Cardiotocography Patterns Research Articles

Relationship between Abnormal CTG Findings and Perinatal Outcome

Background: Continuous monitoring of fetal well-being through cardiotocography (CTG) is a standard practice in antenatal care, aiming to detect and manage potential complications. However, interpreting CTG patterns requires expertise and understanding, especially in diverse clinical settings such as those in Bangladesh. Objective: To assess normal and abnormal CTG patterns and their implications for perinatal outcomes in a tertiary level hospital in Bangladesh. Methods: A cross sectional study was conducted on CTG recordings of pregnant women admitted to the antenatal unit of a tertiary level hospital in Bangladesh from January 2024 to June 2024. CTG pattern was abnormal based on established criteria. Perinatal outcomes including fetal distress, neonatal outcomes, and obstetric interventions were recorded and analyzed in relation to CTG findings. The aims of the study were to evaluate the abnormal cardiotocography (CTG) patterns during the antenatal period and their impact on perinatal outcomes at a tertiary level hospital in Bangladesh. Results: The incidence of fetal distress was significantly higher in cases with abnormal CTG patterns compared to normal patterns (p<0.05). Furthermore, neonatal outcomes such as Apgar scores <7 at 1 minute and 5 minutes were more prevalent in pregnancies with abnormal CTG patterns. Among the abnormal CTGs groups, who had more risk factors abnormal outcomes were more. Most of the patients in both the normal and abnormal CTGs groups were associated with DM. In abnormal CTGs groups pre-eclampsia, PROM Many pregnant women had other risk factors associated with DM. Conclusion: This study highlights the importance of accurately assessing CTG patterns in the antenatal period for predicting perinatal outcomes. The identification of abnormal CTG patterns can aid in timely interventions to prevent adverse outcomes for both the mother and the newborn.

Massive fetomaternal hemorrhage: A case report.

We present a case with an incidental finding of abnormal cardiotocography (CTG) pattern as well as elevated middle cerebral artery peak systolic velocity (MCA-PSV) in an otherwise inconspicuous pregnancy. Massive fetomaternal hemorrhage (FMH) was detected as the cause by flow cytometry (FC), resulting in multiple cycles of fetal blood sampling (FBS) showing severe anemia, intrauterine transfusions (IUTs), a preterm delivery, and a healthy infant in follow-up examinations.

Analysis of CTG patterns in cases with metabolic acidosis at birth with and without neonatal neurological alterations

Objective To determine cardiotocographic patterns in newborns with metabolic acidosis, based on clinical signs of neurological alteration (NA) and the need for hypothermic treatment. Methods All term newborns with metabolic acidosis in a single center from 2016 to 2020 were included in the study. Three segments of intrapartum CTG (cardiotocography) were considered (first 30 min of active labor, 90 to 30 min before birth, and last 30 min before delivery) and a longitudinal analysis of CTG pattern was performed according to the 2015 FIGO classification. Results Three hundred and twenty-four neonates with metabolic acidosis diagnosed at birth were divided into three groups: the first group included all neonates with any clinical sign of neurological alteration, requiring hypothermia according to the recommendation of the Italian Society of Neonatology (group TNA—Treated neurological Alteration, n = 17), the second encompassed neonates with any clinical sign of neurological alteration not requiring hypothermia (group NTNA—Not Treated neurological Alteration, n = 83), and the third enclosed all neonates without any sign of clinical neurological involvement (group NoNA—No neurological Alteration, n = 224). The most frequent alterations of CTG in TNA group were late decelerations, reduced variability, bradycardia, and tachysystole. Unexpectedly, from the longitudinal analysis of the CTG, 49% of all cases with metabolic acidosis never showed a pathological CTG with normal trace at the beginning of labor followed by normal or suspicious trace in the final part of labor, the same as in TNA and NTNA groups (10 and 39%, respectively). Conclusions CTG has limited specificity in identifying cases of acidosis at birth, even in babies who will develop NA.

Correlation of Cardiotocography with neonatal outcome in term pregnancies at a tertiary care centre in Bihar, India: A prospective observational study

Early recognition of foetal distress by intrapartum cardiotocography (CTG) has a pivotal role in the improvement of perinatal outcome. So, the aim of this study was to correlate the findings of CTG with neonatal outcome.This Prospective Observational study was conducted on 300 pregnant women in labour having singleton term pregnancy with cephalic presentation. Intrapartum cardiotocography was done. CTG pattern was correlated with neonatal outcomes by analysing Apgar score, NICU admission and neonatal mortality rate. Statistical analysis was done by using chi square test and Fisher Exact test and p value < 0.05 was considered as statistically significant.Out of 300 patients, reactive CTG pattern was observed in 67% while suspicious and pathological pattern was observed in 22% and 11% of pregnancies respectively. The percentage of caesarean deliveries were significantly more among abnormal CTG group as compared to reactive group (p value < 0.0001). The sensitivity and specificity of CTG for predicting foetal distress and NICU admission was 80 % and 78.75% respectively. There was high NPV of 94.03%, and the diagnostic accuracy of test was 79%.Reactive CTG is more predictive of favourable neonatal outcomes while Pathological CTG tracing requires immediate intervention. Suspicious CTG requires close observation during intrapartum period after correcting underlying causes and taking conservative measures and Immediate delivery is not required unless it became pathological and hence caesarean section rate can be reduced in this group Overall, intrapartum CTG is an important screening tool for early identification of foetal distress.

Intrapartum Electronic Fetal Monitoring and Perinatal Outcomes

Aim: The aim of this study was to assess the components of cardiotocography (CTG) during labor to identify the variables associated with the risk of adverse perinatal outcomes and to ascertain the mode of delivery in these women. Materials and Methods: This prospective observational study included 191 women at term with singleton pregnancy in labor. The CTG findings including baseline heart rate, accelerations, beat-to-beat variability, and type and severity of decelerations were noted as per the International Federation of Gynecology and Obstetrics classification and grouped into Category II or III patterns as per the National Institute of Child Health and Human Development classification. Low APGAR score, cord PH <7, neonatal intensive care unit admission, respiratory distress, and hypoxic-ischemic encephalopathy were considered adverse neonatal outcomes. Results: Persistent fetal tachycardia, poor beat-to-beat variability, and severe variable deceleration showed a significant association with adverse neonatal outcome and delivery by cesarean section (P < 0.05). Adverse neonatal outcomes were noted in 4.2% of babies and 40.9% of babies born to mothers whose CTG was categorized as II and III patterns, respectively (P < 0.001). Birth by cesarean section was significantly different between those with Category II and Category III patterns, 33.7% and 65.4%, respectively (P < 0.01). Conclusion: Reduction in the beat-to-beat variability and presence of severe variable decelerations are independent risks for adverse neonatal outcomes, irrespective of the category of CTG pattern. Category III fetal heart rate pattern shows a significant association with adverse outcomes and risk of cesarean delivery. Grading the Category II patterns may help in identifying variables that are truly associated with acidemia and further research into this is recommended.

Correlation of cardiotocography abnormalities with position and attitude of the fetal head in labor

BACKGROUNDFetal distress indicated as the cause for cesarean delivery based on cardiotocography findings most often does not reflect in the newborn assessment. Cardiotocography findings are just the decision indicators for cesarean delivery, in the background of labor abnormalities owing to deflexed head or occipitoposterior position.OBJECTIVEThis study aimed to investigate the association between cardiotocography findings and the attitude of fetal head and occiput position.STUDY DESIGNWe conducted a prospective observational study in a tertiary hospital in South India, including 304 women in labor with vertex presentation. Fetal attitude, the position of the head, labor abnormalities, and cardiotocography findings were noted. The chi-square test was applied using MedCalc software (version 19) to investigate the association of cardiotocography findings with the attitude of fetal head and occiput position.RESULTSCardiotocography findings had significant association with occipitoposterior position (relative risk, 1.70; 95% confidence interval, 1.32–2.19) and deflexed attitude of the fetal head (relative risk, 1.44; 95% confidence interval, 1.11–1.87). Among cases with occipitoposterior position, 10 of 42 (24%) had pathologic cardiotocography, and 19 of 42 (45%) had suspicious cardiotocography, whereas among cases with deflexed head position, these proportions were 12 of 61 (20%) and 24 of 61 (40%), respectively.CONCLUSIONPathologic and suspicious cardiotocography tracings were more frequent in women with fetal occipitoposterior and deflexed head position. However, the association was not specific to any cardiotocography pattern.

Association of Intrapartum CTG with Fetomaternal Outcome

Objective: To determine the association of intrapartum CTG with fetomaternal outcome Material and Methods: A total number of 120 pregnant females who presented in the department of obstetrics and gynecology with labour pain were included in this cross-sectional analysis. A written informed consent was taken from all patients. The study was conducted in the department of Obstetrics & Gynaecology at Islam Teaching Hospital, Sialkot from January, 2021 to September, 2021. At presentation in the labor room, 20 minutes CTG was performed and patients were divided into two groups, those having abnormal trace including suspicious and pathological trace (Group A) and normal cardiotocography (CTG) pattern (Group B). After that the patients were followed till delivery to determine the feto-maternal outcomes e.g. APGAR score, NICU admission, perinatal mortality and caesarean section rate. Results: The mean age was 26.9±4.12 years in group A and 27. 1 ± 3.9 years in group B (p-value 0.78). On comparison of maternal outcomes, caesarean section was done in 38 (63.3%) patients in group-A and in 17 (28.3%) patients in group-B (p-value <0.0001).Regarding neonatal outcomes, NICU admission was needed in 9 (15%) patients in group A, versus in 4 (6.7%) patients in group B (p-value 0.14). Perinatal mortality occurred in 03 (5.0%) patients in group A and in no patient in group B (p-value 0.07). APGAR score at 5 minutes was >7 in 46 (76.7%) patients in group A versus in 52 (86.7%) patients in group B (p-value 0.18). Conclusion: The intrapartum abnormal CTG cannot be used as the only tool to identify fetal hypoxia during labor. It may lead to increased caesarean section rate because of high false positive rate of abnormal CTG. Keywords: Cardiotocography, Fetal Distress, Cesarean section

Association of Intrapartum CTG with Fetomaternal Outcome

Objective: To determine the association of intrapartum CTG with fetomaternal outcome Material and Methods: A total number of 120 pregnant females who presented in the department of obstetrics and gynecology with labour pain were included in this cross-sectional analysis. A written informed consent was taken from all patients. The study was conducted in the department of Obstetrics & Gynaecology at Islam Teaching Hospital, Sialkot from January, 2021 to September, 2021. At presentation in the labor room, 20 minutes CTG was performed and patients were divided into two groups, those having abnormal trace including suspicious and pathological trace (Group A) and normal cardiotocography (CTG) pattern (Group B). After that the patients were followed till delivery to determine the feto-maternal outcomes e.g. APGAR score, NICU admission, perinatal mortality and caesarean section rate. Results: The mean age was 26.9±4.12 years in group A and 27. 1 ± 3.9 years in group B (p-value 0.78). On comparison of maternal outcomes, caesarean section was done in 38 (63.3%) patients in group-A and in 17 (28.3%) patients in group-B (p-value <0.0001).Regarding neonatal outcomes, NICU admission was needed in 9 (15%) patients in group A, versus in 4 (6.7%) patients in group B (p-value 0.14). Perinatal mortality occurred in 03 (5.0%) patients in group A and in no patient in group B (p-value 0.07). APGAR score at 5 minutes was >7 in 46 (76.7%) patients in group A versus in 52 (86.7%) patients in group B (p-value 0.18). Conclusion: The intrapartum abnormal CTG cannot be used as the only tool to identify fetal hypoxia during labor. It may lead to increased caesarean section rate because of high false positive rate of abnormal CTG. Keywords: Cardiotocography, Fetal Distress, Cesarean section

\u201cTo get the baby out off the hook\u201d: a prospective, longitudinal, multicenter, observational study about decision making in vacuum-assisted operative vaginal delivery

BackgroundSince operative vaginal delivery may be risky for women and might cause neonatal complications, the aim of this study is to assess appropriateness of the procedure.This is a prospective, longitudinal, multicenter, observational study and it was conducted in three Italian Obstetric Units (Pisa, Massa Carrara and Prato). All term pregnant women, either nulliparous and multiparous, with singleton pregnancy and a cephalic fetus, with spontaneous or induced labour, requiring vacuum-assisted delivery were enrolled.Indications to operative vaginal delivery were grouped as alterations of fetal cardiotocography (CTG) patterns, delay/arrest of second stage of labour or elective shortening of second stage of labour. A board consisting of five among authors evaluated appropriateness of the procedure.ResultsOverall, 466 women undergoing operative vaginal deliveries were included. Cardiotocography, classified as ACOG category 2 or 3 was the indication for vacuum assisted delivery in 253 patients (54.29%). Among these, 66 women (26.1%) had an operative vaginal delivery which was then considered to be inappropriate, while in 114 cases (45.1%) CTG traces resulted to be unreadable.ConclusionDecision making process, which leads clinicians to go for operative vaginal delivery, is often influenced by shortness of time and complexity of the situation. Therefore, clinicians tend to intervene performing vacuum delivery without adopting critical analysis and without adequately considering the clinical situation.Tweetable abstractOperative vaginal delivery might be a risky procedure and should be performed only when clinically indicated and after adequate critical analysis.

Implementation of a revised classification for intrapartum fetal heart rate monitoring and association to birth outcome: Anational cohort study.

A revised intrapartum cardiotocography (CTG) classification was introduced in Sweden in 2017. The aims of the revision were to adapt to the international guideline published in 2015 and to adjust the classification of CTG patterns to current evidence regarding intrapartum fetal physiology. This study aimed to investigate adverse neonatal outcomes before and after implementation of the revised CTG classification. A before-and-after design was used. Cohort I (n=160210) included births from June 1, 2014 through May 31, 2016 using the former CTG classification, and cohort II (n=166558) included births from June 1, 2018 through May 31, 2020 with the revised classification. Data were collected from the Swedish Pregnancy and Neonatal Registers. The primary outcome was moderate to severe neonatal hypoxic ischemic encephalopathy (HIE 2-3). Secondary outcomes were birth acidemia (umbilical artery pH <7.05 and base excess < -12mmol/L or pH <7.00), A-criteria for neonatal hypothermia treatment, 5-min Apgar scores <4 and <7, neonatal seizures, meconium aspiration, neonatal mortality and delivery mode. Logistic regression was used (period II vs period I), and results are presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs). There were no statistically significant differences in HIE 2-3 (aOR 1.27; 95% CI 0.97-1.66), proportion of neonates meeting A-criteria for hypothermia treatment (aOR 0.96; 95% CI 0.89-1.04) or neonatal mortality (aOR 0.68; 95% CI 0.39-1.18) between the cohorts. Birth acidemia (aOR 1.36; 95% CI 1.25-1.48), 5-min Apgar scores <7 (aOR 1.27; 95% CI 1.18-1.36) and <4 (aOR 1.40; 95% CI 1.17-1.66) occurred more often in cohort II. The absolute risk difference for HIE 2-3 was 0.02% (95% CI 0.00-0.04). Operative delivery (vacuum or cesarean) rates were lower in cohort II (aOR 0.82; 95% CI 0.80-0.85 and aOR 0.94; 95% CI 0.91-0.97, respectively). Although not statistically significant, a small increase in the incidence of HIE 2-3 after implementation of the revised CTG classification cannot be excluded. Operative deliveries were fewer but incidences of acidemia and low Apgar scores were higher in the latter cohort. This warrants further in-depth analyses before a full re-evaluation of the revised classification can be made.

Massive fetomaternal hemorrhage: a case series and review of literature

Abstract Objectives Massive fetomaternal hemorrhage (FMH) is a rare and difficult to diagnose event that can have catastrophic outcomes. Although many etiologies have been associated with FMH, the majority of cases are idiopathic and affect uncomplicated pregnancies. The prevailing symptom is decreased fetal movements but some cases are asymptomatic. Changes in the fetal Doppler ultrasound, a sinusoidal cardiotocographic pattern, neonatal anemia, unexplained hydrops or stillbirth can raise suspicion that such an event has occurred. Case presentation This article presents a case series of severe FMH diagnosed in our center between 2011 and 2020 as well as a review of the current available literature. Conclusions We highlight the importance of the clinician’s awareness on detecting this rare but potentially life-threatening event.

An Optimized Single Layer Perceptron-based Approach for Cardiotocography Data Classification

Uterine Contractions (UC) and Fetal Heart Rate (FHR) are the most common techniques for evaluating fetal and maternal assessment during pregnancy and detecting the changes in fetal oxygenation occurred throughout labor. By monitoring the Cardiotocography (CTG) patterns, doctors can measure fetus state, accelerations, heart rate, and uterine contractions. Several computational and machine learning (ML) methods have been done on CTG recordings to improve the effectiveness of fetus analysis and aid the doctors to understand the variations in their interpretation. However, getting an optimal solution and best accuracy remains an important concern. Among the various ML approaches, artificial neural network (ANN)-based approach has achieved a high performance in several applications. In this paper, an optimized Single Layer Perceptron (SLP)-based approach is proposed to classify the CTG data accurately and predict the fetal state. The approach is able to exploit the advantages of SLP model and optimize the learning rate using a grid search method in which we can arrive at the best accuracy and converge to a local minima. The approach is evaluated on CTG dataset of University of California, Irvine (UCI). The optimized SLP model is trained and tested on the dataset using a 10-fold cross-validation technique to classify the CTG patterns as normal, suspect or pathologic. The experimental results show that the proposed approach achieved 99.20% accuracy compared with the state-of-the-art models.

Intrapartum cardiotocographic monitoring and its correlation with neonatal outcome.

Despite the advancements in perinatal care in past decades, perinatal asphyxia remains a serious problem leading to significant perinatal morbidity and mortality. Therefore, foetal monitoring during the intrapartum period is of paramount importance. Among various methods of fetal monitoring, cardiotocography is a form of electronic foetal monitoring in which there is simultaneous recording of foetal heart rate and uterine contractions. This cross-sectional observational study was done in the labour room and neonatal intensive care unit (NICU) of a teaching Municipal Hospital in North India including 500 pregnant women of age group 18-45 years with singeleton fetus of gestation ≥36 weeks without any known congenital anomaly. Intrapartum cardiotocography (CTG) for 20 minutes was done within 12 hours prior to delivery and babies born to them were observed for birth asphyxia as Apgar score <7 at 1 minute as per using APGAR score less than 7 at 1 minute as per south east asia regional neonatal perinatal database (SEAR-NPD), world health organization (WHO) working definition. CTG tracing was normal/reassuring in 92% of pregnant women, nonreassuring in 7% and was abnormal in only 1%. In patients with abnormal and nonreassuring CTG, delivery by lower segment cesarian section (LSCS) was significantly high (P < .0001). APGAR scoring was done at 1 minute and 5 minutes of life, it was found that 4% babies were having score less than 7 at 1 minute with incidence of birth asphyxia 40 per 1,000 live births Neonatal seizure was significantly more in nonreassuring and abnormal CTG group (P value <.0001). Abnormal CTG tracings result in higher incidence of operative interventions for deliveries. Abnormal CTG pattern during intrapartum CTG has high specificity and negative predictive value but has low sensitivity and positive predictive value for detection of birth asphyxia and need for NICU admission.

Does gestational age at term play a role in the association between cerebroplacental ratio and operative delivery for intrapartum fetal compromise?

To assess the impact of gestational age at term on the association between cerebroplacental ratio (CPR) and operative delivery for intrapartum fetal compromise (IFC) and prognostic performance of CPR to predict operative delivery for IFC. This was a retrospective cohort study including 2052 singleton pregnancies delivered between 37+0 and 41+6 weeks of gestation in a single tertiary referral center over an 8-year period. CPR was measured within 1week of delivery. IFC was defined as the presence of persistent pathological cardiotocography pattern or the combination of pathological cardiotocography pattern and fetal scalp pH<7.20. Operative delivery included instrumental vaginal delivery and cesarean section. Pregnancies were grouped according to birthweight (small for gestational age [SGA, birthweight <10th centile] and appropriate for gestational age [AGA, birthweight 10th-90th centile]) and gestational age by week at delivery. Rates of operative delivery were compared between the subgroups. Prognostic value of CPR was assessed using receiver operating characteristic curve. Of the study cohort, 308 (15%) had a CPR <10th centile, 374 (18%) operative delivery for IFC, and 298 (15%) were SGA at birth. Overall, the rates of operative delivery for IFC were higher in the low CPR group both in SGA (35% vs. 22%; p=0.023) and in AGA (23% vs. 16%; p=0.007). According to gestational age by week at delivery, fetuses with low CPR showed higher rates of operative delivery for IFC with advancing gestational age, mainly in pregnancies delivered at 40weeks (54% vs. 23%; p=0.004) and at 41weeks (60% vs. 19%; p=0.010) for SGA and at 41weeks (39% vs. 20%; p=0.001) for AGA. The predictive value of CPR remained stable throughout term and was poor both in SGA and in AGA. Both SGA and AGA fetuses with low CPR showed higher rates of operative delivery for IFC at term with advancing gestational age. Prognostic value of CPR throughout term was poor.

Intrapartal cardiotocographic patterns and hypoxia-related perinatal outcomes in pregnancies complicated by gestational diabetes mellitus

AimsIn previous reports, cardiotocographic (CTG) fetal heart rate (FHR) monitoring has shown only limited benefits in decreasing adverse perinatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM). The aim of the present study was to evaluate whether an association exists between the recently reported ZigZag pattern (FHR baseline amplitude changes of > 25 bpm with a duration of 2–30 min) and asphyxia-related neonatal outcomes in GDM pregnancies.MethodsIntrapartal CTGs were recorded in a one-year cohort of 5150 singleton childbirths. The following CTG changes were evaluated: ZigZag pattern, saltatory pattern, late decelerations, episodes of tachycardia and bradycardia, reduced variability, and uterine tachysystole. The cohort was divided into three groups: women with GDM, women with normal oral glucose tolerance test (OGTT), and women with no OGTT performed. Umbilical artery (UA) blood gases, Apgar scores, neonatal respiratory distress, and neonatal encephalopathy were used as outcome variables.ResultsGDM was diagnosed in 624 (12.1%), OGTT was normal in 4115 (79.9%), and OGTT was not performed in 411 (8.0%) women. Hypoxia-related ZigZag patterns (OR 1.94, 95% CI 1.64–2.34) and late decelerations (OR 1.65, 95% CI 1.27–2.13) of FHR, as well as a greater risk of fetal asphyxia (UA pH < 7.10 and/or UA BE < -12.0 meq/L and/or Apgar scores < 7 at 5-min) (OR 6.64, 95% CI 1.84–12.03) were observed in those with GDM compared with those without GDM.ConclusionsGDM is associated with intrapartal ZigZag pattern and late decelerations, cord blood acidemia and low 5-min Apgar scores at birth indicating increased occurrence of fetal hypoxia in GDM pregnancies.

Characteristics of Heart Rate Tracings in Preterm Fetus.

Background and Objectives: Prematurity is currently a serious public health issue worldwide, because of its high associated morbidity and mortality. Optimizing the management of these pregnancies is of high priority to improve perinatal outcomes. One tool frequently used to determine the degree of fetal wellbeing is cardiotocography (CTG). A review of the available literature on fetal heart rate (FHR) monitoring in preterm fetuses shows that studies are scarce, and the evidence thus far is unclear. The lack of reference standards for CTG patterns in preterm fetuses can lead to misinterpretation of the changes observed in electronic fetal monitoring (EFM). The aims of this narrative review were to summarize the most relevant concepts in the field of CTG interpretation in preterm fetuses, and to provide a practical approach that can be useful in clinical practice. Materials and Methods: A MEDLINE search was carried out, and the published articles thus identified were reviewed. Results: Compared to term fetuses, preterm fetuses have a slightly higher baseline FHR. Heart rate is faster in more immature fetuses, and variability is lower and increases in more mature fetuses. Transitory, low-amplitude decelerations are more frequent during the second trimester. Transitory increases in FHR are less frequent and become more frequent and increase in amplitude as gestational age increases. Conclusions: The main characteristics of FHR tracings changes as gestation proceeds, and it is of fundamental importance to be aware of these changes in order to correctly interpret CTG patterns in preterm fetuses.

The effect of different positions during non-stress test on maternal hemodynamic parameters, satisfaction, and fetal cardiotocographic patterns.

Maternal position is one of the most important factors to be considered during Non-Stress Test (NST). It should be a part of practice guidelines, where the appropriate maternal position reduces test-related errors and false-positive results. This study aimed to investigate the effect of different maternal positions during NST on maternal hemodynamic parameters, satisfaction, and fetal Cardiotocographic (CTG) pattern. A quasi-experimental research design was conducted at NST clinic, outpatient department/ Maternal and Children hospital at Najran city, Saudi Arabia. The study comprised a convenience sample of 118 low-risk pregnant women in their third trimester of pregnancy. Data was collected from January to June 2020. All women were assessed in the three different positions; supine, left lateral, and semi-fowler position concerning CTG pattern, maternal hemodynamic parameters, and satisfaction. The study results indicated a higher Fetal Heart Rate (FHR), increased accelerations, and fetal movement in the left lateral position, followed by a semi-fowler position compared to the supine position with statistically significant differences. No statistically significant differences (P>0.05) were observed regarding FHR variability and NST reactivity in the three positions. In addition, there were statistically significant differences (P <0.05) between the different maternal positions regarding maternal heart rate, systolic Blood pressure (BP), diastolic BP, and maternal satisfaction. The current study concluded that left lateral and semi- fowler positions were associated with a more favorable CTG pattern, maternal hemodynamic parameters, and satisfaction than the supine position. Left lateral and semi-fowler positions during the NST test should be standardized to reduce practical variations among health care providers, which, in turn, may reduce the need for unnecessary, expensive, and even hazardous interventions.

Quantification of Posterior Risk Related to Intrapartum FIGO 2015 Criteria for Cardiotocography in the Second Stage of Labor

Introduction: Intrapartum cardiotocography (CTG) was used for several decades to detect a stressed fetus so that delivery can be expedited to prevent birth asphyxia. The main aim of the study was to calculate the risk of neonatal acidemia (pH ≤ 7.10) according to duration of the 2nd stage of labor and occurrence of the International Federation of Gynecology and Obstetrics (FIGO) 2015 CTG classification parameters. Materials and Methods: This was a retrospective case-control study on 552 pregnancies receiving continuous CTG monitoring in labor and immediate hemogasanalysis at birth. Cases with umbilical artery (UA) pH ≤ 7.10 and controls with UA pH ≥ 7.10 were matched for parity and gestational age at delivery, with ratio 1:5. Logistic regression analysis, adjusted for the expected risk in the general population, was used to calculate the baseline risk of UA pH ≤ 7.10 in the absence of any CTG pathological feature and those associated with pathological CTG patterns occurring in the 2nd stage according to FIGO 2015. Results: Seventy-three cases and 387 controls reached 2nd stage and were included in the analysis. For those reaching 2nd stage, the mean adjusted risk of acidemia associated with nonpathological CTG was 1.6%. Stratification of risk according to duration of the 2nd stage yielded risks of neonatal acidemia of 1.23, 2.08, 5.81, and 15.22% at 30, 60, 120, and 180 min, respectively. Bradycardia >10 min was associated with risk of neonatal acidemia of 9.9 and 15.8% for 2nd-stage durations of 30 and 60 min, respectively. Risks associated with 1 prolonged deceleration >5 min were 6.80, 11.08, 27.0, and 51.0% at 30, 60, 120, and 180 min, respectively. Repetitive late or prolonged decelerations >30 min were associated with risk of neonatal acidemia of 2.43, 4.14, 11.17, and 26.45% at 30, 60, 120, and 180 min, respectively. Conclusion: The risk of neonatal acidemia is directly proportional to duration of the 2nd stage, irrespective of the presence of CTG abnormalities, increasing 12-fold (1.2–15.3%) from 30 to 180 min. Occurrence of FIGO 2015 pathological CTG patterns showed a decreasing impact from bradycardia >10 min to decelerations >5 min, recurrent later or prolonged decelerations >30 min, and nonpathological CTG.

Opioid effect on the autonomic nervous system in a fetal sheep model.

Opioid use during labour can interfere with cardiotocography patterns. Heart rate variability indirectly reflects a fluctuation in the autonomic nervous system and can be monitored through time and spectral analyses. This experimental study aimed to evaluate the impact of nalbuphine administration on the gasometric, cardiovascular, and autonomic nervous system responses in fetal sheep. This was an experimental study on chronically instrumented sheep fetuses (surgery at 128 ± 2days of gestational age, term = 145days). The model was based on a maternal intravenous bolus injection of nalbuphine, a semisynthetic opioid used as an analgesic during delivery. Fetal gasometric parameters (pH, pO2, pCO2, and lactates), hemodynamic parameters (fetal heart rate and mean arterial pressure), and autonomic nervous system tone (short-term and long-term variation, low-frequency domain, high-frequency domain, and fetal stress index) were recorded. Data obtained at 30-60min after nalbuphine injection were compared to those recorded at baseline. Eleven experiments were performed. Fetal heart rate, mean arterial pressure, and activities at low and high frequencies were stable after injection. Short-term variation decreased at T30 min (P = 0.02), and long-term variation decreased at T60 min (P = 0.02). Fetal stress index gradually increased and reached significance at T60 min (P = 0.02). Fetal gasometric parameters and lactate levels remained stable. Maternal nalbuphine use during labour may lead to fetal heart changes that are caused by the effect of opioid on the autonomic nervous system; these fluctuations do not reflect acidosis.

Performance of the Kleihauer Betke test in the prediction of neonatal anemia

Objectives The aim of this study was to correlate antenatal Kleihauer (KT) test results with fetal hemoglobin at birth to find a threshold for predicting severe fetal anemia. The secondary objectives were to assess the impact of KT on obstetric management and to study the correlation between the middle cerebral artery peack systolic velocity and fetal anemia. Results One thousand forty-six KT were positive over the 10-year period, but only 147 were included from 88 patients, of which 17 fetuses were anemic. Demographic and obstetric characteristics were similar between anemic and non-anemic groups. As regards new-born, there was a higher risk of prematurity among anemic as long as a lower birth rate in accordance. While a negative correlation was observed between KT and hemoglobin at birth, no KT upper threshold could be found that was both sensitive and specific. In addition, there was no case of fetal anemia when KT was repeated, even though it increased. KT showed little usefulness in obstetrics management to help improving neonatal care for anemia. Conversely, the MCA PSV demonstrated good performance in this matter and the ROC curve area was 0.91 (figure). Discussion Feto-maternal hemorrhage is a rare but grave pathology which could lead to anemia. The most common clinical sign is reduced fetal movement and it was the main indication to perform a KT. Cardiotocography patterns suggestive of anemia are sinusoidal, micro-oscillatory and non-reactive monitoring. Ultrasound features were polyhydramnios, hydrop fetalis and increased MCA peack systolic velocity. KT was correlated with MCA PSV and with hemoglobin level at birth. However, the latter showed a better diagnostic performance. MCA PSV measurement is a powerful test to screen for fetal anemia, and should be part of the regular training of obstetricians. Indeed, this technic gives immediate and reliable results, while those of KT are delayed. Conclusion The KT should not be used as a tool to screen for fetal anemia but rather as a test to explain a fetal anemia. However, the MCA PSV is reliable in this matter and give immediate result, thus obstetrician should be trained to routinely perform it.