Continuous Cardiotocography Research Articles

Intrapartum deceleration and acceleration areas are associated with neonatal encephalopathy.

To investigate whether an association exists between deceleration and acceleration areas on continuous fetal cardiotocography (CTG) and neonatal encephalopathy (NE). A single center, retrospective case-control study was conducted to compare CTG characteristics of low-risk pregnancies (35 weeks of gestation or more), complicated by moderate to severe NE with two matched controls for every case. Controls were matched by gestational age and cord blood pH. We analyzed the intrapartum CTG recordings by calculation of the deceleration and acceleration areas and the ratio between the two. During the period between 2013 and 2019, we identified 95 cases of low-risk pregnancies that were complicated by moderate to severe NE in our center. Thirty-three (34.7%) deliveries were excluded, mostly because of an insufficient duration of the CTG recordings. The remaining 62 cases were matched with 123 controls. We found that NE was significantly associated with an increased total deceleration area, a decreased total acceleration area, and a lower acceleration-to-deceleration ratio. NE was significantly associated with increased total deceleration area, decreased total acceleration area, and a lower acceleration-to-deceleration ratio, independent of cord blood pH. Development of a computerized real-time analysis of fetal heart rate tracings may contribute to making these measurements a more valid clinical tool.

Highlights from the International Twins Congress 2021

Highlights from the International Twins Congress 2021

'Labour Hopscotch': Women's evaluation of using the steps during labor.

INTRODUCTIONConcerns have been expressed globally about the decline in rates of physiological birth and rising intervention rates during labor and birth. The ‘Labour Hopscotch’ Framework, a visual depiction of steps required to remain active during labor was implemented in a large tertiary maternity hospital in Ireland. The aim of this study was to evaluate the steps of the Labour Hopscotch women found most useful, examine the use of non-pharmacological and pharmacological methods of pain relief used during labor and finally to investigate the labor and birth outcomes of women who used ‘Labour Hopscotch’ during labor.METHODSA descriptive cross-sectional study was conducted using a study specific questionnaire.RESULTSA total of 809 women completed the questionnaire. The Labour Hopscotch Framework was positively evaluated. Mobilizing, the birthing ball, birthing stool, and water therapy were found to be the most useful steps. Primiparous women were more likely to use non-pharmacological methods of pain relief. Pharmacological methods used by women were entonox (67.5%), pethidine (8%) and epidural analgesia (38.5%). Primiparous women were more likely to have epidural analgesia than multiparous women (p<0.00001). Women that attended either private (p=0.004) or public-led obstetric (p=0.005) antenatal care were more likely to have epidural analgesia in labor. Women attending the community midwives were least likely to receive epidural analgesia during labor. The rates of spontaneous vaginal birth, assisted birth and cesarean section, were 77.1%, 14% and 8.7%, respectively.CONCLUSIONSOur study findings contribute to the increasing national and international evidence that initiatives such as Labour Hopscotch can promote and advocate for women to be active and mobile during labor to support physiological birth.

Machine Learning Model for Classifying the Results of Fetal Cardiotocography Conducted in High-Risk Pregnancies.

PurposeFetal well-being is usually assessed via fetal heart rate (FHR) monitoring during the antepartum period. However, the interpretation of FHR is a complex and subjective process with low reliability. This study developed a machine learning model that can classify fetal cardiotocography results as normal or abnormal.Materials and MethodsIn total, 17492 fetal cardiotocography results were obtained from Ajou University Hospital and 100 fetal cardiotocography results from Czech Technical University and University Hospital in Brno. Board-certified physicians then reviewed the fetal cardiotocography results and labeled 1456 of them as gold-standard; these results were used to train and validate the model. The remaining results were used to validate the clinical effectiveness of the model with the actual outcome.ResultsIn a test dataset, our model achieved an area under the receiver operating characteristic curve (AUROC) of 0.89 and area under the precision-recall curve (AUPRC) of 0.73 in an internal validation dataset. An average AUROC of 0.73 and average AUPRC of 0.40 were achieved in the external validation dataset. Fetus abnormality score, as calculated from the continuous fetal cardiotocography results, was significantly associated with actual clinical outcomes [intrauterine growth restriction: odds ratio, 3.626 (p=0.031); Apgar score 1 min: odds ratio, 9.523 (p<0.001), Apgar score 5 min: odds ratio, 11.49 (p=0.001), and fetal distress: odds ratio, 23.09 (p<0.001)].ConclusionThe machine learning model developed in this study showed precision in classifying FHR signals. This suggests that the model can be applied to medical devices as a screening tool for monitoring fetal status.

Association between Intrapartum Cardiotocography and Umbilical Cord Blood pH in Term Pregnancies: A Cross-sectional Study in a Tertiary Care Centre, Kolkata, India

Introduction: Labour, a physiological process for majority of foetuses, often acts as a challenge to foetal reserves causing foetal hypoxia. Foetal monitoring with intrapartum cardiotocography is an important tool to enable timely intervention to reduce adverse neonatal outcomes like postnatal cerebral palsy. Aim: To determine an association between cardiotocography tracing and umbilical artery cord blood pH in term pregnancies in labour where the influence of drugs and the presence of other comorbid medical/obstetric adverse outcomes have been ruled out. Materials and Methods: This cross-sectional, hospital-based, observational study involved singleton uncomplicated term pregnancies with a normal baseline cardiotocography and spontaneous labour onset and progression admitted to the labour ward of R.G. Kar Medical College and Hospital, Kolkata, West Bengal, India. Intrapartum continuous cardiotocography traces were recorded and those showing abnormal traces were documented and delivery expedited within two hours. Total of 90 such consecutive women were included in the study and umbilical arterial cord blood sample was taken for all these pregnancies immediate postpartum. Cardiotocography traces were then statistically compared with cord blood parameters and the findings were computed using Statistical Package for the Social Sciences (SPSS) software version 22.0. Results: Out of 90 participants the mean age was 24.21±3.43 years, most (43, 47.8%) of them were in between 21 to 25 years. Of the abnormal traces, 51 (56.7%) were NICE Category II (Suspicious) and 39 (43.3%) were NICE category III (pathological). Cord blood analysis revealed that 40% had a pH&lt;7, 44.4% had blood lactate levels above 6 mmol/L and another 47.7% had a base deficit ≥12 mmol/L. On crosstabulation and Chi-square analysis, these were all found to be statistically significant (p-value &lt;0.05). Abnormalities of Foetal Heart Rate (FHR) and baseline variability had higher Odds ratio of predicting umbilical artery acidemia with Odd’s ratio for baseline variability abnormality as high as 2.768. Conclusion: Although there has been a rising trend towards operative deliveries, the overall incidence of neonatal morbidity due to cerebral palsy is still on the rise. Cardiotocography can be a very important tool to identify neonatal acidosis in “at risk” foetuses and helps in timely intervention giving long term best outcomes.

Features of pregnancy, delivery and postpartum on the background of assisted reproductive technologies

The objective: to establish the characteristics of the course of pregnancy and childbirth after the use of assisted reproductive technologies (ART); to stratify the risks in this contingent of pregnant women, to determine the high-risk subgroup among pregnant women after the use of ART and the formation of possible preventive approaches for these categories of patients. Materials and methods. A retrospective analysis of 3450 histories of pregnancy and childbirth that occurred during 2018–2020, was carried out. Inclusion criteria: first singleton delivery in cephalic presentation without critical congenital malformations in the fetus and severe somatic pathologies in pregnant women aged 18–45 years. Two groups were formed: a group with spontaneous pregnancy (3137 histories) and a group with pregnancy after ART (313 histories), which, according to the age factor, were divided into subgroups of active (2686 and 159 histories, respectively) and late reproductive age (451 and 154 histories, respectively).For statistical analysis, odds ratio (OR) and 95% confidence interval (CI) were calculated. The χ-square test was used to assess the significance of the difference in proportions. The level of statistical significance was at p&lt;0.05.Results. The frequency of normal births in the subgroup of late reproductive age with pregnancy after the use of ART was 38.8%, that almost 2 times lower than in the subgroup of spontaneous pregnancy in women of late reproductive age (65.5%; p&lt;0.05). Patients with late reproductive age and pregnancy after using ART (28.5%) had two times higher chances of induction of labor compared with the spontaneous pregnancy subgroup (14.3%; p&lt;0.05). The incidence of cesarean section was 51.1% in the ART subgroup compared to 27% in the spontaneous pregnancy subgroup (p&lt;0.05). In the subgroup of late reproductive age and pregnancy after ART, the probability of cesarean section was in 1.7 times higher than in the subgroup of active reproductive age and pregnancy after ART. The risks of developing massive obstetric bleeding in patients with late reproductive age and pregnancy after ART were in 5.5 times higher than in patients with spontaneous pregnancy (p&lt;0.05) and 2.8 times higher than in patients of active reproductive age and pregnancy after ART. The rate of normal induced labor in the ART group in women under 35 years of age was 51.7%, while in the subgroup of late reproductive age patients with pregnancy after ART, this indicator decreased to 23.5%. The incidence of unsuccessful induction of labor in patients with late reproductive age and pregnancy after ART was 19.6%, the frequency of cesarean section after induced labor in the subgroup of late reproductive age and pregnancy after ART was 70.6%. The likelihood of the massive obstetric bleeding development during induced labor in patients with late reproductive age and pregnancy after ART was in 5 times higher than in spontaneous pregnancy in this age subgroup (OR 5.05; 95% CI: 0.94-27.05) and 6.8 times higher than in the subgroup of active reproductive age after the use of ART (OR 6.84; 95% CI: 2.2-21.24). The newborns conceived after ART and after induced labor had in 2.8 times greater risks of the necessity for primary neonatal resuscitation.Conclusions. The pregnancy and labor after ART were characterized by a higher incidence of preterm birth, caesarean section, assisted vaginal delivery, and massive obstetric bleeding. The rate of complications significantly increased in women of late reproductive age. For patients with pregnancy after the use of ART, it is advisable to conduct labor using continuous cardiotocography monitoring, timely correction of labor abnormalities according to the partogram, the use of modern effective algorithms for the prevention of obstetric bleeding. For the pregnant women of late reproductive age after ART in the absence of spontaneous onset of regular labor, we recommend to consider the possibility of a planned caesarean section at 40–41 weeks of gestation.

Calculation of deceleration and acceleration area may improve the ability to predict neonatal encephalopathy (NE)

While the use of continuous fetal cardiotocography (CTG) resulted in a rise of obstetrical interventions, its ability to improve neonatal morbidity and mortality remains uncertain. We aimed to investigate the association between deceleration area and neonatal encephalopathy (NE).

What Do Women Want? Consent for the Use of Electronic Fetal Monitoring

BACKGROUNDGuidelines published by professional associations of midwives, obstetricians, and nurses in the United States recommend against using continuous cardiotocography (CTG) in low-risk patients. In the United States, CTG or electronic fetal/uterine monitoring (EFM) rather than auscultation with a fetoscope or Pinard horn is the norm. Interpretation of the fetal heart rate (FHR) and uterine activity (UA) tracings provided by continuous EFM may be associated with the decision for a cesarean birth. Typically, consent is not sought in the decision about type of monitoring. No studies were identified where women's attitudes about the need to consent to the type of fetal monitoring used during labor have been explored. Therefore, the purpose of this research was to examine women's attitudes about the use of EFM in a healthcare setting.METHODSWe asked a sample of women aged 18–50 years to respond to one of three monitoringscenarios. The scenarios were used to distinguish between attitudes about monitoring in general, monitoring the health of a mother in labor, and monitoring the health of the fetus during labor. Wemeasured their level of interest in being monitored and their opinions about whether healthcare providers should be required to obtain consent for the monitoring described in the scenario.RESULTSInterest in receiving monitoring (across all three scenarios) was moderate, with the highest level of interest in monitoring the fetus during labor and the least interest in monitoring a general health context. Across all scenarios, 82% of respondents believed that practitioners should obtain consent for monitoring, 14% were unsure, and 4% said there should not be a requirement for consent. While low (6%), the percentage responding that consent was not needed was highest in monitoring a fetus in labor.CONCLUSIONSWomen in our study expressed a strong preference for the opportunity to consent to the use of monitoring regardless of the healthcare scenario. There is findings suggest the need for further research exploring what women do and do not know about CTG and what their informed performance are a pressing need to rethink the role of a pressing need to rethink the role of shared decision-making and informed consent about the type of monitoring use during labor.

Maternal positions during labor: Midwives' knowledge and educational needs in northern Italy.

INTRODUCTIONMaternal positions and mobility during childbirth can have different and specific effects on labor and affect some birth outcomes. The aim of the survey is to investigate the knowledge and skills regarding maternal positions in labor among midwives and to consider the need of training.METHODSA semi-structured questionnaire was distributed in August and September 2020 among midwives working in eight hospitals of Brescia, Northern Italy. The sample consisted of 115 midwives and data were analyzed using a quantitative, descriptive approach.RESULTSThe majority of the sample identified the general and specific benefits of maternal positions. Factors limiting the proposal of maternal positions were the context, the relationships with healthcare providers, the woman features, the fetal heart rate registration, continuous cardiotocography, amniotomy, episiotomy, operative vaginal birth, and epidural analgesia. Vaginal examination, the detection of uterine contractions, intrapartum ultrasounds, and ‘hands-on’ perineum technique were considered irrelevant by the participating midwives. The promoting factors were the presence of the partner, the telemetry, and the partogram with a section dedicated to positions. Nearly the totality of the sample considered appropriate to deepen the topic with training.CONCLUSIONSPost-graduate courses are desirable to improve midwives’ skills. An educational toolkit is proposed to make the promotion of maternal positions more effective and appropriate. In order to improve midwifery intrapartum care, further research addressed to midwives of other settings appears essential to compare different training contexts, to expand the proposed toolkit, and to invest on midwifery practice and education.

Does continuous cardiotocography during labor cause excessive fetal distress diagnosis and unnecessary cesarean sections?

Objective We aimed to evaluate the perinatal outcomes of patients who were continuously monitored by cardiotocography (CTG) during the labor and experienced cesarean operation with a diagnosis of fetal distress. Material and methods This is a retrospective study in which records of the patients, who were diagnosed of fetal distress at Umraniye Training and Research Hospital, Department of Obstetrics and Gynecology, Istanbul, Turkey, between January 2015 and October 2020 were collated. The statistical analysis was done using the Statistical Packagefor Social Sciences version 22 software (SPSS Inc., Chicago IL, USA). Results Of the 32,338 deliveries in this study period, 13,077 (40.4%) deliveries were through caesarean section. A total of 1504 (11.5%) of the 13,077 caesarean sections were due to fetal distress within the study period. A total of 1301 (86.5%) babies were born with ≥7 Apgar score at the1st min of delivery. NICU admission rate was 11.2% and perinatal mortality was 0.1%. More so, in the low-risk pregnancy group, the rate of the babies were born with ≥7 Apgar score at the1st min of delivery was 93.7% and NICU admission rate 2.1% and no perinatal mortality was seen. In the patient group in which pregestational and gestational diseases complicating pregnancy were excluded, newborns with meconium-stained amniotic fluid had statistically significantly lower 1st and 5th-min Apgar scores compared to the group without meconium and higher NICU admission (p = .000, p = .004 and p = .000, respectively). Conclusion The diagnosis of fetal distress should not be made only with fetal heart rate changes in CTG because this causes excessive fetal distress diagnosis and many unnecessary cesarean operations. We believe that rate of cesarean sections will decrease to the desired levels with the routine use of a method such as CTG which is easy to apply, but more sensitive and specific in the diagnosis of fetal distress.

Влияние новой коронавирусной инфекции COVID-19 на систему «мать–плацента–плод»

Impaired placental development during early pregnancy associated with systemic damage to the vascular endothelium in patients with COVID-19 may result in a number of complications. The study was aimed to reveal histological and immunohistochemical (IHC) features of placental tissue in pregnant women with COVID-19 at different stages of gestation, and to examine the contribution of those to pathogenesis of the disease involving mother-placenta-fetus system. The following two groups of pregnant women were studied: index group of 66 patients with COVID-19, and comparison group of 40 women with no symptoms of viral infection. Macroscopic and microscopic examination, and the IHC analysis of placental samples were carried out. Clinical and anamnestic characteristics of patients with COVID-19 were analyzed taking into account disease severity, delivery route and perinatal outcome. ICH staining using primary antibody revealed elevated expression of proinflammatory factors (TNFα, IL8) and reduced level of anti-inflammatory factors (IL4) in placental structures of patients with moderate and severe СOVID-19 (р &lt; 0.05). The villous tree rearrangement and the development of subclinical placental insufficiency, which could in some cases be decompensated during labor, resulting in clinical manifestations of acute fetal hypoxia were detected in the placental samples obtained from the index group patients. The obstetrical tactics for mothers with COVID-19 should be decided individually based on the risk factors; continuous cardiotocography should be used during labor. It may be appropriate to conduct IHC analysis of placenta in puerperant women with COVID-19 in order to fine-tune the tactics of neonatal management and to predict possible neonatal complications.

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.

Recommendations for intrapartum fetal monitoring are not followed in low-risk women: A study from two Norwegian birth units

ObjectiveInternational and national intrapartum fetal monitoring guidelines recommend intermittent auscultation in low-risk women, and admission cardiotocography and continuous cardiotocography in high-risk women. The present study aimed to investigate fetal monitoring practices for low- and high-risk women in two hospitals in Norway, and if practice were according to national and international guidelines. Study designTo this cross sectional study, data on methods of fetal monitoring and women’s risk status were collected from the patient journals of 998 women with intended vaginal birth in 2017 and 2018. Main outcome measuresType of fetal monitoring related to risk status. ResultsOn admission, 401 (40%) of the women were classified as low-risk and 597 (60%) as high-risk. An admission cardiotocography was reported for 327 (82%) low-risk women and 554 (93%) high-risk women. Of the low-risk women, 187 (47%) remained low-risk throughout labor. During labor, 99 (53%) of the women that remained low-risk were monitored with intermittent auscultation, 62 (33%) with cardiotocography, 24 (13%) with partial cardiotocography, and two (1%) had no monitoring documented. In the high-risk women, intermittent auscultation was used for 11 (2%) during labor, cardiotocography for 544 (91%), partial cardiotocography for 35 (6%), and seven (1%) women had no monitoring documented. ConclusionsThe majority of low-risk women had an admission cardiotocography and during labor many low-risk women were monitored with continuous cardiotocography. This is not in accordance with guidelines which recommend intermittent auscultation. In addition, almost one-tenth of high-risk women were not monitored with continuous cardiotocography, as recommended.

Computerized Analysis of Intrapartum Fetal Heart Rate Patterns and Adverse Outcomes in the INFANT Trial

(Abstracted from BJOG 2019;126:1354–1361) During the 1960s and 1970s, intermittent auscultation was replaced by the alternative method of continuous electronic fetal monitoring (EFM) and cardiotocography (electronic monitoring of the fetal heart rate [FHR] and uterine contractions, or CTG). Meta-analyses have reported a 59% drop in intrapartum deaths attributable to hypoxia and a reduced risk of neonatal seizures, but a 2017 Cochrane review concluded that while EFM did reduce the rates of neonatal seizures, it did not provide “clear differences in cerebral palsy, infant mortality, or other standard measures of neonatal well-being.” Human error in interpreting the FHR pattern is a possible explanation for the ineffectiveness of EFM.

Admission Cardiotocography Versus Intermittent Auscultation of the Fetal Heart in Low-risk Pregnancy During Evaluation for Possible Labour Admission—A Multicentre Randomised Trial: The ADCAR Trial

(BJOG. 2019;126:114–121) To identify which deliveries might be at greater risk of intrapartum fetal compromise and therefore may benefit from continuous cardiotocography (cCTG) during labor, either intermittent auscultation (IA) or admission cardiotocography (ACTG) is performed on women upon admission with possible labor onset. Current guidelines are based on studies evaluating the effects of ACTG on women in diagnosed labor, rather than those with signs and symptoms of possible labor onset. This study aimed to compare ACTG with IA in terms of cesarean section, obstetric intervention, and neonatal morbidity in a low-risk population of healthy pregnant women presenting for possible labor onset, before confirmation of labor.

Effect of Nursing Interpretation and Intervention of Intrapartum Cardiotocography on Pregnancy Outcomes

An important goal of intrapartum monitoring is preservation of fetal well-being by early detection and relief, when possible, of those conditions causing fetal distress and adverse outcomes. The aim: Assess the effectiveness of nursing interpretation and intervention of intrapartum cardiotocography on pregnancy outcomes. Design: Quazi experimental design. The sample: Was convenient sample of 120 cases divided into two groups (study, and control) each one is 60 cases (30 low risks, and 30 high risks). Tools: three different tools namely assessment sheet for the mother in first stage includesall significant data about the mother, intrapartum fetal monitoring assessment will be done using cardiotocography strip, and Apgar score at one and five minutes. The settings: Shebin Elkom Teaching and University hospitals-Egypt. The main findings were that no statistically significant relations for low risk cases that being handled with cardiotocography and fetal complications. Instrumental delivery and cesarean section rate for low risk cases in the study group is increased than for low risk in control group shows statistical significance difference. There were strong statistically significant relations between high risk fetal heart rate nursing interpretation and Apgar score in the first minute. Statistical significance to total complications during present labor to the mother. Conclusion: Continuous cardiotocography should recommended for high-risk pregnancies where there is an increased risk of prenatal adverse outcomes. Cardiotocography for low risk is associated with a significant increase in instrumental delivery and caesarean section rates compared with intermittent auscultation. Recommendations: continuous electronic fetal monitoring should be recommended for high-risk pregnancies where there is an increased risk of fetal compromise.

Computerising the intrapartum continuous cardiotocography does not add to its predictive value: AGAINST: Computerising the intrapartum CTG does add to its predictive value.

Computerising the intrapartum continuous cardiotocography does not add to its predictive value: AGAINST: Computerising the intrapartum CTG does add to its predictive value.

Computerising the intrapartum continuous cardiotocography does not add to its predictive value: FOR: Computer analysis does not add to intrapartum continuous cardiotocography predictive value.

Computerising the intrapartum continuous cardiotocography does not add to its predictive value: FOR: Computer analysis does not add to intrapartum continuous cardiotocography predictive value.

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

BackgroundIntermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps.MethodsWe conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach.ResultsThe searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29–2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult.ConclusionAlthough IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa.

National survey of routines for intrapartum fetal monitoring in Norway.

This study describes clinical routines for intrapartum fetal monitoring in Norway and compliance with national clinical recommendations. A national survey of all (n=48) birth units in Norway, using a self-reporting questionnaire about fetal monitoring methods and devices available in the birth units, admission cardiotocography (CTG) use, intrapartum fetal monitoring methods for women with and without risk factors, the availability of fetal scalp blood sampling facilities, and umbilical cord blood sampling routines. All birth units responded. They all had access to Pinard stethoscopes, hand-held Doppler devices, and CTG. Half of the units used ST waveform analysis (STAN) as an adjunct to CTG. Furthermore, 23 of 48 units analyzed fetal blood samples and 43 of 48 umbilical cord blood gas samples. In 11 units, admission CTG was routinely offered to all women. No units used continuous CTG during labor in low-risk women. However, three units routinely used intermittent CTG during the first stage of labor. Three units used CTG without having access to fetal blood samples or STAN. Our findings indicate some deviations from clinical recommendations in the use of intrapartum fetal monitoring in Norway. Three units used intermittent CTG for women without risk factors. Almost one in four units routinely used admission CTG, despite national clinical recommendations. The lack of access to fetal blood samples or STAN in units using CTG is of concern.