Management Of Fetal Distress Research Articles

Health care workers\u2019 experiences of managing foetal distress and birth asphyxia at health facilities in Northern Uganda

BackgroundBirth asphyxia is one of the leading causes of intrapartum stillbirth and neonatal mortality worldwide. We sought to explore the experiences of health care workers in managing foetal distress and birth asphyxia to gain an understanding of the challenges in a low-income setting.MethodsWe conducted in-depth interviews with 12 midwives and 4 doctors working in maternity units from different health facilities in Northern Uganda in 2018. We used a semi-structured interview guide which included questions related to; health care workers’ experiences of maternity care, care for foetal distress and birth asphyxia, views on possible preventive actions and perspectives of the community. Audio recorded interviews were transcribed verbatim and analysed using inductive content analysis.ResultsFour categories emerged: (i) Understanding of and actions for foetal distress and birth asphyxia including knowledge, misconception and interventions; (ii) Challenges of managing foetal distress and birth asphyxia such as complexities of the referral system, refusal of referral, lack of equipment, and human resource problems, (iii) Expectations and blame from the community, and finally (iv) Health care worker’ insights into prevention of foetal distress and birth asphyxia.ConclusionHealth care workers described management of foetal distress and birth asphyxia as complex and challenging. Thus, guidelines to manage foetal distress and birth asphyxia that are specifically tailored to the different levels of health facilities to ensure high quality of care and reduction of need for referral are called for. Innovative ways to operationalise transportation for referral and community dialogues could lead to improved birth experiences and outcomes.

Cesarean Section and Associated Factors at Aira Hospital, Oromia Region, Western Ethiopia: A Retrospective Record Review

Introduction: According to the latest data from 150 countries, currently, 18.6% of all births occur by cesarean section, ranging from 6% to 27.2%. It is alarmingly increasing in the last decade with an average annual rate of increase by 4.4%. Objective: To assess the prevalence of the cesarean section and associated factors among mothers who gave a birth from January 01, 2014, to December 31, 2018, at Aira Hospital, west wollega zone, Oromia region, Ethiopia. Methods and materials: Study was conducted from June 1 to July 25, 2019, by retrospective review of complete medical records of mothers who gave birth from January 01, 2014, to December 31, 2018 at Aira general hospital, west wollega zone, Oromia region, Ethiopia. The sample size was determined by using single population proportion and the final sample size was 339. Check list was used for data collection which was adapted and developed by reviewing relevant literatures. The data was analyzed by statistical package for social science version 20. Odd ratio was used for the interpretation of strength of prediction of independent variable to outcome variable, cesarean section. The statistical significance was declared at P<0.05 with 95% confidence interval. Result: A total of 332 medical records were reviewed. More than half (51.8%) of mother were less than or equal to 24 years with the mean age of 24.23 (±5.17 SD). The prevalence of cesarean section was 33.1% (95%CI 31.3-35.2%). More than two third (85.5%) of mothers had antenatal care follow up and the gestational age at the time of delivery was 37-40 weeks for 90.7% of mothers. Maternal age, gestational age and fetal weight were factors associated with cesarean section. Conclusion: Since the current prevalence of cesarean section surpass the world health organization recommendation threshold vaginal delivery should be encouraged in appropriate cases and the time should be given for conservative management of fetal distress. Maternal age, gestational age and fetal weight were factors associated with cesarean section. We recommend a future researchers to examine the attitude of service providers and their influence on the growing cesarean section delivery rate.

Perceptions and experiences of skilled birth attendants on using a newly developed strap-on electronic fetal heart rate monitor in Tanzania

BackgroundRegular fetal heart rate monitoring during labor can drastically reduce fresh stillbirths and neonatal mortality through early detection and management of fetal distress. Fetal monitoring in low-resource settings is often inadequate. An electronic strap-on fetal heart rate monitor called Moyo was introduced in Tanzania to improve intrapartum fetal heart rate monitoring. There is limited knowledge about how skilled birth attendants in low-resource settings perceive using new technology in routine labor care. This study aimed to explore the attitude and perceptions of skilled birth attendants using Moyo in Dar es Salaam, Tanzania.MethodsA qualitative design was used to collect data. Five focus group discussions and 10 semi-structured in-depth interviews were carried out. In total, 28 medical doctors and nurse/midwives participated in the study. The data was analyzed using qualitative content analysis.ResultsThe participants in the study perceived that the device was a useful tool that made it possible to monitor several laboring women at the same time and to react faster to fetal distress alerts. It was also perceived to improve the care provided to the laboring women. Prior to the introduction of Moyo, the participants described feeling overwhelmed by the high workload, an inability to adequately monitor each laboring woman, and a fear of being blamed for negative fetal outcomes. Challenges related to use of the device included a lack of adherence to routines for use, a lack of clarity about which laboring women should be monitored continuously with the device, and misidentification of maternal heart rate as fetal heart rate.ConclusionThe electronic strap-on fetal heart rate monitor, Moyo, was considered to make labor monitoring easier and to reduce stress. The study findings highlight the importance of ensuring that the device’s functions, its limitations and its procedures for use are well understood by users.

Criteria-based audit to improve quality of care of foetal distress: standardising obstetric care at a national referral hospital in a low resource setting, Tanzania.

BackgroundIn Tanzania, substandard intrapartum management of foetal distress contributes to a third of perinatal deaths, and the majority are term deliveries. We conducted a criteria-based audit with feedback to determine whether standards of diagnosis and management of foetal distress would be improved in a low-resource setting.MethodsDuring 2013–2015, a criteria-based audit was performed at the national referral hospital in Dar es Salaam. Case files of deliveries with a diagnosis of foetal distress were identified and audited. Two registered nurses under supervision of a nurse midwife, a specialist obstetrician and a consultant obstetrician, reviewed the case files. Criteria for standard diagnosis and management of foetal distress were developed based on international and national guidelines, and literature reviews, and then, stepwise applied, in an audit cycle. During the baseline audit, substandard care was identified, and recommendations for improvement of care were proposed and implemented. The effect of the implementations was assessed by the differences in percentage of standard diagnosis and management between the baseline and re-audit, using Chi-square test or Fisher’s exact test, when appropriate.ResultsIn the baseline audit and re-audit, 248 and 251 deliveries with a diagnosis of foetal distress were identified and audited, respectively. The standard of diagnosis increased significantly from 52 to 68 % (p < 0.001). Standards of management improved tenfold from 0.8 to 8.8 % (p < 0.001). Improved foetal heartbeat monitoring using a Fetal Doppler was the major improvement in diagnoses, while change of position of the mother and reduced time interval from decision to perform caesarean section to delivery were the major improvements in management (all p < 0.001). Percentage of cases with substandard diagnosis and management was significantly reduced in both referred public and non-referred private patients (all p ≤ 0.01) but not in non-referred public and referred private patients.ConclusionThe criteria-based audit was able to detect substandard diagnosis and management of foetal distress and improved care using feedback and available resources.

Practice variation in the management of intrapartum fetal distress in The Netherlands and the Western world

ObjectiveSolid evidence on the effect of intrauterine resuscitation on neonatal outcome is limited, and superiority of one intervention over the others is not clear. We therefore surveyed the clinical practice variation in fetal monitoring and the management of fetal distress during labor, in Dutch labor wards. In addition, we have compared recommendations from international guidelines. Study designWe conducted a survey among all 86 Dutch hospitals, using a questionnaire on fetal monitoring and management of fetal distress. In addition, we requested international guidelines of 28 Western countries to study international recommendations regarding labor management. ResultsThe response rate of the national survey was 100%. Labor wards of all hospitals use CTG for fetal monitoring, 98% use additional fetal scalp blood sampling, and 23% use ST-analysis. When fetal distress is suspected, oxytocin is discontinued and tocolytic drugs are applied in all hospitals. Nearly all hospitals (98%) use maternal reposition for fetal resuscitation, 33% use amnioinfusion, and 58% provide maternal hyperoxygenation. Management is mainly based on the Dutch national guideline (58%) or on local guidelines (26%).Eight international guidelines on fetal monitoring were obtained for analysis. Fetal scalp blood sampling facilities are recommended in all the obtained guidelines. Use of ST-analysis is recommended in three guidelines and advised against in three guidelines. Five guidelines also advised on intrauterine resuscitation: discontinuation of oxytocin and use of tocolytic drugs was advised in all guidelines, amnioinfusion was recommended in two guidelines and advised against in two guidelines, whereas maternal hyperoxygenation was recommended in two guidelines and advised against in one guideline. ConclusionNationwide clinical practice, and recommendations from international guidelines agree on the use of fetal scalp blood sampling in addition to cardiotocography during labor. The opinion on the use of ST-analysis differs per clinic and per guideline. Discontinuation of oxytocin, administration of tocolytic drugs and maternal repositioning are rather uniform, on national and international level. However, there is a large variation in the use of amnioinfusion and maternal hyperoxygenation, which may be explained by the contradictory recommendations of the different guidelines.

Management of foetal asphyxia by intrauterine foetal resuscitation.

Management of foetal distress is a subject of gynaecological interest, but an anaesthesiologist should know about resuscitation, because he should be able to treat the patient, whenever he is directly involved in managing the parturient patient during labour analgesia and before an emergency operative delivery. Progressive asphyxia is known as foetal distress; the foetus does not breathe directly from the atmosphere, but depends on maternal circulation for its oxygen requirement. The oxygen delivery to the foetus depends on the placental (maternal side), placental transfer and foetal circulation. Oxygen transport to the foetus is reduced physiologically during uterine contractions in labour. Significant impairment of oxygen transport to the foetus, either temporary or permanent may cause foetal distress, resulting in progressive hypoxia and acidosis. Intrauterine foetal resuscitation comprises of applying measures to a mother in active labour, with the intention of improving oxygen delivery to the distressed foetus to the base line, if the placenta is functioning normally. These measures include left lateral recumbent position, high flow oxygen administration, tocolysis to reduce uterine contractions, rapid intravenous fluid administration, vasopressors for correction of maternal hypotension and amnioinfusion for improving uterine blood flow. Intrauterine Foetal Resuscitation measures are easy to perform and do not require extensive resources, but the results are encouraging in improving the foetal well-being. The anaesthesiologist plays a major role in the application of intrauterine foetal resuscitation measures.

The use of audit to explain the rise in caesarean section

An audit was undertaken in a maternity unit in 1996. The caesarean section in the unit studied in 1996 was 21.7% compared to a UK national rate at that time of 13%. The unit staff believed the main reason for these figures was the influence of maternal request. The aims of the study were to: identify factors influencing the CS rate, assess physiological and psychological implications to both the mother and baby, make recommendations to reduce the rate both safely and effectively, and identify resource implications. Recommendations made include the need to introduce multi-professional evidence-based guidelines on the management of fetal distress, trial of labour with history of previous CS and the use of external cephalic version in the cases of the uncomplicated breech presentation. The need to ensure that women electing to have a CS are fully informed of the risks related to CS was also highlighted.

Intermittent auscultation for the intrapartum assessment of fetal well-being in Western Australia.

In May 1995, in response to a decision of the Perinatal and Infant Mortality Committee of Western Australia, a survey of Western Australian hospitals was performed to ascertain what policies were in use for the monitoring of the fetal heart rate in labour and what proportion of these hospitals had access to electronic monitoring by cardiotocography. A response was received from 96% of the surveyed hospitals. More than half the births in this State (13,950 of 25,238) were monitored in labour using intermittent auscultation as the primary test; 7.5% of Western Australian births each year occurred in hospitals in which electronic monitoring was not available. Fewer than 50% of hospitals had written protocols describing the method of auscultation of the fetal heart during labour, the indications to contact a doctor or the management of fetal distress. The protocols which did exist displayed considerable variation in the recommended frequency of intermittent auscultation. The lack of standard practice in this field probably results from uncertainties in the literature. Intermittent auscultation has not been subjected to rigorous scientific evaluation as a screening tool and guidelines documenting ideal auscultatory practices need to balance the precision of electronic monitoring and freedom from intervention. Based on this compromise and existing evidence, a protocol for intermittent auscultation in normal labour is proposed.

EMERGENCY MANAGEMENT OF FETAL STRESS AND DISTRESS IN THE OBSTETRIC PATIENT

The clinical use of intrapartum fetal heart rate monitoring remains controversial. Because of its widespread use in this country, interpretation skills must be maintained. Clear and concise criteria for the diagnosis of fetal stress and distress are presented in this article, and the management of fetal distress is discussed.

Meeting the challenge of the rising cesarean birth rate

The rising cesarean birth rate is a matter of national concern, and the goal of clinical obstetricians is to contain this trend while maintaining good maternal and perinatal outcome. Despite published reports suggesting that excellent perinatal outcome can be achieved with modest cesarean birth rates, the general increase of abdominal delivery in the United States appears to continue unabated. An educational approach to modify the community cesarean rate was directed at physicians, nurses, and interested lay groups via presentations in the Denver metropolitan community over a 5-year period. The content of these presentations included management of patients with previous cesarean births, diagnosis and management of fetal distress, the approach to patients with apparent failed progress in labor, indications and strategies for the indicated induction of labor, alternatives in the management of breech presentations and twin deliveries, and identification of patients at risk for genital herpes. The total cesarean birth rate increased to a level of 19.3% in this community in 1986, largely accounted for by the increase in the primary rate to 13.7%. Repeat cesarean birth rates remained relatively stable at 5.6% over the 2-year survey. Hospitals in which resident house officers either managed the entire service or participated in patient care achieved some of the lowest rates of both primary and repeat cesarean birth. Although intellectual arguments for decreasing cesarean births are acknowledged by physicians and nurses alike, translating them into practice on a daily basis is tempered by the constraints of time and the burden of medicolegal concerns. Educational efforts alone, therefore, are likely to produce change only slowly.

Ritodrine in the management of fetal distress.

The potential value of a bolus injection of ritodrine in the management of fetal distress was examined in 24 patients. Following the injection of ritodrine, uterine activity measured over a period of 14.7 +/- 6.3 (SD) min was reduced to 22 (+/- 12.4 SD)% of the pre-existing values. The cardiotocographic tracings showed a reversion to a normal or less ominous pattern in 14 of the 16 patients where this could be evaluated. The infants in the ritodrine group took less time to establish regular respirations. The perinatal neurobehaviour in the ritodrine and control groups did not differ. Two mothers who were given ritodrine and who received atropine premedication developed tachycardia and marked systolic hypertension. The administration of a bolus of ritodrine may have a place in the management of fetal distress when caesarean section is unavoidably delayed, but atropine premedication must be avoided as the combination can lead to potentially serious cardiovascular complications.

Diagnosis and Management of Fetal Distress

Both biophysical and biochemical techniques may be used to diagnose fetal distress. Fetal heart rate monitoring should be thought of as a screening technique to define a population at significant risk for fetal acidosis. The addition of fetal scalp blood sampling improves the clinician's diagnostic accuracy. The hallmark of treatment is to alleviate the stress on the fetus, to restore intervillous and cord blood flow, and, hence, to improve fetal oxygenation. This improvement may be accomplished by (1) discontinuing oxytocin, (2) correcting maternal hypotension, (3) administering oxygen to the mother, and (4) attempting to alleviate cord compression by changing the relationship of the fetal presenting part to the umbilical cord and pelvis.

Maternal glucose loading in the management of fetal distress

A group of normal parturients serving as controls and women who exhibited fetal distress in labor have been studied. Normal uterine contractions of labor are associated with findings of a lowered blood pH and elevated pCO2. The effects of maternally administering 25 Gm. of glucose intravenously at the time of detecting a fetal bradycardia followed by a continuous 20 per cent glucose infusion has been evaluated.By this procedure plasma glucose levels were significantly elevated resulting in the induction of both maternal and fetal hyperglycemia. The fetal bradycardia was promptly corrected in the cases studied with the single exception of one case which resulted in a stillborn.Maternal inhalation of 100 per cent oxygen is effective in increasing placental oxygen transfer for a total duration of 30 minutes. After that, a decrease in total oxygen transfer has been noted.

Use of low-molecular-weight dextran in management of foetal distress in labour: Jones: p. 909

Use of low-molecular-weight dextran in management of foetal distress in labour: Jones: p. 909

Use of low-molecular-weight Dextran in management of foetal distress in labour

Use of low-molecular-weight Dextran in management of foetal distress in labour

USE OF LOW-MOLECULAR-WEIGHT DEXTRAN IN MANAGEMENT OF FOETAL DISTRESS IN LABOUR.

USE OF LOW-MOLECULAR-WEIGHT DEXTRAN IN MANAGEMENT OF FOETAL DISTRESS IN LABOUR.

Conservatism in the Management of Foetal Distress

Conservatism in the Management of Foetal Distress

The case for conservatism in management of foetal distress.

The case for conservatism in management of foetal distress.