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Fetal phonocardiography (FPCG) is a non-invasive Fetal Heart Rate (FHR) monitoring technique that can detect vibrations and murmurs in heart sounds. However, acquiring fetal heart sounds from a wearable FPCG device is challenging due to noise and artefacts. This research contributes a resilient solution to overcome the conventional issues by adopting Artificial Intelligence (AI) with FPCG for automated FHR monitoring in an end-to-end manner, named (AI-FHR). Four sequential methodologies were used to ensure reliable and accurate FHR monitoring. The proposed method removes low-frequency noises and high-frequency noises by using Chebyshev II high-pass filters and Enhanced Complete Ensemble Empirical Mode Decomposition with Adaptive Noise (ECEEMDAN) in combination with Phase Shifted Maximal Overlap Discrete Wavelet Transform (PS-MODWT) filters, respectively. The denoised signals are segmented to reduce complexity, and the segmentation is performed using multi-agent deep Q-learning (MA-DQL). The segmented signal is provided to reduce the redundancies in cardiac cycles using the Artificial Hummingbird Optimization (AHBO) algorithm. The segmented and non-redundant signals are converted into 3D spectrograms using a machine learning algorithm called variational auto-encoder-general adversarial networks (VAE-GAN). The feature extraction and classification are carried out by adopting a hybrid of the bidirectional gated recurrent unit (BiGRU) and the multi-boosted capsule network (MBCapsNet). The proposed method was implemented and simulated using MATLAB R2020a and validated by adopting effective validation metrics. The results demonstrate that the proposed method performed better than the current method with accuracy (81.34%), sensitivity (72%), F1-score (83%), Energy (0.808 J), and complexity index (13.34). Like other optimization methods, AHO needs precise parameter adjustment in order to function well. Its performance may be greatly impacted by the selection of parameters, including population size, exploration rate, and learning rate. • Chebyshev filter and EC2EMDAN-PS-MODWT reduce low and high frequency noises. • MA-DRL and optimization algorithms reduce complexity during classification. • Machine learning spectrogram conversion to capture time, frequency, and spectral variations. • Hybrid deep learning algorithms can be used to reduce positive rates. [ABSTRACT FROM AUTHOR]

Intrapartum cardiotocographic monitoring of fetal heart rate by abdominal external ultrasound transducer without simultaneous maternal heart rate recording has been associated with increased risk of early neonatal death and other asphyxia-related neonatal outcomes. It is unclear, however, whether this increase in risk is independently associated with fetal surveillance method or is attributable to other factors. This study aimed to compare different fetal surveillance methods and their association with adverse short- and long-term fetal and neonatal outcomes in a large retrospective cohort of spontaneous term deliveries. Fetal heart rate and maternal heart rate patterns were recorded by cardiotocography during labor in spontaneous term singleton cephalic vaginal deliveries in the Hospital District of Helsinki and Uusimaa, Finland between October 1, 2005, and September 30, 2023. According to the method of cardiotocography monitoring at birth, the cohort was divided into the following 3 groups: women with ultrasound transducer, women with both ultrasound transducer and maternal heart rate transducer, and women with internal fetal scalp electrode. Umbilical artery pH and base excess values, low 1- and 5-minute Apgar scores, need for intubation and resuscitation, neonatal intensive care unit admission for asphyxia, neonatal encephalopathy, and early neonatal death were used as outcome variables. Among the 213,798 deliveries that met the inclusion criteria, the monitoring type was external ultrasound transducer in 81,559 (38.1%), both external ultrasound transducer and maternal heart rate recording in 62,268 (29.1%), and fetal scalp electrode in 69,971 (32.7%) cases, respectively. The rates of both neonatal encephalopathy (odds ratio, 1.48; 95% confidence interval, 1.08–2.02) and severe acidemia (umbilical artery pH <7.00 and/or umbilical artery base excess ≤−12.0 mmol/L) (odds ratio, 2.03; 95% confidence interval, 1.65–2.50) were higher in fetuses of women with ultrasound transducer alone compared with those of women with concurrent external fetal and maternal heart rate recording. Monitoring with ultrasound transducer alone was also associated with increased risk of neonatal intubation for resuscitation (odds ratio, 1.22; 95% confidence interval, 1.03–1.44). A greater risk of severe neonatal acidemia was observed both in the ultrasound transducer (odds ratio, 2.78; 95% confidence interval, 2.23–3.48) and concurrent ultrasound transducer and maternal heart rate recording (odds ratio, 1.37; 95% confidence interval, 1.05–1.78) groups compared with those monitored with fetal scalp electrodes. No difference in risk of neonatal encephalopathy was found between newborns monitored with concurrent ultrasound transducer and maternal heart rate recording and those monitored with fetal scalp electrodes. The use of external ultrasound transducer monitoring of fetal heart rate without simultaneous maternal heart rate recording is associated with higher rates of neonatal encephalopathy and severe neonatal acidemia. We suggest that either external fetal heart rate monitoring with concurrent maternal heart rate recording or internal fetal scalp electrode be used routinely as a fetal surveillance tool in term deliveries. [Display omitted] [ABSTRACT FROM AUTHOR]

Background and Objectives: Monitoring pregnancies with fetal growth restriction (FGR) presents a challenge, especially concerning the time of delivery in cases of early preterm pregnancies below 32 weeks. The aim of our study was to compare different diagnostic parameters in growth-restricted preterm neonates with and without morbidity/mortality and to determine sensitivity and specificity of diagnostic parameters for monitoring preterm pregnancies with early preterm fetal growth restriction below 32 weeks. Materials and Methods: Our clinical study evaluated 120 cases of early preterm deliveries, with gestational age ≤ 32 + 0 weeks, with prenatally diagnosed placental FGR. All the patients were divided into three groups of 40 cases each based on neonatal condition,: I—Neonates with morbidity/mortality (NMM); II—Neonates without morbidity with acidosis/asphyxia (NAA); III—Neonates without neonatal morbidity/acidosis/asphyxia (NWMAA). Results: Amniotic fluid index (AFI) was lower in NMM, while NWMAA had higher biophysical profile scores (BPS). UA PI was lower in NWMAA. NWMAA had higher MCA PI and CPR and fewer cases with CPR 95th‰ or absent/reversed A wave, and pulsatile blood flow in umbilical vein (UV). The incidence of pathological fetal heart rate monitoring (FHRM) was higher in NMM and NAA, although the difference was not statistically significant. ROC calculated by defining a bad outcome as NMM and a good outcome as NAA and NWMAA showed the best sensitivity in DV PIi. ROC calculated by defined bad outcome in NMM and NAA and good outcome in NWMAA showed the best sensitivity in MCA PI. Conclusions: In early fetal growth restriction normal cerebral blood flow strongly predicts good outcomes, while pathological venous blood flow is associated with bad outcomes. In fetal growth restriction before 32 weeks, individualized expectant management remains the best option for the optimal timing of delivery.

Objective: Here, we tested the correlation between maternal placental growth factor (PlGF) and fetal heart rate (FHR) monitoring findings.Methods: We included 35 women with single pregnancies from 35 to 42 weeks of gestation who were hospitalized owing to onset of labor. Blood samples were collected at the start of labor. Intrapartum FHR monitoring parameters included total deceleration area, average deceleration area (mean deceleration area per 10 min), and five-tier classification level.Results: Of the 35 women, 26 (74%) had vaginal delivery and 9 (26%) had cesarean section. After excluding 2 women who had cesarean section for arrest of labor, we analyzed 26 women who had vaginal delivery (VD group) and 7 who had cesarean section for fetal indications (CSF group). PlGF level was significantly higher in the VD group (157 ± 106 pg/ml) than in the CSF group (74 ± 62 pg/ml) (P = 0.03). There were no significant correlations between PlGF and total (r = -0.07) or average (r = -0.08) deceleration area.　There was a significant negative correlation (r = -0.42, P = 0.01) between PlGF and the percentage of level 3 or higher in the five-level classification.Conclusion: PlGF was correlated with FHR monitoring findings and might be a promising biomarker of intrapartum fetal function. [ABSTRACT FROM AUTHOR]

Background: The aim of the present study was to clarify fetal heart rate (FHR) evolution patterns in infants with cerebral palsy (CP) according to different types of umbilical cord complications.Methods: This case-control study included children born: with a birth weight   ≥2000 g, at gestational age   ≥33 weeks, with disability due to CP, and between 2009 and 2014. Obstetric characteristics and FHR patterns were compared among patients with CP associated with (126 cases) and without (594 controls) umbilical cord complications.Results: There were 32 umbilical cord prolapse cases and 94 cases with coexistent antenatal umbilical cord complications. Compared with the control group, the persistent non-reassuring pattern was more frequent in cases with coexistent antenatal umbilical cord complications (p = 0.012). A reassuring FHR pattern was observed on admission, but resulted in prolonged deceleration, especially during the first stage of labor, and was significantly identified in 69% of cases with umbilical cord prolapse and 35% of cases with antenatal cord complications, compared to 17% of control cases (p < 0.001).Conclusion: Hypercoiled cord and abnormal placental umbilical cord insertion, may be associated with CP due to acute hypoxic-ischemic injury as well as sub-acute or chronic adverse events during pregnancy, while umbilical cord prolapse may be characterized by acute hypoxic-ischemic injury during delivery. [ABSTRACT FROM AUTHOR]

Aim: This study aimed to clarify the feasibility of a mobile cardiotocogram (CTG) device for self‐monitoring fetal heart rate (FHR) in low‐risk singleton pregnant women. Methods: This study was conducted at six university hospitals and seven maternity clinics in Japan. Using a mobile cardiotocogram device (iCTG, Melody International Ltd., Kagawa, Japan), participants of more than 34 gestational weeks measured the FHR by themselves at least once a week until hospitalization for delivery. We evaluated the acquisition rate of evaluable FHR recordings and the frequency of abnormal FHR patterns according to the CTG classification system of the Japan Society of Obstetrics and Gynecology (JSOG). The participants also underwent a questionnaire survey after delivery to evaluate their satisfaction level of self‐monitoring FHR using the mobile CTG device. Results: A total of 1278 FHR recordings from 101 women were analyzed. Among them, 1276 (99.8%) were readable for more than 10 min continuously, and the median percentage of the total readable period in each recording was 98.9% (range, 51.4–100). According to the JSOG classification system, 1245 (97.6%), 9 (0.7%), 18 (1.4%), and four (0.3%) FHR patterns were classified as levels 1, 2, 3, and 4, respectively. The questionnaire survey revealed high participant satisfaction with FHR self‐monitoring using the iCTG. Conclusion: The mobile CTG device is a feasible tool for self‐monitoring FHR, with a high participant satisfaction level. [ABSTRACT FROM AUTHOR]

Introduction: Labour, a physiological process for majority of foetuses, often acts as a challenge to foetal reserves causing foetal hypoxia. Foetal monitoring with intrapartum cardiotocography is an important tool to enable timely intervention to reduce adverse neonatal outcomes like postnatal cerebral palsy. Aim: To determine an association between cardiotocography tracing and umbilical artery cord blood pH in term pregnancies in labour where the influence of drugs and the presence of other comorbid medical/obstetric adverse outcomes have been ruled out. Materials and Methods: This cross-sectional, hospital-based, observational study involved singleton uncomplicated term pregnancies with a normal baseline cardiotocography and spontaneous labour onset and progression admitted to the labour ward of R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India. Intrapartum continuous cardiotocography traces were recorded and those showing abnormal traces were documented and delivery expedited within two hours. Total of 90 such consecutive women were included in the study and umbilical arterial cord blood sample was taken for all these pregnancies immediate postpartum. Cardiotocography traces were then statistically compared with cord blood parameters and the findings were computed using Statistical Package for the Social Sciences (SPSS) software version 22.0. Results: Out of 90 participants the mean age was 24.21±3.43 years, most (43, 47.8%) of them were in between 21 to 25 years. Of the abnormal traces, 51 (56.7%) were NICE Category II (Suspicious) and 39 (43.3%) were NICE category III (pathological). Cord blood analysis revealed that 40% had a pH<7, 44.4% had blood lactate levels above 6 mmol/L and another 47.7% had a base deficit ≥12 mmol/L. On crosstabulation and Chi-square analysis, these were all found to be statistically significant (p-value <0.05). Abnormalities of Foetal Heart Rate (FHR) and baseline variability had higher Odds ratio of predicting umbilical artery acidemia with Odd's ratio for baseline variability abnormality as high as 2.768. Conclusion: Although there has been a rising trend towards operative deliveries, the overall incidence of neonatal morbidity due to cerebral palsy is still on the rise. Cardiotocography can be a very important tool to identify neonatal acidosis in "at risk" foetuses and helps in timely intervention giving long term best outcomes. [ABSTRACT FROM AUTHOR]

Introduction: A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. Material and Methods: A before‐and‐after design was used. Cohort I (n = 160 210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n = 166 558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2–3). Secondary outcomes were birth acidemia (umbilical artery pH <7.05 and base excess < −12 mmol/L or pH <7.00), A‐criteria for neonatal hypothermia treatment, 5‐min Apgar scores <4 and <7, neonatal seizures, meconium aspiration, neonatal mortality and delivery mode. Logistic regression was used (period II vs period I), and results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). Results: There were no statistically significant differences in HIE 2–3 (aOR 1.27; 95% CI 0.97–1.66), proportion of neonates meeting A‐criteria for hypothermia treatment (aOR 0.96; 95% CI 0.89–1.04) or neonatal mortality (aOR 0.68; 95% CI 0.39–1.18) between the cohorts. Birth acidemia (aOR 1.36; 95% CI 1.25–1.48), 5‐min Apgar scores <7 (aOR 1.27; 95% CI 1.18–1.36) and <4 (aOR 1.40; 95% CI 1.17–1.66) occurred more often in cohort II. The absolute risk difference for HIE 2–3 was 0.02% (95% CI 0.00–0.04). Operative delivery (vacuum or cesarean) rates were lower in cohort II (aOR 0.82; 95% CI 0.80–0.85 and aOR 0.94; 95% CI 0.91–0.97, respectively). Conclusions: Although not statistically significant, a small increase in the incidence of HIE 2–3 after implementation of the revised CTG classification cannot be excluded. Operative deliveries were fewer but incidences of acidemia and low Apgar scores were higher in the latter cohort. This warrants further in‐depth analyses before a full re‐evaluation of the revised classification can be made. [ABSTRACT FROM AUTHOR]

We aimed to evaluate the cardiotocograph (CTG) traces of 224 women infected with novel coronavirus 2019 (COVID-19) and analyze whether changes in the CTG traces are related to the severity of COVID-19. We designed a prospective cohort study. Two-hundred and twenty-four women who had a single pregnancy of 32 weeks or more, and tested positive for SARS-CoV-2 were included. Clinical diagnosis and classifications were made according to the Chinese management guideline for COVID-19 (version 6.0). Patients were classified into categories as mild, moderate, severe and the CTG traces were observed comparing the hospital admission with the third day of positivity. There was no statistically significant relationship between COVID-19 severity and CTG category, variability, tachycardia, bradycardia, acceleration, deceleration, and uterine contractility, Apgar 1st and 5th min. Maternal COVID-19 infection can cause changes that can be observed in CTG. Regardless of the severity of the disease, COVID-19 infection is associated with changes in CTG. The increase in the baseline is the most obvious change. [ABSTRACT FROM AUTHOR]

The aim of this study is to determine the quality of the foetal heart rate (FHR) recording, defined as signal loss, during preterm labour below 28 weeks gestational age (GA) and contribute to the discussion if cardiotocography (CTG) is of value for the extreme preterm foetus. From January 2010 to December 2019 a retrospective study was conducted with data of 95 FHR recordings of singletons born between 24 and 28 weeks GA at the Amsterdam University Medical Centre, location VUmc. FHR tracings had a duration of at least 30 min and were obtained via external ultrasound mode. Data of all recordings were divided in two groups according to gestation (24–26 weeks and 26–28 weeks). Signal loss was analysed. Statistical significance was calculated by non-parametric tests and chi-square tests. The median signal loss and the proportion of cases exceeding the International Federation of Gynaecology and Obstetrics Guidelines (FIGO) threshold of 20% signal loss were calculated. One-third of the recordings exceeded the 20% FIGO-criterion for adequate signal quality during the first stage of labour. In the second stage, this was nearly 75%. Similarly, the median signal loss was 13% during the first and 30% during the second stage of labour (p<0.01). The quality of FHR monitoring in the extreme preterm foetus is inadequate in a large proportion of the foetuses, especially during the second stage. FHR monitoring is therefore controversial and should be used with caution. [ABSTRACT FROM AUTHOR]

Fetal, perinatal, and neonatal asphyxia are vital health issues for the most vulnerable groups in human beings, including fetuses, newborns, and infants. Severe reduction in oxygen and blood supply to the fetal brain can cause hypoxic-ischemic encephalopathy (HIE), leading to long-term neurological disorders, including mental impairment and cerebral palsy. Such neurological disorders are major healthcare concerns. Therefore, there has been a continuous effort to develop clinically useful diagnostic tools for accurately and quantitatively measuring and monitoring blood and oxygen supply to the fetal and neonatal brain to avoid severe consequences of asphyxia HIE and neonatal encephalopathy. Major diagnostic technologies used for this purpose include fetal heart rate monitoring, fetus scalp blood sampling, ultrasound imaging, magnetic resonance imaging, X-ray computed tomography, and nuclear medicine. In addition, given the limitations and shortcomings of traditional diagnostic methods, emerging technologies such as near-infrared spectroscopy and photoacoustic imaging have also been introduced as stand-alone or complementary solutions to address this critical gap in fetal and neonatal care. This review provides a thorough overview of the traditional and emerging technologies for monitoring fetal and neonatal brain oxygenation status and describes their clinical utility, performance, advantages, and disadvantages. [ABSTRACT FROM AUTHOR]

Umblical cord prolapse is a very rare condition. It is an obstetric emergency that can have unfavourable consequences for the fetus. We aimed to investigate the determinants for poor perinatal outcome following emergency cesarean delivery performed due to umbilical cord prolapse in uncomplicated term pregnancies. Fifty-three term pregnants and their babies born with cesarean section due to umbilical cord prolapse were included in this retrospective study. Newborns who were taken to neonatal intensive care unit were defined as poor perinatal outcome. Eleven of fifty-three newborns needed intensive care. All of them were discharged without any problem after the treatment. The presence of fetal distress detected before or during the umbilical cord prolapse was found to be the only marker associated with poor perinatal outcome. Abnormalities detected in fetal heart rate monitoring before or during umblical cord prolapse increase poor perinatal outcome in uncomplicated term pregnancies. [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 obstetric triage tool (OBTT) is used to record the clinical findings following obstetric triage (OBT). The recorded OBTT provides midwives with clinical information leading to diagnosis of existing and potential maternal and foetal problems that may lead to intrapartum complications, planning of specific midwifery care and communication among the midwifery team about the woman in labour. Aim: This study aimed to explore and describe midwives' experiences of the OBTT used during admission of women in labour in the Bojanala district. Setting: This study was conducted in the two selected facilities in Bojanala district in North West province. Methods: This study is a derivative of a major study, entitled 'Midwives' experiences of OBT by midwives in the Bojanala district'. A qualitative, explorative and descriptive research design was followed. Nine purposefully sampled midwives with over 5 years of clinical midwifery experience, employed in the Bojanala district, attended a semistructured interview. Data obtained were analysed using Colaizzi's descriptive method of data analysis according to the themes and categories which emerged. Results: One central theme with 10 subthemes emerged. Midwives verbalised their dissatisfaction with the current OBTT and made recommendations for the revision of the tool. Conclusion: The study highlighted midwives' experiences of the OBTT and recommendations for an ideal tool based on their knowledge of admission of a woman in labour. Contribution: This study provides a new OBTT from midwives' perspectives that could be useful in improving pregnancy and labour outcomes in clinical midwifery practice. [ABSTRACT FROM AUTHOR]

The study focused on the application value of ultrasound Doppler fetal heart rate detection algorithm based on short-time Fourier transform (STFT) in the diagnosis of twin-to-twin selective intrauterine growth restriction (sIUGR) and the correlation between twin-to-twin sIUGR and sFas/sFasL levels of umbilical cord blood. The normalized method was introduced into the STFT algorithm to optimize it to detect the fetal instantaneous heart rate. 82 pregnant women with twin pregnancies were selected as the research subjects and they were divided into the restricted group (41 cases) and the control group (41 cases) according to whether the fetus had selective growth restriction. The two groups were compared for the differences in the fetal mortality, complication rate, and sFas/sFasL expression levels. The results showed that the STFT-based ultrasonic Doppler fetal heart rate detection algorithm could ensure the quality of the fetal heart rate signal and had high resolution at the 200–400 Hz characteristic frequency band and that the accuracy in distinguishing S1 and S2 was 5.8% higher than that of the traditional autocorrelation algorithm. The proportion of abnormal fetal heart rate in the restricted group was significantly higher than that in the control group (P < 0.05), birth weight was significantly lower than that in the control group (P < 0.05), and fetal mortality was significantly higher than that in the control group (P < 0.05). There was no statistical difference in the incidence of complications between the two groups (P > 0.05). In restricted group, the content of sFas in cord blood was (3326.54 ± 317.42) pg/mL and that in the control group was (2003.29 ± 196.45) pg/mL. The content of sFas in cord blood of the restricted group was significantly higher than that of the control group (P < 0.01). In the restricted group, the content of sFasL in cord blood was (382.52 ± 36.17) pg/mL, and that in the control group was (180.84 ± 16.20) pg/mL. The content of sFasL in cord blood of the restricted group was significantly higher than that of the control group (P < 0.001). It was concluded that the STFT-based ultrasound Doppler fetal heart rate monitoring is beneficial to early diagnosis and timely intervention of twin-to-twin sIUGR. [ABSTRACT FROM AUTHOR]

Background: A new wireless and beltless monitoring device utilising fetal and maternal electrocardiography (ECG) and uterine electromyography, known as 'non-invasive fetal ECG' (NIFECG) was registered for clinical use in Australia in 2018. The safety and reliability of NIFECG has been demonstrated in controlled settings for short periods during labour. As far as we are aware, at the time our study commenced, this was globally the first trial of such a device in an authentic clinical setting for the entire duration of a woman's labour. Methods: This study aimed to assess the feasibility of using NIFECG fetal monitoring for women undergoing continuous electronic fetal monitoring during labour and birth. Women were eligible to participate in the study if they were at 36 weeks gestation or greater with a singleton pregnancy, planning to give birth vaginally and with obstetric indications as per local protocol (NSW Health Fetal Heart Rate Monitoring Guideline GL2018_025. 2018) for continuous intrapartum fetal monitoring. Written informed consent was received from participating women in antenatal clinic prior to the onset of labour. This single site clinical feasibility study took place between January and July 2020 at the Royal Hospital for Women in Sydney, Australia. Quantitative and qualitative data were collected to inform the analysis of results using the NASSS (Non-adoption, Abandonment, Scale up, Spread and Sustainability) framework, a validated tool for analysing the implementation of new health technologies into clinical settings. Results: Women responded positively about the comfort and freedom of movement afforded by the NIFECG. Midwives reported that when no loss of contact occurred, the device enabled them to focus less on the technology and more on supporting women's physical and emotional needs during labour. Midwives and obstetricians noticed the benefits for women but expressed a need for greater certainty about the reliability of the signal. Conclusion: The NIFECG device enables freedom of movement and positioning for labouring women and was well received by women and the majority of clinicians. Whilst measurement of the uterine activity was reliable, there was uncertainty for clinicians in relation to loss of contact of the fetal heart rate. If this can be ameliorated the device shows potential to be used as routinely as cardiotocography (CTG) for fetal monitoring. This is the first time the NASSS framework has been used to synthesise the implementation needs of a health technology in the care of women during labour and birth. Our findings contribute new knowledge about the determinants for implementation of a complex technology in a maternity care setting. Trial registration: The Universal Trial Number is reU1111-1228-9845 and the Australian and New Zealand Clinical Trial Registration Number is 12619000293167p. Trial registration occurred on the 20 February, 2019. The trial protocol may be viewed at http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377027 [ABSTRACT FROM AUTHOR]

A method for the automatic determination of the fetus health status using Cardiotocography (CTG) and computer-based machine learning algorithms was developed. Five computation friendly machine learning algorithms were used to create multiclass classification models to predict the fetus health status from secondary CTG dataset containing normal, suspected and pathologic data available at University California Irvine Machine Learning Repository. Furthermore, a comparative analysis among the built models was executed. According to the comparative analysis, the best model to automatically detect fetal health was the extreme gradient boosting algorithm-based model with an accuracy of 96.7% and an F1-Score of 0.963 in the pathologic class. This finding thus has the potential to diagnose fetal heart conditions unsupervised, and more efficiently and effectively. [ABSTRACT FROM AUTHOR]

Background: This study follows the 2017 UK INFANT Collaborative Group RCT, which compared neonatal outcomes with and without the use of the INFANT cardiotocograph decision support system for over 46 000 patients in labour. The original trial failed to demonstrate a significant improvement to neonatal outcomes; however, the study design was subject to methodological critique. Aims: This Australian retrospective cohort study aimed to report perinatal outcomes before and after the introduction of INFANT decision support software for cardiotocograph use in labour. Materials and Methods: The study cohort was divided into two equivalent 18‐month epochs, before and after the introduction of INFANT‐Guardian® CTG decision support system. Propensity score matching analysis was undertaken to balance pre‐ and post‐implementation groups by baseline covariates. The matched cohort included 11 154 public‐funded women between November 2016 and 2019, with a singleton live fetus ≥34 + 0 weeks, being induced or in spontaneous labour. The main outcome measures were: a composite measure of serious adverse neonatal outcome comprising of one or more of: admission to intensive care nursery >48 h, Apgar <4 at 5 min, cord arterial pH <7.0, hypoxic ischaemic encephalopathy grade 2 or 3, therapeutic hypothermia, neonatal death. Results: The incidence of the composite primary outcome was significantly lower following implementation of INFANT (0.57% vs. 1.00%; OR 0.57, 95%CI 0.37–0.88; P = 0.01). A significant reduction in nursery admission >48 h was also observed (0.05% vs. 0.30%; OR 0.18, 95%CI 0.05–0.60; P = 0.002). Conclusions: INFANT software is associated with a reduction in serious adverse neonatal outcomes, without increasing the rate of operative delivery. [ABSTRACT FROM AUTHOR]

Breathing and sleep of the fetus and mother show changes over the course of pregnancy. Knowledge of the development of fetal respiration is essential for perinatal medicine. Surfactant is only made available in sufficient quantities from the 35th week of pregnancy. In the case of an earlier premature birth, betamethasone must be administered twice. This medication could make a decisive contribution to a reduction in perinatal mortality and morbidity. Knowledge of fetal sleep enables better fetal monitoring through cardiotocography (CTG). Deep sleep phases resemble a hypoxic state in the CTG. Changes in maternal respiration during labor allow optimal oxygen supply to the fetus. Disorders of maternal breathing e.g. bronchial asthma can be associated with an increased likelihood of a disease from the pregnancy-induced hypertension group. Sleep disorders have so far not played a role in assessing the risk profile of pregnancy. Studies show that obstructive sleep apnea syndrome is associated with an increased risk of a disease from the pregnancy-associated hypertension group and other complications in both the mother and the fetus. In the future, sleep disorders should be diagnosed during pregnancy and included in therapeutic considerations. [ABSTRACT FROM AUTHOR]

Objective  This study aimed to evaluate whether intrapartum fetal electrocardiogram (ECG) tracings with ST-elevation or depression occur more frequently in each stage of labor in small-for-gestational age (SGA) or large-for-gestational age (LGA), as compared with appropriate-for-gestational age (AGA) fetuses. Study Design  We conducted a secondary analysis of a large, multicenter trial in which laboring patients underwent fetal ECG waveform-analysis. We excluded participants with diabetes mellitus and major fetal anomalies. Birth weight was categorized as SGA (<10th percentile), LGA (>90th percentile), or AGA (10–90th percentile) by using a gender and race/ethnicity specific nomogram. In adjusted analyses, the frequency of ECG tracings with ST-depression or ST-elevation without depression was compared according to birthweight categories and labor stage. Results  Our study included 4,971 laboring patients in the first stage and 4,074 in the second stage. During the first stage of labor, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (6.7 vs. 5.5%; adjusted odds ratio [aOR]: 1.41, 95% confidence interval [CI]: 0.93–2.13), or in ST-elevation without depression (35.8 vs. 34.1%; aOR: 1.17, 95% CI: 0.94–1.46). During the second stage, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (1.6 vs. 2.0%; aOR: 0.69, 95% CI: 0.27–1.73), or in ST-elevation without depression (16.2 vs. 18.1%; aOR: 0.90, 95% CI: 0.67–1.22). During the first stage of labor, there were no differences in the frequency of ST-depression in LGA fetuses compared with AGA fetuses (6.3 vs. 5.5%; aOR: 0.97, 95% CI: 0.60–1.57), or in ST-elevation without depression (33.1 vs. 34.1%; aOR: 0.80, 95% CI: 0.62–1.03); during the second stage of labor, the frequency of ST-depression in LGA compared with AGA fetuses (2.5 vs. 2.0%, aOR: 1.36, 95% CI: 0.61–3.03), and in ST-elevation without depression (15.5 vs. 18.1%; aOR: 0.83, 95% CI: 0.58–1.18) were similar as well. Conclusion  The frequency of intrapartum fetal ECG tracings with ST-events is similar among SGA, AGA, and LGA fetuses. Key Points SGA and LGA neonates are at increased risk of cardiac dysfunction. Fetal ECG has been used to evaluate fetal response to hypoxia. Fetal ST-elevation and ST-depression occur during hypoxia. Frequency of intrapartum ST-events is similar among SGA, AGA and LGA fetuses. [ABSTRACT FROM AUTHOR]

Background: Obstetric induction procedures are expensive, and little is known of the specific difference in cost between inpatient and outpatient protocols for these procedures. Objective: The objective of this study was to examine the difference in health care costs, maternal and neonatal morbidity, and cesarean birth rates for inpatient versus outpatient Foley induction protocols. Material and methods: We conducted a retrospective study using deliveries from 2013 to 2015 that received an outpatient or inpatient Foley catheter induction. Inductions were matched by race, parity, and maternal age. We used univariate and multivariate logistic regression to test the association between type of induction, length of stay, and cost. Maternal and neonatal factors and cesarean rates were also considered. Results: A total of 163 outpatient Foley inductions were matched 1:1 to inpatient inductions. Outpatient inductions were more likely to have a shorter length of hospitalization from admission to discharge (a 7.17‐hour difference, 95% CI, 71.00, 77.59) and lower costs of hospitalization ($408 per patient, 95% CI, 4305, 4714). In the univariate analysis, there was no difference in rate of cesarean birth (OR 0.95, 95% CI, 0.61, 1.48). However, in the multivariate analysis, there was a decreased rate of cesarean for outpatient inductions (OR 0.5, 95% CI, 0.26, 0.97). Conclusions: Outpatient Foley catheter induction appears to be a safe, cost‐effective method for induction of labor. Generating protocols allowing patients to receive quality care in an outpatient setting is increasingly important in current health care environments. [ABSTRACT FROM AUTHOR]

Objective: In recent years deceleration area has received increasing attention as a potential predictor of intrapartum fetal hypoxia. In several studies, the area has been manually esteemed as triangular in shape, which might introduce bias. In addition, the commonly used outcome acidemia in umbilical artery is affected by mode of delivery. We wanted to investigate the association between the variable deceleration features area, duration, depth and cumulative deceleration area (30 and 60 min) and intrapartum fetal acidemia measured as lactate concentration at fetal scalp blood sampling (FBS) in immediate connection to the decelerations.Study Design: In the source population of 1070 labors at Karolinska University Hospital, Sweden, with FBS performed on indication, we found 507 fetuses with predominantly variable decelerations as the indication for FBS. We examined the last 60- and 30-minutes of fetal monitoring preceding the FBS with focus on deceleration area, duration and depth. The contours of the decelerations were outlined manually but the area was calculated with a computer software program. We assessed area, duration and depth both as mean values per deceleration and as cumulative values during the time period of interest. We analyzed Pearson correlations and area under receiver operating characteristics curves (AUC). We also performed an adjusted analysis, with baseline frequency, variability, and accelerations as covariates.Results: Deceleration area and duration were the best predictors of intrapartum fetal acidemia (fetal lactate concentration >4.8 mmol/L measured with Lactate Pro™) with AUCs of 0.671 (0.682) and 0.678 (0.683) for cumulative measures during 30 (60) minutes prior to FBS, compared to deceleration depth with AUC of 0.632 (0.631). Corresponding Pearson correlations in 30-min (60-min) groups were 0.329 (0.335) and 0.358 (0.354) for deceleration area and duration and 0.212 (0.204) for deceleration depth. Using 250 beats cumulative cut-off for deceleration area during last 30 min, 71% vs. 43% were acidemic and non-acidemic, odds ratio = 3.2 (95% CI 1.7-6.1).Conclusions: Deceleration area and duration were better predictors of intrapartum fetal acidemia than deceleration depth. Cumulative deceleration area >250 beats during 30 min was associated with three-fold higher odds of intrapartum acidemia compared to <250 beats. [ABSTRACT FROM AUTHOR]

Objectives: Computer CTG analysis (cCTG) included short-term variation (STV) is one of the methods of monitoring fetal condition during delivery. The aim of our study was to define appropriability of STV measured within 1 hour before delivery in prediction of neonatal outcomes. Material and methods: The retrospective study included 1014 pregnant women, who gave birth in the Department of Obstetrics and Perinatology. Participants were divided into two groups: group 1 -- term pregnancies (37-41 weeks) and group 2 -- preterm pregnancies (lower than 37 weeks). In each of them, two subgroups have been separated: control (STV = 3 ms) and study group (STV < 3 ms). Results: In both groups 1 and 2, there were no statistically significant differences related to Apgar scores in 1st, 3rd and 5th minute between group with STV < 3 ms and group with STV > 3 ms Moreover, for 37-41 weeks the sensitivity, specificity, positive predictive value and negative predictive value were: 22.7%, 83.9%, 3.3% and 97.8% and for lower than 37: 45.7%, 65.4%, 47.1%, 64.2% in 1st minute after delivery. In group 1 the area under curve (AUC) measurements were 0.45 (95% CI: 0.32-0.58) for 1st minute and 0.55 (95% CI: 0.35-0.74) for 5th minute and in group 2: 0.58 (95% CI: 0.45-0.71) for 1st minute and 0.57 (95% CI: 0.42-0.72) for 5th minute. Conclusions: High specificity and negative predictive value of STV indicates a good Apgar score of newborns in term pregnancies. Analysis of STV in preterm pregnancy is not clear. Fetal well-being in preterm pregnancy should include STV and other non-invasive and invasive tools. [ABSTRACT FROM AUTHOR]

Cesarean section is the most commonly performed operation in the world with an ever-increasing frequency. Among the most common indications for cesarean section are abnormalities of pelvis leading to fetopelvic disproportion during labor, placenta previa, placental abruption, preeclampsia, concomitant diseases of the mother, as well as fetal conditions leading to distress, malpresentation of the fetus, etc. Despite the definite benefits it brings to the mother and fetus, there are a number of early and late complications that worsen obstetric results in women who have given birth by cesarean section. There is evidence that the incidence of cesarean sections is higher than optimal and continues to increase. Often a cesarean section is performed due to relative indications and in a large number of cases a safe vaginal birth is possible. The proportion of emergency cesarean sections performed in the second period of labor is not small. This necessitates a review of obstetric behavior, in particular the usage of operative vaginal delivery (OVD) and cardiotocographic (CTG) monitoring of the fetus in the second period of labor. In contrast to the ever-increasing incidence of cesarean section, the incidence of operative vaginal delivery with both vacuum extractor and forceps has decreased significantly in recent years. This trend is to the detriment of obstetric practice as OVD in the hands of an experienced obstetrician is a safe alternative to cesarean section during vaginal birth. Abnormalities in the fetal heart rate(FHR) is the second most common indication for all cesarean sections. It is estimated that between 65% and 85% of all births at some point have a category II FHR that include bradycardia with variability, tachycardia, minimal variability, no variability with no recurrent decelerations, marked variability, absence of induced accelerations even after fetal stimulation, recurrent variable decelerations with minimal or moderate baseline variability, prolonged decelerations lasting more than two minutes, but less than ten minutes, recurrent late decelerations with moderate variability, variable decelerations with other characteristics such as slow return to baseline, overshooting the baseline, or 'shoulders'. A clear approach in these cases is paramount to the outcome of the labor. Knowledge and proper management of operative vaginal birth by vacuum extractor or forceps, as well as the correct interpretation of CTG patterns can significantly reduce the frequency of cesarean sections during labor without adversely affecting the condition of the mother or newborn. These methods should be mastered as much as possible during the specializations in obstetrics and gynecology in order to improve the outcome of a normal labor and reduce the frequency of cesarean section in the future. [ABSTRACT FROM AUTHOR]

This study examined predictive factors, in addition to Category II Fetal Herat Rate (FHR) monitoring that might imply fetal acidosis and risk of asphyxia. This retrospective cohort study compared three groups of patients with Category II FHR monitoring indicating need for imminent delivery. Groups were divided based on fetal cord blood pH: pH≤7.0, 7.0

Diagnosis of fetal heart rate is very crucial during the prenatal phase of pregnancy as any delay in the early detection and prevention of anomalies in heart functioning may lead to devastating and life-threatening consequences to the child even after birth. Hence fetal electrocardiogram extraction is to be analyzed using either internal or external monitoring devices. One of the main problems is the intrusion of undesirable noise into the biomedical data, leading to misinterpretation of the diagnosis. Therefore, an effective way to identify and suppress such noise is to be formulated for extracting precise information. Several techniques have been excogitated over 200 samples collected from the dataset of MIT- BIH Arrhythmia, and on cross-validation, SVM Classifier with Trusted Ad – Hoc On Demand Distance Vector routing algorithm has been ascertained to have sensitivity to diverse noise at the rate of 88.4%. Adaptive multiband filtering technique eliminates almost all the noise within the bounded ranges that are already being medically defined. This filter offers high speed yet it occupies more area and glitches when the coefficients are increased by 15. Hence an energy-efficient filter is proposed and results are simulated using MATLAB 2013b, Xilinx ISE 9.1, ModelSim 10.0b, and Cadence Virtuoso under 90 nm technology for synthesis of area, power, and delay reports. [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]

Electronic fetal heart rate (FHR) monitoring is a technical means to evaluate the state of the fetus in the uterus by monitoring FHR. The main purpose is to detect intrauterine hypoxia and take corresponding medical measures timely. Because the fetus sleeps quietly for up to 1 hour sometimes, ultrasound Doppler is not easy to continuously detect for a long time. The electronic fetal monitor obtains the fetal heart rate, which not only improves the accuracy and comfort, but also the convenient implementation of long-term monitoring. It is beneficial to reduce perinatal fetal morbidity and mortality. This study used maternal–fetal Holter monitor which is based on the technology of fetal electrocardiograph (FECG) to collect the FHR, and then design algorithm to extract the baseline FHR, acceleration, variation, sleep-wake cycle and nonlinear parameters. There were significant differences in the 22 parameters between the normal and the suspicious group. Using the 22 characteristic parameters, the support vector machine was used to classify the normal and the suspected group of fetuses. 80% of the data was used to train a classification model. The remaining 20% of the data was used as a test set and its accuracy reached 93.75%. [ABSTRACT FROM AUTHOR]

Wharton’s jelly is a specialized connective tissue surrounding and protecting umbilical cord vessels. In its absence, the vessels are exposed to the risk of compression or rupture. Because the condition is very rare and there are no available antepartum investigation methods for diagnosis, these cases are usually discovered after delivery, frequently after in utero fetal demise. We report the fortunate case of a 29-year-old nulliparous woman, with an uncomplicated pregnancy, admitted at 39 weeks in labor where a persistently abnormal cardiotocographic trace led to delivery by cesarean section of a healthy 3500 g newborn. After delivery, a Wharton’s jelly anomaly was identified at the abdominal umbilical insertion (umbilical cord vessels, approximately 1 cm in length, were completely uncovered by Wharton’s jelly), which required surgical thread elective ligation. In the presence of a persistently abnormal CTG trace, in a pregnancy with no clinical settings suggestive of either chronic or acute fetal hypoxemia, the absence of Wharton’s jelly should be taken into consideration in the differential diagnosis. [ABSTRACT FROM AUTHOR]

Background: Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan.Methods: This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital.Results: For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%).Conclusion: Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections. [ABSTRACT FROM AUTHOR]

Aim. The validation of an artificial intelligent system (AIS) - Ankara System Version 5.0 - for the interpretation of antepartum fetal heart rate (FHR) tracings. Methodology. This study consisted of 3100 assuring FHR tracings obtained from normal pregnancies and 467 non-assuring FHR tracings (13.09% of all cases) obtained from pregnancies with various types of maternal health risk factors and/or obstetric complications. Assuring tracings from complicated pregnancies and non-assuring tracings from normal pregnancies were not included in the study, in order to have a qualified database. All tracings were evaluated twice by a single expert. The first evaluation took place just after data acquisition and the second occurred two weeks later without knowledge of the clinical characteristics of the patient (unmatched tracing evaluations were not included in the database). A total of 3032 of them were used for the training of the algorithms, while 535 of them were used for testing and validation. A Doppler ultrasound fetal heart rate monitor with autocorrelation (Hewlett Packard, 8040A) was connected to a computer system by a special frame grabber. Ten-minute recordings were kept in a special file for pattern recognition and decision making. Wavelet transformation was used for feature extraction as the first step of pattern recognition. Unsupervised and supervised artificial neural networks (vector quantization and backpropagation learning algorithm, respectively), the second step of pattern recognition, were used as the classification steps of the hybrid AIS. Results. The testing group consisted of 480 assuring and 55 non-assuring tracings. The sensitivity and specificity of the Ankara System (Version 5.0) were found to be 61.25% and 98.68%, respectively, while the positive predictive value and negative predictive value were calculated to be 89.1% and 93.5%, respectively. Conclusions. This hybrid AIS (Ankara System Version 5.0) might be an effective alternative decision-making tool in the routine practice for the interpretation of FHR tracings. [ABSTRACT FROM AUTHOR]

Background: Fetal scalp blood sampling for lactate measurement (FBSLM) is sometimes used to assist in identification of the need for expedited birth in the presence of an abnormal cardiotocograph (CTG). However, there is no randomised controlled trial evidence to support this. Aim: To determine whether adding FBSLM reduces the risk of birth by emergency caesarean section in labours complicated by an abnormal CTG, compared with CTG without FBS. Material and Methods: Labouring women at a tertiary maternity hospital in Melbourne, Australia with a singleton, cephalic presentation, at ≥37 weeks gestation with an abnormal CTG pattern were randomised to the intervention (n = 61), with intermittent FBSLM in addition to CTG monitoring, or control (CTG without FBS, n = 62). The primary outcome was rate of birth by caesarean section. Secondary outcomes included overall operative birth and fetal and neonatal safety endpoints. Trial registration: ACTRN12611000172909. Results: The smaller than anticipated sample was unable to demonstrate an effect from adding FBSLM to CTG monitoring on birth by caesarean section vs monitoring by CTG without FBS (25/61 and 28/62 respectively, P = 0.64, risk ratio 0.91, 95% confidence intervals 0.60–1.36). One newborn infant in the CTG group met the criteria for the composite neonatal outcome of death or serious outcome, neonatal encephalopathy, five‐minute Apgar score < 4, neonatal resuscitation, admission to neonatal intensive care unit for 96 h or more. Conclusion: We were unable to provide robust evidence of the effectiveness of FBSLM to improve the specificity of the CTG in the assessment of fetal wellbeing. [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]

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Abstract Background The objective of our study was to evaluate the association between perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) with the presence of ante and intrapartum risk factors and/or abnormal fetal heart rate (FHR) findings, in order to improve maternal and neonatal management. Methods We did a prospective observational cohort study from a network of four hospitals (one Hub center with neonatal intensive care unit and three level I Spoke centers) between 2014 and 2016. Neonates of gestational age ≥ 35 weeks, birthweight ≥1800 g, without lethal malformations were included if diagnosed with perinatal asphyxia, defined as pH ≤7.0 or Base Excess (BE) ≤ − 12 mMol/L in Umbical Artery (UA) or within 1 h, 10 min Apgar 10 min. FHR monitoring was classified in three categories according to the American College of Obstetricians and Gynecologists (ACOG). Pregnancies were divided into four classes: 1) low risk; 2) antepartum risk; 3) intrapartum risk; 4) and both ante and intrapartum risk. In the first six hours of life asphyxiated neonates were evaluated using the Thomson score (TS): if TS ≥ 5 neonates were transferred to Hub for further assessment; if TS ≥ 7 hypothermia was indicated. Results Perinatal asphyxia occurred in 21.5‰ cases (321/14,896) and HIE in 1.1‰ (16/14,896). The total study population was composed of 281 asphyxiated neonates: 68/5152 (1.3%) born at Hub and 213/9744 (2.2%) at Spokes (p

Introduction: In clinical practice, fetal heart rate monitoring is performed intermittently using Doppler ultrasound, typically for 30 minutes. In case of a non-reassuring heart rate pattern, monitoring is usually prolonged. Noninvasive fetal electrocardiography may be more suitable for prolonged monitoring due to improved patient comfort and signal quality. This study evaluates the performance and patient experience of four noninvasive electrocardiography devices to assess candidate devices for prolonged noninvasive fetal heart rate monitoring., Material and Methods: Non-critically sick women with a singleton pregnancy from 24 weeks of gestation were eligible for inclusion. Fetal heart rate monitoring was performed during standard care with a Doppler ultrasound device (Philips Avalon-FM30) alone or with this Doppler ultrasound device simultaneously with one of four noninvasive electrocardiography devices (Nemo Fetal Monitoring System, Philips Avalon-Beltless, Demcon Dipha-16 and Dräger Infinity-M300). Performance was evaluated by: success rate, positive percent agreement, bias, 95% limits of agreement, regression line, root mean square error and visual agreement using FIGO guidelines. Patient experience was captured using a self-made questionnaire., Results: A total of 10 women were included per device. For fetal heart rate, Nemo performed best (success rate: 99.4%, positive percent agreement: 94.2%, root mean square error 5.1 BPM, bias: 0.5 BPM, 95% limits of agreement: -9.7 - 10.7 BPM, regression line: y = -0.1x + 11.1) and the cardiotocography tracings obtained simultaneously by Nemo and Avalon-FM30 received the same FIGO classification. Comparable results were found with the Avalon-Beltless from 36 weeks of gestation, whereas the Dipha-16 and Infinity-M300 performed significantly worse. The Avalon-Beltless, Nemo and Infinity-M300 closely matched the performance of the Avalon-FM30 for maternal heart rate, whereas the performance of the Dipha-16 deviated more. Patient experience scores were higher for the noninvasive electrocardiography devices., Conclusions: Both Nemo and Avalon-Beltless are suitable devices for (prolonged) noninvasive fetal heart rate monitoring, taking their intended use into account. But outside its intended use limit of 36 weeks' gestation, the Avalon-Beltless performs less well, comparable to the Dipha-16 and Infinity-M300, making them currently unsuitable for (prolonged) noninvasive fetal heart rate monitoring. Noninvasive electrocardiography devices appear to be preferred due to greater comfort and mobility., (© 2024 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Background: The iPREFACE score may aid in predicting fetal acidemia and neonatal asphyxia in emergency cesarean and vaginal deliveries, which may improve labor management precision in the future., Objective: This study aimed to assess the score use of the iPREFACE as an objective indicator of the need for rapid delivery in cases of repeated abnormal waveforms without concurrent indications for immediate medical intervention during labor., Study Design: This retrospective cohort study was conducted among term (37+ 0 days to 41+6 days) singleton pregnant women who underwent emergency cesarean delivery owing to a nonreassuring fetal status. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery score, calculated from a 30-minute cardiotocography waveform before the decision to perform emergency cesarean delivery, and the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer score, calculated from a 30-minute cardiotocography waveform before cardiotocography transducer removal, were employed. The primary outcome was the assessment of the predictive ability of these scores for fetal acidemia, whereas the secondary outcomes were differences in umbilical artery blood gas findings and postnatal outcomes between the 2 groups, divided by the cutoff values of the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography score., Results: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer scores demonstrated the capability to predict an umbilical artery blood pH of <7.2. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and -removal of cardiotocography transducer score, with cutoff values of 37 and 46 points, respectively, exhibited an area under the receiver operating characteristic curve of 0.82 and 0.87, respectively. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer group with ≥46 points had higher incidence rates of an umbilical cord artery blood pH of <7.2, <7.1, and <7.0 and neonatal intensive care unit admissions for neonatal asphyxia., Conclusion: The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring, derived from cardiotocography during an emergency cesarean delivery, may enable clinicians to predict fetal acidemia in cases of nonreassuring fetal status. Improved prediction of fetal acidemia and facilitation of timely intervention hold promise for enhancing the outcomes of mothers and newborns during childbirth. Prospective studies are warranted to establish precise cutoff values and to validate the clinical application of these scores., (© 2024 The Authors.)

Objective: Although prior attempts have failed to identify the beneficial effects of intensive fetal monitoring on cerebral palsy, the association between nonreassuring fetal status (NRFS) during labor and the incidence of long-term neurodevelopmental delays in offspring remains unclear. This study aimed to evaluate this association using a nationwide birth cohort., Methods: Data from 72 869 women with singleton deliveries at and after 37 weeks of gestation from the Japan Environment and Children's Study (2011-2014) were analyzed. Multivariable logistic regression models were used to analyze the odds ratios (ORs) for neurodevelopmental delays using the Ages & Stages Questionnaire (Third Edition) in offspring aged 3 years., Results: The adjusted ORs for personal-social problems were 1.52 (95% confidence interval [CI], 1.06-2.16) for offspring delivered vaginally by nulliparous mothers and 1.51 (95% CI, 1.05-2.18) (for males, 1.70 [95% CI, 1.15-2.50]) for those delivered via cesarean section. No significant changes in adjusted ORs for neurodevelopmental delays were observed among participants without neonatal Apgar scores (ASs) <7 and without umbilical arterial pH (UmA-pH) <7.20., Conclusion: NRFS during labor was associated with an increased incidence of personal-social problems in offspring aged 3 years. However, this association was not confirmed after excluding participants with neonatal ASs <7 and UmA-pH <7.20. The association between NRFS and offspring's neurodevelopmental delays might vary based on delivery settings, offspring sex, and short-term neonatal outcomes., (© 2023 International Federation of Gynecology and Obstetrics.)

The article describes the case of a 24-year old primiparous woman who was detected with strangulated double nuchal umbilical cord with consequent secondary shoulder dystocia of the fetus. The patient underwent umbilical cord cutting followed by internal Barnum's maneuver and a neonatologist performed resuscitation to an asphyxiated female newborn. A fresh III grade hypoxic-ischemic encephalopathy is verified in the early neonatal period.

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]