Fetal scalp stimulation for assessing fetal well-being during labour.

BACKGROUND: Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. OBJECTIVES: To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. SELECTION CRITERIA: Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. AUTHORS' CONCLUSIONS: There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.

Cervical ripening and labour induction: A critical review of the available methods.

Induction of labour is one of the most common interventions experienced by pregnant women. There are two overlapping components to labour induction, which include cervical ripening and the initiation of regular contractions. A large number of clinical studies have been conducted for evaluating the methods used for induction of labour, their effectiveness and safety, and pregnancy outcomes. Randomised controlled trials (RCTs) provide the strongest form of evidence for clinical practice. These data are brought together in systematic reviews and have been incorporated into national and international guidelines. Despite this, there is considerable variation in the recommendations between guidelines. Heterogeneity between studies, inconsistency in the definitions of trial outcomes, and underpowered sample size contribute to the difficulty in making robust recommendations. There are pharmacological and non-pharmacological approaches that can be compared with each other and with placebo or no treatment. There are also complementary therapies that may appeal to women but lack evidence of their effectiveness. These issues have been addressed in the current chapter, with a critical review of the research evidence presented in clinical trials and systematic reviews.

Severe lymphoedema in gynaecological cancers: Impact of pneumatic compression on quality of life.

OBJECTIVE: Good survival rates from gynaecological cancers focus our attention on the quality of survivorship. Lymphoedema is a common complication that affects many aspects of quality of life (QOL). We undertook a prospective audit of QOL of patients with higher grade lymphoedema using home compression pneumatic devices. The aim of this study was to assess QOL in a mixed gynaecological cancer cohort before and after at least eight weeks of home compression treatment. METHODS: Thirteen patients with the most severely disabling lower limb lymphoedema based on routinely collected QOL scores or a history of hospital admissions with related infection were invited to participate. QOL was assessed using the EORTC QLQ-C30 Version 3.0 and a supplementary gynaecological cancer-specific lymphoedema questionnaire. Home compression therapy was introduced not sooner than 3 months after primary cancer treatment. All patients applied compression treatment for at least one hour per day. Descriptive statistics and Wilcoxon signed-rank test were applied. A p-value < 0.05 was considered statistically significant. RESULTS: All participants' functional and symptom scores improved with compression therapy with the exception of sexual function. CONCLUSIONS: Self-management with pneumatic compression devices at home is a useful adjunct in the management of severe lymphoedema. Our preliminary experience showed a substantial improvement in most QOL parameters. We cannot say if domiciliary treatment with this compression device would have broader application or a role in primary or secondary prevention of lymphoedema if introduced at an earlier stage.