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Computer assisted cardiotocography holds a great promise in minimizing human errors thereby improving perinatal outcome. Despite exponential growth (Moore’s law) in computing power for decades, this promise remains unrealized. The systematic analyses of studies on computerized cardiotocography offer little guide to future. This analytical review presents a more qualitative discussion of available evidence as well as concepts regarding the development and acceptance of computerized cardiotocography. To begin with, a workable approach would be for computer algorithms to follow the most scientific visual cardiotocography interpretation frameworks incorporating multiple fetal heart rate parameters and uterine contractions. This ability could be studied and form the basis for regulation of computer algorithms. Addition of background risk factors would be another step. This may take form of familiar multi-tier systems or new alternative strategies like the fetal reserve index. “Machine learning” will remain challenging because of complex variability in fetal-maternal conditions, labor characteristics and clinical intervention changing the outcomes. Randomized controlled trials of adequate size may remain very rare. However, prospective and retrospective testing of computer algorithms with careful qualitative and comparative approach would help clinicians and hospital managers in their decisions. Singular parameters like the popular “deceleration area” and “deceleration capacity” have poor predictive value for fetal acidemia or hypoxic injury. Scientific pattern-recognition of important fetal heart rate parameters like decelerations seems crucial for visual as well as computerized cardiotocography. Success of computerized cardiotocography depends on team effort by the obstetricians with in-depth practical knowledge/experience and skilled artificial intelligence (AI) specialists. [ABSTRACT FROM AUTHOR]

Background: Commonly used methods of CTG classification do not reliably predict neonatal hypoxic-ischemic encephalopathy (HIE). Objective: To examine whether a relationship exists between the types of hypoxia as identified on the cardiotocograph using novel physiology-based CTG classification and patterns of injury on neonatal cerebral MRI and later neurodevelopmental outcomes. Study design: A retrospective study of term-born infants admitted to four neonatal units with HIE as part of a brain injury biomarkers study between January 2014 and December 2015. Intrapartum CTG traces were analyzed by two obstetricians trained in physiological CTG classification, blind to neonatal outcomes. Neonatal cerebral MR images were assessed independently by a neuroradiologist and an expert neonatologist. CTG traces were classified into types of hypoxia and allocated to groups; (1) chronic hypoxia or antepartum injury; (2) gradually evolving or subacute hypoxia; and (3) acute hypoxia. Results: Of 106 infants recruited to the study, records were available for 58 cases. Of these, CTGs were available for 37. All 37 had abnormal CTGs. Twenty-four infants, all of whom had received therapeutic hypothermia had cerebral MRI. Fourteen of the 24 (58%) infants had abnormal MRI. In group 1 (chronic hypoxia/antenatal injury), total brain injury was most predominant (4/6 infants). Group 2 (gradually evolving/subacute hypoxia) was associated with peripheral brain injury (5/5 infants). Group 3 (acute hypoxia) was associated with basal-ganglia thalamic injury pattern (3/3 infants). Later neurodevelopmental outcomes were available for 35 cases. Infants suspected to have a pre-labor injury on CTG (group 1) had a higher proportion of adverse neurodevelopmental outcomes (4/10, 40%) compared to groups 2 and 3 (4/25, 16%). Conclusion: Using this novel physiology-based CTG classification, we demonstrate an association between types of hypoxia observed on the CTG and MRI patterns of hypoxic brain injury. Infants with CTG trace suggestive of chronic hypoxia or other antenatal injuries were overrepresented in this cohort and were also more likely to have a poor neurodevelopmental outcome. [ABSTRACT FROM AUTHOR]

SUMMARY OF RECOMMENDATIONS 1. Oxytocin for induction or augmentation of labor should not be started when there is a previous scar on the body of the uterus (such as previous classical cesarean section, uterine perforation or myomectomy when uterine cavity is reached) or in any other condition where labor or vaginal delivery are contraindicated. (Moderate quality evidence +++-; Strong recommendation). 2. Oxytocin should not be started before at least 1 h has elapsed since amniotomy, 6 h since the use of dinoprostone (30 min if vaginal insert) and 4 h since the use of misoprostol (Low quality evidence ++- -; Moderate recommendation). 3. Cardiotocography (CTG) should be performed and a normal pattern without tachysystole should be documented for at least 30 min before oxytocin is used. Continuous CTG, with adequate monitoring of both fetal heart rate and uterine contractions, should be maintained for as long as oxytocin is used, and thereafter until delivery (Low ++- - to moderate +++- quality evidence; Strong recommendation). 4. For labor induction, at least 1-h should be allowed after amniotomy before oxytocin infusion is started, to evaluate whether adequate uterine contractility has meanwhile ensued. For augmentation of labor, if the membranes are intact and there are conditions for a safe amniotomy, the latter should be considered before oxytocin is started (Very low quality evidence +- --; Weak recommendation). 5. Oxytocin should be administered intravenously using the following regimen: 5 IU oxytocin diluted in 500 mL of 0.9% normal saline (NaCl) (each mL contains 10 mIU of oxytocin), in an infusion pump at increasing rates, as shown in Table 1, until a frequency of 3-4 contractions per 10 min is reached, a non-reassuring CTG pattern ensues, or maximum rates are reached (Low quality evidence ++ - -; Strong recommendation). If the frequency of contractions exceeds 5 in 10 min, the infusion rate should be reduced, even if a normal CTG pattern is present. With a non-reassuring CTG pattern, urgent clinical assessment by an obstetrician is indicated, and strong consideration should be given to reducing or stopping the oxytocin infusion. The minimal effective dose of oxytocin should always be used. (Low ++- - to Moderate +++- - quality evidence; Strong recommendation). [ABSTRACT FROM AUTHOR]

Objective: To explore the feasibility of conducting a randomized controlled trial (RCT) designed to compare the performance of digital fetal scalp stimulation (dFSS) and fetal blood sampling (FBS) as second-line tests of fetal wellbeing in Labor.Design: A feasibility study included 66 women who consented to both dFSS and FBS performed contemporaneously. A pilot randomized controlled trial included 50 women who were randomized to either dFSS or FBS.Setting: University-affiliated maternity hospital.Population: Women in Labor who required second-line testing of fetal well-being following abnormal fetal heart rate monitoring.Outcome Measures: The primary outcome of interest was delivery by emergency cesarean section. Secondary outcomes included maternal and perinatal morbidity outcomes and procedural factors.Results: Of the 66 women recruited to the feasibility study 50 (76%) received the two interventions as per protocol. The demographic data indicated that future RCT should be limited to nulliparous women. After initial training and reminders, the dFSS procedure appeared to be acceptable to patients and clinicians and was interpreted appropriately. Recruitment of eligible women to the pilot RCT was successful (88%) with 50 of 63 eligible women randomized (79%) and no drop-outs. The cesarean section rate was high in both arms as expected with a cohort of women requiring second-line tests for abnormal fetal heart rate monitoring in Labor (5/25; 20% dFSS versus 13/25; 52% FBS, p = .018). Conservative estimates suggest that a sample size of 2500 randomized women would be required for a definitive RCT.Conclusions: This study suggests that dFSS, which has the potential to be a reliable alternative to FBS, could be evaluated in a well-designed randomized controlled trial.Trial Registration: The definitive trial has been registered ISRCTN 13295826. [ABSTRACT FROM AUTHOR]

Objective: To assess the value of using computerized cardiotocography (cCTG) short-term variation (STV) for intrapartum monitoring in monochorionic twins (MC) complicated by selective intrauterine growth restriction (sIUGR).Material and Methods: All available cCTGs retrieved from computerized medical records of MC with sIUGR were retrospectively studied regarding the behavior of the STV. sIUGR was defined as intertwin estimated fetal weight (EFW) discordance of ≥20% with the abdominal circumference (AC) below the fifth percentile and/or the EFW of the smaller twin below the 10th percentile. The sIUGR classification system proposed by Gratacos et al. was used using types I-III on the basis of umbilical artery Doppler characteristics of the IUGR twin. The admission (entry) STV and final pre-delivery (last) STV values were analyzed. Cases with intrauterine demise, with structural or chromosomal abnormalities, with twin anemia polycythemia sequence (TAPS) and/or twin-to-twin transfusion syndrome (TTTS) were excluded.Results: During the study period, 64 consecutive cases were managed within our department. Thirty-two cases fulfilled the inclusion criteria for analysis. Mean gestational age at assessment and at delivery was 28.4 ± 2.7 and 31.5 ± 2.2 weeks, respectively. The entry STV and last STV before delivery were not statistically different (mean IUGR STV entry: 9.3 ± 3.4 ms versus last 8 ± 2.2 ms; p = .051; mean co-twin STV entry: 9.1 ± 2.8 ms versus last 9.2 ± 3 ms; p = .87). Neither was the sIUGR-type adjusted STV.Conclusions: In MC pregnancies complicated by sIUGR, the cCTG STV does not distinguish between fetuses, nor does it show differences in cases of fetal deterioration monitored by conventional CTG. [ABSTRACT FROM AUTHOR]

Background: The saltatory pattern (SP) has been defined by guidelines as a uniformly increased bandwidth of >25 beats per min lasting for 30 min. However, previous research suggest that it is very unusual to observe such a "uniform" increase in the bandwidth persisting for >30 min. Baseline fetal heart rate variability (FHRV) on cardiotocography reflects the integrity of the central nervous system. During labor, in the presence of a gradually-evolving hypoxia associated with the onset of metabolic acidosis, FHRV may be reduced. However, if a fetus is exposed to rapidly-evolving hypoxia, it may not have sufficient time to release catecholamines and the perfusion of central organs can be impaired. In such cases, simultaneous increased activity of the sympathetic nervous system to obtain more oxygen as well as enhanced parasympathetic activity to reduce the myocardial workload can lead to autonomic instability. This exaggerated autonomic response can be seen frequently on the cardiotocograph as a rapid, irregular, abrupt "up and down" fluctuation across the baseline (amplitude >25 beats per min). The authors have termed this pattern as "ZigZag" when apparent for a minimum of 1 min. It differs from the SP in terms of duration and uniformity of the bandwidth.Objective: To determine the incidence of the SP during labor as well as a shorter and less uniform version of the SP newly called "ZigZag pattern" (ZZP). The intention was to correlate them with perinatal outcomes, taking into account the duration of the ZZP.Study Design: A retrospective analysis of 500 consecutive cardiotocograph traces was performed to identify saltatory patterns and ZigZag patterns of 1 and 2 min of duration. Apgar scores, umbilical cord pH values and admission to the Neonatal Unit were evaluated and correlated with the cardiotocograph findings.Results: Not a single case of the SP was observed. A ZZP of 1 min of duration (ZZP1) was identified in 30.1% of the CTG during the last hour prior to delivery; ZZP lasting for 2 min (ZZP2) were identified in 8.9% of cases during the same period. Apgar scores at 1 min of ≤7 were significantly more frequent in newborns where the ZZP was observed (36.7% in ZZP1 and 54.5% in ZZP2 versus 9.5% in fetuses without); similarly, the Apgar scores at 5 min of ≤7 were also more frequent when ZZP was observed (6.7% in ZZP1 and 13.6% in ZZP2 versus 1.1% in controls). Moderate acidosis (pH 7.0-7.10) was more common in fetuses with the ZZP (14.3% in ZZP1 and 15% in ZZP2) compared to those without (4.6 and 7.2%, respectively). Similarly, mild acidosis (pH 7.1-7.2) was more common with the ZZP (40.3% in ZZP1 and 35% in ZZP2 versus 27.6 and 31.7%, respectively without ZZP). The neonatal admission rate was significantly higher in fetuses with the ZZP (8.7% in ZZP1 and 11.4% in ZZP2 versus 1.1% in controls).Conclusions: In line with previous research, our study suggest that SP is an almost nonexistent phenomenon. Alternatively, the ZigZag pattern (ZZP) has been defined as an exaggerated, irregular, "up and down" fluctuation of the baseline variability with an amplitude of >25 beats per min, lasting for 1 min or longer. It represents autonomic instability during human labor and it differs from the SP in terms of uniformity and length. Newborns with a ZZP during active maternal pushing were found to have statistically-significant lower Apgar scores at the 1st and 5th min, moderate and mild acidosis in the umbilical artery and an 8.7-11.4-fold higher neonatal admission rate. Clinicians should stop oxytocin infusion and/or active maternal pushing to improve fetal oxygenation if the ZZP is observed. [ABSTRACT FROM AUTHOR]

Objective: Fetal monitoring, ubiquitous in obstetrics is used to predict and prevent intrapartum fetal injury. Despite decades of education and nomenclature revision, clinicians show low agreement on key elements, including the types of deceleration and hence their presumed etiology. Cumulative deceleration area is not dependent on deceleration type and could potentially mitigate this problem. Although deceleration area has shown promise as a marker of acidemia, no reports have shown how deceleration area evolves in late labor. Advances in computerization allow for direct measurement of deceleration area and standard fetal heart rate (FHR) patterns. The objective of this study was to compare the evolution and discrimination performance of deceleration area and other FHR patterns in late labor in term neonates with metabolic acidemia (MA) and in those with normal cord gases.Methods: This retrospective cohort study included women with a term singleton (≥37 weeks) in cephalic presentation with cord gas data and FHR tracings available for analysis. MA included neonates with an umbilical artery base deficit >12 mmol/L (n = 132). Controls included those with normal cord gases (base deficit <8 mmol/L) and a 5-minute Apgar score of >6 (n = 1498). Deceleration area and other FHR patterns were summarized and compared in 30-minute segments over the last five hours. Receiver-operating characteristic curves were constructed and AUCs compared.Results: Deceleration area had the highest AUC (0.702, 95% CI 0.655-0.749) and was a superior marker of MA compared to baseline (AUC 0.588, 95% CI 0.530-0.645), baseline variability (AUC 0.611, 95% CI 0.558-0.663), and number of late decelerations (AUC 0.582, 95% CI 0.527-0.637).Conclusion: Cumulative deceleration area reduces the necessity to determine deceleration type. In a single number, it objectively quantifies three important aspects of decelerations; frequency, depth and duration and was a superior marker of MA compared to baseline level, baseline variability and number of late decelerations. The acidemia group had higher deceleration area over the last two hours prior to delivery. This result indicates that the cumulative area and persistence of repetitive decelerations is important clinically. [ABSTRACT FROM AUTHOR]

Objective: Electronic fetal monitoring/cardiotocography (EFM) is nearly ubiquitous, but almost everyone acknowledges there is room for improvement. We have contextualized monitoring by breaking it down into quantifiable components and adding to that, other factors that have not been formally used: i.e. the assessment of uterine contractions, and the presence of maternal, fetal, and obstetrical risk factors. We have created an algorithm, the Fetal Reserve Index (FRI) that significantly improves the detection of at-risk cases. We hypothesized that extending our approach of monitoring to include the immediate newborn period could help us better understand the physiology and pathophysiology of the decrease in fetal reserve during labor and the transition from fetal to neonatal homeostasis, thereby further honing the prediction of outcomes. Such improved and earlier understanding could then potentiate earlier, and more targeted use of neuroprotective attempts during labor treating decreased fetal reserve and improving the fetus' transition from fetal to neonatal life minimizing risk of neurologic injury.Study Design: We have analyzed a 45-year-old research database of closely monitored labors, deliveries, and an additional hour of continuous neonatal surveillance. We applied the FRI prenatally and created a new metric, the INCHON index that combines the last FRI with umbilical cord blood and 4-minute umbilical artery blood parameters to predict later neonatal acid/base balance. Using the last FRI scores, we created 3 neonatal groups. Umbilical cord and catheterized umbilical artery bloods at 4, 8, 16, 32, and 64 minutes were measured for base excess, pH, and PO2. Continuous neonatal heart rate was scored for rate, variability, and reactivity.Results: Neonates commonly do not make a smooth transition from fetal to postnatal physiology. Even in low risk babies, 85% exhibited worsening pH and base excess during the first 4 minutes; 34% of neonates reached levels considered at high risk for metabolic acidosis (≤-12 mmol/L) and neurologic injury. Neonatal heart rate commonly exhibited sustained, significant tachycardia with loss of reactivity and variability. One quarter of all cases would be considered Category III if part of the fetal tracing. Our developed metrics (FRI and INCHON) clearly discriminated and predicted low, medium, and high-risk neonatal physiology.Conclusions: The immediate neonatal period often imposes generally unrecognized risks for the newborn. INCHON improves identification of decreased fetal reserve and babies at risk, thereby permitting earlier intervention during labor (intrauterine resuscitation) or potentially postnatally (brain cooling) to prevent neurologic injury. We believe that perinatal management would be improved by routine, continuous neonatal monitoring - at least until heart rate reactivity is restored. FRI and INCHON can help identify problems much earlier and more accurately than currently and keep fetuses and babies in better metabolic shape. [ABSTRACT FROM AUTHOR]

Objective: To investigate the diagnosis, treatment, and maternal and fetal outcomes of placental abruption.Materials and Methods: We recruited 585 cases of placental abruption from the Women and Children's Hospital Affiliated to Xiamen University between January 2012 and December 2017. Cases were categorized into four groups (class 0-III) according to the clinical guidelines published by the Obstetrics and Gynecology Branch of the Chinese Medical Association. We then compared clinical data and auxiliary examinations across the four groups.Results: The differences were statistically significant (p < .01) among the four groups of placental abruption with regard to the incidence of an abnormal ultrasound finding. Positive ultrasound signs were evident in 6.4% of the patients categorized as class 0 and 100.0% of patients categorized as class III. Monitoring showed that fetal heart rate (FHR) was abnormal in class II patients with placental abruption; patients in class III showed no fetal heart sounds. Cesarean section was carried out for 26.6%, 75.1%, 65.2%, and 47.1% of patients in classes 0, I, II, and III, respectively. The rate of cesarean section for classes I and II was the highest, while the lowest rate occurred for class 0. Postpartum hemorrhage occurred in 2.5%, 9.3%, 15.2%, and 29.4% of patients across the four groups, DIC occurred in 0.0%, 1.3%, 2.3%, and 23.5% of cases, and perinatal death occurred in 1.0%, 1.3%, 7.6%, and 100.0% of cases, respectively. The highest incidence of postpartum hemorrhage was in class III (29.4%) and the lowest was in class 0 (2.5%). The highest incidence of DIC was in class III (23.5%) and the lowest was in class 0 (0.0%). The highest incidence of neonatal asphyxia was in class II (34.1%) and the lowest was in class 0 (10.1%). Regarding perinatal death, the highest incidence was in class III (100.0%) and the lowest was in class 0 (1.0%). These data showed significance differences when compared across the four groups of patients (p < .01).Conclusions: We recommend that the diagnosis of placental abruption should consider risk factors, clinical features, FHR monitoring, and dynamic ultrasound monitoring. Early diagnosis and treatment can improve maternal and infant prognosis. [ABSTRACT FROM AUTHOR]

Objective: To explore the clinical characteristics, treatment and prognosis of fetal intracranial hemorrhage in pregnancy and to improve the level of diagnosis and treatment. Methods: We retrospectively analyzed the clinical data of eight cases of fetal intracranial hemorrhage in our hospital from 2014 to 2017, including the clinical manifestations, etiology, imaging features, treatment and prognosis. Results: All the cases were diagnosed by prenatal color ultrasound or magnetic resonance imaging (MRI); one of the cases had decreased fetal movements and abnormal fetal heart rate monitoring, and the remaining seven cases had no special clinical symptoms. No clear cause was found in all the cases. Two patients with grade I fetal intracranial hemorrhage and 1 patient with grade II had a cesarean delivery, and no neurological sequelae were found in these neonates after 6months of follow-up. There was one patient with grade III and four patients with grade IV fetal intracranial hemorrhage; one of the patients with grade IV was stillborn at the time of the discovery, and cesarean section was selected due to scarring of the uterus; intraamniotic injection of ethacridine lactate was selected to induce labor in three cases, and vaginal delivery was selected; one of the patients with grade IV chose vaginal delivery, and the neonatal cranial brain magnetic resonance imaging after delivery showed no increase in intracranial lesions but showed incomplete development of the remaining nervous system. Conclusion: Fetal intracranial hemorrhage can be diagnosed by prenatal color ultrasound and MRI, yet it is often impossible to determine the cause. The prognosis of fetal intracranial hemorrhage is related to grade, and the prognosis of cerebral hemorrhage in patients with grades III-IV is poor. [ABSTRACT FROM AUTHOR]

Objective: The primary purpose of this study was to examine maternal and fetal responses to a typical, moderate-intensity yoga session in healthy pregnant women during the third trimester using continuous monitoring.Methods: This prospective observational study in low-risk, pregnant women used the Monica AN24 Abdominal ECG wireless maternal-fetal monitor to measure fetal heart rate, maternal heart rate, and uterine activity during a prenatal yoga session. Sessions included 4 time periods: (1) 20-minute rest, (2) 50 minutes standard prenatal yoga, (3) 10-minute meditation, (4) 20-minute recovery. Data were continuously recorded throughout the entire session, stored at 0.25-second intervals, and then averaged over 5-minute intervals. To evaluate changes over time, overall means for the four time periods (rest, yoga, meditation, recovery) were compared using one-way ANOVA with repeated measures. Post-hoc pairwise comparisons (Tukey's) were used to probe significant differences between the four time points. Statistical significance was reached at p < .05.Results: Twenty participants were enrolled; 19 completed the yoga session. Mean gestational age was 35 weeks and 6 days (range of 32-0/7 to 38-6/7) with an average participant age of 32 ± 2.7 years. Maternal heart rates significantly increased during the yoga period (102 ± 11 bpm) compared to rest (90 ± 10), meditation (85 ± 12), and recovery (88 ± 10) (p < .01). The maximum maternal heart rate reached during the yoga session was 125 ± 13 bpm. While fetal heart rates fluctuated slightly over the course of the yoga session, there were no significant fetal heart rate decelerations to suggest deleterious fetal effects. There were no statistically significant differences among resting (138 ± 14 bpm), yoga (137 ± 11 bpm), meditation (139 ± 7 bpm), or recovery (135 ± 22 bpm) fetal heart rates (p = .814). Uterine activity was significantly greater during the yoga period compared with the other time points (p < .001).Conclusion: Yoga can be recommended for low-risk women during pregnancy as no adverse fetal or maternal heart rate changes were observed during a typical prenatal yoga session. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to train midwifery students on electronic fetal monitoring (EFM) within the scope of the course and then to evaluate their pre- and post-course EFM knowledge and EFM interpreting skills.Methods: This interventional study was carried out at the Department of Midwifery, Faculty of Health Sciences. The study population comprised of the senior (last-year, 4th-year) students who attended the Midwifery Department of the Faculty of Health Sciences during the academic years 2015-2016 and 2016-2017. Of the 4th year students in the midwifery department, 42 who attended the school during the academic year 2015-16 and 61 who attended the school during the academic year 2016-2017 and accepted to participate in the study comprised the study sample.Results: The difference between the pre- and post-EFM course scores was statistically significant (p<.05). While the mean score obtained by the students before the EFM course was 55.29 ± 11.17, it was 76.15 ± 6.72 after the EFM course. Analysis of the success rates of the midwifery students in the EFM/NST course demonstrated that 80.6% of the students were successful.Conclusions: The findings of the study demonstrated that the participants' postcourse EFM knowledge and trace interpretation skills were better than their precourse EFM knowledge and trace interpretation skills. [ABSTRACT FROM AUTHOR]

Introduction: Fetal heart rate monitoring presents one of the few available methods for evaluating the fetus prior to birth. However, current devices on the market have significant shortcomings. We sought to describe the use and experiences with external fetal monitoring (EFM) devices among obstetrical providers.Materials and methods: We performed a cross-sectional survey in an academic medical center between April and July 2017 including nurse, midwife, and physician obstetrical providers (n = 217) who were invited to participate in this study regarding their experiences with the external fetal monitoring (EFM) device utilized by their hospital system in the outpatient, inpatient, and labor and delivery (L&D) settings. Associations between provider characteristics, device use, perception of challenging patients, and potential usefulness of an improved system were assessed by Fisher's exact test.Results: The 137 respondents (63.1%) reported difficulties monitoring obese women (98.5%), multiple gestation pregnancies (90.5%), and early gestational ages (71.5%). Over half (59.5%) of L&D nurses reported interacting with EFM devices for greater than 1-hour during a typical 12-hour shift and fewer than half (42.3%) reported being satisfied with current EFM devices. There were no statistically significant associations between provider age, experience, or time spent utilizing the devices with perception of challenging patient types.Conclusions: In conclusion, obstetrical providers perceive shortcomings of current EFM devices across all levels of provider experience and time utilizing these devices. Nurses reported significant time operating the devices, representing an opportunity to reduce time and costs with an improved device. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether intrapartum cardiotocography with computer analysis decreases the incidence of newborn metabolic acidosis or obstetric intervention when compared with visual analysis through a systematic review with meta-analysis of randomized controlled trials.Methods: The research was conducted using Medline, Embase, Web of Science, Scopus, ClinicalTrial.gov, Ovid and Cochrane Library as electronic databases from the inception of each database to May 2018. Selection criteria included randomized trial evaluating women with cephalic presentation at term or late preterm term during labor who were randomized to electronic fetal heart rate monitoring with either computer analysis (i.e. intervention group) or standard visual analysis (i.e. control group). Trials evaluating antenatal fetal heart rate monitoring in women not in labor were excluded. The primary outcome was incidence of newborn metabolic acidosis, defined as pH less than 7.05 and base deficit greater than 12 mmol/L. Secondary outcomes were mode of delivery, admission to neonatal intensive care unit, hypoxic-ischemic encephalopathy, and perinatal death. The summary measures were reported as relative risk (RR) with 95% confidence interval (CI).Results: Three randomized controlled trials (RCTs), including 54,492 participants, which met inclusion criteria for this meta-analysis, were analyzed. All the included trials enrolled women with cephalic presentation at term or late preterm. Women were randomized in the active first stage of labor and all of them received continuous cardiotocography (CTG) from randomization until delivery. Women who received continuous CTG during labor with computerized analysis had similar risk of newborn metabolic acidosis. No between group differences were found in the secondary outcomes.Conclusions: Compared with visual analysis, use of computer analysis of fetal monitoring signals during labor did not significantly reduce the rate of metabolic acidosis or obstetric intervention. [ABSTRACT FROM AUTHOR]

Objective: To investigate the association between fetal left ventricular modified myocardial performance index (LMPI) and intrahepatic cholestasis of pregnancy (ICP) and to evaluate the value of LMPI in predicting adverse perinatal outcomes in ICP.Study design: In a cross-sectional case-control study, 40 women with ICP were compared with 40 gestational age-matched healthy controls. The isovolumetric contraction time (ICT), isovolumetric relaxation time (IRT), and ejection time (ET) were measured using the Doppler signals of the opening and closing of the mitral and aortic valves. LMPI was calculated as (ICT + IRT)/ET. An adverse perinatal outcome was defined with at least one of the following: non-reassuring fetal heart rate tracing, umbilical cord pH <7.20, the presence of meconium in amnion, and neonatal intensive care unit (NICU) admission.Results: Mean gestational age at delivery and mean birth weight were significantly lower and the incidences of cesarean section rate, non-reassuring fetal heart rate tracing, the presence of meconium in amnion, and NICU admission were significantly higher in the ICP group (p < .01). Mean LMPI, ICT, and IRT values were significantly higher in the ICP group (p < .01). The area under the receiver operating characteristic (ROC) curve for LMPI in prediction of adverse perinatal outcome was 0.740 (95% CI: 0.607-0.873, p = .001) and a cut-off LMPI of 0.41 conferred a sensitivity of 85% and a specificity of 61%.Conclusions: There is an impaired global ventricular function in ICP fetuses demonstrated by increased LMPI. High LMPI is associated with adverse perinatal outcome in ICP. [ABSTRACT FROM AUTHOR]

Introduction: The intrapartum cardiotocography (CTG) classification system by FIGO in 2015 (FIGO2015) was introduced to simplify CTG interpretation, but it is not harmonized with the fetal ECG ST analysis (STAN) algorithm from 2007 (STAN2007), which is based on the FIGO CTG system from 1987. The study aimed to determine time courses and sensitivity between the systems in classifying CTG + ST events to indicate metabolic acidosis at birth.Material and methods: Forty-four cases with umbilical cord artery metabolic acidosis were retrieved from a European multicenter database. CTG patterns and timing of the first occurring significant ST events were evaluated post hoc in consensus by an expert panel and sensitivity statistics were performed. Wilcoxon's matched-pairs signed-ranks test and McNemar's test were used with a two-tailed p < .05 regarded significant.Results: STAN2007 had a higher sensitivity (73 versus 43%, p = .0002) and alarmed for metabolic acidosis in mean 34 min earlier than the FIGO2015 system did (p = .002). In every fourth case, the time difference was ≥20 min.Conclusions: In this simulation study, surveillance with STAN2007 combined with fetal ECG ST analysis had a significantly higher sensitivity and would have alarmed for metabolic acidosis significantly earlier than the new FIGO system would have. [ABSTRACT FROM AUTHOR]

Introduction: To examine interobserver agreement in intrapartum cardiotocography (CTG) classification in women undergoing trial of labor after a cesarean section (TOLAC) at term with or without complete uterine rupture. Materials and methods: Nineteen blinded and independent Danish obstetricians assessed CTG tracings from 47 women (174 individual pages) with a complete uterine rupture during TOLAC and 37 women (133 individual pages) with no uterine rupture during TOLAC. Individual pages with CTG tracings lasting at least 20 min were evaluated by three different assessors and counted as an individual case. The tracings were analyzed according to the modified version of the Federation of Gynaecology and Obstetrics (FIGO) guidelines elaborated for the use of STAN (ST-analysis). Occurrence of defined abnormalities was recorded and the tracings were classified as normal, suspicious, pathological, or preterminal. The interobserver agreement was evaluated using Fleiss' kappa. Results: Agreement on classification of a preterminal CTG was almost perfect. The interobserver agreement on normal, suspicious or pathological CTG was moderate to substantial. Regarding the presence of severe variable decelerations, the agreement was moderate. No statistical difference was found in the interobserver agreement between classification of tracings from women undergoing TOLAC with and without complete uterine rupture. Conclusions: The interobserver agreement on classification of CTG tracings from high-risk deliveries during TOLAC is best for assessment of a preterminal CTG and the poorest for the identification of severe variable decelerations. [ABSTRACT FROM AUTHOR]

Purpose: Analysis of the ST segment of the fetal electrocardiogram (ECG) waveform is a relatively new adjunct to support the cardiotocograph in assessing the risk of significant intrapartum fetal acidosis. The use of ST analysis (STAN) combined with cardiotocography (CTG) was reported to significantly lower the incidence of metabolic acidosis. We aimed to assess the role of "baseline T/QRS rise" associated with a normal CTG on the risk of neonatal acidemia.Study Design: This is a prospective cohort study performed at the Division of Perinatal Medicine of Policlinico Abano Terme, Italy. Women in labor with a singleton fetus in cephalic position beyond 36 weeks of gestation were monitored with STAN and CTG.Patients and Methods: The relationship between "baseline T/QRS rise" and neonatal cord arterial acidemia and hypoxic distress were assessed using a linear mixed-model analysis. Magnitude of "baseline T/QRS rise", neonatal cord blood acidemia, electrolytes, lactacidemia, and glycemia levels were measured.Results: "Baseline T/QRS rise" was not associated with neonatal acidemia in the presence of normal CTG, regardless of the magnitude of the T/QRS rise. However, in a linear mixed-model analysis, cord blood sodium levels were negatively (p = .033) associated with T/QRS ratio magnitude.Conclusions: In the presence of a normal CTG, "baseline T/QRS rise" does not predict neonatal acidemia or biochemical derangement. Greater knowledge of fetal ECG parameters including "baseline T/QRS rise" and their associations with normal, intermediary, and abnormal CTG tracing, is required in assessing the performance of the STAN. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to evaluate the associations of electronic fetal heart rate monitoring (EFM) patterns and adverse neonatal outcomes Study design: From 2013 to 2016; 12,067 term, singleton deliveries in labor ≥2 h with abnormal EFM defined as absent accelerations, variable, late or prolonged decelerations, tachycardia, bradycardia, or minimal variability were analyzed as any documentation during labor, in first hour and last hour of labor. Outcomes were composite neonatal adverse outcomes, neonatal intensive care unit (NICU) admission, neonatal hypoxia, neonatal hypoglycemia, umbilical artery pH, and base excess. Independent associations were ascertained using regression analysis. Results: Significant independent associations occurred between any abnormal EFM during the last hour and five adverse neonatal outcomes; between abnormal EFM at any time and one adverse neonatal outcome while there was none with the first hour of labor. In the last hour, accelerations had significant negative associations with three adverse neonatal outcomes, while prolonged decelerations, late decelerations, tachycardia, and bradycardia had significant positive associations with three adverse neonatal outcomes. Throughout labor, increasing accelerations events were significantly negatively correlated with all adverse neonatal outcomes, while increasing frequency of late, variable, and prolonged decelerations were positively associated with five adverse neonatal outcomes. Hierarchical analysis showed that bradycardia/tachycardia contributed only 0.8%, while all EFM periodic changes contributed 1%; the addition of the frequencies of abnormal EFM events contributed 0.6% to the variance in umbilical artery pH and base excess. Conclusions: Terminal EFM patterns are independently associated with neonatal outcomes. Accelerations are protective of adverse neonatal outcomes. Increasing frequency of EFM patterns overtime contributes to neonatal outcome. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to evaluate the associations of electronic fetal heart rate monitoring (EFM) patterns and adverse neonatal outcomes Study design: From 2013 to 2016; 12,067 term, singleton deliveries in labor ≥2 h with abnormal EFM defined as absent accelerations, variable, late or prolonged decelerations, tachycardia, bradycardia, or minimal variability were analyzed as any documentation during labor, in first hour and last hour of labor. Outcomes were composite neonatal adverse outcomes, neonatal intensive care unit (NICU) admission, neonatal hypoxia, neonatal hypoglycemia, umbilical artery pH, and base excess. Independent associations were ascertained using regression analysis. Results: Significant independent associations occurred between any abnormal EFM during the last hour and five adverse neonatal outcomes; between abnormal EFM at any time and one adverse neonatal outcome while there was none with the first hour of labor. In the last hour, accelerations had significant negative associations with three adverse neonatal outcomes, while prolonged decelerations, late decelerations, tachycardia, and bradycardia had significant positive associations with three adverse neonatal outcomes. Throughout labor, increasing accelerations events were significantly negatively correlated with all adverse neonatal outcomes, while increasing frequency of late, variable, and prolonged decelerations were positively associated with five adverse neonatal outcomes. Hierarchical analysis showed that bradycardia/tachycardia contributed only 0.8%, while all EFM periodic changes contributed 1%; the addition of the frequencies of abnormal EFM events contributed 0.6% to the variance in umbilical artery pH and base excess. Conclusions: Terminal EFM patterns are independently associated with neonatal outcomes. Accelerations are protective of adverse neonatal outcomes. Increasing frequency of EFM patterns overtime contributes to neonatal outcome. [ABSTRACT FROM AUTHOR]

Objective: To our knowledge, this is the largest prospective study reporting on maternal heart rate (MHR) levels in laboring women (30 patients), and maternal tachycardia that is a potential risk factor in fetal monitoring confusion. Our objective was to analyze a large population of contiguous laboring patients and to assess the MHR levels attained during the second stage.Methods: We performed a prospective study that analyzed MHR levels of second-stage laboring patients evaluating numerous predisposing maternal conditions. Univariate and stepwise multivariate logistic regression analysis were performed.Results: A total of 1105 contiguous patients were analyzed and 33.9% had a sustained MHR ≥100; 18.8% had an MHR ≥110; and 9.1% had an MHR ≥120. Multivariate analysis of all potential predisposing maternal conditions did not reveal any specific variable as uniformly significant for predicting maternal tachycardia across all levels of analysis.Conclusions: The incidence of maternal tachycardia in the second stage of labor is common. We recommend that if the MHR is ≥100 during labor, the simultaneous maternal and fetal heart rate (FHR) monitoring will be used to minimize the potential for fetal monitoring confusion and risking poor fetal outcome if the fetus is in distress. [ABSTRACT FROM AUTHOR]

Introduction: Instrumental vaginal delivery (IVD) helps expedite delivery during second stage of labour so as to avoid a second stage caesarean section. However, due to mechanical effects on the fetal head, vacuum and forceps may cause cardiotocograph (CTG) abnormalities due to vigal stimulation as well as increased intracranial pressure.Objective: To determine the features observed on the CTG during IVD in term pregnancy and correlate them to perinatal outcomes.Methods: A retrospective analysis of 445 cases who had vacuum deliveries (227) and forceps deliveries (218) at St. George's University Hospitals NHS Foundation Trust during a 12-month period was performed. CTG features were analysed at 10 minutes prior to and immediately after applications of the chosen instrument till delivery. Specific abnormalities were correlated to Apgar score and umbilical blood pH.Results: Specific CTG abnormalities after applications of vacuum and forceps were: tachycardia (99 (43.61%) versus 88 (40.37%)), increased baseline fetal heart rate (FHR) [14 (6.17%) versus 4 (1.83%) p = .0204], baro-receptor-mediated "variable" deceleration (101 (44.49%) versus 85 (38.99%)), chemoreceptor-mediated "late" deceleration (62 (27.31%) versus 76 (34.86%)), prolonged deceleration (32 (14.10%) versus 24 (11.01%)), saltatory pattern [35 (15.42%) versus 76 (34.86%) p < .0001], and reduced baseline variability (10 (4.41%) versus 7 (3.21%)). There were no significant differences in the mean Apgar Scores at 1 and 5 minutes between ventouse and forceps delivery (8 and 9, respectively) or the umbilical blood pH (both >7.20).Conclusions: After application of instruments, 90% of CTG traces showed abnormal features. Tachycardia, baro- and chemoreceptor-mediated decelerations, and saltatory patterns were the most common abnormalities. Increased baseline FHR during vacuum as compared to forceps delivery was possibly secondary to pain/pressure and resultant sympathetic overactivity. The saltatory pattern was more common in forceps deliveries, possibly secondary to increased intracranial pressure and resultant autonomic instability. Despite these CTG abnormalities, the perinatal outcomes were good. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to assess retrospectively the predictive value of fetal scalp pH and base excess (BE) for fetal acidosis and poor neonatal outcome in term, low-risk, spontaneous deliveries with suspicious or pathological intrapartum cardiotocography (CTG) tracings.Methods: Umbilical artery pH and BE values obtained immediately after delivery and Apgar score were the outcomes under consideration. Statistics included receiver-operating characteristic curve (ROC) and multiple logistic regression analysis.Results: Four hundred and six deliveries were included in the study. Scalp pH < 7.20 predicted umbilical pH ≤7.1 with 64.3% sensitivity and 92.9% specificity (p < .001). The corresponding positive-predictive value (PPV) was 24.3% and the negative-predictive value (NPV) was 98.6%. Scalp BE ≤ -7 mmol/l (a cut-off value provided by ROC curve analysis) predicted Apgar score ≤ 7 at 5 min with 61.9% sensitivity and 91.7% specificity (p < .001). The corresponding PPV and NPV were 29.5 and 97.7%, respectively. Neither scalp pH nor BE was significantly associated with umbilical BE values. Infants with intrapartum BE ≤ -7 mmol/l were 30 times on an average more likely to get a low Apgar score, independently of intrapartum pH values.Conclusion: Our study supports the consideration of both scalp pH and BE values, when fetal blood sampling (FBS) is used. [ABSTRACT FROM AUTHOR]

Purpose: To identify obstetric risk factors of delivering a neonate with poor neonatal adaptation at birth.Material and Methods: Nested case-control study. Poor neonatal adaptation was defined for presence of at least: umbilical cord artery pH <7.10, base deficit ≥12 mmol/L, Apgar score at 1' ≤5. Controls were selected from the same population and matched with cases. The association between clinical parameters and poor neonatal adaptation was analyzed by logistic regression.Results: One hundred and thirty three women (2.1% of all live births) with a neonate presenting a poor neonatal adaptation were matched with 133 subsequent controls. Significant contributions for the prediction of poor neonatal adaptation were provided by maternal age ≥35 years (p ≤ .001, odds ratio (OR) 3.9 [95%CI: 2.3-6.8]), nulliparity (p ≤ .001, OR 3.3 [95%CI: 1.8-6]), complications during pregnancy (p = .032, OR 2.2 [95%CI: 1.1-4.4]), gestational age at delivery <37 weeks (p = .008, OR 5.2 [95%CI: 1.5-17.8]) and cardiotocography category II or III (p ≤ .001, OR 36.3 [95%CI: 16.5-80.1]). The receiver operative characteristic curve was 0.91 [95%CI: 0.87-0.95], and detection rates 82.7% and 89.5% at 10% and 20% of false positive rates, respectively.Conclusions: Several obstetric risk factors before and during labor can identify a subgroup of newborns at higher risk of a poor neonatal adaptation at birth. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the performance of fetal scalp stimulation (FSS) compared to fetal blood sampling (FBS) as a second line test of fetal wellbeing in labor.Study Design: A prospective cohort study was conducted including 298 fetal blood sampling procedures performed due to abnormal fetal cardiotocography (CTG). Two independent observers interpreted the CTG following stimulation. The FSS test was classified as normal when an elicited acceleration and/or provoked fetal heart rate variability was recorded. The FBS was classified as normal (pH ≥7.25), borderline (pH 7.21-7.24), and abnormal (pH ≤7.20).Results: Of the 298 procedures, 249 (84%) had a normal scalp pH result, 199 (67%) had an acceleration in response to FSS and 255 (86%) had an acceleration or normal variability in response to FSS. All 11 of the neonates classified as normal by FSS, but abnormal by FBS were born with normal Apgar scores and cord pH results. The consistency between FSS and FBS was "fair" (kappa 0.28) while the consistency between either test and cord arterial pH was "poor".Conclusions: This study suggests that FSS has the potential to be a reliable alternative to FBS. The findings require evaluation in a well-designed randomized controlled trial. [ABSTRACT FROM AUTHOR]

Objective: Explore the effect of the multifunctional airbag abdominal pressure belt on midwifery and on the prevention of postpartum hemorrhage.Methods: Select 363 natural delivery cases of hospitalized primiparae and divide them randomly into two groups. In the observation group, 182 primiparae used the multifunctional airbag abdominal pressure belt during the second and third stages of labor, whereas the control group of 181 did not use the belt. Delivery outcomes of the primiparae and their fetus were then observed.Results: The average duration for the second stage of labor, from head emergence to delivery, placenta delivery and postpartum hemorrhage were all shorter in the observation group (p < 0.01). There was no statistical difference in episiotomy rate, maternal signs 2 h postpartum, neonatal Apgar score and neonatal cord blood gas analysis (p > 0.05). No statistical difference was found in primipara signs and no fetal heart rate change of the primiparae under different internal pressures of the belt during the second stage of labor in the observation group (p > 0.05).Conclusion: By closely monitoring and appropriately adjusting the internal pressure of the belt, the multifunctional airbag abdominal pressure belt can speed up the second and third stages of labor, prevent postpartum hemorrhage and promote natural delivery. [ABSTRACT FROM AUTHOR]

Cardiotocograph (CTG) is associated with a high false positive rate of up to 60% which may increase the risk of unnecessary intrapartum interventions (emergency caesarean sections or operative vaginal deliveries) without any significant benefits. A recent study on variation of caesarean section rates in England has concluded that there was a very wide variation even in the adjusted rates of caesarean section from 14.9% to 32.1%. Cochrane Systematic Reviews have concluded that the use of FBS does not reduce caesarean section rate or any pre-specified neonatal outcomes. Fetal ECG (ST-Analyser or STAN) has been used in the clinical practice for more than 20 years. Although, initial randomised controlled trials (RCTs) showed great promise regarding the role of STAN in reducing operative delivery rates (instrumental vaginal births and emergency caesarean sections) and neonatal metabolic acidosis, subsequent studies have questioned the role of STAN in clinical practice. A recent meta-analysis which included six randomised controlled trials (a total of 26,446 women) has concluded that there was a 36% reduction in the rate of neonatal metabolic acidosis. Practising clinicians currently face a dilemma as to whether STAN has a place in contemporary obstetric practice or whether it?s use should be discouraged and discontinued. [ABSTRACT FROM PUBLISHER]

Purpose: To evaluate the effectiveness of three different first trimester screening models for trisomies 21, 18 and 13, in terms of detection rate, invasive test rate and final costs.Material and Methods: We analyzed the distribution of risk for trisomies 21, 18 and 13 in a population of 20,831 singleton pregnancies based on maternal age, fetal heart rate, nuchal translucency, free beta human chorionic gonadotropin and pregnancy-associated plasma protein A (Combined test). On the basis of our data, we estimated the performance and cost of screening for trisomies using three different models at specific cutoffs: Combined test; Cell free DNA test and Contingent screening test.Results: Using Combined test, DR for major trisomies was estimated to be 94.92%, invasive test rate was 6.3%. cfDNA would result in a DR of 97.92%, with an invasive test rate of 3.64%. Contingent screening approach would result in an overall DR of 97.82, with a rate for invasive procedure of 1.36% and a final cost lower than other screening policies (2,338,433 euro vs 5,796,060 of cfDNA and 2,385,473 of Combined test).Conclusions: Contingent screening test could be a cost-efficient and feasible first trimester screening test for aneuploidies in public health system. [ABSTRACT FROM AUTHOR]

Purpose: To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates.Study Design: Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H2O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively.Results: There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS.Conclusion: The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted. [ABSTRACT FROM AUTHOR]

Aims: To compare the predictive ability for neonatal acidemia of individual components of intrapartum cardiotocography (CTG) described by National Institute of Child Health and Human Development (NICHD) system and deceleration area.Design: Case-control study.Setting: Spanish tertiary obstetrical hospital.Population: CTG patterns of 102 acidemic fetus (umbilical arterial cord gas pH ≤7.10, base deficit (BD) > 8) and 102 nonacidemic controls (umbilical arterial cord gas pH > 7.10).Methods: Two reviewers blind to clinical and outcome data analyzed the last thirty minutes before delivery of 204 fetal heart rate (FHR) tracings, extracting those features defined by NICHD and certain measures of FHR decelerations, including deceleration area, not considered by this system.Outcome Measures: The primary outcome was the predictive ability of NICHD features and non-NICHD deceleration measures for fetal acidemia. The secondary outcome was the impact of deceleration area in the last 30 min of labor on gasometry components (pH, BD and lactate).Results: Minimal variability (area under the curve (AUC) 0.74), total number of late (AUC: 0.75) and prolonged decelerations (0.77) were the three NICHD features with the greatest predictive ability for fetal acidemia in the last thirty minutes of labor. Total deceleration area demonstrated the highest discrimination power (AUC: 0.83) of all the analyzed elements. For each cm2 the area increases in the last 30 min of labor, pH decreases 0.08 units, BD increases 0.272 mEq/L and lactate 0.183 mEq/L.Conclusions: Total deceleration area showed the greatest predictive ability for fetal acidemia and its measure could help to estimate intrapartum fetal acid-base status. [ABSTRACT FROM AUTHOR]

Objective: The assessment of cardiac parameters of the fetus in cardiotocographic record of pregnant women listening to classical music. Study design: Sixty NST records with no musical stimulation and 30 NST records during a 15-min auditive stimulation with Wolfgang Amadeus Mozart's “Turkish March” as well as 30 NST records during Johann Strauss's “Tritsch-Tratsch Polka” were performed for the study. The average stage of the responders' pregnancy was the 36rd week, the lowest – the 27th week, the highest – 41st. Results: Following the listening to W.A. Mozart's composition, a significant increase was observed in values concerning: the number of fetal movements (p < 0.0001), accelerations >10 (p = 0.0063), accelerations >15 (p = 0.0011), high variability (p = 0.0019) and short-term variability (p < 0.0001). Meanwhile, parameters concerning baseline cardiac activity (p = 0.0003) and low variability (p = 0.0021) significantly decreased. The number of uterine contractions decreased insignificantly (p = 0.3718). Following listening to J. Strauss's composition, the following parameters underwent increase: fetal movements (p = 0.0021) and short-term variability (p = 0.0025). The remaining parameters of the cardiotocographic record: accelerations, uterine contractions – underwent an improvement, but the changes were not significant. Conclusion: Music therapy is a noninvasive and uncostly method, significantly improving wellbeing-indicative fetal parameters. [ABSTRACT FROM PUBLISHER]

Of metabolic acidemia. The core findings of this study are that the "deceleration area" had statistically significant correlation with fetal acidemia (BD > 12 mmol/L) and the discrimination power of its AUC was the best [[1]]. Furukawa et al. [[1]] do rightly conclude that a single FHR parameter (even the deceleration area) cannot reliably predict acidemia. [Extracted from the article]

Objective: To compare intrapartum cardiotocography (CTG) analysis in case of first caesarean section (CS) for non-reassuring CTG according to international guidelines.Methods: Four ObGyns retrospectively analysed first CS for non-reassuring CTG during labour blind to neonatal outcome. CTG were analysed according to French National College of Obstetricians and Gynaecologists (CNGOF) and to the FIGO guidelines. First, CTG analysis was done without obstetrical context, then secondly, it was given. ObGyns stated if CS was justified or not. Inter-operator ObGyn agreement was analysed.Results: Among 587 CS, 100 women met the inclusion criteria with a first CS for non-reassuring CTG. The overall inter observer agreement was low but fair. ObGyns were significantly more concordant using the FIGO than the CNGOF guidelines (kappa coefficient = 0.331 [0.27-0.39] versus 0.209 [0.16-0.26] p < 0.001). Without obstetrical context 70% of CS were considered as unjustified. This rate decreased to 16% with the knowledge of the obstetrical context and the use of a classification (p < 0.001). Two-third of the unjustified CS were carried out during night hours (p = 0.026).Conclusion: The FIGO guidelines are more reproducible than CNGOF guidelines. The overall inter-observer agreement was low but fair. The guideline choice could have an impact on first CS decision. [ABSTRACT FROM AUTHOR]

Objective: Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure.Methods: Retrospective cohort study over a 13-year period (2000-2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal-Wallis test was used and statistical significance was set at p < 0.05.Results: There were no significant differences in late decelerations (p = 0.2) between cases and controls. Significantly fewer variable decelerations (p = 0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p = 0.02) were noted during HD compared to controls.Conclusion: There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting. [ABSTRACT FROM AUTHOR]

Intrapartum cardiotocography (CTG) has a high false-positive rate. This has contributed to the rapid increase in obstetric interventions without a strong improvement in perinatal outcomes. We explore the role of ST analysis (STAN®) as an adjunct to CTG in identifying fetal asphyxia during labor. We conclude that STAN® reduces the rate of fetal blood sampling and instrumental vaginal deliveries, and has the potential to reduce the number of Australian operative interventions without compromising neonatal outcome. [ABSTRACT FROM PUBLISHER]

Objectives: To describe the antenatal fetal heart rate (FHR) parameters analyzed by computerizedcardiotocography (cCTG) in fetuses with gastroschisis and compare the FHR parameters with ultrasound gastrointestinal markers.Methods: A retrospective analysis of antepartum cCTG records were conducted in 87 pregnant cases with fetal gastroschisis between 28and 36 weeks (plus 6 days). A comparative analysis of the median distribution of the following FHR parameters was performed: basal FHR, short-term variation (STV), FHR accelerations and decelerations, episodes of high and low variations, and variations in low and high episodes. FHR parameters and ultrasound gastrointestinal markers were also compared.Results: The majority of FHR parameters did not present significant changes throughout gestation. An increased number of records with episodes of low variation (p = 0.019) and an increased number of accelerations >15 bpm (p = 0.001) were the only observed changes throughout gestation. Stomach herniation was significantly associated with a lower STV (p = 0.018) and a higher frequency of records with low episodes (p = 0.049).Conclusions: The cCTG analysis indicated that the FHR parameters in fetuses with gastroschisis presented different patterns from those observed in normal fetuses. Stomach herniation was associated with altered FHR patterns. [ABSTRACT FROM AUTHOR]

Objective: To evaluate autonomic modulation of heart rate in pregnant women treated with oxytocin to induce labor and with atosiban (an oxytocin antagonist) to arrest preterm labor.Methods: A prospective study with two cohorts: 14 pregnant women treated with atosiban for premature uterine contractions, and 28 women undergoing induction of labor with oxytocin. Computerized analyses of the electrocardiogram were performed with spectral and nonlinear dynamic analyses.Results: Atosiban did not alter any of the variables associated with heart rate variability, whereas oxytocin showed a dose-dependent decrease in heart rate (p < 0.05) and a significant increase in all spectral variables studied (p < 0.01).Conclusions: Atosiban has no adverse effects on the cardiovascular system or the modulation of heart rate. Oxytocin, on the other hand, can cause a dose-dependent bradycardic effect and an increase in the spectral power, thus should be used with caution in certain pregnant women. [ABSTRACT FROM AUTHOR]

Objective: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2.Materials and Methods: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders.Results: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis.Conclusion: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2. [ABSTRACT FROM AUTHOR]

Objective: To estimate the association between atypical variable decelerations and neonatal acidemia. Method: We conducted a one-year case-control study comparing the last thirty minutes before delivery of fetal heart rate tracings of 102 acidemic neonates (umbilical arterial cord gas pH ≤ 7.10) with 100 non-acidemic controls (umbilical arterial cord gas pH > 7.10). Incidence of atypical features and total number of decelerations, number of atypical decelerations, number of slow return decelerations and number of decelerations with loss of moderate variability during deceleration were extracted. We estimated the association between atypical features, neonatal acidemia and neonatal morbidity. Results: Acidemic neonates showed a larger number of atypical decelerations (4 [0-12] vs. 3 [0-10]), “slow return” decelerations (4 [0-11] vs. 1 [0-10]) and decelerations with non-moderate variability (0[0-12] vs. 0 [0-6]) compared to non-acidemic controls. “Slow return” was significantly associated with an increased risk of acidemia at birth (OR 4.46; CI 95%: 2.18 – 9.15) “Slow return” was the most discriminating feature between groups with an AUC: 0.745. Conclusion: Certain atypical features, as “slow return” and loss of moderate variability within decelerations are associated with neonatal acidemia. “Slow return” could help in the gradation of acidemia risk levels, as an indicator of gravity. [ABSTRACT FROM AUTHOR]

Objective: To investigate fetal gender and its influences on neonatal outcomes, taking into consideration the available tools for the assessment of fetal well-being. Methods: We conducted a retrospective study comparing maternal, fetal and neonatal outcomes according to fetal gender, in women carrying a singleton gestation. A multivariate analysis was performed for the prediction of adverse neonatal outcomes according to fetal gender, after adjustment for gestational age, maternal age and fetal weight. Results: A total of 682 pregnancies were included in the study, of them 56% (n = 383) were carrying a male fetus and 44% (n = 299) a females fetus. Male gender was associated with a significant higher rate of abnormal fetal heart tracing patterns during the first (67.7% versus 55.1,p = 0.001) and the second stage (77.6 versus 67.7,p = 0.01) of labor. Male gender was also significantly associated with lower Apgar scores at 1' (19.1% versus 10.7%,p < 0.01), as well as lower pH values (7.18 ± 0.15 versus 7.23 ± 0.18,p < 0.001), and significant differences in cord blood components (PCO2, PO2) compared with female fetuses. In the multivariate analysis, male gender was found to be significantly associated with first (OR 1.76, 95% CI 1.28–2.43,p = 0.001) and second stage (OR 1.73, 95% CI 1.20–2.50,p < 0.01) pathological fetal heart tracing patterns, pH < 7.1, and for Apgar scores at 1'< 7. Conclusions: The present study confirms the general trend of a lower clinical performance of male neonates compared with females. In addition, the relation between fetal heart rate patterns during all stages of labor and fetal gender showed an independent association between male fetal gender and abnormal fetal heart monitoring during labor. [ABSTRACT FROM AUTHOR]

Objective: We sought to characterise the influence of an antenatal exercise programme on ECG-derived cardiac variables.Methods: Fifity-one healthy pregnant women were recruited and randomly assigned (2 × 2×2 design) to an exercise group or a control group. Exercising groups attended weekly classes from the 20th week of pregnancy onwards. Cardiovascular assessments (heart rate variabiliy (HRV), QT, and the QT variability index (QTVI)) were performed at 12-16, 26-28, 34-36 weeks and 12 weeks following birth, during supine rest and exercise conditions.Results: Advancing gestation was associated with an increased maternal heart rate (p = 0.001), shorter QT interval (p = 0.003), diminished HRV (p = 0.002) and increased QTVI (p = 0.002). Each of these changes was reversed within 12 weeks postpartum (p < 0.004). The Exercise group displayed exaggerated changes for all variables (except QT) but only during supine rest in the third trimester (p < 0.029).Conclusion: Advancing gestation is associated with a shift in HRV/QTVI towards values that have been associated with an elevated risk of arrhythmia. A 20-week exercise programme undertaken between mid and late pregnancy exaggerated these changes during rest in the third trimester of pregnancy. [ABSTRACT FROM AUTHOR]

SisPorto 4.0 is the most recent version of a program for the computer analysis of cardiotocographic (CTG) signals and ST events, which has been adapted to the 2015 International Federation of Gynaecology and Obstetrics (FIGO) guidelines for intrapartum foetal monitoring. This paper provides a detailed description of the analysis performed by the system, including the signal-processing algorithms involved in identification of basic CTG features and the resulting real-time alerts. [ABSTRACT FROM PUBLISHER]

Objective: To evaluate the association of short-term variation (STV) of the fetal heart rate in predicting fetal acidaemia at birth. Methods: The search strategy employed searching of electronic databases (MEDLINE, Web of Science, Scopus, and Google Scholar) and reference lists of relevant studies. Data were extracted from studies, adhering strictly to the following criteria: singleton pregnancy at ≥24 weeks’ gestation, computerized CTG (index test) and calculation of STV before delivery. The outcome measure was arterial pH assessed in cord blood obtained at birth. Results: Meta-analysis showed moderate accuracy of STV in predicting fetal acidaemia with a sensitivity of 0.57 (95% CI: 0.45–0.68), specificity of 0.81 (95% CI: 0.69–0.89), positive likelihood ratio of 3.14 (95% CI: 2.13–4.63) and negative likelihood ratio of 0.58, (95% CI: 0.46–0.72). However, in intra-uterine growth restricted fetuses, a small improvement in detecting acidaemia was observed; with a sensitivity of 0.63 (95% CI: 0.49–0.75) and negative likelihood ratio of 0.50 (95% CI: 0.31–0.80). Conclusion: STV appears to be a moderate predictor for fetal acidaemia. However, its usefulness as a stand-alone test in predicting acidaemia in clinical setting remains to be determined. [ABSTRACT FROM PUBLISHER]

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

Objective:To establish reference values for the volumes of foetal heart atrial wall by three-dimensional (3D) ultrasound using spatio-temporal image correlation (STIC) and virtual organ computer-aided analysis (VOCAL) methods. Methods:We performed a retrospective cross-sectional study with 170 normal singleton pregnancies between 20 weeks + 0 days (20w0d) and 33 weeks + 6 days (33w6d) of gestation. Foetal heart atrial wall volume was obtained by VOCAL method with 30-degree rotation (six planes) subtracting the internal volume from the atrium volume. Polynomial regression with adjustments by determination coefficient (R2) was performed. To calculate the interobserver reproducibility, concordance correlation coefficient (CCC) was applied. Results:The mean ± standard deviation (SD) for the left atrium wall volume (cm3) ranged from 0.54 ± 0.21 at 20w0d–20w6d to 2.17 ± 0.30 at 33w0d–33w6d. The mean ± SD for the right atrium wall volume (cm3) ranged from 0.45 ± 0.16 at 20w0d–20w6d to 2.17 ± 0.62 at 33w0d–33w6d. We observed a satisfactory interobserver reproducibility with CCC = 0.69 and 0.58 for the left and right volumes of foetal heart atrial wall, respectively. The best-fit models were first-degree: volume for the left atrium wall = −2.194 + 0.139*GA (R2 = 0.41) and volume for the right atrium wall = −2.757 + 0.155*GA (R2 = 0.37). Conclusion: Reference values for the volumes of foetal heart atrial wall by 3D ultrasound using STIC and VOCAL methods between 20w0d and 33w6d weeks of gestation were established. [ABSTRACT FROM PUBLISHER]

Objectives: The purpose of this study was to evaluate the effectiveness of the non-linear adaptive combined approach on the analysis of maternal and fetal signals corrupted by noise.Methods: Empirical mode decomposition (EMD) is a non-linear adaptive technic for data analysis and has been widely used in biomedical data. When we apply EMD on ECG signals, the number of modes that contain cardiac information may vary regarding the subject, type of the signal and recording conditions. This fact can cause some difficulties in signal reconstruction and noise removal using the derived modes. For overcoming this issue, we designed a method to combine principal component analysis (PCA) method with EMD to remove the correlation between the calculated modes and provide a smaller set of uncorrelated orthogonal.Results: We have developed a combined method that proves the power of using PCA on the output of EMD method. The combined method reduces the power of oscillatory artifacts of the baseline. Thus, the PCA-EMD combination provides a noise-free signal.Conclusions: The combination of EMD and PCA methods worked well in being adaptive (from of EMD) and reconstruction (from PCA). It has been proved that this combined method is helpful in separating the signal components, especially in extracting the pure data from the baseline fluctuations. [ABSTRACT FROM AUTHOR]

Objective: To assess the factors affecting neonatal acidemia, including occurrence of tachysystole/hypertonus in fetuses exposed to oxytocin during labour and with continuously-monitored fetal heart rate (FHR) tracings.Methods: Prospective observational study of all women with term pregnancies who received oxytocin for induction/augmentation of labour. FHR tracings were prospectively classified using ACOG classification. Independent predictors of neonatal acidemia were identified using multivariate linear regression with p < 0.05 considered significant.Results: We included 430 women, 236 of whom (54.9%) had spontaneous onset of labour. The duration of active phase of the second stage of labour and the presence of abnormal FHR tracing during labour were significantly associated with UA pH (p < 0.001) and BE (p < 0.001), while maximum dose of oxytocin (p < 0.17; p < 0.7) and tachysystole (p < 0.9; p < 0.8) were not. At logistic regression, the duration of active phase of the second stage of labour was independently predictive of neonatal acidemia (p < 0.009) while abnormal FHR tracing approached significance (p < 0.088).Conclusions: In women receiving oxytocin during labour, the duration of active phase of the second stage of labour correlates with neonatal acidemia, whereas maximum dose of oxytocin, duration of oxytocin administration and occurrence of tachysystole during labour do not. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to evaluate the impact maternal obesity has on the percentage of unmonitored electronic fetal monitoring (EFM).Study Design: Women undergoing induction of labor at term were categorized into three groups: Group 1 (body mass index (BMI) < 30 kg/m2), Group 2 (30 < BMI < 40 kg/m2), and Group 3 (BMI ≥ 40 kg/m2). External EFM tracings were reviewed from the time of induction of labor until amniotomy; the percentage of time off of EFM was calculated. Statistical analysis was performed using commercially available software.Results: Three hundred and thirty-seven patients were stratified into the following groups: 104 patients in Group 1, 156 patients in Group 2, and 77 in Group 3. No significant differences were found between groups when analyzed for gestational age, bishop score, parity, race, and 5 min APGAR less than 7 or admission to the NICU. The mean percentage unmonitored by EFM was 5% for Group 1, 7% for Group 2 and 11% for Group 3. There was a significant association between percent of time unmonitored by EFM and BMI (r = 0.344 p < .0001).Conclusion: At term gestation, the fetuses of obese women spend more time unmonitored by external intrapartum EFM than non-obese women. This represents a disparity among a high-risk group that may result in poor pregnancy outcomes if fetal distress is present. [ABSTRACT FROM AUTHOR]

To understand the mechanisms those are involved in the appearance of foetal heart rate decelerations (FHR) after the combined epidural analgesia in labour. Observational study done at University Hospital for 86-term singleton pregnant women with spontaneous labour. Serial bedside measurement of the main cardiac maternal parameters with USCOM technique; stroke volume (SV), heart rate (HR), cardiac output (CO) and total vascular resistances (TVR) inputting systolic and diastolic blood pressure before combined epidural analgesia and after 5′, 10′, 15′ and 20 min. FHR was continuously recorded though cardiotocography before and after the procedure. Correlation between the appearance of foetal heart rate decelerations and the modification of maternal haemodynamic parameters. Fourteen out of 86 foetuses showed decelerations after the combined spino epidural procedure. No decelerations occurred in the women with low TVR (<1000 dyne/s/cm−5) at the basal evaluation. FHR abnormalities were concentrated in 39 women who presented elevated TVR values at the basal evaluation (>1200 dyne/s/cm−5). Soon after the epidural procedure, the absence of increase in SV and CO was observed in these women. No variations in systolic and diastolic blood pressure values were found. The level of TVR before combined epidural analgesia in labour may indicate the risk of FHR abnormalities after the procedure. Low TVR (<1000 dyne/s/cm−5) showed a reduced risk of FHR abnormalities. FHR decelerations seem to occur in women without the ability to upregulate SV and CO in response to the initial effects of analgesia. [ABSTRACT FROM PUBLISHER]

Objective: Electronic fetal heart monitor chart speeds vary between countries, and it is unclear whether differing chart speeds affect physician tracing interpretation.Methods: Twenty-minute segments of 19 tracings were displayed on both 1 and 3 cm/min strips and interpreted by 14 physicians at the particular speed they were accustomed to reading. Interpretations of tracing characteristics were compared between groups using free margin kappa, a measure of interobserver agreement.Results: Compared to 3 cm/min tracings, 1 cm/min tracings were significantly more often identified as having absent than minimal variability, and minimal than moderate variability. Accelerations were significantly more often identified in 1 versus 3 cm/min strips. There were no significant differences between groups with respect to baseline fetal heart rate, prolonged or repetitive decelerations, or American College of Obstetricians and Gynecologists tracing category. Neither chart speed had substantial interobserver agreement in tracing variables; however, agreement was consistently higher in 3 versus 1 cm/min tracings (all p < 0.05).Conclusions: Tracing interpretation is significantly affected by fetal monitor chart speed with regards to variability, acceleration and deceleration. Further studies are required to determine if differences in chart speed interpretation affect clinical management. [ABSTRACT FROM AUTHOR]