Tending to the machine: The impact of intrapartum fetal surveillance on women in Australia.

Qualitative research about women and birthing people's experiences of fetal monitoring during labour and birth is scant. Labour and birth is often impacted by wearable or invasive monitoring devices, however, most published research about fetal monitoring is focused on the wellbeing of the fetus. This manuscript is derived from a larger mixed methods study, 'WOmen's Experiences of Monitoring Baby (The WOMB Study)', aiming to increase understanding of the experiences of women and birthing people in Australia, of being monitored; and about the information they received about fetal monitoring devices during pregnancy. We constructed a national cross-sectional survey that was distributed via social media in May and June, 2022. Responses were received from 861 participants. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia. This paper comprises the analysis of the free text survey responses, using qualitative and inductive content analysis. Two categories were constructed, Tending to the machine, which explores participants' perceptions of the way in which clinicians interacted with fetal monitoring technologies; and Impressions of the machine, which explores the direct impact of fetal monitoring devices upon the labour and birth experience of women and birthing people. The findings suggest that some clinicians need to reflect upon the information they provide to women and birthing people about monitoring. For example, freedom of movement is an important aspect of supporting the physiology of labour and managing pain. If freedom of movement is important, the physical restriction created by a wired cardiotocograph is inappropriate. Many participants noticed that clinicians focused their attention primarily on the technology. Prioritising the individual needs of the woman or birthing person is key to providing high quality woman-centred intrapartum care. Women should be provided with adequate information regarding the risks and benefits of different forms of fetal monitoring including how the form of monitoring might impact her labour experience.

Enhancing Fetal Electrocardiogram Signal Extraction Accuracy through a CycleGAN Utilizing Combined CNN-BiLSTM Architecture.

The fetal electrocardiogram (FECG) records changes in the graph of fetal cardiac action potential during conduction, reflecting the developmental status of the fetus in utero and its physiological cardiac activity. Morphological alterations in the FECG can indicate intrauterine hypoxia, fetal distress, and neonatal asphyxia early on, enhancing maternal and fetal safety through prompt clinical intervention, thereby reducing neonatal morbidity and mortality. To reconstruct FECG signals with clear morphological information, this paper proposes a novel deep learning model, CBLS-CycleGAN. The model's generator combines spatial features extracted by the CNN with temporal features extracted by the BiLSTM network, thus ensuring that the reconstructed signals possess combined features with spatial and temporal dependencies. The model's discriminator utilizes PatchGAN, employing small segments of the signal as discriminative inputs to concentrate the training process on capturing signal details. Evaluating the model using two real FECG signal databases, namely "Abdominal and Direct Fetal ECG Database" and "Fetal Electrocardiograms, Direct and Abdominal with Reference Heartbeat Annotations", resulted in a mean MSE and MAE of 0.019 and 0.006, respectively. It detects the FQRS compound wave with a sensitivity, positive predictive value, and F1 of 99.51%, 99.57%, and 99.54%, respectively. This paper's model effectively preserves the morphological information of FECG signals, capturing not only the FQRS compound wave but also the fetal P-wave, T-wave, P-R interval, and ST segment information, providing clinicians with crucial diagnostic insights and a scientific foundation for developing rational treatment protocols.

Multicentric intelligent cardiotocography signal interpretation using deep semi-supervised domain adaptation via minimax entropy and domain invariance.

BACKGROUND AND OBJECTIVE: Obstetricians use Cardiotocography (CTG), which is the continuous recording of fetal heart rate and uterine contraction, to assess fetal health status. Deep learning models for intelligent fetal monitoring trained on extensively labeled and identically distributed CTG records have achieved excellent performance. However, creation of these training sets requires excessive time and specialist labor for the collection and annotation of CTG signals. Previous research has demonstrated that multicenter studies can improve model performance. However, models trained on cross-domain data may not generalize well to target domains due to variance in distribution among datasets. Hence, this paper conducted a multicenter study with Deep Semi-Supervised Domain Adaptation (DSSDA) for intelligent interpretation of antenatal CTG signals. This approach helps to align cross-domain distribution and transfer knowledge from a label-rich source domain to a label-scarce target domain. METHODS: We proposed a DSSDA framework that integrated Minimax Entropy and Domain Invariance (DSSDA-MMEDI) to reduce inter-domain gaps and thus achieve domain invariance. The networks were developed using GoogLeNet to extract features from CTG signals, with fully connected, softmax layers for classification. We designed a Dynamic Gradient-driven strategy based on Mutual Information (DGMI) to unify the losses from Minimax Entropy (MME), Domain Invariance (DI), and supervised cross-entropy during iterative learning. RESULTS: We validated our DSSDA model on two datasets collected from collaborating healthcare institutions and mobile terminals as the source and target domains, which contained 16,355 and 3,351 CTG signals, respectively. Compared to the results achieved with deep learning networks without DSSDA, DSSDA-MMEDI significantly improved sensitivity and F1-score by over 6%. DSSDA-MMEDI also outperformed other state-of-the-art DSSDA approaches for CTG signal interpretation. Ablation studies were performed to determine the unique contribution of each component in our DSSDA mechanism. CONCLUSIONS: The proposed DSSDA-MMEDI is feasible and effective for alignment of cross-domain data and automated interpretation of multicentric antenatal CTG signals with minimal annotation cost.

Fetal Heart Rate Auscultation, 4th Edition.

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition.

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Anesthetic recommendations for maternal and fetal safety in nonobstetric surgery: a balancing act.

PURPOSE OF REVIEW: Nonobstetric surgery during pregnancy is associated with maternal and fetal risks. Several physiologic changes create unique challenges for anesthesiologists. This review highlights physiologic changes of pregnancy and presents clinical recommendations based on recent literature to guide anesthetic management for the pregnant patient undergoing nonobstetric surgery. RECENT FINDINGS: Nearly every anesthetic technique has been safely used in pregnant patients. Although it is difficult to eliminate confounding factors, exposure to anesthetics could endanger fetal brain development. Perioperative fetal monitoring decisions require an obstetric consult based on anticipated maternal and fetal concerns. Given the limitations of fasting guidelines, bedside gastric ultrasound is useful in assessing aspiration risk in pregnant patients. Although there is concern about appropriateness of sugammadex for neuromuscular blockade reversal due its binding to progesterone, preliminary literature supports its safety. SUMMARY: These recommendations will equip anesthesiologists to provide safe care for the pregnant patient and fetus undergoing nonobstetric surgery.

Joint Improved Fast Independent Component Analysis and Singular Value Decomposition for Fetal Electrocardiogram Extraction.

Combined the improved fast independent component analysis (FastICA) algorithm with the singular value decomposition algorithm, a single-channel fetal electrocardiogram (fECG) extraction method is proposed. First, the improved FastICA algorithm is used to estimate the maternal ECG component from a single-channel abdominal signal of pregnant women using an overrelaxation factor. Then, a preliminary estimate of the fECG signal is obtained by subtracting from the single-channel abdominal signal. Subsequently, the singular value decomposition algorithm is used to denoise the preliminarily estimated fECG signal to obtain a high signal-to-noise ratio. In addition, in the singular value decomposition algorithm for fetal arrhythmia, an improved method for constructing the ECG signal reconstruction matrix is proposed. Finally, the fECG extraction experiments on synthetic abdominal signals and actual abdominal signals (data from 49 abdominal channels sourced from DAISY database and the non-invasive fECG database in PhysioNet) are carried out. The experimental results show that the method in this paper can effectively improve the signal-to-noise ratio and the accuracy of fECG signal extraction, and is suitable for maternal or fetal arrhythmias. Compared with the FastICA algorithm, the signal-to-noise ratio of the fECG signal extracted by the method in this paper is improved by about 5 dB, and the accuracy of fECG extraction in the PhysioNet database can reach 96.54%.

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.

Template subtraction based methods for non-invasive fetal electrocardiography extraction.

Assessment of fetal heart rate (fHR) through non-invasive fetal electrocardiogram (fECG) is challenging task. This study compares the performance of five template subtraction (TS) methods on Labor (12 5-min recordings) and Pregnancy datasets (10 20-min recordings). The methods include TS without adaptation, TS using singular value decomposition (TS[Formula: see text]), TS using linear prediction (TS[Formula: see text]), TS using scaling factor (TS[Formula: see text]), and sequential analysis (SA). The influence of the chosen maternal wavelet for the continuous wavelet transform (CWT) detector is also compared. The F1 score was used to measure performance. Each recording in both datasets consisted of four signals, resulting in a total comparison of 88 signals for the TS-based methods. The study reported the following results: F1 = 95.71% with TS, F1 = 95.93% with TS[Formula: see text], F1 = 95.30% with TS[Formula: see text], F1 = 95.82% with TS[Formula: see text], and F1 = 95.99% with SA. The study identified gaus3 as the suitable maternal wavelet for fetal R-peak detection using the CWT detector. Furthermore, the study classified signals from the tested datasets into categories of high, medium, and low quality, providing valuable insights for subsequent fECG signal extraction. This research contributes to advancing the understanding of non-invasive fECG signal processing and lays the groundwork for improving fetal monitoring in clinical settings.

The Correlation Between the Total Decelerations and Accelerations Areas and Cord Blood pH in Women with Low-Risk Pregnancies.

Fetal acidosis among low-risk pregnancies is not common; however, identifying those at risk for this complication antenatally is of great interest. We aimed to assess the correlation between the total decelerations area during the last 120 min of fetal monitoring prior to delivery and neonatal acidemia in low-risk pregnancies and whether the total acceleration area has a protective effect in the presence of decelerations. A retrospective cohort study was conducted among women with term low-risk pregnancies. A researcher blinded to fetal outcomes interpreted electronic fetal monitor patterns during the 120 min prior to delivery. The primary outcome was fetal acidemia, defined as umbilical artery pH below 7.10. The correlation between the total decelerations and accelerations areas and cord blood pH was tested using the Spearman correlation coefficient. A total of 109 women were included and of these, six (5.5%) delivered infants with cord blood pH < 7.10. A significant correlation was demonstrated between the total decelerations area and cord blood pH (p = 0.01). No correlation was found between the total accelerations area and cord blood pH. Among low-risk pregnancies, a correlation was found between the total decelerations area but not the total accelerations area during the final 120 min of labor and cord blood pH.

Efectividad audiovisual del monitoreo independiente del bienestar fetal sobre el apego materno-fetal y los resultados del parto / Audiovisual Effectiveness of Independent Fetal Well-being Monitoring on Mother-Fetus Attachment and Birth Outcomes

Introducción: El vínculo madre-feto juega un papel importante en la atención del embarazo, impactando los resultados del nacimiento. El monitoreo del movimiento fetal es una competencia fundamental para que las mujeres embarazadas lo hagan de manera independiente. Objetivo: Producir monitoreo audiovisual del movimiento fetal independiente y probar su efectividad en el apego materno-fetal y los resultados del parto. Métodos: La etapa I, desarrollo de Monitoreo de Bienestar Fetal Audiovisual, con estudio de literatura, etapas, desarrollo de escenarios, creación de audiovisuales, prueba de validez de expertos. La etapa 2 probó la efectividad de los medios audiovisuales sobre el apego materno-fetal con el instrumento Inventario de Apego Prenatal y los resultados del nacimiento a partir del peso del bebé al nacer. Diseño de un verdadero enfoque experimental de grupo de control pretest-postest. Muestras de mujeres embarazadas con antecedentes de atención prenatal en el Centro de Salud Kasihan II, Bantul, Yogyakarta, Indonesia con los siguientes criterios: embarazo único, normal, edad gestacional de 28 a 36 semanas. Los encuestados de 60 sujetos se dividieron en grupos experimentales y de control. Los datos normales se probaron mediante la prueba t pareada, la prueba t independiente y MANOVA. Resultados: Puntaje de prueba de validez de experto en contenido 81% muy válido, puntaje de validez de experto en medios 80.33%, válido. La aplicación audiovisual mostró los resultados de la prueba t pareada, tanto en el grupo experimental como en el control hubo diferencias en el pretest y postest, P<0.05. La prueba t de muestra independiente P < 0,05 y los resultados MANOVA simultáneos mostraron una puntuación de apego materno-fetal y un resultado del nacimiento P < 0,05 (AU)

Introduction: The mother-fetus bond plays an important role in pregnancy care, impacting birth outcomes. Monitoring fetal movement is a fundamental competence for pregnant women to do independently. Objective: to produce audiovisual monitoring of independent fetal movement and prove its effectiveness on maternal-fetal attachment and birth outcomes. Methods: Phase I, developing Audiovisual Fetal Well-being Monitoring, with literature study steps, developing scenarios, creating audiovisuals, testing the validity of experts. Stage 2 tested the effectiveness of audiovisual media on maternal-fetal attachment with the Prenatal Attachment Inventory instrument and birth outcomes from infant birth weight. Design of true experimental pretest-posttest control group approach. Samples of pregnant women with a history of antenatal care at the Kasihan II Health Center, Bantul, Yogyakarta, Indonesia with the following criteria: single pregnancy, normal, gestational age 28-36 weeks. Respondents of 60 subjects were divided into experimental and control groups. Normal data were tested by paired t test, independent t-test and MANOVA. Results: Content expert validity test score 81% very valid, media expert validity score 80.33%, valid. The audiovisual application showed the results of the paired t-test, both in the experimental and control groups there were differences in pretest and posttest, P <0.05. Independent sample t-test P < 0.05 and simultaneous MANOVA results showed maternal-fetal attachment score and birth outcome P < 0.05. Conclusion: Independent monitoring of fetal well-being using audiovisual media simultaneously affects the increase in maternal-fetal attachment scores and birth outcomes so it is recommended that second trimester pregnant women be taught techniques for counting fetal movements and practicing them routinely (AU)

Real-time fetal monitoring using photoacoustic measurement of placental oxygen saturation in a rabbit hypoxia model.

INTRODUCTION: Ensuring adequate fetal oxygenation is an essential aim of fetal monitoring. The purpose of this study was to establish a basic technique for real-time measurement of blood oxygen saturation of the placenta by photoacoustic (PA) technique as a new fetal monitoring method. METHODS: The hypoxia model established in our previous study was applied to 7 pregnant rabbits. Three phases were induced: normal phase, hypoxia phase, and recovery phase. Three methods were simultaneously used for real-time fetal monitoring: fetal heat rate (FHR) monitoring, oxygen saturation (SO2) measurement by near-infrared spectroscopy (SNO2), and placenta SO2 measured by PA technique (SplO2). The maternal hypoxia was assessed by skin SO2 measured by PA technique (SsO2), and arterial blood SO2 by blood gas analysis (SaO2). RESULTS: The average of SplO2 in normal phase was 52.6 ± 13.9 %. The averages of SNO2, SSO2, and SplO2 in the seven rabbits changed in parallel from the normal phase to hypoxia phase. In the recovery phase, the SplO2 rose in parallel with recovery of SaO2. There was lag in increase of the FHR compared to the change in the other values. In the detailed analysis of PA signals from the labyrinth and decidua, a unique change in oxygen saturation was seen in one case. DISCUSSION: Results of this study showed that sensitivity of our novel PA technique in detecting tissue hypoxia was similar to near-infrared spectroscopy (NIRS). As an advantage, unlike NIRS, monitoring with PA technique was unaffected by ischemia and surface changes in oxygen saturation because of its higher spatial resolution. We conclude that PA technique provides more accurate information about fetal blood placenta than NIRS. Ultrasound imaging, combined with oxygen saturation monitoring by PA technique, would improve fetal monitoring and fetal diagnosis in the future.

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

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

Re-evaluating fetal scalp pH thresholds: An examination of fetal pH variations during labor.

INTRODUCTION: Since the 1970s, fetal scalp blood sampling (FSBS) has been used as a second-line test of the acid-base status of the fetus to evaluate fetal well-being during labor. The commonly employed thresholds that delineate normal pH (>7.25), subnormal (7.20-7.25), and pathological pH (<7.20) guide clinical decisions. However, these experienced-based thresholds, based on observations and common sense, have yet to be confirmed. The aim of the study was to investigate if pH drop rate accelerates at the common thresholds (7.25 and 7.20) and to explore the possibility of identifying more accurate thresholds. MATERIAL AND METHODS: A retrospective study was conducted at a tertiary maternity hospital between June 2017 and July 2021. Patients with at least one FSBS during labor for category II fetal heart rate and delivery of a singleton cephalic infant were included. The rate of change in pH value between consecutive samples for each patient was calculated and plotted as a function of pH value. Linear regression models were used to model the evolution of the pH drop rate estimating slope and standard errors across predefined pH intervals. Exploration of alternative pH action thresholds was conducted. To explore the independence of the association between pH value and pH drop rate, multiple linear regression adjusted on age, body mass index, parity, oxytocin stimulation and suspected small for gestational age was performed. RESULTS: We included 2047 patients with at least one FSBS (total FSBS 3467); with 2047 umbilical cord blood pH, and a total of 5514 pH samples. Median pH values were 7.29 1 h before delivery, 7.26 30 min before delivery. The pH drop was slow between 7.40 and 7.30, then became more pronounced, with median rates of 0.0005 units/min at 7.25 and 0.0013 units/min at 7.20. Out of the alternative pH thresholds, 7.26 and 7.20 demonstrated the best alignment with our dataset. Multiple linear regression revealed that only pH value was significantly associated to the rate of pH change. CONCLUSIONS: Our study confirms the validity and reliability of current guideline thresholds for fetal scalp pH in category II fetal heart rate.

Intrapartum fetal heart rate monitoring: Rationalise, refine or replace?

Monitoring the fetal heartbeat underpins assessment of fetal wellbeing in labour. Although commonly employed in clinical practice, shortcomings remain. A recent review of clinical practice guidelines highlights the variation in definitions of the fetal heart rate that will lead to differences in interpretation. Will intrapartum care be improved by greater consensus around clinical practice guidelines through rationalisation or refinement of guidelines, or will the future see this technique replaced by more accurate forms of fetal monitoring?

Fetal Assessment in Pregnancy (Indication and Methodology for Fetal Monitoring in a low-risk Population). Guideline of the DGGG, DEGUM, OEGGG and SGGG (S3-Level, AWMF Registry No. 015/089, February 2023). / Fetale Überwachung in der Schwangerschaft (Indikation und Methodik zur fetalen Zustandsdiagnostik im Low-Risk-Kollektiv). Leitlinie der DGGG, DEGUM, OEGGG und SGGG (S3-Level, AWMF-Registernummer 015/089, Februar 2023).

PURPOSE: The aim of this guideline was to find evidence on whether carrying out Doppler examinations and CTGs in low-risk cohorts of pregnant women improves outcomes. METHODS: First, a systematic search for guidelines was carried out. Identified guidelines were evaluated using the DELPHI instrument of the AWMF. Three guidelines were found to be suitable to evaluate CTG. Two DEGUM best practice guidelines were judged suitable to describe the methods. All studies on this issue were additionally analyzed using 8 PICO questions. A structured consensus of the participating professional societies was achieved using a nominal group process and a structured consensus conference moderated by an independent moderator. RECOMMENDATIONS: No antepartum Doppler sonography examinations should be carried out in low-risk cohorts in the context of antenatal care. No antepartum CTG should be carried out in low-risk cohorts. NOTE: The guideline will be published simultaneously in the official journals of both professional societies (i. e., Geburtshilfe und Frauenheilkunde for the DGGG and Ultraschall in der Medizin/European Journal of Ultrasound for the DEGUM).

Is the fetus fit for labor? Introducing fast-and-frugal trees (FFTrees) to simplify triage of women for STAN monitoring: An interobserver agreement comparison with traditional classification.

INTRODUCTION: It is a shortcoming of traditional cardiotocography (CTG) classification table formats that CTG traces are frequently classified differently by different users, resulting in poor interobserver agreements. A fast-and-frugal tree (FFTree) flow chart may help provide better concordance because it is straightforward and has clearly structured binary questions with understandable "yes" or "no" responses. The initial triage to determine whether a fetus is suitable for labor when utilizing fetal ECG ST analysis (STAN) is very important, since a fetus with restricted capacity to respond to hypoxic stress may not generate STAN events and therefore may become falsely negative. This study aimed to compare physiology-focused FFTree CTG interpretation with FIGO classification for assessing the suitability for STAN monitoring. MATERIAL AND METHODS: A retrospective study of 36 CTG traces with a high proportion of adverse outcomes (17/36) selected from a European multicenter study database. Eight experienced European obstetricians evaluated the initial 40 minutes of the CTG recordings and judged whether STAN was a suitable fetal surveillance method and whether intervention was indicated. The experts rated the CTGs using the FFTree and FIGO classifications at least 6 weeks apart. Interobserver agreements were calculated using proportions of agreement and Fleiss' kappa (κ). RESULTS: The proportions of agreement for "not suitable for STAN" were for FIGO 47% (95% confidence interval [CI] 42%-52%) and for FFTree 60% (95% CI 56-64), ie a significant difference; the corresponding figures for "yes, suitable" were 74% (95% CI 71-77) and 70% (95% CI 67-74). For "intervention needed" the figures were 52% (95% CI 47-56) vs 58% (95% CI 54-62) and for "expectant management" 74% (95% CI 71-77) vs 72% (95% CI 69-75). Fleiss' κ agreement on "suitability for STAN" was 0.50 (95% CI 0.44-0.56) for the FIGO classification and 0.57 (95% CI 0.51-0.63) for the FFTree classification; the corresponding figures for "intervention or expectancy" were 0.53 (95% CI 0.47-0.59) and 0.57 (95% CI 0.51-0.63). CONCLUSIONS: The proportion of agreement among expert obstetricians using the FFTree physiological approach was significantly higher compared with the traditional FIGO classification system in rejecting cases not suitable for STAN monitoring. That might be of importance to avoid false negative STAN recordings. Other agreement figures were similar. It remains to be shown whether the FFTree simplicity will benefit less experienced users and how it will work in real-world clinical scenarios.

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.