Labor curves based on cervical dilatation over time and their accuracy and effectiveness: A systematic scoping review.

OBJECTIVES: This systematic scoping review was conducted to 1) identify and describe labor curves that illustrate cervical dilatation over time; 2) map any evidence for, as well as outcomes used to evaluate the accuracy and effectiveness of the curves; and 3) identify areas in research that require further investigation. METHODS: A three-step systematic literature search was conducted for publications up to May 2023. We searched the Medline, Maternity & Infant Care, Embase, Cochrane Library, Epistemonikos, CINAHL, Scopus, and African Index Medicus databases for studies describing labor curves, assessing their effectiveness in improving birth outcomes, or assessing their accuracy as screening or diagnostic tools. Original research articles and systematic reviews were included. We excluded studies investigating adverse birth outcomes retrospectively, and those investigating the effect of analgesia-related interventions on labor progression. Study eligibility was assessed, and data were extracted from included studies using a piloted charting form. The findings are presented according to descriptive summaries created for the included studies. RESULTS AND IMPLICATIONS FOR RESEARCH: Of 26,073 potentially eligible studies, 108 studies were included. Seventy-three studies described labor curves, of which ten of the thirteen largest were based mainly on the United States Consortium on Safe Labor cohort. Labor curve endpoints were 10 cm cervical dilatation in 69 studies and vaginal birth in 4 studies. Labor curve accuracy was assessed in 26 studies, of which all 15 published after 1986 were from low- and middle-income countries. Recent studies of labor curve accuracy in high-income countries are lacking. The effectiveness of labor curves was assessed in 13 studies, which failed to prove the superiority of any curve. Patient-reported health and well-being is an underrepresented outcome in evaluations of labor curves. The usefulness of labor curves is still a matter of debate, as studies have failed to prove their accuracy or effectiveness.

Becoming Dad: Expectant Fathers' Attachment Style and Prenatal Representations of the Unborn Child.

How expectant fathers think and feel about the unborn child (prenatal representations), has shown associations with fathers' postnatal parenting behaviors, observed father-infant interactional quality and child cognitive development. There is limited knowledge about fathers' prenatal representations. The present study examined if fathers' partner-related attachment styles were related to their prenatal representations of the unborn child. In the "Little in Norway Study", an ongoing prospective, longitudinal population-based study, 396 expectant fathers completed the Experiences in Close Relationships Scale at enrollment (mean gestational week = 23.76, SD = 4.93), and in gestational weeks 27-35 completed three questions assessing prenatal representations. Correlations of attachment style and prenatal representations were reported using logistic regression analyses. We found that an avoidant attachment style by fathers were predicted to have absent or negative representations on all three items (1) "strongest feeling about the unborn child" (Cl = 1.19-2.73), (2) "thoughts about child personality" (Cl = 1.16-1.87), and (3) "experiences of relationship with the child" (Cl = 1.14-1.75). Father anxious attachment style was not significantly associated with absent or negative prenatal representations. Results suggest that expectant fathers with a partner related avoidant attachment style have an increased risk of having absent or negative prenatal representations of the unborn child.

Reliability and agreement in intrapartum fetal heart rate monitoring interpretation: A systematic review.

INTRODUCTION: Fetal heart rate (FHR) monitoring is routine in intrapartum care worldwide and one of the most common obstetrical procedures. Intrapartum FHR monitoring helps assess fetal wellbeing and interpretation of the FHR help form decisions for clinical management and intervention. It relies on the observers' subjective assessments, with variation in interpretations leading to variations in intrapartum care. The purpose of this systematic review was to summarize and evaluate extant inter- and intrarater reliability research on the human interpretation of intrapartum FHR monitoring. MATERIAL AND METHODS: We searched for the terms "fetal heart rate monitoring," "interpretation agreement" and related concepts on Embase, Medline, Maternity and Infant Care Database and CINAHL. The last search was made on January 31, 2022. The protocol for the study was prospectively registered in PROSPERO (CRD42021260937). Studies that assess inter- and intrarater reliability and agreement of health professionals' intrapartum FHR monitoring were included and studies including other assessment of fetal wellbeing excluded. We extracted data in reviewer pairs using quality appraisal tool for studies of diagnostic reliability (QAREL) forms. The data retrieved from the studies are presented as narrative synthesis and in additional tables. RESULTS: Forty-nine articles concerning continuous FHR monitoring were included in the study. For interrater reliability and agreement, in total 577 raters assessed 6315 CTG tracings. There was considerable heterogeneity in quality and measures across the included articles. We found higher reliability and agreement for the basic FHR features than for overall classification and higher agreement for intrarater reliability and agreement than for their interrater counterparts. CONCLUSIONS: There is great variation in reliability and agreement measures for continuous intrapartum FHR monitoring, implying that intrapartum CTG should be used with caution for clinical decision making given its questionable reliability. We found few high-quality studies and noted methodological concerns in the studies. We recommend a more standardized approach to future reliability studies on FHR monitoring.

Anxiety and depression in expectant parents: ART versus spontaneous conception.

STUDY QUESTION: Do expectant parents experience increased anxiety and depression during pregnancies conceived through ART compared to spontaneous conception? SUMMARY ANSWER: Among all expectant parents in the sample, those who conceived through ART reported overall lower levels of anxiety and depression in pregnancy compared to expectant parents who conceived spontaneously, while in the subsample of parents who conceived both through ART and spontaneous conception, expectant mothers experienced increased anxiety and depression in early pregnancy following ART compared to spontaneous conception. WHAT IS KNOWN ALREADY: Previous research on expectant parents' psychosocial adjustment in response to ART has found mixed results, with some studies suggesting ART is associated with increased anxiety and depression, and other studies suggesting improved mental health or no relationship. Mixed findings may relate to the use of cross-sectional designs that do not account for confounding differences between groups, or variability in the timing of assessment. STUDY DESIGN, SIZE, DURATION: This prospective cohort study used data from the Norwegian Mother, Father and Child Cohort Study (MoBa), which includes 2960 pregnant women who underwent ART and 108 183 women who conceived spontaneously. Of these, a subsample of expectant parents had two consecutive pregnancies with one pregnancy resulting from ART and one conceived spontaneously (n = 286 women, n = 211 partners). Women self-reported their composite symptoms of anxiety and depression at two timepoints during each pregnancy (gestational weeks 17 and 30). Their partners self-reported composite symptoms of anxiety and depression at 17 weeks gestation during each pregnancy. Couples reported their relationship satisfaction at 17 weeks gestation. MAIN RESULTS AND THE ROLE OF CHANGE: Using a conventional full-cohort analysis we found that ART was associated with less total anxiety and depression and greater relationship satisfaction, compared to spontaneous conception among both women and men. However, in the subsample of parents who experienced both ART and spontaneous pregnancies, ART was associated with increased levels of maternal anxiety and depression at gestational age 17 weeks (M = 1.19), compared to spontaneous pregnancies (M = 1.15), 95% CI of the mean difference 0.006, 0.074. At 30 weeks gestation, anxiety and depression were similar across both types of pregnancies. Expectant fathers reported similar levels of anxiety and depression at 17 weeks gestation during both pregnancies. Among women relationship satisfaction was higher following ART conception than spontaneous conception. LIMITATIONS, REASONS FOR CAUTION: There is potential for selection effects in the sample, as women who have conceived through both ART and spontaneous conception in their first two pregnancies are rare. In addition, several factors that may be important predictors of mental health in this context, such as previous miscarriages and long-term infertility, were not assessed in the current study. WIDER IMPLICATIONS OF THE FINDINGS: Our findings indicate that previous discrepancies in the literature may be related to inherent differences between the groups of parents receiving reproductive treatment and those who do not. This study addresses that limitation by prospectively comparing different types of pregnancies within the same expectant parents. Earlier inconsistencies may also relate to variations in gestational age when anxiety and depression were assessed. By examining symptoms at two timepoints in each pregnancy, we were able to examine the relation between gestational age and symptoms of anxiety and depression. STUDY FUNDING/COMPETING INTEREST(S): The MoBa is supported by the Norwegian Ministry of Health and the Norwegian Research Council/FUGE (grant number 151918/S10). This work was also supported by the Research Council of Norway grant number 288083 and 301004. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Experiences of Norwegian co-parents during COVID-19 pandemic restrictions: A qualitative study.

PURPOSE: The COVID-19 pandemic restrictions have had a major impact on the organization of health services in Europe. Co-parents' experiences of not being allowed to fully participate during pregnancy, childbirth, and the postpartum period is poorly understood. We investigated how the non-birthing partner experienced becoming a parent during the pandemic. METHODS: We applied a qualitative design. We recruited the participants from all part of the country by using snowball sampling. 18 individual interviews were conducted by using videotelephony software program/telephone. The transcripts were analysed using a six-step model for thematic analysis. RESULTS: The non-birthing participants were not considered by the healthcare system to be equal partners in terms of their involvement in the process of becoming parents. Three themes were constructed from the interview analysis- deprivation of the opportunity of "doing their part" of the job; participation by proxy to enhance togetherness; and choosing between obedience or opposition to the restrictions. CONCLUSION: The non-birthing co-parents felt deprived of doing what they considered to be their most important job-namely, to support and comfort their partners during pregnancy and childbirth. The healthcare system's decision to exclude co-parents from being physically present thus requires further reflection and discussion.

Umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes in children: a systematic review and meta-analysis.

BACKGROUND: Umbilical cord blood acid-base sampling is routinely performed at many hospitals. Recent studies have questioned this practice and the association of acidosis with cerebral palsy. OBJECTIVE: To investigate the associations between the results of umbilical cord blood acid-base analysis at birth and long-term neurodevelopmental outcomes and mortality in children. SEARCH STRATEGY: We searched six databases using the search strategy: umbilical cord AND outcomes. SELECTION CRITERIA: Randomised controlled trials, cohorts and case-control studies from high-income countries that investigated the association between umbilical cord blood analysis and neurodevelopmental outcomes and mortality from 1 year after birth in children born at term. DATA COLLECTION AND ANALYSIS: We critically assessed the included studies, extracted data and conducted meta-analyses comparing adverse outcomes between children with and without acidosis, and the mean proportions of adverse outcomes. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. MAIN RESULTS: We have very low confidence in the following findings: acidosis was associated with higher cognitive development scores compared with non-acidosis (mean difference 5.18, 95% CI 0.84-9.52; n = two studies). Children with acidosis also showed a tendency towards higher risk of death (relative risk [RR] 5.72, 95% CI 0.90-36.27; n = four studies) and CP (RR 3.40, 95% CI 0.86-13.39; n = four studies), although this was not statistically significant. The proportion of children with CP was 2.39/1000 across the studies, assessed as high certainty evidence. CONCLUSION: Due to low certainty of evidence, the associations between umbilical cord blood gas analysis at delivery and long-term neurodevelopmental outcomes in children remains unclear.

Long-Term Impact of Diagnosed Fetal Anomaly on Parental Traumatic Stress, Resilience, and Relationship Satisfaction.

OBJECTIVE: Knowledge regarding the long-term psychological adjustment of parents to children with prenatal diagnosis of congenital malformation is scarce. The aim of this study is to examine traumatic stress trajectories, resilience, and relationship satisfaction among parents to children with prenatal diagnosis of a congenital malformation, and to compare this to a sample of non-affected parents. METHODS: A prospective longitudinal cohort study was conducted at a tertiary perinatal referral center. Ninety-three mothers and 80 fathers who received a diagnosis of fetal anomaly during obstetric ultrasound examination (study group), and 110 mothers and 98 fathers with normal ultrasound findings (comparison group), reported their traumatic stress at four timepoints during pregnancy (T1-T4), 6 weeks after birth (T5), and 10-12 years after birth (T6). Resilience and relationship satisfaction was reported at 10-12 years after birth. RESULTS: Parents to children with a congenital malformation experienced significantly elevated traumatic stress levels over time, compared with parents of children without congenital malformation. The difference between groups was largest acutely after diagnosis and remained significant 10-12 years after the birth of the child. Resilience and relationship satisfaction levels were similar in both groups. CONCLUSIONS: Despite experiencing high levels of traumatic stress over time, parents to children with a congenital malformation reported resilience and relationship satisfaction at similar levels to non-affected parents. This suggests that despite ongoing long-term distress, parents are still able to maintain positive psychological coping resources.

The impact of diagnosed fetal anomaly, diagnostic severity and prognostic ambiguity on parental depression and traumatic stress: a prospective longitudinal cohort study.

INTRODUCTION: The detection of a fetal anomaly during routine obstetric ultrasound is a potentially traumatic experience. The aim of this study is to examine longitudinally the impact of diagnosis of fetal anomaly on symptoms of depression and traumatic stress among mothers and fathers, and to examine how variations in psychological adjustment relate to diagnostic severity and prognostic ambiguity. MATERIAL AND METHODS: In this prospective observational study conducted at a tertiary perinatal referral center, 81 mothers and 69 fathers with ultrasound findings of fetal anomaly completed the Edinburgh Postnatal Depression Scale (EPDS) and Impact of Events Scale (IES) at four time points in pregnancy (T1-T4) and 6 weeks after birth (T5). We compared this with depression and traumatic stress in a sample of non-affected parents (n = 110 mothers, 98 fathers). RESULTS: Linear mixed effects models indicated that parents who received a diagnosis of fetal anomaly experienced higher levels of depression and traumatic stress over time, compared with non-affected parents. Depression: mean difference mothers = 4.46 ± 0.47, fathers = 2.80 ± 0.42. Traumatic stress: mean difference mothers = 20.04 ± 2.13, fathers = 12.66 ± 1.74. Parents with a more severe diagnosis experienced elevated symptoms compared with parents with a less severe diagnosis. Among mothers, prognostic ambiguity and changes in the anticipated diagnosis after birth were also associated with increased distress, regardless of whether the change was for the better or worse. CONCLUSIONS: Diagnosis of fetal anomaly increases risk of depression and traumatic stress in expectant mothers and fathers, both acutely and over time.

Practice, skills and experience with the Pinard stethoscope for intrapartum Foetal monitoring: Focus group interviews with Norwegian midwives.

OBJECTIVE: In most high-income countries, the cardiotocography and handheld Doppler device have replaced the Pinard stethoscope for intrapartum foetal monitoring. As a result, the skills required to use the Pinard are rapidly disappearing from midwifery. The aim of this study was thus to illuminate the knowledge before it is lost, by exploring the practice, skills and experience of Norwegian midwives familiar with the Pinard for intrapartum foetal monitoring. We included midwives who still regularly use the Pinard in their current practice in a variety of birth settings, and those who used the Pinard in the era prior to the introduction of the CTG. DESIGN: This study followed a qualitative descriptive design based on mainly focus group interviews, but also including one individual interview. The interviews explored the participants` perspective on their practice, skills and experience regarding the use of the Pinard for intrapartum foetal monitoring. Reflexive thematic analysis captured common patterns across the data, and contextualism was used as research paradigm. SETTING AND PARTICIPANTS: In total, 21 midwives with experience using the Pinard for intrapartum foetal monitoring were interviewed. The midwives were either retired and had experience using the Pinard from before the CTG became widespread; worked in an alongside midwifery unit that only oversees low-risk births; or worked in an obstetric unit in a university hospital with an active policy of using the Pinard for intrapartum foetal monitoring. FINDINGS: The analysis resulted in four main themes: "Practice and experience with the Pinard are related to context", "Skills with the Pinard come with work experience", "The Pinard reveals certain characteristics of foetal sound" and "Midwives` experience with the benefits of using the Pinard". The midwives considered the context for using the Pinard for intrapartum foetal monitoring relevant. The e availability of technology and applicable situations for using the Pinard influenced how and when they use the Pinard. They further underpinned training and work experience as important for feeling secure when using the Pinard, and this experience made them recognize normal and abnormal foetal sounds. Defining and characterizing these sounds appeared difficult for the midwives, however, and they hesitated and imitated the sound. The midwives felt that the Pinard is beneficial for both the labouring woman and the midwife, as the Pinard's features bring them closer to the labouring woman and help calm the birth suite. They also felt that the Pinard adds further information about the birth and birth process, such as foetal lie, rotation and descent. KEYCONCLUSIONS: Norwegian midwives' practice, and experiences in using the Pinard for intrapartum foetal monitoring are connected to context as technological development and applicable situations. The midwives explained that knowledge obtained through experience gives them skills to differentiate between normal and abnormal foetal sound characteristics, though they found it difficult to define the characteristics themselves. Using the Pinard stethoscope during birth calms the birth suite and brings the midwife closer to the labouring woman.

Changes in maternal cortisol, cortisol binding globulin and cortisone levels following diagnosis of fetal anomaly.

The diagnosis of fetal anomaly can be a major stressor to the expectant mother. Current understanding of the relationship between psychological stress and cortisol in pregnancy is limited. This study examined: (1) differences in the ratio of serum cortisol to cortisol binding globulin (SC/CBG) and cortisone levels among women with and without a diagnosis of fetal anomaly, (2) the association between self-reported stress and cortisol from mid to late pregnancy, and (3) the agreement between two different techniques for analyzing cortisol: liquid chromatography-tandem mass spectrometry (LC-MS/MS) and radioimmunoassay (RIA). Thirty-six pregnant women with a diagnosis of fetal anomaly (study group) and 101 women with healthy pregnancies (comparison group) provided blood samples and completed self-report questionnaires at gestational weeks 18-24 (T1) and 30 (T2). In the comparison group, mean SC/CBG increased from 0.341 nmol/L at T1 to 0.415 at T2 (p < .001), whereas in the study group there was no change (0.342 nmol/L at T1, 0.343 at T2). There was no difference in cortisone levels between the groups at either timepoints. There was a negative association between both depression and traumatic stress at T1, and SC/CBG at T2 (p < .05). There was no association between general distress and SC/CBG. The two methods for analyzing cortisol gave similar results, but with LC-MS/MS showing a lower detection limit than RIA. Increased cortisol with advancing gestational age is expected, thus these findings indicate that under certain conditions of severe stress there may be a suppression of maternal cortisol increase from mid to late gestation. The discrepancy does not seem to be due to differences in the metabolization of cortisol, as indicated by the similar levels of cortisone. Further research is needed in order to understand the potential underlying mechanisms limiting the expression of cortisol in response to certain types of stress in pregnancy.

Recommendations for intrapartum fetal monitoring are not followed in low-risk women: A study from two Norwegian birth units.

OBJECTIVE: International and national intrapartum fetal monitoring guidelines recommend intermittent auscultation in low-risk women, and admission cardiotocography and continuous cardiotocography in high-risk women. The present study aimed to investigate fetal monitoring practices for low- and high-risk women in two hospitals in Norway, and if practice were according to national and international guidelines. STUDY DESIGN: To this cross sectional study, data on methods of fetal monitoring and women's risk status were collected from the patient journals of 998 women with intended vaginal birth in 2017 and 2018. MAIN OUTCOME MEASURES: Type of fetal monitoring related to risk status. RESULTS: On admission, 401 (40%) of the women were classified as low-risk and 597 (60%) as high-risk. An admission cardiotocography was reported for 327 (82%) low-risk women and 554 (93%) high-risk women. Of the low-risk women, 187 (47%) remained low-risk throughout labor. During labor, 99 (53%) of the women that remained low-risk were monitored with intermittent auscultation, 62 (33%) with cardiotocography, 24 (13%) with partial cardiotocography, and two (1%) had no monitoring documented. In the high-risk women, intermittent auscultation was used for 11 (2%) during labor, cardiotocography for 544 (91%), partial cardiotocography for 35 (6%), and seven (1%) women had no monitoring documented. CONCLUSIONS: The majority of low-risk women had an admission cardiotocography and during labor many low-risk women were monitored with continuous cardiotocography. This is not in accordance with guidelines which recommend intermittent auscultation. In addition, almost one-tenth of high-risk women were not monitored with continuous cardiotocography, as recommended.

Paternal Psychological Stress After Detection of Fetal Anomaly During Pregnancy. A Prospective Longitudinal Observational Study.

BACKGROUND AND AIMS: Knowledge of carrying a fetus with a prenatal diagnosed anomaly may cause acute psychological stress to the parents. Most studies focus on maternal stress, yet fathers are often present at the ultrasound examinations and birth, and therefore may be affected, similarly, to the expectant mother. However, to date no existing studies have examined how detection of a fetal anomaly emotionally affects the expectant fathers throughout the pregnancy. Our aim was to longitudinally examine general health perceptions, social dysfunction and psychological distress in a subgroup of men where fetal anomaly was detected during pregnancy. METHODS AND RESULTS: This study is part of the SOFUS study, a prospective, longitudinal, observational study. Participants were recruited when referred for an ultrasound examination conducted by a specialist in fetal medicine at Oslo University Hospital on suspicion of fetal malformation (study group). We examined differences between the men in the study group (N = 32) and a comparison group (N = 83) on the General Health Questionnaire (GHQ), Impact of Event Scale (IES) and Edinburgh Postnatal Depression Scale (EDPS) across four time points in pregnancy. Results from repeated measured ANOVA suggests that depression decreased over time among men in both groups (η2 = 0.15, p < 0.001). This effect was stronger in the study group, and differed from the comparison group (η2 = 0.08, p < 0.001). There was also a main effect of time on IES scores, which decreased over time for both men in the study group and in the comparison group (η2 = 0.32, p < 0.001). That is, men in the study group were higher on IES initially, but this effect decreased more in the study group than in the comparison group. Men in the study group and comparison group did not differ on perceived general health (GHQ: p = 0.864). CONCLUSION: Results suggests that detection of a fetal anomaly has implications for paternal mental health during pregnancy. Expectant fathers scored higher on EPDS and IES than the comparison group in the acute phase after detection of fetal anomaly, thus there is impetus to provide psychological support for fathers, as well as mothers, at this difficult time.

Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy.

BACKGROUND: Intermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps. METHODS: We conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach. RESULTS: The searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29-2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult. CONCLUSION: Although IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa.

National survey of routines for intrapartum fetal monitoring in Norway.

INTRODUCTION: This study describes clinical routines for intrapartum fetal monitoring in Norway and compliance with national clinical recommendations. MATERIAL AND METHODS: A national survey of all (n = 48) birth units in Norway, using a self-reporting questionnaire about fetal monitoring methods and devices available in the birth units, admission cardiotocography (CTG) use, intrapartum fetal monitoring methods for women with and without risk factors, the availability of fetal scalp blood sampling facilities, and umbilical cord blood sampling routines. RESULTS: All birth units responded. They all had access to Pinard stethoscopes, hand-held Doppler devices, and CTG. Half of the units used ST waveform analysis (STAN) as an adjunct to CTG. Furthermore, 23 of 48 units analyzed fetal blood samples and 43 of 48 umbilical cord blood gas samples. In 11 units, admission CTG was routinely offered to all women. No units used continuous CTG during labor in low-risk women. However, three units routinely used intermittent CTG during the first stage of labor. Three units used CTG without having access to fetal blood samples or STAN. CONCLUSIONS: Our findings indicate some deviations from clinical recommendations in the use of intrapartum fetal monitoring in Norway. Three units used intermittent CTG for women without risk factors. Almost one in four units routinely used admission CTG, despite national clinical recommendations. The lack of access to fetal blood samples or STAN in units using CTG is of concern.

Maternal psychological responses during pregnancy after ultrasonographic detection of structural fetal anomalies: A prospective longitudinal observational study.

In this longitudinal prospective observational study performed at a tertiary perinatal referral centre, we aimed to assess maternal distress in pregnancy in women with ultrasound findings of fetal anomaly and compare this with distress in pregnant women with normal ultrasound findings. Pregnant women with a structural fetal anomaly (n = 48) and normal ultrasound (n = 105) were included. We administered self-report questionnaires (General Health Questionnaire-28, Impact of Event Scale-22 [IES], and Edinburgh Postnatal Depression Scale) a few days following ultrasound detection of a fetal anomaly or a normal ultrasound (T1), 3 weeks post-ultrasound (T2), and at 30 (T3) and 36 weeks gestation (T4). Social dysfunction, health perception, and psychological distress (intrusion, avoidance, arousal, anxiety, and depression) were the main outcome measures. The median gestational age at T1 was 20 and 19 weeks in the group with and without fetal anomaly, respectively. In the fetal anomaly group, all psychological distress scores were highest at T1. In the group with a normal scan, distress scores were stable throughout pregnancy. At all assessments, the fetal anomaly group scored significantly higher (especially on depression-related questions) compared to the normal scan group, except on the IES Intrusion and Arousal subscales at T4, although with large individual differences. In conclusion, women with a known fetal anomaly initially had high stress scores, which gradually decreased, resembling those in women with a normal pregnancy. Psychological stress levels were stable and low during the latter half of gestation in women with a normal pregnancy.

Maternal psychological distress and placental circulation in pregnancies after a previous offspring with congenital malformation.

INTRODUCTION: Antenatal maternal psychological distress may be associated with reduced placental circulation, which could lead to lower birthweight. Studies investigating this in humans show mixed results, which may be partially due to type, strength and timing of distress. In addition, the arterial vascular resistance measures often used as outcome measures do not detect smaller changes in placental volume blood flow. We aimed to investigate the effect of a specific stressor, with increased levels of stress early in pregnancy, on the fetoplacental volume blood flow in third trimester. METHODS: This was a prospective observational study of 74 pregnant women with a congenital malformation in a previous fetus or child. Psychological distress was assessed twice, around 16 and 30 weeks' gestation. Psychometric measures were the General Health Questionnaire-28 (subscales anxiety and depression), Edinburgh Postnatal Depression Scale, and Impact of Event Scale-22 (subscales intrusion, avoidance, and arousal). Placental circulation was examined at 30 weeks, using Doppler ultrasonography, primarily as fetoplacental volume blood flow in the umbilical vein, normalized for abdominal circumference; secondarily as vascular resistance measures, obtained from the umbilical and the uterine arteries. RESULTS: Maternal distress in second but not third trimester was associated with increased normalized fetoplacental blood flow (P-values 0.006 and 0.013 for score > mean for depression and intrusion, respectively). Post-hoc explorations suggested that a reduced birthweight/placental weight ratio may mediate this association. Psychological distress did not affect vascular resistance measures in the umbilical and uterine arteries, regardless of adjustment for confounders. CONCLUSIONS: In pregnant women with a previous fetus or child with a congenital malformation, higher distress levels in second trimester were associated with third trimester fetoplacental blood flow that was higher than expected for the size of the fetus. The results do not support placental blood flow reduction as a pathway between maternal distress and reduced birthweight.

Paternal psychological response after ultrasonographic detection of structural fetal anomalies with a comparison to maternal response: a cohort study.

BACKGROUND: In Norway almost all pregnant women attend one routine ultrasound examination. Detection of fetal structural anomalies triggers psychological stress responses in the women affected. Despite the frequent use of ultrasound examination in pregnancy, little attention has been devoted to the psychological response of the expectant father following the detection of fetal anomalies. This is important for later fatherhood and the psychological interaction within the couple. We aimed to describe paternal psychological responses shortly after detection of structural fetal anomalies by ultrasonography, and to compare paternal and maternal responses within the same couple. METHODS: A prospective observational study was performed at a tertiary referral centre for fetal medicine. Pregnant women with a structural fetal anomaly detected by ultrasound and their partners (study group,n=155) and 100 with normal ultrasound findings (comparison group) were included shortly after sonographic examination (inclusion period: May 2006-February 2009). Gestational age was >12 weeks. We used psychometric questionnaires to assess self-reported social dysfunction, health perception, and psychological distress (intrusion, avoidance, arousal, anxiety, and depression): Impact of Event Scale. General Health Questionnaire and Edinburgh Postnatal Depression Scale. Fetal anomalies were classified according to severity and diagnostic or prognostic ambiguity at the time of assessment. RESULTS: Median (range) gestational age at inclusion in the study and comparison group was 19 (12-38) and 19 (13-22) weeks, respectively. Men and women in the study group had significantly higher levels of psychological distress than men and women in the comparison group on all psychometric endpoints. The lowest level of distress in the study group was associated with the least severe anomalies with no diagnostic or prognostic ambiguity (p < 0.033). Men had lower scores than women on all psychometric outcome variables. The correlation in distress scores between men and women was high in the fetal anomaly group (p < 0.001), but non-significant in the comparison group. CONCLUSION: Severity of the anomaly including ambiguity significantly influenced paternal response. Men reported lower scores on all psychometric outcomes than women. This knowledge may facilitate support for both expectant parents to reduce strain within the family after detectionof a fetal anomaly.

Does antenatal maternal psychological distress affect placental circulation in the third trimester?

INTRODUCTION: Some types of antenatal maternal psychological distress may be associated with reduced fetal growth and birthweight. A stress-mediated reduction in placental blood flow has been suggested as a mechanism. Previous studies have examined this using ultrasound-derived arterial resistance measures in the uterine (UtA) and umbilical (UA) arteries, with mixed conclusions. However, a reduction in placental volume blood flow may occur before changes in arterial resistance measures are seen. Fetoplacental volume blood flow can be quantified non-invasively in the umbilical vein (UV). Our objective was to study whether specific types of maternal psychological distress affect the placental circulation, using volume blood flow quantification in addition to arterial resistance measures. METHODS: This was a prospective observational study of 104 non-smoking pregnant women (gestational age 30 weeks) with uncomplicated obstetric histories. Psychological distress was measured by General Health Questionnaire-28 (subscales anxiety and depression) and Impact of Event Scale-22 (subscales intrusion, avoidance and arousal). UtA and UA resistance measures and UV volume blood flow normalized for fetal abdominal circumference, were obtained by Doppler ultrasound. RESULTS: IES intrusion scores above the mean were associated with a reduction in normalized UV volume blood flow (corresponding to -0.61 SD; P = 0.003). Adjusting for UA resistance increased the strength of this association (difference -0.66 SD; P<0.001). Other distress types were not associated with UV volume blood flow. Maternal distress was not associated with arterial resistance measures, despite adjustment for confounders. CONCLUSIONS: Intrusive thoughts and emotional distress regarding the fetus were associated with reduced fetoplacental volume blood flow in third trimester. Uterine and umbilical artery resistance measures were not associated with maternal distress. Our findings support a decrease in fetoplacental blood flow as a possible pathway between maternal distress and reduced fetal growth.