Improving intrapartum surveillance: an individualised T/QRS ratio?

A systematic review on the utility of non-invasive electrophysiological assessment in evaluating for intra uterine growth restriction

Background

Non-invasive electrophysiological assessment (NIEA) is an evolving area in fetal surveillance and is attracting increasing research interest. There is however, limited data outlining its utility in evaluating intra uterine growth restriction (IUGR). The objective of this study was to carry out a systematic review to outline the utility of NIEA parameters in evaluating IUGR.

Methods

A systematic review of peer reviewed literature was performed, searching PUBMED, Ovid MEDLINE and EMBASE. The outcomes of interest included NIEA parameters [P wave duration, PR interval, QRS duration, QT interval, T/QRS ratio, short term variability (STV) and long term variability (LTV)] and a descriptive summary of relevant studies as well.

Results

Sixteen studies were identified as suitable for inclusion. The utility of NIEA parameters were investigated in tabular form. In particular, QRS and QT duration, T/QRS ratio, STV and PRSA analysis displayed utility and merit further consideration in evaluating for IUGR. Issues identified in the review were in relation to variances in definition of IUGR, small sample sizes and the lack of technological consistency across studies.

Conclusion

NIEA shows promise as an adjunct surveillance tool in fetal diagnostics for IUGR. Larger prospective studies should be directed towards establishing reliable parameters with a focus on uniformity of IUGR definition, technological consistency and the individualisation of NIEA parameters.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2357-9) contains supplementary material, which is available to authorized users.

Caesarean Section for Foetal Distress and Correlation with Perinatal Outcome

BACKGROUND

The main documented indication of intrapartum caesarean section is foetal distress (MacKenzie and Cooke in BMJ 323(7318):930, 2001). Foetal distress indicates foetal hypoxia and acidosis during intrauterine life.

PURPOSE

To correlate the diagnosis of foetal distress and perinatal outcome.

METHODS

This was a prospective observational study of women who underwent caesarean section for foetal distress as detected by cardiotocography and not responding to intrauterine resuscitation. The foetal Apgar score at 1 and 5 min was recorded and cord blood pH was measured in all cases. The neonatal outcome was studied with regard to the need for supportive ventilation and admission to NICU/nursery.

RESULTS

In our study, 14.38 % cases diagnosed with foetal distress subsequently had poor outcome. Twenty-one babies had a 5-min Apgar score <7, required immediate resuscitation and were admitted in NICU. Twelve foetuses had a 1-min Apgar score <4, while there were three cases of severe birth asphyxia (Apgar score <4 at 5 min); of these, two babies died. The neonatal outcome was poorer in cases with associated complicating factors.

CONCLUSION

The diagnosis of foetal distress is imprecise and a poor predictor of foetal outcome-the result is a tendency for unnecessary caesarean sections. On the contrary, lack of adverse outcome could reflect that our unit makes decisions at a time before clinically significant foetal compromise occurs.

Cesarean section for suspected fetal distress, continuous fetal heart monitoring and decision to delivery time

OBJECTIVE

To find out the efficacy of continuous fetal heart monitoring by analyzing the cases of cesarean section for nonreassuring fetal heart in labor, detected by cardiotocography (CTG) and correlating these cases with perinatal outcome. To evaluate whether a 30 minute decision to delivery (D-D) interval for emergency cesarean section influences perinatal outcome.

METHODS

This was a prospective observational study of 217 patients who underwent cesarean section at > or = 36 weeks for non-reassuring fetal heart in labor detected by CTG. The maternal demographic profile, specific types of abnormal fetal heart rate tracing and the decision to delivery time interval were noted. The adverse immediate neonatal outcomes in terms of Apgar score <7 at 5 minutes, umbilical cord thornH <7.10, neonates requiring immediate ventilation and NICU admissions were recorded. The correlation between non-reassuring fetal heart, decision to delivery interval and neonatal outcome were analyzed.

RESULTS

Out of 3148 patients delivered at > or = 36 weeks, 217 (6.8%) patients underwent cesarean section during labor primarily for non-reassuring fetal heart. The most common fetal heart abnormality was persistent bradycardia in 106 (48.8%) cases followed by late deceleration in 38 (17.5%) cases and decreased beat to beat variability in 17 (7.8%) cases. In 33 (15.2%) babies the 5 minutes Apgar score was <7 out of which 13 (5.9%) babies had cord thornH <7.10. Thirty three (15.2%) babies required NICU admission for suspected birth asphyxia. Rest 184 (84.7%) neonates were born healthy and cared for by mother. Regarding decision to delivery interval of < or =30 minutes versus >30 minutes, there was no significant difference in the incidence of Apgar score <7 at 5 minutes, cord pH <7.10 and new born babies requiring immediate ventilation. But the need for admission to NICU in the group of D-D interval < or = 30 minutes was significantly higher compared to the other group where D-D interval was >30 minutes.

CONCLUSION

Non-reassuring fetal heart rate detected by CTG did not correlate well with adverse neonatal outcome. There was no significant difference in immediate adverse neonatal outcome whether the D-D time interval was < or = 30 minutes or >30 minutes; contrary to this, NICU admission for suspected birth asphyxia in </= 30 minutes group was significantly higher.