Cardiotocography Traces Research Articles

Velamentous Cord Insertion: A Rare Cause of Emergency Caesarean Section

Pregnancies complicated with velamentous cord insertion (VCI) are at risk of adverse perinatal outcome. Placental and umbilical cord assessment should be performed during routine obstetric ultrasound. We report a case of velamentous cord insertion that was not identified antenatally. A 28-year-old primigravida at 40 weeks gestation presented in active phase of labour. Intrapartum, cardiotocography (CTG) tracing was pathological. Thus, decision was made for emergency caesarean section and a velamentous cord insertion was found. Despite a favourable outcome, this case highlighted the importance of antenatal diagnosis of VCI and thus preventing catastrophic outcome.

Interobserver agreement in CTG interpretation using the 2015 FIGO guidelines for intrapartum fetal monitoring

BackgroundVisual analysis of cardiotocographic (CTG) tracings has been shown to be prone to poor intra- and interobserver agreement when several interpretation guidelines are used, and this may have an important impact on the technology’s performance. ObjectivesThe aim of this study was to evaluate agreement in CTG interpretation using the new 2015 FIGO guidelines on intrapartum fetal monitoring. Study designA pre-existing database of intrapartum CTG tracings was used to sequentially select 151 cases acquired with a fetal electrode, with duration exceeding 60minutes, and signal loss less than 15%. These tracings were presented to six clinicians, three with more than 5 years’ experience in the labor ward, and three with 5 or less years’ experience. Observers were asked to evaluate tracings independently, to assess basic CTG features: baseline, variability, accelerations, decelerations, sinusoidal pattern, tachysystole, and to classify each tracing as normal, suspicious or pathologic, according to the 2015 FIGO guidelines on intrapartum fetal monitoring. Agreement between observers was evaluated using the proportions of agreement (Pa), with 95% confidence intervals (95%CI). ResultsA good interobserver agreement was found in the evaluation of most CTG features, but not bradycardia, reduced variability, saltatory pattern, absence of accelerations and absence of decelerations. For baseline classification Pa was 0.85 [0.82–0.90], for variability 0.82 [0.78–0.85], for accelerations 0.72 [0.68–0.75], for tachysystole 0.77 [0.74–0.81], for decelerations 0.92 [0.90–0.95], for variable decelerations 0.62 [0.58–0.65], for late decelerations 0.63 [0.59–0.66], for repetitive decelerations 0.73 [0.69–0.78], and for prolonged decelerations 0.81 [0.77–0.85]. For overall CTG classification, Pa were 0.60 [0.56–0.64], for classification as normal 0.67 [0.61–0.72], for suspicious 0.54 [0.48–0.60] and for pathologic 0.59 [0.51–0.66]. No differences in agreement according to the level of expertise were observed, except in the identification of accelerations, where it was better in the more experienced group. ConclusionsA good interobserver agreement was found in evaluation of most CTG features and in overall tracing classification. Results were better than those reported in previous studies evaluating agreement in overall tracing classification. Observer experience did not appear to play a role in agreement.

92 Electronic evaluation of fetal vitality in hypertensive syndromes – Comparison between two methods

Introduction Electronic methods are adopted for the evaluation of fetal vitality in hypertensive syndromes, comparing pros and cons to contribute when choosing one. Objective Compare two resources of study of fetal vitality: cardiotocography and fetal monitor AN24 (Monica Health Care) in hypertensive pregnancies. Methods This is a study control case with a sample of 22 patients in which we compare the tracing using the conventional cardiotocography, and transabdominal fetal electrocardiography by choice of the fetal monitor AN24. The study was conducted with pregnant women equal or above 34 weeks, alive fetus and single, with hypertensive disorders according to the criteria NHBPEP – 2000 at Hospital Guilherme Alvaro-Santos/SP-Brazil from june to october of 2015. The study had 22 patients with diagnosis of hypertensive syndrome. The applicability of both methods was performed according to the standardized recommendations. The variables examined in the study were: gestational age, analyzed in weeks; number of pregnancies; parity; body mass index (BMI), which was divided into 3 criteria (BMI less than 30; BMI ⩾ 30 and less than 35; BMI ⩾ 35); preparation time, which means the time (in minutes) since the starting of local asepsis up to the beginning of the record of cartography. Also was analyzed the success in capturing, which was defined as the successful capture of the signal to execute the cardiotocography; signal loss, defined as any interruption of cardiotocographic tracing. Finally, it was analyzed the concordance in categorical classification in both methods. Following the criterias divided in class I, II and III (ACOG, 2009).1 Results Afterwards analysed 22 patients, were obtained: average of the gestational age 36,71 weeks, average of pregnancies 2,14, average of births 1,09 and average of BMI 34,17. This study has shown 100% of agreement in categorical classification in both procedures. The success capitation between the methods was similar (p = 0,999). In AN24 monitor, six tracings has showed signal loss, while in the CTB only three has shown this loss (p = 0,505). The monitor AN24 have showed a bigger preparation time than the other method, analysed in 1,94 min. The CTB method showed better results when comparing the variable preparation time in patients with BMI > 35 (p = 0,094). Conclusion No differences were identified concerning the quality of analysis of fetal viability between the resources and were also in agreement on the categorical analysis of each tracing. Both methods showed agreement in the variables: success of capturing in the whole sample and in BMI between 30 and 35. The AN24 showed better results than the CTB, when analyzing the variables: success of capturing in BMI higher than 35 and signal loss, in the whole sample and in BMI between 30 and 35. On the other hand, CTB had more success in capturing only in BMI less than 30, and showed faster preparation time in the whole sample and in all BMI groups. Further studies may broaden the comparison between these current methods. 1. American College of Obstetricians and Gynecologists, ACOG Practice Bulletin No. 106: Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles, Obstet Gynecol. 114(1) (2009) 192–202.

Notching in the Umbilical Artery Doppler Waveform in the Absence of Cord and Placental Structural Abnormalities: A Case of Massive Fetomaternal Hemorrhage

Massive fetomaternal hemorrhage can cause severe anemia and fetal death. Early diagnosis and blood transfusion can prevent life-threatening events. We describe a case of massive fetomaternal hemorrhage in a previously well primigravida who visited our hospital with a chief complaint of decreased fetal movements and presented with a sinusoidal fetal heart rate pattern in the cardiotocographic tracings. The umbilical artery Doppler waveform showed notching, and the peak systolic velocity of the fetal middle cerebral artery (MCA) was normal. Emergency cesarean section was performed; however, the neonate died despite providing life-support. Thus, we recommend consideration of impending fetal death in patients with non-reassuring fetal heart rate and notching in the umbilical artery Doppler waveform even in the absence of increased peak systolic velocity of the fetal MCA. J Clin Gynecol Obstet. 2016;5(1):50-52 doi: http://dx.doi.org/10.14740/jcgo386w

Does knowledge of fetal outcome influence the interpretation of intrapartum cardiotocography and subsequent clinical management? A multicentre European study.

To investigate whether knowledge of fetal outcome influences retrospective interpretation of cardiotocographic tracings and subsequent management recommendations. Prospective online study. Seven university hospitals in five European countries. Forty-two intrapartum tracings from women with singleton pregnancies and uneventful antepartum courses. Using an online questionnaire, 123 healthcare professionals interpreted 42 tracings without any knowledge of fetal outcome and provided management recommendations according to the National Institute of Clinical Excellence guidelines (intrapartum care). Two months later, 93 of the 123 participants re-interpreted the same re-ordered tracings, this time with information on the newborn's umbilical artery pH. Comparison of the evaluation of tracing features, overall tracing classification, and management recommendations between the initial analysis and re-interpretation. In newborns with umbilical artery pH ≤ 7.05, knowledge of the pH value led to significant changes in the evaluation of all basic tracing features. In this group, classification of tracings as 'normal' decreased 76% (8.8-2.1%, P < 0.001), whereas classification as 'pathologic' increased 51% (44.7-67.5%, P < 0.001). In newborns with pH 7.06-7.19, classification of tracings as 'normal' decreased 36% (22.4-14.4%, P < 0.001), and in those with pH ≥ 7.20, classification of tracings as 'pathologic' decreased 40% (23.4-14.1%, P < 0.001). In the group of newborns with umbilical artery pH ≤ 7.05, the recommendations 'no attention needed' decreased 75% (10.2-2.6%, P < 0.001), and the number of recommendations 'rapid reversal of hypoxic cause or immediate delivery' increased 70.3% (42.1-71.7%, P < 0.001). When provided with information on adverse fetal outcome, healthcare professionals provide a more pessimistic evaluation of basic tracing features, overall classification, and clinical management recommendations. Knowledge of adverse fetal outcome leads to more pessimistic CTG evaluation and management recommendations.

Software for computerised analysis of cardiotocographic traces

Despite the widespread use of cardiotocography in foetal monitoring, the evaluation of foetal status suffers from a considerable inter and intra-observer variability. In order to overcome the main limitations of visual cardiotocographic assessment, computerised methods to analyse cardiotocographic recordings have been recently developed. In this study, a new software for automated analysis of foetal heart rate is presented. It allows an automatic procedure for measuring the most relevant parameters derivable from cardiotocographic traces. Simulated and real cardiotocographic traces were analysed to test software reliability. In artificial traces, we simulated a set number of events (accelerations, decelerations and contractions) to be recognised. In the case of real signals, instead, results of the computerised analysis were compared with the visual assessment performed by 18 expert clinicians and three performance indexes were computed to gain information about performances of the proposed software. The software showed preliminary performance we judged satisfactory in that the results matched completely the requirements, as proved by tests on artificial signals in which all simulated events were detected from the software. Performance indexes computed in comparison with obstetricians’ evaluations are, on the contrary, not so satisfactory; in fact they led to obtain the following values of the statistical parameters: sensitivity equal to 93%, positive predictive value equal to 82% and accuracy equal to 77%. Very probably this arises from the high variability of trace annotation carried out by clinicians.

Litigation related to intrapartum fetal surveillance

The role of intrapartum care including cardiotocography (CTG) monitoring in cases of perinatal neurological injury receives considerable debate in both clinical and medicolegal settings. The debate, however, has distracted attention from fundamental questions about the timing, mechanism, and preventability of perinatal injury. CTG tracings are used as a surrogate for asphyxia with the timing of intervention ("rescue") predicated on the presumed severity of asphyxia. Using CTG in this way has prevented intrapartum stillbirth, but it has not reduced the long-term injury in part, because, contrary to popular belief, the majority of intrapartum fetal injuries are unassociated with severe hypoxia or severe neonatal depression. This article describes the timing and mechanisms, including mechanical factors, of intrapartum perinatal injury and the benefit of using the CTG, not for the purpose of "rescue", but for identifying risk factors for fetal injury and keeping the fetus out of harm's way.

Analysis of pregnancy, labor and neonatal course in babies with prenatally-diagnosed complete atrioventricular heart block

Complete heart block (third-degree atrioventricular block) is a defect of the conduction system of the heart, in which the impulse generated in the sinoatrial node does not propagate to the ventricles, and thus the latter contract independently of the atria. A third-degree atrioventricular block can be either congenital or acquired. In 60-70% of the cases, the congenital heart block results from destruction of the conduction system of the fetal heart by anti-Ro/SSA and anti-La/SSB antibodies present in maternal serum. The antibodies are synthesized in the course of autoimmune maternal conditions, most often systemic lupus erythematosus or rarer rheumatoid arthritis, dermatomyositis or Sjögren's syndrome. The complete block can occur as an isolated defect or be associated with structural anomalies of the fetal heart. A total of five patients whose fetuses were diagnosed with the third-degree atrioventricular block have been hospitalized at the Department of Obstetrics, Medical University of Gdansk between 2012 and 2014. We present the data of the five patients, hospitalized at the Department of Obstetrics, Medical University of Gdansk, whose fetuses were diagnosed prenatally with the complete heart block. The cases differ in terms of etiology clinical outcome, and postnatal treatment. All data are presented in Table I. We emphasize the role of appropriate pregnancy management and careful monitoring of the fetal condition. From obstetrical perspective, it is important to monitor the condition of fetuses with the third-degree atrioventricular block ultrasonographically and echocardiographically; in turn, cardiotocography is less useful in this setting. Therefore, a non-reactive cardiotocographic tracing should not constitute an indication for a preterm delivery. An affected fetus should be delivered in a tertiary center for perinatal care that cooperates with a pediatric cardiology center. An efficient program for cardologic prenatal care and close cooperation between obstetricians, neonatologists, pediatric cardiologists, and cardiac surgeons constitute the key to a successful outcome.

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Objectives Comparison between two electronic methods of antepartum fetal assessment in hypertensive pregnant women. Methods Comparison of conventional cardiotocography tracing and transabdominal fetal electrocardiography with the use of the fetal monitor AN24 (Monica Healthcare), in women with gestational age ⩾34 weeks, single fetus, with hypertensive disorders according to the criteria of NHBPEP-2000 at Guilherme Alvaro Hospital – Santos/SP – Brazil (Dec/2013–Jun/2014). The cardiotocography recorded the fetal heart rate by a Doppler transducer, dependent on correct identification of fetal positioning, the AN24 detected electrophysiological signals using electrodes arranged on the maternal abdomen. The tests were performed according to standard recommendation; variables evaluated: gestational age, number of pregnancies, parity, baseline, variability, body mass index (BMI), obesity, preservation of mobility adhesion, successful recording, Preparation time ( 20″), facility of captation/stability of signal in the group with BMI > 30, agreement in diagnostic classification (ACOG Practice Bulletin 106, 2009). Results Of the 10 tracings evaluated: 03 pregnant women with pre-eclampsia, 07 with chronic hypertensive (06 developed superimposed pre-eclampsia). The AN24 monitor preserved the mobility and made it easier to obtain the registration in women with BMI > 30 with better adherence in this group once it dismissed the additional manipulation of the abdomen to obtain registration. Gestational age average (weeks) 34.8 Good capitation MONICA 80% Number of pregnancies (average) 4.4 Good capitation cardiotocography 50% Parity (average) 2.5 Preparation time MONICA ( 70% Base line fetal heart rate (average) 134.6 Time procedure MONICA (>20′) 80% Variability (oscillation 6–25 bpm) 67% Preparation time cardiotocography ( 90% BMI (average) 37.4 Time procedure cardiotocography (>20′) 90% Obesity 60% Concordance in the classification 100% In the group with BMI ⩾ 30 (07 pregnancies), facility of captation/stability of signal was 85%, instead of when BMI ⩽ 30 was 42%. Conclusions We have not identified any differences regarding the quality of analysis fetal vitality between the methods. The easy achievement/continuity of record by AN24 monitor in maternal obesity may indicate that this resource is particularly valuable for this group. Additional studies may increase the information for this research. Disclosures C. Geraldes: None. M. Saco: None. P. Coelho: None. G. Calestini: None. C. Cury: None. F. Fuentes: None. B. Zeiger: None. J. Garcia: None. S. de Toledo: None. R. Guidoni: None. M. Saito: None. F. Sousa: None. C. Mariani Neto: None.

Neonatal outcome and delivery mode in labors with repetitive fetal scalp blood sampling

ObjectiveTo investigate if repeat (≥3) fetal scalp blood sampling (FBS) is associated with increased risk of caesarean delivery and worse neonatal outcome than occasional (1–2) FBS. Study designProspective cohort study of women undergoing intrapartum FBS at Karolinska University Hospital, Sweden. FBS with lactate analysis was performed if the attending doctor found the cardiotocography (CTG) tracing suspicious or abnormal. Lactate concentration was measured bedside. As a routine in all deliveries, acid-base analyses were performed on umbilical artery and vein blood immediately after delivery. Main outcome measures were metabolic acidemia in umbilical artery at delivery, Apgar score <7 at 5min and caesarean delivery. ResultsDuring the study period there were 2134 FBSs performed on 1070 laboring women with a median of two samplings (range 1–8). There were no differences in Apgar score <7 at 5min or metabolic acidemia in umbilical artery blood at birth between labors with 1–2 FBS and ≥3 FBS. Among women who underwent 1–2 FBS, 23% had a caesarean delivery as compared with 42% of those having ≥3 FBS. After adjustment for confounders, repeat FBS remained an independent risk factor for caesarean delivery (adj OR 2.05; 95%C.I 1.5–2.8). ConclusionFetal monitoring with repetitive FBS (≥3) during labors with CTG changes is safe for the baby, but the rate of caesarean delivery is doubled as compared to labors where 1–2 FBS are needed. Still, more than 50% of women with repetitive FBS will be delivered vaginally, and 1/3 of these spontaneously.

Cardiotocography patterns and risk of intrapartum fetal acidemia.

To identify cardiotocography (CTG) patterns associated with increased risk of intrapartum fetal acidemia. A prospective observational cohort study of 1070 women with fetal scalp blood sampling (FBS) during labor was conducted at Karolinska University Hospital, Stockholm, Sweden. Women with a nonreassuring CTG pattern underwent FBS, and lactate concentration was measured at the bedside. Lactate concentrations >4.8 mmol/L were defined as fetal acidemia. A senior obstetrician, blinded to the lactate concentration at FBS, visually interpreted the CTG tracings that had prompted FBS. There were 2134 FBSs performed on 1070 laboring women, constituting 11% of all deliveries at this labor ward. The CTG patterns with the highest frequency of lactacidemia at FBS were late or severe variable decelerations combined with tachycardia (20%-25% at first FBS and 33%-49% at last FBS). With a normal baseline fetal heart rate, normal variability, and absence of serious decelerations, the fetal scalp blood lactate concentration at the first FBS was normal in 97.5% of cases. The group with isolated reduced variability had no increased prevalence of acidemia and median lactate concentration did not differ from the normal group. Isolated reduced variability is in most cases not a sign of hypoxia. If development of hypoxia is ruled out with one FBS, this pattern does not require monitoring with repetitive FBSs throughout labor. Late decelerations and severe variable decelerations increase the risk for intrapartum fetal metabolic acidemia to the same extent. The combination of these decelerations and tachycardia was associated with the highest rate of fetal metabolic acidemia.

Classification of fetal abnormalities based on CTG signal

The fetal heart rate (FHR) signal processing based on Artificial Neural Networks (ANN),Fuzzy Logic (FL) and frequency domain Discrete Wavelet Transform(DWT) were analysis in order to perform automatic analysis using personal computers. Cardiotocography (CTG) is a primary biophysical method of fetal monitoring. The assessment of the printed CTG traces was based on the visual analysis of patterns that describing the variability of fetal heart rate signal. Fetal heart rate data of pregnant women with pregnancy between 38 and 40 weeks of gestation were studied. The first stage in the system was to convert the cardiotocograghy (CTG) tracing in to digital series so that the system can be analyzed ,while the second stage ,the FHR time series was transformed using transform domains Discrete Wavelet Transform(DWT) in order to obtain the system features .At the last stage the approximation coefficients result from the Discrete Wavelet Transform were fed to the Artificial Neural Networks and to the Fuzzy Logic, then compared between two results to obtain the best for classifying fetal heart rate.

Classification of fetal abnormalities based on CTG signal

The fetal heart rate (FHR) signal processing based on Artificial Neural Networks (ANN),Fuzzy Logic (FL) and frequency domain Discrete Wavelet Transform(DWT) were analysis in order to perform automatic analysis using personal computers. Cardiotocography (CTG) is a primary biophysical method of fetal monitoring. The assessment of the printed CTG traces was based on the visual analysis of patterns that describing the variability of fetal heart rate signal. Fetal heart rate data of pregnant women with pregnancy between 38 and 40 weeks of gestation were studied. The first stage in the system was to convert the cardiotocograghy (CTG) tracing in to digital series so that the system can be analyzed ,while the second stage ,the FHR time series was transformed using transform domains Discrete Wavelet Transform(DWT) in order to obtain the system features .At the last stage the approximation coefficients result from the Discrete Wavelet Transform were fed to the Artificial Neural Networks and to the Fuzzy Logic, then compared between two results to obtain the best for classifying fetal heart rate.

Medico-Legal Issues with CTG Interpretation

Electronic fetal monitoring is the recommended method of intrapartum fetal surveillance in high risk pregnancies and the cardiotocography (CTG) forms an integral part of intrapartum care on most modern labour wards. Despite the questions about its efficacy and controversy regarding increased rates of operative delivery associated with its use, continuous CTG remains the predominant method of intrapartum fetal monitoring. Although CTG is sensitive in detecting abnormalities of fetal heart rate (FHR), its specificity for detection of fetal hypoxia is low and therefore confirmatory tests such as fetal scalp blood sampling or analysis of fetal electrocardiography (ECG) become necessary. The intrapartum CTG trace forms a central piece of documentary evidence in litigations related to adverse perinatal outcomes which are alleged to have arisen due to events that took place during the labour and/or delivery of the baby. The main reasons for litigation are not just for recovery of costs determined by injury, pain, loss and future care of a brain damaged child; but the parents also want to know what happened and why, and expect the healthcare staff to be held accountable for their actions. Majority of medico-legal cases have similar problems which can be laid down to a few factors such as - a) inability to interpret FHR trace, b) inappropriate action, c) technical aspects and d) record keeping. Not only can litigations have long-term consequences for the working lives of midwives or obstetricians but they have been influential in changing practice trends such as rising caesarean rates. Unfortunately obstetric litigation with its huge costs is a growing problem and for the foreseeable future, the CTG is here to stay. The best defence against litigation is good clinical practice with adherence to evidence based guidelines and regular mandatory training in the interpretation of CTG for all labour ward staff. There should be a mechanism for the rapid review of adverse obstetric events and dissemination of key learning points to all staff. Keywords: CTG, fetal, hypoxia, intrapartum, medico-legal, monitoring, surveillance.

Impact of the introduction of fetal central monitoring on hospital expenses with cardiotocographic paper

Digital storage of cardiotocographic (CTG) tracings by fetal central monitoring systems (fCMS) obviates the need for printing, or alternatively, the tracings can be printed in regular paper instead of CTG thermal paper. We aimed at evaluating the impact of the introduction of the Omniview-SisPorto® system on CTG paper costs in a large university hospital. After introduction of the fCMS, there was an 87% reduction in median annual expenses with CTG paper in the labour ward (p = 0.011) and a 78% decrease in the prenatal clinic (p = 0.017), despite a more than 40% increase in the median number of observed women. Routine use of fCMS may provide an important reduction in hospital expenses associated with the use of thermal CTG paper, thus reducing the investment made in their acquisition and maintenance.

What is the "normal" fetal heart rate?

Aim. There is no consensus about the normal fetal heart rate. Current international guidelines recommend for the normal fetal heart rate (FHR) baseline different ranges of 110 to 150 beats per minute (bpm) or 110 to 160 bpm. We started with a precise definition of “normality” and performed a retrospective computerized analysis of electronically recorded FHR tracings.Methods. We analyzed all recorded cardiotocography tracings of singleton pregnancies in three German medical centers from 2000 to 2007 and identified 78,852 tracings of sufficient quality. For each tracing, the baseline FHR was extracted by eliminating accelerations/decelerations and averaging based on the “delayed moving windows” algorithm. After analyzing 40% of the dataset as “training set” from one hospital generating a hypothetical normal baseline range, evaluation of external validity on the other 60% of the data was performed using data from later years in the same hospital and externally using data from the two other hospitals.Results. Based on the training data set, the “best” FHR range was 115 or 120 to 160 bpm. Validation in all three data sets identified 120 to 160 bpm as the correct symmetric “normal range”. FHR decreases slightly during gestation.Conclusions. Normal ranges for FHR are 120 to 160 bpm. Many international guidelines define ranges of 110 to 160 bpm which seem to be safe in daily practice. However, further studies should confirm that such asymmetric alarm limits are safe, with a particular focus on the lower bound, and should give insights about how to show and further improve the usefulness of the widely used practice of CTG monitoring.

Misidentification of Maternal Heart Rate as Fetal on Cardiotocography During the Second Stage of Labor

Objective To identify the incidence of fetal heart rate (FHR) accelerations in the second stage of labor and the role of fetal electrocardiograph (ECG) in avoiding misidentification of maternal heart rate (MHR) as FHR. Design Retrospective observational study. Setting University hospital labor ward, London, UK. Sample Cardiotocograph (CTG) tracings of 100 fetuses monitored using external transducers and internal scalp electrodes. Methods CTG traces that fulfilled inclusion criteria were selected from an electronic FHR monitoring database. Main outcome measures Rate of accelerations during external and internal monitoring as well as decelerations for a period of 60 minutes prior to delivery were determined. The role of fetal ECG in differentiating between MHR and FHR trace was explored. Results Decelerations occurred in 89% of CTG traces during the second stage of labor. Accelerations indicating possible recording of FHR or MHR were found in 28.1 and 10.9% of cases recorded by an external ultrasound transducer as well as internal scalp electrode, respectively. Accelerations coinciding with uterine contractions occurred only in 11.7 and 4% of external and internal recording of FHR, respectively. Absence of 'p-wave' of the ECG waveform was associated with MHR trace. Conclusion Decelerations were the commonest CTG feature during the second stage of labor. The incidence of accelerations coinciding with uterine contractions was less than half in fetuses monitored using a fetal scalp electrode. Analysing the ECG waveform for the absence of 'p-wave' helps in differentiating MHR from FHR.

AN OVERVIEW OF RESEARCH CHALLENGES FOR CLASSIFICATION OF CARDIOTOCOGRAM DATA

Cardiotocography (CTG) is a simultaneous recording of Fetal Heart Rate (FHR) and Uterine Contractions (UC). The most common diagnostic techniques to evaluate maternal and fetal well-being during pregnancy and before delivery. By observing the Cardiotocography trace patterns doctors can understand the state of the fetus. There are several signal processing and computer programming based techniques for interpreting a typical Cardiotocography data. A model based CTG data classification system using a supervised Artificial Neural Network (ANN) which can classify the CTG data based on its training data. The performance neural network based classification model has been compared with the most commonly used unsupervised clustering methods Fuzzy C-mean and k-mean clustering. The arrived results show that the performance of the supervised machine learning based classification approach provided significant performance than other compared unsupervised clustering methods. The traditional clustering methods can identify the Normal CTG patterns; they were incapable of finding Suspicious and Pathologic patterns. The ANN based classifier was capable of identifying Normal, Suspicious and Pathologic condition, from the nature of CTG data with very good accuracy.

Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace.

Fetal vibroacoustic stimulation (VAS) is a simple, non-invasive technique where a device is placed on the maternal abdomen over the region of the fetal head and sound is emitted at a predetermined level for several seconds. It is hypothesised that the resultant startle reflex in the fetus and subsequent fetal heart rate (FHR) acceleration or transient tachycardia following VAS provide reassurance of fetal well-being. This technique has been proposed as a tool to assess fetal well-being in the presence of a nonreassuring cardiotocographic (CTG) trace during the first and second stages of labour. To evaluate the clinical effectiveness and safety of VAS in the assessment of fetal well-being during labour, compared with mock or no stimulation for women with a singleton pregnancy exhibiting a nonreassuring FHR pattern. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 September 2012) and reference lists of all retrieved articles. We sought unpublished trials and abstracts submitted to major international congresses and contacted expert informants. All published and unpublished randomised trials that compared maternal and fetal/neonatal/infant outcomes when VAS was used to evaluate fetal status in the presence of a nonreassuring CTG trace during labour, compared with mock or no stimulation. Two review authors independently sought to assess for inclusion all the potential studies we identified as a result of the search strategy. We planned to resolve any disagreement through discussion or, if required, to consult a third person. Where there was uncertainty about a particular study, we attempted to contact study authors for additional information. However, these attempts were unsuccessful. The search strategies yielded six studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review. There are currently no randomised controlled trials that address the safety and efficacy of VAS used to assess fetal well-being in labour in the presence of a nonreassuring CTG trace. Although VAS has been proposed as a simple, non-invasive tool for assessment of fetal well-being, there is insufficient evidence from randomised trials on which to base recommendations for use of VAS in the evaluation of fetal well-being in labour in the presence of a nonreassuring CTG trace.

Governance of Innovation and Appropriateness of Hospitalization for High-Risk Pregnancy: The TOCOMAT System

Over the last 30 years, a great increase in the application of technologies in public health, with an undisputed impact on both the effectiveness of performance and the investment and management costs, has occurred. This evidence has induced the development of assessment tools to clarify the relationships among resources, outputs, and outcomes of technological innovations. This analysis was developed in order to examine the use of a telematic system for reporting remotely transmitted cardiotocographic traces, specifically (1) its impact on the health organization and on the appropriateness of the care setting used and (2) the efficiency of its adoption in a regional network. We adopted a case-control study on patients' medical records during the first 4 months of 2009, 2010, and 2011 and a cost analysis of resources used for the creation of a computerized telecardiotocography network connecting eight peripheral areas to the operations center. The case-control study showed a reduction in the average hospital stay days for high-risk patients (1.32) and for low-risk patient (1.7) with a total of cost savings of €89,628 for high-risk patients and €170,170 for low-risk patients. The cost savings of the regional network was €20,769.04. The adoption of a remote transmission system of cardiotocography provided a managerial and economic advantage in the reduction of inappropriate admissions for prepartum symptoms and an improvement in the admission indicators (hospital stay days).