Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act.

PURPOSE OF REVIEW: Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS: Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY: These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.

The use of continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals.

OBJECTIVE: Freedom of movement and choice of positioning in labour and birth is known to enhance physiological processes and positive experiences for women during childbirth. Continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies, such as wireless CTG, have been marketed for clinical use in most high resource settings since 2003 but there is a paucity of midwifery literature about its clinical use. The aim of this survey was to determine how often, and for whom, wireless and beltless technologies are being used in maternity settings across Australia and New Zealand and to identify any barriers to their uptake. DESIGN: A survey tool developed by Watson et al. (2018) for use in the United Kingdom was adapted for the Australian/New Zealand context. One Maternity Unit Manager or key midwifery clinician from each of 208 public and private hospitals across Australia and New Zealand was invited by email to participate in an online survey between October 2019 and January 2020. Descriptive statistics were used to describe the characteristics of the facilities and the frequency of availability of the monitors. Free text responses were thematically analysed. FINDINGS: The survey received a high (71%) response rate from a range of public and private hospitals in urban and rural settings. Women's freedom of movement and sense of choice and control in labour were seen by most respondents to be positively influenced by wireless monitoring technology. Most facilities reported having at least one wireless or beltless foetal monitor available, however, results suggest that many women consenting to continuous monitoring still do not have access to technology that enables freedom of movement. KEYCONCLUSIONS: Further research is required to explore the barriers and facilitators to enabling freedom of movement and positioning to all women in childbirth, including those women with complex pregnancies who may consent to continuous foetal monitoring.

Intrapartum Fetal Monitoring.

Continuous electronic fetal monitoring was developed to screen for signs of hypoxic-ischemic encephalopathy, cerebral palsy, and impending fetal death during labor. Because these events have a low prevalence, continuous electronic fetal monitoring has a false-positive rate of 99%. The widespread use of continuous electronic fetal monitoring has increased operative and cesarean delivery rates without improved neonatal outcomes, but its use is appropriate in high-risk labor. Structured intermittent auscultation is an underused form of fetal monitoring; when employed during low-risk labor, it can lower rates of operative and cesarean deliveries with neonatal outcomes similar to those of continuous electronic fetal monitoring. However, structured intermittent auscultation remains difficult to implement because of barriers in nurse staffing and physician oversight. The National Institute of Child Health and Human Development terminology is used when reviewing continuous electronic fetal monitoring and delineates fetal risk by three categories. Category I tracings reflect a lack of fetal acidosis and do not require intervention. Category II tracings are indeterminate, are present in the majority of laboring patients, and can encompass monitoring predictive of clinically normal to rapidly developing acidosis. Presence of moderate fetal heart rate variability and accelerations with absence of recurrent pathologic decelerations provides reassurance that acidosis is not present. Category II tracing abnormalities can be addressed by treating reversible causes and providing intrauterine resuscitation, which includes stopping uterine-stimulating agents, fetal scalp stimulation and/or maternal repositioning, intravenous fluids, or oxygen. Recurrent deep variable decelerations can be corrected with amnioinfusion. Category III tracings are highly concerning for fetal acidosis, and delivery should be expedited if immediate interventions do not improve the tracing.

The Goal of Continuous Fetal Heart Rate Monitoring During Labor: Have We Been Successful?

Despite its ubiquitous use, fetal heart rate (FHR) monitoring has not resulted in a significant reduction in hypoxic-ischemic encephalopathy following delivery. This manuscript reviews the reasons for this failure including limitations of FHR to accurately predict hypoxia, low prevalence of hypoxic-ischemic encephalopathy, and lack of standardization of interpretation and intervention. We propose an alternative goal for FHR monitoring during labor to provide optimal care by early identification of truly concerning features, initiation of appropriate interventions, clear documentation of concerns and plans, and clear communication between team members on labor and delivery, including initiation of the chain of command as needed.

A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses.

INTRODUCTION: Intermittent auscultation (IA) is an accepted standard of care for intrapartum fetal assessment for low-risk individuals and is the exclusive method used to monitor fetal status in birth centers. However, there are conflicting national guidelines for practice and skill training. As a result, IA technique and skills vary across the perinatal care workforce, with many health care providers receiving no or minimal formal training. This article describes the design, implementation, and evaluation of a quality improvement program aimed at strengthening the IA skills of nurse-midwives and nurses. PROCESS: The project was implemented in a multisite network of freestanding birth centers and involved clinical practice guideline development, simulation-based training, audit and feedback, in-person training, and electronic health record configuration. OUTCOMES: The training resulted in self-reported increases in knowledge in all areas assessed. The integrated quality improvement initiative resulted in substantial improvements in consistency of practice and documentation. DISCUSSION: Policy change was not sufficient to improve use of IA, a nuanced skill that many midwives and nurses have limited exposure to in basic education programs and hospital-based clinical practice. Clinical improvement was possible when the policy change was accompanied by a comprehensive training and implementation strategy including interactive, simulation-based learning, audit and feedback, and an electronic health record configuration that better reflected the documentation standards.

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study.

BACKGROUND: Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines. METHODS: A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process. RESULTS: A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2). CONCLUSIONS: Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

Fetal heart rate monitoring practices at a public hospital in Northern Uganda - what health workers document, do and say.

Background: In Uganda, perinatal mortality is 38 per 1000 pregnancies. One-third of these deaths are due to birth asphyxia. Adequate fetal heart rate (FHR) monitoring during labor may detect birth asphyxia but little is known about monitoring practices in low resource settings.Objective: To explore FHR monitoring practices among health workers at a public hospital in Northern Uganda.Methods: A sequential explanatory mixed methods study was conducted by reviewing 251 maternal records and conducting 11 interviews and two focus group discussions with health workers complemented by observations of 42 women in labor until delivery. Quantitative data were summarized using frequencies and percentages. Content analysis was used for qualitative data.Results: FHR was assessed in 235/251 (93.6%) of records at admission. Health workers documented the FHR at least once in 175/228 (76.8%) of cases during the first stage of labor compared to observed 17/25 (68.0%) cases. Median intervals between FHR monitoring were 30 (IQR 30-120) minutes in patients' records versus 139 (IQR 87-662) minutes according to observations. Observations suggested no monitoring of FHR during the second stage of labor but records indicated monitoring in 3.2% of cases. Reported barriers to adequate FHR monitoring were inadequate number of staff and monitoring devices, institutional challenges such as few beds, documentation problems and perceived non-compliant women not reporting for repeated checks during the first stage of labor. Health workers demonstrated knowledge of national FHR monitoring guidelines and acknowledged that practice was different.Conclusions: When compared to national and international guidelines, FHR monitoring is sub-optimal in the studied setting. Approximately one in four women was not monitored during the first stage of labor. Barriers to appropriate FHR monitoring included shortage of staff and devices, institutional challenges and mother's negative attitudes. These barriers need to be addressed in order to reduce neonatal mortality.

Relative accuracy of computerized intrapartum fetal heart rate pattern recognition by ultrasound and abdominal electrocardiogram detection.

INTRODUCTION: Noninvasive fetal heart rate monitoring using transabdominal fetal electrocardiographic detection is now commercially available and has been demonstrated to be an effective alternative to traditional Doppler ultrasonographic techniques. Our objective in this study was to compare the results of computerized identification of fetal heart rate patterns generated by ultrasound-based and transabdominal fetal electrocardiogram-based techniques with simultaneously obtained fetal scalp electrode-derived heart rate information. MATERIAL AND METHODS: We applied an objective computer-based analysis for recognition of fetal heart rate patterns (Monica Decision Support) to data obtained simultaneously from a direct fetal scalp electrode, Doppler ultrasound, and the abdominal-fetal electrocardiogram techniques. This allowed us to compare over 145 hours of fetal heart rate patterns generated by the external devices with those derived from the scalp electrode in 30 term singleton uncomplicated pregnancies during labor. The direct fetal scalp electrode is considered to be the most accurate and reliable technique used in current clinical practice, and was, therefore, used as the standard for comparison. The program quantified the baseline heart rate, long- and short-term variability. It indicated when an acceleration or deceleration was present and whether it was large or small. RESULTS: Ultrasound was associated with significantly greater deviations from the fetal scalp electrode results than the abdominal fetal electrocardiogram technique in recognizing the correct baseline heart rate, its variability, and the presence of small and large accelerations and small decelerations. For large decelerations the two external methods were each not significantly different from the scalp electrode results. CONCLUSIONS: Noninvasive fetal heart rate monitoring using maternal abdominal wall electrodes to detect fetal cardiac activity more reliably reproduced the computerized analysis of heart rate patterns derived from a direct fetal scalp electrode than did traditional ultrasound-based monitoring. Abdominal-fetal electrocardiogram should, therefore, be considered a primary option for externally monitored patients.

Delphi consensus statement on intrapartum fetal monitoring in low-resource settings.

OBJECTIVE: To determine acceptable and achievable strategies of intrapartum fetal monitoring in busy low-resource settings. METHODS: Three rounds of online Delphi surveys were conducted between January 1 and October 31, 2017. International experts with experience in low-resource settings scored the importance of intrapartum fetal monitoring methods. RESULTS: 71 experts completed all three rounds (28 midwives, 43 obstetricians). Consensus was reached on (1) need for an admission test, (2) handheld Doppler for intrapartum fetal monitoring, (3) intermittent auscultation (IA) every 30 minutes for low-risk pregnancies during the first stage of labor and after every contraction for high-risk pregnancies in the second stage, (4) contraction monitoring hourly for low-risk pregnancies in the first stage, and (5) adjunctive tests. Consensus was not reached on frequency of IA or contraction monitoring for high-risk women in the first stage or low-risk women in the second stage of labor. CONCLUSION: There is a gap between international recommendations and what is physically possible in many labor wards in low-resource settings. Research on how to effectively implement the consensus on fetal assessment at admission and use of handheld Doppler during labor and delivery is crucial to support staff in achieving the best possible care in low-resource settings.

Labour & delivery monitoring patterns in facility births across five districts of India: A cross-sectional observational study.

BACKGROUND & OBJECTIVES: India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India. METHODS: A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets. RESULTS: A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases. INTERPRETATION & CONCLUSIONS: The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.

Reevaluation of intrapartum fetal monitoring using fetal oximetry: A review.

AIM: Although several studies reported the measurement of fetal oxygen saturation using fetal pulse oximetry (FPO) for evaluation of the fetal intrapartum condition, a systematic review of the seven randomized controlled trials (RCTs) provided no evidence to support FPO for intrapartum fetal monitoring. In the present review, we re-evaluate an overview for the use of FPO and seven RCTs of FPO. METHODS: We reviewed numerous previous reports on FPO and seven RCTs of intrapartum FPO. RCTs were conducted with the main outcome measure being a reduction in the cesarean section rate. RESULTS: The largest trial with 5341 entries failed to show any reduction. The negative result from this RCT may be explained by the use of a different cutoff value for fetal oxygen saturation compared to the other RCT; in addition, there were differences in the indications for cesarean section due to dystocia and in the definition of non-reassuring fetal status (NRFS). An abnormal FPO value, defined as the fetal oxygen saturation value <30% for at least 10 min, is useful for making a diagnosis of fetal acidosis. A newly developed device, an examiner's finger-mounted tissue oximetry, accurately measures tissue oxygen saturation while overcoming the drawbacks of FPO, such as infection risk and slipping off of the sensor during descent of the fetal head. CONCLUSION: FPO (including the new device) with fetal heart rate monitoring in selected cases of NRFS may reduce the cesarean section rate.

Non-invasive fetal monitoring using electrocardiography and phonocardiography: A preliminary study.

BACKGROUND: Continuous fetal monitoring is commonly used during pregnancy and labor to assess fetal wellbeing. The most often used technology is cardiotocography (CTG), but this technique has major drawbacks in clinical use. OBJECTIVES: Our aim is to test a non-invasive multimodal technique of fetal monitoring using phonocardiography (PCG) and electrocardiography (ECG) and to evaluate its feasibility in clinical practice, by comparison with CTG. METHODS: This prospective open label study took place in a French university hospital. PCG and ECG signals were recorded using abdominal and thoracic sensors from antepartum women during the second half of pregnancy, simultaneously with CTG recording. Signals were then processed to extract fetal PCG and ECG and estimate fetal heart rate (FHR). RESULTS: A total of 9 sets of recordings were evaluated. Very accurate fetal ECG and fetal PCG signals were recorded, enabling us to obtain FHR for several subjects. The FHR calculated from ECG was highly correlated with the FHR from the CTG reference (from 74% to 84% of correlation). CONCLUSION: This work with preliminary signal processing algorithms proves the feasibility of the approach and constitutes the beginnings of a unique database that is needed to improve and validate the signal processing algorithms.

A Standardized Approach for Category II Fetal Heart Rate with Significant Decelerations: Maternal and Neonatal Outcomes.

OBJECTIVE: To determine if a standardized intervention process for Category II fetal heart rates (FHRs) with significant decels (SigDecels) would improve neonatal outcome and to determine the impact on mode of delivery rates. STUDY DESIGN: Patients with Category II FHRs from six hospitals were prospectively managed using a standardized approach based on the presence of recurrent SigDecels. Maternal and neonatal outcomes were compared between pre- (6 months) and post-(11 months) implementation. Neonatal outcomes were: 5-minute APGAR scores of <7, <5, <3, and severe unexpected newborn complications (UNC). Maternal outcomes included primary cesarean and operative vaginal birth rates of eligible deliveries. RESULTS: Post implementation there were 8,515 eligible deliveries, 3,799 (44.6%) were screened, and 361 (9.5%) met criteria for recurrent SigDecels. Compliance with the algorithm was 97.8%. The algorithm recommended delivery in 68.0% of cases. Relative to pre-implementation, 5-minute APGAR score of <7 were reduced by 24.6% (p < 0.05) and severe UNC by -26.6%, p = < .05. The rate of primary cesarean decreased (19.8 vs 18.3%, p < 0.05), while there were nonsignificant increases in vaginal (74.6 vs 75.8%, p = 0.13) and operative vaginal births (5.7 vs 5.9%, p = 0.6). CONCLUSION: Standardized management of recurrent SigDecels reduced the rate of 5-minute APGAR scores of < 7 and severe UNC.

An evaluation by the Norwegian Health Care Supervision Authorities of events involving death or injuries in maternity care.

INTRODUCTION: We aimed to determine how serious adverse events in obstetrics were assessed by supervision authorities. MATERIAL AND METHODS: We selected cases investigated by supervision authorities during 2009-2013. We analyzed information about who reported the event, the outcomes of the mother and infant, and whether events resulted from errors at the individual or system level. We also assessed whether the injuries could have been avoided. RESULTS: During the study period, there were 303 034 births in Norway, and supervision authorities investigated 338 adverse events in obstetric care. Of these, we studied 207 cases that involved a serious outcome for mother or infant. Five mothers (2.4%) and 88 infants (42.5%) died. Of the 207 events reported to the supervision authorities, patients or relatives reported 65.2%, hospitals reported 39.1%, and others reported 4.3%. In 8.7% of cases, events were reported by more than 1 source. The supervision authority assessments showed that 48.3% of the reported cases involved serious errors in the provision of health care, and a system error was the most common cause. We found that supervision authorities investigated significantly more events in small and medium-sized maternity units than in large units. Eighteen health personnel received reactions; 15 were given a warning, and 3 had their authority limited. We determined that 45.9% of the events were avoidable. CONCLUSIONS: The supervision authorities investigated 1 in 1000 births, mainly in response to complaints issued from patients or relatives. System errors were the most common cause of deficiencies in maternity care.

No. 197b-Fetal Health Surveillance: Intrapartum Consensus Guideline.

OBJECTIVE: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide intrapartum care in Canada. OPTIONS: Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: LABOUR SUPPORT DURING ACTIVE LABOUR: RECOMMENDATION 2: PROFESSIONAL ONE-TO ONE CARE AND INTRAPARTUM FETAL SURVEILLANCE: RECOMMENDATION 3: INTERMITTENT AUSCULTATION IN LABOUR: RECOMMENDATION 4: ADMISSION FETAL HEART TEST: RECOMMENDATION 5: INTRAPARTUM FETAL SURVEILLANCE FOR WOMEN WITH RISK FACTORS FOR ADVERSE PERINATAL OUTCOME: When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased (III-B). RECOMMENDATION 6: DIGITAL FETAL SCALP STIMULATION: RECOMMENDATION 7: FETAL SCALP BLOOD SAMPLING: RECOMMENDATION 8: UMBILICAL CORD BLOOD GASES: RECOMMENDATION 9: FETAL PULSE OXIMETRY: RECOMMENDATION 10: ST WAVEFORM ANALYSIS: RECOMMENDATION 11: INTRAPARTUM FETAL SCALP LACTATE TESTING.

No. 197a-Fetal Health Surveillance: Antepartum Consensus Guideline.

OBJECTIVE: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum care in Canada. OPTIONS: Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance antepartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). SPONSOR: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program. RECOMMENDATION 1: FETAL MOVEMENT COUNTING: RECOMMENDATION 2: NON-STRESS TEST: RECOMMENDATION 3: CONTRACTION STRESS TEST: RECOMMENDATION 4: BIOPHYSICAL PROFILE: RECOMMENDATION 5: UTERINE ARTERY DOPPLER: RECOMMENDATION 6: UMBILICAL ARTERY DOPPLER.

Monitoring fetal growth in settings with limited ultrasound access.

Abnormal fetal growth significantly increases neonatal mortality and the risk of stillbirth. This creates the need for accurately monitoring fetal growth in all pregnancies regardless of the risk status. Several methods used in clinical practice include abdominal palpation, symphysio-fundal height measurements, and obstetric ultrasound. Of these, obstetric ultrasound remains the most reliable and objective way to monitor fetal growth. However, in most low-resource areas, access to obstetric ultrasound remains poor and this leaves the two as the only options available. This not only has effect on fetal growth monitoring but more importantly on the accuracy of pregnancy dating. To improve the current situation, we propose strategies for training of health workers, educating the public on importance of obstetric ultrasound, and improving access to basic equipment. However, interim solutions have to be implemented hand in hand with other strategies to ensure universal access to ultrasound technology for fetal growth monitoring.