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Though misoprostol is commonly used for inpatient cervical ripening, its use in outpatient settings has been limited by safety concerns. This study was conducted to assess the association between early fetal heart tracing (FHT) and maternal tocodynamometry patterns and the incidence of adverse fetal and pregnancy outcomes after the administration of oral misoprostol for cervical ripening. We conducted a retrospective cohort study of 9908 low-risk patients at ≥37 weeks gestation who received oral misoprostol for cervical ripening prior to rupture of membranes between 01/01/2012 and 12/31/2017 at Kaiser Permanente Northern California hospitals as inpatients. We excluded patients who received a different agent for cervical ripening or had any need for additional inpatient monitoring, including hypertensive disorders of pregnancy, diabetes, or intrauterine growth restriction. Abnormal FHT, abnormal uterine activity, and adverse pregnancy or fetal-related events documented in the electronic health record in the four hours after administration of the first and second doses of misoprostol were assessed using descriptive statistics. We found that 0.9% of patients experienced tachysystole after the first dose of misoprostol (0.6% without decelerations; 0.3% with decelerations). The incidence of variable decelerations only and other FHT abnormalities (i.e. bradycardia, late or prolonged decelerations, or absent or minimal variability) in the first hour after misoprostol administration were 7.1% and 6.7% respectively, and diminished over time. The need for tocolytic use was 0.2% in the first hour and declined over time to 0.03% in the fourth hour after the first dose. Urgent cesarean delivery occurred in 0.1% of patients after receiving the first dose of misoprostol. Patients who did not experience variable, prolonged, or late decelerations in the first hour after the initial misoprostol dose were less likely to have such FHT abnormalities in the subsequent three hours compared to patients who had other FHT abnormalities (11.8% among patients with no FHT abnormalities vs. 43.7% among patients with other FHT abnormalities; p <.001). The overall trends in outcomes over time were similar after the second dose of misoprostol. The risk of short-term adverse outcomes associated with misoprostol is low among relatively low-risk patients. FHT abnormalities occurred in up to 32% of patients in the first four hours of monitoring post-misoprostol. Patients with no FHT abnormalities in the first hour after receiving misoprostol had a low risk of developing adverse outcomes and FHT abnormalities on continued monitoring, while patients with any type of deceleration in the first hour were at higher risk of adverse outcomes and FHT abnormalities. Our data may inform the development of protocols for cervical ripening that allow reduced monitoring for a subset of low-risk patients, however, more research is needed to validate findings and develop clinical protocols. [ABSTRACT FROM AUTHOR]

Objective To evaluate the interobserver reliability of fetal heart rate (FHR) pattern definition and interpretation assessed by physicians at various levels of training using standard Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) definitions and standard principles of interpretation. Study Design We conducted an interrater reliability study of the intrapartum FHR tracings of 32 singleton term pregnancies at Los Angeles County.University of Southern California (LAC + USC) Medical Center. Analysis included the 5 hours immediately preceding delivery, divided into 10- minute segments. A medical student, resident, and three attending physicians evaluated the same set of FHR tracings. Interobserver agreement was assessed using the free-marginal kappa coefficient. Results Reviewers demonstrated substantial to excellent agreement on baseline rate (Κ = 0.97), moderate variability (Κ = 0.80), accelerations (Κ = 0.62), decelerations (Κ = 0.63), category (Κ = 0.68), and the ability to identify the presence of either moderate variability or accelerations (Κ = 0.82). Conclusions Interobserver agreement was significantly higher on all components of FHR definition and interpretation than previously expected. Standardization of FHR definitions and interpretation may improve interobserver reliability and patient safety. [ABSTRACT FROM AUTHOR]

A practical management protocol to handle the large volume of post-term gestations at the Los Angeles County/University of Southern California Medical Center was introduced and evaluated in 880 patients seen between March 1, 1979, and February 29, 1980. The protocol divided patients into 2 groups based on substantiated "good" or unsubstantiated "poor" obstetric dates. After clinical examinations, the primary screening test used was twice weekly plasma unconjugated estriol (E3) determinations. Antepartum fetal heart rate testing, in the form of nonstress tests, was used initially in the good obstetric dates group, and then done twice weekly only if the E3 value was abnormal (less than 18 ng/ml with good obstetric dates and less than 12 ng/ml with poor obstetric dates). Patients with good obstetric dates were delivered electively at more than 42 weeks' gestation if the cervix was favorable (Bishop score 9 or greater); otherwise, intervention occurred only with abnormal tests and a positive or suspicious contraction stress test, or with other medical indications. Only 8 perinatal losses (3 neonatal deaths and 5 stillbirths) occurred in 880 patients. Each of these patients received a follow-up evaluation: 3 had severe congenital anomalies, and 5 deaths occurred in patients who did not comply with the protocol. The cesarean section rate was 15.8%.