontaneous labor who were noted to have prolonged fetal heart rate deceleration(s) in the 1 h prior to the time of delivery. Two groups were compared: "crash" cesarean sections versus "emergent" cesarean sections. The primary outcome was if fetal heart tones were rechecked in the operating room prior to cesarean section incision. Secondary outcomes included maternal-fetal monitoring versus Doppler fetal heart tones in the operating room, return to baseline noted in the operating room, fetal outcomes, fetal monitoring characteristics, and anesthesia type between crash versus emergent groups. RESULTS Of 1969 term singleton cesarean sections, 119 patients met our inclusion criteria (emergent group n = 80) (crash group n = 39), which accounted for 13.9% of all primary cesarean sections during the study period. The emergent group had a significantly higher rate of reassessment of fetal heart tones in the operating room n = 61 (76.2%) versus the crash group n = 15 (38.4%) (p ≤ 0.0001). There were no statistically significant differences regarding fetal outcomes between the two groups. The crash group had a higher rate of category 1 fetal heart rate tracing prior to the prolonged deceleration, a longer median prolonged deceleration, and a deeper median nadir of the prolonged deceleration; these differences were statistically significant. The prolonged-to-delivery interval was significantly shorter in the crash group (median = 15 min) than tin he emergent group (median = 33 min) (p ≤ 0.0001). The crash group also had a higher rate of general anesthesia (n = 11, 28.2%) than the emergent group (n = 6, 7.5%) (p = 0.002). The crash group was specifically investigated. Of the 15 patients with fetal heart tones rechecked in the crash group, 7 had returned to baseline in the operating room, but underwent cesarean section without fetal monitoring. CONCLUSION Our results indicate that the practice of placing patients on fetal monitor upon arrival to the operating room prior to performing crash cesarean delivery could reduce the rate of primary cesarean deliveries performed for prolonged decelerations in labor. When fetal heart tones have returned to baseline upon arrival in the operating room, the decision to proceed with cesarean delivery can be reconsidered. However, many clinical factors must be taken into consideration, and the decision to proceed is ultimately at the discretion of the obstetrics provider.
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Affiliation(s)
- John A Morgan
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Miriam E Hankins
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Yuping Wang
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Donna Hutchinson
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Hannah L Sams
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - John H Voltz
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Charles E McCathran
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
| | - Alan D Kaye
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA.
| | - David F Lewis
- Department of Obstetrics and Gynecology, Louisiana State University Health Sciences Center, Shreveport, Shreveport, LA, USA
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Abstract
OBJECTIVE The use of pH and base excess (FSSPHBE) from fetal scalp sampling (FSS) was abandoned when cardiotocography (CTG) was believed to be sufficiently accurate to direct patient management. We sought to understand the fetus' tolerance to stress in the 1st stage of labor and to develop a better and earlier screening test for its risk for developing acidosis. To do so, we investigated sequential changes in fetal pH and BE obtained from FSS in the 1st stage of labor as part of a research protocol from the 1970s. We then examined the utility of multiple of the median (MoM's) conversion of BE and pH values, and the capacity of Fetal Reserve Index (FRI) scores to be a proxy for such changes. We then sought to examine the predictive capacity of 1st stage FRI and its change over the course of the first stage of labor for the subsequent development of acidosis risk in the 2nd stage of labor. METHODS Using a retrospective research database evaluation, we evaluated FSSPHBE data from 475 high-risk parturients monitored in labor and their neonates for 1 h postpartum. We categorized specimens according to cervical dilatation (CxD) at the time of FSSPHBE and developed non-parametric, multiples of the median (MOMs) assessments. FRI scores and their change over time were used as predictors of FSSPHBE. Our main outcome measures were the changes in BE and pH at different cervical dilatations (CxD) and acidosis risk in the early 2nd stage of labor. RESULTS FSSPHBE worsens over the course of the 1st stage. The implications of any given BE are very different depending upon CxD. At 9 cm, -8 Mmol/L is 1.1 MOM; at 3 cm, it would be 2.0 MOM. The FRI level and its trajectory provide a 1st stage screening tool for acidosis risk in the second stage. CONCLUSIONS Fetal acid-base balance ("reserve") deteriorates beginning early in the 1st stage of labor, irrespective of whether the fetus reaches a critical threshold of concern for actual acidosis. The use of MoM's logic improves appreciation of such information. The FRI and its trajectory reasonably approximate the trajectory of the FSSPHBE and appears to be a suitable screening test for early deterioration and for earlier interventions to keep the fetus out of trouble rather than wait until high risk status develops.
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Affiliation(s)
- Mark I Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA.,Departments of Obstetrics and Gynecology, Icahn School of Medicine at Mt. Sinai, New York, NY, USA
| | - David W Britt
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA
| | - Robert D Eden
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA.,SUNY Syracuse, New York, NY, USA
| | - Shara M Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA.,Departement of Maternal Child Health, Gillings School of Public Health, University of North Carolina at Chapel Hill Chapel Hill, NC, USA
| | - Barry S Schifrin
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY, USA
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15
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Romagnoli S, Sbrollini A, Burattini L, Marcantoni I, Morettini M, Burattini L. Annotation dataset of the cardiotocographic recordings constituting the "CTU-CHB intra-partum CTG database". Data Brief 2020; 31:105690. [PMID: 32490069 PMCID: PMC7256311 DOI: 10.1016/j.dib.2020.105690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/09/2020] [Accepted: 05/04/2020] [Indexed: 11/30/2022] Open
Abstract
The proposed dataset provides annotations for the 552 cardiotocographic (CTG) recordings included in the publicly available "CTU-CHB intra-partum CTG database" from Physionet (https://physionet.org/content/ctu-uhb-ctgdb/1.0.0/). Each CTG recording is composed by two simultaneously acquired signals: i) the fetal heart rate (FHR) and ii) the maternal tocogram (representing uterine activity). Annotations consist in the detection of starting and ending points of specific CTG events on both FHR signal and maternal tocogram. Annotated events for the FHR signal are the bradycardia, tachycardia, acceleration and deceleration episodes. Annotated events for the maternal tocogram are the uterine contractions. The dataset also reports classification of each deceleration as early, late, variable or prolonged, in relation to the presence of a uterine contraction. Annotations were obtained by an expert gynecologist with the support of CTG Analyzer, a dedicated software application for automatic analysis of digital CTG recordings. These annotations can be useful in the development, testing and comparison of algorithms for the automatic analysis of digital CTG recordings, which can make CTG interpretation more objective and independent from clinician's experience.
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Affiliation(s)
- Sofia Romagnoli
- Cardiovascular Bioengineering Lab, Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Agnese Sbrollini
- Cardiovascular Bioengineering Lab, Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Luca Burattini
- Obstetric and Gynecology Clinic, Ospedali Riuniti di Ancona (Salesi Hospital), Ancona, Italy
| | - Ilaria Marcantoni
- Cardiovascular Bioengineering Lab, Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Micaela Morettini
- Cardiovascular Bioengineering Lab, Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
| | - Laura Burattini
- Cardiovascular Bioengineering Lab, Department of Information Engineering, Università Politecnica delle Marche, Ancona, Italy
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Knupp RJ, Andrews WW, Tita ATN. The future of electronic fetal monitoring. Best Pract Res Clin Obstet Gynaecol 2020; 67:44-52. [PMID: 32299728 DOI: 10.1016/j.bpobgyn.2020.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 12/14/2022]
Abstract
Continuous electronic fetal monitoring (EFM) was first introduced commercially over 50 years ago with the hope of improving perinatal outcomes during labor. However, despite the increased use of EFM, definitive improvements in perinatal outcomes have not been demonstrated. Variance in tracing interpretation and intervention has led to increased rates of cesarean and operative vaginal deliveries and perhaps increased maternal and neonatal morbidity. Since its inception, several strategies have been developed in hopes of optimizing EFM and improving these outcomes. We discuss the current standards of intrapartum fetal monitoring and review optimization strategies and technologies in development to improve intrapartum fetal monitoring.
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Affiliation(s)
- Rubymel Jijón Knupp
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - William W Andrews
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, AL, USA
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17
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Britt DW, Evans MI, Schifrin BS, Eden RD. Refining the Prediction and Prevention of Emergency Operative Deliveries with the Fetal Reserve Index. Fetal Diagn Ther 2018; 46:159-165. [PMID: 30463080 DOI: 10.1159/000494617] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 10/17/2018] [Indexed: 11/19/2022]
Abstract
Electronic fetal monitoring (EFM) is a poor predictor of outcomes attributable to delivery problems. Contextualizing EFM by adding maternal, obstetrical, and fetal risk-related information to create an index called the Fetal Reserve Index (FRI) improves the predictive capacity and facilitates the timing of interventions. Here, we test critical assumptions of FRI as a clinical tool. Our conceptualization implies that the earlier one reaches the red zone (FRI ≤25) and the longer one spends in the red zone, the greater the likelihood of emergency operative deliveries (EOD). METHODS We analyzed 1,402 patients using logistic regression predicting the probability of EOD and employed qualitative methodology techniques to refine predictive capabilities. RESULTS Reaching the red zone early and staying there > 1 h increases the probability of EOD. When these risk factors are paired with intrauterine resuscitation (IR) in Stage 1, the reduction of EOD is substantial. CONCLUSION FRI is a capable predictor of EOD because it accurately identifies the level of malleable risk. FRI analysis increases the risk of using IR in Stage 1. Matching risk and resources dramatically reduces the chances of EOD. Earlier IR improves the outcomes if the calculated risk is high.
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Affiliation(s)
- David W Britt
- Fetal Medicine Foundation of America, New York, New York, USA
| | - Mark I Evans
- Fetal Medicine Foundation of America, New York, New York, USA.,Comprehensive Genetics, PLLC/Department of Obstetrics and Gynecology, Mt. Sinai School of Medicine, New York, New York, USA
| | | | - Robert D Eden
- Fetal Medicine Foundation of America, New York, New York, USA
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Diejomaoh MFE, Al-Jassar W, Bello Z, Karunakaran K, Mohammed A. The Relevance of the Second Cesarean Delivery in the Reduction of Institutional Cesarean Delivery Rates. Med Princ Pract 2018; 27:555-561. [PMID: 30165369 PMCID: PMC6422118 DOI: 10.1159/000493362] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Revised: 08/30/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The cesarean delivery rate has increased worldwide. The aim of our study was to assess the events associated with the second cesarean deliveries in our institution. SUBJECTS AND METHODS All cesarean deliveries at the Maternity Hospital, Kuwait, from January 1 to December 31, 2013, were identified. A comparative study was undertaken on patients having their first and second cesarean deliveries. The social and clinical characteristics of these patients were extracted from our records and the antenatal, intrapartum, and postpartum course of the pregnancies and their outcomes documented. RESULTS During the study period, 10,586 deliveries were recorded, including 3,676 cesarean deliveries, i.e., a cesarean delivery rate of 34.7%. 840 of these patients were undergoing their first cesarean delivery (group A) and 607 patients were undergoing their second (group B); 484 patients from group A and 341 patients from group B with complete records were analyzed. Mean age (30.89 ± 4.93 vs. 29.94 ± 5.56 years, p = 0.008), parity (1.49 ± 1.22 vs. 0.98 ± 1.60, p < 0.0001), gestational age at delivery (38.12 ± 2.61 vs. 37.66 ± 3.11 weeks, p = 0.02), and fetal birth weight (3,211.60 ± 691.51 vs. 2,829.73 ± 863.26 g, p < 0.001) were significantly higher in group B than in group A. 53.2% of the patients in group B requested repeat cesarean delivery, their second cesarean. The rate of maternal morbidity was low. CONCLUSIONS The incidence of repeat cesarean delivery in group B is high, and its reduction should contribute to a lowering of the overall cesarean delivery rate.
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Affiliation(s)
- Michael F E Diejomaoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat,
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat,
| | - Waleed Al-Jassar
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat, Kuwait
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat, Kuwait
| | - Zainab Bello
- Department of Obstetrics and Gynecology, Maternity Hospital, Safat, Kuwait
| | | | - Asiya Mohammed
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kuwait University, Safat, Kuwait
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19
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Abstract
Electronic fetal monitoring (EFM) is widely used to assess fetal status in labor. Use of intrapartum continuous EFM is associated with a lower risk of neonatal seizures but a higher risk of cesarean or operative delivery. Category II fetal heart tracings (FHTs) are indeterminate in their ability to predict fetal acidemia. Certain patterns of decelerations and variability within this category may be predictive of neonatal morbidity. Adjunct tests of fetal well-being can be used during labor to further triage patients. Intrauterine resuscitation techniques should target the suspected etiology of intrapartum fetal hypoxia. Clinical factors play a role in the interpretation of EFM.
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Affiliation(s)
- Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Maternity Building, 5th Floor, St Louis, MO 63110, USA.
| | - Alison G Cahill
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Washington University School of Medicine in St. Louis, 660 South Euclid Avenue, Maternity Building, 5th Floor, St Louis, MO 63110, USA
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20
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Sartwelle TP, Johnston JC, Arda B. A half century of electronic fetal monitoring and bioethics: silence speaks louder than words. Matern Health Neonatol Perinatol 2017; 3:21. [PMID: 29201387 PMCID: PMC5697350 DOI: 10.1186/s40748-017-0060-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 09/08/2017] [Indexed: 11/10/2022] Open
Abstract
Bioethics abolished the prevailing Hippocratic tenet instructing physicians to make treatment decisions, replacing it with autonomy through informed consent. Informed consent allows the patient to choose treatment after options are explained by the physician. The appearance of bioethics in 1970 coincided with the introduction of electronic fetal monitoring (EFM), which evolved to become the fetal surveillance modality of choice for virtually all women in labor. Autonomy rapidly pervaded all medical procedures, but there was a clear exemption for EFM. Even today, EFM remains immune to the doctrine of informed consent despite continually mounting evidence which proves the procedure is nothing more than myth, illusion and junk science that subjects mothers and babies alike to increased risks of morbidity and mortality. And ethicists have remained utterly silent through a half century of EFM misuse. Our article explores this egregious ethical failure by reviewing EFM's lack of clinical efficacy, discussing the EFM related harm to mothers and babies, and focusing on the reasons that this obstetrical procedure eluded the revolutionary change from the Hippocratic tradition to autonomy through informed consent.
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Affiliation(s)
| | - James C. Johnston
- 1150 N Loop 1604 W, Ste 108-625, San Antonio, TX 98110 USA
- Global Neurology Consultants, Auckland, New Zealand
| | - Berna Arda
- Department of Medical Ethics, University of Ankara, Ankara, Turkey
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21
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Akhavan S, Lak P, Rahimi-Sharbaf F, Mohammadi SR, Shirazi M. Admission Test and Pregnancy Outcome. Iran J Med Sci 2017; 42:362-368. [PMID: 28761202 PMCID: PMC5523043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The admission test (AT) has been carried out for many years, but there are still debates about the prognostic value of the test. Therefore, we aimed to examine the value of the AT in predicting the adverse outcome in neonates. METHODS In this cross-sectional study, 425 pregnant women with normal vaginal delivery were studied between2009 and 2014at Vali-e-Asr Hospital. Based on the results, the women were divided into 2groups of normal and abnormal ATs. All the patients were followed up until the birth of their baby, when the status of mother and neonate was determined. The main outcomes of the study were cesarean rate, neonatal intensive care unit (NICU) admission, fetus demise, neonatal acidosis, and Apgar score. The independent t-test, chi-square test, Fisher exact test, and logistic regression were used for statistical analysis. The data were analyzed using SPSS (version 17). RESULTS Of 425 pregnant women studied, 142 (33.4%) had abnormal ATs with a mean age of 29 (±4.5) years. Multivariate analysis showed that an abnormal AT was able to predict the incidence of cesarean section, intrauterine growth restriction, turned cord, and Apgar<7, but it could not predict neonatal death and hypoxia. CONCLUSION The AT was shown to be a useful screening test with risk factors such as oligohydramnios, bloody amniotic fluid, meconium amniotic fluid, intrauterine growth restriction, and turned cord. Additionally, the test was also able to predict NICU admission and the need for cesarean section, but it could not predict the occurrence of neonatal death.
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Affiliation(s)
- Setareh Akhavan
- Department of Gynecology, Tehran University of Medical Sciences, Tehran, Iran
| | - Parvaneh Lak
- Department of Obstetrics and Gynaecology, Shaheed Chamran Hospital, Iran University of Medical Sciences, Tehran, Iran
| | | | | | - Mahboobeh Shirazi
- Maternal Fetal and Neonatal Research Center, Tehran University of Medical Sciences, Tehran, Iran,Correspondence: Mahboobeh Shirazi, MD; Department of Obstetrics and Gynaecology, Yas Hospital, Karim Khan Blvd, Ostad Nejatollahi St, Tehran, Iran Tel: +98 912 3903352 Fax: +98 21 88948217
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22
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Mugyenyi GR, Atukunda EC, Ngonzi J, Boatin A, Wylie BJ, Haberer JE. Functionality and acceptability of a wireless fetal heart rate monitoring device in term pregnant women in rural Southwestern Uganda. BMC Pregnancy Childbirth 2017; 17:178. [PMID: 28595604 PMCID: PMC5465540 DOI: 10.1186/s12884-017-1361-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 05/31/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Over 3 million stillbirths occur annually in sub Saharan Africa; most occur intrapartum and are largely preventable. The standard of care for fetal heart rate (FHR) assessment in most sub-Saharan African settings is a Pinard Stethoscope, limiting observation to one person, at one point in time. We aimed to test the functionality and acceptability of a wireless FHR monitor that could allow for expanded monitoring capacity in rural Southwestern Uganda. METHODS In a mixed method prospective study, we enrolled 1) non-laboring healthy term pregnant women to wear the device for 30 min and 2) non-study clinicians to observe its use. The battery-powered prototype uses Doppler technology to measure fetal cardiotocographs (CTG), which are displayed via an android device and wirelessly transmit to cloud storage where they are accessible via a password protected website. Prototype functionality was assessed by the ability to obtain and transmit a 30-min CTG. Three obstetricians independently rated CTGs for readability and agreement between raters was calculated. All participants completed interviews on acceptability. RESULTS Fifty pregnant women and 7 clinicians were enrolled. 46 (92.0%) CTGs were successfully recorded and stored. Mean scores for readability were 4.71, 4.71 and 4.83 (out of 5) with high agreement (intra class correlation 0.84; 95% CI 0.74 to 0.91). All pregnant women reported liking or really liking the device, as well as high levels of comfort, flexibility and usefulness of the prototype; all would recommend it to others. Clinicians described the prototype as portable, flexible, easy-to-use and a time saver. Adequate education for clinicians and women also seemed to improve correct usage and minimise concerns on safety of the device. CONCLUSIONS This prototype wireless FHR monitor functioned well in a low-resource setting and was found to be acceptable and useful to both pregnant women and clinicians. The device also seemed to have potential to improve the experience of the users compared with standard of care and expand monitoring capacity in settings where bulky, wired or traditional equipment are unreliable. Further research needs to investigate the potential impact and cost of such innovations to improve perinatal outcomes.
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Affiliation(s)
- Godfrey R Mugyenyi
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Esther C Atukunda
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Joseph Ngonzi
- Mbarara University of Science and Technology, Mbarara, Uganda
- Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Adeline Boatin
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Blair J. Wylie
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
| | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, USA
- Harvard Medical School, Boston, USA
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Kapaya H, Broughton Pipkin F, Hayes-Gill B, Loughna PV. Circadian changes and sex-related differences in fetal heart rate parameters. Matern Health Neonatol Perinatol 2016; 2:9. [PMID: 27595008 PMCID: PMC5010766 DOI: 10.1186/s40748-016-0037-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/25/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous researchers have studied circadian changes in the fetal heart rate (FHR) on small sample sizes and in a strictly controlled environment. This study was undertaken to investigate these changes during the late second and third trimesters, using a portable fetal electrocardiogram recording device (Monica AN24) in pregnant women in home and hospital environments with unrestricted mobility. METHODS This was a prospective cohort study of 54 pregnant women with uncomplicated singleton pregnancies between 25 and 40 weeks gestation. FHR recordings were made up to 16 h at home or in the hospital setting in the United Kingdom. FHR data over 90 min periods were averaged and the day (7:00 am-11:00 pm) and night (11:00 pm-7:00 am) data from the same individual were compared. Data were examined for evidence of sex-related differences. RESULTS During the night, there was a significant reduction in basal heart rate (bFHR) and a significant increase in short term variation (STV) and long term variation (LTV) (P < 0.05). Basal FHR decreased (P < 0.002), whereas LTV increased (P = 0.014) with advancing gestation. Male fetuses showed greater day: night variation than females regardless of gestation (P = 0.014). There was a higher bFHR in fetuses monitored during the day in hospital (P = 0.04). CONCLUSION This study demonstrates that there are sex-, environment and time-related differences in the FHR parameters measured. These differences may need to be considered taken when interpreting FHR data.
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Affiliation(s)
- Habiba Kapaya
- Department of Oncology and Metabolism, Academic Unit of Reproductive & Developmental Medicine, 4th Floor Jessop Wing, Tree Root Walk, Sheffield, S102SF UK
| | - Fiona Broughton Pipkin
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, NG7 2RD UK
| | - Barrie Hayes-Gill
- Electrical Systems and Optics Research Division, University of Nottingham, University Park, Nottingham, NG7 2RD UK
| | - Pamela V Loughna
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, NG7 2RD UK
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24
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Abstract
A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.
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Affiliation(s)
- James C Johnston
- Legal Medicine Consultants, 1150 N Loop 1604 West, Suite 108-625, San Antonio, TX 78248, USA.
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen 5021, Norway
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25
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Yeom GJ, Kim IO. Development and Effects of Supplementary Material about Electronic Fetal Monitoring for Nursing Students. Korean J Women Health Nurs 2016; 22:21-29. [PMID: 37684840 DOI: 10.4069/kjwhn.2016.22.1.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 03/08/2016] [Accepted: 03/13/2016] [Indexed: 09/10/2023] Open
Abstract
PURPOSE This study aimed to develop supplementary material about the electronic fetal monitoring for nursing students, and to test the effects on electronic fetal monitoring related knowledge and confidence on nursing performance in delivery room. METHODS Totally 58 nursing students were recruited either experimental group (n=30) or a control group (n=28). A non-equivalent control group pretest-posttest design was employed to test the effects on fetal monitoring related knowledge and confidence on nursing performance in delivery room. The supplementary material about the electronic fetal monitoring was developed based on Analysis, Design, Development, Implement and Evaluation (ADDIE) model. Fetal monitoring related knowledge and confidence on nursing performance in delivery room were self-reported by the scales that author developed. Data were collected at pre-test and after the 6-week intervention. RESULTS There was significant difference in confidence on nursing performance in delivery room between two groups after intervention. CONCLUSION These findings suggest the importance of the supplementary material about the electronic fetal monitoring for nursing students to improve confidence on nursing performance in delivery room.
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Affiliation(s)
- Gye Jeong Yeom
- Department of Nursing, Kyongbuk Science College, Chilgok, Korea
| | - Il Ok Kim
- Department of Nursing, Kyongbuk Science College, Chilgok, Korea
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26
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Sholapurkar SL. Imperative for improvements and international convergence of intrapartum fetal monitoring: A bird’s eye view. World J Obstet Gynecol 2016; 5:102-109. [DOI: 10.5317/wjog.v5.i1.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/25/2015] [Accepted: 11/25/2015] [Indexed: 02/05/2023] Open
Abstract
Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography (CTG) has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about significant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [definitions of fetal heart rate (FHR) parameters, CTG recording speed, 3-tier systems, etc.] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefining the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography (ECG) is discussed. The FHR decelerations are often deterministic (center-stage) in CTG interpretation and 3-tier categorization. It is discussed if their scientific and physiological classification (avoiding framing and confirmation biases) may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG (STAN) have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable (overcome human factors) and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often difficult and resource-intensive.
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27
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Sholapurkar SL. Intermittent Auscultation in Labor: Could It Be Missing Many Pathological (Late) Fetal Heart Rate Decelerations? Analytical Review and Rationale for Improvement Supported by Clinical Cases. J Clin Med Res 2015; 7:919-25. [PMID: 26566404 PMCID: PMC4625811 DOI: 10.14740/jocmr2298w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/11/2015] [Indexed: 12/12/2022] Open
Abstract
Intermittent auscultation (IA) of fetal heart rate (FHR) is recommended/preferred in low risk labors. Its usage even in developed countries is poised to increase because of perceived benefit of reduction in operative intervention and some disillusionment with the cardiotocography (CTG). Many national guidelines have stipulated regimes (frequency/timing) of IA based on level IV evidence. These tend to get faithfully and exactingly followed. It was observed that deliveries of many unexpectedly asphyxiated infants occurred despite rigorously performed and documented IA compliant with the guidelines. This triggered a reappraisal of the robustness of IA leading to this focused review supplemented by two anonymized cases. It concludes that the current methodology of IA may be flawed in that it poses a risk of missing many or most late (pathological) FHR decelerations, one of the foremost goals of IA. This is because many late decelerations reach their nadir before the end of the contraction. Thus the currently recommended auscultation of FHR for 60 seconds after the contraction by all national guidelines seemed to encompass their “recovery” phase and appeared to be misinterpreted as normal FHR or even as a reassuring accelerative pattern in the clinical practice. A recent recommendation of recording of the FHR as a single figure (rather than a range) does not remedy this anomaly and seems even less informative. It would be better to auscultate FHR before and after the contractions (or contraction to contraction) and take the FHR just before the contraction as the baseline FHR and interpret the FHR after contraction in the context of this baseline. This relatively simple improvement would detect most late FHR decelerations thus ameliorating the risk and significantly enhancing the patient safety.
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28
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Sholapurkar SL. Categorization of Fetal Heart Rate Decelerations in American and European Practice: Importance and Imperative of Avoiding Framing and Confirmation Biases. J Clin Med Res 2015; 7:672-80. [PMID: 26251680 PMCID: PMC4522983 DOI: 10.14740/jocmr2166w] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2015] [Indexed: 12/04/2022] Open
Abstract
Interpretation of electronic fetal monitoring (EFM) remains controversial and unsatisfactory. Fetal heart rate (FHR) decelerations are the commonest aberrant feature on cardiotocographs and considered “center-stage” in the interpretation of EFM. A recent American study suggested that the lack of correlation of American three-tier system to neonatal acidemia may be due to the current peculiar nomenclature of FHR decelerations leading to loss of meaning. The pioneers like Hon and Caldeyro-Barcia classified decelerations based primarily on time relationship to contractions and not on etiology per se. This critical analysis debates pros and cons of significant anchoring/framing and confirmation biases in defining different types of decelerations based primarily on the shape (slope) or time of descent. It would be important to identify benign early decelerations correctly to avoid unnecessary intervention as well as to improve the positive predictive value of the other types of decelerations. Currently the vast majority of decelerations are classed as “variable”. This review shows that the most common rapid decelerations during contractions with trough corresponding to peak of contraction cannot be explained by “cord-compression” hypothesis but by direct/pure (defined here as not mediated through baro-/chemoreceptors) or non-hypoxic vagal reflex. These decelerations are benign, most likely and mainly a result of head-compression and hence should be called “early” rather than “variable”. Standardization is important but should be appropriate and withstand scientific scrutiny. Significant framing and confirmation biases are necessarily unscientific and the succeeding three-tier interpretation systems and structures embodying these biases would be dysfunctional and clinically unhelpful. Clinical/pathophysiological analysis and avoidance of flaws/biases suggest that a more physiological and scientific categorization of decelerations should be based on time relationship to contractions alone irrespective of shape or descent time as indeed proposed by pioneers like Hon and Caldeyro-Barcia. Such meaningful categorization, apart from being a scientific necessity, could improve the practical performance of three-tier FHR interpretation systems and possibly application of dependent complementary techniques like fetal ECG/pulse oximetry/computer-aided analysis, thus facilitating future progress in the field of intrapartum fetal monitoring.
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Abstract
Electronic fetal heart rate monitoring is a widely utilized means of assessment of fetal status during labor. Whereas little evidence exists regarding efficacy, this modality continues to be used extensively in every modern labor and delivery unit in developed countries. It is of importance that all providers of health care to the woman in labor and her newborn have a clear understanding of the basic pathophysiology of fetal heart rate monitoring and an appreciation for labor course and concerns as they arise in order to optimize outcomes and patient safety.
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Affiliation(s)
- Michael P Nageotte
- Miller Children's and Women's Hospital, Long Beach, 2801 Atlantic Avenue, Long Beach, CA 90801, USA.
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30
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Philopoulos D. [ Electronic fetal monitoring and its relationship to neonatal and infant mortality in a national database: A sensitivity analysis]. J Gynecol Obstet Hum Reprod 2015; 44:451-462. [PMID: 25239158 DOI: 10.1016/j.jgyn.2014.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Revised: 06/29/2014] [Accepted: 07/08/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVE Sensitivity analysis of the association between electronic fetal monitoring and neonatal and infant mortality previously reported from a United States database. MATERIALS AND METHODS Retrospective cohort study of 11,916,806 live births linked to neonatal and infant deaths during the years 1997-2002 from the United States Centers for Disease Control's National Center of Health Statistics (NCHS) linked birth and infant death data. Restrictions were performed to exclude deliveries occurring outside of a hospital, precipitous labors, breech deliveries, eleven risk factors of pregnancy, multiple gestations, deliveries before 24 and after 44 weeks, implausible birthweights, repeat cesarean sections, and congenital anomalies. An additional analysis explored the effect of further restrictions to term births, birth weight≥2500 g, absence of maternal fever (>38°C), and absence of labor induction or augmentation. For each year, adjusted relative risks (RR) were estimated with log binomial regression. A six-year pooled association was estimated by the generic inverse variance method using a random effects model. RESULTS For the six-year period, there was a significant reduction in risk in the group with electronic fetal monitoring for early neonatal mortality (RR=0.54, 95 % CI: 0.52-0.57), late neonatal mortality (RR=0.84, 95 % CI: 0.78-0.90), post-neonatal mortality (RR=0.86, 95 % CI: 0.83-0.90), and infant mortality from all causes (RR=0.75, 95 % CI: 0.73-0.77), from perinatal causes (RR=0.60, 95 % CI: 0.57-0.63), and from hypoxia (RR=0.67, 95 % CI: 0.54-0.84). In the additional analysis, which only examined the outcome of infant mortality from all causes, there was also a significant reduction in risk (RR=0.91, 95 % CI: 0.85-0.97). CONCLUSION Using the NCHS linked birth and infant death data over a 6-year period, electronic fetal monitoring was associated with decreased neonatal and infant mortality as has been previously reported. These results were robust to two levels of restriction applied on potential confounding variables.
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Affiliation(s)
- D Philopoulos
- Cabinet Philopoulos, 22, avenue de l'Observatoire, 75014 Paris, France.
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31
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Saadia Z. Rates and indicators of Continuous Electronic fetal monitoring - A study from Saudi Arabia. Int J Health Sci (Qassim) 2015; 9:3-8. [PMID: 25901127 PMCID: PMC4394932 DOI: 10.12816/0024677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND This observational study aimed to describe the rates and indicators for continuous electronic fetal monitoring (EFM) during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above). METHODS The study was conducted at Mother and Child Hospital, Buraidah from July-Sept, 2013 as a descriptive cross sectional study. RESULTS Seventy four percent of labouring women had EFM and 25.7% had intermittent auscultation. Amongst the EFM group 62% were Primigravidas and 37.9% were multigravidas. When compared between PG and multigravidas, maconium staining (14.18vs 1.22, p value=0.001), maternal concerns for fetal heart rate (14.93 vs 6.10 p value=0.049), and syntocinon usage (14.18 vs 2.44 p value=0.005) were significantly prominent indications for Primigravidas. However trial of scar (0.00vs 15.85 p value <0.001) and associated medical problems (6.72 vs 19.51 p value 0.004) were the most frequent indications for G2 and above. For a large population of women including 13 PG and 18 Multigravidas (Overall 14.3%) there was no particular indication assigned for EFM and this was more frequent amongst Gravida2 and above (P < 0.013). CONCLUSION Electronic fetal monitoring is a very common obstetric intervention. It remains a challenge to review its rates and indications in order to identify areas that needs improvement.
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Affiliation(s)
- Zaheera Saadia
- Assistant Professor Obstetrics and Gynaecology, College of Medicine, Qassim University, Saudi Arabia
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32
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Sartwelle TP. Electronic Fetal Monitoring: A Defense Lawyer's View. Rev Obstet Gynecol 2012; 5:e121-e125. [PMID: 23483132 PMCID: PMC3594858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Electronic fetal monitoring (EFM) has been used for four decades, after its introduction without clinical trials. EFM spawned a birth injury litigation crisis centered on the myth that it predicts cerebral palsy (CP). The myth has resulted in lottery-like judgments against physicians. The American Congress of Obstetricians and Gynecologists (ACOG) and sister organizations worldwide have the power to halt EFM's clinical proliferation and the undeserved litigation verdicts against physicians unjustly blamed for causing CP. This power has been unused. If ACOG and other organizations would declare EFM unreliable, it could change the clinical standard of care and alleviate the CP-EFM malpractice lottery.
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Robinson B. A Review of NICHD Standardized Nomenclature for Cardiotocography: The Importance of Speaking a Common Language When Describing Electronic Fetal Monitoring. Rev Obstet Gynecol 2008; 1:56-60. [PMID: 18769667 PMCID: PMC2505172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Despite evidence demonstrating no neonatal benefit, the medicolegal climate in the United States requires obstetricians to integrate continuous intrapartum surveillance into their care of the pregnant laboring patient. The intent of this article is to familiarize the reader with the standardized, quantitative nomenclature recommended to describe intrapartum cardiotocography in order to reduce miscommunication among providers caring for the laboring patient.
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Affiliation(s)
- Barrett Robinson
- Maternal Fetal Medicine, Northwest Memorial Hospital Chicago, IL
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34
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Robinson B, Nelson L. A Review of the Proceedings from the 2008 NICHD Workshop on Standardized Nomenclature for Cardiotocography: Update on Definitions, Interpretative Systems With Management Strategies, and Research Priorities in Relation to Intrapartum Electronic Fetal Monitoring. Rev Obstet Gynecol 2008; 1:186-192. [PMID: 19173023 PMCID: PMC2621055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Despite evidence demonstrating no neonatal benefit, the medicolegal climate in the United States requires obstetricians to integrate continuous intrapartum surveillance into their care of the pregnant laboring patient. The intent of this article is to familiarize the reader with the most recent, standardized, quantitative nomenclature recommended to describe intrapartum CTG in order to reduce miscommunication among providers caring for the laboring patient, propagate consistent, evidence-based responses to CTG patterns, and systematize the terminology used by researchers investigating intrapartum CTG.
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Affiliation(s)
- Barrett Robinson
- Maternal Fetal Medicine, Northwestern Memorial Hospital Chicago, IL
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