Impact of nuchal cord on antenatal and intrapartum foetal heart rate surveillance and perinatal outcome.

Analysing antepartum and intrapartum computerised cardiotocographic (cCTG) parameters in physiological term pregnancies with nuchal (NC) or body cord (BC), in order to correlate them with labour events and neonatal outcome. We enrolled 808 pregnant women, composed of 264 with 'one NC', 121 with 'multiple NCs', 39 with BC and 384 with 'no NC', were monitored from the 37th week of gestation before labour, while 49 pregnant women with 'one or more NCs' and 47 with 'no NCs' were analysed during labour. No differences in maternal characteristics, foetal pH at birth and 5-min Apgar score were observed. The birth weight was significantly lower in the 'multiple NCs' group, while 1-minute Apgar score was lower in the BC group than the other groups, respectively. No relevant differences in cCTG parameters were observed, except for LTI, Delta and number of variable decelerations in antepartum period and only variable deceleration in intrapartum period.Impact statementWhat is already known on this subject? Ultrasound cannot predict which foetuses with NCs are likely to have problem during labour. The question arose if single or multiple NC could affects FHR monitoring prior and during labour.What do the results of this study add? Computerised cardiotocography (cCTG) is a standardised method developed to reduce inter- and intra-observer variability and the poor reproducibility of visual analysis. Few studies have investigated the influence of NCs on FHR variability and, to our knowledge, no one has evaluated its linear and nonlinear characteristics in antepartum and intrapartum period using a computerised analysis system. No differences in maternal characteristics, foetal pH at birth and 5-min Apgar score were observed. Birth weight was significantly lower in the 'multiple NCs' group, while 1-min Apgar score was lower in the BC group than the other groups, respectively. Foetuses with 'one or more NCs' evidenced a larger number of prolonged second stage and meconium-stained liquor cases, while the operative vaginal delivery and emergency caesarean section rates were unchanged. No relevant differences in cCTG parameters were observed, except for LTI, Delta and number of variable decelerations in antepartum period and only variable deceleration in intrapartum period.What are the implications of these findings for clinical practice and/or further research? cCTG monitoring results confirmed their usefulness for assessing the state of good oxygenation for all foetuses investigated.

Ethnic analogies and differences in fetal heart rate variability signal: A retrospective study.

AIM: We aimed to analyze computerized cardiotocographic (cCTG) parameters (including fetal heart rate baseline, short-term variability, Delta, long-term irregularity [LTI], interval index [II], low frequency [LF], movement frequency [MF], high frequency [HF], and approximate entropy [ApEn]) in physiological term pregnancies in order to correlate them with ethnic differences. The clinical meaning of numerical parameters may explain physiological or paraphysiological phenomena that occur in fetuses of different ethnic origins. METHODS: A total of 696 pregnant women, including 384 from Europe, 246 from sub-Saharan Africa, 45 from South-East Asia, and 21 from South America, were monitored from the 37th to the 41st week of gestation. Statistical analysis was performed with the analysis of variance test, Pearson correlation test and receiver-operator curves (P < 0.05). RESULTS: Our results showed statistically significant differences (P < 0.05) between white and black women for Delta, LTI, LF, MF, HF, and ApEn; between white and Asian women for Delta, LTI, MF, and the LF/(HF + MF) ratio; and between white and Latina women for Delta, LTI, and ApEn. In particular, Delta and LTI performed better in the white group than in the black, Asian, and Latina groups. Instead, LF, MF, HF, and ApEn performed better in the black than in the white group. CONCLUSION: Our results confirmed the integrity and normal functionality of both central and autonomic nervous system components for all fetuses investigated. Therefore, CTG monitoring should include both linear and nonlinear components of fetal heart rate variability in order to avoid misinterpretations of the CTG trace among ethnic groups.

Telemedicine to Improve Access to Specialist Care in Fetal Heart Rate Monitoring: Analysis of 17 Years of TOCOMAT Network Clinical Activity.

BACKGROUND: The objective of this article is to provide an overview of the clinical experience of our telemedicine network (TOCOMAT) for fetal well-being assessment through computerized Cardiotocography (cCTG), analyzing cultural, socioeconomic, and environmental conditions of pregnant women and its economic sustainability over time. MATERIALS AND METHODS: We used the central data store, including all cCTG records collected in Campania region (Italy) during 17 years of activity. The Operations Center acquires the traces recorded in the Remote Units and simultaneously performs a complex fetal heart rate analysis. An Internet or phone conference calling is available to discuss the information transmitted. Finally, the report is send back to the Remote Units. RESULTS: The number of cCTG traces performed was constantly increasing, despite the progressive reduction in the number of peripheral units involved. Pregnant women in Remote Unit group were younger and overweight and showed a higher incidence of diabetes and fetal defects than Operations Center ones. Moreover, a high rate of African migrant women and low socioeconomic and cultural standards were found in Remote Unit group. The cost analysis showed an economic advantage both in the reduction of inappropriate admissions and in the improvement of admission indicators (hospital stay days) for pregnant women. DISCUSSION: The global economic recession has had a significant impact on the Italian regional healthcare system and socioeconomic deprivation. CONCLUSIONS: Telemedicine could avoid unnecessary referral to Level III centers (Hospital) in Campania region, where the average population density is very high, allowing equal access to ultra-specialist assessment irrespective of the geographical location of the pregnant woman with medium to high risk, as well as rationalizing the costs for maternal and fetal care.

Computerised analysis of antepartum foetal heart parameters: New reference ranges.

We selected 4012 cCTG records (one trace for each patient) performed in healthy pregnancies from 30th to 42nd gestational week using foetal heart rate (FHR), short-term variability (STV), long-term irregularity (LTI), Delta, approximate entropy (ApEn), spectral components as low frequency (LF), median frequency (MF), high frequency (HF) and LF/(HF + MF) ratio were analysed. Reference nomograms were created and sensitivity and specificity for the prediction of foetal compromise were calculated which were 90% and 89%, respectively. Changes of cCTG parameters according to gestational week were evaluated: FHR (r = -.65) and LF (r = -.87) showed a statistically significant reduction (p < .05) with gestational age. STV (r = .59), LTI (r = .69), Delta (r = .67), and MF (r = .88) showed a statistically significant increase (p < .05) with gestational age. In contrast, for ApEn (r = -.098), HF (r = .14) and LF/(HF + MF) ratio (r = -.47) a non-statistically significant change was found (p > .05). The identification of reference ranges for cCTG indexes in according to gestational age could provide a more objective examination of cCTG trace.

Computerized analysis of fetal heart rate variability signal during the stages of labor.

AIM: To analyze computerized cardiotocographic (cCTG) parameters (baseline fetal heart rate, baseline FHR; short term variability, STV; approximate entropy, ApEn; low frequency, LF; movement frequency, MF; high frequency, HF) in physiological pregnancy in order to correlate them with the stages of labor. This could provide more information for understanding the mechanisms of nervous system control of FHR during labor progression. METHODS: A total of 534 pregnant women were monitored on cCTG from the 37th week before the onset of spontaneous labor and during the first and the second stage of labor. Statistical analysis was performed using Kruskal-Wallis test and Wilcoxon rank-sum test with the Bonferroni adjusted α (< 0.05). RESULTS: Statistically significant differences were seen between baseline FHR, MF and HF (P < 0.001), in which the first two were reduced and the third was increased when compared between pre-labor, and the first and second stages of labor. Differences between some of the stages were found for ApEn, LF and for LF/(HF + MF), where the first and the third were reduced and the second was increased. CONCLUSIONS: cCTG modifications during labor may reflect the physiologic increased activation of the autonomous nervous system. Using computerized fetal heart rate analysis during labor it may be possible to obtain more information from the fetal cardiac signal, in comparison with the traditional tracing.

Intrapartum cardiotocography with and without computer analysis: a systematic review and meta-analysis of randomized controlled trials.

Objective: To evaluate whether intrapartum cardiotocography with computer analysis decreases the incidence of newborn metabolic acidosis or obstetric intervention when compared with visual analysis through a systematic review with meta-analysis of randomized controlled trials.Methods: The research was conducted using Medline, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid and Cochrane Library as electronic databases from the inception of each database to May 2018. Selection criteria included randomized trial evaluating women with cephalic presentation at term or late preterm term during labor who were randomized to electronic fetal heart rate monitoring with either computer analysis (i.e. intervention group) or standard visual analysis (i.e. control group). Trials evaluating antenatal fetal heart rate monitoring in women not in labor were excluded. The primary outcome was incidence of newborn metabolic acidosis, defined as pH less than 7.05 and base deficit greater than 12 mmol/L. Secondary outcomes were mode of delivery, admission to neonatal intensive care unit, hypoxic-ischemic encephalopathy, and perinatal death. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI).Results: Three randomized controlled trials (RCTs), including 54,492 participants, which met inclusion criteria for this meta-analysis, were analyzed. All the included trials enrolled women with cephalic presentation at term or late preterm. Women were randomized in the active first stage of labor and all of them received continuous cardiotocography (CTG) from randomization until delivery. Women who received continuous CTG during labor with computerized analysis had similar risk of newborn metabolic acidosis. No between group differences were found in the secondary outcomes.Conclusions: Compared with visual analysis, use of computer analysis of fetal monitoring signals during labor did not significantly reduce the rate of metabolic acidosis or obstetric intervention.

Evaluation of the Acceleration and Deceleration Phase-Rectified Slope to Detect and Improve IUGR Clinical Management.

OBJECTIVE: This study used a new method called Acceleration (or Deceleration) Phase-Rectified Slope, APRS (or DPRS) to analyze computerized Cardiotocographic (cCTG) traces in intrauterine growth restriction (IUGR), in order to calculate acceleration- and deceleration-related fluctuations of the fetal heart rate, and to enhance the prediction of neonatal outcome. METHOD: Cardiotocograms from a population of 59 healthy and 61 IUGR fetuses from the 30th gestation week matched for gestational age were included. APRS and DPRS analysis was compared to the standard linear and nonlinear cCTG parameters. Statistical analysis was performed through the t-test, ANOVA test, Pearson correlation test and receiver operator characteristic (ROC) curves (p < 0, 05). RESULTS: APRS and DPRS showed high performance to discriminate between Healthy and IUGR fetuses, according to gestational week. A linear correlation with the fetal pH at birth was found in IUGR. The area under the ROC curve was 0.865 for APRS and 0.900 for DPRS before the 34th gestation week. CONCLUSIONS: APRS and DPRS could be useful in the identification and management of IUGR fetuses and in the prediction of the neonatal outcome, especially before the 34th week of gestation.

Fetal vibroacoustic stimulation in computerized cardiotocographic analysis: the role of short-term variability and approximate entropy.

The aim of this study was to evaluate the impact of vibroacoustic stimulation (VAS) on computerized cardiotocography short-term variability (STV) and approximate entropy (ApEn) in both low- and high-risk pregnancies. VAS was performed on 121 high- and 95 low-risk pregnancies after 10 minutes of continuous quiet, while their FHR parameters were monitored and recorded by cCTG analysis. Fetal heart rate was recorded using a computer-assisted equipment. Baseline FHR, accelerations, decelerations, STV, long-term irregularity (LTI), ApEn, and fetal movements (FMs) were calculated for defined observational periods before VAS and after 10 minutes. Data were also investigated in relationship with the perinatal outcome. In each group of patients, FHR after VAS remained almost unmodified. Fetal movements significantly increased after VAS in both groups. Results show that only in the high-risk pregnancies, the increase of STV and the decrease of ApEn after VAS were significantly associated with favorable perinatal outcomes.