Fetal heart rate monitoring by telephone. II. Clinical experience in four centres with a commercially produced system

Fetal home monitoring for the prenatal management of gastroschisis

BACKGROUND

Fetal distress is a frequent complication of gastroschisis, and could be screened for by home monitoring, as many pregnant women expecting an affected child live far away from a specialized perinatal center. This study was undertaken to audit a policy of fetal home monitoring (FHM) to achieve early detection of fetal heart rate (FHR) abnormalities in gastroschisis.

METHODS

Daily FHM was started at a median age of 30 weeks in 31 pregnant women referred following prenatal diagnosis of isolated gastroschisis. Monitoring was considered abnormal in cases with decelerations, tachycardia, bradycardia, decreased baseline variability or absence of accelerations. When an ominous FHR was detected and confirmed by in-hospital monitoring, an emergency cesarean section (C-section) was indicated. Otherwise, an elective C-section was planned.

RESULTS

In 20 cases FHM remained normal. There were 16 elective C-sections, two emergency C-sections for FHR abnormalities detected by in-hospital monitoring, and two spontaneous premature vaginal deliveries. In 11 cases, an abnormal FHM was detected. There was one intrauterine death with acute ischemic necrosis of the large bowel. The other abnormalities consisted of decreased baseline variability with tachycardia (n = 7) or without tachycardia (n = 3) and were confirmed by in-hospital follow-up in nine cases, leading to emergency C-section.

CONCLUSION

The high rate of abnormal FHR patterns picked up by FHM in gastroschisis led to a rate of emergency C-sections of 9/31. However, this strategy failed to prevent one intrauterine death due to acute bowel necrosis.

Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies

OBJECTIVES

To evaluate the feasibility of high-risk pregnancy surveillance by patient-directed fetal heart rate monitoring and transmission, and to assess patient satisfaction with this technology.

METHODS

Thirty-six women with high-risk pregnancies performed daily non-stress tests at home and transmitted the data to our perinatal care center by telephone. At each transmission, patients were asked by a physician about perceived fetal movements and uterine contractions and given the results. If the tracing was unsatisfactory, further evaluation was performed. In addition, patients completed a questionnaire on quality of life and anxiety state before and after the study.

RESULTS

All patients were able to perform the tests and transmissions. The quality of recorded data was significantly correlated with maternal body mass index, but not with gestational age at the time of monitoring or birth weight. Thirty-nine of the total 562 tracings (6.9%) were inconclusive or non-reassuring. After repeated testing, 32 of them (82%) were considered normal, and seven patients (18%) were referred for additional in-hospital evaluation. Of this group, four were discharged for further surveillance with routine home monitoring and the remaining three were hospitalized for continued evaluation. There were no significant immediate adverse maternal or neonatal outcomes as a result of the monitoring. Patient satisfaction was high.

CONCLUSIONS

Daily home FHR monitoring in high-risk patients is safe and feasible at all gestational ages, based on this initial pilot evaluation. It is easily and reliably performed and accepted by patients with a high level of satisfaction.

Telemedicine for antenatal surveillance of high-risk pregnancies with ambulatory and home fetal heart rate monitoring--an update

Antepartum fetal surveillance is routinely used to assess the risk of fetal death in high-risk pregnancies. Traditionally, testing is performed in the hospital or outpatient clinic by trained medical staff. New equipment is now available that is easy to operate and can be used for self-monitoring of the fetal heart rate (FHR) in the home setting. The tracings are transmitted by modem to a referral center for immediate interpretation by a health provider. The aim of this review was to assess the current data on the application of this new technology with regard to feasibility, access to care, maternal and neonatal outcome, patient and physician satisfaction, and cost-effectiveness.

Telephone fetal heart rate monitoring in South Australia

A pilot trial was conducted to assess the technical feasibility of long range fetal heart monitoring by telephone in an Australian setting. The indications for such monitoring and patient ability and attitude towards self-monitoring was also assessed. One hundred and fifty seven tracings were received from 57 women using a simple doppler device to transmit fetal heart sounds to the central hospital fetal monitor. Thirty three of the patients were in country hospitals and 24 were at home. Gestation ranged from 26 to 42 weeks' gestation. Eighty six percent of the country hospital tracings and 94% of the home tracings were easily interpretable. The large majority of tracings were normal and appeared to encourage conservative management by the attendants. Two tracings were abnormal and these influenced early delivery in both cases. Nearly all women using the monitor at home found the procedure easy and reassuring. Tracings from country hospitals were initiated usually after an acute antenatal complication, whereas the indications for home-monitoring were prompted by longer-term, medium-risk factors. Home-monitoring may reduce the inconvenience and expense of inpatient or outpatient care and country hospitals without electronic fetal monitors may benefit from such a service. The selection of patients who might benefit from such technology remains controversial and warrants a prospective randomized controlled trial.

A controlled trial of self-nonstress test versus assisted nonstress test in the evaluation of fetal well-being

OBJECTIVE

New portable devices have become available for home monitoring of fetal heart rates; these devices have the potential to immediately transmit these tracings to a medical facility. The null hypothesis of this study is the inability of mothers to perform their own nonstress tests (self-nonstress tests) and that such tests are not comparable to those performed by professional medical personnel (assisted nonstress tests).

STUDY DESIGN

The feasibility of maternal self-testing was established in 50 high-risk patients followed by a controlled clinical trial conducted in 60 patients. The latter study represents the first controlled trial in which patients performed self-nonstress tests at their homes and transmitted the tracings via telecommunication to our perinatal unit. In all cases these patients came to our hospital within 60 minutes after the self-nonstress tests to have a perinatal nurse perform a second nonstress test. The pairs of self and assisted fetal heart rate tracings were independently reviewed by two investigators.

RESULTS

The self and assisted tracing pairs were judged satisfactory for interpretation in 100% and 90%, respectively; self and assisted were interpreted by each examiner to be nonreactive in 20% and 14%, respectively. However, both examiners were unable to distinguish between tracings generated by assisted nonstress and self-nonstress tests. Furthermore, cost analysis revealed an estimated twofold savings with self-nonstress testing compared with the assisted nonstress test.

CONCLUSION

Self-nonstress testing is a reliable and accurate method of antepartum fetal heart rate testing. This method of fetal assessment not only introduces a new approach to fetal surveillance with added convenience to patients, but may also significantly reduce medical cost without compromising the results of fetal testing.

Two-tier approach to biophysical assessment of the fetus

The biophysical profile score is widely accepted as a superior predictor of acute-on-chronic fetal asphyxia over the nonstress test. Nevertheless, in the United Kingdom facilities for assessment of high-risk pregnancies by nonstress test are more widely available than with the biophysical profile score. After a retrospective review of 2038 biophysical assessments in 500 high-risk pregnancies, it is suggested that biophysical evaluation of the fetus can be rationalized on the basis of the clinical problem and fetal growth. Terminal acute-on-chronic fetal asphyxia can be excluded by a two-tier method of fetal assessment by initial nonstress test backed up by the biophysical profile score when the nonstress test is suboptimal.

Domiciliary fetal monitoring in a district maternity unit

Domiciliary Fetal Monitoring is a new technique which allows fetal heart rate monitoring from within a patient's home. The 30 minute cardiotocograph is transmitted by telephone, to a central labour ward computer, within 45 seconds. Of 522 domiciliary cardiotocographs performed on 100 consecutive patients, 356 (68%) were performed for suspected intrauterine growth retardation or reduced fetal movements. Thirty one (5.9%) recordings were abnormal; a repeat cardiotocograph in hospital was abnormal in 9 cases (1.3%); all such patients were delivered within 7 days. The induction rate for the study group was increased by a factor of 3.2 with respect to all hospital confinements; 49% of infants were small for gestational age (less than 10th percentile). Caesarean section and forceps delivery rates were the same for both groups. No stillbirths occurred in the study group. After the introduction of domiciliary monitoring, the number and duration of hospital admissions for fetal surveillance were reduced by 29% and 52% respectively. Patients were equally as able as midwives to perform domiciliary fetal monitoring. A patient survey revealed widespread satisfaction with the DFM system.

Patient-recorded domiciliary fetal monitoring

Domiciliary fetal monitoring via a telephone link has been in clinical use at the Royal Free Hospital for 2 years, during which time 858 traces of 134 patients who were moderately at risk have been transmitted to the hospital. All recognized abnormal heart rate patterns were detected during the study period. In seven patients obstetric intervention took place on the basis of the domiciliary fetal monitoring recording and subsequent hospital monitoring. There were no intrauterine or neonatal deaths, and there was no overall increase in obstetric operative intervention. There appeared to be a significant reduction in the inconvenience suffered by the patient and her family, compared with conventional monitoring. Fetal heart recordings performed solely by the patient were of a high quality and reduced the demand on midwifery resources. To allow this only 3 hours of midwifery time daily was required and no additional demands on obstetric staff were made. It is anticipated that domiciliary fetal monitoring, performed by patients, will become an essential and established service throughout the United Kingdom (and probably Europe) as the principal means of monitoring fetal well-being.

A randomised study of a domiciliary antenatal care scheme: maternal psychological effects

The Cardiff Integrated Antenatal Care Scheme (CIACS) places emphasis on home-centred care for selected women with a high-risk pregnancy. The Scheme is intended to make better use of midwifery and obstetric resources, and it provides a new type of care where close surveillance is required. A randomised controlled trial was undertaken in which anxiety levels were compared between two groups of women with an identified high-risk pregnancy. Sixty-five women were eligible for entry to the study. Five refused randomisation and 60 were randomised 2:1 either to care under the CIAC Scheme (domiciliary group n = 40) or to conventional hospital antenatal care (conventional group n = 17). Zung depression and STAI 'trait' levels conducted at weekly intervals were similar in both groups whilst 'state' levels were 34.05 (SD 9.24) in the domiciliary group and 41.05 (SD 9.93) in the conventional care group (P less than 0.01). It is suggested that the observed difference is due to the greater security provided by the home environment coupled with individual support from a midwife.

Fetal heart rate monitoring by telephone. I. Development of an integrated system in Cardiff

We report the development of a practical dedicated system for domiciliary fetal monitoring integrated in a scheme for its rational application. From experience of 1120 domiciliary recordings in 74 women (64 with high-risk pregnancies), we suggest that domiciliary monitoring applied within a structured clinical context should be as safe as monitoring in hospital.