Cardiotocography Interpretation Research Articles

Neonatal Outcome in Relation to Cardiotocography Interpretation During Pregnancy

Neonatal Outcome in Relation to Cardiotocography Interpretation During Pregnancy

Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool

BackgroundWhile the effectiveness of cardiotocography in reducing neonatal morbidity is still debated, it remains the primary method for assessing fetal well-being during labor. Evaluating how accurately professionals interpret cardiotocography signals is essential for its effective use. The objective was to evaluate the accuracy of fetal hypoxia prediction by practitioners through the interpretation of cardiotocography signals and clinical variables during labor.Material and methodsWe conducted a cross-sectional online survey, involving 120 obstetric healthcare providers from several countries. One hundred cases, including fifty cases of fetal hypoxia, were randomly assigned to participants who were invited to predict the fetal outcome (binary criterion of pH with a threshold of 7.15) based on the cardiotocography signals and clinical variables. After describing the participants, we calculated (with a 95% confidence interval) the success rate, sensitivity and specificity to predict the fetal outcome for the whole population and according to pH ranges, professional groups and number of years of experience. Interobserver agreement and reliability were evaluated using the proportion of agreement and Cohen’s kappa respectively.ResultsThe overall ability to predict a pH level below 7.15 yielded a success rate of 0.58 (95% CI 0.56-0.60), a sensitivity of 0.58 (95% CI 0.56-0.60) and a specificity of 0.63 (95% CI 0.61-0.65). No significant difference in the success rates was observed with respect to profession and number of years of experience. The success rate was higher for the cases with a pH level below 7.05 (0.69) and above 7.20 (0.66) compared to those falling between 7.05 and 7.20 (0.48). The proportion of agreement between participants was good (0.82), with an overall kappa coefficient indicating substantial reliability (0.63).ConclusionsThe use of an online tool enabled us to collect a large amount of data to analyze how practitioners interpret cardiotocography data during labor. Despite a good level of agreement and reliability among practitioners, the overall accuracy is poor, particularly for cases with a neonatal pH between 7.05 and 7.20. Factors such as profession and experience level do not present notable impact on the accuracy of the annotations. The implementation and use of a computerized cardiotocography analysis software has the potential to enhance the accuracy to detect fetal hypoxia, especially for ambiguous cardiotocography tracings.

Hybrid-FHR: a multi-modal AI approach for automated fetal acidosis diagnosis

BackgroundIn clinical medicine, fetal heart rate (FHR) monitoring using cardiotocography (CTG) is one of the most commonly used methods for assessing fetal acidosis. However, as the visual interpretation of CTG depends on the subjective judgment of the clinician, this has led to high inter-observer and intra-observer variability, making it necessary to introduce automated diagnostic techniques.MethodsIn this study, we propose a computer-aided diagnostic algorithm (Hybrid-FHR) for fetal acidosis to assist physicians in making objective decisions and taking timely interventions. Hybrid-FHR uses multi-modal features, including one-dimensional FHR signals and three types of expert features designed based on prior knowledge (morphological time domain, frequency domain, and nonlinear). To extract the spatiotemporal feature representation of one-dimensional FHR signals, we designed a multi-scale squeeze and excitation temporal convolutional network (SE-TCN) backbone model based on dilated causal convolution, which can effectively capture the long-term dependence of FHR signals by expanding the receptive field of each layer’s convolution kernel while maintaining a relatively small parameter size. In addition, we proposed a cross-modal feature fusion (CMFF) method that uses multi-head attention mechanisms to explore the relationships between different modalities, obtaining more informative feature representations and improving diagnostic accuracy.ResultsOur ablation experiments show that the Hybrid-FHR outperforms traditional previous methods, with average accuracy, specificity, sensitivity, precision, and F1 score of 96.8, 97.5, 96, 97.5, and 96.7%, respectively.ConclusionsOur algorithm enables automated CTG analysis, assisting healthcare professionals in the early identification of fetal acidosis and the prompt implementation of interventions.

Recognition of Chorioamnionitis on the Cardiotocograph (CTG): The role of the “Chorio Duck Score”

Chorioamnionitis refers to the inflammation of the chorion and amnion by the bacteria and their toxins as well as by the inflammatory cytokines. Therefore, it is a fetal disease with the bacteria, their toxins as well as the fetal immunological responses involving inflammatory cytokines (interleukins, interferons, and tumour necrosis factor-alpha) exerting their detrimental effects within the fetal compartment (i.e., amniotic fluid, fetal membranes, the placenta, and fetal tissues and organs). The vast majority of fetal inflammation occurs as a result of an ascending infection (i.e., entry of the bacteria from the maternal genital tract through the cervix). Therefore, maternal signs (tachycardia and pyrexia) may not be observed until the late stages of the disease. Cardiotocograph (CTG) trace was introduced into clinical practice in the 1960s as a tool to timely recognise ongoing fetal hypoxic stress so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths. Unfortunately, the CTG was introduced into clinical practice without any prior randomised controlled trials, which resulted in panicking and reacting to the observed morphology of fetal heart rate decelerations, which reflect an ongoing fetal compensatory response to reduce the myocardial workload. A sudden and reflex reduction of the heart rate in response to ongoing intermittent hypoxic stress (i.e., repetitive compression of the umbilical cord or interruptions in uteroplacental oxygenation due to uterine contractions) would ensure a reduction in myocardial oxygen demand and maintenance of aerobic metabolism to avoid the onset of anaerobic metabolism and production of lactic acid within the myocardium. Lack of understanding of fetal compensatory responses resulted in the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious, and Pathological”. The same parameters were used in fetuses with chorioamnionitis with an alternative, inflammatory pathway of neurological injury. The international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries in 2018 ensured a paradigm shift and recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, by applying the knowledge of fetal physiology whilst interpreting CTG traces. During the last 5 years, research has highlighted CTG features in fetal neuro-inflammation, which include an absence of fetal heart rate cycling, the ZigZag Pattern, and sinusoidal patterns. The proposed “Chorio Duck Score” is a scoring system based on recently published scientific evidence on CTG features in subclinical and clinical chorioamnionitis to enable timely diagnosis of fetal systemic inflammatory response syndrome (FIRS). This will help avoid the continuation of super-imposed hypoxic stress (i.e., progressive increasing frequency, duration, and strength of uterine contractions) on the background fetal inflammation, to prevent fetal neurological injury.

Updated NICE Cardiotocograph (CTG) Guideline: Is it Suspicious or Pathological?

Cardiotocograph (CTG) trace was introduced into clinical practice in 1960s as a tool to record the changes in the fetal heart rate (cardio) in response to ongoing uterine contractions (toco). The intention was to timely recognise the features of fetal decompensation so that immediate action could be taken to avoid hypoxic ischaemic encephalopathy (HIE) and/ or intrapartum hypoxia-related perinatal deaths, without increasing unnecessary operative interventions to the mother. However, very unfortunately, unlike other tools in clinical medicine, CTG was introduced into clinical practice without any randomised controlled trials or robust scientific studies not only to confirm its effectiveness, but to determine the CTG features which actually reflected fetal central organ oxygenation. This chasm of deficiency of knowledge of fetal physiology created a vacuum of understanding regarding what features were reflecting fetal compromise. Regrettably, this vacuum was soon filled by prominent obstetricians from national societies who were presumed to have the knowledge, but they began the arduous journey of classifying decelerations which are normal fetal cardioprotective reflexes, and they misclassified them as signs of “fetal distress”. Classification of these decelerations based on the observed morphology into “reassuring” and “nonreasoning” categories has resulted in disastrous consequences for women and babies. In the UK, since the publication of the first CTG guideline in 2001, due to continuing lack of knowledge and confusion, these guidelines were repetitively revised in 2007, 2014, 2017 and 2022. Despite the international consensus guidelines of physiological interpretation of CTG produced by 44 CTG experts from 14 countries which recommended classification of CTG traces based on the type of fetal hypoxia and fetal response to stress, the latest revised guideline produced by the National Institute of Health and Care Excellence (NICE), had continued the illogical approach of grouping arbitrary features into different categories and then randomly combining them to classify the CTG traces into “Normal, Suspicious and Pathological”. Therefore, all practising clinicians who are focussed on protecting their patients from harm have a responsibility to ask the question whether the revised NICE CTG Guideline itself is suspicious or pathological from a patient safety perspective.

Neonatal factors associated with immediate low Apgar score in newborn babies in an intermediate hospital in Namibia: a case control study.

Apgar score is conducted to a baby immediately after birth checking how the baby tolerated the birth process and outside the uterus. To describe the neonatal factors associated with immediate low Apgar score and analysing the associations among factors associated with low Apgar score in new-born babies. A quantitative, case-control, descriptive research design was used. Study population were all maternal records of deliveries conducted between 01 January 2019 and 31 December 2019. Simple random sampling was used to select the sample size for 194 cases and 194 controls using a 1:1 case-control ratio. Records indicating low Apgar scores were the cases while normal Apgar scores were the controls. A total of 388 maternal files were reviewed. Data were collected using a document review checklist and analysed using SPSS version 26. The study found that, neonatal factors associated with immediate low Apgar score are; gestational age, foetal presentation, cord prolapse, cord around the neck and the importance of cardiotocography interpretation as they had a P-value > 0.005. Gestational age, birth weight, foetal presentation, cord around the neck and lack of cardiotocography assessment were found to be associated with immediate low Apgar score.

Immediate and longer-term impacts of fetal surveillance education on workforce knowledge and cognitive skills.

Background: Following the development of the Royal Australian College of Obstetricians and Gynaecologists Intrapartum Fetal Surveillance Guideline in 2003, an education program was developed to support guideline implementation and clinical practice. It was intended that improved clinician knowledge, particularly of cardiotocography, would reduce rates of intrapartum fetal morbidity and mortality. The program contains a multiple-choice assessment, designed to assess fetal surveillance knowledge and the application of that knowledge. We used the results of this assessment over time to evaluate the impact of the education program on clinicians' fetal surveillance knowledge and interpretive skills, in the immediate and longer-term. Methods: We undertook a retrospective analysis of the assessment results for all participants in the Fetal Surveillance Education Program, between 2004 and 2018. Classical Test Theory and Rasch Item Response Theory analysis were used to evaluate the statistical reliability and quality of the assessment, and the measurement invariance or stability of the assessments over time. Clinicians' assessment scores were then reviewed by craft group and previous exposure to the program. Results: The results from 64,430, broadly similar assessments, showed that participation in the education program was associated with an immediate improvement in clinician performance in the assessment. Performance improvement was sustained for up to 18 months following participation in the program and recurrent participation was associated with progressive improvements. These trends were observed for all craft groups (consultant obstetricians, doctors in training, general practitioners, midwives, student midwives). Conclusions: These findings suggest that the Fetal Surveillance Education Program has improved clinician knowledge and the associated cognitive skills over time. The stable difficulty of the assessment tool means any improvement in clinician's results, with ongoing exposure to the program, can be reliably assessed and demonstrated. Importantly this holds true for all craft groups involved in intrapartum care and the interpretation of cardiotocography.

Knowledge and Attitudes of Midwives Concerning the Interpretation and Use of Cardiotocographs in Jordan

Introduction: A midwife needs to know how to assess fetal heart rates, recognize and interpret fetal heart patterns, report any substandard patterns, and initiate supportive measures as necessary. Objective: This study aims to assess the knowledge and attitudes of midwives concerning the interpretation and use of cardiotocographs. Materials and Methods: This cross-sectional study involves 183 midwives working in maternity units across all Jordanian regions. An online survey was used to collect data, including 6 demographic questions, 10 questions about knowledge, and 25 questions about attitude. The data were analyzed using descriptive statistics (Mean±SD, No. [%]), ANOVA, and the Pearson correlation tests. The significance level was set to be <0.05. Results: Most participants were 21 to 30 years old, and most midwives (59.6%) had no more than six years of experience. The result showed that the total scores for the knowledge and attitude regarding cardiotocographs (CTGs) interpretation and usage were 68.7% and 73.0%, respectively. There is a significant relationship between the knowledge about the interpretation and use of CTGs and the years of experience (P=0.003), with higher knowledge scores among midwives with fewer than 6 years of experience. Furthermore, there is a significant relationship between the knowledge of CTGs and level of education (P=0.002), indicating higher knowledge scores among midwives with a degree. The knowledge about classifying the CTG traces was significantly correlated with the region of work (P=0.018), with higher scores among midwives from the southern region. Finally, there was a positive correlation between knowledge and attitude (r=0.007, P<0.05). Conclusion: Based on the study result, the participant’s knowledge and attitudes are not satisfactory; thus, comprehensive education and training should be prioritized to improve midwives’ knowledge and attitudes toward using cardiotocograph.

Cardiotocography in practice: a qualitative study to explore obstetrical care professionals’ experiences with using cardiotocography information in Dutch practice

ObjectiveThis study aimed to explore obstetric care professionals’ experiences with using cardiotocograph (CTG) information and how they employ this tool in their practice.DesignQualitative study, involving 30 semi-structured interviews and two...

Physiological Interpretation of Cardiotocograph: Does the Emerging Scientific Evidence Suggest a Reversal in the “Thunder and Lightning” Phenomenon?

Physiological interpretation of Cardiotocograph (CTG) involves incorporation of the knowledge of fetal physiological response to intrapartum hypoxic and mechanical stresses and diagnosing different types of fetal hypoxia, to individualise care.

Does a physiology-based interpretation of cardiotocography allow to dispense with second-line methods? A cross-sectional online survey.

Second line methods are used to help obstetricians to identify abnormalities that reflect fetal acidosis. Since the use of a new technique of cardiotocography (CTG) interpretation based on the pathophysiology of the fetal period, the use of second-line tests has been questioned. To evaluate the impact of specific training in CTG physiology-based interpretation on professional attitudes towards the use of second-line methods. This cross-sectional study included 57 French obstetricians divided into two groups: the trained group (obstetricians who had already participated in a training course in physiology-based interpretation of CTG) and the control group. Ten medical records of patients who had abnormal CTG tracings and underwent fetal blood sampling pH measurement during labour were presented to the participants. They were given three choices: use a second-line method, continue labour without using second-line method, or perform a caesarean section. The main outcome measures was the median number of decisions to use second-line method. Forty participants were included in the trained group and 17 in the control group. The median number of recourses to second-line method was significantly inferior for the trained group (4/10 second-line methods) than for the control group (6/10, p=0.040). Regarding the 4 records for which a caesarean section was the real outcome, the median number of decisions of continuing labour was significantly superior in the trained group than in the control group (p=0.032). Participation in a training course in physiology-based interpretation of CTG could be associated with a less frequent use of second-line method at the cost of more frequently continuing labour with the risk compromising fetal and maternal well-being. Additional studies are required to determine whether this change in attitude is safe for the fetal well-being.

Computerized cardiotocography analysis during labor - A state-of-the-art review.

Cardiotocography is defined as the recording of fetal heart rate and uterine contractions and is widely used during labor as a screening tool to determine fetal wellbeing. The visual interpretation of the cardiotocography signals by the practitioners, following common guidelines, is subject to a high interobserver variability, and the efficiency of cardiotocography monitoring is still debated. Since the 1990s, researchers and practitioners work on designing reliable computer-aided systems to assist practitioners in cardiotocography interpretation during labor. Several systems are integrated in the monitoring devices, mostly based on the guidelines, but they have not clearly demonstrated yet their usefulness. In the last decade, the availability of large clinical databases as well as the emergence of machine learning and deep learning methods in healthcare has led to a surge of studies applying those methods to cardiotocography signals analysis. The state-of-the-art systems perform well to detect fetal hypoxia when evaluated on retrospective cohorts, but several challenges remain to be tackled before they can be used in clinical practice. First, the development and sharing of large, open and anonymized multicentric databases of perinatal and cardiotocography data during labor is required to build more accurate systems. Also, the systems must produce interpretable indicators along with the prediction of the risk of fetal hypoxia in order to be appropriated and trusted by practitioners. Finally, common standards should be built and agreed on to evaluate and compare those systems on retrospective cohorts and to validate their use in clinical practice.

Outstanding research paper awards of the Journal of the Chinese Medical Association in 2021.

Outstanding research paper awards of the Journal of the Chinese Medical Association in 2021.

Intrapartum cardiotocography trace pattern pre-processing, features extraction and fetal health condition diagnoses based on RCOG guideline.

ContextThe computerization of both fetal heart rate (FHR) and intelligent classification modeling of the cardiotocograph (CTG) is one of the approaches that are utilized in assisting obstetricians in conducting initial interpretation based on (CTG) analysis. CTG tracing interpretation is crucial for the monitoring of the fetal status during weeks into the pregnancy and childbirth. Most contemporary studies rely on computer-assisted fetal heart rate (FHR) feature extraction and CTG categorization to determine the best precise diagnosis for tracking fetal health during pregnancy. Furthermore, through the utilization of a computer-assisted fetal monitoring system, the FHR patterns can be precisely detected and categorized.ObjectiveThe goal of this project is to create a reliable feature extraction algorithm for the FHR as well as a systematic and viable classifier for the CTG through the utilization of the MATLAB platform, all the while adhering to the recognized Royal College of Obstetricians and Gynecologists (RCOG) recommendations.MethodThe compiled CTG data from spiky artifacts were cleaned by a specifically created application and compensated for missing data using the guidelines provided by RCOG and the MATLAB toolbox after the implemented data has been processed and the FHR fundamental features have been extracted, for example, the baseline, acceleration, deceleration, and baseline variability. This is followed by the classification phase based on the MATLAB environment. Next, using the guideline provided by the RCOG, the signals patterns of CTG were classified into three categories specifically as normal, abnormal (suspicious), or pathological. Furthermore, to ensure the effectiveness of the created computerized procedure and confirm the robustness of the method, the visual interpretation performed by five obstetricians is compared with the results utilizing the computerized version for the 150 CTG signals.ResultsThe attained CTG signal categorization results revealed that there is variability, particularly a trivial dissimilarity of approximately (+/−4 and 6) beats per minute (b.p.m.). It was demonstrated that obstetricians’ observations coincide with algorithms based on deceleration type and number, except for acceleration values that differ by up to (+/−4).DiscussionThe results obtained based on CTG interpretation showed that the utilization of the computerized approach employed in infirmaries and home care services for pregnant women is indeed suitable.ConclusionsThe classification based on CTG that was used for the interpretation of the FHR attribute as discussed in this study is based on the RCOG guidelines. The system is evaluated and validated by experts based on their expert opinions and was compared with the CTG feature extraction and classification algorithms developed using MATLAB.

Intrapartum cardiotocography: an exploratory analysis of interpretational variation

Our aim was to evaluate the intra- and inter-operator agreement in cardiotocography (CTG) traces analysis using the 2015 FIGO classification guidelines, and whether the educational background and the knowledge of anamnestic data can influence the interpretation of CTG traces. A retrospective interpretation of 73 intrapartum CTGs at time 0 (T0) for a first blind interpretation and at time 1 (T1) two months later with additional anamnestic pregnancy information was made by eight different operators (four obstetricians and four midwives with different years of work experience). The intra-observer agreement demonstrates that midwifes are more concordant than obstetricians with a mean of 77.05% versus a mean of 65.75%. There is moderate inter-observer agreement in classifying a CTG trace as ‘normal’; on the contrary, there is no consensus on the ‘suspect’ and ‘pathological’ classification category. IMPACT STATEMENT What is already known on this subject? Interpretation of intrapartum CTG is affected by significant subjective variables with relevant intra- and inter-observer lack of optimal agreement, especially in case of abnormal o pathologic findings. What do the results of this study add? Clinical data seem to play a role in interpretation of suspicious and pathological traces while they do not affect the rate of agreement for normal traces. Midwives tend to be less influenced by anamnestic data in visual CTG interpretation. Instead, obstetricians tend to be more focussed on clinical data and clinical setting that, as a consequence, tend to have great impact on CTG trace interpretation. What are the implications of these findings for clinical practice and/or further research? Cooperation among obstetricians and between obstetricians and midwives should be encouraged in order to optimise CTG reading and improve maternal and neonatal outcomes. Regarding the influence of clinical parameters in classification of intrapartum CTG traces, especially in case of abnormal CTG traces, it should be conceivable to improve medical skills in CTG blind interpretation and further investigate which clinical parameters are mainly related with an augmented risk of foetal asphyxia and adverse neonatal outcomes.

Correlation between Intrapartum Cardiotocogram Findings and Cord Blood pH in Term and Preterm Labors

Background: The purpose of intrapartum fetal monitoring by cardiotocograph (CTG) is to identify early signs of developing hypoxia so that appropriate action can be taken to improve the perinatal outcome. Although CTG findings are well known to monitor the progress of the labor due to the paucity of recommendations, there has always been a clinical dilemma as the term fetuses respond differently than a preterm fetus. However, umbilical cord blood pH can distinguish the infant at high risk for asphyxia and related sequel. Therefore, because of differences in fetal physiology in term and preterm fetuses, CTG findings vary, and hence the validity of CTG to determine fetal acidosis should be different. Aims and Objectives: This study aimed to correlate abnormal intrapartum CTG findings with umbilical cord blood pH in term and preterm labor and thus evaluate the success of CTG in predicting fetal acidosis during labor. Methods: The present study included 210 women in labor (70 preterm and 140 term) with abnormal intrapartum CTG that was classified as per 2015 revised International Federation of Gynecologists and Obstetrician (FIGO) guidelines. Immediately after delivery, 2 ml Umbilical artery cord blood sample was taken in a pre-heparinized syringe for analysis, pH <=7.2 was taken as acidosis and pH >7.2 was taken as normal. The measured data were general maternal characteristics which included gravida status, associated comorbidities, method of induction and character of liquor, the intrapartum CTG tracings recorded, the cord arterial blood pH and the neonatal characteristics such as APGAR score and neonatal outcome. Results: Data from 70 preterm labor was compared with 140 term labor. In this study, 20.9% of the babies had acidosis. Suspicious CTG due to decreased variability were more common in the preterm group than in the term group (21.4% vs. 8.6% p<0.05). Positive predictive value (PPV) of abnormal CTG for fetal acidosis in the preterm group was found to be higher than that in the term group, PPV of pathological CTG being even higher than suspicious CTG. Women with suspicious CTG had 82% less risk of fetal acidosis as compared to pathological CTG. Women with Bradycardia had 5.9 times the risk of fetal acidosis as compared with normal and tachycardia. Conclusion: Abnormal CTG should be managed appropriately without any delay to prevent acidosis and cord blood pH should be done in all labors with abnormal CTG. However, our findings of a higher incidence of lower cord blood pH and suspicious CTG due to decreased variability alone highlight the limitation of criteria currently used for interpretation of CTG in preterm labors.

Announcing the winner of the John J. Sciarra IJGO Prize Paper Award for 2021

The editors of the International Journal of Gynecology & Obstetrics (IJGO) are pleased to announce the winner of the prize paper award for the best clinical research paper from a low- or middle-income country published in IJGO during 2021. The winning paper is: Tang X, Guo C, Liu S, Guo J, Hua K and Qiu J. A novel prognostic nomogram utilizing the 2018 FIGO staging system for cervical cancer: A large multicenter study. Int J Gynecol Obstet 2021;155:86–94. https://doi.org/10.1002/ijgo.13644. It was published in the October 2021 issue of IJGO. This award brings with it a stipend of £800, a certificate of recognition, and complimentary access to IJGO for a period of 1 year from the date the prize is awarded. All clinical research articles submitted to the IJGO from low- and middle-income countries that were published in 2021 were considered for this prize. The paper was chosen from 95 qualifying articles. Selection and review were undertaken by the editors, and the Editorial Board of IJGO endorsed the decision. The winning paper by Tang et al. evaluated the prognostic performance of the revised 2018 FIGO staging system for cervical cancer in a multicentre study across four sites. In 3238 patients with cervical cancer, 1841 (almost 60%) were re-staged. Almost one third of these were re-staged due to tumor size, approximately 30% due to lymph node metastasis, and one third due to the inconsistency between the pre-operative and post-operative assessments. They concluded that the 2018 FIGO staging system was a better reflection of the survival of cervical cancer patients. This very important work also allowed the group to establish a nomogram that allowed them to predict the prognosis of cervical cancer more accurately. Additional papers that are worthy of special recognition are awarded an honorable mention. While the honorable mention recognition does not include a financial award, each author receives a certificate of recognition and a letter of commendation from the editors of IJGO. The IJGO Prize Paper Award was established in 1998 for the purpose of encouraging investigators, especially young scientists, from low- and middle-income countries to submit their best clinical research articles for publication in the journal. IJGO is the official publication of FIGO (International Federation of Gynecology and Obstetrics), the primary international organization for the specialty of obstetrics and gynecology. FIGO is dedicated to enhancing the health care of women worldwide. HONORABLE MENTIONS 2021 The following 11 papers receive an honorable mention: China Li Y, Wang H, Zhang Y, et al. Correlation between multi-type human papillomavirus infections and viral loads and the cervical pathological grade. Int J Gynecol Obstet. 2020;152:96–102. https://doi.org/10.1002/ijgo.13406 Wang X, Zhang C, Li X, Qi H, Liu Q, Lei J. Safety and efficacy of titrated oral misoprostol solution versus vaginal dinoprostone for induction of labor: a single-center randomized control trial. Int J Gynecol Obstet. 2021;154:436–443. https://doi.org/10.1002/ijgo.13546 Brazil Laporte M, Becerra A, Castro L, Veiga N Jr, Espejo-Arce X, Bahamondes L. Evaluation of clinical performance when intrauterine devices are inserted by different categories of healthcare professional. Int J Gynecol Obstet. 2021;152:196–201. https://doi.org/10.1002/ijgo.13396 Barbieri MM, Herculano TB, Dantas Silva A, Bahamondes L, Juliato CRT, Surita FG. Acceptability of ENG-releasing subdermal implants among postpartum Brazilian young women during the COVID-19 pandemic. Int J Gynecol Obstet. 2021;154:106–112. https://doi.org/10.1002/ijgo.13663 Turkey Karakas LA, Atilgan AO, Akilli H, Kuscu UE, Haberal A, Ayhan A. Nulliparity and postmenopausal status are independent factors of malignancy potential of endometrial intraepithelial neoplasia in polyps. Int J Gynecol Obstet. 2021;152:433–438. https://doi.org/10.1002/ijgo.13448 Iran Ghotbizadeh Vhdani F, Nasiri Khormoji N, Eftekhar N, et al. A double-blind randomized trial on subendometrial injection of vasopressin to control bleeding in postpartum hysterectomy due to abnormally invasive placenta. Int J Gynecol Obstet. 2021;153:228–233. https://doi.org/10.1002/ijgo.13440 South Africa Budhram S, Vannevel V, Botha T, et al. Maternal characteristics and pregnancy outcomes of hospitalized pregnant women with SARS-CoV-2 infection in South Africa: An International Network of Obstetric Survey Systems-based cohort study. Int J Gynecol Obstet. 2021;155:455–465. https://doi.org/10.1002/ijgo.13917 Goldman B, Naidoo T. Formal training in cardiotocograph interpretation of healthcare practitioners improves interpretation: a prospective descriptive analytical study in a resource constrained setting. Int J Gynecol Obstet. 2021;153:527–532. https://doi.org/10.1002/ijgo.13513 Kenya Gwako GN, Obimbo MM, Gichangi PB, Kinuthia J, Gachuno OW, Were F. Association between obstetric and medical risk factors and stillbirths in a low-income urban setting. Int J Gynecol Obstet. 2021;154:331–336. https://doi.org/10.1002/ijgo.13528 Egypt Abdallah A, Khairy M, Tawfik M, et al. Role of first-trimester three-dimensional (3D) power Doppler of placental blood flow and 3D placental volume in early prediction of pre-eclampsia. Int J Gynecol Obstet. 2021;154:466–473. https://doi.org/10.1002/ijgo.13572 Malaysia Goh YP, Tan PC, Hong JGS, Sulaiman S, Omar, SZ. Combined massage and warm compress to the perineum during active second stage of labor in nulliparas: a randomized trial. Int J Gynecol Obstet. 2021;155:532–538. https://doi.org/10.1002/ijgo.13613

Intrapartum cardiotocography in pregnancies with and without fetal CHD.

Congenital heart defects (CHD) are the most common inherited abnormalities. Intrapartum cardiotocography (CTG) is still considered a "gold standard" during labor. However, there is a lack of evidence regarding the interpretation of intrapartum CTG in fetuses with CHD. Therefore, the study aimed to compare intrapartum CTG in normal fetuses and fetuses with CHD and describe the association between CTG and neonatal outcomes. The present study is a retrospective analysis of the CTG of 395 fetuses. There were three study groups: Group 1: 185 pregnancies with a prenatal diagnosis of CHD, Group 2: 132 high-risk pregnancies without CHD, and Group 3: 78 low-risk pregnancies without CHD. Abnormal CTG was present statistically OR=3.4 (95%CI: 1.61-6.95) more often in Group 1. The rate of the emergency CS was higher in this group OR=3 (95%CI: 1.3-3.1). Fetuses with CHD and abnormal CTG were more often scored≤7 Apgar, with no difference in acidemia. The multivariate regression model for Group 1 does not show clinical differences between Apgar scores or CTG assessment in neonatal acidemia prediction. CTG in fetuses with CHD should be interpreted individually according to the type of CHD and conduction abnormalities. Observed abnormalities in CTG are associated with the fetal heart defect itself. Preterm delivery and rapid cesarean delivery lead to a higher rate of neonatal complications. Health practitioners should consider this fact during decision-making regarding delivery in cases complicated with fetal cardiac problems.

Prediction of Neonatal Acidosis Based on the Type of Fetal Hypoxia Observed on the Cardiotocograph (CTG)

Cardiotocograph (CTG) was introduced into clinical practice to promptly recognize the features of intrapartum fetal hypoxic stress, so that timely action could be taken to avoid hypoxic-ischaemic encephalopathy (HIE) and perinatal deaths. However, the current systematic evidence suggests that the introduction of CTG into clinical practice over 50 years has not resulted in improvement in the rates of cerebral palsy or perinatal deaths. This is because most fetuses are able to withstand intrapartum hypoxic stresses without sustaining damage, and if the features of fetal compensatory responses are erroneously considered as “pathological”, “Abnormal” or “Category III” CTG tracing, it would lead to an exponential increase in unnecessary operative interventions without any improvement in perinatal outcomes. Neonatal acidosis at birth, determined by the estimation of pH in the umbilical artery has been considered as a surrogate marker of poor perinatal outcome. This is because significant intrapartum fetal hypoxic stress which leads to fetal decompensation, would lead to the onset of anaerobic metabolism and production of lactic acid in fetal tissues and organs. Entry of lactic acid into the fetal systemic circulation may cause damage to fetal central organs resulting in organ damage and death, and this lactate may lower the pH in the umbilical artery. Understanding the different types of fetal hypoxia on the CTG trace may help practicing clinicians to predict the rate of fall in fetal pH, and therefore, predict the umbilical cord pH at birth. It is important to appreciate that non-hypoxic pathways of fetal compromise such as chorioamnionitis may not be associated with low umbilical arterial pH at birth. Fetal pathophysiological approach to CTG interpretation based on deeper understanding of types of intrapartum hypoxia and features of non-hypoxic pathways of injury may help avoid the onset of neonatal metabolic acidosis and improve perinatal outcomes.

284 Do new paradigms on cardiotocography interpretation based on the pathophysiology of fetal acidosis have an impact on obstetric practices?

Introduction: There is currently a paradigm shift in the cardiotocography (CTG) interpretation with some promoting a return to an analysis based on the pathophysiology of fetal acidosis. The teaching of this interpretation method is booming with the emergence of many specific training. Thus, the usefulness of second-line methods has been tacitly questioned. Objective: Determine the impact of CTG trainings on obstetric practices. Method: This was a multicentric pilot study based on online questionnaires.