Fetal Heart Rate Accelerations Research Articles

Decreased fetal movements at home were recorded by a newly developed fetal movement recorder in a case of a non-reassuring fetal status

A fetal movement acceleration measurement (FMAM) recorder was developed for home monitoring of fetal movements. We provided a 32-year-old pregnant woman with the FMAM recorder to home monitor fetal movements, thereby self-recording decreased fetal movements at 30 weeks’ gestation. On routine checkup, a non-stress test revealed scant fetal heart rate accelerations. At 31 weeks’ gestation, the woman underwent an emergent caesarean delivery because of a non-reassuring fetal heart rate pattern, and delivered a female neonate weighing 1312 g, whose umbilical cord was slightly narrowed at the umbilicus. Our experience with the present case suggests the usefulness of the FMAM recorder.

Origin of the long-term variability and acceleration of FHR studied for the prevention of cerebral palsy in fetal hypoxia and general insults

The development of fetal heart rate (FHR) variability and acceleration, and their loss in the hypoxic brain damage and cerebral palsy (CP) is investigated. FHR, movements in physiologic sinusoidal FHR and fetal movements were studied by actocardiogram. Periodic fetal respiratory movements evoked moderate FHR variation similar to medium variability. Small fetal movements provoked FHR variability, and large fetal movement burst developed the acceleration. The brain centers should be midbrain for variability and acceleration. FHR variability and acceleration develop by the reaction of fetal brain to fetal movements. As severe organic fetal brain damage could develop through fetal hypoxia in the loss of variability, early delivery before the loss of variability will prevent infantile CP. As the abnormal FHR would be developed by fetal brain damage in non-hypoxic fetal insults, early delivery before the loss of variability could also prevent the brain damage in viral and bacterial infections.

Electronic fetal heart rate monitoring in five fetuses with Ebstein's anomaly

It is not clear whether fetuses with Ebstein's anomaly are likely to show abnormalities on electronic fetal heart rate (FHR) monitoring during labor. We performed retrospective analysis of FHR monitoring results obtained between 2.5 and 0.5 h prior to delivery in all of five fetuses prenatally diagnosed as having Ebstein's anomaly and born at our institution during the period between March 2005 and July 2011. All five mothers attempted to give birth vaginally. The results of FHR monitoring in 100 consecutive women with otherwise healthy singletons who attempted vaginal delivery were included as controls. The absence of FHR acceleration (4/5 [80%]), decreased baseline FHR variability (3/5 [60%]) and late deceleration (4/5 [80%]) were seen significantly more often in the five fetuses with Ebstein's anomaly than the 100 fetuses born to control women (6.0%, 6.0%, and 10%, respectively). Fetuses with Ebstein's anomaly during labor were likely to exhibit absent acceleration, decreased baseline FHR variability and late deceleration compared to infants without cardiac structural anomalies.

Misidentification of Maternal Heart Rate as Fetal on Cardiotocography During the Second Stage of Labor

Objective To identify the incidence of fetal heart rate (FHR) accelerations in the second stage of labor and the role of fetal electrocardiograph (ECG) in avoiding misidentification of maternal heart rate (MHR) as FHR. Design Retrospective observational study. Setting University hospital labor ward, London, UK. Sample Cardiotocograph (CTG) tracings of 100 fetuses monitored using external transducers and internal scalp electrodes. Methods CTG traces that fulfilled inclusion criteria were selected from an electronic FHR monitoring database. Main outcome measures Rate of accelerations during external and internal monitoring as well as decelerations for a period of 60 minutes prior to delivery were determined. The role of fetal ECG in differentiating between MHR and FHR trace was explored. Results Decelerations occurred in 89% of CTG traces during the second stage of labor. Accelerations indicating possible recording of FHR or MHR were found in 28.1 and 10.9% of cases recorded by an external ultrasound transducer as well as internal scalp electrode, respectively. Accelerations coinciding with uterine contractions occurred only in 11.7 and 4% of external and internal recording of FHR, respectively. Absence of 'p-wave' of the ECG waveform was associated with MHR trace. Conclusion Decelerations were the commonest CTG feature during the second stage of labor. The incidence of accelerations coinciding with uterine contractions was less than half in fetuses monitored using a fetal scalp electrode. Analysing the ECG waveform for the absence of 'p-wave' helps in differentiating MHR from FHR.

Vibroacoustic stimulation for fetal assessment in labour in the presence of a nonreassuring fetal heart rate trace.

Fetal vibroacoustic stimulation (VAS) is a simple, non-invasive technique where a device is placed on the maternal abdomen over the region of the fetal head and sound is emitted at a predetermined level for several seconds. It is hypothesised that the resultant startle reflex in the fetus and subsequent fetal heart rate (FHR) acceleration or transient tachycardia following VAS provide reassurance of fetal well-being. This technique has been proposed as a tool to assess fetal well-being in the presence of a nonreassuring cardiotocographic (CTG) trace during the first and second stages of labour. To evaluate the clinical effectiveness and safety of VAS in the assessment of fetal well-being during labour, compared with mock or no stimulation for women with a singleton pregnancy exhibiting a nonreassuring FHR pattern. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (6 September 2012) and reference lists of all retrieved articles. We sought unpublished trials and abstracts submitted to major international congresses and contacted expert informants. All published and unpublished randomised trials that compared maternal and fetal/neonatal/infant outcomes when VAS was used to evaluate fetal status in the presence of a nonreassuring CTG trace during labour, compared with mock or no stimulation. Two review authors independently sought to assess for inclusion all the potential studies we identified as a result of the search strategy. We planned to resolve any disagreement through discussion or, if required, to consult a third person. Where there was uncertainty about a particular study, we attempted to contact study authors for additional information. However, these attempts were unsuccessful. The search strategies yielded six studies for consideration of inclusion. However, none of these studies fulfilled the requirements for inclusion in this review. There are currently no randomised controlled trials that address the safety and efficacy of VAS used to assess fetal well-being in labour in the presence of a nonreassuring CTG trace. Although VAS has been proposed as a simple, non-invasive tool for assessment of fetal well-being, there is insufficient evidence from randomised trials on which to base recommendations for use of VAS in the evaluation of fetal well-being in labour in the presence of a nonreassuring CTG trace.

Actocardiographic Analysis of Fetal Hypoxia Detected by the Bradycardia, Loss of Fetal Heart Rate Acceleration, and Long Term Variability

Aims: To clarify the mechanism of hypoxic Fetal Heart Rate (FHR) by the actocardio-gram. Methods: Hypoxic rabbit heart rate and PaO 2 were studied. Long Term FHR Variability (LTV) was studied in physiologic sinusoidal FHR and anencephalic fetus, the acceleration in hypoxia, and by its electronic simulation and adult heart rate. Results: Anencephalic neonatal bradycardia was caused by the excitation of remained medulla oblongata. Rabbit's bradycardia was parallel to PaO 2 bunder 50 mm Hg, which disappeared after urethane anesthesia. Human fetal bradycardia was caused by the hypoxia, because fetal PaO2 is less than 50 mm Hg. FHR acceleration was evoked in the midbrain by the large fetal movement bursts, and minor movements evoked LTV. Physiological sinusoidal FHR was a particular form of LTV. Triangular acceleration was simulated by the electronic integral circuit, and by the triangular heart rate in adult exercises. Fetal outcome was correlated to the acceleration duration. Hypoxia damaged fetal brain in nonreactive FHR, loosing acceleration, and advanced hypoxia further damaged brain a few days after the loss of acceleration, showing the loss of LTV and bradycardia. The loss of LTV which was confirmed by the frequency power spectrum was rare, but its brain damage was as severe as the apnea of anencephalic neonate, which lost cerebral respiratory center. Conclusion: Hypoxic bradycardia was evoked by the excited medulla oblongata in the decreased PaO 2 , which was lower than 50 mm Hg. The hypoxia damaged fetus in fetal bradycardia, the losses of acceleration and LTV, in relation to fetal movements.

Quantitative Analysis of Fetal Actocardiogram: Update

Abstract Aims: The actocardiogram (ACG), which recorded fetal heart rate (FHR) and movements, was quantitatively analyzed, due to its advantage to the FHR patterns diagnosis, to recognize the effect of fetal movement on FHR, to solve controversial FHR problems, to correctly evaluate fetal disorders, and to evaluate the loss of variability and acceleration. Methods: FHR changes were diagnosed by the FHR score, fetal movements were evaluated by 4 ACG parameters, fetal behavior and abnormal FHR were quantitatively determined, physiologic sinusoidal FHR was diagnosed by the ACG and FHR frequency analysis, the developing mechanism of FHR acceleration and variability were studied to diagnose the brain damage in the loss of FHR variability. 1.3 Results: The FHR score, neural network analysis and A/B ratio predicted short and long term outcomes in the 1st stage of labor or even in pregnancy. The ACG and frequency analysis differentiated physiologic sinusoidal from the true one, Contoversial problems in FHR were solved by the quantitative ACG analysis. The loss of FHR variability was the sign of fetal brain damage even in fetal non-hypoxic insults. Results: The FHR score, neural network analysis and A/B ratio predicted short and long term outcomes in the 1st stage of labor or even in pregnancy. The ACG and frequency analysis differentiated physiologic sinusoidal from the true one, Contoversial problems in FHR were solved by the quantitative ACG analysis. The loss of FHR variability was the sign of fetal brain damage even in fetal non-hypoxic insults. Conclusion: Quantitative analyses of FHR and fetal movements in ACG were indispensable in the fetal diagnosis even in general insults. Since cerebral palsy (CP) could develop in the loss of FHR variability, C-section is recommended to perform before the loss of FHR variability.

Fetal assessment before and after dosing with buprenorphine or methadone

To determine pre- and post-dosing effects of prenatal methadone compared to buprenorphine on fetal wellbeing. A secondary analysis of data derived from the Maternal Opioid Treatment: Human Experimental Research (MOTHER) study, a double-blind, double-dummy, randomized clinical trial. Six United States sites and one European site that provided comprehensive opioid-dependence treatment to pregnant women. Eighty-one of the 131 opioid-dependent pregnant women completing the MOTHER clinical trial, assessed between 31 and 33 weeks of gestation. Two fetal assessments were conducted, once before and once after study medication dosing. Measures included mean fetal heart rate (FHR), number of FHR accelerations, FHR reactivity in the fetal non-stress test (NST) and biophysical profile (BPP) score. Significant group differences were found for number of FHR accelerations, non-reactive NST and BPP scores (all Ps < 0.05). There were no significant group differences before time of dosing. Significant decreases (all Ps < 0.05) occurred from pre- to post-dose assessment for mean FHR, FHR accelerations, reactive NST and fetal movement. The decrease in accelerations and reactive NST were significant only for fetuses in the methadone group, and this resulted in a significantly lower likelihood of a reactive NST compared to fetuses in the buprenorphine group. Buprenorphine compared with methadone appears to result in less suppression of mean fetal heart rate, fetal heart rate reactivity and the biophysical profile score after medication dosing and these findings provide support for the relative safety of buprenorphine when fetal indices are considered as part of the complete risk-benefit ratio.

Nonstress testing at ≤32.0 weeks' gestation: a randomized trial comparing different assessment criteria

Comparison of time and outcomes of National Institutes of Child Health and Human Development defined fetal heart rate acceleration criteria at ≤ 32 weeks (≥ 10 beats/min, ≥ 10 seconds) compared with standard criteria (≥ 15 beats/min, ≥ 15 seconds). Singleton high-risk pregnancies that were referred for nonstress testing at ≤ 32 weeks' gestation were randomly assigned to 15 × 15 or 10 × 10 criteria. Data included nonstress test information, maternal data, and outcomes. One hundred forty-three women were randomly assigned to 15 × 15 (n = 71) or 10 × 10 (n = 72). The groups were similar in maternal and pregnancy characteristics. Median time to reactive nonstress testing was shorter in the 10 × 10 group (37.3 minutes) than the 15 × 15 group (41.3 minutes; P = .04). There were no serious adverse events. The time to attain a reactive nonstress testing at ≤ 32 weeks' gestation was 4 minutes shorter when the 10 × 10 criteria were used. There were no adverse events related to use of 10 × 10 nonstress testing criteria.

Misidentification of maternal heart rate as fetal on cardiotocography during the second stage of labor: the role of the fetal electrocardiograph

To identify the incidence of fetal heart rate (FHR) accelerations in the second stage of labor and the role of fetal electrocardiograph (ECG) in avoiding misidentification of maternal heart rate (MHR) as FHR. Retrospective observational study. University hospital labor ward, London, UK. Cardiotocograph (CTG) tracings of 100 fetuses monitored using external transducers and internal scalp electrodes. CTG traces that fulfilled inclusion criteria were selected from an electronic FHR monitoring database. Rate of accelerations during external and internal monitoring as well as decelerations for a period of 60 minutes prior to delivery were determined. The role of fetal ECG in differentiating between MHR and FHR trace was explored. Decelerations occurred in 89% of CTG traces during the second stage of labor. Accelerations indicating possible recording of FHR or MHR were found in 28.1 and 10.9% of cases recorded by an external ultrasound transducer as well as internal scalp electrode, respectively. Accelerations coinciding with uterine contractions occurred only in 11.7 and 4% of external and internal recording of FHR, respectively. Absence of 'p-wave' of the ECG waveform was associated with MHR trace. Decelerations were the commonest CTG feature during the second stage of labor. The incidence of accelerations coinciding with uterine contractions was less than half in fetuses monitored using a fetal scalp electrode. Analysing the ECG waveform for the absence of 'p-wave' helps in differentiating MHR from FHR.

The significance of amplitude and duration of fetal heart rate acceleration in non-stress test analysis

ObjectiveThis study was conducted to assess the relative significance of the amplitude versus the duration of accelerations in non-stress test (NST) analysis. Materials and MethodsA total of 3055 normal fetal heart rate (FHR) tracings at 30–42 weeks' gestation were analyzed by automated FHR analyzing software. Accelerations were classified as one of four combinations of amplitude and duration: 15 bpm–15 seconds (Acc15–15), 15 bpm–10 seconds (Acc15–10), 10 bpm–15 seconds (Acc10–15) and 10 bpm–10 seconds (Acc10–10). We estimated the correlation among the FHR acceleration combinations using correlation analysis based on linear regression models. ResultsLinear regression models demonstrated statistically significant linear associations between Acc15–15 and Acc15–10 (r2 = 0.998, p < 0.0001) and between Acc10–10 and Acc10–15 (r2 = 0.989, p < 0.0001). There was significant association based on amplitude and relatively low correlation based on duration (Pearson correlation coefficient = 0.99 between Acc10–10 and Acc10–15, and 0.99 between Acc15–15 and Acc15–10). In the relationships of the FHR-work values, amplitude was a more important component of FHR acceleration than duration [Acc10–10 (1.67 beat) < Acc10–15 (2.50 beats) = Acc15–10 (2.50 beats) < Acc15–15 (3.75 beats)]. ConclusionAmplitude was a more significant component of FHR acceleration than duration in the computerized analysis of NST.

Average acceleration and deceleration capacity of fetal heart rate in normal pregnancy and in pregnancies complicated by fetal growth restriction

Objective: To study fetal heart rate (FHR), its short term variability (STV), average acceleration capacity (AAC), and average deceleration capacity (ADC) throughout uncomplicated gestation, and to perform a preliminary comparison of these FHR parameters between small-for dates (SFD) and control fetuses. Methods: Prospective observational study of 7 h FHR-recordings obtained with a fetal-ECG monitor in the second half of uncomplicated pregnancies (n = 90) and pregnancies complicated by fetal SFD (n = 30). FHR and STV were calculated according to established analysis. True beat-to-beat FHR, recorded at 1 ms accuracy, was used to calculate AAC and ADC using Phase Rectified Signal Averaging (PRSA). Mean values of FHR, STV, AAC, and ADC derived from recordings in SFD fetuses were compared with the reference curves. Results: Compared with the control group the mean z-scores for STV, AAC, and ADC in SFD fetuses were lower by 1.0 SD, 1.5 SD, and 1.7 SD, respectively (p < 0.0001 for all comparisons). In SFD fetuses, both the AAC and ADC z-scores were lower than the STV z-scores (p < 0.02 and p < 0.002, respectively). Conclusions: Analysis of the AAC and ADC as recorded with a high resolution fECG recorder may differentiate better between normal and SFD fetuses than STV.

A big smile for spring

Old farming ladies such as the one smiling off the May issue cover are probably more commonly seen in the Baltic rather than theNordic states now-a-days. The EBCOGcongress is in Tallinn, Estonia in May, – a venue for European obstetricians and gynecologists to acquaint themselves with what is in the forefront of professional discussion and to visit this fascinating region of Europe. But thismeeting also competes with the Nordic congress in Bergen in June. The large number of speciality and subspecialitymeetings available, within countries, regions, continents and even world-wide (FIGO in Rome in October), coupled to more limited financial resources available to doctors and lesser possibilities for sponsoring, may require some innovative rethinking of how we keep up with the need for continued education and updating. Learning off and conferencing on the net are competitors to traditional conferences. At AOGS it is now becoming vital to move from the traditional print issue to more on-line based communication, using the many new possibilities that unfold to reach the readers in an effective way. Chronic pelvic pain is a multifaceted entity and we start thismonthwith a commentary froma group known for quality work in the field of evidence-based medicine on an aspect of this, the pelvic venous congestion syndrome. Elizabeth Ball and colleagues inLondon,UK(pp. 525–528), pose the important questionofwhether this exists at all.Dilated and tortuous veins in the pelvis can be demonstrated both in relation to the uterine and ovarian veins, possibly with links to vulvar and thigh varicosities, but how well does that correlate with illness, a dull chronic pain sensed in the pelvis bywomenwho do not have any other demonstrable anomaly? That venous anomalies and tortuositiesmay cause discomfort seems likely, but the condition is under-researched and much of the work on this was done rather long ago. Novel treatment modalities with embolisation are questionable. This condition, which seems to have held limited interest in the Nordic countries, is well discussed in this commentary. Backy Naoulou andMing Tsai from New York, USA (pp. 529–537) deal with another gynecologic condition for which there has traditionally been much more interest in the Nordic countries, dysfunctional uterine bleeding or heavy menstrual bleeding as it is now called. Some of the early studies in this field were published in AOGS (1,2) andNordic researchers were leading in the development of methods to manage heavy menstrual bleeding, – one of which is the levonorgestrel intrauterine system, as recently discussed in this journal (3). Tranexamic acid is an effective treatmentmodality in heavymenstrual bleeding and is a safe treatment, when judiciously used. In the future we will have more information from ongoing studies on the use of tranexamic acid in the treatment of, – or even prophylaxis for, postpartum hemorrhage. With the large problem of overweight women and pregnancy, it is highly relevant to try to modify life-style at a time whenwomenmight beparticularly receptive for this, not least because of the well demonstrated effects on the unborn baby. Can exercise help? This is discussed in a review from another group active in the field of systematic reviews on pp. 538–545 (Zhixian Sui and co-workers, Adelaide, Australia). There are clearly benefits, but they must be better researched to find effective ways to get the obese women, who by nature move less (4), to change their poor life-style habits, because these are passed on to their families and offspring with detrimental effects for society and future health-care (5). There is also a connection to a related problem, low back pain and the effect of exercise on that condition. This has been comprehensively dealt with in a large randomized study from Trondheim and Oslo in Norway and Lund, Sweden (Signe Stafne and colleagues pp. 552–559), a study which should be noted. The effects of exercise are indirect, but still positive and if they could be translated into lifestyle changes, then that might have an impact on public health again. Lone Norgaard and colleagues from Hillerod and Copenhagen, Denmark, present a large cohort study on neonatal outcomewhen themother has placenta previa (pp. 546–551). Placenta previa carries well-known dangers for the mother and at least doubles major risks for the baby. The authors call attention to the increasing chance of placenta previa with a higher mean maternal age, more assisted reproduction and excessive cesarean section rates.We should try to reverse such

Maternal heart rate patterns in the first and second stages of labor

Objective. To analyze typical maternal heart rate (MHR) patterns in the first and second stages of labor. Design. Observational study. Setting. Tertiary care community hospital. Population. Normal term parturients with epidural anesthesia. Methods. Confirmed MHR and uterine activity were simultaneously recorded. The average MHR was analyzed 10 seconds before, as well as at the peak of, each contraction and/or pushing effort. Each woman contributed one datapoint at each time point to the analysis. Main outcome measure. Change in MHR during contractions. Results. First stage: 7.6±2.1 contractions per woman (n=18) were analyzed. Average MHR decreased during contractions: from 83±13 to 74±10bpm; p<0.001). In 56% (10/18) of the women, 'early' type decelerations were seen in at least 50% of contractions. Second stage: 3.5±1.5 contractions per woman. All women (n=15) showed MHR accelerations during every pushing effort (ΔMHR: +35±13bpm; 88±14 to 123±17bpm; p<0.001). MHR was persistently >100bpm in three women (17%) in the first stage, and in four women (27%) in the second stage. Peak MHR >140bpm occurred during pushing in 20%. Conclusion. Decreases in MHR during contractions in the first stage of labor can mimic fetal heart rate (FHR) accelerations as well as early type decelerations. Thus, first stage tracings with a low baseline and early type decelerations may be maternal in origin and FHR should be independently confirmed in such tracings. Because second stage MHR accelerations generally show greater amplitude than FHR accelerations, tracings with repetitive accelerations during contractions (especially when Δ >20bpm) should be considered MHR until proven otherwise.

690: Vibroacoustic stimulation significantly reduces time that high risk patients spend in an urban antenatal testing unit

A reactive non-stress test (NST) indicates fetal wellbeing. Vibroacoustic stimulation (VAS) has been used to elicit fetal heart rate accelerations. Our primary objective was to determine whether the use of VAS in a tertiary care antenatal testing unit (ATU) would decrease the time patients spend in the ATU. Secondary objectives included decreased time on the NST monitor and number of biophysical profiles (BPPs) required due to a non-reactive NST, as well as increased patient satisfaction.

Knowledge of Adverse Neonatal Outcome Alters Clinicians' Interpretation of the Intrapartum Cardiotocograph

Presumed intrapartum hypoxic events are commonly cited in malpractice cases in obstetrics. Clinical interpretation of the fetal heart rate, known in the United Kingdom as a cardiotocograph (CTG), tracing has a direct impact on classifying a specific tracing as abnormal. Interpretation by clinicians of various types of deceleration in a tracing is subjective, and there have been frequent reports of inconsistencies related to CTG interpretation. The aim of this study was to test the hypothesis that existing knowledge of a severe obstetrical outcome by experienced clinicians would affect their interpretation of CTG tracings and that absence of such prior knowledge would result in a different classification of outcome. A database of previously recorded intrapartum CTGs from a published study was used to sequentially select tracings of 20 cases with newborn umbilical artery pH <7.05 and 20 cases with arterial pH >7.20. All CTGs were recorded with a scalp electrode in singleton fetuses at >36 weeks of gestation. Individual tracings of the 40 cases were analyzed by 5 experienced obstetricians in different maternity hospitals according to the International Federation of Gynecology and Obstetrics guidelines. Clinicians analyzed the tracings twice (first and second round) without knowing the purpose of the study or that the tracings were the same. No information on neonatal outcome was provided to the clinicians in the first round. Two months later in the second round, the clinician reanalyzed the 40 tracings, but the order was changed and information on the arterial pH in each case was provided. The primary study outcome measures were differences between the 2 rounds with respect to the identification of fetal heart rate accelerations, decelerations, variability, and overall classification. Clinicians who examined tracings of cases with artery pH <7.05 in the second round reported a significantly larger number of repetitive decelerations (P < 0.001) and reduced variability (P = 0.001) as well as a larger number of pathological classifications (P = 0.002); variable decelerations were identified less frequently (P = 0.008). Among the cases with normal pH analyzed in the second round, fewer were identified as having prolonged decelerations (P = 0.013) and no accelerations (P = 0.013), but more had pronounced decelerations (P = 0.031) and reduced variability (P = 0.007); there was also a reduction in pathological classification that did not meet statistical significance (P = 0.051). These findings show that prior knowledge of a low umbilical artery pH is associated with increased identification of intrapartum CTG as abnormal, primarily due to differences in evaluation of decelerations and variability.

Terbutaline: effects on the fetal heart at term

The aims of this study were to evaluate the cardiac effects of subcutaneous terbutaline on the mother and fetus. Terbutaline was given in 250 or 500 μg doses to term gravidas not in labor. The mean arterial pressure (MAP), pulse, and uterine activity were measured. The fetal heart rate (FHR), accelerations, and decelerations were recorded. There were significant increases in maternal heart rate, FHR, and FHR accelerations, and a decrease in uterine basal activity after 500 μg, but not significantly after 250 μg of terbutaline. MAP was not significantly increased with either dose, although a small mean increase was observed. Terbutaline has a direct effect on the fetal heart apart from the effect of uterine relaxation.

The IDvIP Trial: A two-centre randomised double-blind controlled trial comparing intramuscular diamorphine and intramuscular pethidine for labour analgesia

BackgroundIntramuscular pethidine is routinely used throughout the UK for labour analgesia. Studies have suggested that pethidine provides little pain relief in labour and has a number of side effects affecting mother and neonate. It can cause nausea, vomiting and dysphoria in mothers and can cause reduced fetal heart rate variability and accelerations. Neonatal effects include respiratory depression and impaired feeding. There are few large studies comparing the relative side effects and efficacy of different opioids in labour. A small trial comparing intramuscular pethidine with diamorphine, showed diamorphine to have some benefits over pethidine when used for labour analgesia but the study did not investigate the adverse effects of either opioid.MethodsThe Intramuscular Diamorphine versus Intramuscular Pethidine (IDvIP) trial is a randomised double-blind two centre controlled trial comparing intramuscular diamorphine and pethidine regarding their analgesic efficacy in labour and their side effects in mother, fetus and neonate. Information about the trial will be provided to women in the antenatal period or in early labour. Consent and recruitment to the trial will be obtained when the mother requests opioid analgesia. The sample size requirement is 406 women with data on primary outcomes. The maternal primary outcomes are pain relief during the first 3 hours after trial analgesia and specifically pain relief after 60 minutes. The neonatal primary outcomes are need for resuscitation and Apgar Score <7 at 1 minute. The secondary outcomes are an additional measure of pain relief, maternal sedation, nausea and vomiting, maternal oxygen saturation, satisfaction with analgesia, whether method of analgesia would be used again, use of Entonox, umbilical arterial and venous pH, fetal heart rate, meconium staining, time from delivery to first breath, Apgar scores at 5 mins, naloxone requirement, transfer to neonatal intensive care unit, neonatal haemoglobin oxygen saturation at 30, 60, 90, and 120 mins after delivery, and neonatal sedation and feeding behaviour during first 2 hours.DiscussionIf the trial demonstrates that diamorphine provides better analgesia with fewer side effects in mother and neonate this could lead to a change in national practice and result in diamorphine becoming the preferred intramuscular opioid for analgesia in labour.Trial RegistrationISRCTN14898678Eudra No: 2006-003250-18, REC Reference No: 06/Q1702/95, MHRA Authorisation No: 1443/0001/001-0001, NIHR UKCRN reference 6895, RfPB grant PB-PG-0407-13170_IR5

Fetal response to abbreviated relaxation techniques. A randomized controlled study

Background Stress during pregnancy can have adverse effects on the course of pregnancy and on fetal development. There are few studies investigating the outcome of stress reduction interventions on maternal well-being and obstetric outcome. Aims This study aims (1) to obtain fetal behavioral states (quiet/active sleep, quiet/active wakefulness), (2) to investigate the effects of maternal relaxation on fetal behavior as well as on uterine activity, and (3) to investigate maternal physiological and endocrine parameters as potential underlying mechanisms for maternal–fetal relaxation–transferral. Study design The behavior of 33 fetuses was analyzed during laboratory relaxation/quiet rest (control group, CG) and controlled for baseline fetal behavior. Potential associations between relaxation/quiet rest and fetal behavior (fetal heart rate (FHR), FHR variation, FHR acceleration, and body movements) and uterine activity were studied, using a computerized cardiotocogram (CTG) system. Maternal heart rate, blood pressure, cortisol, and norepinephrine were measured. Results Intervention (progressive muscle relaxation, PMR, and guided imagery, GI) showed changes in fetal behavior. The intervention groups had higher long-term variation during and after relaxation compared to the CG ( p = .039). CG fetuses had more FHR acceleration, especially during and after quiet rest ( p = .027). Women in the PMR group had significantly more uterine activity than women in the GI group ( p = .011) and than CG women. Maternal heart rate, blood pressure, and stress hormones were not associated with fetal behavior. Conclusions This study indicates that the fetus might participate in maternal relaxation and suggests that GI is superior to PMR. This could especially be true for women who tend to direct their attention to body sensations such as abdominal activity.

Association between intrapartum fetal heart rate patterns and neonatal abstinence syndrome in methadone exposed neonates

Objective. Determine whether infants exposed to chronic maternal methadone with abnormal intrapartum fetal heart rate (FHR) patterns are more likely to require treatment for neonatal abstinence syndrome (NAS).Study design. Intrapartum FHR tracings analyzed in 104 pregnancies at ≥34 weeks gestation for FHR variability, accelerations, and decelerations. FHR patterns compared between neonates based on treatment with methadone for NAS. Secondary analysis included relation between maternal methadone dose and intrapartum FHR patterns, initiation of methadone, age at methadone initiation, and total neonatal methadone dose. Study powered to detect 30% increase in NAS incidence in neonates with abnormal FHR tracings.Results. Seventy-six (73%) of 104 neonates required methadone treatment for NAS. Neonates who required methadone had higher average baseline FHR (131 vs. 126 bpm; p < 0.04) in active labor and less likely to have FHR tracings without accelerations (1.7% vs. 20.3%; p = 0.007) in latent labor. No significant associations between neonate's need for methadone and intrapartum FHR variability or FHR decelerations. No association between maternal methadone dose (range 30–280 mg) and treatment for NAS.Conclusion. The need for an infant to require methadone treatment for NAS was not reliably predicted by the intrapartum FHR patterns or the maternal methadone dose.