Non-reassuring Cardiotocography Research Articles

Umbilical cord arterial blood pH an indicator of rise in cesarean section rate due to false-positive indications by CTG

Background: Cesarean section rate is rising globally, now accounting for more than 1 in 5 (21%) of all childbirths. This number is set to continue increasing over the coming decade unless the factors which increase the rate of cesarean section are kept in check. Intrapartum cardiotocography (CTG) has shown a false-positive rate of cesarean section. This has been correlated with neonatal umbilical cord blood pH analysis. Aims and Objectives: (1) Correlation of non-reassuring CTG, resulting in cesarean section with umbilical cord arterial blood pH. (2) To find the false-positive indications of cesarean section due to CTG. Materials and Methods: This observational study was conducted in the Department of Obstetrics and Gynecology of SKIMS, Soura, from September 2020 to July 2022 over a period of 22 months. Women with a gestational age of more than 34 weeks with singleton pregnancy were included in the study. Those with CTG-documented fetal distress were subjected to umbilical cord arterial blood pH monitoring. Results: A total of 85 patients underwent cesarean sections in view of fetal distress documented by CTG, but only 45 neonates had actual distress as documented by umbilical cord blood sampling. Conclusion: Social and non-medical factors no doubt have caused an alarming rise in cesarean sections, but at the same time, there are some iatrogenic causes, namely CTG, which lead to the rise in the cesarean section rate due to false-positive indications. This has been further supported by the fact that the pH of the umbilical cord blood of neonates with intrapartum non-reassuring CTG does not correspond to fetal acidemia in all cases. Hence, a significant number of cesarean sections is being done for false-positive indications.

Analysis of Intrapartum Cardiotocography Findings in Labour, its Correlation with Umbilical Arterial Blood pH and Neonatal Outcome

Background: Cardiotocography (CTG) is being used in all labouring women to detect intrapartum hypoxemia which further requires confirmatory tests. But in a setting where these facilities are not available, umbilical artery pH analysis can help not only in identifying neonates with intrapartum hypoxemia but can also help in anticipating neonatal adverse outcomes. The aim of the study was to analyse intrapartum cardiotocography and its correlation with umbilical artery pH and neonatal outcome. Methods: Total of 317 consecutive single, term, labouring women were included in the present study. After taking CTG, it was classified into normal, non-reassuring and abnormal groups according to National Institute of Clinical Excellence (NICE) guideline 2017. At birth umbilical cord arterial blood was taken to detect neonatal hypoxemia. At the same time, APGAR score at 5 minute of birth, NICU admission and neonatal mortality was also recorded. Neonates with umbilical artery blood pH of ≤7.2 were considered as asphyxiated. Results: Among 317 women 48.8% had normal CTG, 35% had non-reassuring and 15.4% had abnormal CTG. APGAR score was found to be <7 in 17.3%, and same number of neonates had NICU admission. Out of 113 non-reassuring CTG, 5.9% had acidosis. This number was much higher in abnormal CTG group where 11% had acidosis. There were 6 neonatal mortalities. A statistically significant association was found between intrapartum CTG and umbilical artery pH and neonatal outcomes. Conclusion: Cardiotocography is an effective screening tool that is routinely used in all labouring women for screening of fetal hypoxia. By doing that timely intervention can be under taken to avoid neonatal morbidity and mortality.

Fetal scalp stimulation for assessing fetal well-being during labour.

Continuous fetal heart rate monitoring by cardiotocography (CTG) is used in labour for women with complicated pregnancies. Fetal heart rate abnormalities are common and may result in the decision to expedite delivery by caesarean section. Fetal scalp stimulation (FSS) is a second-line test of fetal well-being that may provide reassurance that the labour can continue. To evaluate methods of FSS as second-line tests of intrapartum fetal well-being in cases of non-reassuring CTG. FSS and CTG were compared to CTG alone, and to CTG with fetal blood sampling (FBS). We searched Cochrane Pregnancy and Childbirth's Trials Register (which includes trials from CENTRAL, MEDLINE, Embase, CINAHL, the WHO ICTRP and conference proceedings), ClinicalTrials.gov (18 October 2022), and reference lists of retrieved studies. Eligible studies were randomised controlled trials (RCTs) that compared any form of FSS to assess fetal well-being in labour. Quasi-RCTs, cluster-RCTs and studies published in abstract form were also eligible for inclusion, but none were identified. Two review authors independently assessed studies for inclusion and risk of bias, extracted data and checked them for accuracy. We assessed the certainty of the evidence using the GRADE approach. Two trials, involving 377 women, met the inclusion criteria for this review. Both trials were conducted in hospital settings and included women with singleton, term (37+0 weeks or more) pregnancies, a cephalic presentation, and abnormal CTG. Follow-up was until hospital discharge after the birth. A pilot trial of 50 women in a high-income country (Ireland) compared CTG and digital fetal scalp stimulation (dFSS) with CTG and fetal blood sampling (FBS). A single-centre trial of 327 women in a lower middle-income country (India) compared CTG and manual fetal stimulation (abdominal or vaginal scalp stimulation) with CTG alone. The two included studies were at moderate or unclear risk of bias. Both trials provided clear information on allocation concealment but it was not possible to blind participants or health professionals in relation to the intervention. Although objective outcome measures were reported, outcome assessment was not blinded or blinding was unclear. dFSS and CTG versus FBS and CTG There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. The risk of caesarean section (CS) may be lower with dFSS compared to FBS (risk ratio (RR) 0.38, 95% confidence interval (CI) 0.16 to 0.92; 1 pilot trial, 50 women; very low-certainty evidence) but the evidence is very uncertain. There were no cases of neonatal encephalopathy reported. The evidence was also very uncertain between dFSS and FBS for assisted vaginal birth (RR 1.44, 95% CI 0.76 to 2.75; very low-certainty evidence) and for the spontaneous vaginal birth rate (RR 2.33, 95% CI 0.68 to 8.01, very low-certainty evidence). Maternal acceptability of the procedures was not reported. FSS and CTG versus CTG alone Manual stimulation of the fetus was performed either abdominally (92/164) or vaginally (72/164). There were no perinatal deaths and data were not reported for neurodevelopmental disability at >/= 12 months. There may be little differences in the risk of CS on comparing manual fetal stimulation and CTG with CTG alone (RR 0.83, 95% CI 0.59 to 1.18; 1 trial, 327 women; very low-certainty evidence), but again the evidence was very uncertain. There were no cases of neonatal encephalopathy reported. There may be no differences in the risk of assisted vaginal birth (RR 1.43, 95% CI 0.78 to 2.60; very low-certainty evidence) or in the rates of spontaneous vaginal birth (RR 1.01, 95% CI 0.85 to 1.21, very low-certainty evidence), but again the evidence is very uncertain. Maternal acceptability of abdominal stimulation/FSS was not reported although 13 women withdrew consent after randomisation due to concerns about fetal well-being. There is very low-certainty evidence available which makes it unclear whether stimulating the fetal scalp is a safe and effective way to confirm fetal well-being in labour. Evidence was downgraded based on limitations in study design and imprecision. Further high-quality studies of adequate sample size are required to evaluate this research question. In order to be generalisable, these trials should be conducted in different settings, including broad clinical criteria at both preterm and term gestational ages, and standardising the method of stimulation. There is an ongoing study (FIRSST) that will be incorporated into this review in a subsequent update.

Nudo verdadero como causa de taquicardia fetal persistente. Reporte de un caso

Umbilical cord abnormalities are associated with adverse effects during pregnancy. The true umbilical cord knot is present in 0.3-2.1% of pregnancies and has been associated with fetal death. Risk factors include maternal age, high BMI, multiparity, hypertensive disorders, smoking, polyhydramnios, gestational diabetes, male sex of the fetus, and other malformations. Prenatal diagnosis of the true knot is rare and challenging. Most are diagnosed at birth and only 0.08% of true knots are diagnosed prenatally. Non-reassuring cardiotocography traces may be present, reflecting hypoxic or mechanical stress disrupting fetal oxygenation. The aim of this case report is to present a case of true umbilical cord knot presenting with persistent fetal tachycardia during labor, resolved by vaginal delivery. Keywords: True knot; umbilical cord; fetal achycardia; stillbirth; fetal asphyxia.

Association of CTG Diagnosis of Intrapartum Fetal Distress and Immediate Postpartum Acidemia in Foetal Umbilical Artery.

Intrapartum fetal hypoxia which is one of the leading causes of neonatal morbidity and mortality is a preventable cause. Over the past years, many methods have been employed to diagnose fetal distress, a sign of fetal hypoxia, among these, cardiotocography (CTG) is the most widely used method. Diagnosis of fetal distress based on CTG can have high inter and intraobserver variation leading to either delayed or inessential intervention henceforth increasing maternal morbidity and mortality. Fetal cord arterial blood pH is an objective method to diagnose intrapartum fetal hypoxia, hence by observing the incidence of acidemia in cord blood pH among those newborns born through cesarean section (CS) in view of non-reassuring CTG can help make a judicious decision. In this single institutional observational study, patients admitted for safe confinement were subjected to CTG in the latent and active phases of labor. Non-Reassuring traces were further classified based on NICE guideline CG190. The cord blood of these neonates born through CS in view of non-reassuring CTG was drawn and sent for ABG analysis. Among the 87 neonates delivered through CS in view of fetal distress, 19.5% had acidosis. Among those with pathological traces, 16(28.6%) had acidosis and one (100%) which was categorized as the need for urgent intervention showed acidosis. This result showed a statistically significant association (p value-0.003). No statistically significant association was obtained when variation in baseline characters of CTG when taken independently. In our study, neonatal acidemia which is the objective evidence of fetal distress was seen in 19.5% of our study population who underwent cesarean in view of non-reassuring CTG. Among these, acidemia was significantly associated with pathological CTG trace compared to suspicious trace. We also observed that abnormal FHR features when taken independently showed no significant association with acidosis. Acidosis among newborns certainly increased the requirement for active resuscitation and additional hospital stay. Hence, we conclude that by recognizing specific fetal heart rate patterns associated with acidosis in a fetus, a more judicious decision can be made, thereby preventing both delayed as well as inessential intervention.

Nudo verdadero de cordón umbilical, hallazgo incidental al nacimiento. Reporte de 4 casos en un hospital de tercer nivel.

The true umbilical cord knot is a pathology with an incidence relatively low. It is associated with the risk of loss of fetal well-being and stillbirth. There are both maternal and fetal risk factors, with different associated perinatal outcomes. Prenatal diagnosis of a true knot is a diagnostic challenge for the obstetrician, however, nowadays it is possible by ultrasound for incidental finding or by intentional search, mainly in patients with risk factors. In the same way it should be suspected in the presence of a non-reassuring cardiotocography, especially when there is no response to the usual intrauterine resuscitation maneuvers, such as left lateral decubitus position, supplemental oxygen and maternal hydration. The purpose of this report is to describe 4 cases of true knot in term pregnancies, in a third level hospital, where an incidence of 0.03% was estimated, with a mean gestational age of 39.3 weeks and a mean maternal age of 32.2 years. The main intrapartum findings were alterations in the cardiotocography, such as variable and late decelerations. The route of pregnancy resolution was equitable among the patients, 2 were resolved by vaginal delivery and the other 2 by cesarean section. Pregnancy was resolved by vaginal delivery in 2 of the patients, while the other 2 were resolved by cesarean section. One case of stillbirth was registered Keywords: Umbilical cord; true knot; perinatal outcomes; prenatal diagnosis.

Interobserver Agreement and Reliability of Intrapartum Nonreassuring Cardiotocography and Prediction of Neonatal Acidemia

Abstract Objective: To evaluate the agreement and reliability of intrapartum nonreasurring cardiotocography (CTG) interpretation and prediction of neonatal acidemia by obstetricians working in different centers. Methods: A retrospective cohort study involving two tertiary hospitals (The First Affiliated Hospital of Sun Yat-sen University and Perking University Third Hospital) was conducted between 30th September 2018 and 1st April 2019. Six obstetricians from two hospitals with three levels of experience (junior, medium, and senior) reviewed 100 nonreassuring fetal heart rate (FHR) tracings from 1 hour before the onset of abnormalities until delivery. Each reviewer determined the FHR pattern, the baseline, variability, and presence of acceleration, deceleration, sinusoidal pattern, and predicted whether neonatal acidemia and abnormal umbilical arterial pH < 7.1 would occur. Inter-observer agreement was assessed using the proportions of agreement (Pa) and the proportion of specific agreement (Pa for each category). Reliability was evaluated with the kappa statistic (k-Light's kappa for n raters) and Gwet's AC1 statistic. Results: Good inter-observer agreement was found in evaluation of most variables (Pa > 0.5), with the exception of early deceleration (Pa = 0.39, 95% confidence interval (CI): 0.36,0.43). Reliability was also good among most variables (AC1 > 0.40), except for acceleration, early deceleration, and prediction of neonatal acidemia (AC1 = 0.17, 0.10, and 0.25, respectively). There were no statistically significant differences among the three groups, except in the identification of accelerations (Pa = 0.89, 95% CI: 0.83,0.95; Pa = 0.50, 95% CI: 0.41,0.60, and Pa = 0.35, 95% CI: 0.25,0.43 in junior, medium and senior groups, respectively) and the prediction of neonatal acidemia (Pa = 0.52, 0.52, and 0.62 in junior, medium and senior groups, respectively), where agreement was highest and lowest in the junior-level group, respectively. The accuracy and sensitivity of the prediction for umbilical artery pH < 7.1 were similar among the three groups, but the specificity was higher in the senior groups (93.68% vs. 92.53% vs. 98.85% in junior, medium and senior groups, P = 0.015). Conclusion: Although we found a good inter-observer agreement in the evaluation of the most basic CTG features and FHR category statistically, it was insufficient to meet the clinical requirements for “no objection” interpretation for FHR tracings. Further specialized training is needed for standardized interpretation of intrapartum FHR tracings.

Maternal risk factors and meconium stained amniotic fluid

Background: Meconium is a sterile, thick, black-green, odourless material that results from accumulation of debris in fetal intestine during the third month of gestation. The risk factors for meconium-stained amniotic fluid (MSAF) are both maternal and fetal. MSAF is associated with higher rate of caesarean delivery, increased need for neonatal resuscitation and meconium aspiration syndrome. This observational study was undertaken so that such expecting mothers can be screened at an early stage and prompt intervention can be done to minimize neonatal morbidity and mortality.Methods: This prospective observational study was conducted in department of paediatrics of Sri Guru Ram Das University from December 2014 to June 2016 included all deliveries with meconium stained amniotic fluid excluding Twins, neonates with congenital malformations, multi organ dysfunction or requiring surgical intervention.Results: The incidence of MSAF was 3.42% with 10.5% mortality. Various maternal factors including multiparity, bad obstetric history, pregnancy-induced hypertension (PIH), intrauterine growth restriction (IUGR), maternal diabetes, anaemia and non-reassuring cardiotocography (CTG) record were found to be statistically important and associated with poor outcome.Conclusions: MSAF and poor neonatal outcome is related to antenatal care. Thus, good antenatal and perinatal care can prevent morbidity and mortality in neonate by early identification of signs of fetal distress and passage of meconium inutero and improve outcome.

Intrapartum cardiotocographic monitoring and its correlation with neonatal outcome.

Despite the advancements in perinatal care in past decades, perinatal asphyxia remains a serious problem leading to significant perinatal morbidity and mortality. Therefore, foetal monitoring during the intrapartum period is of paramount importance. Among various methods of fetal monitoring, cardiotocography is a form of electronic foetal monitoring in which there is simultaneous recording of foetal heart rate and uterine contractions. This cross-sectional observational study was done in the labour room and neonatal intensive care unit (NICU) of a teaching Municipal Hospital in North India including 500 pregnant women of age group 18-45 years with singeleton fetus of gestation ≥36 weeks without any known congenital anomaly. Intrapartum cardiotocography (CTG) for 20 minutes was done within 12 hours prior to delivery and babies born to them were observed for birth asphyxia as Apgar score <7 at 1 minute as per using APGAR score less than 7 at 1 minute as per south east asia regional neonatal perinatal database (SEAR-NPD), world health organization (WHO) working definition. CTG tracing was normal/reassuring in 92% of pregnant women, nonreassuring in 7% and was abnormal in only 1%. In patients with abnormal and nonreassuring CTG, delivery by lower segment cesarian section (LSCS) was significantly high (P < .0001). APGAR scoring was done at 1 minute and 5 minutes of life, it was found that 4% babies were having score less than 7 at 1 minute with incidence of birth asphyxia 40 per 1,000 live births Neonatal seizure was significantly more in nonreassuring and abnormal CTG group (P value <.0001). Abnormal CTG tracings result in higher incidence of operative interventions for deliveries. Abnormal CTG pattern during intrapartum CTG has high specificity and negative predictive value but has low sensitivity and positive predictive value for detection of birth asphyxia and need for NICU admission.

Dandy-Walker syndrome with bilateral choanal atresia: A case report.

IntroductionDandy-Walker syndrome is a rare congenital brain malformation characterized by cerebellar vermis agenesis or hypoplasia, cystic dilatation of the fourth ventricle and a large posterior fossa causing upward displacement of tentorium and torcula. In this paper, we present a case of bilateral choanal atresia with Dandy-Walker Syndrome in a female newborn.Case presentationWe present a case of a female patient who was born at 38th weeks of gestation via emergency cesarean section due to non-reassuring cardiotocography and abnormal antenatal ultrasounds findings. The imaging revealed the presence of Dandy-walker malformation. The patient presented with cyanosis and respiratory distress. Bedside flexible nasoendoscopy revealed bilateral choanal atresia which is confirmed by computed tomography of sinuses. Endoscopic bilateral choanal atresia repair was performed. On postoperative follow up, nasal endoscopy showed bilateral intact flap and patent neochoana.Discussion and conclusionDandy-Walker syndrome is a congenital disorder that can be diagnosed prenatally. The syndrome is associated with multiple anomalies. However, there are few published reports of bilateral choanal atresia in Dandy-Walker Syndrome. Bilateral choanal atresia is considered a life-threatening condition in newborns that requires early surgical intervention.

Fetal monitoring from 39\xa0weeks\u2019 gestation to identify South Asian-born women at risk of perinatal compromise: a retrospective cohort study

To investigate whether earlier “post-term” monitoring of South Asian (SA) pregnancies from 39 weeks’ gestation with amniotic fluid index (AFI) and cardiotocography (CTG) detected suspected fetal compromise. Retrospective cohort study of all SA-born women at an Australian health service with uncomplicated, singleton pregnancies following the introduction of twice-weekly AFI and CTG monitoring from 39 weeks. Monitoring results, and their association with a perinatal compromise composite (including assisted delivery for fetal compromise, stillbirth, and NICU admission) were determined. 771 SA-born women had earlier monitoring, triggering delivery in 82 (10.6%). 31 (4%) had a non-reassuring antepartum CTG (abnormal fetal heart rate or variability, or decelerations) and 21 (2.7%) had an abnormal AFI (≤ 5 cm). Women with abnormal monitoring were 53% (95% CI 1.2–1.9) more likely to experience perinatal compromise and 83% (95% CI 1.2–2.9) more likely to experience intrapartum compromise than women with normal monitoring. Monitoring from 39 weeks identified possible fetal compromise earlier than it otherwise would have been, and triggered intervention in 10% of women. Without robust evidence to guide timing of birth in SA-born women to reduce rates of stillbirth, earlier monitoring provides an alternative to routine induction of labour.

Slow-release vaginal insert of misoprostol versus orally administrated solution of misoprostol for the induction of labour in primiparous term pregnant women: a randomised controlled trial.

To compare the World Health Organization (WHO) recommended orally administrated dosage of misoprostol (25μg) with a vaginal slow-release (7μg/hour) insert of misoprostol regarding time from induction to delivery and safety of the method. Open label, Randomised controlled trial (RCT). Delivery ward at a secondary referral hospital in Stockholm, Sweden, from 1 October 2016 to 21 February 2018. One hundred and ninety-six primiparous women with singletons in cephalic presentation at ≥37weeks of gestation and with a Bishop score of ≤4. Women were randomised to an oral solution of misoprostol (Cytotec® n=99) or vaginal slow-release misoprostol (Misodel® [MVI] n=97). Primary outcome: time from induction to vaginal delivery. mode of delivery; proportion of vaginal deliveries within 24hours (VD24); neonates with an Apgar score of <7 at 5minutes; pH<7.10; postpartum haemorrhage (PPH) of >1000ml; hyperstimulation; and women's delivery experience (VAS). There was no difference in the time to delivery [corrected] (median 21.1hours in the MVI group and 23.2hours in the oral group; Kaplan-Mayer log rank P=0.31). There was no difference regarding the proportion of VD24 (50.5 versus 55.7%, P=0.16). Hyperstimulation with non-reassuring cardiotocography (CTG) was more common in the MVI group (14.4 versus 3.0%, P<0.01). Terbutaline (Bricanyl® ) was used more often for hyperstimulation in the MVI group (22.7 versus 4.0%, P<0.01). There was no difference in the numbers of children admitted to the neonatal intensive care unit (NICU). Vaginal delivery after induction of labour (IOL) with slow-release misoprostol did not result in a shorter time from induction to vaginal delivery, compared with oral misoprostol solution, but was associated with a higher risk for hyperstimulation and fetal distress. There were no differences in mode of delivery or neonatal outcome. IOL with MVI was similar to oral solution of misoprostol but hyperstimulation and fetal distress were more common.

Meconium aspiration syndrome: risk factors and predictors of severity

Purpose: To identify risk factors and predictors of severity associated with meconium aspiration syndrome (MAS) in the patients admitted to the neonatal intensive care unit (NICU).Materials and methods: Retrospective study including newborns admitted, between 2005 and 2015, with a diagnosis of MAS.Results: Of the newborns admitted to the NICU, 0.66% were diagnosed with MAS. These had higher prevalence of caesarean delivery (p < .001), nonreassuring or abnormal cardiotocography (CTG) (p < .001), intrapartum maternal fever (p = .002), Apgar scores at the first minute <7 (p < .001) and need of endotracheal intubation at birth (p < .001). Newborns with severe MAS had higher median reactive C protein (86.9 versus 9.65, p = .001) and 73.3% had pulmonary hypertension (p = .027). They required significantly more days of oxygen therapy, mechanical ventilation, nitric oxide, inotropic, and surfactant therapy, as well as longer hospital stay.Conclusions: Nonreassuring or abnormal CTG and low Apgar score at the first minute were established as risk factors for MAS and need of surfactant therapy as a predictor of severity.

Mother-newborn health indicators in possible victims of gender-based violence during pregnancy

BackgroundPregnancy increases the risk of gender-based violence, considered an underdiagnosed public health problem. ObjectiveTo determine the association between the situation of possible gender-based violence in the pregnant woman and variables related to pregnancy, labor, puerperium, and newborn health. DesignAn observational multicenter study. SettingsThree Spanish hospitals during 2015. Participants141 pregnant women in which information is collected sociodemographic variables and data related to pregnancy, labor, and puerperium were gathered by interview and from clinical records. Comparisons of means and logistic regression analyses were performed, calculating crude and adjusted odds ratios. ResultsThe study included 141 women; 44 in a situation of possible abuse required more medication during labor (p=0.018), had less early skin contact with their newborn (p=0.021) and more non-reassuring cardiotocography traces (p=0.012), and reported greater pain during labor (p=0.013). The children of the mothers in this situation had a lower mean Apgar score (p˂0.059), less frequently began breastfeeding early (p=0.008), and had higher risk of low birth weight (p˂0.001). ConclusionThe situation of possible abuse in pregnant women may negatively affect their pregnancy, their pain and need for medication during labor, and other newborn health indicators, among other health parameters.

Increasing rate of Caesarean Section Due to Non-Reassuring Cardiotocography

Objective: To evaluate increasing rate of caesarean section due to non-reassuring cardiotocography. Methods: This study is carried out in obs/gyn department of Liaquat university hospital from 2012 to 2013. After permission from ERC, patients enrolled for study meeting inclusion criteria with non-reactive cardiotocography undergo caesarean section, and results are analysis through SSPS version 17. Results: There was wide variation of maternal age ranging from a minimum of 20 years to 30 years. The mean age was 26 ± 2.1 years. In our study mostly patients were primigravida 58 (58%) between 2 - 4 were 22 (22%) more than para 5 were 20 (20%) patients. In our study mostly patients undergone caesarean section 81 (81%) 19 delivered vaginally (19%). In our study the gestational age was >37 weeks, ranging from a minimum of 37 weeks to 42 weeks. The mean age was 37 + 2.4 week. Mostly patients observed 37 - 38 wks in (52.67%), 39 - 40 wks in (32.14%) and 41 - 42 wks in (15.17%). In our study mostly Apgar score were more than 7 was 63 (63%) cases and less than 7 Apgar score in 37 (37%). Conclusion: Cardiotocography is a useful and indispensable adjunct to monitor the condition of endangered fetus. However, there is a need to develop a standardized and unambiguous definition of FHR tracing to reduce the incidence of false positive findings that may result in increased incidence of unnecessary intervention particularly caesarean section.

Guideline choice for CTG analysis influences first caesarean decision

Objective: To compare intrapartum cardiotocography (CTG) analysis in case of first caesarean section (CS) for non-reassuring CTG according to international guidelines.Methods: Four ObGyns retrospectively analysed first CS for non-reassuring CTG during labour blind to neonatal outcome. CTG were analysed according to French National College of Obstetricians and Gynaecologists (CNGOF) and to the FIGO guidelines. First, CTG analysis was done without obstetrical context, then secondly, it was given. ObGyns stated if CS was justified or not. Inter-operator ObGyn agreement was analysed.Results: Among 587 CS, 100 women met the inclusion criteria with a first CS for non-reassuring CTG. The overall inter observer agreement was low but fair. ObGyns were significantly more concordant using the FIGO than the CNGOF guidelines (kappa coefficient = 0.331 [0.27–0.39] versus 0.209 [0.16–0.26] p < 0.001). Without obstetrical context 70% of CS were considered as unjustified. This rate decreased to 16% with the knowledge of the obstetrical context and the use of a classification (p < 0.001). Two-third of the unjustified CS were carried out during night hours (p = 0.026).Conclusion: The FIGO guidelines are more reproducible than CNGOF guidelines. The overall inter-observer agreement was low but fair. The guideline choice could have an impact on first CS decision.

NEONATAL OUTCOME

Objective: The objective of this study was to determine the neonatal outcomein women undergoing cesarean section due to non-reassuring cardiotocography (CTG). Crosssectional study. Setting: Department of Gynecology &amp; Obstetrics at Liaquat University ofMedical &amp; Health Sciences Hyderabad. Period: October 2012 to August 2013. Methodology:Detailed Clinical examination of the patient was done. Systemic review was also done to seeany co-morbidity. All patients underwent for base line like CBC and specific investigationsespecially ultrasound pelvis. Inclusion criteria were all patients with gestational age &gt; 37 weeksand maternal age 20 -30 years with non-reassuring CTG. Exclusion criteria were history ofprevious caesarean section operation, less than 37 weeks pregnancy, any other obstetricalindication for caesarean section (except non reactive CTG) like cephalo pelvic disproportion,previous caesarean section and severe intrapartum hemorrhage. Results were prepared withhelp of tables and graphs. Data was analyzed through SPSS software. Results: This studywas conducted on 112 patients. Wide variation of maternal age ranging from a minimum of 20years to 30 years with mean age was 26+2.1 years. Gestational age was &gt; 37weeks, rangingfrom a minimum of 37 weeks to 42weeks. The mean age was 37+2.4 weeks. Mostly patientswere observed 37-38wks in 52.67%, 39-40wks in 32.14% and 41-42wks in 15.17%. Apgarscore was more than 7 in 61.60% cases and less than 7 apgar score in 38.39% cases whichis statistically not significant. Conclusion: It is concluded that apgar score was &gt;7 in 61.60%cases and &lt;7 apgar score in 38.39% cases which is statistically not significant. CTG is a usefuland indispensable adjunct to monitor the condition of endangered fetus. Reduce the incidenceof false positive findings that may result in increased incidence of unnecessary interventionparticularly caesarean section CTG should not be used as sole test CTG finding should becorrelated with colour of liquor ,if facility is present scalp PH should be done.

English

Objective: The objective of this study was to determine the neonatal outcomein women undergoing cesarean section due to non-reassuring cardiotocography (CTG). Crosssectional study. Setting: Department of Gynecology &amp; Obstetrics at Liaquat University ofMedical &amp; Health Sciences Hyderabad. Period: October 2012 to August 2013. Methodology:Detailed Clinical examination of the patient was done. Systemic review was also done to seeany co-morbidity. All patients underwent for base line like CBC and specific investigationsespecially ultrasound pelvis. Inclusion criteria were all patients with gestational age &gt; 37 weeksand maternal age 20 -30 years with non-reassuring CTG. Exclusion criteria were history ofprevious caesarean section operation, less than 37 weeks pregnancy, any other obstetricalindication for caesarean section (except non reactive CTG) like cephalo pelvic disproportion,previous caesarean section and severe intrapartum hemorrhage. Results were prepared withhelp of tables and graphs. Data was analyzed through SPSS software. Results: This studywas conducted on 112 patients. Wide variation of maternal age ranging from a minimum of 20years to 30 years with mean age was 26+2.1 years. Gestational age was &gt; 37weeks, rangingfrom a minimum of 37 weeks to 42weeks. The mean age was 37+2.4 weeks. Mostly patientswere observed 37-38wks in 52.67%, 39-40wks in 32.14% and 41-42wks in 15.17%. Apgarscore was more than 7 in 61.60% cases and less than 7 apgar score in 38.39% cases whichis statistically not significant. Conclusion: It is concluded that apgar score was &gt;7 in 61.60%cases and &lt;7 apgar score in 38.39% cases which is statistically not significant. CTG is a usefuland indispensable adjunct to monitor the condition of endangered fetus. Reduce the incidenceof false positive findings that may result in increased incidence of unnecessary interventionparticularly caesarean section CTG should not be used as sole test CTG finding should becorrelated with colour of liquor ,if facility is present scalp PH should be done.

Correlation between Nonreassuring Patterns in Fetal Cardiotocography and Birth Asphyxia

Objectives: Cardiotocography (CTG) is a tool for assessing the fetus during labor and identifying the risk of asphyxia. Abnormal CTG can lead to stress in the physician and mother and result in their decision in terminating the pregnancy and the complications of an emergency cesarean section. The purpose of this study was the evaluation of the correlation between nonreassuring patterns in fetal CTG and birth asphyxia. Materials and Methods: In a cross-sectional analytic study, 324 term pregnant women were included. The association between nonreassuring patterns in CTG (fetal tachycardia, fetal bradycardia, absent or minimal baseline variability, and absence of acceleration and periodic or episodic deceleration) and birth asphyxia were assessed. Results: Birth asphyxia existed in 10 newborns; in all cases mild hypoxic ischemic encephalopathy (HIE) was observed. Within the nonreassuring CTG patterns, baseline fetal heart variability and periodic or episodic deceleration had a significant relationship with birth asphyxia. Most asphyxia cases had occurred in absent and minimal baseline fetal heart rate (FHR) variability (R = 0.49, P < .001). In periodic or episodic decelerations, most asphyxia cases occurred in recurrent late decelerations with normal baseline variability and variable decelerations with shoulders or overshoots (R = 0.42, P = .014). Conclusion: With regard to the findings of the present study we can use nonreassuring cardiotocographic patterns, especially absent and minimal baseline FHR variability and periodic or episodic decelerations in prediction of birth asphyxia. It seems however that most birth asphyxias occur in normal cardiotocographs.

How safely can post-term pregnancies with uncertain gestational age be followed up using amniotic fluid index measurements?

Objective. To review whether 2 weeks’ follow-up is safe for women at 42 weeks with an uncertain gestational age (GA) and amniotic fluid index (AFI) of ≥10 cm, as well as reassuring cardiotocography (CTG). Methods. A retrospective descriptive study of women with an uncertain GA of 42 weeks was done at Tygerberg Hospital. The women had weekly CTG and AFI determinations. Induction of labour followed non-reassuring CTG or an AFI of <5. Results. A total of 135 women were studied. The time interval between first evaluation at uncertain 42 weeks and delivery ranged between 0 and 46 days (median 10 days). Of the women, 104 had normal vaginal deliveries and 31 (23.0%) caesarean sections. Eleven women (8.1%) with an AFI ≥10 had CS for fetal distress within 2 weeks of the visit at 42 weeks. No neonatal morbidity or mortality was noted. Conclusion. Weekly monitoring with CTG and AFI at 42 weeks with unsure GA is safe. A follow-up visit after 2 weeks cannot be recommended, as 8% of women required CS within less than 2 weeks because of fetal distress.