Intrapartum Fetal Monitoring Research Articles

O12 - Tending to the machine: the impact of intrapartum fetal monitoring on women and birthing people in Australia

O12 - Tending to the machine: the impact of intrapartum fetal monitoring on women and birthing people in Australia

Women’s experiences of intermittent auscultation fetal monitoring in labour: A qualitative study

BackgroundInternationally, intermittent auscultation (IA) is recommended for monitoring the fetal heart rate during labour and birth for women with uncomplicated pregnancies. IA can identify changes in the fetal heart rate that may indicate the need for additional care or intervention. IA is a central facet of midwifery practice, but there is little evidence about women’s experience of IA. AimOur study aimed to explore women’s experiences of IA in the UK. MethodsBetween February and May 2023, 23 women were recruited through social media, service user organisations and charities, for a single episode, online interview or focus group with informed consent. Audio recordings were transcribed and thematically analysed. FindingsThe analysis constructed two over-arching themes: ‘Choice takes work’ and ‘Impact of IA monitoring on the labouring woman’. DiscussionWomen reported a lack of informed decision-making in relation to intrapartum fetal monitoring. The experience of our participants showed that not all women for whom IA would be recommended according to current clinical guidelines were offered it, while others experienced IA without understanding its function or the availability of other options. ConclusionLimited antenatal communication from maternity care professionals about fetal monitoring in labour has an impact on women’s opportunities to make informed decisions. A committed approach to informed decision making in the antenatal period could reduce practice variation and better support midwives to support women in their birth choices.

Intrapartum fetal monitoring practices in Norway: A population-based study

ObjectiveTo describe intrapartum fetal monitoring methods used in all births in Norway in 2019–2020, assess adherence to national guidelines, investigate variation by women’s risk status, and explore associations influencing monitoring practices. MethodsA nationwide population-based study. We collected data about all pregnancies with a gestational age ≥ 22 weeks during 2019–2020 from the Medical Birth Registry of Norway. We used descriptive analyses, stratified for risk status, to examine fetal monitoring methods used in all deliveries. Univariable and multivariable logistic regression models were used to determine factors associated with monitoring with cardiotocography (CTG) in low-risk, straightforward births. ResultsIn total, 14 285 (14%) deliveries were monitored with only intermittent auscultation (IA), 46214 (46%) with only CTG, and 33417 (34%) with IA and CTG combined. Four percent (2 067/50 533) of women with risk factors were monitored with IA only. Half (10589/21 282) of the low-risk women with straightforward births were monitored with CTG. Maternal and fetal characteristics, size of the birth unit and regional practices influenced use of CTG monitoring in this group. ConclusionsMost births are monitored with CTG only, or combined with IA. Half the women with low-risk pregnancies and straightforward births were monitored with CTG although national guidelines recommending IA.

Tending to the machine: The impact of intrapartum fetal surveillance on women in Australia

Qualitative research about women and birthing people’s experiences of fetal monitoring during labour and birth is scant. Labour and birth is often impacted by wearable or invasive monitoring devices, however, most published research about fetal monitoring is focused on the wellbeing of the fetus. This manuscript is derived from a larger mixed methods study, ‘WOmen’s Experiences of Monitoring Baby (The WOMB Study)’, aiming to increase understanding of the experiences of women and birthing people in Australia, of being monitored; and about the information they received about fetal monitoring devices during pregnancy. We constructed a national cross-sectional survey that was distributed via social media in May and June, 2022. Responses were received from 861 participants. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia. This paper comprises the analysis of the free text survey responses, using qualitative and inductive content analysis. Two categories were constructed, Tending to the machine, which explores participants’ perceptions of the way in which clinicians interacted with fetal monitoring technologies; and Impressions of the machine, which explores the direct impact of fetal monitoring devices upon the labour and birth experience of women and birthing people. The findings suggest that some clinicians need to reflect upon the information they provide to women and birthing people about monitoring. For example, freedom of movement is an important aspect of supporting the physiology of labour and managing pain. If freedom of movement is important, the physical restriction created by a wired cardiotocograph is inappropriate. Many participants noticed that clinicians focused their attention primarily on the technology. Prioritising the individual needs of the woman or birthing person is key to providing high quality woman-centred intrapartum care. Women should be provided with adequate information regarding the risks and benefits of different forms of fetal monitoring including how the form of monitoring might impact her labour experience.

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.

Implementation barriers and facilitators of Moyo foetal heart rate monitor during labour in public hospitals in Nepal

ABSTRACT Background Globally, every year, approximately 1 million foetal deaths take place during the intrapartum period, fetal heart monitoring (FHRM) and timely intervention can reduce these deaths. Objective This study evaluates the implementation barriers and facilitators of a device, Moyo for FHRM. Methods The study adopted a qualitative study design in four hospitals in Nepal where Moyo was implemented for HRM. The study participants were labour room nurses and convenience sampling was used to select them. A total of 20 interviews were done to reach the data saturation. The interview transcripts were translated to English, and qualitative content analysis using deductive approach was applied. Results Using the deductive approach, the data were organised into three categories i) changes in practice of FHRM, ii) barriers to implementing Moyo and iii) facilitators of implementing Moyo. Moyo improved adherence to intermittent FHRM as the device could handle higher caseloads compared to the previous devices. The implementation of Moyo was hindered by difficulty to organise training ondevice during non-working hours, technical issue of the device, nurse mistrust towards the device and previous experience of poor implementation to similar innovations. Facilitators for implementation included effective training on how to use Moyo, improvement in intrapartum foetal monitoring and improvement in staff morale, ease of using the device, Plan Do Study Act (PDSA) meetings to improve use of Moyo and supportive leadership. Conclusion The change in FHRM practice suggests that the implementation of innovative solution such as Moyo was successful with adequate facilitation, supportive staff attitude and leadership.

The iPREFACE score is useful for predicting fetal acidemia: A retrospective cohort study of 113 patients who underwent emergency cesarean section for non-reassuring fetal status during labor

The iPREFACE score may aid in predicting fetal acidemia and neonatal asphyxia in emergency cesarean and vaginal deliveries, which may improve labor management precision in the future. This study aimed to assess the score use of the iPREFACE as an objective indicator of the need for rapid delivery in cases of repeated abnormal waveforms without concurrent indications for immediate medical intervention during labor. This retrospective cohort study was conducted among term (37+ 0 days to 41+6 days) singleton pregnant women who underwent emergency cesarean delivery owing to a nonreassuring fetal status. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery score, calculated from a 30-minute cardiotocography waveform before the decision to perform emergency cesarean delivery, and the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer score, calculated from a 30-minute cardiotocography waveform before cardiotocography transducer removal, were employed. The primary outcome was the assessment of the predictive ability of these scores for fetal acidemia, whereas the secondary outcomes were differences in umbilical artery blood gas findings and postnatal outcomes between the 2 groups, divided by the cutoff values of the integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography score. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer scores demonstrated the capability to predict an umbilical artery blood pH of <7.2. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-decision of emergency cesarean delivery and -removal of cardiotocography transducer score, with cutoff values of 37 and 46 points, respectively, exhibited an area under the receiver operating characteristic curve of 0.82 and 0.87, respectively. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring-removal of cardiotocography transducer group with ≥46 points had higher incidence rates of an umbilical cord artery blood pH of <7.2, <7.1, and <7.0 and neonatal intensive care unit admissions for neonatal asphyxia. The integrated score index to predict fetal acidemia by intrapartum fetal heart rate monitoring, derived from cardiotocography during an emergency cesarean delivery, may enable clinicians to predict fetal acidemia in cases of nonreassuring fetal status. Improved prediction of fetal acidemia and facilitation of timely intervention hold promise for enhancing the outcomes of mothers and newborns during childbirth. Prospective studies are warranted to establish precise cutoff values and to validate the clinical application of these scores.

Association between intrapartum fetal pulse oximetry and adverse perinatal and long-term outcomes: a systematic review and meta-analysis protocol.

Current methods of intrapartum fetal monitoring based on heart rate, increase the rates of operative delivery but do not prevent or accurately detect fetal hypoxic brain injury. There is a need for more accurate methods of intrapartum fetal surveillance that will decrease the incidence of adverse perinatal and long-term neurodevelopmental outcomes while maintaining the lowest possible rate of obstetric intervention. Fetal pulse oximetry (FPO) is a technology that may contribute to improved intrapartum fetal wellbeing evaluation by providing a non-invasive measurement of fetal oxygenation status. This systematic review and meta-analysis aims to synthesise the evidence examining the association between intrapartum fetal oxygen saturation levels and adverse perinatal and long-term outcomes in the offspring. We will include randomised control trials (RCTs), cohort, cross-sectional and case-control studies which examine the use of FPO during labour as a means of measuring intrapartum fetal oxygen saturation and assess its effectiveness at detecting adverse perinatal and long-term outcomes compared to existing intrapartum surveillance methods. A detailed systematic search of PubMed, EMBASE, CINAHL, The Cochrane Library, Web of Science, ClinicalTrials.Gov and WHO ICTRP will be conducted following a detailed search strategy until February 2024. Three authors will independently review titles, abstracts and full text of articles. Two reviewers will independently extract data using a pre-defined data extraction form and assess the quality of included studies using the Risk of Bias tool for RCTs and Newcastle-Ottawa Scale for observational studies. The grading of recommendations, assessment, development, and evaluation (GRADE) approach will be used to evaluate the certainty of the evidence. We will use random-effects meta-analysis for each exposure-outcome association to calculate pooled estimates using the generic variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-analyses and MOOSE guidelines. CRD42023457368 (04/09/2023).

Correlation between total deceleration area in CTG records and cord blood pH in pregnancies with IUGR.

Fetal cardiotocography is the most common method to assess fetal well-being during labor. Nevertheless, its predictive ability for acidemia is limited, both in low-risk and high-risk pregnancies (Nelson et al. in N Engl J Med 334: 613-9, 1996; Rinciples P et al. in Health and Human Development Workshop Report on Electronic Fetal Monitoring : Update on Definitions. no. 2007, 510-515, 2008), especially in high-risk pregnancies, such as those complicated by growth restriction. In this study we aim examine the association between deceleration and acceleration areas and other measure of fetal heart rate in intrapartum fetal monitoring and neonatal arterial cord blood pH in pregnancies complicated by growth restriction. A retrospective cohort study of 100 deliveries complicated by growth restriction, delivered during 2018, was conducted. Known major fetal anomalies, non-vertex presentation and elective cesarean deliveries were excluded. Total deceleration and acceleration areas were calculated as the sum of the areas within the deceleration and acceleration, respectively. In deliveries complicated by growth restriction, cord blood pH is significantly associated with total deceleration area (p = 0.05) and correlates with cumulative duration of the decelerations (Spearman's rank -0.363, p < 0.05), and total acceleration area (-0.358, p < 0.05). By comparing the cord blood pH in deliveries with a total deceleration area that was above and below the median total deceleration area, we demonstrated a significant difference between the categories. Cord blood pH significantly correlates with total deceleration area and other fetal monitoring characteristics in neonates with growth restriction. Future studies using real-time, machine-learning based techniques of fetal heart rate monitoring, may provide population specific threshold values that will support bedside clinical decision making and perhaps achieve better outcomes.

245 Accuracy of deep learning models in interpreting intrapartum fetal monitoring to predict fetal acidemia

245 Accuracy of deep learning models in interpreting intrapartum fetal monitoring to predict fetal acidemia

Neonatal death audits at Kgapane Hospital, Limpopo province.

Neonatal deaths (NNDs) are a global public health challenge, predominantly affecting low- and middle-income countries. The causes of most NNDs are preventable. Therefore, this study reviewed perinatal clinical audit data at Kgapane Hospital over a 4-year period with a special focus on the factors associated with NNDs. File audits were performed for all NNDs occurring at Kgapane Hospital and its catchment area from 2018 to 2021. The data from these audits were analysed to identify factors associated with NNDs. The NND rate for the study period was 12.6/1000 live births. In this study (n= 236), 90% of the deaths could be associated with four factors, namely prematurity (44%); intrapartum complications (19%) including asphyxia, meconium aspiration and breech deliveries; neonatal infections (16%) of which human immunodeficiency virus (HIV) positivity was the most prevalent; and foetal congenital abnormalities (11%). The modifiable factors included inadequate intrapartum foetal monitoring; delays in management interventions; instances where no attempts were made to refer patients for specialised care, or where no beds were available at the next level of care; patient-related factors; and inadequate adherence to management protocols, such as for the management of prematurity and HIV. Understanding factors associated with NNDs can guide health worker training and improvement strategies to reduce this heart-breaking complication of pregnancy.Contribution:Family physicians working in rural hospitals are also responsible for newborn care. Understanding the factors associated with NNDs will guide them to focus training and develop improvement strategies to reduce these preventable deaths.

ST waveform analysis vs cardiotocography alone for intrapartum fetal monitoring: An updated systematic review and meta-analysis of randomized trials.

ST waveform analysis (STAN) was introduced as an adjunct to cardiotocography (CTG) to improve neonatal and maternal outcomes. The aim of the present study was to quantify the efficacy of STAN vs CTG and assess the quality of the evidence using GRADE. We performed systematic literature searches to identify randomized controlled trials and assessed included studies for risk of bias. We performed meta-analyses, calculating pooled risk ratio (RR) or Peto odds ratio (OR). We also performed post hoc trial sequential analyses for selected outcomes to assess the risk of false-positive results and the need for additional studies. Nine randomized controlled trials including 28 729 women were included in the meta-analysis. There were no differences between the groups in operative deliveries for fetal distress (10.9 vs 11.1%; RR 0.96; 95% confidence interval [CI] 0.82-1.11). STAN was associated with a significantly lower rate of metabolic acidosis (0.45% vs 0.68%; Peto OR 0.66; 95% CI 0.48-0.90). Accordingly, 441 women need to be monitored with STAN instead of CTG alone to prevent one case of metabolic acidosis. Women allocated to STAN had a reduced risk of fetal blood sampling compared with women allocated to conventional CTG monitoring (12.5% vs 19.6%; RR 0.62; 95% CI 0.49-0.80). The quality of the evidence was high to moderate. Absolute effects of STAN were minor and the clinical significance of the observed reduction in metabolic acidosis is questioned. There is insufficient evidence to state that STAN as an adjunct to CTG leads to important clinical benefits compared with CTG alone.

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...

Association between intrapartum fetal pulse oximetry and adverse perinatal and long-term outcomes: a systematic review and meta-analysis protocol

Background: Current methods of intrapartum fetal monitoring based on heart rate, increase the rates of operative delivery but do not prevent or accurately detect fetal hypoxic brain injury. There is a need for more accurate methods of intrapartum fetal surveillance that will decrease the incidence of adverse perinatal and long-term neurodevelopmental outcomes while maintaining the lowest possible rate of obstetric intervention. Fetal pulse oximetry (FPO) is a technology that may contribute to improved intrapartum fetal wellbeing evaluation by providing a non-invasive measurement of fetal oxygenation status. Objective: This systematic review and meta-analysis aims to synthesise the evidence examining the association between intrapartum fetal oxygen saturation levels and adverse perinatal and long-term outcomes in the offspring. Methods: We will include randomised control trials (RCTs), cohort, cross-sectional and case-control studies which examine the use of FPO during labour as a means of measuring intrapartum fetal oxygen saturation and assess its effectiveness at detecting adverse perinatal and long-term outcomes compared to existing intrapartum surveillance methods. A detailed systematic search of PubMed, EMBASE, CINAHL, The Cochrane Library and Web of Science will be conducted following a detailed search strategy until August 2023. Three authors will independently review titles, abstracts and full text of articles. Two reviewers will independently extract data using pre-defined data extraction and assess the quality using the Risk of Bias tool for RCTs and Newcastle-Ottawa Scale for observational studies. We will use random-effects meta-analysis for each exposure-outcome association to calculate pooled estimates using the generic variance method. This systematic review will follow the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines. PROSPERO registration: CRD42023457368 (04/09/2023)

Fetal Electrocardiogram: St Waveform Analysis in Intrapartum Surveillance (Analisi Del Tratto St Dell’elettrocardiografia Fetale In Travaglio Di Parto)

ST-analysis of the fetal electrocardiogram (ECG) (STAN (®)) combined with cardiotocography (CTG) for intrapartum fetal monitoring has been developed following many years of animal research. Changes in the ST-segment of the fetal ECG correlated with fetal hypoxia occurring during labor. In 1993 the first randomized controlled trial (RCT), comparing CTG with CTG + ST-analysis was published. STAN (®) was introduced for daily practice in 2000. To date, six RCTs have been performed, out of which five have been published. Furthermore, there are six published meta-analyses. The meta-analyses showed that CTG + ST-analysis reduced the risks of vaginal operative delivery by about 10% and fetal blood sampling by 40%. There are conflicting results regarding the effect on metabolic acidosis, much because of controveries about which RCTs should be included in a meta-analysis, and because of differences in methodology, execution and quality of the meta-analyses. Several cohort studies have been published, some showing significant decrease of metabolic acidosis after the introduction of ST-analysis. In this review, we discuss not only the scientific evidence from the RCTs and meta-analyses, but also the limitations of these studies. In conclusion, ST-analysis is effective in reducing operative vaginal deliveries and fetal blood sampling but the effect on neonatal metabolic acidosis is still under debate. Further research is needed to determine the place of ST-analysis in the labor ward for daily practice.

Comparison of a Newly-Designed and Conventional Strap Used for Cardiotocograph Recoding in Preterm Labor

Objective: 1) To compare the outcomes of fetal heart rate monitoring using a newly-designed elastic cardiotocograph (CTG) bandage and a conventional ultrasound transducer bandage, and 2) to evaluate the satisfaction of the participants and labor staff using the newly-designed elastic CTG bandage compared to those using the conventional ultrasound transducer bandage. Materials and Methods: The researchers invented the newly-designed elastic CTG bandage and conducted a quasi-experimental study with thirty-four pregnant women gestational age under 37 weeks using both the newly-designed elastic CTG bandage and the conventional ultrasound transducers. A comparison of the outcomes of fetal heart rate monitoring between the two methods was done using Wilcoxon signed-rank test. Then, two instruments (the CTG band satisfaction questionnaire for women, and the CTG band satisfaction questionnaire and fetal heart rate graph absence record for the labor staff) were administered to the respective participants. They were adapted for the study based on the diffusion of innovation model, which postulated that an innovation was generally adopted when five main factors (compatibility, complexity, trial-ability, observability, and relative advantage) were met. Results: The median score of signals of fetal heart rate loss when solely using the newly-designed elastic CTG bandage was only 1.0 times and the conventional ultrasound transducer bandage was 3.0 times. There was a significant difference (p&lt;0.001). Most members of the labor staff were satisfied with the suitability of the newly-designed elastic CTG bandage. Conclusion: The newly-designed elastic CTG bandage improved the quality of fetal heart rate assessment compared to the conventional ultrasound transducer bandage, resulting in the reduction of errors during examinations and the labor staff’s workloads while providing the ability to continuously assess the fetal heart rate. Keywords: Cardiotocograph; Fetal heart rate; Intrapartum fetal monitoring

Rate of Cesarean Delivery among Physicians Practicing in A Teaching Hospital in Tigray Region, Northern Ethiopia

Abstract Introduction: The Ethiopian national cesarean section rate is about 5%. Rates of cesarean delivery (CD) vary widely among population segments in Ethiopia suggesting unequal access. Within this context, this study aimed to assess the rate of CD among physicians practicing at Ayder Comprehensive Specialized Hospital (ACSH). Methods: This was cross-sectional study. All female physicians who are parous (n = 15) and all male physicians whose spouses are parous (n = 86) were interviewed to evaluate the mode of delivery among them. Indications for CD were also assessed. Results: The overall CD rate among participants was 81 (44.3%). Thirteen out of 18 (87%) female obstetrician/gynecologists and male obstetrician/gynecologists' spouses delivered via CD. Cesarean delivery for maternal request (CDMR) accounted for 22.6% of primary CDs. Nearly all (95%) potential candidates for Trial of Labor after Cesarean delivery (TOLAC) opted for repeat elective CD. The driving factors for CD were: lack of confidence in the process of intrapartum fetal monitoring, “uncertainty” of outcome of vaginal delivery, fear of labor pain (due to absence of labor analgesia), and managing obstetricians' fear of blame for poor outcome by their colleagues. Conclusion: This study revealed a disparity in CD rates in physician community vs the general Ethiopian population. More revealing are the reasons why they underwent CD. Rate of CD may be decreased by winning the confidence of the parturient mothers through instituting international-standard intrapartum fetal monitoring and labor analgesia protocols. Key Words Mode of delivery, Cesarean delivery, maternal request, physicians

Obesity in Pregnancy: A Comprehensive Review of Influential Guidelines.

Obesity is one of the most common clinical entities complicating pregnancies and is associated with short- and long-term consequences for both the mother and the offspring. The aim of this study were to review and compare the most recently published influential guidelines on the management of maternal obesity in the preconceptional, antenatal, intrapartum, and postpartum period. A descriptive review of guidelines from the American College of Obstetricians and Gynecologists, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynecologists of Canada, the Royal College of Obstetricians and Gynecologists, and the Royal Australian and New Zealand College of Obstetricians and Gynecologists on obesity in pregnancy was carried out. There is an overall agreement among the reviewed guidelines regarding the importance of prepregnancy weight loss with behavioral modification, optimization of gestational weight gain, and screening for comorbidities in improving pregnancy outcomes of obese women. Women with previous bariatric surgery should be screened for nutritional deficiencies and have a closer antenatal surveillance, according to all guidelines. In addition, folic acid supplementation is recommended for 1 to 3 months before conception and during the first trimester, but several discrepancies were identified with regard to other vitamins, iodine, calcium, and iron supplementation. All medical societies recommend early screening for gestational diabetes mellitus and early anesthetic assessment in obese women and suggest the use of aspirin for the prevention of preeclampsia when additional risk factors are present, although the optimal dosage is controversial. The International Federation of Gynecology and Obstetrics, Society of Obstetricians and Gynecologists of Canada, Royal College of Obstetricians and Gynecologists, and Royal Australian and New Zealand College of Obstetricians and Gynecologists point out that specific equipment and adequate resources must be readily available in all health care facilities managing obese pregnant women. Moreover, thromboprophylaxis and prophylactic antibiotics are indicated in case of cesarean delivery, and intrapartum fetal monitoring is justified during active labor in obese patients. However, there are no consistent protocols regarding the fetal surveillance, the monitoring of multiple gestations, the timing and mode of delivery, and the postpartum follow-up, although weight loss and breastfeeding are unanimously supported. Obesity in pregnancy is a significant contributor to maternal and perinatal morbidity with a constantly rising global prevalence among reproductive-aged women. Thus, the development of uniform international protocols for the effective management of obese women is of paramount importance to safely guide clinical practice and subsequently improve pregnancy outcomes.

Implementing quality improvement intervention to improve intrapartum fetal heart rate monitoring during COVID-19 pandemic- observational study.

Adherence to intrapartum fetal heart rate monitoring (FHRM) for early decision making in high-risk pregnancies remains a global health challenge. COVID-19 has led to disruption of routine intrapartum care in all income settings. This study aims to evaluate the implementation of quality improvement (QI) intervention to improve intrapartum FHRM and birth outcome before and during pandemic. We conducted an observational study among 10,715 pregnant women in a hospital of Nepal, over 25 months. The hospital implemented QI intervention i.e facilitated plan-do-study-act (PDSA) meetings before and during pandemic. We assessed the change in intrapartum FHRM, timely action in high-risk deliveries and fetal outcomes before and during pandemic. The number of facilitated PDSA meetings increased from an average of one PDSA meeting every 2 months before pandemic to an average of one PDSA meeting per month during the pandemic. Monitoring and documentation of intrapartum FHRM at an interval of less than 30 minutes increased from 47% during pre-pandemic to 73.3% during the pandemic (p<0.0001). The median time interval from admission to abnormal heart rate detection decreased from 160 minutes to 70 minutes during the pandemic (p = 0.020). The median time interval from abnormal FHR detection to the time of delivery increased from 122 minutes to 177 minutes during the pandemic (p = 0.019). There was a rise in abnormal FHR detection during the time of admission (1.8% vs 4.7%; p<0.001) and NICU admissions (2.9% vs 6.5%; p<0.0001) during the pandemic. Despite implementation of QI intervention during the pandemic, the constrains in human resource to manage high risk women has led to poorer neonatal outcome. Increasing human resources to manage high risk women will be key to timely action among high-risk women and prevent stillbirth.

Experiences with intrapartum fetal monitoring in the Netherlands: A survey study

IntroductionWorldwide, cardiotocography is used for continuous monitoring of fetal heart rate (FHR) and uterine contractions during labour. Different methods for FHR registration and registration of contractions are available. Literature about the frequency of use of different fetal monitoring methods is lacking. ObjectiveTo evaluate the use of and preferences for fetal monitoring methods for intrapartum fetal monitoring among Dutch obstetric care providers. Study designBetween October and November 2020 the Dutch Society of Obstetrics and Gynaecology sent an email invitation to all secondary care midwives and gynaecologists (in training) in the Netherlands to complete an online survey regarding the use and personal experience with fetal monitoring methods. The survey mainly consisted of multiple choice questions. Descriptive statistics are reported. Continuous variables were presented as median with interquartile ranges (IQR). Categorical variables were expressed as numbers with percentages. ResultsThe response rate was 29 % (n/N = 510/1748). All Dutch hospitals were represented. The respondents estimated the use of fetal scalp electrode (FSE) at 71 % (IQR 58–85 %) of deliveries. The most common indication for use of the FSE was inadequate external FHR registration (94 %). More than half (54 %) of the respondents reported to use intrauterine pressure catheter with an estimated use of 5 % (IQR 2–8 %) of deliveries. The most common indication for use of intrauterine pressure catheter was inadequate external contraction registration (75 %). The use of ST-analysis was reported in 25 % of the respondents with an estimated use of 60 % (IQR 30–72 %) of deliveries. Almost all respondents (99 %) reported to use fetal blood sampling with an estimated use of 15 % (IQR 10–23 %) of deliveries. Ninety percent of respondents would prefer a valid and reliable external monitoring technique during labour. Thirty-one percent of respondents assume that external fetal monitoring with non-invasive fetal electrocardiography and electrohysterography will become standard care within the next 5 years. ConclusionsCurrently, the FSE is the most used technique for FHR monitoring during labour in the Netherlands. The most common indication for use of FSE is inadequate external FHR registration. Obstetric care providers would prefer a non-invasive external registration method that provides reliable data.