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Bart Y, Meyer R, Moran O, Tsur A, Kassif E, Mohr-Sasson A, Hamilton E, Sivan E, Yinon Y, Mazaki-Tovi S, Yoeli R. Perinatal Outcome following the Suspension of Intrapartum Oxygen Treatment. Am J Perinatol 2024; 41:e1479-e1485. [PMID: 36894155 DOI: 10.1055/a-2051-4047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE This study aimed to evaluate whether the suspension of intrapartum maternal oxygen supplementation for nonreassuring fetal heart rate is associated with adverse perinatal outcomes. STUDY DESIGN A retrospective cohort study, including all individuals that underwent labor in a single tertiary medical center. On April 16, 2020, the routine use of intrapartum oxygen for category II and III fetal heart rate tracings was suspended. The study group included individuals with singleton pregnancies that underwent labor during the 7 months between April 16, 2020, and November 14, 2020. The control group included individuals that underwent labor during the 7 months before April 16, 2020. Exclusion criteria included elective cesarean section, multifetal pregnancy, fetal death, and maternal oxygen saturation <95% during delivery. The primary outcome was defined as the rate of composite neonatal outcome, consisting of arterial cord pH <7.1, mechanical ventilation, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage grade 3/4, and neonatal death. The secondary outcome was the rate of cesarean and operative delivery. RESULTS The study group included 4,932 individuals, compared with 4,906 individuals in the control group. The suspension of intrapartum oxygen treatment was associated with a significant increase in the rate of composite neonatal outcome (187 [3.8%] vs. 120 [2.4%], p < 0.001), including the rate of abnormal cord arterial pH <7.1 (119 [2.4%] vs. 56 [1.1%], p < 0.01). A higher rate of cesarean section due to nonreassuring fetal heart rate was noted in the study group (320 [6.5%] vs. 268 [5.5%], p = 0.03).A logistic regression analysis revealed that the suspension of intrapartum oxygen treatment was independently associated with the composite neonatal outcome (adjusted odds ratio = 1.55 [95% confidence interval, 1.23-1.96]) while adjusting for suspected chorioamnionitis, intrauterine growth restriction, and recent coronavirus disease 2019 exposure. CONCLUSION Suspension of intrapartum oxygen treatment for nonreassuring fetal heart rate was associated with higher rates of adverse neonatal outcomes and urgent cesarean section due to fetal heart rate. KEY POINTS · The available data on intrapartum maternal oxygen supplementation are equivocal.. · Suspension of maternal oxygen for nonreassuring fetal heart rate during labor was associated with adverse neonatal outcomes.. · Oxygen treatment might still be important and relevant during labor..
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Affiliation(s)
- Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Raanan Meyer
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Orit Moran
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Abraham Tsur
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Eran Kassif
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Aya Mohr-Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Emily Hamilton
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Eyal Sivan
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
| | - Rakefet Yoeli
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
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Sulaiman SP, Jha N, Bethou A, Nandeeha H, Jha AK. Effect of maternal hyperoxygenation on neonatal outcomes among women in labour with pathological cardiotocography: an open-label randomized controlled trial. Am J Obstet Gynecol 2024; 230:454.e1-454.e11. [PMID: 37778675 DOI: 10.1016/j.ajog.2023.09.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 09/21/2023] [Accepted: 09/23/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Hyperoxygenation has shown promise in improving suspicious fetal heart patterns in women in labor. However, the effect of hyperoxygenation on neonatal outcomes in women in labor with pathologic fetal heart rate tracing has not been studied. OBJECTIVE This study aimed to evaluate the effect of fractional inspiration of oxygen of 80% compared with fractional inspiration of oxygen of 40% on neonatal outcomes in women with pathologic fetal heart rate tracing. STUDY DESIGN This randomized, open-label, parallel arm, outcome assessor-blinded clinical trial was conducted in a large tertiary care university hospital. Singleton parturients aged ≥18 years at term gestation in active labor (cervical dilatation of ≥6 cm) with pathologic fetal heart rate tracing were recruited in the study. Pathologic fetal heart rate tracing was defined according to the International Federation of Gynecology and Obstetrics 2015 guidelines. The International Federation of Gynecology and Obstetrics classifies fetal heart rate tracings into 3 categories (normal, suspicious, and pathologic) based on rate, variability, and deceleration. Women in the intervention arm received oxygen at 10 L/min via a nonrebreathing mask, and those in the usual care arm received oxygen at 6 L/min with a simple face mask. Oxygen supplementation was continued until cord clamping. The primary outcome measure was a 5-minute Apgar score. The secondary outcome measures were the proportion of neonatal intensive care unit admission, umbilical cord blood gas variables, level of methyl malondialdehyde in the cord blood, and mode of delivery. RESULTS Overall, 148 women (74 women in the high fractional inspiration of oxygen arm and 74 in the low fractional inspiration of oxygen arm) with pathologic fetal heart rate tracing were analyzed. The demographic data, obstetrical profiles, and comorbidities were comparable. The median 5-minute Apgar scores were 9 (interquartile range, 8-10) in the hyperoxygenation arm and 9 (interquartile range, 8-10) in the usual care arm (P=.12). Furthermore, the rate of neonatal intensive care unit admission (9.5% vs 12.2%; P=.6) and the requirement of positive pressure ventilation (6.8% vs 8.1%; P=.75) were comparable. Concerning cord blood gas parameters, the hyperoxygenation arm had a significantly higher base deficit in the umbilical vein and lactate level in the umbilical artery. The cesarean delivery rate was significantly lower in women who received hyperoxygenation (4.1% [3/74]) than in women who received normal oxygen supplementation (25.7% [19/74]) (P=.00). In addition, umbilical vein malondialdehyde level in the umbilical vein was lower in the hyperoxygenation group (8.28±4.65 μmol/L) than in the normal oxygen supplementation group (13.44±8.34 μmol/L) (P=.00). CONCLUSION Hyperoxygenation did not improve the neonatal Apgar score in women with pathologic fetal heart rate tracing. In addition, neonatal intensive care unit admission rate and blood gas parameters remained comparable. Therefore, the results of this trial suggest that a high fractional inspiration of oxygen supplementation confers no benefit on neonatal outcomes in women with pathologic fetal heart rate tracings and normal oxygen saturation.
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Affiliation(s)
- Sruthy P Sulaiman
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Nivedita Jha
- Department of Obstetrics and Gynecology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India.
| | - Adhisivam Bethou
- Department of Neonatology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Hanumanthappa Nandeeha
- Department of Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ajay Kumar Jha
- Department of Anaesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Abati I, Micaglio M, Giugni D, Seravalli V, Vannucci G, Di Tommaso M. Maternal Oxygen Administration during Labor: A Controversial Practice. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1420. [PMID: 37628419 PMCID: PMC10453930 DOI: 10.3390/children10081420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Revised: 08/11/2023] [Accepted: 08/16/2023] [Indexed: 08/27/2023]
Abstract
Oxygen administration to the mother is commonly performed during labor, especially in the case of a non-reassuring fetal heart rate, aiming to increase oxygen diffusion through the placenta to fetal tissues. The benefits and potential risks are controversial, especially when the mother is not hypoxemic. Its impact on placental gas exchange and the fetal acid-base equilibrium is not fully understood and it probably affects the sensible placental oxygen equilibrium causing a time-dependent vasoconstriction of umbilical and placental vessels. Hyperoxia might also cause the generation of radical oxygen species, raising concerns for the developing fetal cells. Moreover, this practice affects the maternal cardiovascular system, causing alterations of the cardiac index, heart rate and vascular resistance, and unclear effects on uterine blood flow. In conclusion, there is no evidence that maternal oxygen administration can provide any benefit in the case of a non-reassuring fetal heart rate pattern, while possible collateral effects warn of its utilization. Oxygen administration during labor should be reserved for cases of maternal hypoxia.
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Affiliation(s)
- Isabella Abati
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (M.M.); (D.G.)
| | - Dario Giugni
- Department of Anesthesia and Intensive Care, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (M.M.); (D.G.)
| | - Viola Seravalli
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Giulia Vannucci
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
| | - Mariarosaria Di Tommaso
- Department of Health Sciences, Division of Obstetrics and Gynecology, Careggi Hospital, University of Florence, Largo Brambilla 3, 50134 Florence, Italy; (I.A.); (V.S.); (G.V.)
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Burd J, Raghuraman N. Intrapartum Oxygen for Fetal Resuscitation: State of the Science. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2023; 12:1-5. [PMID: 37360259 PMCID: PMC10191681 DOI: 10.1007/s13669-023-00363-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/28/2023]
Abstract
Purpose of Review This review aims to summarize the current evidence regarding maternal oxygen supplementation for Category II fetal heart tracings (FHT) in labor. We aim to evaluate the theoretical rationale for oxygen administration, the clinical efficacy of supplemental oxygen, and the potential risks. Recent Findings Maternal oxygen supplementation is an intrauterine resuscitation technique rooted in the theoretic rationale that hyperoxygenating the mother results in increased oxygen transfer to the fetus. However, recent data suggest otherwise. Randomized controlled trials on the efficacy of oxygen supplementation in labor suggest no improvement in umbilical cord gases or other adverse maternal and neonatal outcomes compared to room air. Two meta-analyses demonstrated that oxygen supplementation is not associated with an improvement in umbilical artery pH or reduction in cesarean delivery. Although we lack data on definitive clinical neonatal outcomes with this practice, there is some suggestion of adverse neonatal outcomes with excess in utero oxygen exposure, including lower umbilical artery pH. Summary Despite historic data suggesting the benefit of maternal oxygen supplementation in increasing fetal oxygenation, recent randomized trials and meta-analyses have demonstrated a lack of efficacy of this practice and some suggestion of harm. This has led to conflicting national guidelines. Further research is needed on short- and long-term neonatal clinical outcomes following prolonged intrauterine oxygen exposure.
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Affiliation(s)
- Julia Burd
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63108 USA
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Washington University in St. Louis, 1 Barnes Jewish Hospital Plaza, St. Louis, MO 63108 USA
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5
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, Nothacker M, Roiter S, Volk T, Worth H, Fühner T. German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients. Respiration 2021; 101:214-252. [PMID: 34933311 DOI: 10.1159/000520294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital Würzburg, Wuerzburg, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management, Marburg, Germany
| | - Sabrina Roiter
- Intensive Care Unit, Israelite Hospital Hamburg, Hamburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, University Hospital of Saarland, Saarland University, Homburg, Germany
| | | | - Thomas Fühner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
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Deng Y, Jin Y, Xu R, Zeng S. Fetal Hemodynamic Response to Maternal Oxygenation in Normal and Complicated Pregnancies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2021; 42:607-613. [PMID: 32971542 DOI: 10.1055/a-1187-1459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Maternal oxygenation (MO) is widely applied in obstetrics. Scholars have conducted numerous studies on maternal hyperoxygenation and have reported many theoretical and applied achievements and a number of different points of view. The main purpose of this article is to discuss the effect of maternal oxygenation on fetal circulation during normal and complicated pregnancies and to ascertain its potential side effects and research gaps in this field. In complicated pregnancies, the fetus may benefit from oxygen therapy. However, large randomized controlled trials and longitudinal studies are necessary to support the widespread application of maternal oxygenation in this context.
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Affiliation(s)
- Yan Deng
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
| | - Ying Jin
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
| | - Ran Xu
- Urology, Second Xiangya Hospital, Changsha, China
| | - Shi Zeng
- Department of Ultrasonography, Second Xiangya Hospital, Changsha, China
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7
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Evaluation of an Initiative to Decrease the Use of Oxygen Supplementation for Category II Fetal Heart Rate Tracings. Obstet Gynecol 2021; 138:627-632. [PMID: 34623075 DOI: 10.1097/aog.0000000000004544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 07/22/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To examine compliance with a guideline to reduce exposure to supplemental oxygen for category II fetal heart rate (FHR) tracings in normally oxygenated laboring patients. METHODS All patients in labor in an urban academic medical center from January 1 to July 31, 2020 were assessed. The preintervention group included those who delivered from January 1 to March 19, 2020. On March 20, 2020, a new guideline took effect that recommended no maternal supplemental oxygen for category II FHR tracings. The postintervention group delivered from March 20 to July 31, 2020. Exclusion criteria were planned cesarean delivery, multiple gestations, delivery at less than 24 weeks of gestation, intrauterine fetal death, and patients who received supplemental oxygen for an oxygen saturation lower than 95%. The primary outcome was the percentage of patients who received oxygen in labor analyzed by control charts and the rules of special cause variation. Chi-squared and t tests were used for secondary outcome assessment. P<.05 was considered significant. RESULTS A total of 1,333 patients were included, 474 patients in the preintervention group and 859 in the postintervention group. Oxygen was administered to 22.6% of patients before guideline implementation, compared with 0.6% after the guideline. Special cause variation was detected with an 8-point shift starting the month that the guideline was implemented, indicating statistical significance. There were no differences in any studied secondary maternal or fetal outcomes, although our statistical power to detect differences in infrequent outcomes was limited. CONCLUSION This quality-improvement study demonstrated significant adherence to the guideline that supplemental oxygen would no longer be given to patients with category II FHR tracings in the absence of maternal hypoxemia, with no significant change in maternal or perinatal outcomes.
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8
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. Pneumologie 2021; 76:159-216. [PMID: 34474487 DOI: 10.1055/a-1554-2625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie Bundeswehrzentralkrankenhaus Koblenz
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg
| | | | | | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin
| | | | | | - Thomas Fühner
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
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Burd J, Quist-Nelson J, Moors S, Raghuraman N, Aly H, Berghella V. Effect of intrapartum oxygen on the rate of cesarean delivery: a meta-analysis. Am J Obstet Gynecol MFM 2021; 3:100374. [PMID: 33836306 DOI: 10.1016/j.ajogmf.2021.100374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/23/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This study aimed to determine if maternal intrapartum administration of oxygen altered the rate of cesarean delivery compared with room air. DATA SOURCES This study was a systematic review and meta-analysis of randomized controlled trials. Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials using a combination of key words related to "pregnant patients," "labor," "oxygen," "fetus," "newborn," and pregnancy outcomes from database inception until April 2020. The study was registered in PROSPERO (registration number CRD42020162110). STUDY ELIGIBILITY CRITERIA The inclusion criteria were randomized controlled trials of maternal administration of oxygen compared with room air in labor. The exclusion criteria were quasi-randomized trials and oxygen administered for planned cesarean deliveries. The primary outcome was the rate of cesarean delivery. Secondary maternal and neonatal outcomes, including cord gas values, were analyzed. METHODS The Cochrane Handbook guidelines were used to assess bias in trials. To calculate the relative risk or mean differences with confidence intervals, a random-effects model was employed. Subgroup analyses were performed for women who received oxygen for nonreassuring fetal heart rate monitoring or prophylactically. RESULTS Five randomized controlled trials, including 768 women, were included in the meta-analysis, 3 using prophylactic oxygen and 2 using oxygen for nonreassuring fetal heart rate monitoring. The risk of bias was generally considered low. There was no statistically significant difference in the rate of cesarean delivery between patients administered oxygen and patients provided room air (16 of 365 [4.4%] vs 11 of 379 [2.9%]; risk ratio 1.5; 95% confidence interval, 0.7-3.3). In addition, there were no statistically significant differencs in the rates of cesarean delivery for nonreassuring fetal heart rate monitoring, operative vaginal deliveries, Apgar scores of <7, neonatal intensive care unit admissions, or cord blood gas values. There were no statistically significant difference when analyzing oxygen for nonreassuring fetal heart rate monitoring alone or prophylactic oxygen alone. Data regarding FHT is mixed, with one study suggesting an improvement and three suggesting no change. CONCLUSION Maternal intrapartum oxygen administration was not associated with any differences in the rate of cesarean delivery or any secondary outcomes compared with room air overall and in the subgroups of therapeutic (for nonreassuring fetal heart rate monitoring) or prophylactic administration in this meta-analysis. Large randomized controlled trials are necessary to further examine any possible benefits or harms of oxygen administration in labor, particularly for nonreassuring fetal heart rate monitoring.
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Affiliation(s)
- Julia Burd
- Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Johanna Quist-Nelson
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Suzanne Moors
- Department of Obstetrics and Gynecology, St. Antonius Hospital, Utrecht, the Netherlands
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's Hospital, Cleveland, OH
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine; Department of Obstetrics and Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA.
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10
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Moors S, Joshi R, Bullens LM, van Oostrum NHM, Regis M, van den Heuvel ER, Oei SG, van Laar JOEH, van der Hout-van der Jagt MB. A randomized controlled trial studying the effect of maternal hyperoxygenation on fetal heart rate in suspected fetal distress. Physiol Meas 2020; 41:115002. [PMID: 33049730 DOI: 10.1088/1361-6579/abc0b6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To investigate the effect of maternal hyperoxygenation on fetal heart rate (FHR) when applied for suspected fetal distress during the second stage of term labor. APPROACH A single-center randomized controlled trial was conducted in a tertiary care hospital in The Netherlands. Participants were included during the second stage of labor in case of an intermediary or abnormal FHR pattern. Patients were randomized to receive either 100% oxygen at 10 l/min until delivery, or conventional care without additional oxygen. The primary outcome was the change in FHR pattern before and after the onset of the study, measured as the change in depth and duration of FHR decelerations. Secondary outcome measures were features based on phase-rectified signal averaging (PRSA), baseline assignability, and deceleration characteristics of the FHR pattern. MAIN RESULTS Between March 2016 and April 2018, 117 women were included. The FHR pattern could be analyzed for 71 participants, the other 46 women delivered before the end of the post time-frame. A 2.3% reduction in depth and duration of FHR decelerations was found after maternal hyperoxygenation, compared to a 10% increase in the control group (p = 0.24). Maternal hyperoxygenation had a significantly positive effect on PRSA metrics, with a decrease in PRSA-acceleration capacity (p = 0.03) and PRSA-deceleration capacity (p = 0.02) in the intervention group compared to the control group. SIGNIFICANCE The difference in depth and duration of decelerations after the start of the study was not significantly different between both study groups. A statistically significant positive effect on PRSA-deceleration capacity and PRSA-acceleration capacity was found after maternal hyperoxygenation, which might be associated with a positive effect on neonatal outcome.
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Affiliation(s)
- S Moors
- Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, The Netherlands. Eindhoven MedTech Innovation Center (e/MTIC), Groene Loper 19, Eindhoven 5600 MB, The Netherlands. Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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11
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The effect of intrapartum oxygen supplementation on category II fetal monitoring. Am J Obstet Gynecol 2020; 223:905.e1-905.e7. [PMID: 32585226 DOI: 10.1016/j.ajog.2020.06.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 06/04/2020] [Accepted: 06/18/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Maternal oxygen administration is a widely used intrauterine resuscitation technique for fetuses with category II electronic fetal monitoring patterns, despite a paucity of evidence on its ability to improve electronic fetal monitoring patterns. OBJECTIVE This study investigated the effect of intrapartum oxygen administration on Category II electronic fetal monitoring patterns. STUDY DESIGN This is a secondary analysis of a randomized trial conducted in 2016-2017, in which patients with fetuses at ≥37 weeks' gestation in active labor with category II electronic fetal monitoring patterns were assigned to 10 L/min of oxygen by face mask or room air until delivery. Trained obstetrical research nurses blinded to allocation extracted electronic fetal monitoring data. The primary outcome was a composite of high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, or minimal variability 60 minutes after randomization to room air or oxygen. Secondary outcomes included individual components of the composite high-risk category II features, resolution of recurrent decelerations within 60 minutes of randomization, and total deceleration area. The outcomes between the room air and oxygen groups were compared using univariable statistics. Time-to-event analysis was used to compare time to resolution of recurrent decelerations between the groups. Paired analysis was used to compare the pre- and postrandomization outcomes within each group. RESULTS All 114 randomized patients (57 room air and 57 oxygen) were included in this analysis. There was no difference in resolution of recurrent decelerations within 60 minutes between the oxygen and room air groups (75.4% vs 86.0%; P=.15). The room air and oxygen groups had similar rates of composite high-risk category II features including recurrent variable decelerations, recurrent late decelerations, prolonged decelerations, tachycardia, and minimal variability 60 minutes after randomization. Time to resolution of recurrent decelerations and total deceleration area were similar between the room air and oxygen groups. Among patients who received oxygen, there was no difference in the electronic fetal monitoring patterns pre- and postrandomization. Similar findings were observed in the electronic fetal monitoring patterns pre- and postrandomization in room air patients. CONCLUSION Intrapartum maternal oxygen administration for category II electronic fetal monitoring patterns did not resolve high-risk category II features or hasten the resolution of recurrent decelerations. These results suggest that oxygen administration has no impact on improving category II electronic fetal monitoring patterns.
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Watkins VY, Martin S, Macones GA, Tuuli MG, Cahill AG, Raghuraman N. The duration of intrapartum supplemental oxygen administration and umbilical cord oxygen content. Am J Obstet Gynecol 2020; 223:440.e1-440.e7. [PMID: 32497605 DOI: 10.1016/j.ajog.2020.05.056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Maternal oxygen (O2) administration is a commonly performed intrauterine resuscitation technique though to improve fetal oxygenation. However, hyperoxygenation is known to be harmful in both neonates and adults. Currently, there are no formal recommendations on whether a certain dose or duration of O2 may be most helpful in improving umbilical cord gases or neonatal outcomes. OBJECTIVE We tested the hypothesis that prolonged supplemental O2 exposure during labor is associated with increased umbilical cord O2 concentrations. STUDY DESIGN This was a planned secondary analysis of a randomized noninferiority trial comparing O2 with room air in laboring patients. Patients were randomized to receive either 10 L/min O2 or room air at any point during active labor when they developed a category II fetal heart tracing that would otherwise require resuscitation. The primary outcome variable for this analysis was partial pressure of O2 in the umbilical vein. The secondary outcome variable was partial pressure of O2 in the umbilical artery. These outcome variables were compared between patients with short durations of O2 exposure and those with long durations of O2 exposure, defined as <75th percentile and ≥75th percentile of duration, respectively. The outcomes were also compared among the groups that received room air, O2 for short durations, and O2 for long durations. RESULTS Among the 99 patients with paired and validated cord gases who were included in this analysis, the partial pressure of O2 in the umbilical vein was significantly lower in patients who received O2 supplementation for longer durations than in those who received O2 for shorter durations (median interquartile range 25.5 [21.5-33] vs 32.5 [26.5-37.5] mm Hg; P<.03). There was no difference in the partial pressure of O2 in the umbilical artery or other cord gases between the short and long duration O2 supplementation groups. Other methods of intrauterine resuscitation were similar between the short and long duration O2 supplementation groups. There was no difference in the partial pressure of O2 in the umbilical artery or in the umbilical vein when the room air, short duration O2 supplementation, and long duration O2 supplementation groups were compared. CONCLUSION Longer durations of O2 exposure are not associated with a higher partial pressure of O2 in the umbilical cord. In fact, patients with longer durations of O2 exposure had lower partial pressure of O2 in the umbilical vein, suggesting impaired placental O2 transfer with prolonged O2 exposure.
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Stephens AJ, Barton JR, Bentum NAA, Blackwell SC, Sibai BM. General Guidelines in the Management of an Obstetrical Patient on the Labor and Delivery Unit during the COVID-19 Pandemic. Am J Perinatol 2020; 37:829-836. [PMID: 32344441 PMCID: PMC7356067 DOI: 10.1055/s-0040-1710308] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/11/2020] [Indexed: 02/06/2023]
Abstract
Novel coronavirus disease 2019 (COVID-19) is a respiratory tract infection that was first identified in China. Since its emergence in December 2019, the virus has rapidly spread, transcending geographic barriers. The World Health Organization and the Centers for Disease Control and Prevention have declared COVID-19 as a public health crisis. Data regarding COVID-19 in pregnancy is limited, consisting of case reports and small cohort studies. However, obstetric patients are not immune from the current COVID-19 pandemic, and obstetric care will inevitably be impacted by the current epidemic. As such, clinical protocols and practice on labor and delivery units must adapt to optimize the safety of patients and health care workers and to better conserve health care resources. In this commentary, we provide suggestions to meet these goals without impacting maternal or neonatal outcomes. KEY POINTS: • Novel coronavirus disease 2019 (COVID-19) is a pandemic.• COVID-19 impacts care of obstetric patients.• Health care should be adapted for the COVID-19 pandemic.
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Affiliation(s)
- Angela J. Stephens
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - John R. Barton
- Division of Maternal-Fetal Medicine, Baptist Health Lexington, Lexington, Kentucky
| | - Nana-Ama Ankumah Bentum
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Sean C. Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Baha M. Sibai
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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14
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Moors S, Bullens LM, van Runnard Heimel PJ, Dieleman JP, Kulik W, Bakkeren DL, van den Heuvel ER, van der Hout-van der Jagt MB, Oei SG. The effect of intrauterine resuscitation by maternal hyperoxygenation on perinatal and maternal outcome: a randomized controlled trial. Am J Obstet Gynecol MFM 2020; 2:100102. [PMID: 33345953 DOI: 10.1016/j.ajogmf.2020.100102] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/05/2020] [Accepted: 03/14/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Maternal hyperoxygenation is widely used during labor as an intrauterine resuscitation technique. However, robust evidence regarding its beneficial effect and potential side effects is scarce, and previous studies show conflicting results. OBJECTIVE To assess the effect of maternal hyperoxygenation upon suspected fetal distress during the second stage of term labor on fetal heart rate, neonatal outcome, maternal side effects, and mode of delivery. MATERIALS AND METHODS In a single-center randomized controlled trial in a tertiary hospital in The Netherlands, participants were randomized in case of an intermediary or abnormal fetal heart rate pattern during the second stage of term labor, to receive either conventional care or 100% oxygen at 10 L/min until delivery. The primary outcome was the change in fetal heart rate pattern. Prespecified secondary outcomes were Apgar score, umbilical cord blood gas analysis, neonatal intensive care unit admission, perinatal death, free oxygen radical activity, maternal side effects, and mode of delivery. We performed subgroup analyses for intermediary and abnormal fetal heart rate, and for small for gestational age fetuses. RESULTS From March 2016 through April 2018, a total of 117 women were included. Fetal heart rate patterns could be analyzed in 71 women. Changes in fetal heart rate (defined as improvement, equal, or deterioration) in favor of maternal hyperoxygenation were significant (odds ratio, 5.7; 95% confidence interval, 1.7-19.1) using ordinal logistic regression. Apgar score, umbilical cord blood gas analysis, free oxygen radicals, and mode of delivery showed no significant differences between the intervention and control group. Among women with an abnormal fetal heart rate, there were fewer episiotomies on fetal indication in the intervention group (25%) than in the control group (65%, P < .01). CONCLUSION Maternal hyperoxygenation has a positive effect on the fetal heart rate in the presence of suspected fetal distress during the second stage of labor. There was no significant difference in the mode of delivery or neonatal outcome; however, significantly fewer episiotomies on fetal indication were performed following maternal hyperoxygenation in the subgroup with abnormal fetal heart rate pattern.
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Affiliation(s)
- Suzanne Moors
- 1Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands.
| | - Lauren M Bullens
- 1Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Pieter J van Runnard Heimel
- 1Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands
| | | | - Wim Kulik
- Laboratory Genetic Metabolic Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Dirk L Bakkeren
- Department of Clinical Chemistry, Máxima Medical Center, Veldhoven, Netherlands
| | - Edwin R van den Heuvel
- Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands; Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, Netherlands
| | - M Beatrijs van der Hout-van der Jagt
- 1Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - S Guid Oei
- 1Department of Obstetrics and Gynecology, Máxima Medical Center, Veldhoven, Netherlands; Eindhoven MedTech Innovation Center (e/MTIC), Eindhoven, Netherlands; Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
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15
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Abstract
Electronic fetal monitoring (EFM) is the most commonly used tool to screen for intrapartum fetal hypoxia. Category II EFM is present in over 80% of laboring patients and poses a unique challenge to management given the breadth of EFM features that fall within this category. Certain Category II patterns, such as recurrent late or recurrent variable decelerations, are more predictive of neonatal acidemia than others. A key feature among many published algorithms for Category II management is the use of intrauterine fetal resuscitation techniques including maternal oxygen administration, amnioinfusion, intravenous fluid bolus, discontinuation of oxytocin, and tocolytic administration. The goal of intrauterine resuscitation is to prevent or reverse fetal hypoxia. This is most likely to be successful if the etiology of the Category II EFM pattern is identified and targeted resuscitative measures are performed.
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Affiliation(s)
- Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, Center for Outpatient Health, 10th floor, 4901 Forest Park Ave, St Louis, MO 63110, United States.
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16
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Affiliation(s)
- Christopher P Bonafide
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ron Keren
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Office of Clinical Quality Improvement, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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17
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Raghuraman N, Wan L, Temming LA, Woolfolk C, Macones GA, Tuuli MG, Cahill AG. Effect of Oxygen vs Room Air on Intrauterine Fetal Resuscitation: A Randomized Noninferiority Clinical Trial. JAMA Pediatr 2018; 172:818-823. [PMID: 30039159 PMCID: PMC6143068 DOI: 10.1001/jamapediatrics.2018.1208] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Two-thirds of women in labor receive supplemental oxygen to reverse perceived fetal hypoxemia and prevent acidemia. Oxygen is routinely administered for category II fetal heart tracings, a class of fetal tracing used to designate intermediate risk for acidemia. This liberal use of oxygen may not be beneficial, particularly because neonatal hyperoxygenation is harmful. OBJECTIVE To test the hypothesis that room air is noninferior to oxygen in improving fetal metabolic status among patients with category II fetal heart tracings. DESIGN, SETTING, AND PARTICIPANTS This was a randomized, unblinded noninferiority clinical trial conducted between June 2016 and July 2017 in the labor and delivery ward of a single tertiary care center. Women with singleton pregnancies at 37 weeks' gestational age or more who were admitted for delivery were eligible. Of those who met inclusion criteria, the patients who developed category II tracings in labor that necessitated intrauterine resuscitation were randomized in a 1:1 ratio to room air or oxygen. Analyses were intention-to-treat. INTERVENTIONS The oxygen group received 10 L of oxygen per minute by nonrebreather facemask until delivery. The room air group was exposed to room air only without a facemask. MAIN OUTCOMES AND MEASURES The primary outcome was umbilical artery lactate, a marker of metabolic acidosis and neonatal morbidity. Noninferiority was defined as a mean difference between groups of less than 9.0 mg/dL (1.0 mmol/L). Secondary outcomes were other umbilical artery gases, cesarean delivery for nonreassuring fetal status, and operative vaginal delivery. RESULTS Of the 705 patients who met inclusion criteria, 277 (39.3%) were enrolled on admission. During labor, 114 patients (41.2% of the enrolled patients) developed category II tracings and were randomized to room air (57 patients; 50.0% of the randomized patients) or oxygen (57 patients; 50.0% of the randomized patients). A total of 99 patients (86.8% of the randomized patients) with paired cord gases were included in the modified intention-to-treat analysis. The 99 patients included 76 African American women (77%); mean (SD) age was 27.3 (6.3) years in the oxygen group and 27.8 (5.3) years in the room air group. There was no difference in umbilical artery lactate between the group on oxygen and the group on room air (mean, 30.6 mg/dL [95% CI, 27.0 to 34.2 mg/dL] vs 31.5 mg/dL [95% CI, 27.9 to 36.0 mg/dL]); P = .69). The mean difference in lactate was 0.9 mg/dL (95% CI, -4.5 to 6.3 mg/dL), which was within the noninferiority margin. There was no difference in other umbilical artery gas components or mode of delivery between groups. CONCLUSIONS AND RELEVANCE Among patients with category II fetal heart tracings, intrauterine resuscitation with room air is noninferior to oxygen in improving umbilical artery lactate. The results of this trial challenge the efficacy of a ubiquitous obstetric practice and suggest that room air may be an acceptable alternative. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02741284.
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Affiliation(s)
- Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Leping Wan
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Lorene A. Temming
- Department of Obstetrics and Gynecology, Carolinas Medical Center, Charlotte, North Carolina
| | - Candice Woolfolk
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - George A. Macones
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Methodius G. Tuuli
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Alison G. Cahill
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St Louis, St Louis, Missouri
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18
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Chu JJ, Hinshaw K, Paterson-Brown S, Johnston T, Matthews M, Webb J, Sharpe P. Perimortem caesarean section - why, when and how. ACTA ACUST UNITED AC 2018. [DOI: 10.1111/tog.12493] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Justin J Chu
- Birmingham Women's Hospital; Edgbaston, Birmingham B15 2TG UK
| | - Kim Hinshaw
- City Hospitals Sunderland NHS Foundation Trust; Sunderland SR4 7TP UK
| | | | - Tracey Johnston
- Birmingham Women's Hospital; Edgbaston, Birmingham B15 2TG UK
| | | | - Julian Webb
- Surrey and Sussex Healthcare NHS Trust; East Surrey Hospital; Redhill RH1 5RH UK
| | - Paul Sharpe
- University Hospitals of Leicester NHS Trust; Leicester Royal Infirmary; Leicester LE1 5WW UK
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19
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Bullens LM, Hulsenboom ADJ, Moors S, Joshi R, van Runnard Heimel PJ, van der Hout-van der Jagt MB, van den Heuvel ER, Guid Oei S. Intrauterine resuscitation during the second stage of term labour by maternal hyperoxygenation versus conventional care: study protocol for a randomised controlled trial (INTEREST O2). Trials 2018; 19:195. [PMID: 29566729 PMCID: PMC5865381 DOI: 10.1186/s13063-018-2567-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Accepted: 03/01/2018] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Perinatal asphyxia is, even in developed countries, one the major causes of neonatal morbidity and mortality. Therefore, if foetal distress during labour is suspected, one should try to restore foetal oxygen levels or aim for immediate delivery. However, studies on the effect of intrauterine resuscitation during labour are scarce. We designed a randomised controlled trial to investigate the effect of maternal hyperoxygenation on the foetal condition. In this study, maternal hyperoxygenation is induced for the treatment of foetal distress during the second stage of term labour. METHODS/DESIGN This study is a single-centre randomised controlled trial being performed in a tertiary hospital in The Netherlands. From among cases of a suboptimal or abnormal foetal heart rate pattern during the second stage of term labour, a total of 116 patients will be randomised to the control group, where normal care is provided, or to the intervention group, where before normal care 100% oxygen is supplied to the mother by a non-rebreathing mask until delivery. The primary outcome is change in foetal heart rate pattern. Secondary outcomes are Apgar score, mode of delivery, admission to the neonatal intensive care unit and maternal side effects. In addition, blood gas values and malondialdehyde are determined in umbilical cord blood. DISCUSSION This study will be the first randomised controlled trial to investigate the effect of maternal hyperoxygenation for foetal distress during labour. This intervention should be recommended only as a treatment for intrapartum foetal distress, when improvement of the foetal condition is likely and outweighs maternal and neonatal side effects. TRIAL REGISTRATION EudraCT, 2015-001654-15; registered on 3 April 2015. Dutch Trial Register, NTR5461; registered on 20 October 2015.
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Affiliation(s)
- Lauren M Bullens
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands. .,Department of Electrical Engineering, Eindhoven University of Technology, PO Box 513, 5600, MB, Eindhoven, The Netherlands.
| | - Alexandra D J Hulsenboom
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands
| | - Suzanne Moors
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands
| | - Rohan Joshi
- Department of Clinical Physics, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands.,Department of Industrial Design, Eindhoven University of Technology, PO Box 513, 5600, MB, Eindhoven, The Netherlands
| | - Pieter J van Runnard Heimel
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands
| | - M Beatrijs van der Hout-van der Jagt
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, PO Box 513, 5600, MB, Eindhoven, The Netherlands
| | - Edwin R van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, PO Box 513, 5600, MB, Eindhoven, The Netherlands
| | - S Guid Oei
- Department of Obstetrics and Gynaecology, Máxima Medical Centre, PO Box 7777, 5500, MB, Veldhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, PO Box 513, 5600, MB, Eindhoven, The Netherlands
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20
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Sanapo L, Pruetz JD, Słodki M, Goens MB, Moon-Grady AJ, Donofrio MT. Fetal echocardiography for planning perinatal and delivery room care of neonates with congenital heart disease. Echocardiography 2017; 34:1804-1821. [DOI: 10.1111/echo.13672] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Laura Sanapo
- Division of Fetal and Transitional Medicine; Children's National Health System; George Washington University; Washington DC USA
| | - Jay D. Pruetz
- Division of Cardiology; Children's Hospital Los Angeles; Keck School of Medicine; University of Southern California; Los Angeles CA USA
| | - Maciej Słodki
- Department of Prenatal Cardiology; Polish Mother's Memorial Hospital Research Institute; Lodz Poland
- Faculty of Health Sciences; The State University of Applied Sciences; Plock Poland
| | - M. Beth Goens
- Special Delivery Service; Pediatric Cardiology; University of New Mexico; Albuquerque NM USA
| | - Anita J. Moon-Grady
- Division of Cardiology; Department of Pediatrics; UCSF Benioff Children's Hospital; San Francisco CA USA
| | - Mary T. Donofrio
- Division of Fetal and Transitional Medicine; Children's National Health System; George Washington University; Washington DC USA
- Fetal Heart Program; Division of Cardiology; Children's National Health System; Washington DC USA
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21
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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Raghuraman N, Temming LA, Stout MJ, Macones GA, Cahill AG, Tuuli MG. Intrauterine Hyperoxemia and Risk of Neonatal Morbidity. Obstet Gynecol 2017; 129:676-682. [PMID: 28277364 PMCID: PMC5559887 DOI: 10.1097/aog.0000000000001931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that intrauterine hyperoxemia is associated with an increased risk of neonatal morbidity. METHODS This was a secondary analysis of a prospective study of singleton, nonanomalous deliveries at or beyond 37 weeks of gestation at an institution with a universal umbilical cord gas policy from 2010 to 2014. The primary outcome was a composite of neonatal morbidity including neonatal death, meconium aspiration syndrome, intubation, mechanical ventilation, hypoxic-ischemic encephalopathy, and hypothermic therapy. Intrauterine hyperoxemia was defined as umbilical vein partial pressure of oxygen 90th percentile or greater of the cohort. Adjusted relative risks (RRs) were estimated for neonatal morbidity controlling for confounders. Analysis was performed for the entire cohort and stratified by the presence of acidemia defined as umbilical artery pH less than 7.1. RESULTS Of 7,789 patients with validated paired cord gases, 106 (1.4%) had the composite neonatal morbidity. There was no difference in composite neonatal morbidity in patients with and without intrauterine hyperoxemia in the entire cohort (1.5% compared with 1.3%, adjusted RR 1.5, 95% confidence interval [CI] 0.9-2.7). The rate of acidemia was not significantly different in the two groups (1.9% compared with 1.8%, adjusted RR 1.5, 95% CI 0.9-2.5). In stratified analysis, there was evidence of effect modification (P for interaction <.001) with a significant association between intrauterine hyperoxemia and neonatal morbidity in the presence of acidemia (41.2% compared with 21.4%, adjusted RR 2.3, 95% CI 1.1-3.5), but not in its absence (0.8% compared with 1.0%, adjusted RR 1.0, 95% CI 0.5-2.2). CONCLUSION Intrauterine hyperoxemia, compared with normoxemia, is associated with a small but significantly increased risk of neonatal morbidity in acidemic neonates.
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Affiliation(s)
- Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University School of Medicine in St. Louis, St. Louis, Missouri
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Battaloglu E, Porter K. Management of pregnancy and obstetric complications in prehospital trauma care: faculty of prehospital care consensus guidelines. Emerg Med J 2017; 34:318-325. [PMID: 28264877 DOI: 10.1136/emermed-2016-205978] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 10/14/2016] [Accepted: 10/30/2016] [Indexed: 11/04/2022]
Abstract
This consensus statement seeks to provide clear guidance for the management of pregnant trauma patients in the prehospital setting. Pregnant patients sustaining trauma injuries have certain clinical management priorities beyond that of the non-pregnant trauma patients and that if overlooked may be detrimental to maternal and fetal outcomes.
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Affiliation(s)
- E Battaloglu
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - K Porter
- Academic Department of Clinical Traumatology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Abstract
BACKGROUND Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. This is an update of a review first published in 2013. OBJECTIVES The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, issue 11), MEDLINE (1948 to November 2014) and EMBASE (1980 to November 2014). The original search was first performed in February 2012. We reran the search in CENTRAL, MEDLINE, EMBASE in February 2016. One potential new study of interest was added to the list of 'Studies awaiting Classification' and will be incorporated into the formal review findings during the next review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses. MAIN RESULTS We found one new included study in this updated version. In total, our updated review includes 11 trials (with 753 participants). The low quality of evidence showed no significant differences in average Apgar scores at one minute (N = six trials, 519 participants; 95% confidence (CI) -0.16 to 0.31, P = 0.53) and at five minutes (N = six trials, 519 participants; 95% CI -0.06 to 0.06, P = 0.98). None of the 11 trials reported maternal desaturation. The very low quality of evidence showed that in comparison to room air, women in labour receiving supplementary oxygen had higher maternal oxygen saturation (N = three trials, 209 participants), maternal PaO2 (oxygen pressure in the blood; N = six trials, 241 participants), UaPO2 (foetal umbilical arterial blood; N = eight trials, 504 participants; 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; N = 10 trials, 683 participants). There was high heterogeneity among these outcomes. A subgroup analysis showed no significant difference in UaPO2 between the two intervention groups in low-risk studies, whereas the high-risk studies showed a benefit for the neonatal oxygen group. AUTHORS' CONCLUSIONS Overall, we found no convincing evidence that giving supplementary oxygen to healthy term pregnant women during elective caesarean section under regional anaesthesia is either beneficial or harmful for either the mother or the foetus' short-term clinical outcome as assessed by Apgar scores. Although, there were significant higher maternal and neonatal blood gas values and markers of free radicals when extra oxygen was given, the results should be interpreted with caution due to the low grade quality of the evidence.
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Affiliation(s)
- Sunisa Chatmongkolchart
- Faculty of Medicine, Prince of Songkla UniversityDepartment of AnesthesiaHatyaiSongklaThailand90110
| | - Sumidtra Prathep
- Faculty of Medicine, Prince of Songkla UniversityDepartment of AnesthesiaHatyaiSongklaThailand90110
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Hamel MS, Anderson BL, Rouse DJ. Oxygen for intrauterine resuscitation: of unproved benefit and potentially harmful. Am J Obstet Gynecol 2014; 211:124-7. [PMID: 24412117 DOI: 10.1016/j.ajog.2014.01.004] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 12/24/2014] [Accepted: 01/07/2014] [Indexed: 10/25/2022]
Abstract
Maternal oxygen is often given to laboring women to improve fetal metabolic status or in an attempt to alleviate nonreassuring fetal heart rate patterns. However, the only 2 randomized trials investigating the use of maternal oxygen supplementation in laboring women do not support that such supplementation is likely to be of benefit to the fetus. And by increasing free radical activity, maternal oxygen supplementation may even be harmful. Based on a review of the available literature, we conclude that until it is studied properly in a randomized clinical trial, maternal oxygen supplementation in labor should be reserved for maternal hypoxia, and should not be considered an indicated intervention for nonreassuring fetal status.
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Abstract
BACKGROUND Supplementary oxygen is routinely administered to low-risk pregnant women during an elective caesarean section under regional anaesthesia; however, maternal and foetal outcomes have not been well established. OBJECTIVES The primary objective was to determine whether supplementary oxygen given to low-risk term pregnant women undergoing elective caesarean section under regional anaesthesia can prevent maternal and neonatal desaturation. The secondary objective was to compare the mean values of maternal and neonatal blood gas levels between mothers who received supplementary oxygen and those who did not (control group). SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2012), MEDLINE (1948 to February 2012) and EMBASE (1980 to February 2012). We did not apply language restrictions. SELECTION CRITERIA We included randomized controlled trials of low-risk pregnant women undergoing an elective caesarean section under regional anaesthesia and compared outcomes with, and without, oxygen supplementation. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, assessed methodological quality and performed subgroup and sensitivity analyses. MAIN RESULTS We included 10 trials with a total of 683 participants. Supplementary oxygen administration varied widely in dose and duration between trials. No cases of maternal desaturation were reported, although none of the 10 trials focused on maternal desaturation. Significant differences were noted in maternal oxygen saturation (higher with oxygen, N = three trials; mean difference (MD) 1.6%, 95% confidence interval (CI) 0.8 to 2.3, P < 0.0001), maternal PaO2 (oxygen pressure in the blood; higher with oxygen, N = six trials; MD 141.8 mm Hg, 95% CI 109.3 to 174.3, P < 0.00001), neonatal UaPO2 (foetal umbilical arterial blood; higher with oxygen, N = eight trials; MD 3.3 mm Hg, 95% CI 1.8 to 4.9, P < 0.0001) and UvPO2 (foetal umbilical venous blood; higher with oxygen, N = 10 trials; MD 5.9 mm Hg, 95% CI 3.2 to 8.5, P < 0.0001). No significant differences were reported in neonatal UapH (N = eight trials; MD 0.00, 95% CI -0.01 to 0.00, P = 0.26) and in average Apgar scores at one minute (N = five trials; MD 0.07, 95% CI -0.20 to 0.34, P = 0.6) and at five minutes (N = five trials; MD 0.00, 95% CI -0.06 to 0.05, P = 0.91).Only two out of 10 trials had a low risk of bias in all categories. When we separated the studies into low risk and high risk for bias, we found substantial statistical heterogeneity. None of the low-risk studies showed a significant difference in neonatal UaPO2 between the two intervention groups, whereas the high-risk studies showed a benefit for the neonatal oxygen group.The level of oxygen free radicals (malondialdehyde (MDA) and 8-isoprostane) was higher in participants who received supplementary oxygen (N = two trials; MD 0.2 µmol/L, 95% CI 0.1 to 0.4, P = 0.0002; MD 64.3 pg/mL, 95% CI 51.7 to 76.8, P < 0.00001, respectively). AUTHORS' CONCLUSIONS Current evidence suggests that supplementary oxygen given to healthy term pregnant women during elective caesarean section under regional anaesthesia is associated with higher maternal and neonatal oxygen levels (maternal SpO2, PaO2, UaPO2 and UvPO2) and higher levels of oxygen free radicals. However, the intervention was neither beneficial nor harmful to the neonate's short-term clinical outcome as assessed by Apgar scores.
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Affiliation(s)
- Sunisa Chatmongkolchart
- Department of Anesthesia, Faculty of Medicine, Prince of Songkla University, Hatyai, Thailand.
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Abstract
BACKGROUND Maternal oxygen administration has been used in an attempt to lessen fetal distress by increasing the available oxygen from the mother. This has been used for suspected fetal distress during labour, and prophylactically during the second stage of labour on the assumption that the second stage is a time of high risk for fetal distress. OBJECTIVES The objective of this review was to assess the effects of maternal oxygenation for fetal distress during labour and to assess the effects of prophylactic oxygen therapy during the second stage of labour on perinatal outcome. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012) and searched reference lists of retrieved studies. SELECTION CRITERIA Randomized trials comparing maternal oxygen administration for fetal distress during labour and prophylactic oxygen administration during the second stage of labour with a control group (dummy or no oxygen therapy). DATA COLLECTION AND ANALYSIS Both review authors assessed eligibility and trial quality. Data were extracted, checked and entered into Review Manager software. For dichotomous data, we calculated relative risks (RR) and 95% confidence intervals (CI). For continuous data, we calculated weighted mean differences and 95% CI. MAIN RESULTS We located no trials addressing maternal oxygen therapy for fetal distress. We included two trials which addressed prophylactic oxygen administration during labour. Abnormal cord blood pH values (less than 7.2) were recorded significantly more frequently in the oxygenation group than the control group (RR 3.51, 95% CI 1.34 to 9.19). There were no other statistically significant differences between the groups. There were conflicting conclusions on the effect of the duration of oxygen administration on umbilical artery pH values between the two trials. AUTHORS' CONCLUSIONS Implications for practice There is not enough evidence to support the use of prophylactic oxygen therapy for women in labour, nor to evaluate its effectiveness for fetal distress.Implications for research In view of the widespread use of oxygen administration during labour and the possibility that it may be ineffective or harmful, there is an urgent need for randomized trials to assess its effects.
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Affiliation(s)
- Bukola Fawole
- Department of Obstetrics and Gynaecology, University of Ibadan, Ibadan, Nigeria.
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