Intrapartum Electronic Fetal Monitoring Research Articles

Comparing Clark’s 2017 Category II Electronic Fetal Monitoring Algorithm to Actual Management When Umbilical Cord Arterial pH Was Less Than 7 [ID 2683452

INTRODUCTION: Our previously published study reported that, in only 47% of labors resulting in a baby with severe acidemia (defined as umbilical cord arterial pH less than 7), intrapartum electronic fetal monitoring (EFM) was interpreted as concerning, with delivery expedited. We compared Clark’s EFM Category II algorithm to EFM interpretation and actual management of these deliveries. METHODS: Institutional review board approval was obtained. A retrospective cohort study was performed on deliveries with umbilical cord arterial pH less than 7. Two groups were identified in actual management: 1) expedited delivery (urgent/emergent operative vaginal delivery or cesarean section) and 2) nonexpedited delivery. We then reviewed all fetal heart tracings (FHTs) to determine whether the algorithm would have recommended expedited delivery or not. Data were analyzed using chi-squared test for independence and Fisher's exact test. RESULTS: Thirty deliveries were identified with severe fetal acidemia. Forty-seven percent were delivered in expedited fashion. The Clark algorithm recommended expedited delivery in 30%. The algorithm was not applicable to 3 out of 30 deliveries. Of actually expedited deliveries, the algorithm agreed with expediting 75% of the time, 78% of which should have been delivered even earlier. Of actually nonexpedited deliveries, the algorithm would have only expedited 7% of those. CONCLUSION: The Clark 2017 Category II FHT algorithm had a lower sensitivity for predicting severe fetal acidemia and recommending expedited delivery. Although only 47% of babies with severe acidemia were delivered in expedited fashion, the Clark algorithm would only have expedited delivery in 30% overall.

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

(BJOG. 2023;130:407–414) Although it has been considered the standard of care to evaluate the fetus during labor, intrapartum electronic fetal monitoring (EFM) is controversial in its effectiveness for reducing cerebral palsy and perinatal mortality. Research on fetal heart rate (FHR) analysis has demonstrated high interobserver variability and with low specificity. Further, the pathophysiology of FHR marked variability is not well understood and research is limited.

Why is safety in intrapartum electronic fetal monitoring so hard? A qualitative study combining human factors/ergonomics and social science analysis

BackgroundProblems in intrapartum electronic fetal monitoring with cardiotocography (CTG) remain a major area of preventable harm. Poor understanding of the range of influences on safety may have hindered improvement. Taking...

Intrapartum electronic fetal monitoring features associated with a clinical diagnosis of nonreassuring fetal status

Nonreassuring fetal status detected by continuous electronic fetal monitoring accounts for almost 1 in 4 primary cesarean deliveries. However, given the subjective nature of the diagnosis, there is a need to identify the electronic fetal monitoring patterns that are clinically considered nonreassuring. This study aimed to describe which electronic fetal monitoring features are most commonly associated with first-stage cesarean delivery for nonreassuring fetal status, and to evaluate the risk of neonatal acidemia following cesarean delivery for nonreassuring fetal status. This was a nested case-control study in a prospectively collected cohort of patients with singleton pregnancies at ≥37 weeks' gestation, admitted in spontaneous labor or for induction of labor from 2010 to 2014 at a single tertiary care center. Patients with preterm pregnancies, multiple gestations, planned cesarean delivery, or nonreassuring fetal status in the second stage of labor were excluded. Cases were identified as having nonreassuring fetal status on the basis of what was documented in the operative note by the delivering physician. Controls were patients without nonreassuring fetal status within 1 hour of delivery. Cases were matched to controls in a 1:2 ratio by parity, obesity, and history of cesarean delivery. Electronic fetal monitoring data were abstracted by credentialed obstetrical research nurses for the 60 minutes before delivery. The primary exposure of interest was the incidence of high-risk category II electronic fetal monitoring features in the 60 minutes before delivery; in particular, the incidence of minimal variability, recurrent late decelerations, recurrent variable decelerations, tachycardia, and >1 prolonged deceleration were compared between groups. We also compared neonatal outcomes between cases and controls, including fetal acidemia (umbilical artery pH <7.1), other umbilical artery gas analytes, and neonatal and maternal outcomes. Of the 8580 patients in the parent study, 714 (8.3%) underwent cesarean delivery for nonreassuring fetal status in the first stage of labor. Patients diagnosed with nonreassuring fetal status requiring cesarean delivery were more likely to have recurrent late decelerations, >1 prolonged deceleration, and recurrent variable decelerations compared with controls. More than 1 prolonged deceleration was associated with 6 times increased rate of nonreassuring fetal status diagnosis resulting in cesarean delivery (adjusted odds ratio, 6.73 [95% confidence interval, 2.47-8.33]). Rates of fetal tachycardia were similar between groups. Minimal variability was less common in the nonreassuring fetal status group compared with controls (adjusted odds ratio, 0.36 [95% confidence interval, 0.25-0.54]). Compared with control deliveries, cesarean delivery for nonreassuring fetal status was associated with nearly 7 times higher risk of neonatal acidemia (7.2% vs 1.1%; adjusted odds ratio, 6.93 [95% confidence interval, 3.83-12.54]). Composite neonatal morbidity and composite maternal morbidity were more likely among patients delivered for nonreassuring fetal status in the first stage (3.9% vs 1.1%; adjusted odds ratio, 5.70 [2.60-12.49]; and 13.3% vs 8.0%; adjusted odds ratio, 1.99 [1.41-2.80]). Although multiple category II electronic fetal monitoring features have been traditionally linked to acidemia, the presence of recurrent late decelerations, recurrent variable decelerations, and prolonged decelerations seemed to concern obstetricians enough to surgically intervene for nonreassuring fetal status. A clinical intrapartum diagnosis of nonreassuring fetal status in the setting of these electronic fetal monitoring features is also associated with increased risk of acidemia, suggesting clinical validity to the diagnosis of nonreassuring fetal status.

SOCIO DEMOGRAPHIC DETERMINANTS AND CAUSES OF STILLBIRTHS

Introduction-Stillbirth creates difcult situation for the Obstetrician and results in great psychological and emotional trauma to the couple. It reects the suboptimum quality of maternal and child health services. Study was carried out to nd out the causes of stillbirths and the socio demographic prole of women, who had stillbirth. Material And Methods -Aclinical observational study of 7994 deliveries and 262 stillbirths was undertaken at tertiary care hospital over a period of 10 months from January 2020 to October 2020. Results- Stillbirth rate was 33.30/thousand births. Lack of antenatal care (78%),low socioeconomic status(66%)were commonly associated with stillbirths. Pregnancy induced hypertension (25%), ante-partum haemorrhage (12%), cord related accidents (8%)and preterm labour (24%) were mainly responsible for stillbirths. Conclusion-Early recognition of high risk factors, regular antenatal checkup. Ultrasonograpy to diagnose cord abnormalities, use of intrapartum electronic fetal monitoring, partograph and prevention of prolongation of second stage of labour will help in reduction of fresh stillbirths.

Electronic intrapartum fetal monitoring: a systematic review of international clinical practice guidelines

BACKGROUNDElectronic fetal monitoring or fetal assessment using a cardiotocograph is currently the most commonly employed tool for intrapartum surveillance. Furthermore, there are numerous guidelines informing best practice worldwide.OBJECTIVEThis systematic review aimed to compare and appraise all available practice guidelines on intrapartum electronic fetal monitoring to describe the similarities and variations in recommendations.STUDY DESIGNA systematic protocol was developed per Preferred Reporting Item for Systematic Review and Meta-Analysis Protocols. A total of 4 independent reviewers were involved with independent searches and quality assessment using the Appraisal of Guidelines for Research and Evaluation Instrument for guideline quality reporting.RESULTSOverall, 7 international practice guidelines were included in this systematic review. Appraisal of Guidelines for Research and Evaluation Instrument showed higher scores for scope and purpose and for clarity of presentation; however, the overall assessment varied between 25% and 89%. When individual characteristics of electronic fetal monitoring or cardiotocograph were compared, all guidelines and guidance were essentially trying to describe the characters similarly, with critical differences described in the full article.CONCLUSIONIn the context of globalization, a uniform approach for defining terminology, classifying characters and similar interpretation of results is needed for electronic fetal monitoring. Therefore, we should consider a unified, simple, logistically approved, and acceptable guideline, which is probably accepted worldwide.

Training in the use of intrapartum electronic fetal monitoring with cardiotocography: systematic review and meta‐analysis

BackgroundSub‐optimal classification, interpretation and response to intrapartum electronic fetal monitoring using cardiotocography are known problems. Training is often recommended as a solution, but there is lack of clarity about the effects of training and which type of training works best.ObjectivesSystematic review of the effects of training healthcare professionals in intrapartum cardiotocography (PROSPERO protocol: CRD42017064525).Search strategyCENTRAL, Cochrane Library, MEDLINE, EMBASE, PsycINFO, British Nursing Database, CINAHL, ERIC, Scopus, Web of Science, ProQuest, grey literature and ongoing clinical trials were searched.Selection criteriaPrimary studies that reported impact of training healthcare professionals in intrapartum cardiotocography. Title/abstract, full‐text screening and quality assessment were conducted in duplicate.Data collection and analysisData were synthesised both narratively and using meta‐analysis. Risk of bias and overall quality were assessed with the Mixed Methods Appraisal Tool and GRADE.Main resultsSixty‐four studies were included. Overall, training and reporting were heterogeneous, the outcomes evaluated varied widely and study quality was low. Five randomised controlled trials reported that training improved knowledge of maternity professionals compared with no training, but evidence was of low quality. Evidence for the impact of cardiotocography training on neonatal and maternal outcomes was limited, showed inconsistent effects, and was of low overall quality. Evidence for the optimal content and method of delivery of training was very limited.ConclusionsGiven the scale of harm and litigation claims associated with electronic fetal monitoring, the evidence‐base for training requires improvement. It should address intervention design, evaluation of clinical outcomes and system‐wide contexts of sub‐optimal practice.Tweetable abstractTraining in fetal monitoring: systematic review finds little evidence of impact on neonatal outcomes.

545: Putting teamwork to the test: a randomized trial of collaboration in electronic fetal monitoring (EFM)

While numerous innovations for improving the performance of EFM have been tested over the past two decades, none have proven effective. The impact of teamwork and collaboration on improving EFM performance is not known. We aimed to assess the effects of collaboration in obstetric providers at YNHH as it pertains to intrapartum EFM. From December 2018 to May 2019 we conducted a randomized trial of obstetric clinicians (MDs, CNMs, RNs) in simulations using the Perinatal Quality Foundation’s (PQF) Fetal Monitoring Credentialing (FMC) exam, a standardized, nationally validated exam that evaluates an examinee’s knowledge and judgement related to intrapartum EFM interpretation and management. After taking an individual baseline exam, participants were randomized to retake the exam, either as an individual or as a member of a team of two individuals. The differences in exam scores were compared between those taking the exam as an individual and as a team. An anonymous post-test survey was conducted to assess participants’ opinions regarding the two exams, our study and teamwork. We recruited 92 participants (42 RNs, 11 CNMs and 39 MDs). Characteristics between the two groups were not significantly different (Table 1). Baseline exam (overall, knowledge and judgement) scores were similar between the two groups (p=0.635, p=0.409, p=0.741). One half retook the exam as an individual (46) and the other half as a member of a team (23 teams of 2 individuals). Exam scores improved more significantly for those participants in a team. When allocated to a team, MD’s showed more improvement in total and knowledge scores, while nurses showed more improvement only in total score (Table 2). More participants in the team group self-reported changing answers on the second exam (68% v 16%). In a simulated environment performance in EFM interpretation and management improves by working as a team. Interdisciplinary teamwork may be one way to improve quality and safety in the use of EFM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth (the IMMO programme): protocol for a qualitative study

IntroductionSuboptimal electronic fetal heart rate monitoring (EFM) in labour using cardiotocography (CTG) has been identified as one of the most common causes of avoidable harm in maternity care. Training staff...

A Prospective Cohort Study of Fetal Heart Rate Monitoring: Deceleration Area is Predictive of Fetal Acidemia

(Am J Obstet Gynecol. 2018;218:523.e1–523.e12) While intrapartum electronic fetal monitoring (EFM) is commonly used and promises to reduce adverse neonatal outcomes by predicting acidemia, there is a lack of data regarding an association between EFM patterns and acidemia. This study aimed to assess EFM patterns and their association with acidemia and neonatal morbidity and determine which visually interpreted EFM patterns were associated with acidemia and neonatal morbidity.

A Prospective Cohort Study of Fetal Heart Rate Monitoring: Deceleration Area Is Predictive of Fetal Acidemia

(Abstracted from Am J Obstet Gynecol 2018;218:523.e1–523.e12) Intrapartum electronic fetal monitoring (EFM) is the most commonly used tool in obstetrics in the United States, used ubiquitously in US hospitals to monitor the fetal heart rate during labor. However, clear categorization of EFM patterns that predict acidemia remains unclear, and there is a lack of evidence supporting EFM's ability to reduce neonatal morbidity and mortality.

Electronic Fetal Monitoring Predicts Severe Fetal Acidemia (Umbilical Cord Arterial pH [25D

INTRODUCTION: The purpose of this study was to determine how frequently intrapartum electronic fetal monitoring (EFM) was interpreted as concerning, with delivery expedited, in babies with severe acidemia (umbilical cord arterial pH &lt; 7). METHODS: A retrospective cohort study was performed on babies with umbilical cord arterial pH &lt; 7. Two groups were identified: (1) expedited delivery (either operative vaginal delivery or urgent/emergent cesarean section) and (2) non-expedited delivery (spontaneous vaginal delivery, scheduled or non-urgent cesarean section). Maternal, labor, and neonatal characteristics between the groups were compared using Chi-squared test for independence and the Fisher’s Exact Test. RESULTS: 30 babies were identified with umbilical cord arterial pH &lt; 7. 47% were delivered in expedited fashion. 53% were delivered in non-expedited fashion. Of the expedited delivery group, 79% were delivered by cesarean section and 21% by operative vaginal delivery. Of the non-expedited delivery group, 56% were delivered by cesarean section (scheduled or non-urgent). There was no statistical difference between groups in average umbilical cord arterial pH or base excess, gestational age, if labor was induced, length of labor, Pitocin usage for labor augmentation, sentinel events, 5 minute Apgar score or neonatal length of stay. CONCLUSION: Only 47% of babies with umbilical cord arterial pH of &lt; 7 delivered in expedited fashion. There was no statistical difference in maternal, labor or neonatal characteristics between the expedited and non-expedited delivery groups. Poor sensitivity of EFM in predicting intrapartum hypoxia and acidemia limits the ability to expedite delivery in the presence of fetal acidemia.

A prospective cohort study of fetal heart rate monitoring: deceleration area is predictive of fetal acidemia

Intrapartum electronic fetal monitoring is the most commonly used tool in obstetrics in the United States; however, which electronic fetal monitoring patterns predict acidemia remains unclear. This study was designed to describe the frequency of patterns seen in labor using modern nomenclature, and to test the hypothesis that visually interpreted patterns are associated with acidemia and morbidities in term infants. We further identified patterns prior to delivery, alone or in combination, predictive of acidemia and neonatal morbidity. This was a prospective cohort study of 8580 women from 2010 through 2015. Patients were all consecutive women laboring at ≥37 weeks' gestation with a singleton cephalic fetus. Electronic fetal monitoring patterns during the 120 minutes prior to delivery were interpreted in 10-minute epochs. Interpretation included the category system and individual electronic fetal monitoring patterns per the Eunice Kennedy Shriver National Institute of Child Health and Human Development criteria as well as novel patterns. The primary outcome was fetal acidemia (umbilical artery pH ≤7.10); neonatal morbidities were also assessed. Final regression models for acidemia adjusted for nulliparity, pregestational diabetes, and advanced maternal age. Area under the receiver operating characteristic curves were used to assess the test characteristics of individual models for acidemia and neonatal morbidity. Of 8580 women, 149 (1.7%) delivered acidemic infants. Composite neonatal morbidity was diagnosed in 757 (8.8%) neonates within the total cohort. Persistent category I, and 10-minute period of category III, were significantly associated with normal pH and acidemia, respectively. Total deceleration area was most discriminative of acidemia (area under the receiver operating characteristic curves, 0.76; 95% confidence interval, 0.72-0.80), and deceleration area with any 10minutes of tachycardia had the greatest discriminative ability for neonatal morbidity (area under the receiver operating characteristic curves, 0.77; 95% confidence interval, 0.75-0.79). Once the threshold of deceleration area is reached the number of cesareans needed-to-be performed to potentially prevent 1 case of acidemia and morbidity is 5and 6, respectively. Deceleration area is the most predictive electronic fetal monitoring pattern for acidemia, and combined with tachycardia for significant risk of morbidity, from the electronic fetal monitoring patterns studied. It is important to acknowledge that this study was performed in patients delivering ≥37 weeks, which may limit the generalizability to preterm populations. We also did not use computerized analysis of the electronic fetal monitoring patterns because human visual interpretation was the basis for the Eunice Kennedy Shriver National Institute of Child Health and Human Development categories, and importantly, it is how electronic fetal monitoring is used clinically.

Obesity’s impact on intrapartum electronic fetal monitoring

Objective: The objective of this study is to evaluate the impact maternal obesity has on the percentage of unmonitored electronic fetal monitoring (EFM).Study design: Women undergoing induction of labor at term were categorized into three groups: Group 1 (body mass index (BMI) < 30 kg/m2), Group 2 (30 < BMI < 40 kg/m2), and Group 3 (BMI ≥ 40 kg/m2). External EFM tracings were reviewed from the time of induction of labor until amniotomy; the percentage of time off of EFM was calculated. Statistical analysis was performed using commercially available software.Results: Three hundred and thirty-seven patients were stratified into the following groups: 104 patients in Group 1, 156 patients in Group 2, and 77 in Group 3. No significant differences were found between groups when analyzed for gestational age, bishop score, parity, race, and 5 min APGAR less than 7 or admission to the NICU. The mean percentage unmonitored by EFM was 5% for Group 1, 7% for Group 2 and 11% for Group 3. There was a significant association between percent of time unmonitored by EFM and BMI (r = 0.344 p < .0001).Conclusion: At term gestation, the fetuses of obese women spend more time unmonitored by external intrapartum EFM than non-obese women. This represents a disparity among a high-risk group that may result in poor pregnancy outcomes if fetal distress is present.

Utility of Intrapartum Fetal Heart Rate Monitoring in a Contemporary Labor and Delivery Unit [4Q

INTRODUCTION: To evaluate the use of intrapartum electronic fetal heart rate monitoring (EFM) as a screening tool for adverse neonatal outcomes. METHODS: This is a retrospective study of 16,980 term, singleton deliveries at a single hospital from 2013-2014. Cases of adverse neonatal outcomes were compared to unaffected controls by the following predictor variables: late, variable, early, and prolonged decelerations; accelerations; tachycardia; bradycardia; and minimal variability. The primary outcome was a composite adverse outcome comprised of five-minute Apgar score less than 4, umbilical arterial pH less than 7.0, sepsis, seizures, encephalopathy, and respiratory failure. Secondary outcomes were neonatal intensive care unit (NICU) admission, hypoxia, hypoglycemia, pH less than 7.0, seizures, and abstinence syndrome. Independent associations were ascertained using logistic regression. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for significant parameters. RESULTS: For the composite adverse outcome, prolonged decelerations were positively (OR 2.19) and accelerations were negatively (OR 0.044) associated. For NICU admission, associations included prolonged (OR 1.24) and late (OR 1.39) decelerations, minimal variability (OR 1.17), and tachycardia (OR 1.81). Neonatal hypoxia (OR 0.076), hypoglycemia (OR 0.21) and seizures (OR 0.005) were all negatively associated with accelerations. Low five-minute Apgar score was positively associated with prolonged decelerations (OR 8.69). For the composite adverse outcome, prolonged decelerations had sensitivity, specificity, PPV, and NPV of 0.372, 0.657, 0.00606, and 0.995, while for absence of accelerations were 0.0185, 0.998, 0.0357, and 0.996, respectively. CONCLUSION: Standard EFM parameters have excellent NPV but poor PPV when used intrapartum to screen for adverse neonatal outcomes.

657: Cost-effectiveness of continuous intrapartum electronic fetal monitoring vs intermittent auscultation in low-risk term pregnancies

657: Cost-effectiveness of continuous intrapartum electronic fetal monitoring vs intermittent auscultation in low-risk term pregnancies

The Value of the Cerebroplacental Ratio for the Prediction of Intrapartum Fetal Monitoring in Low-Risk Term Pregnancies

Aim: The study aimed to investigate the use of fetal cerebroplacental ratio (CPR) to identify fetuses at high risk before labor due to the brain sparing phenomenon. Materials and Methods: Four hundred and seventy-six singleton pregnancies were enrolled in this study. The CPR was recorded within 1 week of delivery and labor was managed according to local protocols and guidelines. Intrapartum and neonatal outcome details were recorded. Results: The CPR values of fetuses subsequently presenting category III intrapartum electronic fetal monitoring (EFM) or category II EFM without improvement (category IIB EFM) or with progression to category III (category IIC EFM) were significantly lower. On multivariate logistic regression, CPR was independently associated with the risk of categories III EFM, IIB EFM and IIC EFM. CPR was also a predictor of categories III EFM, IIB EFM and IIC EFM. Conclusions: Fetal CPR could be used to identify fetuses at high risk before labor and to help guide intrapartum management decisions.

Variations on fetal heart rate variability.

Intrapartum electronic fetal monitoring (EFM) is widely used throughout the developed and developing world. This practice is based on the understanding that fetal heart rate (FHR) is sensitive to hypoxia. During labour, the fetus may be exposed to acute hypoxia during uterine contractions or intrapartum insults, and has well‐established cardiovascular compensatory defence mechanisms, which ideally prevent hypoxic–ischaemic encephalopathy by maintaining perfusion pressure and substrate delivery to essential organs (Giussani et al. 1993). Failure of these compensatory mechanisms results in a progressively worsening metabolic acidosis. Development of severe acidaemia (pH < 7.05) is a key turning point after which fetuses are unable to maintain fetal cardiovascular defence mechanisms and cerebral perfusion, rendering them at risk of asphyxial brain injury (Gunn & Bennet, 2009). Therefore, intrapartum EFM aims to identify, via changes in FHR patterns, fetuses unable to initiate or maintain such compensatory adaptations in response to hypoxia, which become acidotic, and deliver them before they are at risk of asphyxia, severe acidosis, cardiovascular collapse, end organ damage or death.

456: Predicting normal pH with Intrapartum electronic fetal monitoring (EFM)

456: Predicting normal pH with Intrapartum electronic fetal monitoring (EFM)

29: Predicting acidemia with intrapartum electronic fetal monitoring (EFM)

29: Predicting acidemia with intrapartum electronic fetal monitoring (EFM)