Identification of cases with adverse neonatal outcome monitored by cardiotocography versus ST analysis: secondary analysis of a randomized trial.

OBJECTIVE: To evaluate whether correct adherence to clinical guidelines might have led to prevention of cases with adverse neonatal outcome. DESIGN: Secondary analysis of cases with adverse outcome in a multicenter randomized clinical trial. SETTING: Nine Dutch hospitals. POPULATION: Pregnant women with a term singleton fetus in cephalic position. METHODS: Data were obtained from a randomized trial that compared monitoring by STAN® (index group) with cardiotocography (control group). In both trial arms, three observers independently assessed the fetal surveillance results in all cases with adverse neonatal outcome, to determine whether an indication for intervention was present, based on current clinical guidelines. MAIN OUTCOME MEASURES: Adverse neonatal outcome cases fulfilled one or more of the following criteria: (i) metabolic acidosis in umbilical cord artery (pH < 7.05 and base deficit in extracellular fluid >12 mmol/L); (ii) umbilical cord artery pH < 7.00; (iii) perinatal death; and/or (iv) signs of moderate or severe hypoxic ischemic encephalopathy. RESULTS: We studied 5681 women, of whom 61 (1.1%) had an adverse outcome (26 index; 35 control). In these women, the number of performed operative deliveries for fetal distress was 18 (69.2%) and 16 (45.7%), respectively. Reassessment of all 61 cases showed that there was a fetal indication to intervene in 23 (88.5%) and 19 (57.6%) cases, respectively. In 13 (50.0%) vs. 11 (33.3%) cases, respectively, this indication occurred more than 20 min before the time of delivery, meaning that these adverse outcomes could possibly have been prevented. CONCLUSIONS: In our trial, more strict adherence to clinical guidelines could have led to additional identification and prevention of adverse outcome.

Prediction of neonatal metabolic acidosis in women with a singleton term pregnancy in cephalic presentation.

We sought to predict neonatal metabolic acidosis at birth using antepartum obstetric characteristics (model 1) and additional characteristics available during labor (model 2). In 5667 laboring women from a multicenter randomized trial that had a high-risk singleton pregnancy in cephalic presentation beyond 36 weeks of gestation, we predicted neonatal metabolic acidosis. Based on literature and clinical reasoning, we selected both antepartum characteristics and characteristics that became available during labor. After univariable analyses, the predictors of the multivariable models were identified by backward stepwise selection in a logistic regression analysis. Model performance was assessed by discrimination and calibration. To correct for potential overfitting, we (internally) validated the models with bootstrapping techniques. Of 5667 neonates born alive, 107 (1.9%) had metabolic acidosis. Antepartum predictors of metabolic acidosis were gestational age, nulliparity, previous cesarean delivery, and maternal diabetes. Additional intrapartum predictors were spontaneous onset of labor and meconium-stained amniotic fluid. Calibration and discrimination were acceptable for both models (c-statistic 0.64 and 0.66, respectively). In women with a high-risk singleton term pregnancy in cephalic presentation, we identified antepartum and intrapartum factors that predict neonatal metabolic acidosis at birth.

Cost-effectiveness of cardiotocography plus ST analysis of the fetal electrocardiogram compared with cardiotocography only.

OBJECTIVE: To assess the cost-effectiveness of addition of ST analysis of the fetal electrocardiogram (ECG; STAN) to cardiotocography (CTG) for fetal surveillance during labor compared with CTG only. DESIGN: Cost-effectiveness analysis based on a randomized clinical trial on ST analysis of the fetal ECG. SETTING: Obstetric departments of three academic and six general hospitals in The Netherlands. Population. Laboring women with a singleton high-risk pregnancy, a fetus in cephalic presentation, a gestational age >36 weeks and an indication for internal electronic fetal monitoring. METHODS: A trial-based cost-effectiveness analysis was performed from a health-care provider perspective. MAIN OUTCOME MEASURES: Primary health outcome was the incidence of metabolic acidosis measured in the umbilical artery. Direct medical costs were estimated from start of labor to childbirth. Cost-effectiveness was expressed as costs to prevent one case of metabolic acidosis. RESULTS: The incidence of metabolic acidosis was 0.7% in the ST-analysis group and 1.0% in the CTG-only group (relative risk 0.70; 95% confidence interval 0.38-1.28). Per delivery, the mean costs per patient of CTG plus ST analysis (n= 2 827) were €1,345 vs. €1,316 for CTG only (n= 2 840), with a mean difference of €29 (95% confidence interval -€9 to €77) until childbirth. The incremental costs of ST analysis to prevent one case of metabolic acidosis were €9 667. CONCLUSIONS: The additional costs of monitoring by ST analysis of the fetal ECG are very limited when compared with monitoring by CTG only and very low compared with the total costs of delivery.

Neonatal morbidity in term neonates is related to gestational age at birth and level of care.

AIMS: The objective of this study was to assess whether the incidence of neonatal morbidity of neonates born at term and admitted to a neonatal intensive care unit (NICU) differs by gestational age and level of care. METHODS: This is a 5-year retrospective cohort study of singleton term births admitted to the NICU of the VU University Medical Center with a gestational age ≥37+0 weeks. RESULTS: In total, 497 neonates were included in the study. The incidence of neonates born with an arterial cord blood pH<7.10, neonatal asphyxia, and meconium aspiration syndrome increased with advancing gestational age. The incidence of secondary cesarean section and operative vaginal delivery also increased with advancing gestational age. Neonatal death occurred in 29 (5.84%) of the 497 cases; 27 (93%) of 29 were due to asphyxia. Seventeen (34%) of the 50 neonates born in primary care were admitted for asphyxia. Eight (47%) of these 17 neonates died. CONCLUSIONS: Neonatal morbidity in term neonates is related to gestational age at birth. Since asphyxia is an important cause of both morbidity and mortality in term neonates, it is important to clearly define and include asphyxia in future perinatal audits.

Fetal brain sonography and fetal heart rate patterns in the preterm fetus.

OBJECTIVE: The objective of the study was to study whether peri- and intraventricular echodensities in the brain of fetuses at risk for preterm birth are associated with changes in fetal heart rate (FHR) parameters. STUDY DESIGN: Twenty preterm fetuses with peri- and intraventricular echodensities detected by transvaginal ultrasonography were matched with 20 fetuses without echodensities for gestational age, growth parameters, clinical disease, and maternal medication. Baseline FHR, long- and short-term variability, and the presence of accelerations and decelerations were analyzed with a computerized system and compared with the Wilcoxon matched-pairs signed-rank test. Both cases and controls were compared with a normal population. RESULTS: No statistical differences in FHR parameters were found between cases with and controls without peri- and intraventricular echodensities. Both cases and controls had lower long- and short-term variabilities than the normal population. CONCLUSION: No association between the presence of peri- and intraventricular echodensities and specific FHR changes was demonstrated.

Use of recombinant activated factor VII in massive postpartum haemorrhage.

OBJECTIVE: Postpartum haemorrhage (PPH) remains an important cause of maternal morbidity and mortality. With regard to morbidity, preservation of the uterus is of paramount importance in fertile women. The objective of the study was to describe the cumulative experience of a cohort of women that were treated with recombinant factor VIIa. STUDY DESIGN: In this retrospective, descriptive study we approached all departments of obstetrics and gynaecology in the Netherlands to find out if they had used rFVIIa for this indication. Twenty-seven cases were reported to us. To evaluate each case, we used a standardized case record form. RESULTS: The main cause of PPH was uterine atony (82%). In 21 cases rFVIIa was explicitly given to prevent a hysterectomy. This was successful in 16 cases (76%). Relevant reduction or complete cessation of bleeding after rFVIIa was noted in 24/27 cases (89%). There was a reduction in blood product requirements following rFVIIa administration. The dose of rFVIIa was variable and ranged from 16 to 128mug/kg. CONCLUSION: There appears to be a role for the use of rFVIIa in PPH unresponsive to conventional therapy. Recombinant FVIIa can be helpful and avoid an emergency hysterectomy.

A randomised clinical trial on cardiotocography plus fetal blood sampling versus cardiotocography plus ST-analysis of the fetal electrocardiogram (STAN) for intrapartum monitoring.

BACKGROUND: Cardiotocography (CTG) is worldwide the method for fetal surveillance during labour. However, CTG alone shows many false positive test results and without fetal blood sampling (FBS), it results in an increase in operative deliveries without improvement of fetal outcome. FBS requires additional expertise, is invasive and has often to be repeated during labour. Two clinical trials have shown that a combination of CTG and ST-analysis of the fetal electrocardiogram (ECG) reduces the rates of metabolic acidosis and instrumental delivery. However, in both trials FBS was still performed in the ST-analysis arm, and it is therefore still unknown if the observed results were indeed due to the ST-analysis or to the use of FBS in combination with ST-analysis. METHODS/DESIGN: We aim to evaluate the effectiveness of non-invasive monitoring (CTG + ST-analysis) as compared to normal care (CTG + FBS), in a multicentre randomised clinical trial setting. Secondary aims are: 1) to judge whether ST-analysis of fetal electrocardiogram can significantly decrease frequency of performance of FBS or even replace it; 2) perform a cost analysis to establish the economic impact of the two treatment options. Women in labour with a gestational age > or = 36 weeks and an indication for CTG-monitoring can be included in the trial. Eligible women will be randomised for fetal surveillance with CTG and, if necessary, FBS or CTG combined with ST-analysis of the fetal ECG. The primary outcome of the study is the incidence of serious metabolic acidosis (defined as pH < 7.05 and Bdecf > 12 mmol/L in the umbilical cord artery). Secondary outcome measures are: instrumental delivery, neonatal outcome (Apgar score, admission to a neonatal ward), incidence of performance of FBS in both arms and cost-effectiveness of both monitoring strategies across hospitals. The analysis will follow the intention to treat principle. The incidence of metabolic acidosis will be compared across both groups. Assuming a reduction of metabolic acidosis from 3.5% to 2.1 %, using a two-sided test with an alpha of 0.05 and a power of 0.80, in favour of CTG plus ST-analysis, about 5100 women have to be randomised. Furthermore, the cost-effectiveness of CTG and ST-analysis as compared to CTG and FBS will be studied. DISCUSSION: This study will provide data about the use of intrapartum ST-analysis with a strict protocol for performance of FBS to limit its incidence. We aim to clarify to what extent intrapartum ST-analysis can be used without the performance of FBS and in which cases FBS is still needed. TRIAL REGISTRATION NUMBER: ISRCTN95732366.

Does intra-uterine environment influence fetal head-position preference? A comparison between breech and cephalic presentation.

BACKGROUND: Cephalic fetuses have increasing lateralised head-position near term. AIM: Is this development affected by breech presentation? SUBJECTS AND METHODS: Fetal head-position was studied longitudinally in 13 healthy fetuses in breech presentation and 10 healthy fetuses in cephalic presentation by means of real-time ultrasound. Recordings were obtained weekly from 33 weeks gestational age until birth. RESULTS: As in previous research, a significant (p = 0.045) decrease in midline head-position was found for the cephalic fetuses with advancing gestational age. The development of a lateralised head-position preference was clearly less outspoken in the breech fetuses when compared to the cephalic ones, especially after 36 weeks gestational age. Furthermore, as cephalic fetuses showed a preference for a right-sided head-position, breech fetuses that did show a lateralised head-position did not have a clear preference for left or right. Our data show an association between the orientation of the fetal vertebral column and head-position predominance in the group of cephalic fetuses, which complies with Previc's left-otolithic dominance theory. No association could be detected between fetal head shape and head-position preference. CONCLUSIONS: This study shows evidence that development in head laterality is influenced by the breech presentation. The discussion addresses possible explanations for the differences we found between the breech and cephalic fetuses.

TNF-receptor levels in preeclampsia--results of a longitudinal study in high-risk women.

OBJECTIVE: Tumor necrosis factor-alpha (TNF-alpha) is thought to play a role in immune activation in preeclampsia. The objective of this study was to establish if soluble TNF-receptor I (sTNF-rI) levels relate to the onset and severity of preeclampsia. METHODS: Maternal plasma sTNF-rI levels were studied throughout pregnancy in 68 women with a history of severe preeclampsia or intra-uterine growth restriction (IUGR), and primigravidas with chronic hypertension. Data are presented as mean (SD) in ng/ml. RESULTS: In the second trimester there was a significant difference in sTNF-rI levels between preeclamptic pregnancies with and without IUGR (means 1.33 (0.20) and 1.11 (0.15) respectively, p < 0.005). In severe preeclampsia with delivery before 34 weeks of gestation, sTNF-rI levels were higher than in mild preeclampsia in the second and third trimesters (means 1.40 (0.16) vs. 1.16 (0.19), p < 0.02 and 1.82 (0.47) vs. 1.42 (0.22), p < 0.05, respectively). CONCLUSION: sTNF-rI levels were higher in preeclampsia with fetal involvement, suggesting that increased TNF-alpha production in preeclampsia is related to impaired placentation rather than to the maternal syndrome.

Successful treatment of life-threatening postpartum hemorrhage with recombinant activated factor VII.

BACKGROUND: Postpartum hemorrhage is one of the most common causes of maternal mortality and morbidity worldwide. The aims of treatment are to maintain the circulation and to stop the bleeding. The latter is achieved by either medical or surgical management. In intractable bleeding, emergency hysterectomy is usually required. CASE: A 30-year-old nullipara presented with major postpartum hemorrhage due to uterine atony and vaginal lacerations. The patient developed hemorrhagic shock, resulting in prolonged prothrombin time, prolonged activated partial thromboplastin time, and low levels of factor VIII and fibrinogen. Treatments with uterotonic drugs, suturing, ligation of internal iliac arteries, subtotal hysterectomy, packing of the pelvis, and blood transfusion failed to control diffuse pelvic and vaginal bleeding. Recombinant activated factor VIIa (60-microg/kg intravenous bolus injection) was given as a final attempt to control the bleeding. The bleeding was successfully controlled within 10 minutes after administration. No side effects were noted. CONCLUSION: Recombinant factor VIIa may be an alternative hemostatic agent in a patient with life-threatening postpartum hemorrhage unresponsive to conventional therapy.

Ketanserin in women with chronic hypertension and underlying thrombophilia.

BACKGROUND: Pregnant women with chronic hypertension and thrombophilia have an increased risk for preeclampsia and/or intrauterine growth restriction (IUGR). Ketanserin lowers blood pressure and inhibits serotonin-induced platelet aggregation. CASES: A 38-year-old woman with chronic hypertension had a first pregnancy with severe hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. A second pregnancy with prophylactic oral ketanserin and low-dose aspirin was uneventful. The third pregnancy without oral ketanserin was again complicated by severe superimposed preeclampsia and IUGR. During this pregnancy a prothrombin mutation was found. A 37-year-old woman with chronic hypertension developed severe early-onset superimposed preeclampsia in her first pregnancy. In the 3 consecutive pregnancies, she was treated with low-molecular-weight heparin because of a factor XII deficiency. Only the pregnancy with the use of prophylactic oral ketanserin was uncomplicated. CONCLUSION: Clinical trials are warranted to analyze the role of oral ketanserin in preventing preeclampsia and IUGR.

Cervical incompetence: a reappraisal of an obstetric controversy.

UNLABELLED: Cervical incompetence is not a categoric but rather a continuous variable, meaning that there are various degrees in the competency of the cervix. Furthermore, a certain degree of competency of the cervix can be expressed differently in subsequent pregnancies. Women with risk factors for cervical incompetence in their gynecological/obstetric history should be followed by transvaginal ultrasonography. History alone is not an indication for a prophylactic cerclage. Although transvaginal ultrasonography identifies women at high risk of preterm delivery, it does not discriminate between different underlying pathologies. Short cervical length alone is not an indication for a therapeutic cerclage. Serial transvaginal ultrasonographic measurements of cervical length in women with risk factors can identify those women truly at high risk of preterm delivery. A transvaginal cervical cerclage with bed rest reduces preterm delivery and improves perinatal outcome in women with a short cervical length and risk factors for cervical incompetence. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to define cervical incompetence, explain the role of transvaginal ultrasonography in the prediction of preterm delivery, and summarize the data on the use of transvaginal cervical cerclage.

Maternal admission characteristics as risk factors for preterm birth.

OBJECTIVE: The aim of this study is to identify a subset of women presenting with preterm labor not responding upon tocolytic therapy, eventually resulting in preterm birth. STUDY DESIGN: The maternal admission characteristics of 185 women with preterm labor receiving tocolysis were analysed for risk factors that could predict which women will deliver within 48 h after the start of tocolysis, or before 34 weeks gestation. Univariate analysis and multivariate logistic regression analysis was performed. RESULTS: Logistic regression analysis identified the following risk factors for delivery within 48 h after the start of tocolysis: cervical dilatation at admission (odds ratio (OR, cm(-1)) 1.47; 95% confidence interval (CI), 1.44-1.49), elevated leukocyte count at admission (per 10(3) leukocytes/mm(3)) (OR 1.27; 95% CI, 1.26-1.28), use of nifedipine (OR 0.49; 95% CI, 0.26-0.49), and developing signs suggestive of chorioamnionitis following admission (OR 2.12; 95% CI, 1.04-4.33). For delivery before 34 weeks of gestation the following risk factors were identified: use of steroids (OR 5.87; 95% CI, 2.34-14.7), use of nifedipine (OR 0.46; 95% CI, 0.27-0.85), developing signs suggestive of chorioamnionitis following admission (OR 10.6; 95% CI, 3.1-35.9), and preterm premature rupture of the membranes (OR 12; 95% CI, 4.1-35.2). CONCLUSIONS: Risk factors associated for delivery within 48 h after starting tocolysis are: cervical dilatation at admission, elevated leukocyte count at admission, and developing signs suggestive of chorioamnionitis following admission. Use of nifedipine was associated with a delay of delivery >48 h. Risk factors associated for delivery within 34 weeks gestation are: use of steroids, developing signs suggestive of chorioamnionitis following admission, and ruptured membranes. Use of nifedipine was associated with a delay >34 weeks.

The optimal dosage of ketanserin for patients with severe hypertension in pregnancy.

OBJECTIVE: To establish the optimal dosage of ketanserin in the treatment of severe hypertension in pregnancy. STUDY DESIGN: A double blind prospective randomised controlled trail, comparing 10 mg ketanserin given as intravenous boluses either every 10 or 20 min, until the therapeutic goal of 90 mmHg (diastolic blood pressure) was reached, to a maximum of eight boluses. Main outcome measures were treatment failures and caesarean sections for fetal distress. RESULTS: There was no difference in reaching the therapeutic goal between patients receiving 10 mg ketanserin either every 10 or 20 min. CONCLUSION: Ketanserin appears to be an attractive medicine in the treatment of severe hypertension in pregnancy, but the optimal dosage could not be established.

Cardiotocography plus ST analysis of fetal electrocardiogram compared with cardiotocography only for intrapartum monitoring: a randomized controlled trial.

OBJECTIVE: To estimate the effectiveness of intrapartum fetal monitoring by cardiotocography plus ST analysis using a strict protocol for performance of fetal blood sampling. METHODS: We performed a multicenter randomized trial among laboring women with a high-risk singleton pregnancy in cephalic presentation beyond 36 weeks of gestation. Participants were assigned to monitoring by cardiotocography with ST analysis (index) or cardiotocography only (control). Primary outcome was metabolic acidosis, defined as an umbilical cord artery pH below 7.05 combined with a base deficit calculated in the extracellular fluid compartment above 12 mmol/L. Secondary outcomes were metabolic acidosis in blood, operative deliveries, Apgar scores, neonatal admissions, and hypoxic-ischemic encephalopathy. RESULTS: We randomly assigned 5,681 women to the two groups (2,832 index, 2,849 control). The fetal blood sampling rate was 10.6% in the index compared with 20.4% in the control group (relative risk 0.52; 95% [CI] 0.46-0.59). The primary outcome occurred 0.7% in the index compared with 1.1% in the control group (relative risk 0.70; 95% CI 0.38-1.28; number needed to treat 252). Using metabolic acidosis calculated in blood, these rates were 1.6% and 2.6%, respectively (relative risk 0.63; 95% CI 0.42-0.94; number needed to treat 100). The number of operative deliveries, low Apgar scores, neonatal admissions, and newborns with hypoxic-ischemic encephalopathy was comparable in both groups. CONCLUSION: Intrapartum monitoring by cardiotocography combined with ST analysis does not significantly reduce the incidence of metabolic acidosis calculated in the extracellular fluid compartment. It does reduce the incidence of metabolic acidosis calculated in blood and the need for fetal blood sampling without affecting the Apgar score, neonatal admissions, hypoxic-ischemic encephalopathy, or operative deliveries. LEVEL OF EVIDENCE: I.

Recurrent incarceration of the gravid uterus.

Incarceration of the gravid uterus is a rare phenomenon, associated with maternal and fetal morbidity and mortality. A 37-year-old gravida 2 para 1 develops a recurrent incarceration in her second pregnancy. Therefore, examination and follow-up early in the next pregnancy is advised.

Misidentification of maternal for fetal heart rate patterns after delivery of the first twin.

BACKGROUND: The 2nd born in twin delivery is at higher risk of fetal asphyxia. We tested the hypothesis that inadequate, fetal heart rate (FHR) monitoring has contributed to an inadvertent outcome. STUDY DESIGN: A database was reviewed consisting of 41 twin deliveries with a pH in the umbilical artery of the 2nd twin below 7.05. Cardiotocograms were examined for possible signs of a maternal instead of a fetal origin of the heart rate pattern. RESULTS: In four of the reviewed cases, a good outcome had been anticipated by the attending physician based on the cardiotocogram, whereas the 2nd twin was born with low Apgar scores and a low pH of the umbilical artery. In retrospect it was concluded that the recorded heart rate pattern was of maternal origin. In all four cases the heart rate tracings had characteristics typical for a maternal origin. CONCLUSION: Misidentifying the maternal for the fetal heart rate increases the risk that a compromised fetal condition is missed. This occurrence may contribute to the increased incidence of fetal asphyxia in 2nd twins.

Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study.

OBJECTIVE: To evaluate the incidence of serious maternal complications after the use of various tocolytic drugs for the treatment of preterm labour in routine clinical situations. DESIGN: Prospective cohort study. SETTING: 28 hospitals in the Netherlands and Belgium. PARTICIPANTS: 1920 consecutive women treated with tocolytics for threatened preterm labour. MAIN OUTCOME MEASURES: Maternal adverse events (those suspected of being causally related to treatment were considered adverse drug reactions) leading to cessation of treatment. RESULTS: An independent panel evaluated the recorded adverse events, without knowledge of the type of tocolytic used. Of the 1920 women treated with tocolytics, 1327 received a single course of treatment (69.1%), 282 sequential courses (14.7%), and 311 combined courses (16.2%). Adverse drug reactions were categorised as serious or mild in 14 cases each. The overall incidence of serious adverse drug reaction was 0.7%. Compared with atosiban, the relative risk of an adverse drug reaction for single treatment with a beta adrenoceptor agonist was 22.0 (95% confidence interval 3.6 to 138.0) and for single treatment with a calcium antagonist was 12 (1.9 to 69). Multiple drug tocolysis led to five serious adverse drug reactions (1.6%). Multiple gestation, preterm rupture of membranes, and comorbidity were not independent risk factors for adverse drug reactions. CONCLUSIONS: The use of beta adrenoceptor agonists or multiple tocolytics for preventing preterm birth is associated with a high incidence of serious adverse drug reactions. Indometacin and atosiban were the only drugs not associated with serious adverse drug reactions. A direct comparison of the effectiveness of nifedipine and atosiban in postponing preterm delivery is needed.

The quality of intrapartum uterine activity monitoring.

AIMS: To determine the quality of intrapartum uterine activity (UA) monitoring in daily practice during the first and second stage of labor. The total duration of inadequate UA monitoring is quantified in relation to the technique applied: external or internal. METHODS: One hundred and ninety-two UA recordings, collected from 1 April 2006 untill 1 October 2006 from consecutive deliveries at the Vrije Universiteit Medical Center in Amsterdam, were analyzed. Included recordings were from singleton, spontaneous, vaginal deliveries. The last two hours of the first stage and the complete second stage had to be monitored. Internal and external UA recordings were judged by their quality: adequate, a recognizable and reliable UA pattern during the complete registration, or inadequate. Recordings labeled as inadequate were divided into two groups: absence of UA recording (non recognizable) or inadequate calibration (unreliable). Statistical analyses were performed with the Mann-Whitney U-test and the Wilcoxon signed ranks test. RESULTS: The percentages of adequate UA recordings in the first stage of labor were much higher for the internal than the external mode. Only 2% of the external recordings were of good quality vs. 40% of the internal recordings. In the second stage, percentages of adequate UA recordings were nearly equal, approximately 30%. Inadequate external registrations were characterized by almost 30% of the time absent UA monitoring, whereas with inadequate internal registrations the primary problem was correct calibration. CONCLUSION: Intrapartum UA monitoring in daily practice via the direct mode provides a more recognizable UA trace.