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Thayer SM, Faramarzi P, Krauss MJ, Snider E, Kelly JC, Carter EB, Frolova AI, Odibo AO, Raghuraman N. Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system. Am J Obstet Gynecol MFM 2023; 5:101001. [PMID: 37146688 DOI: 10.1016/j.ajogmf.2023.101001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/28/2023] [Accepted: 04/30/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Electronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings. OBJECTIVE This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings. STUDY DESIGN This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non-university-affiliated hospital). RESULTS Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non-university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02). CONCLUSION There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.
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Affiliation(s)
- Sydney M Thayer
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman).
| | - Parisa Faramarzi
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Melissa J Krauss
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Elsa Snider
- Brown School at Washington University in St. Louis, St. Louis, MO (Mses Krauss and Snider)
| | - Jeannie C Kelly
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Ebony B Carter
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Antonina I Frolova
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Anthony O Odibo
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
| | - Nandini Raghuraman
- Department of Obstetrics and Gynecology, Washington University in St. Louis, St. Louis, MO (Dr Thayer, Ms Faramarzi, and Drs Kelly, Carter, Frolova, Odibo, and Raghuraman)
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Current Innovative Methods of Fetal pH Monitoring—A Brief Review. Diagnostics (Basel) 2022; 12:diagnostics12112675. [DOI: 10.3390/diagnostics12112675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/24/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
In this study, we explore the “why?”, and “how?”, monitoring the pH of the fetal scalp is used, and show its limitations. In addition, we review the development of new devices based on the modern physics and nanomaterials serving this topic. Most of the works we found in our search have focused on improving the prognostic of fetal heart rate monitoring, because it is the “golden standard” in determining fetal distress. Although the best-known screening method, it can only provide limited information about the actual status of the fetus. The best predictive assessment, with the highest reproducibility, states that a normal fetal heart rate is indicative of a healthy baby. However, its excellent sensitivity is much reduced when identifying the actual “distress”. This is when second-line monitoring methods come into play to guide the diagnostics and direct the obstetrician towards an action plan. Although a historic method, fetal scalp pH sampling is still under review as to its efficiency and place in the current obstetrics. Continuous surveillance of the fetal parameters is important, especially for the fetuses undergoing intrauterine growth restricted (IUGR). Since fetal scalp blood sampling is still under research and is a randomized controlled trial, which compares the relevance of pH and lactates to the obstetrical situation, the maternal-fetal medicine could greatly benefit from the introduction of engineered nanomedicines to the field.
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Matmor Loeub S, Weintraub AY, Rotem R, Geva Y, Yaniv Salem S. Correlation between total deceleration area and fetal cord blood pH in neonates complicated with meconium-stained amniotic fluid at term. Int J Gynaecol Obstet 2022; 159:974-978. [PMID: 35598120 DOI: 10.1002/ijgo.14274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 04/10/2022] [Accepted: 05/10/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To assess the correlation between total area under the Curve (AUC) of decelerations and accelerations and neonatal acidemia in pregnancies complicated with meconium-stained amniotic fluid (MSAF). METHODS A retrospective cohort study was conducted among women who delivered with a diagnosis of MSAF. Electronic fetal monitoring (EFM) patterns 120 min before delivery were interpreted by a researcher blinded to fetal outcomes. The primary outcome was fetal acidemia, defined as umbilical artery pH below 7.10. The correlation was tested using the Spearman correlation coefficient. RESULTS A total of 102 women were included; 24 delivered infants with cord blood pH < 7.20, and only five delivered infants with cord blood pH < 7.10. A significant correlation was demonstrated between total AUC of decelerations and accelerations and cord blood pH (P = 0.02). A sub-analysis according to gestational age at delivery (up to and beyond 40 weeks) was conducted. A significant correlation was demonstrated (P = 0.02) only in the term group(n = 37). CONCLUSION A correlation was demonstrated between total AUC of decelerations and accelerations and cord blood pH in neonates with MSAF. This correlation was significant for neonates delivered before 40 weeks of gestation, but not for those delivered after 40 weeks of gestation.
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Affiliation(s)
- Shirel Matmor Loeub
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Adi Y Weintraub
- Joyce and Irving Goldman School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yael Geva
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel
| | - Shimrit Yaniv Salem
- Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel
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Fetal Heart Rate Decelerations in Women with Sleep-Disordered Breathing. Reprod Sci 2021; 28:2602-2609. [PMID: 33847976 DOI: 10.1007/s43032-021-00563-w] [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: 08/06/2020] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
Emerging literature has shown that women with sleep-disordered breathing (SDB) have increased risk for gestational hypertension/preeclampsia and gestational diabetes. Case reports suggest an association between maternal apnea and fetal heart rate deceleration but data are lacking on how maternal sleep impacts fetal health. Since decelerations may be associated with adverse outcomes, we sought to determine whether fetal heart rate decelerations were associated with SDB. A cohort study of third trimester pregnant women with a singleton fetus was conducted. Participants underwent a home sleep test with continuous portable electronic fetal monitoring. SDB was defined as a respiratory disturbance index (RDI)≥10 events/hour. The temporality between a respiratory event and fetal heart rate decelerations was determined to be present if a deceleration occurred < 30 s after a respiratory event. Forty women were included with mean (±SD) age, BMI, and gestational age of 32.0±5.5 years, 37.1±8.0 kg/m2, and 34.6±2.4 weeks respectively. Overall, n=23 (57.5%) women had SDB. Thirty-seven late decelerations were observed in 18 women; of these, 84% were temporally associated with a respiratory event. Nine of the 18 women (50%) had SDB. Ten prolonged decelerations were observed in 6 women of which nine (90%) were temporally associated with a respiratory event. Five of the six women (83%) had an RDI≥10. These initial data suggest that, in this population, the majority of both late and prolonged fetal heart rate decelerations occur with a maternal respiratory event. Since respiratory events are characteristic of maternal SDB, this raises the possibility that SDB may influence fetal well-being.
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Zheng YY, Pubu ZM, Ge Y, Bianba ZM, Xu XH. Prevalence and causes of cesarean births among women residing at high altitude in Lhasa, Tibet: A retrospective observational study of 7365 women. Taiwan J Obstet Gynecol 2019; 58:380-384. [PMID: 31122529 DOI: 10.1016/j.tjog.2019.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2019] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Currently, there is paucity of data on the rate of vaginal deliveries and cesarean section among women in Tibet. In this study, we carried out an observational study of 7365 consecutive pregnant women in Lhasa, Tibet who gave birth at our tertiary care institution between 2012 and 2015. MATERIALS AND METHODS In this retrospective study, we reviewed the hospital records for demographic data, obstetric history, and the number of vaginal and emergency cesarean section deliveries. The overall and annual rate of vaginal and cesarean section deliveries was calculated. Causes, indications or risks for cesarean section were also analyzed. RESULTS During the review period, 7365 neonates were delivered at our hospital, including 1690 (23.0%) deliveries via cesarean section. The yearly rate of cesarean section progressively declined from 26.7% in 2012 to 18% in 2015 (P < 0.001). Furthermore, the annual rate of emergency cesarean section declined 53.9%between 2012 and 2015(P < 0.001). Fetal risk factors (39.9%) and maternal risk factors (40.3%) were the major causes of cesarean section in the women. Social factors as a cause of cesarean section fluctuated between 7.9% and 11.1%. CONCLUSION This study has demonstrated a steady decline in the annual rate of cesarean section in women in Tibet between 2012 and 2015. A decrease in the rate of emergency cesarean section contributed substantially to this decline. Moreover, approximately 10% caesarian sections were performed without clear indications, highlighting the need for strengthening prenatal counseling for pregnant women in Tibet.
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Affiliation(s)
- Yuan-Yuan Zheng
- Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Zhuo-Ma Pubu
- Department of Obstetrics and Gynecology, Lhasa People's Hospital, Lhasa, Tibet, China
| | - Yang Ge
- Department of Obstetrics and Gynecology, Lhasa People's Hospital, Lhasa, Tibet, China
| | - Zhuo-Ma Bianba
- Department of Obstetrics and Gynecology, Lhasa People's Hospital, Lhasa, Tibet, China
| | - Xiao-Hong Xu
- Department of Gynecologic Oncology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China.
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Medeiros TKDS, Dobre M, da Silva DMB, Brateanu A, Baltatu OC, Campos LA. Intrapartum Fetal Heart Rate: A Possible Predictor of Neonatal Acidemia and APGAR Score. Front Physiol 2018; 9:1489. [PMID: 30405441 PMCID: PMC6204407 DOI: 10.3389/fphys.2018.01489] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 10/02/2018] [Indexed: 12/20/2022] Open
Abstract
Background: Predicting perinatal outcomes based on patterns of fetal heart rate (FHR) remains a challenge. The aim of this study was to evaluate intrapartum FHR variability as predictor for neonatal acidemia and APGAR score. Methods: This was a retrospective observational study of 552 childbirths. Multivariable linear regression models were used to assess the association between FHR variability and each of the following outcomes: arterial cord blood pH and base deficit, Apgar 1, and 5 scores. Variables used for adjustment were maternal age, comorbidities (gestational diabetes, preeclampsia, maternal fever, and hypertension), parity, gravidity, uterine contractions, and newborn gestational age, and weight at birth. Results: The following factors were associated with an increased risk of metabolic acidosis and low Apgar scores at birth: increased mean and coefficient of variation (CV) of the FHR, type of delivery and decreased parity. Each 10-beat/min increase in the FHR was associated with an increase of 0.43 mEq/L in the base deficit, and a decrease of 0.01 in the pH, 0.2 in the Apgar 1, and 0.14 in the Apgar 5 scores. Each 10% increase in the CV of the FHR was associated with an increase of 4.05 mEq/L in the base deficit and a decrease of 0.13 in the pH, 1.31 in the Apgar 1, and 0.86 in the Apgar 5 scores. Conclusion: These data suggest the intrapartum FHR variability is physiologically relevant and can be used for predicting the acidemia and Apgar scores at birth of the newborn infants without severe cases of morbidity and from uncomplicated pregnancies.
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Affiliation(s)
- Thâmila Kamila de Souza Medeiros
- Center of Innovation, Technology and Education at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil.,School of Health Sciences at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals, Cleveland, OH, United States
| | - Daniela Monteiro Baptista da Silva
- Center of Innovation, Technology and Education at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil.,School of Health Sciences at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil
| | - Andrei Brateanu
- Medicine Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Ovidiu Constantin Baltatu
- Center of Innovation, Technology and Education at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil.,School of Health Sciences at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil
| | - Luciana Aparecida Campos
- Center of Innovation, Technology and Education at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil.,School of Health Sciences at Anhembi Morumbi University - Laureate International Universities, São José dos Campos, Brazil
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