Continuous Fetal Heart Rate Monitoring Research Articles

Computer Vision for Identification of Increased Fetal Heart Variability in Cardiotocogram

Introduction: Increased fetal heart rate variability (IFHRV), defined as fetal heart rate (FHR) baseline amplitude changes of >25 beats per minute with a duration of ≥1 min, is an early sign of intrapartum fetal hypoxia. This study evaluated the level of agreement of machine learning (ML) algorithms-based recognition of IFHRV patterns with expert analysis. Methods: Cardiotocographic recordings and cardiotocograms from 4,988 singleton term childbirths were evaluated independently by two expert obstetricians blinded to the outcomes. Continuous FHR monitoring with computer vision analysis was compared with visual analysis by the expert obstetricians. FHR signals were graphically processed and measured by the computer vision model labeled SALKA. Results: In visual analysis, IFHRV pattern occurred in 582 cardiotocograms (11.7%). Compared with visual analysis, SALKA recognized IFHRV patterns with an average Cohen’s kappa coefficient of 0.981 (95% CI: 0.972–0.993). The sensitivity of SALKA was 0.981, the positive predictive rate was 0.822 (95% CI: 0.774–0.903), and the false-negative rate was 0.01 (95% CI: 0.00–0.02). The agreement between visual analysis and SALKA in identification of IFHRV was almost perfect (0.993) in cases (N = 146) with neonatal acidemia (i.e., umbilical artery pH <7.10). Conclusions: Computer vision analysis by SALKA is a novel ML technique that, with high sensitivity and specificity, identifies IFHRV features in intrapartum cardiotocograms. SALKA recognizes potential early signs of fetal distress close to those of expert obstetricians, particularly in cases of neonatal acidemia.

The effect of prone positioning on maternal haemodynamics and fetal wellbeing in the third trimester-A primary cohort study with a scoping review.

Supine sleep position is associated with stillbirth, likely secondary to inferior vena cava compression, and a reduction in cardiac output (CO) and uteroplacental perfusion. Evidence for the effects of prone position in pregnancy is less clear. This study aimed to determine the effect maternal prone position on maternal haemodynamics and fetal heart rate, compared with left lateral position. Twenty-one women >28 weeks' gestation underwent non-invasive CO monitoring (Cheetah) every 5 minutes and continuous fetal heart rate monitoring (MONICA) in left lateral (20 minutes), prone (30 minutes), followed by left lateral (20 minutes). Anxiety and comfort were assessed by questionnaires. Regression analyses (adjusted for time) compared variables between positions. The information derived from the primary study was used in an existing mathematical model of maternal circulation in pregnancy, to determine whether occlusion of the inferior vena cava could account for the observed effects. In addition, a scoping review was performed to identify reported clinical, haemodynamic and fetal effects of maternal prone position; studies were included if they reported clinical outcomes or effects or maternal prone position in pregnancy. Study records were grouped by publication type for ease of data synthesis and critical analysis. Meta-analysis was performed where there were sufficient studies. Maternal blood pressure (BP) and total vascular resistance (TVR) were increased in prone (sBP 109 vs 104 mmHg, p = 0.03; dBP 74 vs 67 mmHg, p = 0.003; TVR 1302 vs 1075 dyne.s-1cm-5, p = 0.03). CO was reduced in prone (5.7 vs 7.1 mL/minute, p = 0.003). Fetal heart rate, variability and decelerations were unaltered. However, fetal accelerations were less common in prone position (86% vs 95%, p = 0.03). Anxiety was reduced after the procedure, compared to beforehand (p = 0.002), despite a marginal decline in comfort (p = 0.04).The model predicted that if occlusion of the inferior vena cava occurred, the sBP, dBP and CO would generally decrease. However, the TVR remained relatively consistent, which implies that the MAP and CO decrease at a similar rate when occlusion occurs. The scoping review found that maternal and fetal outcomes from 47 included case reports of prone positioning during pregnancy were generally favourable. Meta-analysis of three prospective studies investigating maternal haemodynamic effects of prone position found an increase in sBP and maternal heart rate, but no effect on respiratory rate, oxygen saturation or baseline fetal heart rate (though there was significant heterogeneity between studies). Prone position was associated with a reduction in CO but an uncertain effect on fetal wellbeing. The decline in CO may be due to caval compression, as supported by the computational model. Further work is needed to optimise the safety of prone positioning in pregnancy. This trial was registered at clinicaltrials.gov (NCT04586283).

Association Between Marked Fetal Heart Rate Variability and Neonatal Acidosis: A Prospective Cohort Study

ABSTRACT Monitoring of fetal heart rate (FHR) is an important indicator of fetal well-being during labor, but it is subject to low specificity and interpretation variability; this causes the clinical effectiveness for preventing adverse outcomes to remain controversial. Fetal heart rate has inherent variability, but reduced or marked variability can reflect poor autonomic activity, indicating conditions such as fetal acidosis. Recent research has highlighted that marked variability can indicate fetal distress; more research is needed to validate and investigate this claim. This study aimed to understand the association between marked FHR variability during labor and subsequent neonatal acidosis. Data were collected from 2 French maternity units; inclusion criteria extended to women at 37 weeks' gestation or greater, with continuous FHR monitoring during labor. Exclusion criteria were intrauterine fetal death, medical termination, multiple pregnancies, noncephalic presentation, and cesarean delivery. The primary outcome for this study was neonatal acidosis, or an umbilical artery pH of less than or equal to 7.10. Secondary outcomes included severe acidosis (pH ≤7.0), a 5-minute Apgar score of less than 7, respiratory distress, neonatal intensive care unit admission, neonatal infection, and neonatal death. Final analysis included 4394 women who gave birth between January 1 and December 31, 2019. Of this population, 177 neonates experienced marked variability in FHR within 1 hour before delivery, with a median duration of marked variability of 2 minutes. Prevalence of neonatal acidosis was 15.3% in neonates who experienced marked FHR variability and 5.6% in those who did not (aRR, 2.30; 95% confidence interval [CI], 1.53–3.44). In addition, those with marked FHR variability more often experienced respiratory distress (aRR, 1.73; 95% CI, 1.15–2.58). Analysis was subsequently performed according to the National Institute of Child Health and Human Development category of FHR; the association between FHR variability and neonatal acidosis was significant in category I (aRR, 5.48; 95% CI, 1.88–15.96) and category II (aRR, 2.29; 95% CI, 1.40–3.74) groups. Category III FHR, however, had no significant association. Strengths of this study include the prospective cohort design, as well as generalizability. Subcategory assessment of the FHR patterns allowed for more accurate examination of the risk of neonatal acidosis. Limitations include an observational design and the strict exclusion criteria required to minimize bias, which reduces generalizability to low-risk groups. The findings of this study are consistent with previous literature in that FHR variability can be a significant marker for fetal outcomes. Clinically, these results can help providers recognize the risk of fetal and neonatal acidosis. Further research is needed to delineate further associations and assess interpretations of pattern variability.

Fetal scalp stimulation for assessing fetal well-being during labour.

Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.

Association between marked fetal heart rate variability and neonatal acidosis: A prospective cohort study.

To assess the association between marked variability in fetal heart rate (FHR) and neonatal acidosis. Bicentric prospective cohort study. From January 2019 to December 2019, in two French tertiary care maternity units. Women in labour at ≥37 weeks of gestation, with continuous FHR monitoring until delivery and with the availability of umbilical arterial pH. Women with intrauterine fetal death or medical termination, multiple pregnancies, non-cephalic presentation or planned caesarean delivery were excluded. The exposure was marked variability in FHR in the 60 minutes before delivery, defined as a variability greater than 25 beats per minute, with a minimum duration of 1minute. To assess the association between marked variability and neonatal acidosis, we used multivariable modified Poisson regression modelling. We then conducted subgroup analyses according to the US National Institute of Child Health and Human Development (NICHD) category of the associated fetal heart rate. Neonatal acidosis, defined as an umbilical artery pH of ≤7.10. Among the 4394 women included, 177 (4%) had marked variability in fetal heart rate in the 60 minutes before delivery. Acidosis occurred in 6.0% (265/4394) of the neonates. In the multivariable analysis, marked variability was significantly associated with neonatal acidosis (aRR2.30, 95%CI 1.53-3.44). In subgroup analyses, the association between marked variability and neonatal acidosis remained significant in NICHD category-I and category-II groups. Marked variability was associated with a twofold increased risk of neonatal acidosis.

Maternal and fetal outcomes in meconium-stained amniotic fluid deliveries in a tertiary center

Backgrounds and objectives: Meconium -stained liquor could be an alarming sign of fetal distress and needs continuous fetal heart rate monitoring and urgent interventions. The study aimed to determine maternal and fetal outcomes among women presented with meconium-stained amniotic fluid during labor in relation to mode of delivery, rate of caesarian section, Admission to neonatal intensive care unit and neonatal complications and mortality. Methods: A cross-sectional study was carried out in Duhok Obestetric and Gynecology Teaching Hospital between 1st of September 2019 and 1st of April 2020 where 100 women in labor diagnosed with meconium stained amniotic fluid gestational age between (37_40+6 weeks) included in this study, all participants were meet inclusion criteria for this study and a written consent obtained from them. Results: The study showed that out of 100 participants with meconium stained liquor 48% of them delivered by lower segment cesarean section and the cause of 76.6% of them was fetal distress .The study showed significant statistical association between meconium stained liquor and lower mean scores of APGAR scores at 1 and 5 min , and rate of neonatal intensive care unit admission which was 74 (74.0%) and neonatal complications rate such as meconium Aspiration Syndrome (31.0%), Respiratory Distress Syndrome (14.0%), and Early Neonatal Death (3.0%) ,the study showed that women with spontaneous rupture membrane and thick meconium were significantly more likely to have infants with meconium aspiration syndrome; 46.2% and 48.1% respectively. Conclusions: This study showed that women in labor with meconium-stained amniotic fluid had higher fetal and maternal complications

Category II Intrapartum Fetal Heart Rate Patterns Unassociated With Recognized Sentinel Events: Castles in the Air.

The evolution of continuous electronic fetal heart rate (FHR) monitoring has presented the obstetrician with a critical clinical conundrum: basic science observations suggest that such monitoring might be associated with improved long-term neurologic outcomes, yet, after a half century of use and millions of cesarean deliveries based on FHR monitoring, evidence for such improvement remains absent. This dichotomy appears to be related to widespread misconceptions regarding the physiology underlying various FHR patterns and the developmental origins of cerebral palsy. These misconceptions are strengthened by a reliance on anecdotal experience and tradition in lieu of evidence-based medicine, the confusing "category II" FHR designation, medical-legal considerations, and our tendency to view fetal monitoring, as originally conceptualized, as a single, indivisible entity whose concepts must be accepted or rejected en bloc. Ill-defined and largely imaginary conditions such as "depletion of fetal reserve" are particularly harmful and their use in clinical medicine uniquely not evidence based. A solution to this self-inflicted injury to our specialty will require a concerted effort involving teachers, authors, and researchers.

Impact of Meconium-Stained Amniotic Fluid on Neonatal Outcome in a Tertiary Hospital.

ObjectiveThe aim of this study was to determine the perinatal outcome of pregnant patients complicated with meconium-stained amniotic fluid (MSAF) compared with clear amniotic fluid.MethodologyThis prospective cross-sectional study was conducted in the Department of Obstetrics and Gynecology in collaboration with the Department of Pediatrics at Indira Gandhi Institute of Medical Sciences, Patna, India, from September 2016 to January 2018. A total of 200 patients were included in the study after taking their written consent. Out of these 200 patients, 100 patients had MSAF, and the other 100 patients with clear liquor were taken as controls after fulfilling the inclusion and exclusion criteria. These two groups of patients were compared regarding various maternal and neonatal parameters. These parameters were compared and tested statistically for significance.ResultsAmong the 100 patients with MSAF, 20 patients had grade 1 meconium (X), 22 patients had grade 2 meconium (Y), and 58 patients had grade 3 meconium (Z). The majority of patients in the MSAF group were primigravida and more than 25 years of age. In addition, 47% of patients in the MSAF group had some associated high-risk factors and 50% of patients had non-reassuring fetal heart rate patterns, and among these, 39 patients had grade 3 MSAF (X). In the MSAF group, 49% of patients had undergone lower segment cesarean section (LSCS), whereas in the non-MSAF group, it was 37%. Also, 30% of babies in the MSAF group and 13% in the non-MSAF group had neonatal intensive care unit (NICU) admission; 22% of babies in the MSAF group and 12% of babies in the non-MSAF group had an adverse neonatal outcome. Meconium aspiration syndrome was present in 14% of the patients in the MSAF group, and among these, two babies had neonatal death and both had severe birth asphyxia. In the non-MSAF group, there was one neonatal death due to neonatal sepsis. However, after statistically analyzing the neonatal outcome in both the groups, there was no statistical difference between the two groups (p<0.001).ConclusionMSAF is associated with increased frequency of operative delivery, poor neonatal outcomes, and increased NICU admission. Management of labor with MSAF requires appropriate intrapartum care with continuous fetal heart rate monitoring, and this can reduce unnecessary cesarean sections in patients with MSAF.

Safety of Internal Electronic Fetal Heart Rate Monitoring During Labor

Abstract Objective: To investigate the safety and efficacy of internal electronic fetal heart rate (FHR) monitoring during labor. Methods: This was a retrospective case-control study, which was an analysis of monitoring FHR with a fetal scalp electrode or a Doppler probe (94 pregnant women per group). In the internal monitoring group, when the opening of the uterine orifice was ≥3 cm, the fetal scalp electrode was placed after natural or artificial rupture of the membrane. FHR was simultaneously monitored using a Doppler probe. In the external monitoring group, continuous FHR monitoring was performed using an ultrasound Doppler transducer fixed on the maternal abdomen. The toco transducer was used to record uterine contractions. Pathological examination of the placenta was performed prospectively in 49 and 48 cases in the internal electronic FHR monitoring group and control group, respectively. Maternal-infant outcomes (e.g. fever, puerperal infection, puerperal morbidity, delivery mode, Apgar score, and scalp injury) were recorded. Umbilical artery blood was extracted for blood gas analysis. Differences between the two groups were compared using the paired t-test, χ 2 test, Yates corrected χ 2 test or Fisher exact test. Results: Non-statistically significant differences between the internal and external monitoring groups were observed in the incidence of neonatal acidosis (1/94 (1.06%) vs. 3/94 (3.19%), respectively; χ 2 = 0.255, P = 0.613), cesarean section/operative vaginal delivery (8/94 (8.51%) vs. 15/94 (15.96%), respectively; χ 2 = 2.427, P = 0.181), fever during labor (18/94 (19.15%) vs. 15/94 (15.96%), respectively; χ 2 = 0.331, P = 0.565), puerperal morbidity (2/94 (2.13%) vs. 3/94 (3.19%), respectively; χ 2 = 0.000, P = 1.000), chorioamnionitis (9/49 (18.37%) vs. 7/48 (14.58%), respectively; χ 2 = 0.252, P = 0.616), and neonatal asphyxia (0/94 (0.00%) vs. 1/94 (1.06%), respectively; χ 2 = 0.000, P = 1.000). There were no puerperal infections, neonatal scalp injuries, or scalp abscesses found in either group. Using the internal monitoring value as reference, the incidence of FHR false deceleration in external FHR monitoring was 20.21% (19/94 women). Conclusion: Internal FHR monitoring during labor does not increase the incidence of adverse perinatal outcomes. External monitoring was associated with FHR false decelerations.

Intrapartum fetal heart rate monitoring and offspring long-term neurological health

Although some evidence suggests that intrapartum fetal heart rate (FHR) monitoring is associated with a reduction in intrapartum death, a reduction in long-term neurological impairment or cerebral palsy (CP) has not been proven. However, continuous intrapartum FHR monitoring resulted in more cesarean deliveries (CDs) for abnormal FHR patterns. In this study, we sought to evaluate offspring long-term neurological morbidity of children born via CD for non-reassuring FHR (NRFHR) indication as compared with non-progressive labor (NPL)

Admission cardiotocography: Forecasting perinatal outcome

The Admission test (AT) in high risk pregnancy for continuous monitoring of FHR (fetal heart rate) has become crucial in the modern day obstetric practice. As it senses the presence of fetal intrapartum hypoxia and assist the obstetrician in making decision on the mode of delivery to improve perinatal outcome in high risk pregnancy.A prospective observational study was carried out in 230 pregnant women with high risk pregnancy in KIMS BBSR, Odisha during period of 2018-2020 who were admitted to labor room with gestational age more than 33 weeks for continuous FHR monitoring with CTG (cardiotocography) for 20 minutes.Among 230 patients majority of them were primigravida in age group of 21-25 years. About 39.1% were postdated pregnancy followed by Pregnancy Induced Hypertension (PIH) (21.1%), Premature Rupture of the Membranes (PROM) (10.4%), Bad Obstetric History (BOH) (6.9%), PIH with IUGR (Intrauterine Growth Restriction) (6.5%), IUGR (5.6%), Oligohydramnios (4.3%), Diabetes (3.5%) and Rh negative pregnancy (2.6%). The admission test were normal in (68.7%), suspicious in (21.7%) and pathological in (9.6%). The incidence of fetal distress, meconium stained liqour, NICU (Neonatal Intensive Care Unit) admission and APGAR score less than 7 was significantly higher with pathological AT as compared with suspicious and normal AT.The admission CTG appears to be simple noninvasive tool for screening the high risk pregnancy and prioritizing fetuses and deciding the mode of delivery.

Spontaneous Umbilical Cord Hematoma

Spontaneous umbilical cord hematoma is a rare complication with a usually benign course but is potentially fatal without vigilant and timely medical intervention.We present the case of a 23-year-old primigravida mother who presented in labor. She was placed on continuous fetal heart rate monitoring, which showed two episodes of fetal heart rate tracing of the category II variety. The labor was induced with oxytocin, and the ammonitic membrane was incised artificially. The baby was male, term at 38 weeks, with an appropriate weight, length, and head circumference. There was no gross anomaly or dysmorphic features; the APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) score of the baby was 9 and 9 at the first and fifth minutes, respectively. A 4.5 cm hematoma was discovered on the umbilical cord immediately following delivery. He was admitted to the regular nursery for routine newborn care and was discharged home in stable condition. Spontaneous umbilical cord hematoma is usually due to the rupture of the umbilical vein. Mostly, the umbilical cord hematoma occurs spontaneously and often follows a benign course, however, in some cases, the perinatal loss secondary to umbilical cord hematoma could very high, especially if associated with abnormal fetal heart rate tracing. Because of the potential for fatality inherent in this condition and to understand the clinical manifestations, risk factors, and eventual course of spontaneous cord hematoma, we present this case to help fellow pediatricians reduce morbidity and mortality associated with it.

Continuous Fetal Monitoring During Electroconvulsive Therapy: A Prospective Observation Study.

ObjectiveThe use of electroconvulsive therapy in pregnancy has been limited by concerns about its effects on fetal well-being, despite limited evidence that suggests it is safe and effective. No studies have utilized continuous fetal heart rate monitoring during electroconvulsive therapy sessions. We aimed to describe the fetal heart rate patterns of patients undergoing electroconvulsive therapy.DesignThis study is a prospective case series of pregnant patients undergoing electroconvulsive therapy with continuous fetal heart rate monitoring.SettingUniversity-based hospital.PopulationPregnant patients with a psychiatric indication for electroconvulsive therapy.MethodsPatients underwent fetal heart rate monitoring immediately prior, during and immediately after ECT therapy.Main Outcome MeasuresCharacterization of the fetal heart rate tracing.ResultsFive subjects underwent 44 electroconvulsive therapy sessions. Continuous fetal monitoring was performed on 34 of the sessions. Transient fetal heart rate decelerations occurred in 4 sessions, all self-resolved and none required intervention.ConclusionThis case series is the first to report the results of continuous FHR monitoring during electroconvulsive therapy. The most common finding was a transient, self-resolving bradycardia that was not associated with adverse perinatal outcomes. This supports the opinion that electroconvulsive therapy is a safe treatment option in pregnancy in women with severe mental disease.

VP45.02: Screening for COVID‐19 and maternal‐fetal outcomes in a cohort of asymptomatic pregnant patients at term in Lombardy, Italy

The RCOG recommends continuous fetal heart rate (cFHR) monitoring during labour in COVID-19 patients, whereas other sources do not consider this necessary if patients are asymptomatic. Vascular complications in COVID-19 are emerging; potential risks of both fetal hypoxia due to placental dysfunction and maternal disease deterioration secondary to cardiopulmonary overload may occur in labour. Our aim was to observe maternal-fetal outcomes in an unpublished series of asymptomatic pregnant patients screened for COVID-19 before admission to labour ward. COVID-19 screening with qRT-PCR on nasopharyngeal swabs was performed in patients admitted for delivery in a tertiary centre in Milan between 16 March and 2 May 2020. cFHR monitoring was performed and maternal-fetal outcomes were compared in COVID-19 positive and negative patients. 195 patients were admitted for delivery at a mean gestational age of 39.4 ± 1.8 weeks. Nine (4.6%) tested positive for COVID-19 (all NIH class “asymptomatic”); two were delivered via an emergency CS for fetal distress and one to elective CS for genital Herpes. Six out of 8 patients (75%) eligible for vaginal birth had vaginal delivery with no maternal symptoms developing thereafter. No significant differences in Apgar scores at 1 and 5 minutes (9.2 ± 1.2 vs 9.6 ± 0.5; p = 0.36; 9.9 ± 0.5 vs 10 ± 0.0; p = 0.42), umbilical artery pH at birth (7.27 ± 0.08 vs 7.26 ± 0.07; p = 0.69), and rate of urgent deliveries for fetal distress (20.3% vs 22.2%, p = 0.89) between patients testing negative and positive for COVID-19 were seen. No false-negative/positive swabs were recorded on the basis of a two week clinical follow-up. Screening results were comparable to the general population. Vaginal delivery appeared safe for the mother and the risk of fetal distress was not increased in our series of asymptomatic pregnant patients with COVID-19 at term. Further research is required to confirm this conclusion.

Neonatal Outcomes of Continues Fetal Heart Rate Monitoring in Low-Risk Pregnant Women During Labor

Various methods are used in order to describe the heart rate patterns of the fetus. The use of electronic monitoring during labor is widely accepted today. The aim of this study was to compare the neonatal outcomes of continuous Fetal Heart Rate (FHR) monitoring to intermittent auscultation among lowrisk pregnant women during labor. This randomized clinical trial was conducted among 900 low-risk pregnant women who met inclusion criteria and were admitted to maternity wards of academic hospitals of Mashhad University of Medical Sciences for labor. They were randomly divided into two groups: the intermittent auscultation group and the Continuous FHR monitoring group. The pregnancy and neonatal outcomes were compared in two groups; data were processed in SPSS16 software. P less than 0.05 was considered as significant level. In this study, the first and fifth minutes Apgar scores, the rate of NICU admission, advance resuscitation requirement, neonatal seizure incidence, and the neonatal or fetal death did not differ significantly between two groups (P&gt;0.05). In the Continues monitoring group, the rate of cesarean section due to fetal distress and operative vaginal delivery was significantly higher rather than the other group (P=0.001). The results of this study showed that continuous FHR monitoring in low-risk pregnancies during labor increases the risk of cesarean and instrumental delivery without improving neonatal outcomes.

Is short-term-variation of fetal-heart-rate a better predictor of fetal acidaemia in labour? A feasibility study.

Continuous intrapartum fetal monitoring is challenging and its clinical benefits are debated. The project evaluated whether short-term-variation (STV) and other computerised fetal heart rate (FHR) parameters (baseline FHR, long-term-variation, accelerations and decelerations) predicted acidaemia at birth. The aims of the study were to assess the changes in FHR pattern during labour and determine the feasibility of undertaking a definitive trial by reporting the practicalities of using the monitoring device, participant recruitment, data collection and staff training. 200 high-risk women carrying a term singleton, non-anomalous fetus, requiring continuous FHR monitoring in labour were consented to participate from the Jessop Wing maternity unit, Sheffield, UK. The trans-abdominal fetal ECG monitor was placed as per clinical protocol. During the monitoring session, clinicians were blinded to the computerised FHR parameters. We analysed the last hour of the FHR and its ability to predict umbilical arterial blood pH <7.20 using receiver operator characteristics (ROC) curves. Of 200 women, 137 cases were excluded as either the monitor did not work from the onset of labour (n = 30), clinical staff did not return or used the monitor on another patient (n = 37), umbilical cord blood not obtained (n = 25), FHR data not recorded within an hour of birth (n = 34) and other reasons (n = 11). In 63 cases included in the final analysis, the computer-derived FHR parameters did not show significant correlation with umbilical artery cord pH <7.20. Labour was associated with a significant increase in short and long term variation of FHR and number of deceleration (P<0.001). However, baseline FHR decreased significantly before delivery (P<0.001). The project encountered a number of challenges, with learning points crucial to informing the design of a large study to evaluate the potential place of intrapartum computerised FHR parameters, using abdominal fetal ECG monitor before its clinical utility and more widespread adoption can be ascertained.

Identification of the Fetus at Risk for Metabolic Acidemia Using Continuous Fetal Heart Rate Monitoring.

The fetal heart rate can be used to assess the current metabolic state of the fetus and predict the risk of the evolution of metabolic acidemia through the course of labor. In this chapter, we will present the pathophysiology of the development of fetal acidemia and provide an organized approach to identifying the risk of worsening acidemia using changes noted in the fetal heart rate pattern to allow for interventions that might alter this course.

Doppler Ultrasound Technology for Fetal Heart Rate Monitoring: A Review.

Fetal well-being is commonly assessed by monitoring the fetal heart rate (fHR). In clinical practice, the de facto standard technology for fHR monitoring is based on the Doppler ultrasound (US). Continuous monitoring of the fHR before and during labor is performed using a US transducer fixed on the maternal abdomen. The continuous fHR monitoring, together with simultaneous monitoring of the uterine activity, is referred to as cardiotocography (CTG). In contrast, for intermittent measurements of the fHR, a handheld Doppler US transducer is typically used. In this article, the technology of Doppler US for continuous fHR monitoring and intermittent fHR measurements is described, with emphasis on fHR monitoring for CTG. Special attention is dedicated to the measurement environment, which includes the clinical setting in which fHR monitoring is commonly performed. In addition, to understand the signal content of acquired Doppler US signals, the anatomy and physiology of the fetal heart and the surrounding maternal abdomen are described. The challenges encountered in these measurements have led to different technological strategies, which are presented and critically discussed, with a focus on the US transducer geometry, Doppler signal processing, and fHR extraction methods.

Implementation of a novel continuous fetal Doppler (Moyo) improves quality of intrapartum fetal heart rate monitoring in a resource-limited tertiary hospital in Tanzania: An observational study.

BackgroundIntrapartum Fetal Heart Rate (FHR) monitoring is crucial for the early detection of abnormal FHR, facilitating timely obstetric interventions and thus the potential reduction of adverse perinatal outcomes. We explored midwifery practices of intrapartum FHR monitoring pre and post implementation of a novel continuous automatic Doppler device (the Moyo).MethodologyA pre/post observational study among low-risk pregnancies at a tertiary hospital was conducted from March to December 2016. In the pre-implementation period, intermittent monitoring was conducted with a Pinard stethoscope (March to June 2016, n = 1640 women). In the post-implementation period, Moyo was used for continuous FHR monitoring (July-December 2016, n = 2442 women). The primary outcome was detection of abnormal FHR defined as absent, FHR<120or FHR>160bpm. The secondary outcomes were rates of assessment/documentation of FHR, obstetric time intervals and intrauterine resuscitations. Chi-square test, Fishers exact test, t-test and Mann-Whitney U test were used in bivariate analysis whereas binary and multinomial logistic regression were used for multivariate.ResultsMoyo use was associated with greater detection of abnormal FHR (8.0%) compared with Pinard (1.6%) (p<0.001). There were higher rates of non-assessment/documentation of FHR pre- (45.7%) compared to post-implementation (2.2%) (p<0.001). At pre-implementation, 8% of deliveries had FHR documented as often as ≤ 60 minutes, compared to 51% post-implementation (p<0.001). Implementation of continuous FHR monitoring was associated with a shorter time interval from the last FHR assessment to delivery i.e. median (IQR) of 60 (30,100) to 45 (21,85) minutes (p<0.001); and shorter time interval between each FHR assessment i.e. from 150 (86,299) minutes to 60 (41,86) minutes (p<0.001). Caesarean section rates increased from 2.6 to 5.4%, and vacuum deliveries from 2.2 to 5.8% (both p<0.001). Perinatal outcomes i.e. fresh stillbirths and early neonatal deaths were similar between time periods. The study was limited by both lack of randomization and involvement of low-risk pregnant women with fewer adverse perinatal outcomes than would be expected in a high-risk population.ConclusionImplementation of the Moyo device, which continuously measures FHR, was associated with improved quality in FHR monitoring practices and the detection of abnormal FHR. These improvements led to more frequent and timely obstetric responses. Follow-up studies in a high-risk population focused on a more targeted description of the FHR abnormalities and the impact of intrauterine resuscitation is a critical next step in determining the effect on reducing perinatal mortality.

The relationship between intrapartum cerebroplacental ratio and adverse perinatal outcomes in term fetuses

ObjectivesThe cerebroplacental ratio (CPR) Doppler has been proposed as an instrument for predicting adverse perinatal outcomes particularly during antepartum period. Abnormal CPR is associated with non-reassuring fetal status requiring operative delivery, low Apgar score and neonatal complications. The aim of this study was to assess the role of CPR Doppler in the labor triage suite, so as to identify fetuses at risk for non-reassuring status as well as other adverse perinatal outcomes. MethodsThis was a prospective cohort study of term pregnancies who attended the labor room during the latent phase of labor. Both fetal Middle Cerebral Artery Pulsatility Index (MCA-PI) and Umbilical Artery Pulsatility Index (UA-PI) were measured and these values were converted to CPR values. Non-reassuring fetal status requiring operative delivery and other adverse perinatal outcomes were compared between women with normal and abnormal CPR values. Accuracy of CPR for predicting non-reassuring fetal status and abnormal fetal heart rate patterns were calculated. ResultsA total of 384 women were recruited. Lower CPR values were observed in women who underwent operative delivery for non-reassuring fetal status. However, when dividing women into normal and abnormal CPR groups, using 3 different cut-off values, the rate of non-reassuring fetal status was not significantly different between the groups. There was a significantly higher rate of abnormal fetal heart rate monitoring in fetuses with CPR < 5th percentile and CPR < 1. CPR appeared to have a low positive predictive value (PPV) for predicting non-reassuring fetal heart rate patterns, however, the negative predictive value (NPV) was high. ConclusionsIn term fetuses, lower CPR is associated with non-reassuring fetal status. CPR measurement during the intrapartum period with currently available CPR cut-off values is not a good predictor for adverse perinatal outcomes, with the exception of abnormal fetal heart rate patterns. However, the high NPV may be used to stratify pregnant women who may benefit from continuous fetal heart rate monitoring.