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Background Problems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking an interdisciplinary perspective, we sought to characterise the everyday practice of CTG monitoring and the work systems within which it takes place, with the goal of identifying potential sources of risk. Methods Human factors/ergonomics (HF/E) experts and social scientists conducted 325 hours of observations and 23 interviews in three maternity units in the UK, focusing on how CTG tasks were undertaken, the influences on this work and the cultural and organisational features of work settings. HF/E analysis was based on the Systems Engineering Initiative for Patient Safety 2.0 model. Social science analysis was based on the constant comparative method. Results CTG monitoring can be understood as a complex sociotechnical activity, with tasks, people, tools and technology, and organisational and external factors all combining to affect safety. Fetal heart rate patterns need to be recorded and interpreted correctly. Systems are also required for seeking the opinions of others, determining whether the situation warrants concern, escalating concerns and mobilising response. These processes may be inadequately designed or function suboptimally, and may be further complicated by staffing issues, equipment and ergonomics issues, and competing and frequently changing clinical guidelines. Practice may also be affected by variable standards and workflows, variations in clinical competence, teamwork and situation awareness, and the ability to communicate concerns freely. Conclusions CTG monitoring is an inherently collective and sociotechnical practice. Improving it will require accounting for complex system interdependencies, rather than focusing solely on discrete factors such as individual technical proficiency in interpreting traces. [ABSTRACT FROM AUTHOR]

Background: Globally, 2.5 million neonates died in 2018, accounting for 46% of under-5 deaths. Multiparameter continuous physiological monitoring (MCPM) of neonates allows for early detection and treatment of life-threatening health problems. However, neonatal monitoring technology is largely unavailable in low-resource settings.Methods: In four evaluation rounds, we prospectively compared the accuracy of the EarlySense under-mattress device to the Masimo Rad-97 pulse CO-oximeter with capnography reference device for heart rate (HR) and respiratory rate (RR) measurements in neonates in Kenya. EarlySense algorithm optimisations were made between evaluation rounds. In each evaluation round, we compared 200 randomly selected epochs of data using Bland-Altman plots and generated Clarke error grids with zones of 20% to aid in clinical interpretation.Results: Between 9 July 2019 and 8 January 2020, we collected 280 hours of MCPM data from 76 enrolled neonates. At the final evaluation round, the EarlySense MCPM device demonstrated a bias of -0.8 beats/minute for HR and 1.6 breaths/minute for RR, and normalised spread between the 95% upper and lower limits of agreement of 6.2% for HR and 27.3% for RR. Agreement between the two MCPM devices met the a priori-defined threshold of 30%. The Clarke error grids showed that all observations for HR and 197/200 for RR were within a 20% difference.Conclusion: Our research indicates that there is acceptable agreement between the EarlySense and Masimo MCPM devices in the context of large within-subject variability; however, further studies establishing cost-effectiveness and clinical effectiveness are needed before large-scale implementation of the EarlySense MCPM device in neonates.Trial Registration Number: NCT03920761. [ABSTRACT FROM AUTHOR]

Objective: Economic evaluation of computerised decision-support software intended to assist in the interpretation of a cardiotocography (CTG) during birth.Design: Individual patient level data from the INFANT study (an unmasked randomised controlled trial).Setting: Maternity units in the UK and Ireland.Population: Singleton or twin pregnancy women of 35 weeks' gestation or more and receiving continuous electronic fetal monitoring during labour.Intervention: Computerised decision-support software.Methods: Cost-consequence analysis presenting costs and outcomes with a time horizon of 2 years from a government healthcare perspective. Unit cost data collected from a combination of primary and secondary sources.Main Outcome Measures: Primary clinical outcomes were (i) composite 'poor neonatal outcome' and (ii) developmental assessment at age 2 years in a subset of surviving children. Mean cost per mother and infant dyad from birth to hospital discharge, and from hospital discharge to 24 months follow-up. Maternal health-related quality of life was assessed at 12 and 24 months follow-up using the EuroQol three-level health-related quality of life instrument (EQ-5D-3L).Results: Data were analysed for 46 042 women and 46 614 infants. No statistically significant differences were detected between trial arms in any of the primary clinical outcomes or maternal quality of life. No statistically significant differences in costs were detected in maternal or infant costs from trial entry to hospital discharge or overall from hospital discharge to 2-year follow-up.Conclusions: Decision-support software during labour is not associated with additional maternal or infant benefits and over a 2-year period the software did not lead to additional costs or savings to the National Health Service.Trial Registration Number: ISRCTN98680152. [ABSTRACT FROM AUTHOR]

The article looks at the National Institute for Health and Care Excellence guidelines for preterm labour in terms of prevention, screening and management. Topics discussed include prevention measures for women like prophylactic vaginal progesterone and prophylactic cervical cerclage, transvaginal ultrasound measurement as a recommended preterm labour screening option, and preterm labour treatment choices like tocolysis, corticosteroids and magnesium sulfate.

Objectives: To monitor preterm infants in a cot and a car seat and compare an observed car seat trial with polysomnography (PSG). Design: Non-randomised controlled trial. Setting: Regional neonatal unit. Patients: Preterm infants before discharge. Interventions: Nap PSG respiratory and sleep variables were measured including gastro-oesophageal pH. Nurse observations included respiratory distress, apnoea measured by apnoea alarm, oxygen saturation and heart rate. Infants were studied supine in a cot and then in a car seat. Nursing observations were compared with PSG during the car seat trial only. Criteria for failure of the PSG and observed tests were predefined. Main outcome measures: Difference in respiratory instability between cot and car seat. Concurrence regarding failure of the car seat trial between nurse-observed data and PSG. Results: 20 infants (median gestation 33 weeks (range 28-35 weeks; median postmenstrual age (PMA) at study 36.5 weeks (range 35-38 weeks)) were studied. There were sufficient car seat data on 18 infants for comparison. There were fewer central apnoeas and arousals in the cot than the car seat (p=0.047 and p=0.024, respectively). Airway obstruction was not more common in the car seat. Younger PMA at time of study predicted failure in both car seat (p=0.022) and cot (p=0.022). The nurse-observed test had low sensitivity for predicting PSG failure but more accurately predicted airway obstruction on PSG. Conclusions: Immature infants exhibit respiratory instability in cots and car seats. A car seat test does not accurately detect all adverse events during sleep in the seat. [ABSTRACT FROM AUTHOR]

The article examines the different diagnostic modalities used in the detection and assessment of fetal rhythm abnormalities. It discusses the various types of arrhythmias that encountered before the child is born, which include extrasystoles, tachyarrhythmias, and bradyarrhythmias. Moreover, it presents a review of the management procedure and outcome assessment of fetal arrhythmias with or without intervention.

Objective: To assess the accuracy of prenatal diagnosis, the association with genetic and extracardiac anomalies, and outcome in fetuses with isolated pulmonary atresia with ventricular septal defect (PA-VSD). Design and setting: Retrospective study in a tertiary centre for fetal cardiology. Patients and outcome measures: Echocardiographic video recordings of 27 consecutive fetuses with PA-VSD were reviewed for: (1) intracardiac anatomy; (2) presence of confluence and size of the branch pulmonary arteries; (3) source of pulmonary blood supply; and (4) side of the aortic arch. Postmortem and postnatal data were added. Karyotyping was performed in 25 patients and, in 23 of these, fluorescent in situ hybridisation to identify 22q1 1.2 deletion. Results: PA-VSD was correctly diagnosed in 19 of 21 patients (90%) with postnatal or autopsy confirmation of diagnosis. Central pulmonary arteries were correctly identified in 79% (15/19), the source of pulmonary blood supply in 62% (13/21) and major aortopulmonary collateral arteries in 44% (4/9). Aneuploidy was detected in 4 of 25 patients (16%) and 22q1 1.2 deletion in 6 of 23 patients (26%). Five of 27 patients (19%) had extracardiac anomalies. Eleven pregnancies were interrupted. Eleven of 16 liveborn babies survived. Neonatal survival was 15 of 16 (94%, 95% confidence interval (CI) 70 to 100), one-year survival was 9 of 12 (75%, 95% Cl 43 to 95) and two-year survival was 5 of 9 (56%, 95% CI 21 to 86). Conclusion: PA-VSD can be diagnosed by fetal echocardiography with a high degree of accuracy. However, it can be difficult to determine the morphology of the central pulmonary arteries and to locate the source of pulmonary blood supply. In most liveborn infants, complete surgical repair can be achieved. [ABSTRACT FROM AUTHOR]

Presents letters to the editor on medical topics as of February 23, 2002. Postoperative starvation after gastrointestinal surgery; Cardiotocography versus Doppler auscultation; Gastro-esophageal reflux disease in general practice; Cesarean section rate in England and Wales; Management of chronic disease.

This study has confirmed that among women with low risk features at the onset of labour, the admission cardiotocogram is no better than Doppler auscultation of the fetal heart in identifying a potentially compromised fetus. Admission cardiotocography was associated with increased obstetric intervention including higher rates of operative delivery. Although caution is needed in generalising conclusions to the whole population, our results point to potential problems with admission cardiotocography. These problems are likely to persist while difficulties remain in interpreting cardiotocograms. [ABSTRACT FROM AUTHOR]

Focuses on congenital syphilis as a cause of abnormal cardiotocogram in Great Britain. Use of prelabor fetal heart monitoring to determine wellbeing of babies at risk of growth retardation; Health effects of intrauterine growth retardation; Treatments for the disease.

Assesses the value of antenatal fetal heart rate monitoring. Classification of heart rate tracings as reactive or non-reactive; Increase in perinatal mortality and fetal distress in non-reactive group; Interrelation between intrapartum fetal monitoring and immediate neonatal outcome.

Examines the effectiveness of different methods in monitoring intrapartum fetal heart rate at the maternity hospital in Harare, Zimbabwe. Use of Doppler ultrasound and Pinard stethoscope in the research; Importance of operative delivery for fetal distress; Risk of pregnancies in developing countries with scarce resources. INSET: Clinical implications.

Objectives--To determine whether pre-eclampsia, hypothesised to be an inflammatory condition, is associated with fever in term labour, and confirm and examine the reported association of pre-eclampsia at term with neonatal encephalopathy. Design--Prospective cohort study. Setting--A Dublin teaching hospital. Participants--6163 women in labour with singleton pregnancies at term at low risk for intrapartum hypoxia, recruited to a randomised trial examining the effect of admission cardiotocography on neonatal outcome. Results--Pre-eclampsia was associated with maternal fever > 37.5° in labour (odds ratio (OR) 3.39, 95% confidence interval (CI) 2.1 to 5.4); this was independent of obstetric intervention (adjusted OR 2.07, 95% CI 1.24 to 3.47). Pre-eclampsia was associated with neonatal encephalopathy (OR 25.5, 95% CI 8.4 to 74.7); this too was independent of obstetric intervention (adjusted OR 18.5,95% CI 5.9 to 58.1). Cord arterial pH values were significantly lower in pre-eclamptics (7.20 v 7.24), although severe cord acidaemia was not significantly more common (OR 2.91,95% CI 0.7 to 9.9). The association of pre-eclampsia with encephalopathy was independent of maternal fever (adjusted OR 16.5, 95% CI 5.1 to 54) and cord acidaemia (adjusted OR 13.5, 95% CI 3.2 to 56.7). Conclusions--The association of pre-eclampsia with maternal fever at term supports the hypothesis that pre-eclampsia is an inflammatory condition. The association of pre-eclampsia with neonatal encephalopathy is independent of obstetric intervention and cannot be explained by either acidaemia or maternal fever. A systemic inflammatory response in the fetus, perhaps secondary to oxidative stress, could explain the link between maternal pre-eclampsia and neonatal encephalopathy, and this may occur through cerebral vasoconstriction. [ABSTRACT FROM AUTHOR]

Determines the reliability of cardiotocography in predicting the infants condition at birth. Relationship between Apgar scores of the babies and the cardiotocograph tracing in labor; Explanation on the high incidence of false positive predictions; Examination of the overdependence on fetal monitoring by cardiotocography.

Attempts to monitor all women admitted in labor by continuous fetal heart rate recording. Elimination of intra-partum stillbirths; Reduction in neonatal mortality; Importance of monitoring to predict intra-partum fetal distress.

Examines the accessibility of invasive investigation and revascularization procedures for coronary heart disease in South West Thames, Great Britain. Performance of the National Health Service (NHS); Analysis of patients referral to the regional cardiothoracic centers; Difference in time to investigation and intervention between NHS and the private patients.

The author comments on a study by Devane and colleagues which revealed that women allocated to admission cardiotocograph (CTG) were more likely to experience continuous electronic fetal monitoring. The author mentions that the study concluded that admission CTG should not be routinely offered in low-risk women as it increases the risk of caesarean section (CS). She states that the study confirms the recommendations of the current guidelines for selective use of CTG monitoring.

The article presents information related to a study which suggests that cardiotocographic monitoring of the fetal heart reduces the rate of neonatal seizures although it does not reduce rates of intrapartum death or cerebral palsy. According to the study, the risk of neonatal seizures is decreased with continuous cardiotocographic monitoring. It is mentioned that low risk pregnant women undergoing continuous monitoring showed significantly lower risk of neonatal seizures. It is stated that it is not possible to predict the size of the effect although continuous cardiotocography in low risk women might increase the rate of caesarean sections.

The article presents a case study of a baby girl born through an emergency caesarean section at 28 weeks gestation caused by nonreassuring cardiotocography and reduced fetal movement. A complication of red cell alloimmunisation next to maternal anti-C and anti-D antibodies was observed during the pregnancy. The baby was diagnosed with omental herniation with an unusual complication of intrauterine transfusion.

The article warns parents of the flaws in over-the-counter fetal heart monitor device. It relates the experience of a 34-year-old woman who was 38 weeks pregnant with her first baby. The two types of fetal heart monitors marketed on the Internet are sound amplifiers and Doppler ultrasound devices. It explains how fetal movement can be utilized as a market of fetal wellbeing. The authors point out that home monitoring devices only offer a snapshot of the heart rate and provide no signs of other important prognostic features.

Comments on a randomised controlled trial of cardiotocography versus Doppler auscultation of fetal heart at admission in labour. Suggestion that changes between protocol and manuscript should be declared at submission; Thoughts on the decision to conduct an interim audit and modify the targets; Questions on how such a protocol should be managed.

Editorial. Discusses electronic fetal monitoring. How electronic fetal monitoring with the cardiotocograph is standard practice during labour in most obstetric units in the United Kingdom; Introduction of the technique; Effect of the process on women in labour; Use of an admission cardiotocograph; Recommendation that intermittent auscultation is the most appropriate method of fetal monitoring for women in labour who are low risk.

Neonatal teratomas, the most common perinatal neoplasm, are usually benign with the sacrococcygeal region being the commonest site. Researchers report a case of a mediastinal teratoma presenting as an apparent fresh stillbirth. A female infant, birth weight 3.23 kg, was born by normal delivery to a 36 year old primigravida at 36 weeks gestation. The pregnancy had been uneventful, and a 19 week fetal anomaly scan was normal. A fetal heart was detected by cardiotocograph just before delivery, however, at birth there were no signs of life and the baby had evidence of mild hydrops.

Examines the early diagnosis of chronic fetal hypoxia in a diabetic pregnancy. Decline of the fetal heart rate; Abnormalities of the blood flow; Association of chronic fetal hypoxia with decrease of gestational age.

Investigates the possibility of treating fetal thyrotoxicosis prior to delivery. Administration of carbimazole; Importance of fetal heart rate measurement; Increase of long-lasting thyroid stimulator and long-lasting thyroid stimulator-protector.

Examines the fluid loading in reduction of abnormalities of fetal heart rate and maternal hypotension during epidural analgesia in labor. Record of fetal heart rate (FHR); Measurement of blood pressure during administration of lumbar epidural analgesia; Presence of preloading case during inducement of analgesia.

Examines the effect of amniocentesis on fetal breathing movements (FBM). Observation of FBM using a linear array real time B-scan; Increase of urine activity after amniocentesis; Relation of increase activity to the fall of FBM.

Examines fetal heart rate in ambulant women in labor by radiotelemetry. Importance of heart rate monitoring in reducing perinatal mortality; Technical limitations to continuous heart rate monitoring; Benefits of the monitoring method in reducing risk for thromboembolism.

Focuses on the significance of cardiotocographs at a distance in medicine practice in Great Britain. Description of techniques for recording the fetal heart rate; Reasons for widely use of antenatal cardiotocographic monitoring; Correlation between abnormal patterns of the antenatal fetal heart rate and poor neonatal outcome.

Focuses on the efficacy of traditional childbirth in Great Britain. Comparison with technological processes; Application of cardiotocography; Complexities of cardiotocography result interpretations.

Focuses on the employment of cardiotocography during labor in Great Britain. Significance of fetal monitoring; Disadvantages of cardiotocography; Complications associated with the use of the method.

The article relates the concerns of the Medicines and Healthcare Products Regulatory Agency of Great Britain over the growing popularity of over-the-counter fetal heart rate monitoring devices as of November 14, 2009. The agency therefore warns consumers to purchase only CE marked fetal monitors for home use. Examples of these products are medical grade ultrasound Doppler devices and the Summer Infant Prenatal Listening Device. Also cited are opinions by medical professionals.

The article describes the clinical case of a 27 year old pregnant woman who complained of reduced fetal movements. The patient noted a reduction in fetal activity after she used a home Doppler device to listen to the fetal heart beat. Her baby was delivered through a caesarian section. A warning on the use of hand-held home Doppler device is offered. The article also emphasizes that despite the false reassurance associated with self monitoring, it is recommended that patients should not use these devices.

The article presents first person details on a doctor's medical experience with an ill pregnant patient in rural Tanzania. Obstetrician Sally Edmonds reports her experience serving a woman without a fetal heartbeat. She describes her efforts to resuscitate the baby and eventually her work in operating on the mother and child. She states the patient had a peri-mortem appearance and that the anaesthetist was reluctant to take action. The report states Edmonds discovered two macerated babies, a deflated uterus and a concealed abruption. The patient eventually returned to normal health.

Describes an artefactual fetal heart trace from a scalp electrode attached to a macerated dead fetus. Influence of the electrolytic voltage production in the scalp electrode on the fetal heart trace; Evaluation of the practice of electronic monitoring of the fetal heart rate during labor in most obstetric units.

Focuses on the long distance telemetry of fetal heart rate from the homes of patients using public telephone network. Evaluation of the technique of fetal heart rate; Cost of the hospital admission; Identification of signal noise and validated genuine heart periods.