Assessment of uterine contractions in labor and delivery.

Normal labor and delivery are dependent on the presence of regular and effective contractions of the uterine myometrium. The mechanisms responsible for the initiation and maintenance of adequate and synchronized uterine activity that are necessary for labor and delivery result from a complex interplay of hormonal, mechanical, and electrical factors that have not yet been fully elucidated. Monitoring uterine activity during term labor and in suspected preterm labor is an important component of obstetrical care because cases of inadequate and excessive uterine activity can be associated with substantial maternal and neonatal morbidity and mortality. Inadequate labor progress is a common challenge encountered in intrapartum care, with labor dystocia being the most common indication for cesarean deliveries performed during labor. Hereafter, an accurate assessment of uterine activity during labor can assist in the management of protracted labor by diagnosing inadequate uterine activity and facilitating the titration of uterotonic medications before a trial of labor is prematurely terminated. Conversely, the ability to diagnose unwanted or excessive uterine activity is also critical in cases of threatened preterm labor, tachysystole, or patients undergoing a trial of labor after cesarean delivery. Knowledge of uterine activity in these cases may guide the use of tocolytic medications or raise suspicion of uterine rupture. Current diagnostic capabilities are less than optimal, hindering the medical management of term and preterm labor. Currently, different methods exist for evaluating uterine activity during labor, including manual palpation, external tocodynamometry, intrauterine pressure monitoring, and electrical uterine myometrial activity tracing. Legacy uterine monitoring techniques have advantages and limitations. External tocodynamometry is the most widespread tool in clinical use owing to its noninvasive nature and its ability to time contractions against the fetal heart rate monitor. However, it does not provide information regarding the strength of uterine contractions and is limited by signal loss with maternal movements. Conversely, the intrauterine pressure catheter quantifies the strength of uterine contractions; however, its use is limited by its invasiveness, risk for complications, and limited additive value in all but few clinical scenarios. New monitoring methods are being used, such as electrical uterine monitoring, which is noninvasive and does not require ruptured membranes. Electrical uterine monitoring has yet to be incorporated into common clinical practice because of lack of access to this technology, its high cost, and the need for appropriate training of clinical staff. Further work needs to be done to increase the accessibility and implementation of this technique by experts, and further research is needed to implement new practical and useful methods. This review describes current clinical tools for uterine activity assessment during labor and discusses their advantages and shortcomings. The review also summarizes current knowledge regarding novel technologies for monitoring uterine contractions that are not yet in widespread use, but are promising and could help improve our understanding of the physiology of labor, delivery, and preterm labor, and ultimately enhance patient care.

Novel uterine contraction monitoring to enable remote, self-administered nonstress testing.

BACKGROUND: The serial fetal monitoring recommended for women with high-risk pregnancies places a substantial burden on the patient, often disproportionately affecting underprivileged and rural populations. A telehealth solution that can empower pregnant women to obtain recommended fetal surveillance from the comfort of their own home has the potential to promote health equity and improve outcomes. We have previously validated a novel, wireless pregnancy monitor that can remotely capture fetal and maternal heart rates. However, such a device must also detect uterine contractions if it is to be used to robustly conduct remote nonstress tests. OBJECTIVE: This study aimed to describe and validate a novel algorithm that uses biopotential and acoustic signals to noninvasively detect uterine contractions via a wireless pregnancy monitor. STUDY DESIGN: A prospective, open-label, 2-center study evaluated simultaneous detection of uterine contractions by the wireless pregnancy monitor and an intrauterine pressure catheter in women carrying singleton pregnancies at ≥32 0/7 weeks' gestation who were in the first stage of labor (ClinicalTrials.gov Identifier: NCT03889405). The study consisted of a training phase and a validation phase. Simultaneous recordings from each device were passively acquired for 30 to 60 minutes. In a subset of the monitoring sessions in the validation phase, tocodynamometry was also deployed. Three maternal-fetal medicine specialists, blinded to the data source, identified and marked contractions in all modalities. The positive agreement and false-positive rates of both the wireless monitor and tocodynamometry were calculated and compared with that of the intrauterine pressure catheter. RESULTS: A total of 118 participants were included, 40 in the training phase and 78 in the validation phase (of which 39 of 78 participants were monitored simultaneously by all 3 devices) at a mean gestational age of 38.6 weeks. In the training phase, the positive agreement for the wireless monitor was 88.4% (1440 of 1692 contractions), with a false-positive rate of 15.3% (260/1700). In the validation phase, using the refined and finalized algorithm, the positive agreement for the wireless pregnancy monitor was 84.8% (2722/3210), with a false-positive rate of 24.8% (897/3619). For the subgroup who were monitored only with the wireless monitor and intrauterine pressure catheter, the positive agreement was 89.0% (1191/1338), with a similar false-positive rate of 25.4% (406/1597). For the subgroup monitored by all 3 devices, the positive agreement for the wireless monitor was significantly better than for tocodynamometry (P<.0001), whereas the false-positive rate was significantly higher (P<.0001). Unlike tocodynamometry, whose positive agreement was significantly reduced in the group with obesity compared with the group with normal weight (P=.024), the positive agreement of the wireless monitor did not vary across the body mass index groups. CONCLUSION: This novel method to noninvasively monitor uterine activity, via a wireless pregnancy monitoring device designed for self-administration at home, was more accurate than the commonly used tocodynamometry and unaffected by body mass index. Together with the previously reported remote fetal heart rate monitoring capabilities, this added ability to detect uterine contractions has created a complete telehealth solution for remote administration of nonstress tests.

Non-invasive fetal electrocardiography, electrohysterography and speckle-tracking echocardiography in the second trimester: study protocol of a longitudinal prospective cohort study (BEATS-study).

BACKGROUND: Worldwide, hypertensive disorders of pregnancy (HDP), fetal growth restriction (FGR) and preterm birth remain the leading causes of maternal and fetal pregnancy-related mortality and (long-term) morbidity. Fetal cardiac deformation changes can be the first sign of placental dysfunction, which is associated with HDP, FGR and preterm birth. In addition, preterm birth is likely associated with changes in electrical activity across the uterine muscle. Therefore, fetal cardiac function and uterine activity can be used for the early detection of these complications in pregnancy. Fetal cardiac function and uterine activity can be assessed by two-dimensional speckle-tracking echocardiography (2D-STE), non-invasive fetal electrocardiography (NI-fECG), and electrohysterography (EHG). This study aims to generate reference values for 2D-STE, NI-fECG and EHG parameters during the second trimester of pregnancy and to investigate the diagnostic potential of these parameters in the early detection of HDP, FGR and preterm birth. METHODS: In this longitudinal prospective cohort study, eligible women will be recruited from a tertiary care hospital and a primary midwifery practice. In total, 594 initially healthy pregnant women with an uncomplicated singleton pregnancy will be included. Recordings of NI-fECG and EHG will be made weekly from 22 until 28 weeks of gestation and 2D-STE measurements will be performed 4-weekly at 16, 20, 24 and 28 weeks gestational age. Retrospectively, pregnancies complicated with pregnancy-related diseases will be excluded from the cohort. Reference values for 2D-STE, NI-fECG and EHG parameters will be assessed in uncomplicated pregnancies. After, 2D-STE, NI-fCG and EHG parameters measured during gestation in complicated pregnancies will be compared with these reference values. DISCUSSION: This will be the a large prospective study investigating new technologies that could potentially have a high impact on antepartum fetal monitoring. TRIAL REGISTRATION: Registered on 26 March 2020 in the Dutch Trial Register (NL8769) via https://www.trialregister.nl/trials and registered on 21 October 2020 to the Central Committee on Research Involving Human Subjects (NL73607.015.20) via https://www.toetsingonline.nl/to/ccmo_search.nsf/Searchform?OpenForm .

Knowledge on intrapartum care practices among skilled birth attendants in Cambodia-a cross-sectional study.

BACKGROUND: Delivery is a critical moment for pregnant women and babies, and careful monitoring is essential throughout the delivery process. The partograph is a useful tool for monitoring and assessing labour progress as well as maternal and foetal conditions; however, it is often used inaccurately or inappropriately. A gap between practices and evidence-based guidelines has been reported in Cambodia, perhaps due to a lack of evidence-based knowledge in maternity care. This study aims to address to what extent skilled birth attendants in the first-line health services in Cambodia have knowledge on the management of normal delivery, and what factors are associated with their level of knowledge. METHODS: Midwives and nurses were recruited working in maternity in first-line public health facilities in Phnom Penh municipality, Kampong Cham and Svay Rieng provinces. Two self-administered questionnaires were applied. The first consisted of three sections with questions on monitoring aspects of the partograph: progress of labour, foetal, and maternal conditions. The second consisted of questions on diagnostic criteria, normal ranges, and standard intervals of monitoring during labour. A multiple linear regression analysis was performed to identify relationships between characteristics of the participants and the questionnaire scores. RESULTS: Of 542 eligible midwives and nurses, 523 (96%) participated. The overall mean score was 58%. Only 3% got scores of more than 90%. Multivariate analysis revealed that 'Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score. Substantial proportions of misclassification of monitoring items during labour were found; for example, 61% answered uterine contraction as a foetal condition, and 44% answered foetal head descent and 26% answered foetal heart rate as a maternal condition. CONCLUSION: This study found that knowledge was low on delivery management among skilled birth attendants. Previous training experience did not influence the knowledge level. A lack of understanding of physiology and anatomy was implied. Further experimental approaches should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Pregnancy and childbirth are natural phenomena, but sometimes have risk for mothers and babies. Therefore, childbirth should be carefully and continuously monitored by the health care professional. The 'partograph' is a useful tool that defines three monitoring aspects of the delivery progress, and conditions of the mother and intrauterine baby. However, it is often used inaccurately or inappropriately in low- and middle-income countries. We hypothesised that health professionals who assist childbirth cannot effectively monitor delivery conditions because their knowledge is insufficient. Therefore, we evaluated the knowledge on monitoring the process of childbirth and explored factors which affect the level of knowledge among health care providers in Cambodia.Midwives and nurses were targeted in this study who deal with normal deliveries in the capital city and two provinces. The questionnaire was designed to evaluate if their knowledge on three monitoring aspects is accurate.Of 542 eligible personnel, 523 (96%) participated. The mean score was 58%. Only 3% got scores of more than 90%. According to the statistical analysis, 'working in Kampong Cham province', 'younger age', and 'higher qualification' were significantly associated with higher scores. Previous training experience was not associated with the score.This study found that basic knowledge was low on delivery management among health care providers. We suspect that a deficiency of basic medical knowledge, such as physiology and anatomy, causes the lack of knowledge on the childbirth process. Further intervention should be attempted to improve the knowledge and quality of maternity services in Cambodia.

Clinical evaluation of labor: an evidence- and experience-based approach.

During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process.

Intrauterine versus external tocodynamometry in monitoring labour: a randomised controlled clinical trial.

OBJECTIVE: To investigate whether the use of intrauterine tocodynamometry versus external tocodynamometry (IT versus ET) during labour reduces operative deliveries and improves newborn outcome. As IT provides more accurate information on labour contractions, the hypothesis was that it may more appropriately guide oxytocin use than ET. DESIGN: Randomised controlled trial. SETTING: Two labour wards, in a university tertiary hospital and a central hospital. POPULATION: A total of 1504 parturients with singleton pregnancies, gestational age ≥37 weeks and fetus in cephalic position: 269 women with uterine scars, 889 nulliparas and 346 parous women with oxytocin augmentation. METHODS: Participants underwent IT (n = 736) or ET (n = 768) during the active first stage of labour. MAIN OUTCOME MEASURES: Primary outcome: rate of operative deliveries. SECONDARY OUTCOMES: duration of labour, amount of oxytocin given, adverse neonatal outcomes. RESULTS: Operative delivery rates were 26.9% (IT) and 25.9% (ET) (odds ratio 1.05, 95% CI 0.84-1.32, P = 0.663). The ET to IT conversion rate was 31%. We found no differences in secondary outcomes (IT versus ET). IT reduced oxytocin use during labours with signs of fetal distress, and trial of labour after caesarean section. CONCLUSIONS: IT did not reduce the rate of operative deliveries, use of oxytocin, or adverse neonatal outcomes, and it did not shorten labour duration. TWEETABLE ABSTRACT: IT (versus ET) reduced oxytocin use in high-risk labours but did not influence operative delivery rate or adverse neonatal outcomes.

Utilization of Partograph and its associated factors among midwives working in public health institutions, Addis Ababa City Administration,Ethiopia,2017.

BACKGROUND: Partograph is cost effective and affordable tool designed to provide a continuous pictorial overview and labour progress used to prevent prolonged and obstructed labour. It consists of key information about progress of labour, fetal condition and maternal condition. Its role is to improve outcomes and predict the progress of labour. The aim of this study was to assess utilization of partograph and its predictors among midwives working in public health facilities, Addis Ababa city administration, Ethiopia, 2017. METHODS: An institution based cross-sectional study design was conducted in Addis Ababa, Ethiopia from 15/10/2017-15/12/2017.Simple random sampling under multistage sampling technique was applied to select a total of 605 midwives working in maternity unit of selected public health facilities. Data were collected using structured self-administered questionnaire. Checklist based direct observations were made to all midwife participants to determine the actual practical use of partograph. Data first entered in to EpiInfo version 3.5.1 and transported to SPSS Version 21.Descriptive statistics such as frequency, percentage, mean, and median were calculated. Biviriate and multivariable logistic regression analysis were applied. Any personal identification of the study participants was not recorded during data collection to ensure confidentiality of information. RESULTS: In this study, the utilization of partograph was 409(69%) out of 594 study participants. Being mentored(AOR = 3.1; 95% CI: 1.7, 5.3),received training (AOR = 2.4; 95% CI:1.5,3.6),being knowledgeable about partograph (AOR = 1.6; 95% CI: 1.1, 2.5), health center workers(AOR = 12.6; 95% CI:5.1,31.6),supportive supervision 4 times per year (AOR = 18.6; 95% CI: 6.6,25),supportive supervision twice per a year (AOR = 4.7; 95% CI: 1.9, 11.3),supportive supervision once per year (AOR =3.8;95% CI:1.7,8.8) were positive predictors of partograph utilization. Two midwives per shift (AOR = 0.101; 95% CI: 0.05, 0.65), and 4 per shift (AOR = 0.105, 95% CI: 0.03, 0.40) were protective predictors of partograph utilization. CONCLUSIONS: More than half of the respondents utilized partograph. All public health institutions avail partograph in their laboring room but didn't utilize it according to WHO recommended standard. Working facility, supportive supervision, mentoring, training on partograph, number of midwives working per shift, and knowledge were factors affecting partograph utilization. Encouraging interventions are recommended to the response of the above significantly associated factors.

Safety of misoprostol vaginal insert for labor induction using standard vs. adjusted retrieval criteria: a comparative cohort study.

Objective To compare the safety of misoprostol vaginal insert (MVI) for labor induction using standard and adjusted criteria. Methods This was a single-center, comparative cohort study of 138 pregnant women ≥37/0 weeks undergoing labor induction with MVI using standard (69 women; administration for up to 24 h; MVI-24) or adjusted (69 women; administration for up to 10 h; MVI-10) criteria in a tertiary academic center in Germany. The main maternal safety outcomes were the rate of tachysystole and rate of tachysystole requiring tocolysis. Neonatal safety assessments included Apgar score at 5 min and postpartum arterial fetal pH. Results Uterine tachysystole occurred in more women in the MVI-24 group compared with the MVI-10 group [47.8% vs. 25.5%; P = 0.001; relative risk (RR) 2.36 (95% confidence interval [CI]: 1.39-4.00)] and as did uterine tachysystole requiring tocolysis [MVI-24: 26.1% vs. MVI-10: 11.6%; P = 0.049; RR 2.25 (95% CI: 1.05-4.83)]. The mean 5-min Apgar scores were 9.64 for the MVI-24 group and 9.87 for the MVI-10 (P = 0.016). Low postpartum umbilical arterial pH values occurred more often in the MVI-24 compared with the MVI-10 group (pH 7.10-7.19: 26.1% vs. 20.3% and pH <7.10: 4.4% vs. 0.0%, respectively). Conclusion Adjusted retrieval criteria for MVI of up to 10 h exposure instead of the standard 24 h reduced uterine tachysystole and improved the neonatal outcome.

A Comparative Study of Vaginal Labor and Caesarean Section Postpartum Uterine Myoelectrical Activity.

Postpartum hemorrhage (PPH) is one of the major causes of maternal mortality and morbidity worldwide, with uterine atony being the most common origin. Currently there are no obstetrical techniques available for monitoring postpartum uterine dynamics, as tocodynamometry is not able to detect weak uterine contractions. In this study, we explored the feasibility of monitoring postpartum uterine activity by non-invasive electrohysterography (EHG), which has been proven to outperform tocodynamometry in detecting uterine contractions during pregnancy. A comparison was made of the temporal, spectral, and non-linear parameters of postpartum EHG characteristics of vaginal deliveries and elective cesareans. In the vaginal delivery group, EHG obtained a significantly higher amplitude and lower kurtosis of the Hilbert envelope, and spectral content was shifted toward higher frequencies than in the cesarean group. In the non-linear parameters, higher values were found for the fractal dimension and lower values for Lempel-Ziv, sample entropy and spectral entropy in vaginal deliveries suggesting that the postpartum EHG signal is extremely non-linear but more regular and predictable than in a cesarean. The results obtained indicate that postpartum EHG recording could be a helpful tool for earlier detection of uterine atony and contribute to better management of prophylactic uterotonic treatment for PPH prevention.

Diagnostic accuracy of the partograph alert and action lines to predict adverse birth outcomes: a systematic review.

BACKGROUND: There are questions about the use of the 'one-centimetre per hour rule' as a valid benchmark for assessing the adequacy of labour progress. OBJECTIVES: To determine the accuracy of the alert (1-cm/hour) and action lines of the cervicograph in the partograph to predict adverse birth outcomes among women in first stage of labour. SEARCH STRATEGY: PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies. SELECTION CRITERIA: Observational studies and other study designs reporting data on the correlation between the alert line status of women in labour and the occurrence of adverse birth outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers at a time independently identified eligible studies and independently abstracted data including population characteristics and maternal and perinatal outcomes. MAIN RESULTS: Thirteen studies in which 20 471 women participated were included in the review. The percentage of women crossing the alert line varied from 8 to 76% for all maternal or perinatal outcomes. No study showed a robust diagnostic test accuracy profile for any of the selected outcomes. CONCLUSIONS: This systematic review does not support the use of the cervical dilatation over time (at a threshold of 1 cm/h during active first stage) to identify women at risk of adverse birth outcomes. TWEETABLE ABSTRACT: Alert line of partograph does not identify women at risk of adverse birth outcomes.

Update on uterine tachysystole.

Uterine tachysystole (TS) is a potentially significant intrapartum complication seen most commonly in induced or augmented labors but may also occur in women with spontaneous labor. When it occurs, maternal and perinatal complications can arise if not identified and managed promptly by obstetric care providers. Over recent years, new definitions of the condition have facilitated further research into the field, which has been synthesized to inform clinical management guidelines and protocols. We propose a set of recommendations pertaining to TS in line with contemporary evidence and obstetric practice.

Fetal seizure: A video recording and possible etiology.

Fetal seizure is rarely observed. Investigation of both video-recording of seizures and cardiotocography is crucial for a precise diagnosis. Here, we report a case of fetal seizure, and also show a video-ultrasound recording. A 40-year-old woman was admitted to us due to loss of variability in cardiotocography. Ultrasound repeatedly revealed opisthotonus-like and clonic-seizure-like movements. After the abnormal movement, tachycardia up to 210 bpm (postictal tachycardia) was noted. Ultrasound revealed a nuchal cord. A careful investigation of video-ultrasound recording by an epilepsy specialist led to the confirmation of epileptic seizures. At 364/7 , she vaginally gave birth to an infant with an umbilical artery pH of 7.22. The infant died 30 min after birth. No clear video-recordings associated with fetal seizure were available for cases reported so far in the literature. The video provided in this case may be of use for further analyses.

Is Prolonged Labor Managed Adequately in Rural Rwandan Hospitals?

Unnecessary interventions to manage prolonged labor may cause considerable maternal and perinatal ill-health. We explored how prolonged labor was managed in three rural Rwandan hospitals using a partograph. A retrospective chart review was done to assess whether (A) the action line on the partograph was reached or crossed, (B) artificial rupture of membranes (ARM) performed, (C) oxytocin augmentation instituted, and (D) vacuum extraction (VE) considered when in second stage of labor. Adequate management of prolonged labor was considered if three clinical criteria were fulfilled in the first and four in the second stage. Out of 7605 partographs, 299/7605 women (3.9%) were managed adequately and 1252/7605 women (16.5%) inadequately for prolonged labor. While 6054 women (79.6%) remained at the left of the alert line, still 1651/6054 (27.3%) received oxytocin augmentation unjustifiably. Amongst women whom were managed adequately for prolonged labor until their cervical dilatation plot reached or crossed the action line. In 115/299 women (38.5%), however, second stage of labor was reached but CS performed without a trial of VE. In 1252/7605 women (16.5%) management was inadequate, when their cervical dilatation plot reached between the alert and action lines, 495/1252 women (39.5%) did not reach the second stage of labor and remained left of the action line had their membranes ruptured and labor augmented, and gave birth by CS. CS was, however, also performed in 151/1252 women (12.1%) whose membranes were still intact. We recommend training for more appropriate decision-making during labor to prevent unnecessary CS and proper use of ARM, oxytocin augmentation and VE can be provided safely.

Cervical dilatation over time is a poor predictor of severe adverse birth outcomes: a diagnostic accuracy study.

OBJECTIVE: To assess the accuracy of the World Health Organization (WHO) partograph alert line and other candidate predictors in the identification of women at risk of developing severe adverse birth outcomes. DESIGN: A facility-based, multicentre, prospective cohort study. SETTING: Thirteen maternity hospitals located in Nigeria and Uganda. POPULATION: A total of 9995 women with spontaneous onset of labour presenting at cervical dilatation of ≤6 cm or undergoing induction of labour. METHODS: Research assistants collected data on sociodemographic, anthropometric, obstetric, and medical characteristics of study participants at hospital admission, multiple assessments during labour, and interventions during labour and childbirth. The alert line and action line, intrapartum monitoring parameters, and customised labour curves were assessed using sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, and the J statistic. OUTCOMES: Severe adverse birth outcomes. RESULTS: The rate of severe adverse birth outcomes was 2.2% (223 women with severe adverse birth outcomes), the rate of augmentation of labour was 35.1% (3506 women), and the caesarean section rate was 13.2% (1323 women). Forty-nine percent of women in labour crossed the alert line (4163/8489). All reference labour curves had a diagnostic odds ratio ranging from 1.29 to 1.60. The J statistic was less than 10% for all reference curves. CONCLUSIONS: Our findings suggest that labour is an extremely variable phenomenon, and the assessment of cervical dilatation over time is a poor predictor of severe adverse birth outcomes. The validity of a partograph alert line based on the 'one-centimetre per hour' rule should be re-evaluated. FUNDING: Bill & Melinda Gates Foundation, United States Agency for International Development (USAID), UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and WHO (A65879). TWEETABLE ABSTRACT: The alert line in check: results from a WHO study.

Effect of partograph use on outcomes for women in spontaneous labour at term and their babies.

BACKGROUND: The partograph (sometimes known as partogram) is usually a pre-printed paper form on which labour observations are recorded. The aim of the partograph is to provide a pictorial overview of labour, and to alert midwives and obstetricians to deviations in maternal or fetal well-being and labour progress. Charts have traditionally contained pre-printed alert and action lines. An alert line, which is based on the slowest 10% of primigravid women's labours, signifies slow progress. An action line is placed a number of hours after the alert line (usually two or four hours) to prompt effective management of slow progress of labour.This review is an update of a review last published in 2013. OBJECTIVES: The primary objective was to determine the effectiveness and safety of partograph use on perinatal and maternal morbidity and mortality. The secondary objective was to determine which partograph design is most effective for perinatal and maternal morbidity and mortality outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (31 August 2017), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised, cluster-randomised, and quasi-randomised controlled trials involving a comparison of partograph use with no partograph, or comparison between different partograph designs. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed eligibility, quality and extracted data. When one review author was also the trial author, the two remaining review authors assessed the studies independently. We assessed the evidence using the GRADE approach. MAIN RESULTS: We have included 11 studies, involving 9475 women in this review; three studies assessed partograph use versus no partograph, seven assessed different partograph designs, and one assessed partograph use versus labour scale. Risk of bias varied in all studies. It was infeasible to blind staff or women to the intervention. Two studies did not adequately conceal allocation. Loss to follow-up was low in all studies. We assessed the evidence for partograph use versus no partograph using the GRADE approach; downgrading decisions were due to study design, inconsistency, indirectness, and imprecision of effect estimates.Most trials reported caesarean section rates and Apgar scores less than 7 at five minutes; all other outcomes were not consistently reported (e.g. duration of first stage of labour and maternal experience of childbirth).Partograph versus no partograph (3 trials, 1813 women)It is uncertain whether there is any clear difference between partograph use and no partograph in caesarean section rates (average risk ratio (RR) 0.77, 95% confidence interval (CI) 0.40 to 1.46; n = 1813; 3 trials; I² = 87%; very low-quality evidence); oxytocin augmentation (RR 1.02, 95% CI 0.95 to 1.10; n = 1156; 1 trial; moderate-quality evidence); duration of first stage of labour (mean difference (MD) 0.80 hours, 95% CI -0.06 to 1.66; n = 1156; 1 trial; low-quality evidence); or Apgar score less than 7 at five minutes (RR 0.76, 95% CI 0.29 to 2.03; n = 1596; 2 trials; I² = 87%; very low-quality evidence).Partograph with different placement of action lines (4 trials, 5051 women)When compared to a four-hour action line, women in the two-hour action line group were more likely to receive oxytocin augmentation (average RR 2.44, 95% CI 1.36 to 4.35; n = 4749; 4 trials; I² = 96%). There was no clear difference in caesarean section rates (RR 1.06, 95% CI 0.88 to 1.28; n = 4749; 4 trials); duration of first stage of labour (RR 0.81 hours, 95% CI 0.32 to 2.04; n = 948; 1 trial); maternal experience of childbirth (average RR 0.61, 95% CI 0.28 to 1.35; n = 2269; 2 trials; I² = 83%); or Apgar score less than 7 at five minutes (RR 0.93, 95% CI 0.61 to 1.42; n = 4749; 4 trials) between the two- and four-hour action line.The following comparisons only include data from single studies. Fewer women reported negative childbirth experiences in the two-hour action line group compared to the three-hour action line group (RR 0.49, 95% CI 0.27 to 0.90; n = 348; 1 trial). When we compared the three- and four-hour action line groups, the caesarean section rate was higher in the three-hour action line group (RR 1.70, 95% CI 1.07 to 2.70; n = 613; 1 trial). We did not observe any clear differences in any of the other outcomes in these comparisons.Partograph with alert line only versus partograph with alert and action line (1 trial, 694 women)The caesarean section rate was lower in the alert line only group (RR 0.68, 95% CI 0.50 to 0.93). There were no clear differences between groups for oxytocin augmentation, low Apgar score, instrumental vaginal birth and perinatal death.Partograph with latent phase (composite) versus partograph without latent phase (modified) (1 trial, 743 women)The caesarean section and oxytocin augmentation rates were higher in the partograph with a latent phase (RR 2.45, 95% CI 1.72 to 3.50; and RR 2.18, 95% CI 1.67 to 2.83, respectively). There were no clear differences between groups for oxytocin augmentation, and Apgar score less than 7 at five minutes.Partograph with two-hour action line versus partograph with stepped dystocia line (1 trial, 99 women)Fewer women received oxytocin augmentation in the dystocia line group (RR 0.62, 95% CI 0.39 to 0.98). We did not observe any clear differences in any of the other primary outcomes in this comparison.Partograph versus labour scale (1 trial, 122 women)The use of the partograph compared with the labour scale resulted in fewer women receiving oxytocin augmentation (RR 0.32, 95% CI 0.18 to 0.54), but did not produce any clear differences for any of the other primary outcomes. AUTHORS' CONCLUSIONS: On the basis of the findings of this review, we cannot be certain of the effects of routine use of the partograph as part of standard labour management and care, or which design, if any, are most effective. Further trial evidence is required to establish the efficacy of partograph use per se and its optimum design.

Automated electrohysterographic detection of uterine contractions for monitoring of pregnancy: feasibility and prospects.

BACKGROUND: Preterm birth is a major public health problem in developed countries. In this context, we have conducted research into outpatient monitoring of uterine electrical activity in women at risk of preterm delivery. The objective of this preliminary study was to perform automated detection of uterine contractions (without human intervention or tocographic signal, TOCO) by processing the EHG recorded on the abdomen of pregnant women. The feasibility and accuracy of uterine contraction detection based on EHG processing were tested and compared to expert decision using external tocodynamometry (TOCO) . METHODS: The study protocol was approved by local Ethics Committees under numbers ID-RCB 2016-A00663-48 for France and VSN 02-0006-V2 for Iceland. Two populations of women were included (threatened preterm birth and labour) in order to test our system of recognition of the various types of uterine contractions. EHG signal acquisition was performed according to a standardized protocol to ensure optimal reproducibility of EHG recordings. A system of 18 Ag/AgCl surface electrodes was used by placing 16 recording electrodes between the woman's pubis and umbilicus according to a 4 × 4 matrix. TOCO was recorded simultaneously with EHG recording. EHG signals were analysed in real-time by calculation of the nonlinear correlation coefficient H2. A curve representing the number of correlated pairs of signals according to the value of H2 calculated between bipolar signals was then plotted. High values of H2 indicated the presence of an event that may correspond to a contraction. Two tests were performed after detection of an event (fusion and elimination of certain events) in order to increase the contraction detection rate. RESULTS: The EHG database contained 51 recordings from pregnant women, with a total of 501 contractions previously labelled by analysis of the corresponding tocographic recording. The percentage recognitions obtained by application of the method based on coefficient H2 was 100% with 782% of false alarms. Addition of fusion and elimination tests to the previously obtained detections allowed the false alarm rate to be divided by 8.5, while maintaining an excellent detection rate (96%). CONCLUSION: These preliminary results appear to be encouraging for monitoring of uterine contractions by algorithm-based automated detection to process the electrohysterographic signal (EHG). This compact recording system, based on the use of surface electrodes attached to the skin, appears to be particularly suitable for outpatient monitoring of uterine contractions, possibly at home, allowing telemonitoring of pregnancies. One of the advantages of EHG processing is that useful information concerning contraction efficiency can be extracted from this signal, which is not possible with the TOCO signal.

Labor estimation by informational objective assessment (LEIOA) for preterm delivery prediction.

PURPOSE: To introduce LEIOA, a new screening method to forecast which patients admitted to the hospital because of suspected threatened premature delivery will give birth in < 7 days, so that it can be used to assist in the prognosis and treatment jointly with other clinical tools. METHODS: From 2010 to 2013, 286 tocographies from women with gestational ages comprehended between 24 and 37 weeks were collected and studied. Then, we developed a new predictive model based on uterine contractions which combine the Generalized Hurst Exponent and the Approximate Entropy by logistic regression (LEIOA model). We compared it with a model using exclusively obstetric variables, and afterwards, we joined both to evaluate the gain. Finally, a cross validation was performed. RESULTS: The combination of LEIOA with the medical model resulted in an increase (in average) of predictive values of 12% with respect to the medical model alone, giving a sensitivity of 0.937, a specificity of 0.747, a positive predictive value of 0.907 and a negative predictive value of 0.819. Besides, adding LEIOA reduced the percentage of incorrectly classified cases by the medical model by almost 50%. CONCLUSIONS: Due to the significant increase in predictive parameters and the reduction of incorrectly classified cases when LEIOA was combined with the medical variables, we conclude that it could be a very useful tool to improve the estimation of the immediacy of preterm delivery.

Uterine electrical activity, oxytocin and labor: translating electrical into mechanical.

PURPOSE: Uterine activity plays a crucial role in labor, especially when utero-tonic materials are administered. We aimed to determine the electrical responsiveness of the uterine musculature to labor augmentation with oxytocin using electrical uterine myography (EUM) technology, and to assess whether the kinetics of the EUM device may serve as a predictor for successful vaginal delivery. METHODS: EUM prospectively measured electrical uterine activity in women with singleton gestations at term (≥ 37 + 0 weeks) undergoing labor augmentation by oxytocin administration. The results were reported as the EUM index, which represented the mean electrical activity in 10-min intervals and measured in units of microwatt per second (mW/s). Measurements were performed at least 30 min before oxytocin initiation and until at least four contractions per 10 min were recorded by standard tocodynamometry. The delta EUM index was defined as the difference between the mean EUM index before and after the initiation of oxytocin. RESULTS: The mean EUM index increased significantly during oxytocin augmentation in all the parturients (P < 0.001). Mean and minimum (but not maximum) uterine electrical activity during oxytocin infusion correlated with the baseline uterine activity. The delta EUM index was not significantly affected by demographic or obstetric parameters. There was no correlation between the delta EUM index and time to delivery or the mean EUM index during oxytocin administration and time to delivery. CONCLUSIONS: Uterine electrical activity as evaluated by EUM is significantly intensified following oxytocin administration, regardless of obstetrical characteristics, and is correlated with the baseline uterine electrical activity prior to oxytocin infusion.

Oxytocin Use in Labor: Legal Implications.

Oxytocin is one of the most commonly used medications in obstetrics and has been associated with claims of negligence in cases of adverse outcomes. Errors involving intravenous oxytocin administration for induction or augmentation of labor are most commonly dose related and include failure to avoid or treat tachysystole or failure to asses or treat a fetal heart rate pattern indicative of disruption in oxygenation. Clinicians should be knowledgeable regarding pharmacokinetics of oxytocin and the effect of uterine contractions on fetal oxygenation as well as safe titration of oxytocin to achieve the desired effect while minimizing harm.

Home uterine monitoring for detecting preterm labour.

BACKGROUND: To reduce the morbidity and mortality associated with preterm birth, home uterine activity monitoring aims for early detection of increased contraction frequency, and early intervention with tocolytic drugs to inhibit labour and prolong pregnancy. However, the effectiveness of such monitoring is disputed. OBJECTIVES: To determine whether home uterine activity monitoring is effective in improving the outcomes for women and their infants considered to be at high risk of preterm birth, when compared with care that does not include home uterine activity monitoring. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2016), CENTRAL (Cochrane Library 2016, Issue 5), MEDLINE (1966 to 28 June 2016), Embase (1974 to 28 June 2016), CINAHL (1982 to 28 June 2016), and scanned reference lists of retrieved studies. SELECTION CRITERIA: Randomised control trials of home uterine activity monitoring, with or without patient education programmes, for women at risk of preterm birth, compared with care that does not include home uterine activity monitoring. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and risks of bias, extracted data and checked them for accuracy. We did not attempt to contact authors to resolve queries. We assessed the evidence using the GRADE approach. MAIN RESULTS: There were 15 included studies (6008 enrolled participants); 13 studies contributed data. Women using home uterine monitoring were less likely to experience preterm birth at less than 34 weeks (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; three studies, 1596 women; fixed-effect analysis) (GRADE high). This difference was not evident when we carried out a sensitivity analysis, restricting the analysis to studies at low risk of bias based on study quality (RR 0.75, 95% CI 0.57 to 1.00; one study, 1292 women). There was no difference in the rate of perinatal mortality (RR 1.22, 95% CI 0.86 to 1.72; two studies, 2589 babies) (GRADE low).There was no difference in the number of preterm births at less than 37 weeks (average RR 0.85, CI 0.72 to 1.01; eight studies, 4834 women; random-effects, Tau2 = 0.03, I2 = 68%) (GRADE very low). Infants born to women using home uterine monitoring were less likely to be admitted to neonatal intensive care unit (average RR 0.77, 95% CI 0.62 to 0.96; five studies, 2367 babies; random-effects, Tau2 = 0.02, I2 = 32%) (GRADE moderate). This difference was not maintained when we restricted the analysis to studies at low risk of bias (RR 0.86, 95% CI 0.74 to 1.01; one study, 1292 babies). Women using home uterine monitoring made more unscheduled antenatal visits (mean difference (MD) 0.48, 95% CI 0.31 to 0.64; two studies, 1994 women) (GRADE moderate). Women using home uterine monitoring were also more likely to have prophylactic tocolytic drug therapy (average RR 1.21, 95% CI 1.01 to 1.45; seven studies, 4316 women; random-effects, Tau2 = 0.03, I2 = 62%), but this difference was no longer evident when we restricted the analysis to studies at low risk of bias (average RR 1.22, 95% CI 0.90 to 1.65; three studies, 3749 women; random-effects, Tau2 = 0.05, I2 = 76%) (GRADE low). The number of antenatal hospital admissions did not differ between home groups (RR 0.91, 95% CI 0.74 to 1.11; three studies, 1494 women (GRADE low)). We found no data on maternal anxiety or acceptability. AUTHORS' CONCLUSIONS: Home uterine monitoring may result in fewer admissions to a neonatal intensive care unit but in more unscheduled antenatal visits and tocolytic treatment; the level of evidence is generally low to moderate. Important group differences were not evident when we undertook sensitivity analysis using only trials at low risk of bias. There is no impact on maternal and perinatal outcomes such as perinatal mortality or incidence of preterm birth.