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

INTRODUCTION: ST waveform analysis (STAN) was introduced as an adjunct to cardiotocography (CTG) to improve neonatal and maternal outcomes. The aim of the present study was to quantify the efficacy of STAN vs CTG and assess the quality of the evidence using GRADE. MATERIAL AND METHODS: We performed systematic literature searches to identify randomized controlled trials and assessed included studies for risk of bias. We performed meta-analyses, calculating pooled risk ratio (RR) or Peto odds ratio (OR). We also performed post hoc trial sequential analyses for selected outcomes to assess the risk of false-positive results and the need for additional studies. RESULTS: Nine randomized controlled trials including 28 729 women were included in the meta-analysis. There were no differences between the groups in operative deliveries for fetal distress (10.9 vs 11.1%; RR 0.96; 95% confidence interval [CI] 0.82-1.11). STAN was associated with a significantly lower rate of metabolic acidosis (0.45% vs 0.68%; Peto OR 0.66; 95% CI 0.48-0.90). Accordingly, 441 women need to be monitored with STAN instead of CTG alone to prevent one case of metabolic acidosis. Women allocated to STAN had a reduced risk of fetal blood sampling compared with women allocated to conventional CTG monitoring (12.5% vs 19.6%; RR 0.62; 95% CI 0.49-0.80). The quality of the evidence was high to moderate. CONCLUSIONS: Absolute effects of STAN were minor and the clinical significance of the observed reduction in metabolic acidosis is questioned. There is insufficient evidence to state that STAN as an adjunct to CTG leads to important clinical benefits compared with CTG alone.

Neonatal outcomes associated with time from a high fetal blood lactate concentration to operative delivery.

INTRODUCTION: Adjunctive technologies to cardiotocography intend to increase the specificity of the diagnosis of fetal hypoxia. If correctly diagnosed, time to delivery could affect neonatal outcome. In the present study, we aimed to investigate the effect of time from when fetal distress is indicated by a high fetal blood sample (FBS) lactate concentration to operative delivery on the risk of adverse neonatal outcomes. MATERIAL AND METHODS: We conducted a prospective observational study. Deliveries with a singleton fetus in cephalic presentation at 36+0 weeks of gestation or later were included. Adverse neonatal outcomes, related to decision-to-delivery interval (DDI), were investigated in operative deliveries indicated by an FBS lactate concentration of at least 4.8 mmol/L. We applied logistic regression to estimate crude and adjusted odds ratios (aOR) of various adverse neonatal outcomes, with associated 95% confidence intervals (CI), for a DDI exceeding 20 minutes, compared with a DDI of 20 minutes or less. CLINICALTRIALS: gov Identifier: NCT04779294. RESULTS: The main analysis included 228 women with an operative delivery indicated by an FBS lactate concentration of 4.8 mmol/L or greater. The risk of all adverse neonatal outcomes was significantly increased for both DDI groups compared with the reference group (deliveries with an FBS lactate below 4.2 mmol/L within 60 minutes before delivery). In operative deliveries indicated by an FBS lactate concentration of 4.8 mmol/L or more, there was a significantly increased risk of a 5-minute Apgar score less than 7 if the DDI exceeded 20 minutes, compared with a DDI of 20 minutes or less (aOR 8.1, 95% CI 1.1-60.9). We found no statistically significant effect on other short-term outcomes for deliveries with DDI longer than 20 minutes, compared with those with DDI of 20 minutes or less (pH ≤7.10: aOR 2.0, 95% CI 0.5-8.4; transfer to the neonatal intensive care unit: aOR 1.1, 95% CI 0.4-3.5). CONCLUSIONS: After a high FBS lactate measurement, the increased risk of adverse neonatal outcome is further augmented if the DDI exceeds 20 minutes. These findings give support to current Norwegian guidelines for intervention in cases of fetal distress.

Deep learning based fetal distress detection from time frequency representation of cardiotocogram signal using Morse wavelet: research study.

BACKGROUND: Clinically cardiotocography is a technique which is used to monitor and evaluate the level of fetal distress. Even though, CTG is the most widely used device to monitor determine the fetus health, existence of high false positive result from the visual interpretation has a significant contribution to unnecessary surgical delivery or delayed intervention. OBJECTIVE: In the current study an innovative computer aided fetal distress diagnosing model is developed by using time frequency representation of FHR signal using generalized Morse wavelet and the concept of transfer learning of pre-trained ResNet 50 deep neural network model. METHOD: From the CTG data that is obtained from the only open access CTU-UHB data base only FHR signal is extracted and preprocessed to remove noises and spikes. After preprocessing the time frequency information of FHR signal is extracted by using generalized Morse wavelet and fed to a pre-trained ResNet 50 model which is fine tuned and configured according to the dataset. MAIN OUTCOME MEASURES: Sensitivity (Se), specificity (Sp) and accuracy (Acc) of the model adopted from binary confusion matrix is used as outcome measures. RESULT: After successfully training the model, a comprehensive experimentation of testing is conducted for FHR data for which a recording is made during early stage of labor and last stage of labor. Thus, a promising classification result which is accuracy of 98.7%, sensitivity of 97.0% and specificity 100% are achieved for FHR signal of 1st stage of labor. For FHR recorded in last stage of labor, accuracy of 96.1%, sensitivity of 94.1% and specificity 97.7% are achieved. CONCLUSION: The developed model can be used as a decision-making aid system for obstetrician and gynecologist.

Chikungunya infection in pregnancy - reassuring maternal and perinatal outcomes: a retrospective observational study.

OBJECTIVE: To evaluate pregnancy and neonatal outcomes, disease severity, and mother-to-child transmission of pregnant women with Chikungunya infection (CHIKV). DESIGN: Retrospective observational study. SETTING: Grenada. POPULATION: Women who gave birth during a Chikungunya outbreak between January 2014 and September 2015 were eligible. METHODS: This descriptive study investigated 731 mother-infant pairs who gave birth during a CHIKV outbreak. Women and infants underwent serological testing for CHIKV by ELISA. MAIN OUTCOME MEASURES: Primary outcomes: composite pregnancy complication (abruption, vaginal bleeding, preterm labour/cervical incompetence, cesarean delivery for fetal distress/abruption/placental abnormality or delivery for fetal distress) and composite neonatal morbidity. RESULTS: Of 416 mother-infant pairs, 150 (36%) had CHIKV during pregnancy, 135 (33%) had never had CHIKV, and 131 (31%) had CHIKV outside of pregnancy. Mean duration of joint pain was shorter among women infected during pregnancy (µ = 898 days, σ = 277 days) compared with infections outside of pregnancy (µ = 1064 days, σ = 244 days) (P < 0.0001). Rates of pregnancy complications (RR = 0.76, P = 0.599), intrapartum complications (RR = 1.50, P = 0.633), and neonatal outcomes were otherwise similar. Possible mother-to-child transmission occurred in two (1.3%) mother-infant pairs and two of eight intrapartum infections (25%). CONCLUSION: CHIKV infection during pregnancy may be protective against long-term joint pain sequelae that are often associated with acute CHIKV infection. Infection during pregnancy did not appear to pose a risk for pregnancy complications or neonatal health, but maternal infection just prior to delivery might have increased risk of mother-to-child transmission of CHIKV. TWEETABLE ABSTRACT: Chikungunya infection did not increase risk of pregnancy complications or adverse neonatal outcomes, unless infection was just prior to delivery.

Reduced mechanical function of the left atrial predicts adverse outcome in pregnant women with clustering of metabolic risk factors.

INTRODUCTION: The left atrial (LA) strain and strain rate are sensitive indicators of LA function. However, they are not widely used for the evaluation of pregnant women with metabolic diseases. The aim of this study was to assess the LA strain and strain rate of pregnant women with clustering of metabolic risk factors and to explore its prognostic effect on adverse pregnancy outcomes. MATERIALS AND METHODS: Sixty-three pregnant women with a clustering of metabolic risk factors (CMR group), fifty-seven women with pregnancy-induced hypertension (PIH group), fifty-seven women with gestational diabetes mellitus (GDM group), and fifty matched healthy pregnant women (control group) were retrospectively evaluated. LA function was evaluated with two-dimensional speckle-tracking imaging. Iatrogenic preterm delivery caused by severe preeclampsia, placental abruption, and fetal distress was regarded as the primary adverse outcome. RESULTS: The CMR group showed the lowest LA strain during reservoir phase (LASr), strain during contraction phase (LASct) and peak strain rate during conduit phase (pLASRcd) among the three groups (P < 0.05). LA strain during conduit phase (LAScd) and peak strain rate during reservoir phase (pLASRr) in the CMR group were lower than those in the control and GDM groups (P < 0.05). Multivariable Cox regression analysis demonstrated systolic blood pressure (HR = 1.03, 95% CI 1.01-1.05, p = 0.001) and LASr (HR = 0.86, 95% CI 0.80-0.92, p < 0.0001) to be independent predictors of iatrogenic preterm delivery. An LASr cutoff value ≤ 38.35% predicted the occurrence of iatrogenic preterm delivery. CONCLUSIONS: LA mechanical function in pregnant women with metabolic aggregation is deteriorated. An LASr value of 38.35% or less may indicate the occurrence of adverse pregnancy outcomes.

The Diagnostic Ability of the Cerebroplacental Ratio for the Prediction of Adverse Perinatal Outcome and Intrapartum Fetal Compromise within One Day of Delivery.

OBJECTIVES: The objectives of this study were to evaluate the diagnostic abilities of the cerebroplacental ratio (CPR) for the prediction of adverse perinatal outcome (APO) and cesarean section for intrapartum fetal compromise (CS-IFC) within 1 day of delivery. DESIGN: Retrospective observational case-control study. METHODS: This was a study of 254 high-risk fetuses attending the day hospital unit of a tertiary referral hospital that underwent an ultrasound examination at 32-41 weeks and gave birth within 1 day of examination. APO was defined as a composite of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20 requiring urgent cesarean section, neonatal umbilical cord pH <7.10, 5-min Apgar score <7, and postpartum admission to neonatal or pediatric intensive care units. CS-IFC was defined in case of abnormal intrapartum fetal heart rate or intrapartum fetal scalp pH <7.20 requiring urgent cesarean section. The diagnostic ability of CPR for the prediction of APO and CS-IFC was calculated alone and in combination with estimated fetal weight and gestational clinical parameters, including the type of labor onset, using ROC curves and logistic regression analysis. RESULTS: CPR in multiples of the median (MoM) was a moderate predictor of APO (area under the curve [AUC] = 0.77, p < 0.0001) and CS-IFC (AUC = 0.82, p < 0.0001). The predictive abilities of the multivariable model for APO (AUC = 0.81, p < 0.0001) and CS-IFC (AUC = 0.82, p < 0.0001) did not differ from those of CPR alone . LIMITATIONS: The small number of cases and the scarcity of information concerning labor induction. CONCLUSION: In high-risk pregnancies, CPR MoM is a moderate predictor of APO and CS-IFC when performed within 24 h of delivery.

Accuracy of predicting neonatal distress using a five-level classification of fetal heart rate monitoring.

AIM: To assess the accuracy of neonatal distress prediction using the five-level classification of fetal heart rate (FHR) and management protocol of the Japan Society of Obstetrics and Gynecology (JSOG). METHODS: A case-control study was conducted. Vertex singleton pregnant women who delivered after 37 weeks' gestation from 2013 to 2015 were enrolled. The participants were categorized into two groups; controls were levels 1-3 (n = 1184), whereas cases were levels 4-5 (n = 117) group. Neonatal distress was defined as Apgar score < 8 points at 5 min or umbilical cord artery pH < 7.1. RESULTS: There were 117 cases (9.0%). The frequency of the neonatal distress was observed in 1.3% controls and 6.8% cases (P < 0.01). Diagnostic accuracy of neonatal distress for cases showed a 6.8% positive-predictive value, 34.8% sensitivity, 91.5% specificity and 98.7% negative-predictive value. Among various obstetrical conditions, high sensitivity (100%) for prediction of neonatal distress was observed in women with chromosome abnormalities, placental abruption, umbilical cord abnormalities and excessive labor pain. Conversely, relatively low specificity (<50%) was observed in cases with oligohydramnios and excessive labor pain. CONCLUSION: The five-level classification scheme was efficient for neonatal distress prediction. However, depending on the obstetric condition, the FHR findings and neonatal condition might be independent.

Intrapartum fetal monitoring and perinatal risk factors of neonatal hypoxic-ischemic encephalopathy.

BACKGROUND: Neonatal hypoxic-ischemic encephalopathy (HIE) in term infants, is a major cause of neonatal mortality and severe neurologic disability. OBJECTIVES: To identify in labor fetal monitoring characteristic patterns and perinatal factors associated with neonatal HIE. STUDY DESIGN: Single-center retrospective case-control study between 2010 and 2017. Cases clinically diagnosed with neonatal HIE treated by therapeutic hypothermia according to strict criteria (HIE-TH) were compared to a group of neonates born in the same period, gestational age-matched diagnosed with fetal distress according to fetal monitoring interpretation that was followed by prompt delivery, without subsequent HIE or therapeutic hypothermia (No-HIE). The primary outcome of the study was the electronic fetal monitoring (EFM) pattern during 60 min prior to delivery; the secondary outcome was the identification of perinatal associated factors. RESULTS: 54 neonates with HIE were treated by therapeutic hypothermia. EFM parameters most predictive of HIE-TH were indeterminate baseline heart rate OR = 47.297, 95% (8.17-273.76) p < 0.001, bradycardia OR = 15.997 95% (4.18-61.18) p < 0.001, low variability OR = 10.224, 95% (2.71-38.45) p < 0.001, higher baseline of the fetal heart rate calculated for each increment of 1 BPM OR = 1.0547, 95% (1.001-1.116) p = 0.047. Rupture of a previous uterine cesarean scar and placental abruption were characteristic of the HIE-TH group 14.8% vs. 1% p < 0.05; and 16.7% vs. 6% p < 0.05, respectively. Adverse neonatal outcomes also differed significantly: HIE-TH had a higher rate of neonatal seizures 46.2% vs. 0% p < 0.001 and mortality 7.7% vs. 0% p < 0.001. CONCLUSIONS: Characteristic fetal monitoring pattern prior to delivery together with acute obstetric emergency events are associated with neonatal HIE, neurological morbidity, and mortality.

Evaluation of an external fetal electrocardiogram monitoring system: a randomized controlled trial.

OBJECTIVE: The objective of the study was to compare interpretability of 2 intrapartum abdominal fetal heart rate-monitoring strategies. We hypothesized that an external fetal electrocardiography monitoring system, a newer technology using wireless abdominal pads, would generate more interpretable fetal heart rate data compared with standard external Doppler fetal heart rate monitoring (standard external monitoring). STUDY DESIGN: We conducted a randomized controlled trial at 4 Utah hospitals. Patients were enrolled at labor admission and randomized in blocks based on body mass index to fetal electrocardiography or standard external monitoring. Two reviewers, blinded to study allocation, reviewed each fetal heart rate tracing. The primary outcome was the percentage of interpretable minutes of fetal heart rate tracing. An interpretable minute was defined as >25% fetal heart rate data present and no more than 25% continuous missing fetal heart rate data or artifact present. Secondary outcomes included the percentage of interpretable minutes of fetal heart rate tracing obtained while on study device only, the number of device adjustments required intrapartum, clinical outcomes, and patient/provider device satisfaction. We determined that 100 patients per arm (200 total) would be needed to detect a 5% difference in interpretability with 95% power. RESULTS: A total of 218 women were randomized, 108 to fetal electrocardiography and 110 to standard external monitoring. Device setup failure occurred more often in the fetal electrocardiography group (7.5% [8 of 107] vs 0% [0 of 109] for standard external monitoring). There were no differences in the percentage of interpretable tracing between the 2 groups. However, fetal electrocardiography produced more interpretable fetal heart rate tracing in subjects with a body mass index ≥30 kg/m2. When considering the percentage of interpretable minutes of fetal heart rate tracing while on study device only, fetal electrocardiography outperformed standard external monitoring for all subjects, regardless of maternal body mass index. Maternal demographics and clinical outcomes were similar between arms. In the fetal electrocardiography group, more device changes occurred compared with standard external monitoring (51% vs 39%), but there were fewer nursing device adjustments (2.9 vs 6.2 mean adjustments intrapartum, P < .01). There were no differences in physician device satisfaction scores between groups, but fetal electrocardiography generated higher patient satisfaction scores. CONCLUSION: Fetal electrocardiography performed similarly to standard external monitoring when considering percentage of interpretable tracing generated in labor. Furthermore, patients reported overall greater satisfaction with fetal electrocardiography in labor. Fetal electrocardiography may be particularly useful in patients with a body mass index ≥30 kg/m2.

Maternal cardiovascular function and risk of intrapartum fetal compromise in women undergoing induction of labor: pilot study.

OBJECTIVE: Identification of the fetus at risk of intrapartum compromise has many benefits. Impaired maternal cardiovascular function is associated with placental hypoperfusion predisposing to intrapartum fetal distress. The aim of this study was to assess the predictive accuracy of maternal hemodynamics for the risk of operative delivery due to presumed fetal compromise in women undergoing induction of labor (IOL). METHODS: In this prospective cohort study, patients were recruited between November 2018 and January 2019. Women undergoing IOL were invited to participate in the study. A non-invasive ultrasonic cardiac output monitor (USCOM-1A®) was used for cardiovascular assessment. The study outcome was operative delivery due to presumed fetal compromise, which included Cesarean or instrumental delivery for abnormal fetal heart monitoring. Regression analysis was used to test the association between cardiovascular markers, as well as the maternal characteristics, and the risk of operative delivery due to presumed fetal compromise. Receiver-operating-characteristics-curve analysis was used to assess the predictive accuracy of the cardiovascular markers for the risk of operative delivery for presumed fetal compromise. RESULTS: A total of 99 women were recruited, however four women were later excluded from the analysis due to semi-elective Cesarean section (n = 2) and failed IOL (n = 2). The rate of operative delivery due to presumed fetal compromise was 28.4% (27/95). Women who delivered without suspected fetal compromise (controls) were more likely to be parous, compared to those who had operative delivery due to fetal compromise (52.9% vs 18.5%; P = 0.002). Women who underwent operative delivery due to presumed fetal compromise had a significantly lower cardiac index (median, 2.50 vs 2.60 L/min/m2 ; P = 0.039) and a higher systemic vascular resistance (SVR) (median, 1480 vs 1325 dynes × s/cm5 , P = 0.044) compared to controls. The baseline model (being parous only) showed poor predictive accuracy, with an area under the curve of 0.67 (95% CI, 0.58-0.77). The addition of stroke volume index (SVI) < 36 mL/m2 , SVR > 7.2 logs or SVR index (SVRI) > 7.7 logs improved significantly the predictive accuracy of the baseline model (P = 0.012, P = 0.026 and P = 0.012, respectively). CONCLUSION: In this pilot study, we demonstrated that prelabor maternal cardiovascular assessment in women undergoing IOL could be useful for assessing the risk of intrapartum fetal compromise necessitating operative delivery. The addition of SVI, SVR or SVRI improved significantly the predictive accuracy of the baseline antenatal model. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Monitoring intrapartum fetal heart rates by mothers in labour in two public hospitals: an initiative to improve maternal and neonatal healthcare in Liberia.

BACKGROUND: In low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected. METHODS: Four hundred seventy-four women admitted in labour without obstetric complications were approached. Four hundred sixty-one consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately 1 minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded. RESULTS: Four hundred sixty-one out of 474 women gave consent, of whom 431 of 461 (93%) completed the monitoring themselves. Three hundred eighty-seven of 400 women who gave comments, reported positive and 13 negative experiences. FHR changes were reported in 28 participants and confirmed in 26. Twenty-four of these 26 FHR changes were first identified by mothers. Fetal death was identified on admission during training in one mother. Thirteen neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl's ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants. CONCLUSIONS: Women in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

Prevalence and risk factors of preterm birth in Pakistan.

OBJECTIVE: To find prevalence of preterm birth in Pakistan and to explore its related risk factors. METHODS: This analytical cross-sectional study was conducted from October 1, 2016, to September 30, 2017, at Hajvery University, Lahore, Pakistan, and data was collected from Obstetrics and Gynaecology departments of various hospitals in four provinces of the country. To find risk factors of preterm birth, data was divided into two groups: Group-1 consisted cases with preterm birth defined as gestational age <37 weeks on ultrasonography; and Group-2 consisted controls with full-term birth defined as gestational age 37-41 weeks. Data was analysed using SPSS 22. RESULTS: There were 1,691 females with mean gestational age of 37.3±2.062 weeks. The prevalence of preterm birth was 366(21.64%). Top 5 major risk factors identified were Placenta Previa (odds ratio: 51.97), maternal thyroid disease (odds ratio: 18.46), being a minority (odds ratio: 7.73), foetal distress (odds ratio: 7.19), and maternal asthma (odds ratio: 6.23). CONCLUSIONS: The prevalence of preterm birth was found to be high with several modifiable and controllable risk factors.

Cerebroplacental ratio assessment in early labor in uncomplicated term pregnancy and prediction of adverse perinatal outcome: prospective multicenter study.

OBJECTIVE: It has been suggested that the use of Doppler ultrasound in term pregnancies with normal-sized fetuses is able to identify those at high risk of subclinical placental function impairment. The objective of this study was to evaluate the relationship between cerebroplacental ratio (CPR) measured in early labor and perinatal and delivery outcomes in a cohort of uncomplicated singleton term pregnancies. METHODS: This was a prospective multicenter observational study conducted at three tertiary centers between January 2016 and July 2017. Low-risk term pregnancies, defined by the absence of maternal morbidity or pregnancy complication, accompanied by normal ultrasound and clinical screening of fetal growth in the third trimester, with spontaneous onset of labor were included. Umbilical artery (UA) and fetal middle cerebral artery (MCA) Doppler was assessed on admission for early labor. All measurements were performed in between uterine contractions and according to international standards. CPR was computed by dividing MCA pulsatility index by UA pulsatility index and converted into multiples of the median (MoM) in order to adjust for gestational age. Doctors and midwives involved in the clinical management of the women were blinded to the results of the Doppler evaluation. Mode of delivery and perinatal outcome were compared between pregnancies with reduced CPR MoM, defined as CPR MoM within the lowest decile of the study population, and those with normal CPR MoM. Receiver-operating characteristics curve analysis was used to assess the predictive performance of CPR for obstetric intervention due to fetal distress and composite adverse perinatal outcome. RESULTS: Overall, 562 women were included. The rate of obstetric intervention for suspected fetal distress in labor was more than three times higher among cases with reduced CPR MoM compared to those with normal CPR MoM (9/54 (16.7%) vs 28/508 (5.5%); P = 0.004). Furthermore, a significantly higher rate of composite adverse perinatal outcome was found in fetuses with CPR MoM < 10th percentile compared to those with CPR MoM ≥ 10th percentile (6/54 (11.1%) vs 19/508 (3.7%); P = 0.012). CPR had low sensitivity and low positive predictive value for prediction of obstetric intervention due to fetal distress (24.3% and 18.0%, respectively) and composite adverse perinatal outcome (24.0% and 11.1%, respectively). CONCLUSIONS: Data on a wide cohort of low-risk term pregnancies in early labor showed that, while reduced CPR is associated with a higher risk of obstetric intervention due to fetal distress and composite adverse perinatal outcome, it is a poor predictor of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania.

BACKGROUND: Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania. METHODS: A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis. RESULTS: The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate. CONCLUSION: The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device's functions, its limitations and its procedures for use are well understood by users.

Hemodynamic factors associated with fetal cardiac remodeling in late fetal growth restriction: a prospective study.

Background Altered cardiac geometry affects a proportion of fetuses with growth restriction (FGR). The aim of this study was to explore the hemodynamic factors associated with cardiac remodeling in late FGR. Methods This was a prospective study of singleton pregnancies complicated by late-onset FGR undergoing assessment of left (LV) and right (RV) ventricular sphericity-index (SI). The study population was divided in two groups according to the presence of cardiac remodelling, defined as LVSI <5th centile. The following outcomes were explored: gestational age at birth, birthweight, caesarean section (CS) for fetal distress, umbilical artery (UA) pH and neonatal admission to special care unit. The differences between the 2 groups in UA pulsatility index (PI), middle cerebral artery (MCA) PI, uterine artery PI, cerebroplacental ratio (CPR) and umbilical vein (UV) flow corrected for fetal abdominal circumference (UVBF/AC) were tested. Results In total, 212 pregnancies with late FGR were enrolled in the study. An abnormal LV SI was detected in 119 fetuses (56.1%). Late FGR fetuses with cardiac remodeling had a lower birthweight (2390 g vs. 2490; P = 0.04) and umbilical artery pH (7.21 vs. 7.24; P = 0.04) and were more likely to have emergency CS (42.8% vs. 26.9%; P = 0.023) and admission to special care unit (13.4% vs. 4.3%; P = 0.03) compared to those with normal LVSI. No difference in either UA PI (p = 0.904), MCA PI (P = 0.575), CPR (P = 0.607) and mean uterine artery PI (P = 0.756) were present between fetuses with or without an abnormal LV SI. Conversely, UVBF/AC z-score was lower (-1.84 vs. -0.99; P ≤ 0.001) in fetuses with cardiac remodeling and correlated with LV (P ≤ 0.01) and RV SI (P ≤ 0.02). Conclusion Fetal cardiac remodelling occurs in a significant proportion of pregnancies complicated by late FGR and is affected by a high burden of short-term perinatal compromise. The occurrence of LV SI is independent from fetal arterial Dopplers while it is positively associated with umbilical vein blood flow.

Admission Cardiotocography in Predicting Perinatal Outcome.

Background Antepartum assessment of the fetus is very important to prevent intra-uterine demise, birth asphyxia, neurological defect of newborns and neonatal mortality. Cardiotocography is the best indicator for fetal surveillance during labour in low resource country. Objective To assess on admission cardiotocography and predict perinatal outcome of antenatal mothers admitted to labour room for delivery at Dhulikhel Hospital, Kathmandu University Hospital. Method A prospective, observational study was conducted from 1st January 2016 to 31st December 2017. Antenatal mothers were evaluated in admission cardiotocography for 20 minutes. Cardiotocography studies were interpreted and categorized according to the classification proposed by National Institute of Clinical Excellence (NICE)- clinical guidelines 2007. Result Total 204 mothers were enrolled, the mean age is 24.06±4.331. Cardiotocography interpretation shows, 81.4% of Normal, 13.7% suspected and only 4.9% accounts pathological. Mother having CTG of pathological had more operative delivery 80% compare to normal and suspicious (0.0001). Similarly, more meconium stained liquor fall in pathological group with p value of 0.002. Fetal distress in labour is seen in all groups, showing 13.3% in normal, 32.1% in suspicious and 80% in pathological with p value 0.000. The duration of on admission cardiotocography to occurrence of fetal distress found to be mean hour of 9.57. Conclusion The admission cardiotocography test is useful to detect fetal distress which is already present at the time of test and can predict fetal wellbeing during the next few hours of labour. This test might lead to higher incidence of operative delivery at low resource countries because of lack of fetal blood sampling test to confirm fetal hypoxia during labour.

The importance of the learning process in ST analysis interpretation and its impact in improving clinical and neonatal outcomes.

BACKGROUND: Intrapartum fetal heart rate monitoring was introduced with the goal to reduce fetal hypoxia and deaths. However, continuous fetal heart rate monitoring has been shown to have a high sensitivity but also a high false-positive rate. To improve specificity, adjunctive technologies have been developed to identify fetuses at risk for intrapartum asphyxia. Intensive research on the value of ST-segment analysis of the fetal electrocardiogram as an adjunct to standard electronic fetal monitoring in lowering the rates of fetal metabolic acidosis and operative deliveries has been ongoing. The conflicting results in randomized and observational studies may partly be due to differences in study design. OBJECTIVE: This study aims to determine the significance of the learning process for the introduction of ST analysis into clinical practice and its impact on initial and subsequent obstetric outcomes. STUDY DESIGN: This was a prospective observational study with the primary objective to evaluate the importance of the learning period on the rates of metabolic acidosis and operative deliveries after the implementation of ST analysis. The study was conducted at the Turku University Hospital, Turku, Finland, with 3400-4200 annual deliveries. The whole study population consisted of all 42,146 deliveries during the study period 2001 through 2011. The ST analysis usage rate was 18%. The data were collected prospectively from labors monitored with ST analysis as an adjunct to conventional intrapartum fetal heart rate monitoring. Primary endpoints were the rates of metabolic acidosis (cord artery pH <7.05 and an extracellular fluid compartment base deficit >12.0 mmol/L), fetal scalp blood sampling, and operative deliveries. Comparisons of these outcomes were made between the initiation period (the first 2 years) and the subsequent usage period (the next 9 years). RESULTS: In the whole study population the prevalence of cord pH <7.05 decreased from 1.5-0.81% (relative risk, 0.54; 95% confidence interval, 0.43-0.67), the rate of cesarean deliveries from 17.2-14.1% (relative risk, 0.82; 95% confidence interval, 0.89-0.97), and the rate of fetal scalp blood sampling from 1.75-0.82% (relative risk, 0.47; 95% confidence interval, 0.38-0.58) when the 2 study periods were compared. In the ST analysis group, the frequency of cord metabolic acidosis rate was reduced from 1.0-0.25% (relative risk, 0.33; 95% confidence interval, 0.15-0.72). CONCLUSION: We provide evidence that the results improve over time and there is a learning curve in the introduction of the ST analysis method. This was demonstrated by the lower rates of metabolic acidosis and operative deliveries after the initial implementation period.

Prelabor screening for intrapartum fetal compromise in low-risk pregnancies at term: cerebroplacental ratio and placental growth factor.

OBJECTIVES: To determine the screening performance of low fetal cerebroplacental ratio (CPR), a marker of fetal adaptation to suboptimal growth, and maternal placental growth factor (PlGF) level, both in isolation and in combination, for the prediction of Cesarean section (CS) for intrapartum fetal compromise (IFC) and composite adverse neonatal outcome (CANO). METHODS: This was a prospective cohort study in low-risk women with uncomplicated singleton pregnancy from 36 weeks' gestation to delivery. CPR and PlGF were assessed fortnightly and intrapartum and neonatal outcomes were recorded. CPR and PlGF values from the final assessment for each woman were corrected for gestational age and assessed for screening performance, firstly as continuous variables and then as binary predictors. RESULTS: Of the 264 women who consented to participate in the study, 207 were included in the final analysis. Seven pregnancies required CS for IFC and 38 had CANO. Pregnancies delivered by CS for IFC had lower CPR and PlGF centiles than those in all other pregnancies. Pregnancies with CANO had a lower PlGF centile. The greatest areas under the receiver-operating characteristics curves (AUCs) for the prediction of CS for IFC (0.92; 95% CI, 0.86-0.97) and CANO (0.64; 95% CI, 0.54-0.74) were achieved by a combination of CPR 20th and PlGF 33rd centile thresholds. This produced sensitivities, specificities and positive likelihood ratios for the prediction of CS for IFC of 100%, 86% and 7.14, respectively, and 34.2%, 87.0% and 2.63, respectively, for the prediction of CANO. There was no statistical difference in the AUC for CS for IFC between the combined model and when CPR was used alone, or for CANO between the combined model and CPR or PlGF in isolation. CONCLUSIONS: This pilot proof-of-concept study describes the screening performance of CPR and maternal PlGF level for CS for IFC in low-risk women from 36 weeks' gestation. It was found that CPR and maternal PlGF improved the overall predictive utility for CS for IFC, as well as that for CANO. However, given the lack of significant difference between the combined model and its individual components, it is debatable whether the combined model is a superior screening test. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Cerebroplacental ratio thresholds measured within 2 weeks before birth and risk of Cesarean section for intrapartum fetal compromise and adverse neonatal outcome.

OBJECTIVES: Prediction of intrapartum fetal compromise in uncomplicated, term pregnancies is a global obstetric challenge. Currently, no widely accepted screening test for this condition exists, although the cerebroplacental ratio (CPR) shows promise. We aimed to evaluate prospectively the screening performance of the CPR 10th centile threshold for prediction of Cesarean section for intrapartum fetal compromise (IFC) and composite adverse neonatal outcome (ANO) after 36 weeks' gestation in low-risk women, and to compare this with CPR ≤ 1 and < 5th centile thresholds described previously in the literature. METHODS: This was a blinded, prospective, observational, cohort study of 483 women with uncomplicated singleton pregnancy who underwent fortnightly CPR measurements from 36 weeks to delivery, and their intrapartum and neonatal outcomes were recorded. The CPR 10th centile threshold screening performance was calculated for emergency Cesarean section for IFC and composite ANO (defined as acidosis at birth, 5-min Apgar score < 7 and/or admission to the neonatal intensive care unit). Comparison of screening performance of CPR ≤ 1 and < 5th and < 10th centile thresholds was also undertaken for these specified outcomes. RESULTS: In total, 437 women were included in the analysis, of whom 4.1% had an emergency Cesarean section for IFC and 17.8% had a composite ANO. Sensitivity and specificity for CPR < 10th centile were, respectively, 55.6% and 87.9% for prediction of Cesarean section for IFC, and 28.2% and 88.0% for composite ANO. Compared with CPR ≤ 1 and < 5th centile, CPR < 10th centile yielded the best overall test performance for detection of Cesarean section for IFC and composite ANO, although its predictive value was only fair for Cesarean section for IFC (area under the receiver-operating characteristics curve (AUC) = 0.72) and poor for composite ANO (AUC = 0.58). CONCLUSION: The CPR 10th centile threshold may be useful as a component of a risk assessment tool for Cesarean section for IFC in low-risk pregnancies at term. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.