[Changes in umbilical cord blood acid-base status after delivery in dependence on time intervall--a continuing forensic problem]. / Veränderungen des Säure-Basen Status in der Nabelschnur post partum in Abhängigkeit vom Zeitintervall--ein anhaltendes forensisches Problem.

BACKGROUND: The time window for measuring blood gases in the umbilical cord after birth is often discussed controversial with regard to birth damage claims. METHODS: 53 umbilical cords from spontaneous deliveries at term were double clamped at room temperature directly after birth and paired arterial and venous samples were taken at 0,5, 10, 20, 40, 60 and 120 min. Arterial and venous blood gases [pH, pO2, pCO2, base-excess (BE)] were measured. Statistical analyses were performed with the t test and Wilcoxon test. RESULTS: We measured data from (arterial/venous) pH 7.27±0.06 or, respectively, 7.34±0.06; BE 3.36±3.42 or, respectively, 3.64±2.58, pCO2 48.6±7.6 or, respectively, 38.6±6.4 mmHg (p<0.001). The arterial and venous pH dropped significantly by 0.02 (p<0.001) at 5 min. The arterial cord base excess dropped significantly to 2 mmol/L (p<0.001) at 5 min. The venous cord base excess dropped slowly at 40 min. Arterial and venous pO2 readings did not drop significantly, but the mean value showed variations. Arterial and venous pCO2 values increased significantly within 40 or, respectively, 60 min. Actual literature reports differ dramatically in the increase or decrease of blood gas parameters. DISCUSSION: Storage of the umbilical cord with room temperature results in changes in blood gas results within a short time of period. To avoid controversial discussion in civil court proceedings the blood gas probes from the umbilical cord should be analysed immediately after birth or stored in heparinised cooled syringes.

[Acute intracranial haemorrhage during delivery--a case report]. / Akute intrakranielle Blutung unter der Geburt--Ein Fallbericht.

An acute intracranial haemorrhage during delivery or pregnancy is a rare complication and usually observed in connection with risk factors. We present the clinical course of a 32-year-old primigravida in the 40th week of gestation delivered in general anaesthesia by Caesarean section after premature rupture of the membranes and obstructed labour. Immediately after delivery and extubation, the patient appeared drowsy and with reduced consciousness. An emergency CCT presented an acute frontal haemorrhage with intraventricular bleeding. In this case there was no history of risk factors and no origin of the bleeding could be identified. A complete remission of the symptoms was achieved after ventricular drainage, intensive care support and consecutive rehabilitation.

[Comments on a report by the BQS on obstetric quality indicators]. / Stellungnahme zu einem Gutachten der BQS über geburtshilfliche Qualitätsindikatoren.

When re-evaluating an epidemiologically oriented BQS expertise concerning the quality indicators in obstetrics, we examined three essential methods in obstetrics to verify their scientific evidence and their clinical relevance. In doing so we ascertained that recording the fetal heart rate sub part, analysing fetal blood and determining the blood gas of the umbilical blood are entirely appropriate quality indicators during delivery from a clinical and medical point of view -- although to varying extents. Above all, these three indicators prove to be essentially better evidence-based than described in the BQS expertise. The search for an optimum of evidence-based data in medicine ends in certain fields such as, for example, in obstetrics there where no further randomized studies can be carried out for methodological or ethical reasons. This lack of evidence for the optimum grade I which can clearly be understood from an epidemiological point of view, however, should not lead to an evidence nihilism that fails to accept or admit existing evidence of the weaker grades II and III.

[Fetal monitoring intra partum with cardiotocography and fetal blood sampling analysis and its possible influence on the C-section rate]. / Fetales Monitoring sub partu mittels Cardiotokographie plus Fetalblutanalyse und ihr möglicher Einfluss auf die Sektiorate.

In times of rising c-section rates worldwide the obstetricians feel a big responsibility in avoiding a secondary c-section for non-reassuring fetal heart rate. No other experimental method has been established beside the gold standard (cardiotocography and fetal blood sampling) in daily routine until today. The two cases presented demonstrate the fallibility of the "gold standard" in predicting fetal asphyxia and why methodology with better positive predictive value is needed.

[Peripartum cardiomyopathy--Obstetric emergency for mother and child]. / Peripartale Kardiomyopathie - Der akute geburtshilflich-neonatologische Notfall für Mutter und Kind -

This case report describes the diagnosis, treatment as well as maternal and fetal outcome of a pregnancy complicated by peripartum cardiomyopathy (PPCM). The article demonstrates criteria that define peripartum cardiomyopathy using clinical and echocardiographic features. In absence of preexisting heart disease an acute left ventricular dysfunction of the mother led to fetal bradycardia and immediate delivery. We discuss possible causes, clinical management and long term outcome in respect of the available literature. Future pregnancies should be avoided with at least 50 % risk of recurrence.

[Fetal pulse oximetry during risk deliveries in German clinics--a representative national survey in 81 obstetric departments]. / Uber den Einsatz der fetalen Pulsoxymetrie bei Risikogeburten in deutschen Kliniken - Ergebnisse einer repräsentativen Anwenderumfrage an 81 Geburtskliniken -

BACKGROUND: The development of a new technique to evaluate the normal fetal acid-base balance in risk deliveries with pathological fetal heart rate has been seen with great expectations over the last years. The aim of this representative survey was to ask for the actual status of the fetal pulse oximetry in clinical use in German delivery rooms and to analyze hopes, expectations and system errors. PATIENTS RESPECTIVELY AND METHODS: Collecting data were done by a representative, time limited anonymous questionnaire in all German clinics who used Nellcors fetal pulse oximetry N-400 in measuring fetal arterial saturation in the years 1995 - 1999 during risk deliveries with non-reassuring fetal heart rate. RESULTS: With 66,6 % of the departments participating a number of 54 clinics returned the questionnaires. An average of 4.5 times per month fetal pulse oximetry was used per clinic and in over 90 % of all cases the handling and fixation of the sensor was without problems. There is qualified staff in every clinic and regarding the satisfaction with this system an average note of 2.8 was assigned. Fetal pulse oximetry will be established in some years to replace fetal blood analysis and to reduce operative deliveries. Technical problems in cases of insufficient sensor fixation at the fetal head and with the re-sterilization of fetal sensors must be solved in the future. CONCLUSIONS: Fetal pulse oximetry will be incorporated as the third method of monitoring the fetus during labor.

The prediction of fetal acidosis by means of intrapartum fetal pulse oximetry.

OBJECTIVES: The study's objectives were to verify a threshold value for fetal arterial oxygen saturation as the critical boundary for fetal compromise during labor and to investigate a method of predicting acidosis caused by hypoxemia. STUDY DESIGN: In a multicenter study involving 3 German obstetric centers, a total of 400 deliveries were monitored by fetal pulse oximetry (Nellcor-Puritan-Bennett Model N-400 Oxygen Saturation Monitor and FS-14 Sensor; Nellcor, Inc, Pleasanton, Calif). The durations of low (60%) fetal arterial oxygen saturations during the measurement were compared between neonates with a pH <7.15 versus >/=7.15 and a base excess <-12 mmol/L versus >-12 mmol/L in the umbilical artery post partum and in neonates with an Apgar score <7 versus >/=7 by Mann-Whitney U test. In 121 of the pulse oximetry measurements the durations of low, medium, and high fetal arterial oxygen saturations were measured from one fetal scalp blood sampling to the next and correlated with the change of scalp blood pH between samplings. Multiple regression analysis was performed to estimate the expected change of pH between 2 fetal scalp blood samplings, and receiver operating characteristic analysis was done to define a minimum duration of low fetal arterial oxygen saturation values to exclude or predict a significant decline of pH. RESULTS: Neonates with a 1-minute Apgar score <7 differed from those with 1-minute Apgar score >/=7 significantly in the duration of low fetal arterial oxygen saturation but not in the durations of medium and high fetal arterial oxygen saturations. The duration of low fetal arterial oxygen saturation had been significantly longer in children with pH <7.15 or base excess <-12 mmol/L in the umbilical artery compared with those with a pH >/=7.15 or base excess >/=-12 mmol/L. The duration of high fetal arterial oxygen saturation was significantly shorter for children with a pH <7.15 or base excess <12 mmol/L than for those with a pH >/=7.15 or base excess >/=12 mmol/L. There was no difference in the groups with respect to the duration of medium fetal arterial oxygen saturation values. The duration of low fetal arterial oxygen saturation proved to be the best predictor of a decline of scalp pH between 2 fetal scalp blood samples. The pH declined significantly with a longer duration of low fetal arterial oxygen saturation (0.02 per 10 minutes). No decrease of pH by more than 0.05 was observed unless fetal arterial oxygen saturation had remained at /=10 minutes. CONCLUSION: An arterial oxygen saturation of 30% was confirmed as the critical boundary for fetal compromise during labor. The development of acidosis seems to be predictable by the duration of hypoxemia, as indicated by fetal arterial oxygen saturation

Predictive agreement between the fetal arterial oxygen saturation and fetal scalp pH: results of the German multicenter study.

OBJECTIVE: To discuss and substantiate the 30% critical threshold of fetal arterial oxygen saturation and to complete the puzzle with low fetal arterial oxygen saturation and low scalp pH data, scalp samples have been performed while fetal arterial oxygen saturation registration during labor was in place and while the saturation was < or = 30%. STUDY DESIGN: Between 1993 and 1996, 46 term fetuses during active labor had parallel arterial oxygen saturation registration by pulse oximetry combined with cardiotocograph. They include patients in whom the saturation was < or = 30% for at least 10 minutes. In these cases scalp pH sample values have been obtained simultaneously. Outcome data, Apgar scores, cord gases, and whether the infants were transferred to the neonatal intensive care unit have been examined. Compared with this, there were other cases during labor that had also parallel fetal arterial oxygen saturation and cardiotocographic registration, where the saturation was > 30%. Also in these cases scalp pH was determined to support and demonstrate the predictive value of fetal arterial oxygen saturation for scalp pH, especially in the low ranges. All 46 fetuses were evaluated during periods of nonreassuring cardiotocograph with Nellcor N-400 Fetal Oxygen Saturation Monitoring Systems and FS 14 B sensors in a multicenter study involving three German obstetric centers. Receiver operating characteristic analysis was done on all raw data, as well as the receiver operating characteristic curve from the preceding analysis. RESULTS: These data validate the critical threshold of 30% fetal arterial oxygen saturation and show an extremely good separation of "good" versus "bad" at a fetal arterial oxygen saturation of 30%, especially when seen in conjunction with data points that are > 7.20. Data at < or = 7.20 scalp pH and < 30% fetal arterial oxygen saturation can be a big help in calculating the sensitivity and specificity of fetal arterial oxygen saturation in predicting neonatal outcome (e.g., Apgar score, cord pH). CONCLUSION: Low fetal arterial oxygen saturation data of < 30% for at least 10 minutes or longer correlate significantly with low scalp pH values and have a predictive value concerning fetal outcome.

[Fetal pulse oximetry: from the first experimental studies of broad clinical use. An assessment of current status]. / Fetale Pulsoxymetrie: Von den ersten experimentellen Untersuchungen zum breiten klinischen Einsatz. Eine Standortbestimmung.

Pulse oximetry has triggered a revolutionary change in monitoring patients in many branches of medicine. For 4 years fetal sensors with specially calibrated pulse oximeters are tested clinically. Additional examination methods are required for accurate monitoring the fetus intrapartum because of the low specificity of cardiotocographs and also to avoid unnecessary operative deliveries. Research on hand up to now has demonstrated that fetal pulse oximetry is a method easy to learn, easily applicable and well quanitifiable to improve fetal monitoring and the interpretation of the fetal heart rate patterns intrapartum. Prospective intervention studies involving management studies still have to prove the clinical value of this new technology. Only after examining a large number of hypoxic-risk fetuses we can assess whether pulse oximetry in a management can replace invasive fetal blood analysis as a continuous, non-invasive method of monitoring. Various teams try to prove a context between arterial saturation values (SpO2) and biochemical changes of the fetus in connection with a crucial limiting value of 30% by correlating changes of the fetal scalp with the oxygen saturation. Guidelines for the assessment of the SpO2-values are established according to the present level of knowledge and future aspects of the method are examined.

Fetal pulse oximetry and non-reassuring heart rate.

The aim of the study is to assess the continuous monitoring of fetal blood oxygen saturation (SpO2) during labour using a fetal pulse oximeter in cases of abnormal fetal heart rate (FHR). To determine whether pulse oximetry has the potential to replace scalp blood pH sampling in infants with abnormal heart rate tracings, the correlation between the Hammacher score and SpO2 during labour, scalp pH and arterial cord pH was evaluated. 34 fetal blood samples (FBS) were evaluated in cases of suspicious, pre-pathological or pathological heart rates. Using the FS-14 prototype, 24 fetal blood samples (FBS) were measured in cases of suspicious FHR with an average SpO2 of 42.3% and pH of 7.28, nine in cases of pre-pathological FHR with an average SpO2 of 34.1% and pH of 7.25 and one pathological FHR with an average SpO2 of 24% and pH of 7.162. In those cases where SpO2 was > 40% during labour, no neonate was observed to suffer on hypoxaemia or acidosis and no arterial cord pH was below 7.20. For the future we have the need of collecting more data to support the use of pulse oximetry as a replacement for fetal blood sampling or as a basis for deciding on operative intervention.

[Fetal pulse oximetry sub partu: on morbidity of infection and acceptance in intrapartum monitoring]. / Fetale Pulsoxymetrie sub partu: Uber die infektiöse Morbidität und Akzeptanz bei der intrapartalen Anwendung.

156 mothers and their newborns (Group A), whose deliveries were monitored using cardiotocography and fetal pulse oximetry, were investigated during and after delivery regarding amnioninfection as well as changes in morbidity und compared to matched controls (Group B). The parameters observed were temperature during labor and delivery and after delivery, infection parameters of mother and baby, bacterial smears of the vagina before placement of the oximetry sensor and smears of the sensor tip when the evaluation was concluded. An amnioninfection syndrome was registered twice in group A and three times in control group B. In 22 cases the evaluation of the smears showed an increase of bacterial growth or additional bacteria, but in no case an amnioninfection syndrome was noted. Three of the newborns in Group A who had an infection after delivery showed negative bacterial smears from the sensor tip. The temperatures of the mothers during and after delivery in Group A were not significantly different from Group B. The results show that the intrauterine application of a sensor even for longer periods of time does not result in an increase of maternal or fetal infection morbidity during labor and delivery and after delivery. In addition, 65 patients were evaluated with an anonymous questionnaire after delivery regarding their acceptance of this new method. 88% of the patients were satisfied with the procedure and stated that they felt an additional sense of security through this supplementary method.