Continuous Electronic Fetal Monitoring Research Articles

Guidelines for Vaginal Birth After Previous Caesarean Birth

Objective:To provide evidence-based guidelines for the provision of a trial of labour (TOL) after Caesarean section.Outcome:Fetal and maternal morbidity and mortality associated with vaginal birth after Caesarean (VBAC) and repeat Caesarean section.Evidence:MEDLINE database was searched for articles published from January 1, 1995, to February 28, 2004, using the key words “vaginal birth after Caesarean (Cesarean) section.” The quality of evidence is described using the Evaluation of Evidence criteria outlined in the Report of the Canadian Task Force on the Periodic Health Exam.Recommendations:1.Provided there are no contraindications, a woman with 1 previous transverse low-segment Caesarean section should be offered a trial of labour (TOL) with appropriate discussion of maternal and perinatal risks and benefits. The process of informed consent with appropriate documentation should be an important part of the birth plan in a woman with a previous Caesarean section (II-2B).2.The intention of a woman undergoing a TOL after Caesarean section should be clearly stated, and documentation of the previous uterine scar should be clearly marked on the prenatal record (II-2B).3.For a safe labour after Caesarean section, a woman should deliver in a hospital where a timely Caesarean section is available. The woman and her health care provider must be aware of the hospital resources and the availability of obstetric, anesthetic, pediatric, and operating-room staff (II-2A).4.Each hospital should have a written policy in place regarding the notification and (or) consultation for the physicians responsible for a possible timely Caesarean section (III-B).5.In the case of a TOL after Caesarean, an approximate time frame of 30 minutes should be considered adequate in the set-up of an urgent laparotomy (III-C).6.Continuous electronic fetal monitoring of women attempting a TOL after Caesarean section is recommended (II-2A).7.Suspected uterine rupture requires urgent attention and expedited laparotomy to attempt to decrease maternal and perinatal morbidity and mortality (II-2A).8.Oxytocin augmentation is not contraindicated in women undergoing a TOL after Caesarean section (II-2A).9.Medical induction of labour with oxytocin may be associated with an increased risk of uterine rupture and should be used carefully after appropriate counselling (II-2B).10.Medical induction of labour with prostaglandin E2 (dinoprostone) is associated with an increased risk of uterine rupture and should not be used except in rare circumstances and after appropriate counselling (II-2B).11.Prostaglandin E1 (misoprostol) is associated with a high risk of uterine rupture and should not be used as part of a TOL after Caesarean section (II-2A).12.A foley catheter may be safely used to ripen the cervix in a woman planning a TOL after Caesarean section (II-2A).13.The available data suggest that a trial of labour in women with more than 1 previous Caesarean section is likely to be successful but is associated with a higher risk of uterine rupture (II-2B).14.Multiple gestation is not a contraindication to TOL after Caesarean section (II-2B).15.Diabetes mellitus is not a contraindication to TOL after Caesarean section (II-2B).16.Suspected fetal macrosomia is not a contraindication to TOL after Caesarean section (II-2B).17.Women delivering within 18 to 24 months of a Caesarean section should be counselled about an increased risk of uterine rupture in labour (II-2B).18.Postdatism is not a contraindication to a TOL after Caesarean section (II-2B).19.Every effort should be made to obtain the previous Caesarean section operative report to determine the type of uterine incision used. In situations where the scar is unknown, information concerning the circumstances of the previous delivery is helpful in determining the likelihood of a low transverse incision. If the likelihood of a lower transverse incision is high, a TOL after Caesarean section can be offered (II-2B).Validation:These guidelines were approved by the Clinical Practice Obstetrics and Executive Committees of the Society of Obstetricians and Gynaecologists of Canada.

Changing the Use of Electronic Fetal Monitoring and Labor Support: A Case Study of Barriers and Facilitators

Decreasing the use of continuous electronic fetal monitoring and increasing professional labor support for low-risk pregnancies are recommended by the Society of Obstetricians and Gynecologists of Canada. This study explored factors influencing the successful (and unsuccessful) introduction of an evidence-based fetal health surveillance guideline. This qualitative case study was conducted at two tertiary and one community hospital. Data were collected in 14 clinician focus groups (51 nurses), followed by 8 interviews with nurse administrators and educators. Analysis of verbatim transcripts and unit records included coding and categorizing data to form profiles that were compared across hospitals. Implementation of the guideline recommendations in the hospital settings was affected by many different factors originating in the practice environment, with the potential adopters, and related to the characteristics of the guideline. The influences of these diverse factors interacted sometimes to magnify or counteract each other's effect. The physical setting, adopter concerns, and the medicolegal issues surrounding the guideline played critical roles in uptake. In addition, changes preceding the introduction of the recommendations, the institution's agenda, and nursing and medical leadership influenced the uptake of guideline recommendations. The number and experience of nurses in each setting and availability of equipment also affected guideline acceptance and use. When implementing best practice, it is important to identify organizational barriers to the change that will need managing by the appropriate level of administration in the organization. Careful tailoring of implementation interventions to the barriers originating with the potential adopters is also necessary. Be prepared for unanticipated effects.

Intrapartum fetal surveillance

In spite of the significant increase in obstetric and neonatal interventions aimed at reducing asphyxia there is no reduction in the rate of cerebral palsy (CP). Metabolic acidosis occurs in 2% of all births and over 90% of such infants do not develop CP. About 10% of cases of CP are due to pathological events that occur after birth, 10–20% of cases are related to intrapartum events, and identifying the cause of the remaining 70% is an ongoing challenge for obstetricians and paediatricians. The original aim of continuous electronic fetal monitoring (EFM) was to prevent harm by detection of fetal hypoxia before it led to disability or death. It was soon realised that EFM had a high false-positive rate and there were no significant differences in outcome measures when compared with intermittent auscultation. The increased operative intervention rates associated with EFM were reduced if fetal scalp blood sampling (FBS) was performed to measure the pH. However, fetal blood sampling used for the diagnosis of intrapartum fetal hypoxia is time consuming and may be associated with equipment failure or inability to obtain a sample. As it is a single measurement it needs to be repeated, with consequent inconvenience to the woman and the staff. Additional or alternative methods are needed to help mothers and babies who, despite abnormal fetal heart rate patterns and clinical findings during labour and delivery, would not benefit from intervention. New methods of pulse oximetry and fetal ECG waveform analysis explore the possibility of continuous surveillance as an adjunct to EFM. Recent studies suggest that maternal pyrexia is associated with increased adverse fetal outcome. Monitoring of maternal temperature and its normalisation should be part of intrapartum care, to avoid fetal neurological injuries.

Is There Logic Behind Fetal Monitoring?

Practitioners of biomedicine pride themselves on making logical decisions based on scientific fact and research evidence. However, continuous electronic fetal monitoring, as it is applied in contemporary North American obstetric practice, does not stand up to the rules of logic or the application of empirical evidence. In the face of growing evidence against the efficacy of continuous electronic fetal monitoring for improving birth outcomes, perinatal health care providers need to critically evaluate the arguments that supported its inception and consider whether its continued application can be defended.

#4: no routine interventions.

In this position paper-one of six care practice papers published by Lamaze International and reprinted here with permission-the benefit of no routine interventions during birth is discussed and presented as an evidence-based practice that helps promote, protect, and support normal birth. The paper is written for childbearing women and their families. It presents evidence related to restrictions on eating and drinking, use of intravenous fluids, continuous electronic fetal monitoring, artificial rupture of the membranes, augmentation of labor, and epidural analgesia. The accompanying commentary-written by an award-winning medical writer-supports and expands on the benefits of no routine interventions during birth. Lamaze International recommends that laboring women avoid restrictions on eating and drinking. The organization also recommends avoidance of IVs, continuous electronic fetal monitoring, epidurals, and efforts to speed up labor, unless a clear indication for their use is evident.

Is midwife workload associated with quality of process of care (continuous electronic fetal monitoring [CEFM]) and neonatal outcome indicators? A prospective study in consultant-led labour wards in Scotland.

Evidence for staffing recommendations in labour wards is scant. This study aimed to test association between midwife workload with adjusted process of continuous electronic fetal monitoring (CEFM) and neonatal outcome indicators. This was a prospective workload study in 23 consultant-led labour wards in Scotland. There were 3489 livebirths during September 2000, and 1561 consecutively delivered women with CEFM case review during the mid-two weeks. Process measures were: adjusted rates of CEFM, appropriate CEFM, and time to medical response for a serious fetal heart trace abnormality. Neonatal outcome indicators were: Apgar score < 7 at 5 minutes, admission to neonatal unit (NNU) > 48 hours, and neonatal resuscitation. Complete information was available for 99% (2553/2576) of workload time points, 99% (1559) of CEFM process, and 3083 eligible neonates. There were no associations between occupancy or staffing ratios and adjusted CEFM process, Apgar < 7 at 5 minutes (0.98 [0.83, 1.15]) or admission to NNU for > 48 hours (0.97 [0.95, 1.00]). However, there was association between increasing staffing ratios and lower odds of adjusted neonatal resuscitation (excluding bag and mask only) (0.97 [0.94, 0.99]). The direction of effect of increasing workload suggests detriment to outcome indicators, although the size of effect may be small.

Should women be given a choice about fetal assessment in labor?

Continuous electronic fetal monitoring (EFM) in labor is one of the most commonly used interventions during intrapartum care. However, randomized controlled trials, observational studies, and meta-analyses about the use of continuous EFM on low-risk intrapartum patients have found no significant differences in infant outcomes between infants whose mothers had EFM or intermittent auscultation (IA) of the fetal heart rate. In addition, research shows a higher incidence of cesarean birth when EFM is used. Although evidence-based practice is supposed to be our goal, the evidence about the lack of efficacy of EFM has not been used in practice. In fact, EFM has become the standard of practice in this country. Considering these facts, should EFM continue to be the standard of practice for low-risk laboring women? Is informed consent indicated, giving women the choice between EFM and IA? Should IA be offered to all low-risk laboring women? Ethical decision-making models are used to examine those questions and to help nurses better delineate their advocacy role.

A randomised controlled trial of admission electronic fetal monitoring in normal labour

Aim: to test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. Design: a randomised controlled trial. Setting: the Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. Participants: healthy pregnant women admitted in normal labour, deemed low risk based on the midwives’ birth unit admission criteria. Intervention: women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). Outcome measures: primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. Secondary outcomes: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. Key findings: there was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. Conclusion: the use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.

Vaginal birth after Caesarean section: a survey of practice in Australia and New Zealand.

Women with a single prior Caesarean section (CS) in a subsequent pregnancy will be offered either a planned elective repeat CS or vaginal birth after Caesarean (VBAC). Recent reports of VBAC have highlighted risks of increased morbidity, including uterine rupture, and adverse infant outcome. A survey of practice was sent to fellows and members of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists to determine current care for women in a subsequent pregnancy with a single prior CS, and to assess variations by length and type of obstetric practice. Questions asked about the safety of VBAC, induction of labour with a uterine scar, and requirements to conduct VBAC and elective repeat CS. A total of 1641 surveys were distributed, with 1091 (67%) returned, 844 from practicing obstetricians (51% of college membership). Almost all respondents (96%) agreed or strongly agreed that VBAC should be presented as an option to the woman, varying from 90% where the indication for primary CS was breech, 88% for fetal distress, and 55% for failure to progress. Forty percent of respondents agreed or strongly agreed that VBAC was the safest option for the woman, and associated with fewer risks than CS. In contrast, 44% of respondents disagreed or strongly disagreed that VBAC was the safest option for the infant, and opinions varied as to whether risks of VBAC outweighed those of CS for the infant. Almost two-thirds of practitioners would offer induction of labour to a woman with a prior CS in a subsequent pregnancy, one-third indicating a willingness to use vaginal prostaglandins, and 77% syntocinon. Most respondents preferred to conduct VBAC in a level two or three hospital (86%); required the availability within 30 min of an anaesthetist (81%), a neonatologist (84%), and operating theatre (97%); recommended continuous electronic fetal heart rate monitoring (86%); intravenous access (90%); and routine group and hold (79%) during labour. For an elective repeat CS, most practitioners request routine blood for group and hold (78%), a neonatologist in theatre (77%), the use of an in-dwelling urinary catheter (96%), and the use of intraoperative antibiotics (82%). Most obstetricians indicated VBAC to be the safest option for the woman, but were less certain about benefits and risks for the infant. The consensus of practice is to present VBAC as an option and induce labour if needed. Vaginal birth after Caesarean is preferred in a level two or three hospital, with an anaesthetist, neonatologist and operating theatre available within 30 min. The use of continuous electronic fetal heart rate monitoring and intravenous access are recommended. In planned CS, a neonatologist in theatre is preferred, and an in-dwelling urinary catheter an;! intraoperative antibiotics will be used.

Intrapartum fetal heart rate patterns in the prediction of neonatal acidemia

Objective: This study was undertaken to correlate changes in the intrapartum electronic fetal heart rate patterns with the development of significant neonatal acidemia. Study Design: We identified 488 fetuses at a gestational age of >37 weeks' gestation who had continuous electronic fetal monitoring during labor for the last 2 hours and umbilical artery cord gas analysis performed at delivery. One investigator blinded to the cord gas outcome reviewed all 488 tracings using the National Institute of Child Health and Human Development guidelines for fetal heart rate monitoring. All fetal heart rate tracings with bradycardia were removed from further analysis. The patients were placed in six groups, depending on the absence or presence of normal variability (amplitude >5 beats) during the last hour of monitoring combined with the absence of decelerations or the presence of variable or late decelerations. The relationship between changes in variability and the outcome variables of pH and base deficit in the six groups was assessed with analysis of variance and χ2 test. Significance was set at the P <.05 level. Results: Patients with normal variability and accelerations, even in the presence of late decelerations or variable decelerations, maintained an umbilical artery pH 7.0 or greater in more than 97% of cases. In the presence of minimal/absent variability (amplitude <5) for at least an hour, the incidence of significant acidemia (pH <7.0) ranged from (12%-31%). Conclusion: The most significant intrapartum fetal heart rate parameter to predict the development of significant acidemia is the presence of minimal/absent variability for at least 1 hour as a solitary abnormal finding or in conjunction with late decelerations in the absence of accelerations. Urgent delivery should be considered in these cases after appropriate ancillary testing. (Am J Obstet Gynecol 2003;188:820-3.)

Effectiveness of Nurses as Providers of Birth Labor Support in North American Hospitals: A Randomized Controlled Trial

How effective is support by staff nurses specially trained in labor support? An answer to this question is of special importance in view of the marked rise in cesarean delivery rates noted in North America since the 1960s. A Cochrane Review has found that continuous caregiver support during labor makes cesarean delivery less likely. In the present controlled trial, 6915 women with a live singleton fetus or twins, seen at 34 weeks' gestation or later at 13 US and Canadian hospitals, were randomized when in established labor to either usual care or continuous support from a trained nurse. All centers had annual cesarean delivery rates of 15% or higher. In the study group, women received continuous support for at least 80% of the time from randomization to delivery. Well over 90% of women in both groups received appropriate intrapartum nursing care. The median interval from admission to delivery was 8.1 hours and from randomization to delivery, 6.6 hours. Rates of cesarean delivery were nearly identical in the two groups: 12.5% with continuous labor support and 12.6% with usual care. With continuous support, continuous electronic fetal monitoring was somewhat less likely. There were no other significant differences in maternal events or in immediate neonatal outcomes. All infants were born alive; there were three neonatal deaths. Differences in perceived control during childbirth differed very little in the two groups when women were questioned 6 to 8 weeks postpartum, and there was no significant difference in the frequency of breast-feeding. A wish for continuous labor support in future labors was expressed by 63% of women having this type of care and by 47% of control women. Although continuous intrapartum nursing support may have many advantages, it cannot by itself be relied on to lower rates of cesarean delivery or other intrapartum interventions.

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.

Fetal heart rate parameters predictive of neonatal outcome in the presence of a prolonged deceleration

OBJECTIVE: To correlate the presence of baseline variability and the duration of a prolonged deceleration/bradycardia in intrapartum fetal heart rate (FHR) tracings with the development of neonatal acidemia. METHODS: We identified 186 patients with term gestations who had continuous electronic fetal monitoring for at least 2 hours before delivery, with an identified bradycardia during that period. Each patient had umbilical artery cord analysis done and delivery within 30 minutes of that bradycardia. One investigator blinded to the cord gas outcome reviewed the last 2 hours of the tracing using the National Institute of Child Health and Human Development guidelines for FHR monitoring. We assessed the presence or absence of variability before the bradycardia and recovery or no recovery of the bradycardia and placed the patients into four groups. Group 1 (128 patients) with normal variability and recovery, group 2 (40 patients) with normal variability and no recovery, group 3 (nine patients) with decreased variability and recovery, and group 4 (nine patients) with decreased variability and no recovery. We compared the incidence of neonatal acidosis defined as a pH of less than 7.0 at birth among the four groups. The relationship between the various groups was assessed using analysis of variance and the χ 2 test. In addition, a multiple logistic regression model was developed with the parameters of amplitude and recovery used to predict pH at birth. RESULTS: The presence of decreased variability and no recovery of the FHR of a bradycardia was associated with the lowest pH 6.83 ± 0.16 and a 78% incidence of significant acidosis. Decreased variability before FHR bradycardia was the FHR parameter significantly correlated with low pH. CONCLUSION: The most significant factor predicting the development of pathologic neonatal acidemia and indicating the need for urgent delivery in the presence of a bradycardia is decreased variability before the bradycardia.

Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood by Naomi Wolf

Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood by Naomi Wolf. Published September 2001 by Doubleday. Misconceptions is a book worth reading and recommending to all new and expectant parents. Naomi Wolf, respected feminist author, has created an honest, well-researched, passionate account of America's pregnancy and birth culture. Perhaps feminism and motherhood will join to form a powerful force for America's women. Wolf writes in her introduction: Real motherhood is more impressive than the fantasy of it. That actual, specific, fierce maternal love that grows in the wake of that immense psychic and physical tremor that is pregnancy and birth should inspire awe, not sentiment. I wrote this book to explore the genuine article, not the Hallmark card; to trace the maternal bond as it forms, heroically and poignantly, in spite of, rather than because of, the obtuse and unnatural ideology of motherhood under which we labor. Professionals in the field of perinatal education will undoubtedly recognize the passion that drives Wolf throughout her account of her own journey through pregnancy, birth, and motherhood. New and expectant parents can now discover the truths regarding America's birth industry. Wolf presents the same evidence-based information taught in childbirth classes in an interesting, easy-to-read format. The book is divided into three parts titled “Pregnancy,” “Birth,” and “New Life.” The first part includes sections that represent the nine months of pregnancy: “Discovery,” “Experts,” “Baby Values,” Losses,” “Mortality,” “Birth Class and Tour,” “Mysteries,” “Powerlessness,” and “Waiting.” In these pages, Wolf exposes the shortcomings of the system to which most women subscribe. She writes honestly about the lack of compassion she received from her obstetrician and staff. She complains frankly about the patronizing tone of the book many pregnant women read religiously, What to Expect When You're Expecting (Eisenberg, Hathaway, & Murkoff, 1996) with its message, “Your baby needs to be protected from you.” A firm pro-choice advocate, Wolf's pregnancy inspires her to re-examine her views on abortion. What is the value assigned to fetuses, collectively and individually? She explores the roller-coaster ride that parents take as “routine” testing, such as amniocentesis and sonograms, which force difficult decisions. The birth class and hospital tour are seen as rites of passage in which students are often given only the information the obstetrical powers-that-be wish them to hear. Wolf states that many instructors are employed by hospitals in which policies differ greatly from what is in the women's and babies' best interests. Women everywhere will likely identify with the experiences Wolf describes in Part Two, “Giving Birth and Behind the Birthing Room.” During the birth of her first child, she remembers being “drugged and pinned.” The unfortunately typical scenario unfolds: failure to progress, pitocin, continuous electronic fetal monitoring, epidural, fetal “distress,” “emergency” cesarean, etc. Midwifery is presented in glowing colors. Ina May Gaskin, the widely known midwife based at The Farm in Summertown, TN, shares many great insights throughout the book. In preparation for writing Misconceptions, Wolf spent time with Gaskin and other midwives. Midwives across America will likely appreciate Wolf's contribution in elevating the profession to a higher level. Part Three, “New Life,” is divided into five sections: “Joy and Blues,” “Calling It Fair,” “Making Mothers,” “Epilogue,” and “A Mother's Manifesto.” Postpartum depression is explored in depth. Wolf attributes much of this condition to the low status assigned to mothering in this culture, workplace pressures, partner pressures, and a general lack of support for new mothers. Personal relationships and division of responsibilities in the home are highlighted through deeply personal accounts shared by women and men interviewed for the book. Great honesty is presented in stories of breastfeeding, working inside and outside the home, falling in love with baby, and appreciating one's partner. It is akin to reading someone's journal, but with the benefit of a tremendous amount of research behind it. The last section of the book, “A Mother's Manifesto,” calls for a new movement: Motherhood Feminism. Concrete ideas are listed to guide the reader in her/his effort to overhaul the current pregnancy, birth, and motherhood industry in America. Included in these ideas are a real family leave act with six months paid leave, community play centers, family areas in airports, stay-at-home parents' contributions to the social security system, and many more. Wolf's book also includes a helpful endnotes section and an excellent bibliography and index. The attention to detail throughout lends a professional quality not likely to be overlooked. Misconceptions should be added to many personal libraries. Order This Book Today! Misconceptions: Truth, Lies, and the Unexpected on the Journey to Motherhood by Naomi Wolf is available through the Lamaze Bookstore and Media Center, Call toll-free (877-952-6293) or visit the online bookstore (www.lamaze.org) to order your copy. Nonmember, $24.95; member, $22.95.

Monitoring the fetus in labor: evidence to support the methods

Electronic fetal monitoring (EFM) was implemented across the United States in the 1970s. By 1998, it was used in 84% of all U.S. births, regardless of whether the primary caregiver was a physician or a midwife. Numerous randomized trials have agreed that continuous EFM in labor increases the operative delivery rate, without clear benefit to the baby. Intermittent auscultation (IA) is safe and effective in low-risk pregnancies and may play a role in helping birth remain normal. Clinicians and educators are encouraged to reconsider the use of IA in the care of healthy childbearing women.

Evidence-based practice: new opportunities, new responsibilities

Evidence-based practice: new opportunities, new responsibilities

Warm water bathing did not reduce use of pharmacological analgesia during the first stage of labour

(2001) Birth 28, 84. Eckert K, Turnbull D, MacLennan A. . Immersion in water in the first stage of labor: a randomized controlled trial. . Jun; . : . –93...

Continuous electronic heart rate monitoring for fetal assessment during labor.

Electronic fetal monitoring (EFM) has been widely adopted. There is debate about its overall effectiveness as well as the relative merits of routine application versus use for high-risk pregnancies only. The objective of this review was to assess the effects of routine continuous electronic fetal monitoring during labour compared with intermittent auscultation. We searched the Cochrane Pregnancy and Childbirth Group trials register, Medline (1966 to 1994), and reference list of relevant articles. We also contacted experts in the field. Randomised trials comparing routine continuous electronic fetal monitoring with intermittent auscultation. Data were extracted by one reviewer, and their accuracy was confirmed independently by a second person. A single reviewer assessed study quality based on criteria developed by others for randomised controlled trials. Data reported from similar studies were used to calculate a combined risk estimate for each of eight outcomes. Nine studies involving 18,561 women and their 18,695 infants were included. The trials were of variable quality. A statistically significant decrease was associated with routine continuous EFM for neonatal seizures (relative risk (RR) = 0. 51, confidence interval (CI) = 0.32,0.82). The protective effect for neonatal seizures was only evident in studies with high-quality scores. No significant differences were observed in 1-minute Apgar scores below 4, 1-minute Apgar scores below 7, rate of admissions to neonatal intensive care units, and perinatal death. An increase associated with the use of EFM was observed in the rate of cesarean delivery (RR = 1.41, CI = 1.23,1.61) and operative vaginal delivery (RR = 1.20, CI = 1.11,1.30). The only clinically significant benefit from the use of routine continuous EFM was in the reduction of neonatal seizures. In view of the increase in cesarean and operative vaginal deliveries, the long-term benefit of this reduction must be evaluated in the decision reached jointly by the pregnant woman and her clinician to use continuous EFM or intermittent auscultation during labor.

Near-infrared spectroscopy for fetal assessment during labour.

Over the past four decades, continuous electronic fetal monitoring (EFM) has been increasingly employed to detect fetal acidemia in labor, with a view toward prevention of hypoxic ischemic encephalopathy, permanent neurologic injury, and death. Although very sensitive, this technology has low specificity, and a high false positive rate. This false positive rate has resulted in operative intervention on behalf of many fetuses who were not in fact in danger of neurologic injury or death. Near-infrared spectroscopy has been developed to directly measure fetal cerebral oxygenation, with a view toward identification of those fetuses truly at risk. To determine the effects of the use of near-infrared spectroscopy (NIRS) to assess fetal condition during labour, on maternal and perinatal outcomes. We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register. Date of last search: November 1999. Randomized trials comparing near-infrared spectroscopy with continuous EFM alone or continuous EFM and scalp pH. Eligibility and trial quality were assessed by one reviewer. No randomized trials were identified. Thus no studies were included. There is currently insufficient evidence to assess the efficacy of fetal surveillance by near-infrared spectroscopy.

Looking for an obstetrical caregiver in the United States: one woman's experience.

Looking for an obstetrical caregiver in the United States: one woman's experience.