Randomised controlled trial of intrapartum fetal heart rate monitoring

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Fetal Heart Rate Auscultation, 4th Edition

Intermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women's Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.

Cardiotocography use for fetal assessment during labor in low- and middle-income countries: A scoping review

BACKGROUND

The use of cardiotocography (CTG) to improve neonatal outcomes is controversial. The medical settings, subjects, utilizations, and interpretation guidelines of CTG are unclear for low- and middle-income countries (LMICs).

OBJECTIVES

To assess and review CTG use for studies identified in LMICs and provide insights on the potential for effective use of CTG to improve maternal and neonatal outcomes.

SEARCH STRATEGY

The databases Medline, CINAHL, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for published and unpublished literature through September 2023.

SELECTION CRITERIA

Publications were identified which were conducted in LMICs, based on the World Bank list of economies for 2019; targeting pregnant women in childbirth; and focusing on the utilization of CTG and neonatal outcomes.

DATA COLLECTION AND ANALYSIS

Publications were screened, and duplicates were removed. A scoping review was conducted using PRISMA-ScR guidelines.

RESULTS

The searches generated 1157 hits, of which 67 studies were included in the review. In the studies there was considerable variation and ambiguity regarding the study settings, target populations, utilizations, timing, frequency, and duration of CTG. While cesarean section rates were extensively investigated as an outcome of studies of CTG itself and the effect of additional techniques on CTG, other clinically significant outcomes, including neonatal mortality, were not well reported.

CONCLUSIONS

Variations and ambiguities were found in the use of CTG in LMICs. Due to the limited amount of evidence, studies are needed to examine CTG availability in the context of LMICs.

Evaluation of The Fetal Heart Rate Monitoring with The Non-Invasive Electrocardiography Signals

Fetal heart rate monitoring is a crucial element in determining the health of the fetus during pregnancy. In this paper, we evaluate the fetal heart rate (FHR) and maternal heart rate (MHR) between our non-invasive fetal monitoring system, Femom, developed by a Biorithm and the Huntleigh computerized cardiotocography (cCTG) together with the Sonicaid FetalCare3 software by comparing the accuracy, sensitivity, and reliability through using Bland-Altman analysis, Positive Percent Agreement (PPA) and Intraclass Correlation Coefficient (ICC) respectively. Femom device is a part of the Femom system which collects abdominal electrocardiogram (aECG) signals. Femom sever then processes the collected signals to generate FHR and MHR using novel algorithms. We collected data from 285 pregnant participants who were at least of 28 weeks of gestational age. FHR accuracy consists of mean bias and limit-of-agreement (LoA). The FHR bias is 0.05 beat per minute (BPM) and LoA is [-8.7 8.8] with 95% confidence interval (95% CI) measured using Bland Altman analysis. The PPA of 90.9% reflects FHR sensitivity. Reliability is measured with absolute ICC and consistency ICC. The absolute ICC is of 88% and consistency ICC of 94%. For MHR evaluation, accuracy is measured using Bland Altman analysis which provided a bias of 0.35 BPM and LoA of [-7 6.2] with 95% CI. The MHR sensitivity calculated using PPA is 98% while the MHR reliability is with the absolute value of 99% and consistency ICC of 99%.

Intrapartum Fetal Heart Monitoring Practices in Selected Facilities in Aspirational Districts of Jharkhand, Odisha and Uttarakhand

Background

The risk of mortality for the mother and the newborn is aggravated during birth in low- and middle-income countries due to preventable causes, which can be addressed with increased quality of care practices. One such practice is intrapartum fetal heart rate (FHR) monitoring, which is crucial for the early detection of fetal ischemia, but is inadequately monitored in low- and middle-income countries. In India, there is currently a lack of sufficient data on FHR monitoring.

Methods

An assessment using facility records, interviews and observation was conducted in seven facilities providing tertiary, secondary or primary level care in aspirational districts of three states. The study sought to investigate the frequency of monitoring, devices used for monitoring and challenges in usage.

Results

FHR was not monitored as per standard protocol. Case sheets revealed 70% of labor was monitored at least once. Only 33% of observed cases were monitored every half hour during active labor, and none were monitored every 5 min during the second stage of labor. More time was observed for monitoring with a Doppler compared with a stethoscope, as providers reported fluctuation in readings. Reportedly, low audibility and a perceived need of expertise were associated with using a stethoscope. High case load and the time required for monitoring were reported as challenges in adhering to standard monitoring protocols.

Conclusion

The introduction of a standardized device and a short refresher training on the World Health Organization and skilled birth attendant protocols for FHR monitoring will improve usage and compliance.

A review of fetal cardiac monitoring, with a focus on low- and middle-income countries

There is limited evidence regarding the utility of fetal monitoring during pregnancy, particularly during labor and delivery. Developed countries rely on consensus ‘best practices’ of obstetrics and gynecology professional societies to guide their protocols and policies. Protocols are often driven by the desire to be as safe as possible and avoid litigation, regardless of the cost of downstream treatment. In high-resource settings, there may be a justification for this approach. In low-resource settings, in particular, interventions can be costly and lead to adverse outcomes in subsequent pregnancies. Therefore, it is essential to consider the evidence and cost of different fetal monitoring approaches, particularly in the context of treatment and care in low-to-middle income countries.

This article reviews the standard methods used for fetal monitoring, with particular emphasis on fetal cardiac assessment, which is a reliable indicator of fetal well-being. An overview of fetal monitoring practices in low-to-middle income counties, including perinatal care access challenges, is also presented. Finally, an overview of how mobile technology may help reduce barriers to perinatal care access in low-resource settings is provided.

Intermittent auscultation (surveillance) of fetal heart rate in labor: a progressive evidence-backed approach with aim to improve methodology, reliability and safety

Intermittent auscultation (IA) of fetal heart has become acceptable in low risk labors even in the developed countries. However, the instances of birth asphyxia occur despite adhering to the guidelines. Such outcomes need not be the inherent limitations of IA, but improvements in the IA regime are highly desirable. The systematic analyses of available studies have been unhelpful to ascertain an optimal regime or suggest improvements. This analytical review uses detailed modeling and reasoning to examine/propose safe and effective regime. It counters a misconception that the Doppler-device is not superior to Pinard stethoscope in usability, accuracy and thereby decision making. Importantly, the Doppler-device should not be used to actually count the fetal heart tones (like a Pinard stethoscope) as insisted by many guidelines. The review demonstrates that counting to 120-160 over a minute is arduous, superfluous and fraught with fallacies and risks. Observation of the digital read-out of the fetal heart rate (FHR) and its trend during the auscultation duration is far more informative. IA should focus on the two FHR parameters namely the baseline and late decelerations. Detection of additional FHR changes like overshoots, cycling or accelerations do not add value. Doppler-device FHR readouts over a steady pattern (commonly just before the contraction) best represent the baseline. FHR observation (IA) should commence in the later part of the contraction and continue till the beginning of next contraction and need not arbitrarily end at 1 min (a legacy of preoccupation with actual counting). Heightened awareness is required to detect late decelerations at the end of contractions. It would suffice to perform IA over a couple of contractions every 20-30 min during the first stage of labor. This improved methodology would avoid mistakes and improve the detection of FHR abnormalities to enhance patient safety in future practice guidelines.

Scale-Up of Doppler to Improve Intrapartum Fetal Heart Rate Monitoring in Tanzania: A Qualitative Assessment of National and Regional/District Level Implementation Factors

High-quality intrapartum care, including intermittent monitoring of fetal heart rates (FHR) to detect and manage abnormalities, is recommended by WHO and the Government of Tanzania (GoT) and creates potential to save newborn lives in Tanzania. Handheld Doppler devices have been investigated in several low-resource countries as an alternative to Pinard stethoscope and are more sensitive to detecting accelerations and decelerations of the fetal heart as compared to Pinard. This study assessed perspectives of high-level Tanzanian policymakers on facilitators and barriers to scaling up use of the hand-held Doppler for assessing FHR during labor and delivery. From November 2018-August 2019, nine high-level policymakers and subject matter experts were interviewed using a semi-structured questionnaire, with theoretical domains drawn from Proctor's implementation outcomes framework. Interviewees largely saw use of Doppler to improve intrapartum FHR monitoring as aligning with national priorities, though they noted competing demands for resources. They felt that GoT should fund Doppler, but prioritization and budgeting should be driven from district level. Recommended ways forward included learning from scale up of Helping Babies Breathe rollout, making training approaches effective, using clinical mentoring, and establishing systematic monitoring of outcomes. To be most effective, introduction of Doppler must be concurrent with improving case management practices for abnormal intrapartum FHR. WHO's guidance on scale-up, as well as implementation science frameworks, should be considered to guide implementation and evaluation.

Systematic review of Doppler for detecting intrapartum fetal heart abnormalities and measuring perinatal mortality in low- and middle-income countries

BACKGROUND

Using Doppler to improve detection of intrapartum fetal heart rate (FHR) abnormalities coupled with appropriate, timely intrapartum care in low- and middle-income countries (LMIC) can save lives.

OBJECTIVE

To review studies using Doppler to improve detection of intrapartum FHR abnormalities and intrapartum care quality in LMIC health facilities.

SEARCH STRATEGY

PubMed, Web of Science, Embase, Global Health, and Scopus were searched from inception to October 2018 by combining terms for Doppler, perinatal outcomes, and FHR monitoring.

SELECTION CRITERIA

Selected studies compared Doppler and Pinard stethoscope for detecting/monitoring intrapartum FHR, or described provider and maternal preferences for FHR monitoring in LMIC settings.

DATA COLLECTION AND ANALYSIS

Two team members independently screened and collected data. Risk of bias was assessed by Cochrane EPOC criteria.

RESULTS

Eleven studies from eight countries were included. Doppler was superior at detecting abnormal intrapartum FHR as compared with Pinard stethoscope, but was not associated with improved perinatal outcomes. Using Doppler on admission helped to accurately measure perinatal deaths occurring after facility admission.

CONCLUSION

Studies and program learning are needed to translate improved detection of FHR abnormalities to improved case management in LMICs. Doppler should be used to calculate a facility indicator of intrapartum care quality. PROSPERO registration: CRD42019121924.

Intermittent auscultation fetal monitoring during labour: A systematic scoping review to identify methods, effects, and accuracy

Background

Intermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps.

Methods

We conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach.

Results

The searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29–2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult.

Conclusion

Although IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa.

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania

Background

Regular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania.

Methods

A qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis.

Results

The participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate.

Conclusion

The electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device’s functions, its limitations and its procedures for use are well understood by users.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2286-7) contains supplementary material, which is available to authorized users.

Fetal Heart Rate Auscultation, 3rd edition

The use of intermittent auscultation (IA) for fetal surveillance during labor decreased with the introduction of electronic fetal monitoring (EFM). The increased use of EFM is associated with an increase in cesarean births. IA is an evidence-based method of fetal surveillance during labor for women with low risk pregnancies and considered one component of comprehensive efforts to reduce the primary cesarean rate and promote vaginal birth. Many clinicians are not familiar with IA practice. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues, and strategies to promote implementation of IA into practice.

Strategies for intrapartum foetal surveillance in low- and middle-income countries: A systematic review

BACKGROUND

The majority of the five million perinatal deaths worldwide take place in low-resource settings. In contrast to high-resource settings, almost 50% of stillbirths occur intrapartum. The aim of this study was to synthesise available evidence of strategies for foetal surveillance in low-resource settings and associated neonatal and maternal outcomes, including barriers to their implementation.

METHODS AND FINDINGS

The review was registered with Prospero (CRD42016038679). Five databases were searched up to May 1st, 2016 for studies related to intrapartum foetal monitoring strategies and neonatal outcomes in low-resource settings. Two authors extracted data and assessed the risk of bias for each study. The outcomes were narratively synthesised. Strengths, weaknesses, opportunities and threats analysis (SWOT) was conducted for each monitoring technique to analyse their implementation. There were 37 studies included: five intervention and 32 observational studies. Use of the partograph improved perinatal outcomes. Intermittent auscultation with Pinard was associated with lowest rates of caesarean sections (10-15%) but with comparable perinatal outcomes to hand-held Doppler and Cardiotocography (CTG). CTG was associated with the highest rates of caesarean sections (28-34%) without proven benefits for perinatal outcome. Several tests on admission (admission tests) and adjunctive tests including foetal stimulation tests improved the accuracy of foetal heart rate monitoring in predicting adverse perinatal outcomes.

CONCLUSIONS

From the available evidence, the partograph is associated with improved perinatal outcomes and is recommended for use with intermittent auscultation for intrapartum monitoring in low resource settings. CTG is associated with higher caesarean section rates without proven benefits for perinatal outcomes, and should not be recommended in low-resource settings. High-quality evidence considering implementation barriers and enablers is needed to determine the optimal foetal monitoring strategy in low-resource settings.

Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study

Background

Intrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo).

Methodology

A pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate.

Results

Moyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. median (IQR) of 60 (30,100) to 45 (21,85) minutes (p<0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p<0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p<0.001). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population.

Conclusion

Implementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.

Intrapartum fetal heart rate monitoring using a handheld Doppler versus Pinard stethoscope: a randomized controlled study in Dar es Salaam

Background

Fetal stethoscopes are mainly used for intermittent monitoring of fetal heart rate (FHR) during labor in low-income countries, where perinatal mortality is still high. Handheld Dopplers are rarely available and are dependent on batteries or electricity. The objective was to compare the Pinard stethoscope versus a new wind-up handheld Doppler in the detection of abnormal FHR.

Materials and methods

We conducted a randomized controlled study at Muhimbili National Hospital, Tanzania, from April 2013 to September 2015. Women with gestational age ≥37 weeks, cephalic presentation, normal FHR on admission, and cervical dilatation <7 cm were included. Primary outcome was abnormal FHR detection (<120 or >160 beats/min). Secondary endpoints were time to delivery, mode of delivery, and perinatal outcomes. χ², Fisher’s exact test, Mann–Whitney test, and logistic regression were conducted. Unadjusted and adjusted odds ratios were calculated with respective 95% confidence interval.

Results

In total, 2,844 eligible women were assigned to FHR monitoring with Pinard (n=1,423) or Doppler (n=1,421). Abnormal FHRs were more often detected in the Doppler (6.0%) versus the Pinard (3.9%) arm (adjusted odds ratio =1.59, 95% confidence interval: 1.13–2.26, p=0.008). Median (interquartile range) time from abnormal FHR detection to delivery was comparable between Doppler and Pinard, ie, 80 (60,161) and 89 (52,165) minutes, respectively, as was the incidence of cesarean delivery (12.0% versus 12.2%). The incidence of adverse perinatal outcomes (fresh stillbirths, 24-hour neonatal admissions, and deaths) was similar overall; however, among newborns with abnormal FHR delivered vaginally, adverse outcomes were less incident in Doppler (7 of 43 births, 16.3%) than in the Pinard arm (10 of 23 births, 43.5%), p=0.021.

Conclusion

Intermittent FHR monitoring using Doppler was associated with an increased detection of abnormal FHR compared to Pinard in a low-risk population. Time intervals from abnormal FHR detection to delivery were longer than recommended in both arms. Perinatal outcomes were better among vaginally delivered newborns with detected abnormal FHR in the Doppler arm.

Intermittent auscultation (IA) of fetal heart rate in labour for fetal well-being

BACKGROUND

The goal of fetal monitoring in labour is the early detection of a hypoxic baby. There are a variety of tools and methods available for intermittent auscultation (IA) of the fetal heart rate (FHR). Low- and middle-income countries usually have only access to a Pinard/Laënnec or the use of a hand-held Doppler device. Currently, there is no robust evidence to guide clinical practice on the most effective IA tool to use, timing intervals and length of listening to the fetal heart for women during established labour.

OBJECTIVES

To evaluate the effectiveness of different tools for IA of the fetal heart rate during labour including frequency and duration of auscultation.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (19 September 2016), contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All published and unpublished randomised controlled trials (RCTs) or cluster-RCTs comparing different tools and methods used for intermittent fetal auscultation during labour for fetal and maternal well-being. Quasi-RCTs, and cross-over designs were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

All review authors independently assessed eligibility, extracted data and assessed risk of bias for each trial. Data were checked for accuracy.

MAIN RESULTS

We included three studies (6241 women and 6241 babies), but only two studies are included in the meta-analyses (3242 women and 3242 babies). Both were judged as high risk for performance bias due to the inability to blind the participants and healthcare providers to the interventions. Evidence was graded as moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Intermittent Electronic Fetal Monitoring (EFM) using Cardiotocography (CTG) with routine Pinard (one trial)There was no clear difference between groups in low Apgar scores at five minutes (reported as < six at five minutes after birth) (risk ratio (RR) 0.66, 95% confidence interval (CI) 0.24 to 1.83, 633 babies, very low-quality evidence). There were no clear differences for perinatal mortality (RR 0.88, 95% CI 0.34 to 2.25; 633 infants, very low-quality evidence). Neonatal seizures were reduced in the EFM group (RR 0.05, 95% CI 0.00 to 0.89; 633 infants, very low-quality evidence). Other important infant outcomes were not reported: mortality or serious morbidity (composite outcome), cerebral palsy or neurosensory disability. For maternal outcomes, women allocated to intermittent electronic fetal monitoring (EFM) (CTG) had higher rates of caesarean section for fetal distress (RR 2.92, 95% CI 1.78 to 4.80, 633 women, moderate-quality evidence) compared with women allocated to routine Pinard. There was no clear difference between groups in instrumental vaginal births (RR 1.46, 95% CI 0.86 to 2.49, low-quality evidence). Other outcomes were not reported (maternal mortality, instrumental vaginal birth for fetal distress and or acidosis, analgesia in labour, mobility or restriction during labour, and postnatal depression). Doppler ultrasonography with routine Pinard (two trials)There was no clear difference between groups in Apgar scores < seven at five minutes after birth (reported as < six in one of the trials) (average RR 0.76, 95% CI 0.20 to 2.87; two trials, 2598 babies, I2 = 72%, very low-quality evidence); there was high heterogeneity for this outcome. There was no clear difference between groups for perinatal mortality (RR 0.69, 95% CI 0.09 to 5.40; 2597 infants, two studies, very low-quality evidence), or neonatal seizures (RR 0.05, 95% CI 0.00 to 0.91; 627 infants, one study, very low-quality evidence). Other important infant outcomes were not reported (cord blood acidosis, composite of mortality and serious morbidity, cerebral palsy, neurosensory disability). Only one study reported maternal outcomes. Women allocated to Doppler ultrasonography had higher rates of caesarean section for fetal distress compared with those allocated to routine Pinard (RR 2.71, 95% CI 1.64 to 4.48, 627 women, moderate-quality evidence). There was no clear difference in instrumental vaginal births between groups (RR 1.35, 95% CI 0.78 to 2.32, 627 women, low-quality evidence). Other maternal outcomes were not reported. Intensive Pinard versus routine Pinard (one trial)One trial compared intensive Pinard (a research midwife following the protocol in a one-to-one care situation) with routine Pinard (as per protocol but midwife may be caring for more than one woman in labour). There was no clear difference between groups in low Apgar score (reported as < six this trial) (RR 0.90, 95% CI 0.35 to 2.31, 625 babies, very low-quality evidence). There were also no clear differences identified for perinatal mortality (RR 0.56, 95% CI 0.19 to 1.67; 625 infants, very low-quality evidence), or neonatal seizures (RR 0.68, 95% CI 0.24 to 1.88, 625 infants, very low-quality evidence)). Other infant outcomes were not reported. For maternal outcomes, there were no clear differences between groups for caesarean section or instrumental delivery (RR 0.70, 95% CI 0.35 to 1.38, and RR 1.21, 95% CI 0.69 to 2.11, respectively, 625 women, both low-quality evidence)) Other outcomes were not reported.

AUTHORS' CONCLUSIONS

Using a hand-held (battery and wind-up) Doppler and intermittent CTG with an abdominal transducer without paper tracing for IA in labour was associated with an increase in caesarean sections due to fetal distress. There was no clear difference in neonatal outcomes (low Apgar scores at five minutes after birth, neonatal seizures or perinatal mortality). Long-term outcomes for the baby (including neurodevelopmental disability and cerebral palsy) were not reported. The quality of the evidence was assessed as moderate to very low and several important outcomes were not reported which means that uncertainty remains regarding the use of IA of FHR in labour.As intermittent CTG and Doppler were associated with higher rates of caesarean sections compared with routine Pinard monitoring, women, health practitioners and policy makers need to consider these results in the absence of evidence of short- and long-term benefits for the mother or baby.Large high-quality randomised trials, particularly in low-income settings, are needed. Trials should assess both short- and long-term health outcomes, comparing different monitoring tools and timing for IA.

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

BACKGROUND

Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001.

OBJECTIVES

To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy.

MAIN RESULTS

We included 13 trials involving over 37,000 women. No new studies were included in this update.One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence).Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial).Data for low risk, high risk, preterm pregnancy and high-quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes.Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision.

AUTHORS' CONCLUSIONS

CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour.The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice).Along with the need for further investigations into long-term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long-term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one-to-one-support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long-term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women.

Use of wind-up fetal Doppler versus Pinard for fetal heart rate intermittent monitoring in labour: a randomised clinical trial

OBJECTIVES

In resource-poor settings, the standard of care to inform labour management is the partograph plus Pinard stethoscope for intermittent fetal heart rate (FHR) monitoring. We compared FHR monitoring in labour using a novel, robust wind-up handheld Doppler with the Pinard as a primary screening tool for abnormal FHR on perinatal outcomes.

DESIGN

Prospective equally randomised clinical trial.

SETTING

The labour and delivery unit of a teaching hospital in Kampala, Uganda.

PARTICIPANTS

Of the 2042 eligible antenatal women, 1971 women in active term labour, following uncomplicated pregnancies, were randomised to either the standard of care or not.

INTERVENTION

Intermittent FHR monitoring using Doppler.

PRIMARY OUTCOME MEASURES

Incidence of FHR abnormality detection, intrapartum stillbirth and neonatal mortality prior to discharge.

RESULTS

Age, parity, gestational age, mode of delivery and newborn weight were similar between study groups. In the Doppler group, there was a significantly higher rate of FHR abnormalities detected (incidence rate ratio (IRR)=1.61, 95% CI 1.13 to 2.30). However, in this group, there were also higher though not statistically significant rates of intrapartum stillbirths (IRR=3.94, 0.44 to 35.24) and neonatal deaths (IRR=1.38, 0.44 to 4.34).

CONCLUSIONS

Routine monitoring with a handheld Doppler increased the identification of FHR abnormalities in labour; however, our trial did not find evidence that this leads to a decrease in the incidence of intrapartum stillbirth or neonatal death.

TRIAL REGISTRATION NUMBER

Clinical Trails.gov (1000031587).

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

BACKGROUND

Cardiotocography (known also as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth.

OBJECTIVES

To evaluate the effectiveness of continuous cardiotocography during labour.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (31 December 2012) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with (a) no fetal monitoring, (b) intermittent auscultation (c) intermittent cardiotocography.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study eligibility, quality and extracted data from included studies.

MAIN RESULTS

Thirteen trials were included with over 37,000 women; only two were judged to be of high quality.Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials). There was no significant difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.63, 95% CI 1.29 to 2.07, n = 18,861, 11 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.15, 95% CI 1.01 to 1.33, n = 18,615, 10 trials).Data for subgroups of low-risk, high-risk, preterm pregnancies and high-quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome.

AUTHORS' CONCLUSIONS

Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed choice without compromising the normality of labour.

Intermittent detection of fetal heart rate abnormalities identify infants at greatest risk for fresh stillbirths, birth asphyxia, neonatal resuscitation, and early neonatal deaths in a limited-resource setting: a prospective descriptive observational study at Haydom Lutheran Hospital

BACKGROUND

Intermittent fetal heart rate (FHR) monitoring during labor using an acoustic stethoscope is the most frequent method for fetal assessment of well-being in low- and middle-income countries. Evidence concerning reliability and efficacy of this technique is almost nonexistent.

OBJECTIVES

To determine the value of routine intermittent FHR monitoring during labor in the detection of FHR abnormalities, and the relationship of abnormalities to the subsequent fresh stillbirths (FSB), birth asphyxia (BA), need for neonatal face mask ventilation (FMV), and neonatal deaths within 24 h.

METHODS

This is a descriptive observational study in a delivery room from November 2009 through December 2011. Research assistants/observers (n = 14) prospectively observed every delivery and recorded labor information including FHR and interventions, neonatal information including responses in the delivery room, and fetal/neonatal outcomes (FSB, death within 24 h, admission neonatal area, or normal).

RESULTS

10,271 infants were born. FHR was abnormal (i.e. <120 or >160 beats/min) in 279 fetuses (2.7%) and absent in 200 (1.9%). Postnatal outcomes included FSB in 159 (1.5%), need for FMV in 695 (6.8%), BA (i.e. 5-min Apgar score <7) in 69 (0.7%), and deaths in 89 (0.9%). Abnormal FHR was associated with labor complications (OR = 31.4; 95% CI: 23.1-42.8), increased need for FMV (OR = 7.8; 95% CI: 5.9-10.1), BA (OR = 21.7; 95% CI: 12.7-37.0), deaths (OR = 9.9; 95% CI: 5.6-17.5), and FSB (OR = 35; 95% CI: 20.3-60.4). An undetected FHR predicted FSB (OR = 1,983; 95% CI: 922-4,264).

CONCLUSIONS

Intermittent detection of an absent or abnormal FHR using a fetal stethoscope is associated with FSB, increased need for neonatal resuscitation, BA, and neonatal death in a limited-resource setting. The likelihood of an abnormal FHR is magnified with labor complications.

Intermittent auscultation of fetal heart rate during labour - a widely accepted technique for low risk pregnancies: but are the current national guidelines robust and practical?

Intermittent auscultation of fetal heart rate is an accepted practice in low risk labours in many countries. National guidelines on intrapartum fetal monitoring were critically reviewed regarding timing and frequency of intermittent auscultation. Hypothetical but plausible examples are presented to illustrate that it may be possible to miss significant fetal distress with strict adherence to current guidelines. Opinion is forwarded that intermittent auscultation should be performed for 60 seconds before and after three contractions over about 10 min every half an hour in the first stage of labour. Reasons are put forward to show how this could be more practical and patient friendly and at the same time could improve detection of fetal distress. The current recommendation of intermittent auscultation every 15 min in the first stage is associated with poor compliance and leads to unnecessary burden, stress and medicolegal liability for birth attendants. Modification of current national guidelines would be desirable.

Reducing intrapartum-related neonatal deaths in low- and middle-income countries-what works?

Each year, 814,000 neonatal deaths and 1.02 million stillbirths result from intrapartum-related causes, such as intrauterine hypoxia. Almost all of these deaths are in low- and middle-income countries, where women frequently lack access to quality perinatal care and may delay care-seeking. Approximately 60 million annual births occur outside of health facilities, and most of these childbirths are without a skilled birth attendant. Conditions that increase the risk of intrauterine hypoxia--such as pre-eclampsia/eclampsia, obstructed labor, and low birth weight--are often more prevalent in low resource settings. Intrapartum-related neonatal deaths can be averted by a range of interventions that prevent intrapartum complications (eg, prevention and management of pre-eclampsia), detect and manage intrapartum problems (eg, monitoring progress of labor with access to emergency obstetrical care), and identify and assist the nonbreathing newborn (eg, stimulation and bag-mask ventilation). Simple, affordable, and effective approaches are available for low-resource settings, including community-based strategies to increase skilled birth attendance, partograph use by frontline health workers linked to emergency obstetrical care services, task shifting to increase access to Cesarean delivery, and simplified neonatal resuscitation training (Helping Babies Breathe(SM)). Coverage of effective interventions is low, however, and many opportunities are missed to provide quality care within existing health systems. In sub-Saharan Africa, recent health services assessments found only 15% of hospitals equipped to provide basic neonatal resuscitation. In the short term, intrapartum-related neonatal deaths can be substantially reduced by improving the quality of services for all childbirths that occur in health facilities, identifying and addressing the missed opportunities to provide effective interventions to those who seek facility-based care. For example, providing neonatal resuscitation for 90% of deliveries currently taking place in health facilities would save more than 93,000 newborn lives each year. Longer-term strategies must address the gaps in coverage of institutional delivery, skilled birth attendance, and quality by strengthening health systems, increasing demand for care, and improving community-based services. Both short- and long-term strategies to reduce intrapartum-related mortality should focus on reducing inequities in coverage and quality of obstetrical and perinatal care.

Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up?

BACKGROUND

Each year, approximately 2 million babies die because of complications of childbirth, primarily in settings where effective care at birth, particularly prompt cesarean delivery, is unavailable.

OBJECTIVE

We reviewed the content, impact, risk-benefit, and feasibility of interventions for obstetric complications with high population attributable risk of intrapartum-related hypoxic injury, as well as human resource, skill development, and technological innovations to improve obstetric care quality and availability.

RESULTS

Despite ecological associations of obstetric care with improved perinatal outcomes, there is limited evidence that intrapartum interventions reduce intrapartum-related neonatal mortality or morbidity. No interventions had high-quality evidence of impact on intrapartum-related outcomes in low-resource settings. While data from high-resource settings support planned cesarean for breech presentation and post-term induction, these interventions may be unavailable or less safe in low-resource settings and require risk-benefit assessment. Promising interventions include use of the partograph, symphysiotomy, amnioinfusion, therapeutic maneuvers for shoulder dystocia, improved management of intra-amniotic infections, and continuous labor support. Obstetric drills, checklists, and innovative low-cost devices could improve care quality. Task-shifting to alternative cadres may increase coverage of care.

CONCLUSIONS

While intrapartum care aims to avert intrapartum-related hypoxic injury, rigorous evidence is lacking, especially in the settings where most deaths occur. Effective care at birth could save hundreds of thousands of lives a year, with investment in health infrastructure, personnel, and research--both for innovation and to improve implementation.

Appropriate medical technology for perinatal care in low-resource countries

Availability of a range of essential life-saving medical devices is central to safe and effective perinatal care. However, many medical devices which are manufactured for use in high-income countries are inappropriate, ineffective and dangerous when used in low-resource settings. Suitable, appropriate-technology devices are becoming available for a range of perinatal applications, including fetal heart rate monitoring, neonatal resuscitation and oxygen delivery and monitoring. Unless the major financial, logistical and educational challenges are overcome to ensure that suitable medical devices are made widely available, improvements in global perinatal care will be severely constrained.

Fetal monitoring in the prehospital setting

BACKGROUND

Prehospital emergency care providers have very little information regarding fetal perfusion adequacy in the field.

OBJECTIVE

This study was conducted to evaluate the feasibility of the use of fetal monitoring in the prehospital setting.

METHODS

A mobile cardiotocometer was used for all consecutive pregnant women managed by our physician-staffed Emergency Medical Services unit. The visualization of interpretable tracings (both fetal heart rate and tocography) at the different stages of prehospital management was evaluated. Any change in a patient's management was also recorded.

RESULTS

There were 145 patients enrolled during 119 inter-hospital transfers and 26 primary prehospital interventions. Interpretable tracings were obtained for 81% of the patients during the initial examination. This rate decreased to 66% during handling and transfer procedures. For 17 patients (12%), the monitoring led to a change in the patient's management.

CONCLUSION

This study shows that cardiotocography can be easily performed in the prehospital setting, and is usually feasible. Moreover, the study demonstrates a positive impact of fetal heart rate monitoring on prehospital management.

Randomized comparison of intravenous terbutaline vs nitroglycerin for acute intrapartum fetal resuscitation

OBJECTIVE

The purpose of this study was to compare terbutaline and nitroglycerin for acute intrapartum fetal resuscitation.

STUDY DESIGN

Women between 32-, 42 weeks' gestation were assigned randomly to 250 microg of terbutaline or 400 microg nitroglycerin intravenously for nonreassuring fetal heart rate tracings in labor. The rate of successful acute intrapartum fetal resuscitation and the maternal hemodynamic changes were compared. Assuming a 50% failure rate in the terbutaline arm, we calculated that a total of 110 patients would be required to detect a 50% reduction in failure in the nitroglycerin group (50% to 25%), with an alpha value of .05, a beta value of .20, and a power of 80%.

RESULTS

One hundred ten women had nonreassuring fetal heart rate tracings in labor; 57 women received terbutaline, and 53 women received nitroglycerin. Successful acute resuscitation rates were similar (terbutaline 71.9% and nitroglycerin 64.2%; P = .38). Terbutaline resulted in lower median contraction frequency per 10 minutes (2.9 [25-75 percentile, 1.7- 3.3] vs 4 [25-75 percentile, 2.5- 5]; P < .002) and reduced tachysystole (1.8% vs 18.9%; P = .003). Maternal mean arterial pressures decreased with nitroglycerin (81-76 mm Hg; P = .02), but not terbutaline (82-81 mm Hg; P = .73).

CONCLUSION

Although terbutaline provided more effective tocolysis with less impact on maternal blood pressure, no difference was noted between nitroglycerin and terbutaline in successful acute intrapartum fetal resuscitation.

WITHDRAWN: Continuous electronic heart rate monitoring for fetal assessment during labor

BACKGROUND

Electronic fetal monitoring (EFM) is used in the management of labor and delivery in nearly three of four pregnancies in the United States. The apparent contradiction between the widespread use of EFM and expert recommendations to limit routine use indicates that a reassessment of this practice is warranted.

OBJECTIVES

To compare the efficacy and safety of routine continuous EFM during labor with intermittent auscultation, using the results of published randomized controlled trials (RCTs).

SEARCH STRATEGY

We identified RCTs by searching MEDLINE and the register maintained by the Cochrane Pregnancy and Childbirth Group, and by contacting experts, and reviewing published references. Date of last search: January 2001.

SELECTION CRITERIA

Randomized controlled trials.

DATA COLLECTION AND ANALYSIS

Data were abstracted by one of us, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for RCTs. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes.

MAIN RESULTS

Our search identified 13 published RCTs addressing the efficacy and safety of EFM; no unpublished studies were found. Four trials that did not fulfil our selection criteria were excluded. The remaining nine trials included 18,561 pregnant women and their 18,695 infants in both high- and low-risk pregnancies from seven clinical centers in the United States, Europe, and Australia. Overall, a statistically significant decrease was associated with routine EFM for neonatal seizures (relative risk (RR) 0.51, 95% confidence interval (CI) 0.32-0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below four or seven, rate of admissions to neonatal intensive care units, perinatal deaths or cerebral palsy. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR 1.41, 95% CI 1.23-1.61) and operative vaginal delivery (RR 1.20, 95% CI 1.11-1.30).

AUTHORS' CONCLUSIONS

The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal delivery, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

BACKGROUND

Cardiotocography (sometimes known as electronic fetal monitoring), records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic), so additional assessments of fetal well-being may be used, or the baby delivered by caesarean section or instrumental vaginal birth.

OBJECTIVES

To evaluate the effectiveness of continuous cardiotocography during labour.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (March 2006), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to December 2005), EMBASE (1974 to December 2005), Dissertation Abstracts (1980 to December 2005) and the National Research Register (December 2005).

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with (a) no fetal monitoring, (b) intermittent auscultation (c) intermittent cardiotocography.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed eligibility, quality and extracted data.

MAIN RESULTS

Twelve trials were included (over 37,000 women); only two were high quality. Compared to intermittent auscultation, continuous cardiotocography showed no significant difference in overall perinatal death rate (relative risk (RR) 0.85, 95% confidence interval (CI) 0.59 to 1.23, n = 33,513, 11 trials), but was associated with a halving of neonatal seizures (RR 0.50, 95% CI 0.31 to 0.80, n = 32,386, nine trials) although no significant difference was detected in cerebral palsy (RR 1.74, 95% CI 0.97 to 3.11, n = 13,252, two trials). There was a significant increase in caesarean sections associated with continuous cardiotocography (RR 1.66, 95% CI 1.30 to 2.13, n =18,761, 10 trials). Women were also more likely to have an instrumental vaginal birth (RR 1.16, 95% CI 1.01 to 1.32, n = 18,151, nine trials). Data for subgroups of low-risk, high-risk, preterm pregnancies and high quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other prespecified outcome.

AUTHORS' CONCLUSIONS

Continuous cardiotocography during labour is associated with a reduction in neonatal seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.

Evidence-based intrapartum care

Routine care in normal labour may range from supportive care at home to intensive monitoring and multiple interventions in hospital. Good evidence of effectiveness is necessary to justify interventions in the normal process of labour. Inadequate evidence is available to support perineal shaving, routine enemas, starvation in labour and excluding the choice for home births. Evidence supports continuity of care led by midwives, companionship in labour, restricting the use of episiotomy, and active management of the third stage of labour, including routine use of 10 units of oxytocin. Both benefits and risks are associated with routine amniotomy, continuous electronic fetal heart rate monitoring, epidural analgesia, and oxytocin-ergometrine to prevent postpartum haemorrhage. More evidence is needed regarding the emotional consequences of labour interventions, home births, vaginal cleansing, opioid use, the partograph, second-stage labour techniques, misoprostol for primary prevention of postpartum haemorrhage, and strategies to promote evidence-based care in labour.

Can clinical risk factors for late stillbirth in West Africa be detected during antenatal care or only during labour?

BACKGROUND

Recent studies have shown that the most important risk factors for perinatal mortality in developing countries are not detectable during antenatal care but can be observed only shortly before or during labour. Although 60% of perinatal deaths in these countries are stillbirths, few epidemiological studies focus on them. We tested the hypothesis that the risk factors for late stillbirth in West Africa are detectable principally shortly before or during labour.

METHODS

Data came from a prospective population-based study (the MOMA survey) that collected information about 20 326 pregnant women in seven areas, primarily urban, in West Africa.

RESULTS

There were 19 870 singleton births. The stillbirth rate was 25.9 per 1000 total births (95% CI: 23.7-28.1). In the crude analysis, after adjustment and consideration of prevalence, the principal risk factors for late stillbirth were: late antenatal or intrapartum vaginal bleeding, intrapartum hypertension, dystocia, and infection. Other risk factors were: maternal height (<150 cm), maternal age (>35 years), previous stillbirths, hypertension at the 8-month antenatal visit and number of antenatal visits (<2).

CONCLUSIONS

The principal risk factors for late stillbirth observed in our study could be detected only in the late antenatal and intrapartum period. These results highlight the potential benefits of partograph use. They need to be confirmed by studies incorporating continuous intrapartum fetal monitoring.

Measuring outcomes of midwifery care: development of an instrument to assess optimality

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home (N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

Intrapartum fetal monitoring: past, present, and future

The concept of intrapartum "monitoring" of the fetal heart rate by auscultation has been extant for almost 200 years and by electronic means for more than 30 years. This article explores historical aspects of fetal monitoring, the advent of electronic fetal monitoring and its controversies, and present and future research opportunities to enhance the reliability, validity, and efficacy of fetal monitoring.

Intermittent auscultation of the fetal heart rate: a review of general principles

Multiple randomized clinical trials have been unsuccessful in providing evidence of efficacy of electronic fetal monitoring; thus, there is renewed interest in intermittent auscultation during labor for women with low-risk pregnancies. Auscultation must be used with palpation or external or internal electronic monitoring of uterine contractions. Auscultation and palpation require education, experience, and competency validation at regular intervals. Institutional policies and standards of care are mandatory for intermittent auscultation. Concerns exist regarding the personnel costs for auscultation; however, these costs may ultimately be shown to be offset by significant benefits in improved outcomes and patient satisfaction.

Fetal heart rate auscultation: current and future practice

Intermittent auscultation (IA) has been reported as equivalent to electronic fetal monitoring (EFM) as a fetal surveillance method in terms of neonatal outcomes based on randomized controlled trials and meta-analyses. Despite recommendations to include IA as a primary method for fetal evaluation, EFM use predominates. Understanding the equipment, method, benefits and limitations, and strategies for implementing IA may assist nurses in providing informed choices for low-risk pregnant women.

Continuous electronic heart rate monitoring for fetal assessment during labor

BACKGROUND

Electronic fetal monitoring (EFM) has been widely adopted. There is debate about its overall effectiveness as well as the relative merits of routine application versus use for high-risk pregnancies only.

OBJECTIVES

The objective of this review was to assess the effects of routine continuous electronic fetal monitoring during labour compared with intermittent auscultation.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register, Medline (1966 to 1994), and reference list of relevant articles. We also contacted experts in the field.

SELECTION CRITERIA

Randomised trials comparing routine continuous electronic fetal monitoring with intermittent auscultation.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for randomised controlled trials. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes.

MAIN RESULTS

Nine studies involving 18,561 women and their 18,695 infants were included. The trials were of variable quality. A statistically significant decrease was associated with routine continuous EFM for neonatal seizures (relative risk (RR) = 0. 51, confidence interval (CI) = 0.32,0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below 4, 1-minute Apgar scores below 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR = 1.41, CI = 1.23,1.61) and operative vaginal delivery (RR = 1.20, CI = 1.11,1.30).

REVIEWER'S CONCLUSIONS

The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Stillbirths and neonatal encephalopathy in Kathmandu, Nepal: an estimate of the contribution of birth asphyxia to perinatal mortality in a low-income urban population

We describe a prospective cross-sectional survey over a 12-month period in the principal maternity hospital of Kathmandu, Nepal, where over 50% of the local population deliver. The study aim was to estimate the contribution of birth asphyxia to perinatal mortality in this setting. During 1995, there were 14,371 livebirths and 400 stillbirths, a total stillbirth rate of 27 per 1000 total births. The fresh term (2000 g or more) stillbirth rate was 8.5 per 1000 total births [95% CI 7.1, 10.1]. Ninety-two cases of neonatal encephalopathy (NE) affecting term infants were detected (excluding those due to congenital malformations, hypoglycaemia and early neonatal sepsis). The birth prevalence of NE was 6.4 per 1000 livebirths [95% CI 5.2, 7.8]. There was evidence of intrapartum compromise in 63 (68%) of the cases of NE and 65 (76%) of the stillbirths, but only in 12 (12%) of controls. The cause-specific early neonatal mortality rate for NE was 2.1 per 1000 livebirths [95% CI 1.4, 3.0]. Combining the NE deaths and fresh stillbirths gives an upper estimate for term birth asphyxia perinatal mortality rate of 10.8 per 1000 total births [95% CI 9.2, 12.6], 24% of all perinatal deaths before hospital discharge. This study suggests that birth asphyxia remains an important cause of perinatal mortality in developing countries. The paper discusses the pros and cons of different strategies to reduce birth asphyxia in low-income countries.

Scalp blood gas analysis

The use of fetal blood sampling has been advocated widely to improve the specificity of fetal heart rate monitoring, but it remains a clinically unpopular procedure. This article considers its physiologic rationale and evidence base. It includes descriptions of the technique with suggestions for improved clinical interpretation and discusses the efficacy of fetal blood sampling with some consideration of possible alternatives.

The art of midwifery: lost to technology?

This paper looks at how the art of midwifery is affected by the increasing availability and use of sophisticated technology. The use of the cardiotocograph is an example of how overuse of such technology can have detrimental affects, not only for the midwife but also for the woman in labour. While this technology has made a great impact in obstetric nursing, the effects on the low-risk pregnancy need to be evaluated. Midwives need to be research-based in their clinical practice and question the overuse of technology, such as the cardiotocograph, in cases where it is not warranted.

The Collaborative Randomised Amnioinfusion for Meconium Project (CRAMP): 2. Zimbabwe

OBJECTIVE

To evaluate transcervical amnioinfusion for meconium stained amniotic fluid during labour.

DESIGN

Multicentre randomised controlled trial.

SETTING

A large urban academic hospital. Electronic fetal heart rate monitoring was not used.

PARTICIPANTS

Women in labour at term with moderate or thick meconium staining of the amniotic fluid.

INTERVENTIONS

Transcervical amnioinfusion of 500 mL saline over 30 minutes, then 500 mL at 30 drops per minute. The control group received routine care. Blinding of the intervention was not possible.

MAIN OUTCOME MEASURES

Caesarean section, meconium aspiration syndrome and perinatal mortality.

RESULTS

There was no difference in risk for caesarean section in the two groups (amnioinfusion 9.5% vs control 12.3%; RR 0.84, 95% CI 0.53-1.32). Meconium aspiration syndrome was significantly less frequent in the amnioinfusion group (3.1% vs 12.8%; RR 0.24, 95% CI 0.12-0.48), and there was a trend towards fewer perinatal deaths (1.2% vs 3.6%; RR 0.34, 95% CI 0.11-1.06).

CONCLUSIONS

Amnioinfusion is technically feasible in a developing country situation with limited intrapartum facilities. In this study amnioinfusion for meconium stained amniotic fluid was associated with striking improvements in perinatal outcome.