Health Research Development Research Articles

Strip of the Month: February 2013

Strip of the Month: February 2013

Strip of the Month: August 2012

Strip of the Month: August 2012

Strip of the Month: February 2011

Strip of the Month: February 2011

Strip of the Month: October 2011

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate patterns, interpretation ,and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1.A three-tier Fetal Heart Rate Interpretation system has been recommended as follows: Data from Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring. Obstet Gynecocol. 2008;112:661–666 and American College of Obstetricians and Gynecologists. Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. Washington, DC: American College of Obstetricians and Gynecologists; 2009.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 28-year-old G2P1 woman at 38–3/7 weeks' gestation presents to labor and delivery in early labor desiring a trial of labor after cesarean section (TOLAC). She is currently contracting every 6 minutes, with intact membranes, and is admitted for augmentation of labor. She reports positive fetal movement and denies bleeding or leaking of fluid. Her history includes gestational diabetes (controlled by diet), a previous cesarean section for arrest of dilation at 3 cm, and a large-for-gestational age baby weighing 9 lb 8 oz. Her temperature is 36.8°C, heart rate is 78 beats/min, respiratory rate is 18 breaths/min, and blood pressure is 95/60 mm Hg. A cervical examination is deferred at this time. An initial FHR tracing is obtained shortly after admission (Fig. 1).Findings on EFM Strip #1 are: Over the next few hours, the patient receives early epidural analgesia and oxytocin therapy, and her contractions increase in intensity and frequency to every 2 minutes. Vital signs remain within normal limits, and she is afebrile. A cervical examination reveals 1 cm dilation, 70% effacement, and −2 station. Membranes are intact and oxytocin infusion is now at 10 MU/min. The FHR tracing remains a Category I, indicating a normal acid-base and a well-oxygenated fetus at this time. Four hours later, cervical examination shows 5 cm dilation, 80% effacement, and a floating station. A fetal tracing is obtained (Fig. 2).Findings on EFM Strip #2 are: Two hours later, results of a cervical examination document no changes, with 5 cm dilation and 80% effacement, but the station is now −2, allowing artificial rupture of the membranes. Clear fluid is noted. A fetal scalp electrode (FSE) and intrauterine pressure catheter (IUPC) are inserted to assess FHR variability more accurately and quantify uterine activity and intrauterine pressure. The associated tracing is seen in Figure 3.Findings on EFM Strip #3 are: Over the next hour, the FHR tracing remains a Category I, with recurrent early decelerations. Contractions continue every 2 minutes, with 180 MVUs. Maternal vital signs are within normal limits. The plan is to continue to monitor FHR and uterine activity and recheck the cervix in 2 hours to rule out an arrest of dilatation. However, the findings on the FHR tracing obtained 1 hour later (Fig. 4) prompt a change in plans.Findings on EFM Strip #4 are: Approximately 9 minutes later, a viable female infant weighing 3,620 kg is delivered by cesarean section with Apgar scores of 8 and 8 at 1 and 5 minutes, respectively. Cord gases indicate a mild respiratory acidosis (Table 2). Even though there was no evidence of a uterine rupture, the decision to deliver immediately was a good one and reflects a very efficient team that was well prepared to expedite the delivery of the infant within minutes of the prolonged deceleration.

Strip of the Month: August 2011

Strip of the Month: August 2011

Strip of the Month: May 2011

Strip of the Month: May 2011

Strip of the Month: April 2011

Strip of the Month: April 2011

Strip of the Month: February 2011

Strip of the Month: February 2011

Strip of the Month: January 2011

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1.A three-tier Fetal Heart Rate Interpretation system has been recommended as follows: Data from Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring. Obstet Gynecol. 2008;112:661–666.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 21-year-old primigravida at 32–6/7 weeks' gestation presents to labor and delivery with preterm labor. Cervical examination reveals 3 cm dilation. Her pregnancy has been complicated by maternal repaired transposition of the great vessels with ventricular inversion and first-trimester bleeding. The fetus had normal echocardiographic findings at 20 weeks' gestation. The patient has no evidence of infection, so she receives nifedipine tocolysis, betamethasone for fetal maturity, and penicillin for group B Streptococcus prophylaxis. The delivery plan is made for an assisted second stage of labor due to maternal cardiac disease. A fetal heart tracing is obtained upon admission (Fig. 1).Findings on EFT Strip #1 are: Tocolysis is discontinued after 48 hours. The woman remains stable for another 24 hours, when she begins having increased contractions and variable decelerations. On physical examination, she is 6 cm dilated, completely effaced, and −2 station. She is afebrile, and other examination findings are within normal parameters. A fetal heart tracing is obtained as her contractions begin to increase (Fig. 2).Findings on EFM Strip #2 are: The decision is made to proceed with augmentation of labor because she has completed her corticosteroid course, has advanced cervical dilation, and is having variable decelerations. Labor progresses rapidly after rupture of membranes and oxytocin augmentation, and her cervix is 9 cm dilated. An intrauterine pressure catheter (IUPC) is placed because of recurrent variable decelerations, but blood returns through the catheter, and it is removed. The fetal tracing is shown in Figure 3.Findings on EFM Strip #3 are: One hour later, the patient has a prolonged deceleration, and the decision is made to move to the operating room for further evaluation and possible operative delivery. The fetal tracing is shown in Figure 4.Findings on EFM Strip #4 are: In the operating room, the bradycardia resolves, but variable decelerations continue. Thirty minutes later, the patient is examined, and her cervix is still 9 cm dilated. A final fetal heart tracing is obtained (Fig. 5).Findings on EFM Strip #5 are: Fifteen minutes later, a primary cesarean delivery is performed. There is a single nuchal cord.A viable male infant is delivered by cesarean section. He weighs 4 lbs 4 oz and has Apgar scores of 5 at 1 minute and 7 at 5 minutes. The arterial blood gas findings are consistent with respiratory acidosis (Table 2). The baby receives continuous positive airway pressure. He is then taken to the neonatal intensive care unit, where he has a normal course for a preterm infant.This infant's FHR tracing could be explained by the presence of a nuchal cord. Single nuchal cords are seen in up to 30% of normal pregnancies. They are rarely associated with significant neonatal morbidity or mortality. Results are mixed on their association with abnormal FHR patterns, low birthweight, and umbilical artery pH of 7.10 or less. The poor sensitivity of ultrasonography in diagnosing nuchal cord and poor predictive value of adverse outcomes do not justify routine screening for its presence. (3)(4)

The Effect of Low to Moderate Patient Volume on Very Low-Birth-Weight Outcomes in a Level III-B Neonatal Intensive Care Unit

We studied the effect of a low- to moderate-volume, level III-B neonatal intensive care unit (NICU) on very low-birth-weight (VLBW) outcomes. We performed a retrospective analysis of the King Abdulaziz Hospital (KAH) NICU electronic database. Short-term outcomes of all inborn VLBW infants (501 to 1500 g) in the well-equipped, well-staffed KAH NICU (2003 to 2008) were benchmarked with data (1997 to 2002) from the National Institute of Children Health and Human Development and Neonatal Research Network (NICHD-NRN). Survival without major neonatal morbidity was defined as survival without bronchopulmonary dysplasia (BPD), grade III to IV intraventricular hemorrhage (IVH), and Bell's stage II to III necrotizing enterocolitis (NEC). The survival rates of VLBW infants at the KAH NICU ( N = 250) and the NICHD-NRN ( N = 18,153) were similar (84 versus 85%). A significantly higher rate of survival without major neonatal morbidity (80 versus 70%, P = 0.002) and lower rate of BPD (14 versus 22%, P = 0.005) were observed in KAH. The rates of grade III to IV IVH, Bell's stage II to III NEC, and late-onset sepsis were comparable in both cohorts. Our low- to moderate-volume, well-equipped, well-staffed, level III-B NICU achieved outcomes similar to the NICHD-NRN. Further study is warranted to ascertain how a lower-volume NICU achieved similar outcomes, as this could then be applied to quality improvement efforts.

Strip of the Month: July 2010

Strip of the Month: July 2010

Strip of the Month: March 2010

Strip of the Month: March 2010

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and was endorsed in 2005 by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). In 2008, ACOG, NICHD, and the Society for Maternal-Fetal Medicine reviewed and updated the definitions for fetal heart rate patterns, interpretation, and research recommendations. Following is a summary of the terminology definitions and assumptions found in the 2008 NICHD workshop report. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.Decelerations occurring with <50% of uterine contractions in a 20-minute segment are intermittent.A three-tier Fetal Heart Rate Interpretation system has been recommended as follows: Data from Macones GA, Hankins GDV, Spong CY, Hauth J, Moore T. The 2008 National Institute of Child Health and Human Development workshop report on electronic fetal monitoring. Obstet Gynecocol. 2008;112:661–666.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 27-year-old G1 P0000 woman presents to her doctor's office at 32–5/7 weeks’ gestation complaining of decreased fetal movement for the past 24 hours. Fetal monitoring in the office reveals a prolonged deceleration followed by an apparent sinusoidal pattern. The patient and her husband are sent immediately to the perinatal diagnostic center for a biophysical profile. The profile score is 2/10, which is associated with fetal compromise. In addition, Doppler studies show an increase in the peak velocity of systolic blood flow in the middle cerebral artery, which is consistent with fetal anemia. The prenatal course was normal up to this point and the past medical history was negative. The woman is transferred to labor and delivery for further evaluation and preparation for a cesarean section. On arrival to labor and delivery, EFM is begun (Fig. 1), and appropriate laboratory tests for surgery are ordered.Findings on EFM Strip #1 are: The noted actions are taken, and an immediate tracing is obtained (Fig. 2).Findings on EFM Strip #2 are: The Kleihauer-Betke test is positive for fetal cells in the maternal bloodstream, which confirms a fetomaternal hemorrhage. Thirty minutes later, another tracing is obtained (Fig. 3).Findings on EFM Strip #3 are: Forty-five minutes later, a pale viable male infant weighing 1,673 g is delivered by cesarean section. Apgar scores are 8 at 1 and 5 minutes. The baby is sent to the neonatal intensive care unit, where neonatal anemia is diagnosed. He ultimately does well. Pathologic examination of the placenta reveals numerous focal infarctions. A specimen for cord gases was drawn but was not sufficient for testing.

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the TableT1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 17-year-old G1P0 is admitted to labor and delivery at term for borderline low amniotic fluid that was discovered at a routine prenatal visit. The patient has a medical history of panic attacks, has no known drug allergies, and reports prenatal vitamins as her only medication during pregnancy. Prenatal laboratory results are within normal limits. Vaginal examination upon admission reveals a cervix dilated 1 cm with an elevated presenting part. A cervical ripening agent followed by oxytocin induction is planned to achieve delivery. A fetal tracing is obtained at the time of insertion of the cervical ripening agent (misoprostol 25 mcg) per vagina (Fig. 1).Findings on EFM Strip #1 are: Five hours later, vaginal examination reveals that the cervix is unchanged. A repeat dose of misoprostol is administered and another tracing is obtained (Fig. 2).Findings on EFT Strip #2 are: Six hours after the last dose of misoprostol, oxytocin augmentation is started. See Figure 3 for the tracing at that time.Findings on EFM Strip #3 are: Three hours later, the cervix has dilated to 3 cm and the presenting part is now at a −2 station. The patient continues to receive a low amount of oxytocin as another fetal tracing is obtained (Fig. 4).Findings on EFM Strip #4 are: Two and a half hours later, an epidural is administered for pain management. Forty minutes later, artificial rupture of membranes is attempted, but no fluid is noted. The fetal tracing obtained at that time is shown in Figure 5.Findings on EFM Strip #5 are: One hour later, an amnioinfusion is started and an intrauterine pressure catheter is placed to measure uterine contractions. The cervix is dilated 3 to 4 cm and 80% effaced, with the station of the presenting part unchanged. One hour after initiation of the amnioinfusion, another tracing is obtained (Fig. 6).Findings on EFM Strip #6 are: Forty minutes later, the physician attempts both scalp stimulation and VAS (Fig. 7).Findings on EFM Strip #7 are: The findings are reviewed with the patient and her family, and a joint decision is made for an emergent cesarean delivery. A viable female infant is delivered approximately 15 minutes later with Apgar scores of 4 and 7 at 1 and 5 minutes, respectively. The infant weighs 7 lb 5 oz. Thick meconium is noted. Umbilical cord gases are obtained, and the infant is admitted to the neonatal intensive care unit in stable condition for observationT2.

815: Fetal heart rate tracing patterns associated with congenital hypothyroidism

This study was undertaken to determine fetal heart rate (FHR) tracing patterns associated with congenital hypothyroidism. FHR patterns of 59 women whose babies were diagnosed in the postnatal period with congenital hypothyroidism were retrospectively compared with tracings of 78 controls. The control group consisted of FHR tracings of the previous and consecutive deliveries of the same patients (if they had such). Tracings were interpreted during the first stage of labor, using the National Institute of Child Health and Human Development Research Planning Workshop guidelines. Multivariable analysis was used to control for confounders. Neonates with congenital hypothyroidism had significantly higher rates of reduced variability in FHR tracing patterns as compared with those without congenital hypothyroidism (49.2% vs. 3.8%; odds ratio [OR] = 24.1, 95% CI 6.8-85.3; P<0.001). No significant differences were noted between the groups regarding other FHR tracing patterns such as decelerations, or baseline abnormalities. The significant association between congenital hypothyroidism and reduced variability persisted after controlling for confounders such as treatment with pethidine, MgSO4, and gestational age,using a multivariable analysis (OR=11.8, 95% CI 1.1-124.8. P=0.004). Congenital hypothyroidism is significantly and independently associated with reduced variability in FHR tracing patterns.

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the TableT1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 27-year-old G1 P0 woman presents to labor and delivery at 41+5 weeks’ gestation with complaints of vaginal bleeding with urination. Her prenatal course was uneventful. Past history is positive for exposure to lead (worked in India), bleeding in the first trimester with threatened abortion, and iron deficiency anemia. Vaginal examination reveals the cervix dilated 2 cm, 70% effaced, and at a −2 station. Uterine contractions are mild and irregular. The patient was scheduled for an induction for postterm dates later in the day. A fetal tracing is obtained at admission (Fig. 1).Findings on EFM Strip #1 are: Administration of intravenous fluids and oxygen are initiated. The nurse also attempts vibroacoustic stimulation (VAS) to elicit an acceleration of the FHR, but the attempt is unsuccessful. A well-oxygenated fetus responds to VAS by demonstrating an acceleration that is more than 15 beats/min above the baseline and lasting more than 15 seconds. Research has shown that this type of acceleration in response to stimulation correlates with a fetal blood pH of greater than 7.2. The absence of an acceleration does not diagnose acidemia, but approximately 40% of fetuses in this group have blood pH values less than 7.2 and always require further evaluation to rule out acidemia. The mother reports that she felt increased fetal movement this morning. The physician discusses the following plan of care with the patient and significant other: Start induction with oxytocin; monitor the fetus continuously to assess its ability to tolerate labor; and if the fetus does not demonstrate a reassuring FHR, consider a cesarean section. Approximately 1½ hours after admission, oxytocin administration is started at 1 MU/min and another tracing is obtained (Fig. 2).Findings on EFM Strip #2 are: All of the previously noted interventions are undertaken, and approximately 2½ hours later, another fetal tracing is obtained (Fig. 3).Findings on EFM Strip #3 are: Seventy minutes later, when the oxytocin administration is at 2 MU/min, another tracing is obtained (Fig. 4).Findings on EFT Strip #4 are: The previously noted interventions are successful in re-establishing a reassuring strip. For the next 3 hours, the labor continues, oxytocin is restarted, and the physician ruptures the patient's membranes, revealing meconium-stained fluid. The vaginal examination reveals the cervix to be dilated 2 to 3 cm. Approximately 1½ hours later, the cervix is 3 cm dilated, 100% effaced, and the presenting part is at a −1 station. A fetal scalp electrode is applied, and another tracing is obtained (Fig. 5).Findings of EFM Strip #5 are: After the previously noted interventions, the fetus recovers to a normal baseline with minimal variability. However, because of the recurrent prolonged deceleration pattern, postterm dates, and the fact that the patient is not likely to deliver vaginally for many hours, delivery by cesarean section is undertaken.Forty minutes later, a viable female infant is delivered by cesarean section with Apgar scores of 8 at 1 minute and 9 at 5 minutes. One nuchal cord is noted at delivery. Arterial cord gas values reveal a mild respiratory acidosis, which is consistent with the fetal heart rate changes.T2

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the TableT1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 32-year-old G1P0 woman presents to labor and delivery at 40 +2 weeks gestation in early labor. Her prenatal course was uneventful. Past history includes infertility, endometriosis, and a laparoscopy performed 3 years ago. Vaginal examination reveals a cervix dilated 3 cm, 50% effaced, and a −2 station. Uterine contractions are mild, occurring every 2 to 3 minutes. Morphine sulfate 10 mg and promethazine 25 mg are administered intramuscularly to the patient, who is sent home to rest and await active labor.Approximately 1 hour later, the patient's membranes rupture spontaneously at home, revealing pink-tinged fluid with small blood clots. She returns to the hospital 1 hour and 20 minutes later. Vaginal examination on admission reveals the cervix to be dilated 4 cm, 80% effaced, and presenting part still at a −2 station. A fetal tracing is obtained at admission (Fig. 1).Findings on EFM Strip #1 are: Over the next 2½ hours, an intravenous line is placed, and the patient receives a fluid bolus prior to receiving epidural analgesia. A vaginal examination reveals the cervix dilated 4 to 5 cm, 90% effaced, and the presenting part remaining at −2 station. A scalp electrode is placed, and another fetal tracing is obtained (Fig. 2).Findings on EFM Strip #2 are: All of the suggested interventions are undertaken. Approximately 1½ hours later, another fetal tracing is obtained (Fig. 3).Findings on EFM Strip #3 are: Thirteen minutes later, a viable female infant is delivered by cesarean section weighing 6 lb 5 oz. Apgar scores of 0 at 1 minute, 0 at 5 minutes, and 1 at 10 minutes necessitate full neonatal resuscitation. The infant is pale at delivery and receives a blood transfusion in the operating room. Intraoperative findings include a velamentous insertion of the cord, resulting in a vasa previa, which occurs when the umbilical cord is implanted into the membranes rather than the placenta. The vessels traverse across the membranes without the protection of supportive tissue or Wharton jelly, which predisposes them to laceration when the membranes rupture. Often, the only indication of a vasa previa is the sudden appearance of bright red blood in conjunction with the sudden onset of a nonreassuring FHR at the time of rupture of the membranes. This condition is associated with a high incidence of fetal morbidity and mortality due to fetal bleeding rapidly leading to shock and exsanguination.

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in the Table T1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.An 18-year-old G1P0 woman presents to labor and delivery at 39 +6 weeks’ gestation in active labor. She had a normal prenatal course, and her vital signs are stable. Vaginal examination upon admission reveals a cervix dilated 3 to 4 cm, 90% effaced, and 0 station. Uterine contractions are documented as occurring every 5 minutes. An initial fetal tracing is obtained upon admission (Fig. 1).Findings on EFM Strip #1 are: Over the next 3 hours, epidural medication is administered for pain management, membranes are ruptured artificially and clear amniotic fluid is noted, and the fetal scalp electrode is inserted. Vaginal examination shows that the cervix has progressed to 6 to 7 cm dilation, 100% effacement, and the presenting part remaining at 0 station. A fetal tracing is obtained 4 hours after admission (Fig. 2).Findings on EFM Strip #2 are: For the next 3 hours, the FHR remains reassuring, with moderate variability and early decelerations. Maternal vital signs remain stable, with a temperature of99.0°F (37.3°C). Approximately 3½ hours later, vaginal examination reveals the cervix to be completely dilated, with the presenting part at +2 station. The patient begins pushing, and another tracing is obtained (Fig. 3).Findings on EFM Strip #3 are: One hour later, the maternal temperature is 101.7°F (38.8°C) and ampicillin 2 g is administered intravenously. The patient continues to push with the physician at her bedside, and another tracing is obtained (Fig. 4).Findings on EFM Strip #4 are: Forty minutes later, a decision is made to deliver the fetus by cesarean section. The patient is instructed to stop pushing and is prepared for surgery. The maternal temperature has spiked to 103.0°F (39.5°C). A final fetal tracing is obtained (Fig. 5)Findings on EFM Strip #5 are: The final segment of this tracing (Fig. 6) shows an increasing FHR to approximately 200 beats/min. This pattern of tachycardia with absent variability and recurrent decelerations is associated with hypoxia or acidosis. Although uterine contractions are required to determine the presence of late decelerations, the pattern resembles late decelerations in shape and is nonreassuring, necessitating an immediate delivery.A viable male weighing 8 lbs 14 oz is delivered by cesarean section. Apgar scores are 3, 6, and 7 at 1, 5, and 10 minutes, respectively. The infant is transferred to the neonatal intensive care unit for further evaluation and care. The placenta is sent to pathology, and evaluation confirms a diagnosis of early acute chorioamnionitis. The umbilical artery cord gas values demonstrate a mixed respiratory and metabolic acidosis (Table 2), which is consistent with the FHR changes. Long-term outcomes for neonates who have chorioamnionitis are guarded. Chorioamnionitis has been demonstrated to increase the risk of cerebral palsy in the term newborn. The mechanism is currently ill-defined but may be related to the release of cytokines due to a fetal immune response to infection.

The Longitudinal Effects of Spirituality on Stress, Depression, and Risk Behaviors Among Men with HIV Infection Attending Three Clinics in the Southeastern United States

ABSTRACT. We examined the associations of two measures of spirituality (i.e., spiritual growth and religious coping) and perceived stress, depression, hazardous alcohol use, and use of tobacco and illicit drugs over time among men who had tested positive for HIV. Data were collected from 226 men at baseline, 197 at a 12‐month follow‐up, and 184 at a 24‐month follow‐up. There were significant time by spiritual growth interactions found for both perceived stress and depression. Increased spiritual growth, that is, spirituality that focuses on seeking meaning, purpose, and transcendence was significantly associated with reduced perceived stress and reduced depression, and the effects varied at different time points. Spiritual growth was not associated with specific risk behaviors (hazardous alcohol use, tobacco and illicit drug use). The effects of religious coping (e.g. Bible reading, prayer, church attendance) on outcomes were consistent across all time points. Religious coping was not significantly associated with perceived stress but it was negatively associated with depression. Moreover, increased religious coping was significantly associated with the likelihood of reduced hazardous alcohol use and illicit drug use. This research was supported by a Veteran's Affairs Health Services Research and Development Nursing Research Initiative Grant (#98‐182) and by a Veteran's Affairs Health Services Research and Development Research Career Development Award (#99011).

Strip of the Month

Electronic fetal monitoring (EFM) is a popular technology used to establish fetal well-being. Despite its widespread use, terminology used to describe patterns seen on the monitor has not been consistent until recently. In 1997, the National Institute of Child Health and Human Development (NICHD) Research Planning Workshop published guidelines for interpretation of fetal tracings. This publication was the culmination of 2 years of work by a panel of experts in the field of fetal monitoring and has been endorsed by both the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). The terminology definitions and assumptions found in the NICHD publication form the basis for interpretation of the fetal tracings in this series and are summarized here. Normal values for arterial umbilical cord gas values and indications of acidosis are defined in Table 1.Decelerations are tentatively called recurrent if they occur with ≥50% of uterine contractions in a 20-minute period.We encourage readers to examine each strip in the case presentation and make a personal interpretation of the findings before advancing to the expert interpretation provided.A 37-year-old G3P2 woman presents to her physician’s office at approximately 37 weeks’ gestation with the complaint of decreased fetal movement. She had had two previous deliveries via cesarean section, the first for cephalopelvic disproportion and the second as a scheduled repeat procedure. Genetic testing earlier in the pregnancy revealed normal chromosomes. The remainder of the woman’s history and prenatal period was unremarkable. A nonstress test is obtained (Figs. 1 and 2).Findings on EFM Strips #1 and #2 are: Two weeks later, the woman again complains of decreased fetal movement, although findings on the remainder of her prenatal evaluation are unremarkable. The gestational age is approximately 39 weeks. Another nonstress test is ordered, and results are seen in Figures 3 and 4.Findings on EFM Strips #3 and #4 are: The following evening, the woman experiences an unusual increase in fetal activity followed by decreased fetal movement and about 1 hour later, no fetal movement. The following morning, the woman presents to the labor and delivery unit with the complaints of absent fetal movement and abdominal cramping. She is evaluated and placed on the EFM (Figs. 5, 6, and 7).Findings on EFM Strips #5, #6, and #7 are: An EFM is obtained in the operating room (Fig. 8). Slightly more than 1 hour after admission, the infant is delivered.Findings on EFM Strip #8 are: A viable infant weighing 3,090 g is delivered and has Apgar scores of 3, 5, and 7 at 1, 5, and 10 minutes, respectively. Umbilical arterial cord gas measurements reveal mixed acidosis (Table 2). Other findings include a hematocrit of 51% (0.51) and a nucleated red blood cell count 25 times the normal value reported by the hospital’s laboratory. Laboratory evaluation of the placenta reveals membranes with focal minimal acute and chronic chorionitis. The infant experiences seizures at 12 hours after birth. Following transfer to the neonatal intensive care unit, the infant does well.