Gonococcal sepsis secondary to fetal monitoring

Expedited Partner Therapy: A Multicomponent Initiative to Boost Provider Counseling

BACKGROUND

Expedited partner therapy prescription remains low and highly variable throughout the United States, leading to frequent reinfections with Chlamydia trachomatis and Neisseria gonorrhoeae . We examined provider counseling on expedited partner therapy before and after an electronic smart tool-based initiative.

METHODS

In this quasi-experimental interrupted time-series study, we implemented an initiative of electronic smart tools and education for expedited partner therapy in March 2020. We reviewed the records of patients with chlamydia and/or gonorrhea at an urban, academic obstetrics and gynecology clinic in the preimplementation (March 2019-February 2020) and postimplementation (March 2020-February 2021) groups. Descriptive statistics and an interrupted time-series model were used to compare the percent of expedited partner therapy offered by clinicians to patients in each group.

RESULTS

A total of 287 patient encounters were analyzed, 155 preintervention and 132 postintervention. An increase in expedited partner therapy counseling of 13% (95% confidence interval [CI], 2%-24%) was observed before the intervention (27.1% [42 of 155]) versus after the intervention (40.2% [53 of 132]). Significant increases in provider counseling were seen for patients who were single (15%; 95% CI, 3%-26%), 25 years or older (21%; 95% CI, 6%-37%), receiving public insurance (15%; 95% CI, 3%-27%), seen by a registered nurse (18%; 95% CI, 4%-32%), or seen for an obstetrics indication (21%; 95% CI, 4%-39%). No difference was seen in patients' acceptance of expedited partner therapy ( P = 1.00).

CONCLUSIONS

A multicomponent initiative focused on electronic smart tools is effective at increasing provider counseling on expedited partner therapy. Further research to understand patient perceptions and acceptance of expedited partner therapy is critical.

Cutaneous and subcutaneous infections in newborns due to anaerobic bacteria

This review describes the microbiology and management of the major cutaneous and subcutaneous infections in newborns where anaerobic bacteria predominate: omphalitis, necrotizing fasciitis, breast abscess, and scalp infection following intrauterine fetal monitoring. The predominant bacteria known to cause these infections are group B streptococcus, group D enterococcus, group A streptococcus, Staphylococcus aureus, Enterobacteriaceae, and anaerobic bacteria. All of these agents can colonize or infect the mother and subsequently colonize or infect the fetus or newborn either intrauterinely or during the passage through the birth canal. Infections due to anaerobes are often polymicrobial, and include also aerobic and facultative bacteria. The anaerobes recovered from these infections are Bacteroided fragilis group, Fusobacterium spp., Peptostreptococcus spp. and Clostridium spp. Early recognition and effective medical and surgical therapy are essential to recovery. Managements of these infections include surgical debridement and drainage when appropriate as well as topical and systemic use of antimicrobial agents effective against both aerobic and anaerobic bacteria.

Randomised evaluation of a prototype suction fetal scalp electrode

OBJECTIVE

To compare the performance and acceptability of a prototype suction fetal scalp electrode with that of a double helix spiral electrode.

SETTING

An urban academic hospital in Johannesburg, South Africa.

DESIGN

Randomised, by means of sealed opaque envelopes opened consecutively.

PARTICIPANTS

One hundred women in active labour with an indication for direct fetal heart rate monitoring.

INTERVENTION

Application of a fetal scalp electrode to the presenting part.

OUTCOME MEASURES

Performance of the electrodes with respect to application success, detachment, quality of the tracings, scalp trauma and women's preferences.

RESULTS

Application of the suction electrode was unsuccessful in 15/50 (30%) compared to 1/50 (2%) with the spiral electrode. Detachment rates were similar. There were more tracings of average quality with the suction electrode (nine versus four). There were three instances of scalp bleeding at delivery with the spiral electrode. The suction electrode was preferred by more women and its application caused somewhat less discomfort.

CONCLUSIONS

The lower rate of successful application with the suction electrode needs to be weighed against the advantage of avoiding fetal scalp penetration. In particular, women's concerns about pain or harm to the baby from needle electrodes, the theoretical risk of viral transmission, and the risk of serious scalp infection must be considered. These factors favour the use of a suction electrode when direct fetal heart rate monitoring is required. Needle electrodes should be considered when suction electrode application is unsuccessful. Correction of practical problems experienced with the prototype suction electrodes used in this study may result in improved success rates.

A nonpenetrating fetal scalp electrode

OBJECTIVE

To develop a nonpenetrating scalp electrode for intrapartum fetal monitoring.

DESIGN

Preliminary observational evaluation of the device.

SETTING

An urban academic hospital in Johannesburg, South Africa.

SUBJECTS

Fifteen women in labour.

INTERVENTION

Application of the electrode for intrapartum monitoring.

OUTCOME MEASURES

Quality of tracings, duration of application, disconnection of the electrode, marking of the scalp.

RESULTS

Application was successful in 13 of 15 women, and high quality tracings obtained in 12.

CONCLUSIONS

The design of scalp electrode tested is effective and produces high quality tracings in most cases.

Intrapartum fetal monitoring

From the fetal viewpoint, labour is a prolonged contraction stress test which most pass without incident. Labour also represents the obstetrician's last opportunity to influence perinatal outcome and ensure that those fetuses who have suffered chronic hypoxia antenatally are recognized promptly, so that labour is supervised in a way that does not place them at increased risk of either death or birth asphyxia. In the case of the fetus who enters labour healthy, with normal reserves, labour is managed with the same aim in mind, but with the foreknowledge that visualization of a normal volume of clear amniotic fluid and reasonable duration of labour makes the development of hypoxia and asphyxia unlikely. Those at increased risk of hypoxia should be monitored electronically, but, for the remainder, intermittent auscultation is satisfactory until labour lasts in excess of 5 hours, or if the patient requires oxytocin, or if an epidural is placed. If EFM is used, then it is important to provide adequate education in trace interpretation, with particular emphasis on the importance of short-term variability. Widespread use of EFM has provided us with an immense amount of knowledge about fetal physiology, but it is critically important for the practising obstetrician to understand that, in the low-risk patient, EFM is not more effective than IA in preventing death from asphyxia, that EFM does protect against asphyxial seizures, but that widespread use of the technique has not been associated with a significant reduction in the population of permanently handicapped infants. This information is particularly relevant in developing nations where money spent on sophisticated monitoring equipment might be better spent in other areas. From the maternal point of view, intensive fetal monitoring has profound implications by virtue of its usual effect on incidence of Caesarean birth, although the Dublin trial results, with regard to incidence of Caesarean section, emphasize the importance of considering intrapartum fetal monitoring as just one part of the overall supervision of labour. Finally, it must be emphasized that the method of fetal monitoring chosen may be strongly influenced by factors other than scientific evidence, as in the United States where the medicolegal climate is such that failure to rigorously document absence of fetal distress/true birth asphyxia may result in a harrowing lawsuit. It is a position this author has developed considerable sympathy with in recent years.

Gonococcal ventriculitis associated with ventriculoamniotic shunt placement

Use of a ventriculoamniotic shunt to control fetal hydrocephalus is a new procedure. Early experience suggests possible benefit to the fetus. Complications have been rare. This report describes the first case of Neisseria gonorrhoeae central nervous system infection associated with a ventriculoamniotic shunt and the third case reported in a neonate. On the basis of this clinical experience, we recommend that the mother be monitored closely for cervical pathogens, that delivery be performed prior to amniorrhexis, and that culturing of the shunt and ventricular fluid be carried out at delivery.

Scalp abscess: a benign and infrequent complication of fetal monitoring

Scalp abscess is an infrequent and usually benign complication of the implantation of fetal heart rate electrodes that becomes noticeable from 2 to 10 days after birth. The lesions are usually single and localized. Most exudates will produce aerobic and/or anaerobic bacteria similar to the cervical flora of the late trimester of pregnancy. Scalp abscesses are more likely to occur subsequent to prolonged rupture of the membranes and an extended period of fetal heart rate monitoring. Local treatment may be adequate in most cases, but parenteral antibiotic therapy may be needed in others. Since herpes simplex virus infection has been reported to start as vesicles around the site of electrode implantation, careful attention to the maternal history must be given. The parents of infants who undergo internal fetal heart rate monitoring should be given careful and concise follow-up instructions when the infant is discharged from the hospital. It is apparent after a decade of experience that the benefits of electronic fetal heart rate monitoring, even when invasive, far outweigh the risks of this still infrequent complication.

Neonatal scalp abscess and fetal monitoring: factors associated with infection

Forty-two of 929 (4.5 per cent) newborn infants prospectively studied following continuous, direct fetal heart rate monitoring during labor developed a scalp abscess at the site of electrode application during the neonatal period. Factors associated with infection with the use of a multivariate analysis were duration of monitoring (p less than 0.01) and high-risk indications for monitoring (p less than 0.01). Of the 42 infected neonates, 33 had complete bacteriologic studies. Microorganisms were isolated from all the infection tended to be polymicrobial, most commonly containing both aerobes and anaerobes. Staphylococcus epidermidis, Streptococcus, Peptostreptococcus, and Peptococcus were the predominant isolates. These data indicate that scalp abscess complicating intrapartum fetal monitoring may be nosocomial importance, and infants monitored should be closely observed in order to prevent more serious infectious complications.

Neonatal scalp abscess following intrapartum fetal monitoring: prospective comparison of two spiral electrodes

During a six-month period, 929 newborn infants had continuous, direct fetal heart rate monitoring during labor. Of these, 481 were monitored with the Berkeley Bio-Electronics spiral electrode and 448 were monitored with the Corometrics spiral electrode. The over-all incidence of scalp abscess complicating fetal monitoring was 4.5 per cent. In the group monitored with the Berkeley electrode, 25 newborn infants (5.2 per cent) developed a scalp abscess; in the group with the Corometrics electrode, 17 newborn infants (3.8 per cent) developed scalp abscess. The incidence of scalp abscess was not significantly different in the two groups.