Cerebral palsy litigation after fifty years: A hoax on you.

The worldwide cerebral palsy (CP) litigation crisis is predicated on the hoax that electronic foetal monitoring (EFM) predicts and prevents CP. There are decades of research disproving this hoax, yet EFM continues to be performed in the vast majority of labours in developed countries with resultant harm to mothers and babies alike through unnecessary caesarean sections with all of the attendant complications and ramifications of that procedure. This article reviews the history and evolution of EFM, explores the reasons for its misuse, discusses how obstetricians have abandoned their ethical mandate by failing to obtain informed consent for EFM, and proposes a realistic, practical solution that would effectively change the standard of care.

Ultrasound Probe Pressure on the Maternal Abdominal Wall and the Effect on Fetal Middle Cerebral Artery Doppler Indices.

Background and objectives: Doppler ultrasound of umbilical and fetal vessels is useful for monitoring fetal well-being, fetal anemia, intrauterine growth retardation, and other perinatal outcomes. The adverse perinatal outcome and circulatory changes can be reflected in fetal Doppler studies. The aim of this study was to evaluate the effect of increased pressure exerted on the maternal abdominal wall during routine ultrasound on the middle cerebral artery (MCA), resistance index (RI), pulsatility index (PI), and peak systolic velocity (PSV). Materials and Methods: A prospective study was conducted, in which we included 40 pregnant women between 24 + 0 and 41 + 3 gestational weeks (GW), with singleton pregnancies, without any associated pathologies, undergoing routine US examination. We recorded the flow velocity waveforms in the MCA, and we measured the RI, PI, PSV, and the applied pressure on to the maternal abdominal wall-needed for a proper evaluation of MCA. We then repeated the same measurements at two different higher pressure levels, at the same time having a proper image of the targeted vessel. Results: We found significant differences for the PI and RI levels with an increase in abdominal pressure (median PI 1.46, 1.58, and 1.92, respectively; median RI 0.74, 0.78, and 0.85, respectively; p < 0.05), for both PI and RI. At the same time, we found no significant differences for PSV in the studied group in relationship with increase in abdominal pressure (median PSV 39.56, 40.10, and 39.70, respectively; p > 0.05). Conclusions: The applied abdominal pressure by the examiner's hand, during routine US scan in pregnancy, can modify the MCA parameters of blood flow resistance (PI and RI) when measured by Doppler US, thus influencing the diagnostic accuracy in a series of pregnancy associated pathologies, such as chronic fetal distress (CFD) or intrauterine growth restriction (IUGR).

Should national guidelines continue to recommend fetal scalp blood sampling during labor?

Intrapartum fetal scalp blood sampling (FBS) (pH or lactate) has not been shown to reduce emergency cesarean sections or operative vaginal births or improve long-term perinatal outcomes. In contrast, it is associated with rare but potentially very serious complications such as leakage of cerebro-spinal fluid (CSF) and perinatal hemorrhagic shock. Therefore, it does not fulfill the "First Do No Harm" principle and its use during labor should be critically re-evaluated.

Delay in intervention increases neonatal morbidity in births monitored with cardiotocography and ST-waveform analysis.

OBJECTIVE: To assess the effect of the time interval from indication of hypoxia to delivery on neonatal outcome in high-risk pregnancies monitored with cardiotocography (CTG) and ST-waveform analysis. DESIGN: Prospective observational study. SETTING: University hospital, Norway, 2004-08. POPULATION: Singleton high-risk births with a gestational age above 35(+6) weeks, monitored with CTG and ST-waveform analysis. METHODS: Logistic regression analysis and Kaplan-Meier survival plots. MAIN OUTCOME MEASURE: Neonatal morbidity in relation to the rapidity of intervention. RESULTS: Of 6010 deliveries monitored with ST-waveform analysis, 1131 (19%) had an indication to intervene for fetal distress according to clinical guidelines. Those fetuses were at increased risk of an adverse neonatal outcome, and if delivered later than 20 min after the indication of hypoxia their risk increased further; i.e. transfer to the neonatal intensive care unit (NICU) from an odds ratio of 1.6 (95% confidence interval 1.2-2.2) to an odds ratio of 3.3 (95% confidence interval 2.5-4.3). The indication-to-delivery interval was longer for neonates with a 5-min Apgar score of <7, transfer to NICU and neonatal encephalopathy than for those without adverse outcome. CONCLUSION: In deliveries monitored with CTG and ST-waveform analysis, the risk of an adverse neonatal outcome was dependent on the time between indication of hypoxia and delivery. Nonadherence to the specific clinical guidelines increased the risk of neonatal morbidity.

Experience of fetal scalp blood sampling during labor.

Fetal scalp blood sampling (FBS) is often claimed to be painful for women in labor and difficult for obstetricians to perform. Our aim was to assess women's experience of pain during FBS and obstetricians' experience of difficulty in performing the test. At a tertiary center in Sweden, a questionnaire with answers on a 10-point scale was completed by 51 women and the obstetricians performing the test. Women's experience of pain had a median of 3.5. FBS was well tolerated in women who had epidural analgesia but might be associated with pain in women without. Higher maternal body mass index and less cervical dilation were associated with higher pain ratings. Obstetricians did not generally experience scalp sampling as difficult to perform (median score 3.0). However, the sampling procedure can be more complicated in situations with higher maternal body mass index, less cervical dilation, and a higher station of the fetal head.

The risks and benefits of internal monitors in laboring patients.

OBJECTIVE: The purpose of this study was to estimate the impact of internal monitors (fetal scalp electrode [FSE] and intrauterine pressure catheter [IUPC]) on maternal and neonatal outcomes. STUDY DESIGN: The study comprised a retrospective cohort of all women who were admitted for labor from 2004-2008. Women with internal monitors (FSE, IUPC, or both) were compared with women without internal monitors. Maternal outcomes were maternal fever and cesarean delivery. Neonatal outcomes were a composite of 5-minute Apgar score of ≤3, cord pH <7.1, cord base excess ≤-12, or admission to level 3 nursery. Logistic regression was performed to estimate the impact of internal monitors with adjustment for confounding variables, including time in labor. RESULTS: Of 6445 subjects, 3944 women (61.2%) had internal monitors. Women with internal monitors were more likely to have a fever than women without internal monitors (11.7% vs 4.5%; adjusted odds ratio [AOR], 2.0; 95% confidence interval [CI], 1.6-2.5). FSE alone was not associated with an increased risk of fever (AOR, 1.5; 95% CI, 1.0-2.1), but IUPC alone was (AOR, 2.4; 95% CI, 1.8-3.2). The risk of cesarean delivery was higher in women with internal monitors (18.6% vs 9.7%; AOR, 1.3; 95% CI, 1.0-1.5). Risk of cesarean delivery was lower in women with an FSE alone (AOR, 0.5; 95% CI, 0.4-0.7) but higher in women with both an FSE and an IUPC (AOR, 1.6; 95% CI, 1.4-2.0). Risk of the composite neonatal outcome was not higher in women with internal monitors (3.3% vs 3.6%; AOR, 0.8; 95% CI, 0.6-1.1). CONCLUSION: Routine use of an IUPC in laboring patients should be avoided because of an increased risk of maternal fever.

Does use of an intrauterine catheter during labor increase risk of infection?

OBJECTIVE: To determine whether the use of an intrauterine catheter during labor is related to the occurrence of infection in mother or newborn during labor and up to 3 weeks postpartum. METHODS: We performed a follow-up study of 1435 women who participated in a previously published multicentre randomized controlled trial in the Netherlands that assigned women in whom labor was induced or augmented with intravenous oxytocin to internal or external tocodynamometry. In the present post hoc analysis, we assessed the risk for infection, defined as a composite measure of any clinical sign of infection, treatment with antibiotics or sepsis during labor or in the postpartum period up to 3 weeks in mother or newborn. RESULTS: There were 64 cases with indication of infection in the intrauterine catheter group (8.8%) versus 74 cases in the external monitoring group (10.4%). Relative risk: 0.91, 95% confidence interval: 0.77-1.1, and p: 0.33. CONCLUSION: Use of an intrauterine catheter during labor does not increase the risk of infection.

Cerebrospinal fluid leakage, an uncommon complication of fetal blood sampling: a case report and review of the literature.

UNLABELLED: In a recently published randomized clinical trial on intrapartum fetal monitoring, fetal blood samples were obtained in 879 women. One serious complication of fetal blood sampling (FBS) was reported, a case in which physical examination of the neonate after delivery revealed clear fluid loss from the incision site. Four layers of the scalp appeared to be incised. The subarachnoid space was closed with 2 sutures, and antibiotics were started due to the risk of meningitis. The patient was discharged in good clinical condition. In this article, the case is presented and the literature reviewed. We found 12 articles reporting 37 cases of a complication due to FBS, none concerning leakage of cerebrospinal fluid. In conclusion, complications of FBS are rare but can be serious. Excessive fetal bleeding is most frequently reported and often associated with an underlying coagulopathy in the neonate. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this educational activity, the obstetrician/gynecologist should be better able to assess the chance of possible complications due to fetal blood sampling; select fetuses at risk for complications due to fetal blood sampling; and evaluate certain technical precautions when performing this procedure.

Foetal monitoring: a woman-centred decision-making pathway.

PROBLEM: Many midwives continue to use continuous foetal monitoring on low risk women in labour, despite evidence based clinical guidelines to the contrary. Continuous foetal monitoring has been linked to increased rates of medical intervention during labour and birth with no improvement in long term neonatal outcomes. PARTICIPANTS: Midwives who used continuous foetal monitoring on low risk women in labour at two regional Queensland hospitals. METHODS: This Grounded Theory study explored midwives' decision-making processes related to the use of continuous electronic foetal monitoring on low risk labouring women. Primary data were gathered in semi-structured interviews with five purposively selected midwives and concurrently analysed using Grounded Theory techniques of theoretical sampling and constant comparison. FINDINGS: The midwives made the decision that led to continuous electronic foetal monitoring on low risk women at two key decision points during labour care; the first during the midwives' initial assessment of the woman and foetus, and the second when the midwives categorised the women as high or low risk. However, various factors impacted on these decisions including trust and staff workloads within a context of risk management and medical dominance. There was limited opportunity for women to be involved in the decision-making process about foetal monitoring and only partial information was provided prior to cardiotocography. CONCLUSIONS: Consistent with current clinical guidelines which recommend open, consultative discussion with the woman about foetal monitoring and a partnership approach towards decision-making following informed choice, a woman-centred foetal monitoring decision-making pathway is proposed. This pathway is applicable in midwifery education, research and clinical practice to promote both evidence based practice and woman-centred decision-making.

Perinatal hemorrhagic shock after fetal scalp blood sampling.

BACKGROUND: Fetal scalp blood sampling is commonly used for fetal monitoring during labor to identify intrapartum fetal hypoxia. CASE: A male term neonate was monitored by fetal scalp blood sampling because of abnormal cardiotocographic recordings. After emergency cesarean delivery, the newborn presented with severe hemorrhagic shock as a result of fetal anemia from the scalp blood sampling. Two scalp incisions were identified as the bleeding source. The underlying reason for the development of hemorrhagic shock was factor IX-deficiency resulting from spontaneous mutation. The neonate was subsequently discharged a week later without further complications. CONCLUSION: Complications during fetal scalp blood sampling are very rare, but obstetricians and neonatologists should be aware of the potential presence of coagulopathies, especially with the persistence of scalp bleeding after delivery.

Subgaleal abscess and E. coli septicemia following scalp electrode in a preterm newborn: a case report.

Escherichia coli as a causative agent for neonatal sepsis is well established. However, there is paucity of reports in the medical literature of E. coli sepsis following scalp electrode placement. We report a preterm infant who developed scalp abscess and E. coli sepsis following a scalp electrode. We recommend a careful examination of babies with a history of fetal electrode monitoring as this could be a nidus for local and generalised infection.

[Fetomaternal hemorrhage: practitioner's point of view]. / Hémorragie foetomaternelle : le point de vue du clinicien.

Fetomaternal hemorrhage is known to have a wide spectrum of clinical presentations. This large variability probably explains why there are still neither consensual classification nor management recommendations. Nevertheless, fetomaternal hemorrhage is a serious condition, which may cause life-threatening fetal anemia. Fetal tolerance mainly depends on the quantity of fetal blood loss as well as the rate at which it occurs. Decrease in perceived fetal movements represents the main clinical sign of fetomaternal hemorrhage and justify use of diagnostic tests such as the Kleihauer-Betke test. Large fetomaternal hemorrhages can also induce fetal hydrops and stillbirth. In this review, we emphasize the clinical and biological features of fetomaternal hemorrhages and we highlight the circumstances associated with false-negative and false-positive results of the Kleihauer-Betke test. We also propose an original algorithm for the management of fetomaternal hemorrhages.

Fetal complications after placement of an intrauterine pressure catheter: a report of two cases and review of the literature.

BACKGROUND: Uterine contractions during labor can be monitored by external tocodynamometry or by the use of an intrauterine pressure catheter (IUPC). Since an IUPC measures the frequency of contractions as well as their strength and duration, it is thought to be more accurate than external tocodynamometry. However, limited evidence on this subject suggests that IUPC may not improve maternal or perinatal outcomes. Moreover, the use of IUPC may cause fetal complications. CASES: We describe the placement of an IUPC during induction of labor with oxytocin in two cases, one presenting with a singleton pregnancy and the other a twin pregnancy. After introduction of the IUPC, both cases were complicated by blood loss and signs of fetal distress on cardiotocography. An emergency cesarean section was performed in both cases. In the first case, extramembranous placement of the IUPC was observed, whereas in the second case, the IUPC had lacerated an arteriovenous anastomosis in the membranes, resulting in perinatal death. CONCLUSION: Placement of an intrauterine pressure catheter instead of external tocodynamometry has a small risk for serious fetal complications.

[Modality of fetal heart monitoring during labor (continuous or intermittent), telemetry and central fetal monitoring]. / Surveillance foetale continue ou discontinue, télémétrie et centrale d'analyse.

Fetal heart monitoring during labor is almost systematic today. Continuous monitoring decreases neonatal convulsions, but increases caesarean section and forceps deliveries without impact on long term neonatal prognosis. Overall, there is no proved impact of cardiac fetal monitoring (continuous or intermittent) on perinatal mortality. The most recent study shows neonatal benefits of continuous monitoring associated with an overall increase of caesarean section rate. Continuous fetal monitoring has a better sensitivity to detect acidosis. Many arguments for continuous fetal monitoring will be reported in this review. In specific conditions, intermittent fetal auscultation can be realised, but in current practice such conditions can rarely be applied. Telemetry has been poorly evaluated to date but experiences are currently undertaken. Central fetal monitoring does not improve neonatal issue but could increase caesarean section rate. Central of fetal monitoring could help in the organisation and the conservation of fetal heart monitoring.

Beware: the misuse of technology and the law of unintended consequences.

Electronic monitoring of the fetal heart rate during labor (EFM), originally designed to assess fetal stress and allow the early detection of the compromised fetus, has instead led to increasing maternal morbidity without decreasing fetal morbidity. The unintended consequences of this technologic advance have led to the creation of a pseudodisease and unwarranted intervention in response to its detection. Is it ethical to introduce a new technology without adequate assessment of its possible consequences? Are we about to repeat this (error resulting from the introduction of EFM?) There is increasing interest in monitoring the function of the newborn brain, to enable the early detection of subclinical seizures. The monitor may also be used for assessing brain function in older children and adults who are comatose or paralyzed and cannot appropriately respond to stimuli. Use of this amplitude-integrated electroencephalography (aEEG) in the newborn for detection of seizures and other brain abnormalities is not dissimilar to the use of electronic fetal heart rate monitoring. Whether seizures or subclinical seizures themselves cause harm to the developing nervous system is unclear. The effectiveness of medications for treatment of seizures in the newborn has not been established. Therefore, the consequences of introducing automated EEG for the detection of subclinical neonatal seizures are likely to be similar to the results of the introduction of EFM: creation of another pseudodisease, followed by unwarranted intervention, and increased legal liability. What are the ethics of continued approval and introduction of unevaluated technology? What is the wisdom of its use? Beware of the unintended consequences.