Electronic fetal monitoring, cerebral palsy, and caesarean section: assumptions versus evidence

Fetal monitoring technologies for the detection of intrapartum hypoxia - challenges and opportunities

Intrapartum fetal hypoxia is related to long-term morbidity and mortality of the fetus and the mother. Fetal surveillance is extremely important to minimize the adverse outcomes arising from fetal hypoxia during labour. Several methods have been used in current clinical practice to monitor fetal well-being. For instance, biophysical technologies including cardiotocography, ST-analysis adjunct to cardiotocography, and Doppler ultrasound are used for intrapartum fetal monitoring. However, these technologies result in a high false-positive rate and increased obstetric interventions during labour. Alternatively, biochemical-based technologies including fetal scalp blood sampling and fetal pulse oximetry are used to identify metabolic acidosis and oxygen deprivation resulting from fetal hypoxia. These technologies neither improve clinical outcomes nor reduce unnecessary interventions during labour. Also, there is a need to link the physiological changes during fetal hypoxia to fetal monitoring technologies. The objective of this article is to assess the clinical background of fetal hypoxia and to review existing monitoring technologies for the detection and monitoring of fetal hypoxia. A comprehensive review has been made to predict fetal hypoxia using computational and machine-learning algorithms. The detection of more specific biomarkers or new sensing technologies is also reviewed which may help in the enhancement of the reliability of continuous fetal monitoring and may result in the accurate detection of intrapartum fetal hypoxia.

Etiology and Ontogeny of Cerebral Palsy: Implications for Practice and Research

Cerebral palsy (CP) has been recognized as a group of neurologic disorders with varying etiologies and ontogenies. While a percentage of CP cases arises during labor, the expanded use of electronic fetal monitoring (EFM) to include prevention of CP has resulted in decades of vastly increased interventions that have not significantly reduced the incidence of CP for infants born at term in the USA. Litigation alleging that poor obstetrical practice caused CP in most of these affected children has led to contentious arguments regarding the actual etiologies of this condition and often resulted in substantial monetary awards for plaintiffs. Recent advances in genetic testing using whole exome sequencing have revealed that at least one-third of CP cases in term infants are genetic in origin and therefore not labor-related. Here, we will present and discuss previous attempts to sort out contributing etiologies and ontogenies of CP, and how these newer diagnostic techniques are rapidly improving our ability to better detect and understand such cases. In light of these developments, we present our vision for an overarching spectrum for proper categorization of CP cases into that the following groups: (1) those begun at conception from genetic causes (nonpreventable); (2) those stemming from adverse antenatal/pre-labor events (possibly preventable with heightened antepartum assessment); (3) Those arising from intrapartum events (potentially preventable by earlier interventions); (4) Those occurring shortly after birth (possibly preventable with closer neonatal monitoring); (5) Those that appear later in the postnatal period from non-labor-related causes such as untreated infections or postnatal intracranial hemorrhages.

Recovering fetal signals transabdominally through interferometric near-infrared spectroscopy (iNIRS)

Noninvasive transabdominal fetal pulse oximetry can provide clinicians critical assessment of fetal health and potentially contribute to improved management of childbirth. Conventional pulse oximetry through continuous wave (CW) light has challenges measuring the signals from deep tissue and separating the weak fetal signal from the strong maternal signal. Here, we propose a new approach for transabdominal fetal pulse oximetry through interferometric near-infrared spectroscopy (iNIRS). This approach provides pathlengths of photons traversing the tissue, which facilitates the extraction of fetal signals by rejecting the very strong maternal signal from superficial layers. We use a multimode fiber combined with a mode-field converter at the detection arm to boost the signal of iNIRS. Together, we can detect signals from deep tissue (>∼1.6 cm in sheep abdomen and in human forearm) at merely 1.1 cm distance from the source. Using a pregnant sheep model, we experimentally measured and extracted the fetal heartbeat signals originating from deep tissue. This validated a key step towards transabdominal fetal pulse oximetry through iNIRS and set a foundation for further development of this method to measure the fetal oxygen saturation.

Improving the interpretation of electronic fetal monitoring: the fetal reserve index

Electronic fetal monitoring, particularly in the form of cardiotocography, forms the centerpiece of labor management. Initially successfully designed for stillbirth prevention, there was hope to also include prediction and prevention of fetal acidosis and its sequelae. With the routine use of electronic fetal monitoring, the cesarean delivery rate increased from <5% in the 1970s to >30% at present. Most at-risk cases produced healthy babies, resulting in part from considerable confusion as to the differences between diagnostic and screening tests. Electronic fetal monitoring is clearly a screening test. Multiple attempts have aimed at enhancing its ability to accurately distinguish babies at risk of in utero injury from those who are not and to do this in a timely manner so that appropriate intervention can be performed. Even key electronic fetal monitoring opinion leaders admit that this goal has yet to be achieved. Our group has developed a modified approach called the "Fetal Reserve Index" that contextualizes the findings of electronic fetal monitoring by formally including the presence of maternal, fetal, and obstetrical risk factors and increased uterine contraction frequencies and breaking up the tracing into 4 quantifiable components (heart rate, variability, decelerations, and accelerations). The result is a quantitative 8-point metric, with each variable being weighted equally in version 1.0. In multiple previously published refereed papers, we have shown that in head-to-head studies comparing the fetal reserve index with the American College of Obstetricians and Gynecologists' fetal heart rate categories, the fetal reserve index more accurately identifies babies born with cerebral palsy and could also reduce the rates of emergency cesarean delivery and vaginal operative deliveries. We found that the fetal reserve index scores and fetal pH and base excess actually begin to fall earlier in the first stage of labor than was commonly appreciated, and the fetal reserve index provides a good surrogate for pH and base excess values. Finally, the last fetal reserve index score before delivery combined with early analysis of neonatal heart rate and acid/base balance shows that the period of risk for neonatal neurologic impairment can continue for the first 30 minutes of life and requires much closer neonatal observation than is currently being done.

Primary cesarean section rate among full-term pregnant women with non-previous uterine scar in a hospital of Vietnam

Aim

This article aims to determine the contributing indications for primary cesarean sections among full-term pregnant women with non-previous uterine scars and suggests several potential solutions to reduce the cesarean section rate.

Methods

This is a descriptive study with data being retrospectively collected from electronic medical records (EMRs) at Hanoi Obstetrics & Gynecology Hospital, Vietnam, in 2020. We studied 23,631 women at ≥37 weeks of gestation with non-previous uterine scars. Main ICD-10 categories of diagnosis on the EMRs were used to classify the indications. The proportions of indications for primary cesarean sections were calculated, thereby offering potential solutions to reduce the cesarean section rate.

Results

The proportion of cesarean sections among full-term pregnancies with non-previous uterine scars was 40.7%. The most common indications for primary cesarean sections were non-reassuring fetal heart rate tracing (40%), labor arrest (31%), and maternal request (11%). Among the low-risk pregnant women, the cesarean section rate was 35.9%, of which the percentages of labor arrest and non-reassuring fetal heart rate tracings and maternal request were 13.6%, 17.7%, and 4.6%, respectively.

Conclusions

The proportion of primary cesarean sections among full-term pregnancies with non-previous uterine scars is high; non-reassuring fetal heart rate tracings, labor arrest, and maternal request were three main indications. It is necessary to build the strategies of health organizations regarding the management of clinical practices and the programs improving the knowledge, attitudes, practices of pregnant women and obstetricians regarding cesarean sections.

Transcranial photoacoustic characterization of neurovascular physiology during early-stage photothrombotic stroke in neonatal pigletsin vivo

OBJECTIVE

Perinatal ischemic stroke is estimated to occur in 1/2300-1/5000 live births, but early differential diagnosis from global hypoxia-ischemia is often difficult. In this study, we tested the ability of a hand-held transcranial photoacoustic (PA) imaging probe to non-invasively detect a focal photothrombotic stroke (PTS) within 2 h of stroke onset in a gyrencephalic piglet brain.

APPROACH

About 17 stroke lesions of approximately 1 cm²area were introduced randomly in anterior or posterior cortex via the light/dye PTS technique in anesthetized neonatal piglets (n= 11). The contralateral non-ischemic region served as control tissue for discrimination contrast for the PA hemoglobin metrics: oxygen saturation, total hemoglobin (tHb), and individual quantities of oxygenated and deoxygenated hemoglobin (HbO₂and HbR).

MAIN RESULTS

The PA-derived tissue oxygen saturation at 2 h yielded a significant separation between control and affected regions-of-interest (p< 0.0001), which were well matched with 24 h post-stroke cerebral infarction confirmed in the triphenyltetrazolium chloride-stained image. The quantity of HbO₂also displayed a significant contrast (p= 0.021), whereas tHb and HbR did not. The analysis on receiver operating characteristic curves and multivariate data analysis also agreed with the results above.

SIGNIFICANCE

This study shows that a hand-held transcranial PA neuroimaging device can detect a regional thrombotic stroke in the cerebral cortex of a neonatal piglet. In particular, we conclude that the oxygen saturation metric can be used alone to identify regional stroke lesions. The lack of change in tHb may be related to arbitrary hand-held imaging configuration and/or entrapment of red blood cells within the thrombotic stroke.

Multi-Detector Heart Rate Extraction Method for Transabdominal Fetal Pulse Oximetry. Annu Int Conf IEEE Eng Med Biol Soc 2021;2021:1072-1075. [PMID: 34891473 PMCID: PMC10631454 DOI: 10.1109/embc46164.2021.9630946]

Intrapartum fetal well-being assessment relies on fetal heart rate (FHR) monitoring. Studies have shown that FHR monitoring has a high false-positive rate for detecting fetal hypoxia during labor and delivery. A transabdominal fetal pulse oximeter device that measures fetal oxygen saturation non-invasively through NIR light source and photodetectors could increase the accuracy of hypoxia detection. As light travels through both maternal and fetal tissue, photodetectors on the surface of mother's abdomen capture mixed signals comprising fetal and maternal information. The fetal information should be extracted first to enable fetal oxygen saturation calculation. A multi-detector fetal signal extraction method is presented in this paper where adaptive noise cancellation is applied to four mixed signals captured by four separate photodetectors placed at varying distances from the light source. As a result of adaptive noise cancellation, we obtain four separate FHR by peak detection. Weighting, outlier rejection and averaging are applied to these four fetal heart rates and a mean FHR is reported. The method is evaluated in utero on data collected from hypoxic lamb model. Ground truth for FHR is measured through hemodynamics. The results showed that using multi-detector fetal signal extraction gave up to 18.56% lower root-mean-square FHR error, and up to 57.87% lower maximum absolute FHR error compared to single-detector fetal signal extraction.

Changing Perspectives of Electronic Fetal Monitoring

The delivery of healthy babies is the primary goal of obstetric care. Many technologies have been developed to reduce both maternal and fetal risks for poor outcomes. For 50 years, electronic fetal monitoring (EFM) has been used extensively in labor attempting to prevent a large proportion of neonatal encephalopathy and cerebral palsy. However, even key opinion leaders admit that EFM has mostly failed to achieve this goal. We believe this situation emanates from a fundamental misunderstanding of differences between screening and diagnostic tests, considerable subjectivity and inter-observer variability in EFM interpretation, failure to address the pathophysiology of fetal compromise, and a tunnel vision focus. To address these suboptimal results, several iterations of increasingly sophisticated analyses have intended to improve the situation. We believe that part of the continuing problem is that the focus of EFM has been too narrow ignoring important contextual issues such as maternal, fetal, and obstetrical risk factors, and increased uterine contraction frequency. All of these can significantly impact the application of EFM to intrapartum care. We have recently developed a new clinical approach, the Fetal Reserve Index (FRI), contextualizing EFM interpretation. Our data suggest the FRI is capable of providing higher accuracy and earlier detection of emerging fetal compromise. Over time, artificial intelligence/machine learning approaches will likely improve measurements and interpretation of FHR characteristics and other relevant variables. Such future developments will allow us to develop more comprehensive models that increase the interpretability and utility of interfaces for clinical decision making during the intrapartum period.

Medico-legal considerations in the context of neonatal encephalopathy and therapeutic hypothermia

Neonatal encephalopathy (NE) is a significant complication of the peripartum period. It can lead to lifelong neurologic disabilities, including cerebral palsy, cognitive impairments, developmental delays, and epilepsy. Induced hypothermia is the first therapy, which has shown promise in improving the outcomes for neonates with moderate to severe NE following a presumed intrapartum insult. NE is also a frequent source of medical malpractice litigation. In this paper, we will review salient features of the American Tort System as it pertains to medical malpractice. We will discuss the obstetric medico-legal implications of therapeutic hypothermia and suggest a five-step approach to analyzing neonatal cases for causation, etiology, timing of occurrence, responsibility, and liability. We will close with three illustrative clinical cases.

Towards Noninvasive Accurate Detection of Intrapartum Fetal Hypoxic Distress

Current intrapartum fetal well-being assessment is performed using electronic fetal monitoring (EFM), technically referred to as cardiotocography (CTG), which transabdominally monitors fetal heart rate (FHR) in relationship to maternal uterine contractions. Sometimes the deceleration in FHR following a uterine contraction can be sign of fetal hypoxic distress, but it may also be a normal physiological response. Multiple studies have shown that EFM has a high false positive rate for detecting fetal hypoxia. This has caused a rise in emergency Cesarean section (C-section) deliveries performed in the US over the years, while the rates of various conditions associated with anoxic brain injury at birth remain unchanged. The underlying problem is that many factors other than hypoxia can cause non-reassuring CTG traces and a more objective measure of oxygen supply to the fetal brain is not conveniently available. We are working to develop a transabdominal fetal pulse oximetry (TFO) system to non-invasively measure fetal arterial blood oxygen saturation (FSpO2) in order to enhance intrapartum fetal monitoring. This paper gives an overview of the past and ongoing work performed to develop TFO, highlights the main engineering and clinical challenges faced and presents preliminary results that demonstrate feasibility of TFO in both pregnant sheep models and human subjects.

No. 396-Fetal Health Surveillance: Intrapartum Consensus Guideline

OBJECTIVE

To present evidence and recommendations regarding use, classification, interpretation, response, and documentation of fetal surveillance in the intrapartum period and to provide information to help minimize the risk of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention.

INTENDED USERS

Members of intrapartum care teams, including but not limited to obstetricians, family physicians, midwives and nurses, and their learners TARGET POPULATION: Intrapartum women OPTIONS: All methods of uterine activity assessment and fetal heart rate surveillance were considered in developing this document.

OUTCOMES

The impact, benefits, and risks of different methods of surveillance on the diverse maternal-fetal health conditions have been reviewed based on current evidence and expert opinion. No fetal surveillance method will provide 100% detection of fetal compromise; thus, all FHS methods are viewed as screening tests. As the evidence continues to evolve, caregivers from all disciplines are encouraged to attend evidence-based Canadian educational programs every 2 years.

EVIDENCE

Literature published between January 1976 and February 2019 was reviewed. Medline, the Cochrane Database, and international guidelines were used to search the literature for all studies on intrapartum fetal surveillance.

VALIDATION METHODS

The principal and contributing authors agreed to the content and recommendations. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care.

BENEFITS, HARM, AND COSTS

Consistent interdisciplinary use of the guideline, appropriate equipment, and trained professional staff enhances safe intrapartum care. Women and their support person(s) should be informed of the benefits and harms of different methods of fetal health surveillance.

RECOMMENDATIONS

CommunicationSupport During Active LabourPrinciples of Intrapartum Fetal SurveillanceSelecting the Method of Fetal Heart Rate Monitoring: Intermittent Auscultation or Electronic Fetal MonitoringPaper SpeedAdmission AssessmentsEpidural AnalgesiaIntermittent Auscultation in LabourElectronic Fetal Monitoring in LabourClassification of Intrapartum Fetal SurveillanceMaternal Heart RateFetal Health Surveillance Assessment in the Active Second Stage of LabourIntrauterine ResuscitationDigital Fetal Scalp StimulationFetal Scalp Blood SamplingUmbilical Cord Blood GasesDocumentationFetal Surveillance Technology Not RecommendedFetal Health Surveillance Education.

"The First Thousand Days" Define a Fetal/Neonatal Neurology Program

Gene-environment interactions begin at conception to influence maternal/placental/fetal triads, neonates, and children with short- and long-term effects on brain development. Life-long developmental neuroplasticity more likely results during critical/sensitive periods of brain maturation over these first 1,000 days. A fetal/neonatal program (FNNP) applying this perspective better identifies trimester-specific mechanisms affecting the maternal/placental/fetal (MPF) triad, expressed as brain malformations and destructive lesions. Maladaptive MPF triad interactions impair progenitor neuronal/glial populations within transient embryonic/fetal brain structures by processes such as maternal immune activation. Destructive fetal brain lesions later in pregnancy result from ischemic placental syndromes associated with the great obstetrical syndromes. Trimester-specific MPF triad diseases may negatively impact labor and delivery outcomes. Neonatal neurocritical care addresses the symptomatic minority who express the great neonatal neurological syndromes: encephalopathy, seizures, stroke, and encephalopathy of prematurity. The asymptomatic majority present with neurologic disorders before 2 years of age without prior detection. The developmental principle of ontogenetic adaptation helps guide the diagnostic process during the first 1,000 days to identify more phenotypes using systems-biology analyses. This strategy will foster innovative interdisciplinary diagnostic/therapeutic pathways, educational curricula, and research agenda among multiple FNNP. Effective early-life diagnostic/therapeutic programs will help reduce neurologic disease burden across the lifespan and successive generations.

Differences in rate and medical indication of caesarean section between Germany and Japan

BACKGROUND

There are growing concerns about the increasing rate of caesarean section (CS) worldwide. Various strategies have been implemented to reduce the proportion of CS to a reasonable level. Most research on medical indications for CS focuses on nationwide evaluations. Comparative research between different countries is sparse. The aim of this study was to evaluate differences in the rate and indications for CS between Japan and Germany in 2012 and 2013.

METHODS

Comparison of the overall rate and medical indications for CS in two cohort studies from Germany and Japan. We used data from the German Perinatal Survey and the Japan Environment and Children's Study (JECS).

RESULTS

We analyzed data of 1 335 150 participants from the German perinatal survey and of 62 533 participants from JECS and found significant differences between the two countries in CS rate (30.6% vs 20.6%) and main medical indications: cephalopelvic disproportion (3.2% vs 1.3%; OR: 2.4 [95% CI: 2.2-2.6]), fetal distress (7.3% vs 2.3%; OR: 3.4 [95%-CI: 3.2-3.6]), and past uterine surgery/repeat CS (8.4% vs 8.8%; OR: 0.9 [95%-CI: 0.9-1]).

CONCLUSION

There are differences in the rate and medical indications for CS between Germany and Japan at the population level. Fetal distress was identified as a medical indication for CS more often Germany than in Japan. Considering the substantial diagnostic uncertainty of electronic fetal monitoring (EFM) as the major indicator for fetal distress, it would seem to be reasonable to rethink CS decision algorithms.

Validation of a Novel Transabdominal Fetal Oximeter in a Hypoxic Fetal Lamb Model

Current intrapartum fetal oxygen saturation (SaO2) monitoring methodologies are limited, mostly consisting of fetal heart rate monitoring which is a poor predictor of fetal hypoxia. A newly developed transabdominal fetal oximeter (TFO) may be able to determine fetal SaO2 non-invasively. This study is to validate a novel TFO in determining fetal SaO2 in a hypoxic fetal lamb model. Fetal hypoxia was induced in at-term pregnant ewe by placing an aortic occlusion balloon infrarenally and inflating it in a stepwise fashion to decrease blood flow to the uterine artery. The inflation was held at each step for 10 min, and fetal arterial blood gases (ABGs) were intermittently recorded from the fetal carotid artery. The balloon catheter was deflated when fetal SaO2 fell below 15%, and the fetus was recovered. A total of three desaturation experiments were performed. The average fetal SpO2 reported by the TFO was derived at each hypoxic level and correlated with the ABG measures. Fetal SaO2 from the ABGs ranged from 10.5 to 66%. The TFO SpO2 correlated with the ABG fetal SaO2 (r-squared = 0.856) with no significant differences (p > 0.5). The fetal SpO2 measurements from TFO were significantly different than the maternal SpO2 (p < 0.01), which suggests that the transcutaneous measurements are penetrating through the maternal abdomen sufficiently and are expressing the underlying fetal tissue physiology. The recently developed TFO system was able to non-invasively report the fetal SpO2, which showed strong correlation with ABG measures and showed no significant differences.

Is perinatal asphyxia predictable?

BACKGROUND

The objective of our study was to evaluate the association between perinatal asphyxia and hypoxic-ischemic encephalopathy (HIE) with the presence of ante and intrapartum risk factors and/or abnormal fetal heart rate (FHR) findings, in order to improve maternal and neonatal management.

METHODS

We did a prospective observational cohort study from a network of four hospitals (one Hub center with neonatal intensive care unit and three level I Spoke centers) between 2014 and 2016. Neonates of gestational age ≥ 35 weeks, birthweight ≥1800 g, without lethal malformations were included if diagnosed with perinatal asphyxia, defined as pH ≤7.0 or Base Excess (BE) ≤ - 12 mMol/L in Umbical Artery (UA) or within 1 h, 10 min Apgar < 5, or need for resuscitation > 10 min. FHR monitoring was classified in three categories according to the American College of Obstetricians and Gynecologists (ACOG). Pregnancies were divided into four classes: 1) low risk; 2) antepartum risk; 3) intrapartum risk; 4) and both ante and intrapartum risk. In the first six hours of life asphyxiated neonates were evaluated using the Thomson score (TS): if TS ≥ 5 neonates were transferred to Hub for further assessment; if TS ≥ 7 hypothermia was indicated.

RESULTS

Perinatal asphyxia occurred in 21.5‰ cases (321/14,896) and HIE in 1.1‰ (16/14,896). The total study population was composed of 281 asphyxiated neonates: 68/5152 (1.3%) born at Hub and 213/9744 (2.2%) at Spokes (p < 0.001, OR 0.59, 95% CI 0.45-0.79). 32/213 (15%) neonates were transferred from Spokes to Hub. Overall, 12/281 were treated with hypothermia. HIE occurred in 16/281 (5.7%) neonates: four grade I, eight grade II and four grade III. Incidence of HIE was not different between Hub and Spokes. Pregnancies resulting in asphyxiated neonates were classified as class 1) 1.1%, 2) 52.3%, 3) 3.2%, and 4) 43.4%. Sentinel events occurred in 23.5% of the cases and FHR was category II or III in 50.5% of the cases. 40.2% cases of asphyxia and 18.8% cases of HIE were not preceded by sentinel events or abnormal FHR.

CONCLUSIONS

We identified at least one risk factor associated with all cases of HIE and with most cases of perinatal asphyxia. In absence of risk factors, the probability of developing perinatal asphyxia resulted extremely low. FHR monitoring alone is not a reliable tool for detecting the probability of eventual asphyxia.

Home and Birth Center Birth in the United States: Time for Greater Collaboration Across Models of Care

There has been a small, but significant, increase in community births (home and birth-center births) in the United States in recent years. The rate increased by 20% from 2004 to 2008, and another 59% from 2008 to 2012, though the overall rate is still low at less than 2%. Although the United States is not the only country with a large majority of births occurring in the hospital, there are other high-resource countries where home and birth-center birth are far more common and where community midwives (those attending births at home and in birth centers) are far more central to the provision of care. In many such countries, the differences in perinatal outcomes between hospital and community births are small, and there are lower rates of maternal morbidity in the community setting. In the United States, perinatal mortality appears to be higher for community births, though there has yet to be a national study comparing outcomes across settings that controls for planned place of birth. Rates of intervention, including cesarean delivery, are significantly higher in hospital births in the United States. Compared with the United States, countries that have higher rates of community births have better integrated systems with clearer national guidelines governing risk criteria and planned birth location, as well as transfer to higher levels of care. Differences in outcomes, systems, approaches, and client motivations are important to understand, because they are critical to the processes of person-centered care and to risk reduction across all birth settings.

Fetal autonomic malfunction as a marker of fetal distress in growth-restricted fetuses: three case reports

Fetal growth restriction (FGR) is characterized by fetal compromise and delayed neurological maturation. We report 3 cases of early FGR in the 26th week of gestation, based on hemodynamic Doppler monitoring, conventional cardiotocography, and non-invasive fetal electrocardiography (NI-FECG). Fetal heart rate variability (HRV), beat-to-beat variations, and fetal autonomic brain age scores (fABASs) were normal despite the absence of umbilical diastolic flow in the first case and the pregnancy continued to 30 weeks. NI-FECG helped achieve better fetal maturity. Fetal HRV and fABASs were low in the second and third cases. Fetal demise occurred soon in both cases. We conclude that NI-FECG could be a prospective method for the detection of fetal distress in early FGR.

Rising Cesarean Rates: Are Primary Sections Overused?

Doubling of C-section rates from year 2000 to 2015 globally was declared an eye-opener on October 13, 2018, in FIGO World Congress. Rapid increase in rates without clear evidence of concomitant decrease in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. This review addresses issues related to exponentially rising rates, reasons for it, and strategies to reduce. Previous cesarean delivery has main contribution to rising rates as per evidence from the literature search in last 5 years. Focus on optimizing indications of primary C-section resulted in making us rethink modifiable indications like labor dystocia, indeterminate fetal heart rate tracing, suspected fetal macrosomia, malposition, risk-adapted obstetrics, litigation fears, on demand cesarean in literate women and overuse of labor induction. Use of uniform classification system (Robson/WHO classification) with recommendations of WHO, FIGO and annual audits with cloud-based anonymous registry will streamline decisions for cesarean in nullipara and help to control the situation.

The effect of unilateral stroke on autonomic function in the term newborn

BACKGROUND

The mature cerebral cortex has a topographically organized influence on reflex autonomic centers of the brainstem and diencephalon and sympathetic activation coming primarily from the right hemisphere and parasympathetic activation from the left. In the term newborn, the maturational status of this central autonomic system remains poorly understood.

METHODS

Sixteen term newborns admitted to Children's National with unilateral middle cerebral artery (MCA) strokes (n = 8 left, n = 8 right) had archived continuous electrocardiograph (EKG) signals available. We compared stroke laterality and severity with indices of autonomic function, as measured by heart rate variability. We performed both time- and frequency-domain analyses on the R-R interval (RRi) over 24h of continuous EKG data at around 7 days of age.

RESULTS

Right MCA stroke significantly increased sympathetic tone, while left MCA stroke increased parasympathetic tone. Regardless of laterality, stroke severity was associated inversely with sympathetic tone and positively with parasympathetic tone. Surprisingly, injury to either insular region had no significant autonomic effect. Phenobarbital blood levels were positively associated with sympathetic tone and inversely related to parasympathetic tone.

CONCLUSION

Based on these findings, it is difficult to reconcile the functional topography of the central autonomic system in term newborns with that currently proposed for the normal mature brain. Further investigation is clearly needed.

When the Evidence Basis Breeds Controversies: Exploring the Value Profile of Robotic Surgery Beyond the Early Introduction Phase

This article investigates qualitatively the value profile of the da Vinci® surgical robot after almost two decades of extensive clinical use and research. We aimed to understand whether the swiftly growing body of published studies on robotic prostate surgery can now, that is, beyond an early stage, guide decisions on the acquisition, procurement, and public provision of this innovation. We explored both published studies and the perspectives of diverse stakeholders in the Netherlands. Both arenas represent conflicting, often polarised arguments on the (added) value of da Vinci surgery. What was unclear a decade ago due to lack of evidence is now unclear because of controversies about evidence. The article outlines controversial value issues and indicates the unlikelihood that awaiting more research - amid the mantra "further studies are needed" - will resolve the controversy. The study underscores multi-stakeholder deliberation to resolve controversies regarding the value of advanced medical innovations.

Medico-legal considerations and operative vaginal delivery

Women undergo operative vaginal delivery (OVD) as an alternative to caesarean section when complications arise in the second stage of labour. The perinatal mortality associated with OVD is very low, and most of the perinatal morbidity is minor. However, when serious adverse events occur, such as traumatic birth injury, shoulder dystocia, cerebral palsy and perinatal death, there are medico-legal implications. There is also the potential for litigation in relation to maternal pelvic floor injury, which is increased with OVD. Obstetricians performing and supervising OVDs need to be aware of the potential pitfalls and minimise the risk of adverse outcomes. Given that most obstetricians will be involved in adverse birth-related events, it is important that they are aware of the legal processes that may ensue. It is also important when reviewing adverse OVD-related outcomes that association is differentiated from causation. These issues are addressed in the current chapter with attention drawn to the Montgomery ruling, which redefines the legal standards expected in relation to informed consent.

Effectiveness of a Novel Continuous Doppler (Moyo) Versus Intermittent Doppler in Intrapartum Detection of Abnormal Foetal Heart Rate: A Randomised Controlled Study in Tanzania

Background: Intrapartum foetal heart rate (FHR) monitoring is crucial for identification of hypoxic foetuses and subsequent interventions. We compared continuous monitoring using a novel nine-crystal FHR monitor (Moyo) versus intermittent single crystal Doppler (Doppler) for the detection of abnormal FHR. Methods: An unmasked randomised controlled study was conducted in a tertiary hospital in Tanzania (ClinicalTrials.gov Identifier: NCT02790554). A total of 2973 low-risk singleton pregnant women in the first stage of labour admitted with normal FHR were randomised to either Moyo (n = 1479) or Doppler (1494) arms. The primary outcome was the proportion of abnormal FHR detection. Secondary outcomes were time intervals in labour, delivery mode, Apgar scores, and perinatal outcomes. Results: Moyo detected abnormal FHR more often (13.3%) compared to Doppler (9.8%) (p = 0.002). Time intervals from admission to detection of abnormal FHR were 15% shorter in Moyo (p = 0.12) and from the detection of abnormal FHR to delivery was 36% longer in Moyo (p = 0.007) compared to the Doppler arm. Time from last FHR to delivery was 12% shorter with Moyo (p = 0.006) compared to Doppler. Caesarean section rates were higher with the Moyo device compared to Doppler (p = 0.001). Low Apgar scores (<7) at the 1st and 5th min were comparable between groups (p = 0.555 and p = 0.800). Perinatal outcomes (fresh stillbirths and 24-h neonatal deaths) were comparable at delivery (p = 0.497) and 24-h post-delivery (p = 0.345). Conclusions: Abnormal FHR detection rates were higher with Moyo compared to Doppler. Moyo detected abnormal FHR earlier than Doppler, but time from detection to delivery was longer. Studies powered to detect differences in perinatal outcomes with timely responses are recommended.

The complex aetiology of cerebral palsy

Cerebral palsy (CP) is the most prevalent, severe and costly motor disability of childhood. Consequently, CP is a public health priority for prevention, but its aetiology has proved complex. In this Review, we summarize the evidence for a decline in the birth prevalence of CP in some high-income nations, describe the epidemiological evidence for risk factors, such as preterm delivery and fetal growth restriction, genetics, pregnancy infection and other exposures, and discuss the success achieved so far in prevention through the use of magnesium sulfate in preterm labour and therapeutic hypothermia for birth-asphyxiated infants. We also consider the complexities of disentangling prenatal and perinatal influences, and of establishing subtypes of the disorder, with a view to accelerating the translation of evidence into the development of strategies for the prevention of CP.

Asking different questions: A call to action for research to improve the quality of care for every woman, every child

Despite decades of considerable economic investment in improving the health of families and newborns world-wide, aspirations for maternal and newborn health have yet to be attained in many regions. The global turn toward recognizing the importance of positive experiences of pregnancy, intrapartum and postnatal care, and care in the first weeks of life, while continuing to work to minimize adverse outcomes, signals a critical change in the maternal and newborn health care conversation and research prioritization. This paper presents "different research questions" drawing on evidence presented in the 2014 Lancet Series on Midwifery and a research prioritization study conducted with the World Health Organization. The results indicated that future research investment in maternal and newborn health should be on "right care," which is quality care that is tailored to individuals, weighs benefits and harms, is person-centered, works across the whole continuum of care, advances equity, and is informed by evidence, including cost-effectiveness. Three inter-related research themes were identified: examination and implementation of models of care that enhance both well-being and safety; investigating and optimizing physiological, psychological, and social processes in pregnancy, childbirth, and the postnatal period; and development and validation of outcome measures that capture short and longer term well-being. New, transformative research approaches should account for the underlying social and political-economic mechanisms that enhance or constrain the well-being of women, newborns, families, and societies. Investment in research capacity and capability building across all settings is critical, but especially in those countries that bear the greatest burden of poor outcomes. We believe this call to action for investment in the three research priorities identified in this paper has the potential to achieve these benefits and to realize the ambitions of Sustainable Development Goal Three of good health and well-being for all.

Obstetrics at Decisive Crossroads Regarding Pattern-Recognition of Fetal Heart Rate Decelerations: Scientific Principles and Lessons From Memetics

The survival of cardiotocography (CTG) as a tool for intrapartum fetal monitoring seems threatened somewhat unjustifiably and unwittingly despite the absence of better alternatives. Fetal heart rate (FHR) decelerations are center-stage (most important) in the interpretation of CTG with maximum impact on three-tier classification. The pattern-discrimination of FHR decelerations is inexorably linked to their nomenclature. Unscientific or flawed nomenclature of decelerations can explain the dysfunctional CTG interpretation leading to errors in detection of acidemic fetuses. There are three contrasting concepts about categorization of FHR decelerations: 1) all rapid decelerations (the vast majority) should be grouped as “variable” because they are predominantly due to cord-compression, 2) all decelerations are due to chemoreflex from fetal hypoxemia hence their timing is not important, and 3) FHR decelerations should be categorized into “early/late/variable” based primarily on their time relationship to contractions. These theoretical concepts are like memes (ideas/beliefs). Lessons from “memetics” are that the most popular, attractive or established beliefs may not necessarily be true, scientific, beneficial or even without harm. Decelerations coincident with contractions with trough corresponding to the peak of contractions cannot be explained by cord-compression or increasing hypoxia (from compromised uteroplacental perfusion, cord-compression or even cerebral hypoperfusion/anoxia purportedly conceivable from head-compression). Decelerations due to hypoxemia would be associated with delayed recovery of decelerations (lag phase). It is a scientific imperative to cast away disproven/falsified theories. Practices based on unscientific theories lead to patient harm. Clinicians should urgently adopt the categorization of FHR decelerations based primarily of the time relationship to contractions as originally proposed by Hon and Caldeyro-Barcia. This analytical review shows it to be underpinned by most robust physiological and scientific hypotheses unlike the other categorizations associated with untruthful hypotheses, irreconcilable fallacies and contradictions. Without truthful framework and meaningful pattern-recognition of FHR decelerations, the CTG will not fulfil its true potential.

Continuous Electronic Fetal Monitoring during Labor: A Critique and a Reply to Contemporary Proponents

A half century after continuous electronic fetal monitoring (EFM) became the omnipresent standard of care for the vast majority of labors in the developed countries, and the cornerstone for cerebral palsy litigation, EFM advocates still do not have any scientific evidence justifying EFM use in most labors or courtrooms. Yet, these EFM proponents continue rationalizing the procedure with a rhetorical fog of meaningless words, misleading statistics, archaic concepts, and a complete disregard for medical ethics. This article illustrates the current state of affairs by providing an evidence-based review penetrating the rhetorical fog of a prototypical EFM advocate.

Critical Imperative for the Reform of British Interpretation of Fetal Heart Rate Decelerations: Analysis of FIGO and NICE Guidelines, Post-Truth Foundations, Cognitive Fallacies, Myths and Occam's Razor

Cardiotocography (CTG) has disappointingly failed to show good predictability for fetal acidemia or neonatal outcomes in several large studies. A complete rethink of CTG interpretation will not be out of place. Fetal heart rate (FHR) decelerations are the most common deviations, benign as well as manifestation of impending fetal hypoxemia/acidemia, much more commonly than FHR baseline or variability. Their specific nomenclature is important (center-stage) because it provides the basic concepts and framework on which the complex "pattern recognition" of CTG interpretation by clinicians depends. Unfortunately, the discrimination of FHR decelerations seems to be muddled since the British obstetrics adopted the concept of vast majority of FHR decelerations being "variable" (cord-compression). With proliferation of confusing waveform criteria, "atypical variables" became the commonest cause of suspicious/pathological CTG. However, National Institute for Health and Care Excellence (NICE) (2014) had to disband the "typical" and "atypical" terminology because of flawed classifying criteria. This analytical review makes a strong case that there are major and fundamental framing and confirmation fallacies (not just biases) in interpretation of FHR decelerations by NICE (2014) and International Federation of Gynecology and Obstetrics (FIGO) (2015), probably the biggest in modern medicine. This "post-truth" approach is incompatible with scientific practice. Moreover, it amounts to setting oneself for failure. The inertia to change could be best described as "backfire effect". There is abundant evidence that head-compression (and other non-hypoxic mediators) causes rapid rather than shallow/gradual decelerations. Currently, the vast majority of decelerations are attributed to unproven cord compression underpinned by flawed disproven pathophysiological hypotheses. Their further discrimination based on abstract, random, trial and error criteria remains unresolved suggesting a false premise to begin with. This is not surprising considering that the commonest pathophysiology of intrapartum hypoxemia is contraction-induced reduction in uteroplacental perfusion (sometimes already compromised) and not cord compression at all. This distorted categorization causes confusion, false-alarm fatigue and difficulty in focusing on real pathological decelerations making CTG interpretation dysfunctional ultimately compromising patient safety. Obstetricians/midwives should demand reverting to the previous more scientific British categorization of decelerations based solely on time relationship to contractions as advocated by the pioneers like Hon and Caldeyro-Barcia, rather than accepting the current "post-truth" scenario.

The Ethics of Teaching Physicians Electronic Fetal Monitoring: And Now for the Rest of the Story

Electronic fetal monitoring (EFM) does not predict or prevent cerebral palsy (CP), but this myth remains entrenched in medical training and practice. The continued use of this ineffectual diagnostic modality increases the cesarean section rate with concomitant harms to mothers and babies alike. EFM, as it is used in defensive medical practice, is a violation of patient autonomy and raises serious ethical concerns. This review addresses the need for improved graduate medical education so that physicians and medical residents are taught both sides of the EFM-CP story.