Willingness to use smart fetal heart rate monitoring devices among pregnant women: an extension of the technology acceptance model.

The purpose of this study was to assess the significant factors that impact pregnant women's willingness to use smart fetal heart-rate monitoring devices. We propose a research model that integrates technological factors (perceived compatibility and perceived credibility) and personal factors (health anxiety, personal physiological conditions, health consciousness, and health beliefs). The subjects of this study were Chinese women who were pregnant or had previously given birth. Data were collected and analyzed from 397 paper-and-pencil and electronic questionnaires. Our structural equation model indicated that perceived usefulness (ß = 0.490, t = 7.591, p < 0.001), perceived ease of use (ß = 0.352, t = 5.631, p < 0.001), health anxiety (ß = 0.095, t = 2.664, p = 0.008), personal physiological conditions (ß = 0.075, t = 2.142, p = 0.032), and health consciousness (ß = 0.078, t = 2.110, p = 0.035) were the determinants of the intention to use smart fetal heart-rate monitoring devices, with perceived usefulness having the highest degree of influence. Furthermore, we discovered that the levels of perceived compatibility and perceived credibility did not have direct correlations with the intention to use these devices, but they did significantly influence the model. Perceived compatibility (ß = 0.345, t = 6.601, p < 0.001) and perceived credibility (ß = 0.519, t = 9.958, p < 0.001) significantly influences perceived ease of use. Perceived credibility (ß = 0.421, t = 7.802, p < 0.001) significantly influences perceived usefulness. Based on these results, suggestions for future research are put forward.

Transcutaneous Discrimination of Fetal Heart Rate from Maternal Heart Rate: A Fetal Oximetry Proof-of-Concept.

Intrapartum care uses electronic fetal heart rate monitoring (EFHRM) for over 50 years to indirectly assess fetal oxygenation. However, this approach has been associated with an increase in cesarean delivery rates and limited improvements in neonatal hypoxic outcome. To address these shortcomings, a novel transabdominal fetal pulse oximeter (TFO) is being developed to provide an objective measurement of fetal oxygenation. Previous studies have evaluated the performance of TFO on pregnant ewe. Building on the animal model, this study aims to determine whether TFO can successfully capture human fetal heart rate (FHR) signals during non-stress testing (NST) as a proof-of-concept. Eight ongoing pregnancies meeting specific inclusion criteria (18-40 years old, singleton, and at least 36 weeks' gestation) were enrolled with consent. Each study session was 15 to 20 min long. Reference maternal heart rate (MHR) and FHR were obtained using finger pulse oximetry and cardiotocography for subsequent comparison. The overall root-mean-square error was 9.7BPM for FHR and 4.4 for MHR, while the overall mean-absolute error was 7.6BPM for FHR and 1.8 for MHR. Bland-Altman analysis displayed a mean bias ± standard deviation between TFO and reference of -3.9 ± 8.9BPM, with limits of agreement ranging from -21.4 to 13.6 BPM. Both maternal and fetal heart rate measurements obtained from TFO exhibited a p-value < 0.001, showing significant correlation with the reference. This proof-of-concept study successfully demonstrates that TFO can accurately differentiate maternal and fetal heart signals in human subjects. This achievement marks the initial step towards enabling fetal oxygen saturation measurement in humans using TFO.

The iPREFACE score is useful for predicting fetal acidemia: A retrospective cohort study of 113 patients who underwent emergency cesarean section for non-reassuring fetal status during labor.

BACKGROUND: The iPREFACE score may aid in predicting fetal acidemia and neonatal asphyxia in emergency cesarean and vaginal deliveries, which may improve labor management precision in the future. OBJECTIVE: This study aimed to assess the score use of the iPREFACE as an objective indicator of the need for rapid delivery in cases of repeated abnormal waveforms without concurrent indications for immediate medical intervention during labor. STUDY DESIGN: This retrospective cohort study was conducted among term (37+ 0 days to 41+6 days) singleton pregnant women who underwent emergency cesarean delivery owing to a nonreassuring fetal status. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery score, calculated from a 30-minute cardiotocography waveform before the decision to perform emergency cesarean delivery, and the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer score, calculated from a 30-minute cardiotocography waveform before cardiotocography transducer removal, were employed. The primary outcome was the assessment of the predictive ability of these scores for fetal acidemia, whereas the secondary outcomes were differences in umbilical artery blood gas findings and postnatal outcomes between the 2 groups, divided by the cutoff values of the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography score. RESULTS: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer scores demonstrated the capability to predict an umbilical artery blood pH of <7.2. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and -removal of cardiotocography transducer score, with cutoff values of 37 and 46 points, respectively, exhibited an area under the receiver operating characteristic curve of 0.82 and 0.87, respectively. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer group with ≥46 points had higher incidence rates of an umbilical cord artery blood pH of <7.2, <7.1, and <7.0 and neonatal intensive care unit admissions for neonatal asphyxia. CONCLUSION: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring, derived from cardiotocography during an emergency cesarean delivery, may enable clinicians to predict fetal acidemia in cases of nonreassuring fetal status. Improved prediction of fetal acidemia and facilitation of timely intervention hold promise for enhancing the outcomes of mothers and newborns during childbirth. Prospective studies are warranted to establish precise cutoff values and to validate the clinical application of these scores.

Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal.

BACKGROUND: Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. OBJECTIVE: This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. METHODS: The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. RESULTS: Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. CONCLUSION: The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.

Main findings: Before the Moyo implementation, foetal heart rate monitoring was sub-optimal in the hospitals, which changed after introduction of the device, as it helped early display of foetal heart rate in the monitor and supported communication with women during the labour and delivery.Added knowledge: Implementation of Moyo in low-resource setting requires an interdisciplinary approach with continuous support to health care providers on how to correctly read Moyo, maintenance of device and management of false reading.Global health impact for policy and action: The global efforts to accelerate reduce preventable intrapartum related neonatal death requires contextual understanding of clinical context for effective implementation of Moyo.

Evaluation and patient experience of wireless noninvasive fetal heart rate monitoring devices.

INTRODUCTION: In clinical practice, fetal heart rate monitoring is performed intermittently using Doppler ultrasound, typically for 30 minutes. In case of a non-reassuring heart rate pattern, monitoring is usually prolonged. Noninvasive fetal electrocardiography may be more suitable for prolonged monitoring due to improved patient comfort and signal quality. This study evaluates the performance and patient experience of four noninvasive electrocardiography devices to assess candidate devices for prolonged noninvasive fetal heart rate monitoring. MATERIAL AND METHODS: Non-critically sick women with a singleton pregnancy from 24 weeks of gestation were eligible for inclusion. Fetal heart rate monitoring was performed during standard care with a Doppler ultrasound device (Philips Avalon-FM30) alone or with this Doppler ultrasound device simultaneously with one of four noninvasive electrocardiography devices (Nemo Fetal Monitoring System, Philips Avalon-Beltless, Demcon Dipha-16 and Dräger Infinity-M300). Performance was evaluated by: success rate, positive percent agreement, bias, 95% limits of agreement, regression line, root mean square error and visual agreement using FIGO guidelines. Patient experience was captured using a self-made questionnaire. RESULTS: A total of 10 women were included per device. For fetal heart rate, Nemo performed best (success rate: 99.4%, positive percent agreement: 94.2%, root mean square error 5.1 BPM, bias: 0.5 BPM, 95% limits of agreement: -9.7 - 10.7 BPM, regression line: y = -0.1x + 11.1) and the cardiotocography tracings obtained simultaneously by Nemo and Avalon-FM30 received the same FIGO classification. Comparable results were found with the Avalon-Beltless from 36 weeks of gestation, whereas the Dipha-16 and Infinity-M300 performed significantly worse. The Avalon-Beltless, Nemo and Infinity-M300 closely matched the performance of the Avalon-FM30 for maternal heart rate, whereas the performance of the Dipha-16 deviated more. Patient experience scores were higher for the noninvasive electrocardiography devices. CONCLUSIONS: Both Nemo and Avalon-Beltless are suitable devices for (prolonged) noninvasive fetal heart rate monitoring, taking their intended use into account. But outside its intended use limit of 36 weeks' gestation, the Avalon-Beltless performs less well, comparable to the Dipha-16 and Infinity-M300, making them currently unsuitable for (prolonged) noninvasive fetal heart rate monitoring. Noninvasive electrocardiography devices appear to be preferred due to greater comfort and mobility.

Nonreassuring fetal status during labor and offspring's childhood neurodevelopment at 3 years of age: The Japan Environment and Children's Study.

OBJECTIVE: Although prior attempts have failed to identify the beneficial effects of intensive fetal monitoring on cerebral palsy, the association between nonreassuring fetal status (NRFS) during labor and the incidence of long-term neurodevelopmental delays in offspring remains unclear. This study aimed to evaluate this association using a nationwide birth cohort. METHODS: Data from 72 869 women with singleton deliveries at and after 37 weeks of gestation from the Japan Environment and Children's Study (2011-2014) were analyzed. Multivariable logistic regression models were used to analyze the odds ratios (ORs) for neurodevelopmental delays using the Ages & Stages Questionnaire (Third Edition) in offspring aged 3 years. RESULTS: The adjusted ORs for personal-social problems were 1.52 (95% confidence interval [CI], 1.06-2.16) for offspring delivered vaginally by nulliparous mothers and 1.51 (95% CI, 1.05-2.18) (for males, 1.70 [95% CI, 1.15-2.50]) for those delivered via cesarean section. No significant changes in adjusted ORs for neurodevelopmental delays were observed among participants without neonatal Apgar scores (ASs) <7 and without umbilical arterial pH (UmA-pH) <7.20. CONCLUSION: NRFS during labor was associated with an increased incidence of personal-social problems in offspring aged 3 years. However, this association was not confirmed after excluding participants with neonatal ASs <7 and UmA-pH <7.20. The association between NRFS and offspring's neurodevelopmental delays might vary based on delivery settings, offspring sex, and short-term neonatal outcomes.

Umbilical cord gas analysis: clinical implications of a comprehensive, contemporary determination of normal ranges.

BACKGROUND: Umbilical cord gases are often used to assess the impact of labor and delivery on the fetus. However, no large series exists that reflects contemporary obstetrical practice or that analyzed blood gas ranges by route of delivery. Baseline, prelabor acid-base status in the human fetus is also poorly defined, rendering the assessment of blood gas changes during labor difficult. OBJECTIVE: This study aimed to define normal umbilical cord gas and lactate values, stratified by mode of delivery, in a large contemporary series in which universal umbilical cord gas evaluation was dictated by protocol. STUDY DESIGN: This was a retrospective cohort study. We analyzed the umbilical cord gas and lactate data of an unselected population of infants born between March 2012 and April 2022 at a large teaching hospital. These values were then analyzed by mode of delivery and, for cesarean deliveries, by indication for cesarean delivery and type of anesthesia. Umbilical cord gas values from infants delivered by elective cesarean delivey under general anesthesia without labor were considered representative of baseline, prelabor values. RESULTS: Data were available for 45,475 infants. The median arterial pH values and interquartile ranges for vaginal births, elective cesarean deliveries without labor, and cesarean deliveries performed for fetal heart rate concerns were 7.27 (0.09), 7.27 (0.06), and 7.25 (0.09), respectively. Arterial lactate values for these same 3 groups were 4.1 (2.5), 2.5 (1.2), and 4.0 (2.8) mmoles/L, respectively. Because of the very large sample size, most comparisons yielded differences that were statistically significant, but clinically irrelevant. Of all the infants, 14% had an arterial pH <7.20; a pH value of 7.1 represents 2 standard deviations from the mean. CONCLUSION: This large, population-based study of umbilical cord gas and lactate levels in an unselected population, stratified by delivery mode, represents a previously unavailable benchmark for the evaluation of umbilical cord gases. Arterial umbilical cord pH values for infants delivered by elective caesarean delivery without labor (median pH 7.28) reflect a lower prelabor fetal pH baseline than previously assumed. This finding, coupled with our determination that a 2 standard deviation below normal pH limit of 7.1, instead of the historic arbitrary pH of 7.2 threshold, helps to explain the poor positive predictive value of electronic fetal heart rate monitoring, a test designed to detect arterial pH levels that have fallen from an assumed baseline near pH 7.4 to an assumed potentially injurious pH level of <7.2. Uncomplicated labor, even when prolonged, does not generally lead to a clinically significant cumulative hypoxic stress to the human fetus. These findings, along with our determination that there is no difference in the acid-base status among infants delivered by cesarean delivery for fetal heart rate concerns, help to explain the failure of current approaches in labor and delivery management to reduce the rates of neonatal hypoxic-ischemic encephalopathy and cerebral palsy, conditions that almost always reflect developmental events rather than the effects of labor on the fetus.

Single Sporadic Deceleration during Reactive Nonstress Test-Clinical Significance and Risk for Cesarean Delivery.

OBJECTIVE: Evidence regarding the clinical significance of a single sporadic variable deceleration (SSD) in reactive non-stress test (NST) is scarce, and optimal management has yet to be established. We aim to evaluate whether SSD during a reactive NST at term is associated with a higher risk for fetal heart rate decelerations during labor and the need for intervention. METHODS: This was a retrospective, case-control study of singleton term pregnancies at one university-affiliated medical center in 2018. The study group consisted of all pregnancies with an SSD in an otherwise reactive NST. For each case, two consecutive pregnancies without SSD were matched in a 1:2 ratio. The primary outcome was the rate of cesarean delivery (CD) due to non-reassuring fetal heart rate monitoring (NRFHRM). RESULTS: 84 women with an SSD were compared to 168 controls. SSD during antenatal fetal surveillance did not increase the rate of CD overall or for NRFHRM (17.9% vs. 13.7% and 10.7% vs. 7.7%, respectively, p > 0.05). Rates of assisted deliveries and maternal and neonatal complications were similar between the groups. CONCLUSIONS: SSD during a reactive NST in term pregnancies is not associated with an increased risk for adverse perinatal outcomes. SSD should not necessarily require induction of labor, and expectant management is a reasonable alternative.

Phase-rectified signal averaging: correlation between two monitors and relationship with short-term variation of fetal heart rate.

OBJECTIVES: To establish the correlation between phase-rectified signal averaging (PRSA) outputs obtained from a novel self-applicable non-invasive fetal electrocardiography (NIFECG) monitor with those from computerized cardiotocography (cCTG). A secondary objective was to evaluate the potential for remote assessment of fetal wellbeing by determining the relationship between PRSA and short-term variation (STV). METHODS: This was a prospective observational study of women with a singleton pregnancy over 28 + 0 weeks' gestation attending a London teaching hospital for cCTG assessment. Participants underwent concurrent cCTG and NIFECG monitoring for up to 60 min. Averaged accelerative (AAC) and decelerative (ADC) capacities and STV were derived by postprocessing and filtration of signals, generating fully (F) and partially (P) filtered results. Linear correlation and accuracy and precision analysis were performed to assess the relationship between PRSA outputs from cCTG and NIFECG, using varying anchor thresholds, and their association with STV. RESULTS: A total of 306 concurrent cCTG and NIFECG traces were collected from 285 women. F-filtered NIFECG PRSA (eAAC/eADC) results were generated from 65% of traces, whereas cCTG PRSA (cAAC/cADC) outputs were generated from all. Strong correlations were observed between cAAC and F-filtered eAAC (r = 0.879, P < 0.001) and between cADC and F-filtered eADC (r = 0.895, P < 0.001). NIFECG anchor detection decreased significantly with increasing signal loss, and NIFECG PRSA indices showed considerable deviation from those of cCTG when derived from traces in which fewer than 100 anchors were detected. Removing anchor filters from NIFECG traces to generate P-filtered PRSA outputs weakened the correlation (AAC: r = 0.505, P < 0.001; ADC: r = 0.560, P < 0.001). Lowering the anchor threshold to 100 increased the yield of eAAC and eADC outputs to approximately 74%, whilst maintaining strong correlation with cAAC (r = 0.839, P < 0.001) and cADC (r = 0.815, P < 0.001), respectively. Both cAAC and cADC showed a very strong linear relationship with cCTG STV (r = 0.928, P < 0.001 and r = 0.911, P < 0.001, respectively). Similar findings were observed with eAAC (r = 0.825, P < 0.001) and eADC (r = 0.827, P < 0.001). CONCLUSIONS: PRSA appears to be a method of fetal assessment equivalent to STV, but, due to its innate ability to eliminate artifacts, it generates interpretable NIFECG traces with high accuracy at a higher rate. These findings raise the possibility of self-applied at-home or remote fetal heart-rate monitoring with automated reporting, thus enabling increased surveillance in high-risk women without impacting on service demand. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Correlation of short-term variation derived from novel ambulatory fetal electrocardiography monitor with computerized cardiotocography.

OBJECTIVES: To compare short-term variation (STV) outputs from a novel self-applied non-invasive fetal electrocardiography (NIFECG) device with those obtained on computerized cardiotocography (cCTG). Technological and algorithmic limitations and mitigation strategies were also evaluated. METHODS: This was a prospective cohort study of women with a singleton pregnancy over 28 + 0 weeks' gestation attending a tertiary London hospital for cCTG assessment between June 2021 and June 2022. Women underwent concurrent monitoring with both NIFECG and cCTG for up to 1 h. Postprocessing of NIFECG data using various filtering methods produced NIFECG-STV (eSTV) values, which were compared with cCTG-STV (cSTV) outputs. Linear correlation, mean bias, precision and limits of agreement were assessed for STV derived by the different methods of computation and mathematical correction. RESULTS: Overall, 306 concurrent NIFECG and cCTG traces were collected from 285 women. Fully filtered eSTV was correlated very strongly with cSTV (r = 0.911, P < 0.001), but generated results only in 142/306 (46.4%) 1-h traces owing to the removal of traces with lower-quality signals. Partial filtering generated more eSTV data (98.4%), but with a weak correlation with cSTV (r = 0.337, P < 0.001). The difference in STV between the monitors (eSTV - cSTV) increased with signal loss; in traces with > 60% signal loss, the values became highly discrepant. Removal of traces with > 60% signal loss resulted in a stronger correlation with cSTV, while still generating eSTV results for 65% of traces. Correcting these remaining eSTV values for signal loss using linear regression analysis further improved correlation with cSTV (r = 0.839, P < 0.001). CONCLUSIONS: The discrepancy between STV computed by NIFECG and cCTG necessitates signal filtering, exclusion of poor-quality traces and eSTV correction. This study demonstrates that, with such correction, NIFECG is able to produce STV values that are strongly correlated with those of cCTG. This evidence base for NIFECG monitoring and interpretation is a promising step forward in the development of safe and effective at-home fetal heart-rate monitoring. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Effectiveness of ambulatory non-invasive fetal electrocardiography: impact of maternal and fetal characteristics.

INTRODUCTION: Non-invasive fetal electrocardiography (NIFECG) has potential benefits over the computerized cardiotocography (cCTG) that may permit its development in remote fetal heart-rate monitoring. Our study aims to compare signal quality and heart-rate detection from a novel self-applicable NIFECG monitor against the cCTG, and evaluate the impact of maternal and fetal characteristics on both devices. MATERIAL AND METHODS: This prospective observational study took place in a university hospital in London. Women with a singleton pregnancy from 28 + 0 weeks' gestation presenting for cCTG were eligible. Concurrent monitoring with both NIFECG and cCTG were performed for up to 60 minutes. Post-processing of NIFECG produced signal loss, computed in both 0.25 (E240)- and 3.75 (E16)-second epochs, and fetal heart-rate and maternal heart-rate values. cCTG signal loss was calculated in 3.75-second epochs. Accuracy and precision analysis of 0.25-second epochal fetal heart-rate and maternal heart-rate were compared between the two devices. Multiple regression analyses were performed to assess the impact of maternal and fetal characteristics on signal loss. CLINICALTRIALS: gov Identifier: NCT04941534. RESULTS: 285 women underwent concurrent monitoring. For fetal heart-rate, mean bias, precision and 95% limits of agreement were 0.1 beats per minute (bpm), 4.5 bpm and -8.7 bpm to 8.8 bpm, respectively. For maternal heart-rate, these results were -0.4 bpm, 3.3 bpm and -7.0 to 6.2 bpm, respectively. Median NIFECG E240 and E16 signal loss was 32.0% (interquartile range [IQR] 6.5%-68.5%) and 17.3% (IQR 1.8%-49.0%), respectively. E16 cCTG signal loss was 1.0% (IQR 0.0%-3.0%). For NIFECG, gestational age was negatively associated with signal loss (beta = -2.91, 95% CI -3.69 to -2.12, P < 0.001). Increased body mass index, fetal movements and lower gestational age were all associated with cCTG signal loss (beta = 0.30, 95% CI 0.17-0.43, P < 0.001; beta = 0.03, 95% CI 0.01-0.05, P = 0.014; and beta = -0.28, 95% CI -0.51 to -0.05, P = 0.017, respectively). CONCLUSIONS: Although NIFECG is complicated by higher signal loss, it does not appear to be influenced by increased body mass index or fetal movement. NIFECG signal loss varies according to method of computation, and standards of signal acceptability need to be defined according to the ability of the device to produce clinically reliable physiological indices. The high accuracy of heart-rate indices is promising for NIFECG usage in the remote setting.

Fetal heart rate responses in chronic hypoxaemia with superimposed repeated hypoxaemia consistent with early labour: a controlled study in fetal sheep.

OBJECTIVE: Deceleration area (DA) and capacity (DC) of the fetal heart rate can help predict risk of intrapartum fetal compromise. However, their predictive value in higher risk pregnancies is unclear. We investigated whether they can predict the onset of hypotension during brief hypoxaemia repeated at a rate consistent with early labour in fetal sheep with pre-existing hypoxaemia. DESIGN: Prospective, controlled study. SETTING: Laboratory. SAMPLE: Chronically instrumented, unanaesthetised near-term fetal sheep. METHODS: One-minute complete umbilical cord occlusions (UCOs) were performed every 5 minutes in fetal sheep with baseline pa O2 <17 mmHg (hypoxaemic, n = 8) and >17 mmHg (normoxic, n = 11) for 4 hours or until arterial pressure fell <20 mmHg. MAIN OUTCOME MEASURES: DA, DC and arterial pressure. RESULTS: Normoxic fetuses showed effective cardiovascular adaptation without hypotension and mild acidaemia (lowest arterial pressure 40.7 ± 2.8 mmHg, pH 7.35 ± 0.03). Hypoxaemic fetuses developed hypotension (lowest arterial pressure 20.8 ± 1.9 mmHg, P < 0.001) and acidaemia (final pH 7.07 ± 0.05). In hypoxaemic fetuses, decelerations showed faster falls in FHR over the first 40 seconds of UCOs but the final deceleration depth was not different to normoxic fetuses. DC was modestly higher in hypoxaemic fetuses during the penultimate (P = 0.04) and final (P = 0.012) 20 minutes of UCOs. DA was not different between groups. CONCLUSION: Chronically hypoxaemic fetuses had early onset of cardiovascular compromise during labour-like brief repeated UCOs. DA was unable to identify developing hypotension in this setting, while DC only showed modest differences between groups. These findings highlight that DA and DC thresholds need to be adjusted for antenatal risk factors, potentially limiting their clinical utility.

Diagnostic Tests in the Prediction of Neonatal Outcome in Early Placental Fetal Growth Restriction.

Background and Objectives: Monitoring pregnancies with fetal growth restriction (FGR) presents a challenge, especially concerning the time of delivery in cases of early preterm pregnancies below 32 weeks. The aim of our study was to compare different diagnostic parameters in growth-restricted preterm neonates with and without morbidity/mortality and to determine sensitivity and specificity of diagnostic parameters for monitoring preterm pregnancies with early preterm fetal growth restriction below 32 weeks. Materials and Methods: Our clinical study evaluated 120 cases of early preterm deliveries, with gestational age ≤ 32 + 0 weeks, with prenatally diagnosed placental FGR. All the patients were divided into three groups of 40 cases each based on neonatal condition,: I-Neonates with morbidity/mortality (NMM); II-Neonates without morbidity with acidosis/asphyxia (NAA); III-Neonates without neonatal morbidity/acidosis/asphyxia (NWMAA). Results: Amniotic fluid index (AFI) was lower in NMM, while NWMAA had higher biophysical profile scores (BPS). UA PI was lower in NWMAA. NWMAA had higher MCA PI and CPR and fewer cases with CPR <5th percentile. NMM had higher DV PI, and more often had ductus venosus (DV) PI > 95th‱ or absent/reversed A wave, and pulsatile blood flow in umbilical vein (UV). The incidence of pathological fetal heart rate monitoring (FHRM) was higher in NMM and NAA, although the difference was not statistically significant. ROC calculated by defining a bad outcome as NMM and a good outcome as NAA and NWMAA showed the best sensitivity in DV PIi. ROC calculated by defined bad outcome in NMM and NAA and good outcome in NWMAA showed the best sensitivity in MCA PI. Conclusions: In early fetal growth restriction normal cerebral blood flow strongly predicts good outcomes, while pathological venous blood flow is associated with bad outcomes. In fetal growth restriction before 32 weeks, individualized expectant management remains the best option for the optimal timing of delivery.

Improved obstetric management after implementation of a scaled-up quality improvement intervention: A nested before-after study in three public hospitals in Nepal.

BACKGROUND: We assessed the change in obstetric management after implementation of a quality improvement intervention, the Nepal Perinatal Quality Improvement Package (NePeriQIP). METHODS: The Nepal Perinatal Quality Improvement Package was a stepped-wedge cluster-randomized controlled trial conducted in 12 public hospitals in Nepal between April 2017 and October 2018. In this study, three hospitals allocated at different time points to the intervention were selected for a nested before-after analysis. We used bivariate and multivariate analyses to compare obstetric management in the control vs intervention group. RESULTS: There were 25 977 deliveries in the three hospitals during the study period: 10 207 (39%) in the control and 15 770 (61%) in the intervention group. After adjusting for maternal age, ethnicity, education, gestational age, stage of labor at admission, complications during labor, and birthweight, the intervention group had a higher proportion of fetal heart rate monitoring performed as per protocol (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 1.12-1.27), shorter time intervals between each fetal heart rate monitoring (aOR 2.09, 95% CI 1.96-2.23), a higher likelihood of abnormal fetal heart rate being detected (aOR 1.53, 95% CI 1.25-1.68), progress of labor more often being recorded immediately after per vaginal examination (aOR 2.73, 95% CI 2.55-2.93), and partograph filled as per standards (aOR 3.18, 95% CI 2.98-3.50). The cesarean birth rate was 2.5% in the control group and 8.2% in the intervention group (aOR 3.12, 95% CI 2.64-3.68). CONCLUSIONS: The NePeriQIP intervention has potential to improve obstetric care, especially intrapartum fetal surveillance, in similar low-resource settings.

Fetal heart rate patterns complicated by chorioamnionitis and subsequent cerebral palsy in Japan.

AIM: This retrospective study was performed to investigate whether certain fetal heart rate patterns were associated with subsequent cerebral palsy (CP) in infants with chorioamnionitis at or near term. METHODS: We used cases registered by the Japan Obstetric Compensation System for CP, which is a nationwide population-based database. Among them, 133 infants with chorioamnionitis who were born at ≥34 weeks of gestation were enrolled. All infants underwent magnetic resonance imaging (MRI), and all fetal heart rate charts had been interpreted according to the National Institute of Child Health and Human Development criteria, focusing on antepartum and immediately before delivery. RESULTS: The incidence of CP after chorioamnionitis at ≥34 weeks of gestation was 0.3 per 10 000 in Japan. Between the clinical (24%) and subclinical groups (76%), the incidence of abnormal fetal heart rate patterns did not differ. According to the MRI classification, 88% of the infants with CP showed hypoxic-ischemic encephalopathy. Half of the infants with CP experienced terminal bradycardia, leading to severe acidosis and exclusively to hypoxic-ischemic encephalopathy. In another half, who did not experience bradycardia, 80% had moderate acidosis (pH 7.00-7.20) resulting in hypoxic-ischemic encephalopathy, and the remaining 20% showed non-acidosis resulting in brain damage other than hypoxic-ischemic encephalopathy. The fetal heart rate patterns before the terminal bradycardia showed that the incidence rates of late deceleration or decreased variability were high (>60%). CONCLUSION: Fifty percent of pregnant women with chorioamnionitis-related CP had terminal bradycardia that exclusively resulted in hypoxic-ischemic encephalopathy.

Computerized cardiotocography analysis during labor - A state-of-the-art review.

Cardiotocography is defined as the recording of fetal heart rate and uterine contractions and is widely used during labor as a screening tool to determine fetal wellbeing. The visual interpretation of the cardiotocography signals by the practitioners, following common guidelines, is subject to a high interobserver variability, and the efficiency of cardiotocography monitoring is still debated. Since the 1990s, researchers and practitioners work on designing reliable computer-aided systems to assist practitioners in cardiotocography interpretation during labor. Several systems are integrated in the monitoring devices, mostly based on the guidelines, but they have not clearly demonstrated yet their usefulness. In the last decade, the availability of large clinical databases as well as the emergence of machine learning and deep learning methods in healthcare has led to a surge of studies applying those methods to cardiotocography signals analysis. The state-of-the-art systems perform well to detect fetal hypoxia when evaluated on retrospective cohorts, but several challenges remain to be tackled before they can be used in clinical practice. First, the development and sharing of large, open and anonymized multicentric databases of perinatal and cardiotocography data during labor is required to build more accurate systems. Also, the systems must produce interpretable indicators along with the prediction of the risk of fetal hypoxia in order to be appropriated and trusted by practitioners. Finally, common standards should be built and agreed on to evaluate and compare those systems on retrospective cohorts and to validate their use in clinical practice.

Strengthening Fetal Heart Rate Monitoring during Labor with a Standard Handheld Doppler - Implementation Experience from India.

Background: India's neonatal and perinatal mortality is among the highest in the world. Intrapartum-related conditions contribute to a significant proportion of neonatal deaths and stillbirths. Fetal heart rate monitoring, a recommended norm to assess fetal well-bring, is not practiced as per standard guidelines in public health facilities. A standardized Doppler along with training on fetal heart rate monitoring was implemented across different levels of healthcare in three states. Methods: Facilities were selected purposively to implement the Doppler. Baseline data for 3 months were collected. Interviews of health providers and observation of labor were conducted quarterly. Data were analyzed through a comparison of baseline and intervention on a number of delivery and monitoring indicators. Results: Among 22,579 total deliveries, monitoring frequency increased along with increase in detection of abnormal fetal heart rate (FHR) while cesarean section and stillbirths reduced slightly. Cases never monitored reduced in the District Hospitals (7.98-2.07, P < 0.01) and in Community Health Centers (14.7-1.67, P < 0.001). Stillbirth rate reduced at the medical college (3.6-1.1, P < 0.001). Interviews with providers revealed acceptance of the device due to its reliable readings. Conclusion: The Doppler demonstrates acceptability and serves as a useful aid to improve intrapartum FHR monitoring.

Intrauterine fetal death during COVID-19 pregnancy: Typical fetal heart rate changes, coagulopathy, and placentitis.

Although various perinatal outcomes in coronavirus disease 2019 (COVID-19) pregnancies have been reported, the fetal and neonatal consequences of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection remain unclear. Several reports of miscarriages and stillbirths have been recorded, but vertical transmission by SARS-CoV-2 is considered very rare, and the cause remains unknown. We report a case of a 22-year-old uncomplicated Japanese woman infected with SARS-CoV-2 during the second trimester, resulting in intrauterine fetal death due to placental insufficiency associated with COVID-19 placentitis. This report emphasizes the importance of longitudinal assessment of fetal well-being by fetal heart rate monitoring and early detection of maternal coagulation dysfunction representing SARS-CoV-2 inflammation to manage COVID-19 in pregnancy.

Placental growth factor level is correlated with intrapartum fetal heart rate findings.

OBJECTIVE: Here, we tested the correlation between maternal placental growth factor (PlGF) and fetal heart rate (FHR) monitoring findings. METHODS: We included 35 women with single pregnancies from 35 to 42 weeks of gestation who were hospitalized owing to onset of labor. Blood samples were collected at the start of labor. Intrapartum FHR monitoring parameters included total deceleration area, average deceleration area (mean deceleration area per 10 min), and five-tier classification level. RESULTS: Of the 35 women, 26 (74%) had vaginal delivery and 9 (26%) had cesarean section. After excluding 2 women who had cesarean section for arrest of labor, we analyzed 26 women who had vaginal delivery (VD group) and 7 who had cesarean section for fetal indications (CSF group). PlGF level was significantly higher in the VD group (157 ± 106 pg/ml) than in the CSF group (74 ± 62 pg/ml) (P = 0.03). There were no significant correlations between PlGF and total (r = -0.07) or average (r = -0.08) deceleration area.　There was a significant negative correlation (r = -0.42, P = 0.01) between PlGF and the percentage of level 3 or higher in the five-level classification. CONCLUSION: PlGF was correlated with FHR monitoring findings and might be a promising biomarker of intrapartum fetal function.