Search

The article discusses the impact and controversies surrounding the 2014 Guidelines for the management of labor issued by American College of Obstetricians and Gynecologists, highlighting unresolved issues regarding dysfunctional labor and rising cesarean section rates. Despite calls for revision, the new Guidelines fail to address concerns, offering unbalanced assessments and contradictory recommendations, raising questions about their evidence-based nature.

Objective The objective of this study was to compare performance of a maternal surface electrode patch with ultrasound- and tocodynamometer-based monitoring to detect fetal heart rate and uterine contractility in late preterm labors. Study Design Thirty women between 34 0/7 and 36 6/7 weeks' gestation were monitored simultaneously with a Doppler/tocodynamometer system and a wireless fetal–maternal abdominal surface electrode system. Fetal and maternal heart rate and uterine contraction data from both systems were compared. Reliability was measured by the success rate and percent agreement. Deming regression and Bland–Altman analysis estimated the concordance between the systems. Uterine contractions were assessed by visual interpretation of monitor tracings. Results The success rate for the surface electrode system was 89.5% (95% confidence interval [CI], 85.7–93.3), and for ultrasound it was 88.4% (95% CI, 84.9–91.9; p = 0.73), with a percent agreement of 88.1% (95% CI, 84.2–92.8). Results were uninfluenced by the patients' body mass. The mean Deming slope was 1 and the y-intercept was −3.0 beats per minute (bpm). Bland–Altman plots also showed a close relationship between the methods, with limits of agreement less than 10 bpm. The percent agreement for maternal heart rate was 98.2% (95% CI, 97.4–98.8), and for uterine contraction detection it was 89.5% (95% CI, 85.5–93.4). Conclusion Fetal heart rate and uterine contraction monitoring at 34 0/7 to 36 6/7 weeks using abdominal surface electrodes was not inferior to Doppler ultrasound/tocodynamometry for fetal–maternal assessment. Registration clinicaltrials.gov/February 20, 2017/identifier NCT03057275. Key Points Monitoring the preterm fetal heart rate with surface electrodes is feasible. Preterm contractions can be monitored with surface electrodes. The technique was noninferior to standard external monitors. [ABSTRACT FROM AUTHOR]

Cesarean birth has increased substantially in many parts of the world over recent decades and concerns have been raised about the propriety of this change in obstetric practice. Sometimes, a cesarean is necessary to preserve fetal and maternal health. But in balancing the risks of surgical intervention the implicit assumption has been that cesarean birth is an equivalent alternative to vaginal birth from the standpoint of the immediate and long-term health of the fetus and neonate. Increasingly, we realize this is not necessarily so. Delivery mode per se may influence short-term and abiding problems with homeostasis in offspring, quite independent of the indications for the delivery and other potentially confounding factors. The probability of developing various disorders, including respiratory compromise, obesity, immune dysfunction, and neurobehavioral disorders has been shown in some studies to be higher among individuals born by cesarean. Moreover, many of these adverse effects are not confined to the neonatal period and may develop over many years. Although the associations between delivery mode and long-term health are persuasive, their pathogenesis and causality remain uncertain. Full exploration and a clear understanding of these relationships is of great importance to the health of offspring. [ABSTRACT FROM AUTHOR]

The article focuses on the "30-minute rule" in obstetrics, which refers to the interval between the decision to perform a cesarean delivery and the start of the incision. Topics discussed include the case of two patients cared for by a single obstetrician; the debate surrounding the rule's medical relevance and its use in legal cases; and the potential risks and benefits of rapid delivery for both mothers and newborns.

Objective: We compared the association between cord arterial catecholamine levels and fetal oxygenation in newborns of mothers with diabetes mellitus to those of nondiabetic pregnancies.Methods: Cord blood obtained at delivery in 25 term appropriate-for-gestational age newborns of women with diabetes and 27 nondiabetic controls were assayed for norepinephrine, epinephrine, insulin, glucose, and blood gases.Results: There was no statistical difference in parity, birth weight, gestational age, delivery mode, use of epidural analgesia, or frequency of low 1-min Apgar scores between the groups. The pO2 and frequency of cord arterial pH < 7.20 were also similar. Diabetic pregnancies had somewhat higher fetal glucose and substantially higher insulin levels than controls. Regression analysis using cord arterial pH to reflect oxygenation revealed significant inverse relationships between cord artery pH and ln norepinephrine (Prob > F = .001) and ln epinephrine (Prob > F = .019) in controls. In newborns of women with diabetes, however, neither relationship was significant.Conclusion: The expected surge in catecholamines associated with diminished oxygenation was attenuated in fetuses of diabetic mothers. This suggests the possibility that fetal exposure to hyperglycemia or other metabolic derangements in pregnant diabetics might compromise the fetal ability to adapt to changes in oxygenation, and might thereby contribute to the risk of fetal death. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction: Noninvasive fetal heart rate monitoring using transabdominal fetal electrocardiographic detection is now commercially available and has been demonstrated to be an effective alternative to traditional Doppler ultrasonographic techniques. Our objective in this study was to compare the results of computerized identification of fetal heart rate patterns generated by ultrasound-based and transabdominal fetal electrocardiogram-based techniques with simultaneously obtained fetal scalp electrode-derived heart rate information.Material and Methods: We applied an objective computer-based analysis for recognition of fetal heart rate patterns (Monica Decision Support) to data obtained simultaneously from a direct fetal scalp electrode, Doppler ultrasound, and the abdominal-fetal electrocardiogram techniques. This allowed us to compare over 145 hours of fetal heart rate patterns generated by the external devices with those derived from the scalp electrode in 30 term singleton uncomplicated pregnancies during labor. The direct fetal scalp electrode is considered to be the most accurate and reliable technique used in current clinical practice, and was, therefore, used as the standard for comparison. The program quantified the baseline heart rate, long- and short-term variability. It indicated when an acceleration or deceleration was present and whether it was large or small.Results: Ultrasound was associated with significantly greater deviations from the fetal scalp electrode results than the abdominal fetal electrocardiogram technique in recognizing the correct baseline heart rate, its variability, and the presence of small and large accelerations and small decelerations. For large decelerations the two external methods were each not significantly different from the scalp electrode results.Conclusions: Noninvasive fetal heart rate monitoring using maternal abdominal wall electrodes to detect fetal cardiac activity more reliably reproduced the computerized analysis of heart rate patterns derived from a direct fetal scalp electrode than did traditional ultrasound-based monitoring. Abdominal-fetal electrocardiogram should, therefore, be considered a primary option for externally monitored patients. [ABSTRACT FROM AUTHOR]

Implementation of clinical practice guidelines may moderate health care costs, improve care, reduce medicolegal liability, and provide a uniformity in care allowing meaningful investigation of treatments and outcomes. However, new guidelines are often uncritically embraced by clinicians, risk management organizations, insurance companies, and the courts as the standard of care. Adoption of incompletely vetted recommendations can lead to patient harm. Recent recommendations made by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine for assessment and management of labor provide an example of well-intended guidelines adopted uncritically. Ideally, but unattainably, each step in a practice guideline would be supported by results of prospective randomized trials. Usually, data from lower on the hierarchy of proof are included, and the personal or institutional preferences of the guideline developers influence the final product. These multiple resources help illuminate critical issues and balance competing perspectives, but can introduce biases that become embedded in our practice. The new labor management guidelines, which were never shown to be superior (or even equivalent) to current standards, have achieved widespread acceptance. Although they provide a formula for reducing the cesarean rate, they do so without concern for their potentially adverse effects on maternal or neonatal outcome. New guidelines should be outcome-based and address how to practice obstetrics to yield the best possible results for mother and baby. [ABSTRACT FROM AUTHOR]

Jackson, Benjamin T., George J. Piasecki, Herbert E. Cohn, and Wayne R. Cohen. Control of fetal insulin secretion. Am J Physiol Regulatory Integrative Comp Physiol 279: R2179-R2188, 2000.--In this study, we investigated the way in which fetal insulin secretion is influenced by interrelated changes in blood glucose and sympathoadrenal activity. Experiments were conducted in late gestation sheep fetuses prepared with chronic peripheral and adrenal catheters. The fetus mounted a brisk insulin response to hyperglycemia but with only a minimal change in the glucose-to-insulin ratio, indicating a tight coupling between insulin secretion and plasma glucose. In well-oxygenated fetuses, [[Alpha].sub.2]-adrenergic blockade by idazoxan effected no change in fetal insulin concentration, indicating the absence of a resting sympathetic inhibitory tone for insulin secretion. With hypoxia, fetal norepinephrine (NE) and epinephrine secretion and plasma NE increased markedly; fetal insulin secretion decreased strikingly with the degree of change related to extant plasma glucose concentration. Idazoxan blocked this effect showing the hypoxic inhibition of insulin secretion to be mediated by a specific [[Alpha].sub.2]-adrenergic mechanism, [[Alpha].sub.2]-Blockade in the presence of sympathetic activation secondary to hypoxic stress also revealed the presence of a potent [Beta]-adrenergic stimulatory effect for insulin secretion. However, based on an analysis of data at the completion of the study, this [Beta]-stimulatory mechanism was seen to be absent in all six fetuses that had been subjected to a prior experimentally induced hypoxic stress but in only one of nine fetuses not subjected to this perturbation. We speculate that severe hypoxic stress in the fetus may, at least in the short term, have a residual effect in suppressing the [Beta]-adrenergic stimulatory mechanism for insulin secretion. hyperglycemia; catecholamines; idazoxan; propranolol; hypoxia

This article discusses the new labor evaluation guidelines issued by the American College of Obstetricians and Gynecologists and the Society for Maternal & Fetal Medicine. Topics covered include the character of birthing practice, the rising cesarean rate in the U.S., and the diagnosis of dystocia and its effect on the cesarean rate. Explained also are abnormal labor progress, misconceptions about the Friedman system of labor assessment and management and the diagnosis of arrest of dilatation.

Implementation of clinical practice guidelines may moderate health care costs, improve care, reduce medicolegal liability, and provide a uniformity in care allowing meaningful investigation of treatments and outcomes. However, new guidelines are often uncritically embraced by clinicians, risk management organizations, insurance companies, and the courts as the standard of care. Adoption of incompletely vetted recommendations can lead to patient harm. Recent recommendations made by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine for assessment and management of labor provide an example of well-intended guidelines adopted uncritically. Ideally, but unattainably, each step in a practice guideline would be supported by results of prospective randomized trials. Usually, data from lower on the hierarchy of proof are included, and the personal or institutional preferences of the guideline developers influence the final product. These multiple resources help illuminate critical issues and balance competing perspectives, but can introduce biases that become embedded in our practice. The new labor management guidelines, which were never shown to be superior (or even equivalent) to current standards, have achieved widespread acceptance. Although they provide a formula for reducing the cesarean rate, they do so without concern for their potentially adverse effects on maternal or neonatal outcome. New guidelines should be outcome-based and address how to practice obstetrics to yield the best possible results for mother and baby. [ABSTRACT FROM AUTHOR]

Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury. [ABSTRACT FROM AUTHOR]

Objective: To compare the accuracy and reliability of uterine contraction identification from maternal abdominal electrohysterogram and tocodynamometer with an intrauterine pressure transducer. Methods: Seventy-four term parturients had uterine contractions monitored simultaneously with electrohysterography, tocodynamometry, and intrauterine pressure measurement. Results: Electrohysterography was more reliable than tocodynamometry when compared to the intrauterine method (97.1 versus 60.9 positive percent agreement; P < 0.001). The root mean square error was lower for electrohysterography than tocodynamometry in the first stage (0.88 versus 1.22 contractions/10 minutes; P < 0.001), and equivalent to tocodynamometry in the second. The positive predictive values for tocodynamometry and electrohysterography (84.1% versus 78.7%) were not significantly different, nor were the false positive rates (21.3% versus 15.9%; P = 0.052). The sensitivity of electrohysterography was superior to that of tocodynamometry (86.0 versus 73.6%; P < 0.001). Conclusion: The electrohysterographic technique was more reliable and similar in accuracy to tocodynamometry in detecting intrapartum uterine contractions. [ABSTRACT FROM AUTHOR]

Antenatal corticosteroid therapy to enhance fetal lung maturation in pregnancies at risk for preterm delivery is used commonly, based on the assumption that its established benefits outweigh associated risks. Corticosteroid treatment does confer some risks, particularly with respect to restricted brain growth and disordered neuronal development. These alterations have the potential for long-term effects on health. They deserve further study, and should not be undervalued. Corticosteroid therapy should be applied selectively in those situations in which the risk of preterm birth is very high and the likelihood of severe respiratory distress syndrome substantial. [ABSTRACT FROM AUTHOR]