Continuous Cardiotocography Research Articles

Optimiert die Fetalblutanalyse die Qualität der geburtshilflichen Versorgung?

Introduction: The additional use of fetal blood sampling has been suggested in cases with continuous cardiotocography to improve fetal surveillance during labor. It was the aim of this study to critically evaluate the potential benefit with the possibility of reducing the number of cesarean sections and improving the outcome of the newborn. Method: Data were prospectively collected during the Hesse perinatal survey from 1990-2000 in >98% of all births in the state. All cases with risks in addition to indications of fetal distress in the cardiotocography tracing were excluded by means of a multivariate analysis. 15468 singleton births at >37 weeks in a vertical position were included. In this sample a statistical evaluation ofcesarean section rate, clinical status of the newborn at birth and necessity of transfering a newborn to the NICU was performed. Results: The number of secondary cesarean sections due to indications of fetal distress was significantly reduced from 14.9 to 8.9% (p < 0.01) when fetal blood sampling was utilized. Furthermore early morbidity (Apgar 5min, 10 min <7) was reduced (p < 0.01). The numbers of newborns which had to be transfered to the neonatal intensive care unit were significantly reduced. Conclusion: The additional use of fetal blood sampling during fetal surveillance is beneficial for mother and child.

Admission cardiotocography: a randomised controlled trial

Admission cardiotocography is widely used to identify pregnancies that might benefit from continuous electronic fetal monitoring in labour. We aimed to compare the effect on neonatal outcome of admission cardiotocography versus intermittent auscultation of the fetal heart rate. 8580 women admitted to the delivery ward of a Dublin teaching hospital who were at low risk of fetal distress in labour were randomly assigned admission cardiotocography (20 min) or the unit's usual care (intermittent auscultation only, with continuous cardiotocography only if clinically indicated). The primary outcome was moderate to severe neonatal morbidity, or perinatal mortality in the absence of a major congenital malformation. Analyses were by intention to treat. 44 (1.0%) women assigned admission cardiotocography did not undergo the procedure; 15 (0.4%) assigned usual care had admission cardiotocography. The primary endpoint occurred in 56 (1.3%) of 4298 women assigned admission cardiotocography and 55 (1.3%) of 4282 in the usual-care group (relative risk 1.01; 95% CI 0.70-1.47). Other indices of neonatal morbidity also showed no differences. Despite an increase in use of continuous cardiotocography (1.39; 1.33-1.45) and fetal blood sampling (1.30; 1.14-1.47) with admission cardiotocography, there were no significant differences in the rates of caesarean delivery (1.13; 0.92-1.40), instrumental delivery (1.03; 0.92-1.16), or episiotomy (1.06; 0.99-1.13). Routine use of cardiotocography for 20 min on admission to the delivery ward does not improve neonatal outcome. No significant increase in operative delivery was apparent, probably because of liberal use of fetal blood sampling.

The admission cardiotocograph: a randomised controlled trial

This study aimed to compare, in a low-risk population of women in labour, the effect on neonatal outcome of an ‘admission’ cardiotocograph with intermittent auscultation of the fetal heart rate. The delivery ward of a Dublin teaching hospital was the setting for this study, which involved women at low risk of fetal distress in labour. This was a randomised controlled trial. The primary outcome was moderate–severe neonatal morbidity, or perinatal mortality in the absence of a major congenital malformation. Twenty-minute admission cardiotocograph was compared to the usual care of intermittent auscultation only, with continuous cardiotocography only if subsequently clinically indicated. A total of 8580 women were randomised and included in analysis: 4298 to receive an admission CTG and 4282 to usual care. Forty-four (1.0%) women allocated to receive an admission CTG did not have one; 15 (0.4%) allocated to usual unit care had an admission CTG. In the admission CTG group, 56 (1.3%) had moderate–severe neonatal morbidity or mortality compared to 55 (1.3%) in the usual care arm (RR=1.01, 95% CI 0.70–1.47). Other parameters of neonatal morbidity also showed no differences. Despite an increase in the use of continuous cardiotocography (RR=1.39. 95% CI 1.33–1.45) and fetal blood sampling (RR=1.30, 95% CI 1.30–1.47) with an admission CTG, there were no significant differences in the incidence of caesarean section (RR=1.13, 95% CI = 0.92–1.40), instrumental delivery (RR=1.03, 95% CI = 0.92–1.16) or episiotomy (RR=1.06, 95% CI 0.99–1.13).

Hemodynamic changes and baroreflex gain in the supine hypotensive syndrome

Objective: The purpose of this study was to determine whether supine hypotensive syndrome is caused by a decreased baroreflex gain that results in inadequate compensatory responses to restore cardiac output. Study Design: Ten third-trimester gravid women with symptoms that were suggestive of supine hypotensive syndrome and 10 control subjects without symptoms were studied. Patients were studied initially for 30 minutes in the lateral recumbent position with continuous heart rate, blood pressure, external cardiotocography, and cardiac output determinations every 5 minutes. After 30 minutes, the patient was repositioned supine for up to an additional 30 minutes, and all measurements were repeated similarly. This lateral-supine sequence was repeated twice or until symptoms precluded further testing. Results: The two groups were demographically similar. With maternal position change to supine, cardiac output (−2.7 L/min vs −1.0 L/min, P =.04) and mean arterial blood pressure (−10.7 mm Hg vs −2.5 mm Hg, P =.03) were respectively lower, and heart rate (+26.9 vs +14.4 beats/min, P =.04) was higher in the subjects with supine hypotensive syndrome than in the control subjects. Baroreflex gain, however, did not differ between the subjects with supine hypotensive syndrome and control subjects (P =.26). Conclusion: We were unable to demonstrate a decrease in baroreflex gain as a possible cause of supine hypotensive syndrome. Inadequate pelvic collateral circulation that leads to a greater decrease in cardiac output may be causative in the syndrome. (Am J Obstet Gynecol 2002;187:1636-41.)

Clonidine added to bupivacaine-epinephrine-sufentanil improves epidural analgesia during childbirth

Background and Objectives. A double-blind study was conducted to assess the efficacy and the side effects of a low dose of clonidine added to an epidural injection of bupivacaine and epinephrine, with or without sufentanil. Methods. One hundred healthy parturients (ASA 1) were randomly allocated into four groups according to the type of epidural analgesia administered. The bupivacaine/epinephrine (BE) group received a 10-mL standard injection of bupivacaine (B) 1.25 mg/mL and epinephrine (E) 1.25 μg/mL. In the bupivacaine/epinephrine/sufentanil (BES) group, 7.5 μg sufentanil (S) was added to the BE mixture. For the bupivacaine/epinephrine/clonidine (BEC) group, 50 μg clonidine (C) was added to the BE mixture, whereas for the bupivacaine/epinephrine/sufentanil/clonidine (BESC) group, both sufentanil and clonidine were added to BE. Fetal heart rate was monitored by continuous cardiotocography. Duration of analgesia, method of delivery, and neonatal outcome (measured using APGAR score, peripheral oxygen saturation, and neurologic adaptive capacity score) and side effects of clonidine were observed. The parturients were routinely asked for their global appreciation of the epidural analgesia technique by visual analog score, 2 hours postpartum. Results. The overall quality and duration of analgesia were superior in the BESC group compared with the other groups, as was the global appreciation by the parturient. The frequency of side effects in the clonidine groups was comparable, with the exception of hypotension and sedation. Hypotension was easily treated by fluids or ephedrine and caused no fetal distress. The level of sedation was mild, and all parturients aroused immediately after verbal commands. Conclusion. The addition of a low dose of clonidine to an epidural injection of bupivacaine with epinephrine and sufentanil provides better analgesia during labor, while keeping the side effects minimal and of minor clinical importance.

UK study of intrapartum care for low risk primigravidas: a survey of interventions.

STUDY OBJECTIVE: To determine the extent of intrapartum intervention received by primigravidas. DESIGN: Cross sectional survey of NHS hospitals in the UK. SETTING: One hundred and one randomly selected hospital...

Indications for operative termination of labor on cardiotocography and fetal blood analysis: the reliability of these methods

In a retrospective study it was possible to show that of 110 cases with operative delivery, performed due to suspicious or pathological fetal blood acidity findings, 93.6% were justified. A pre-pathological or pathological umbilical cord artery pH of < 7.25 was taken as the basis for correct clinical management ("true" positive cases). There was a clear relationship between the pH of the umbilical artery blood and the clinical state of depression in the newborn. This study shows that, with the help of combined fetal supervision using cardiotocography (CTG) as a screening method and fetal blood analysis (FBA) as a method of differentiation, early stages of threatened fetal acidosis can be reliably detected without having too high a rate of operative deliveries, which must inevitably result when continuous CTG supervision is used on its own. Obstetricians should therefore try to prevent severe acidosis combined with a corresponding clinical state of depression of the newborn. This requires the use of modern monitoring (CTG and FBA) and prompt clinical measures (tocolysis or termination of labor) when the pH levels are reduced or are apparently falling.

Regional epidural analgesia for labour following previous caesarean section. A 15 year review, 1972–1987

SummaryEpidural analgesia was employed in 345 (25.5 per cent) of 1350 patients labouring after a previous caesarean section between 1972–1987. On retrospective analysis of results for 1972–1982, a vaginal delivery success of 88 per cent was associated with an unacceptable ‘procedure related' perinatal mortality and incidence of true rupture of the uterus. Stricter management policies were implemented for 1982–1987 with particular attention to the use of a strict regimen for oxytocin administration, continuous cardiotocography and termination of the labour by repeat caesarean section after 6 hours of active labour if vaginal delivery was not imminent. This resulted in an 82 per cent vaginal delivery rate, no perinatal death associated with delivery and elimination of true rupture of the uterus. Oxytocin for induction or acceleration of labour was given to 50 per cent of patients overall and there was a 50 per cent assisted vaginal delivery rate. Comparisons with patients not having epidural analgesia, delivered concurrently, showed it to be safe for mother and fetus in properly conducted labour. No maternal death occurred in these patients but there were two deaths in patients with elective repeat caesarean sections.

EFFECT OF MATERNAL POSITING ON FETAL HEART RATE DURING EXTRADURAL ANALGESIA

Using continuous cardiotocography, the effect of maternal position on fetal heart rate (FHR) was studied during extradural analgesia (EA) with either 50 or 100 mg of etidocaine without adrenaline for labour and vaginal delivery. Of 70 healthy parturients, 39 were supine and 40 were in the lateral position. FHR was normal in all patients during the control period before EA, and remained normal during EA in 53. Transient abnormal patterns occurred in 26 patients, 22 (56%) in the supine group and four (10%) in the lateral group, a significant difference (P less than 0.001). The decrease in arterial pressure (AP) did not differ between the groups, but the frequency of abnormal FHR associated with a small or moderate decrease in AP (30% or less) was greater in the supine (51%) than in the lateral group (3%).