Signs Of Fetal Distress Research Articles

Nonfebrile seizures.

Nonfebrile seizures.

Fetal distress due to placental insufficiency at 26 through 31 weeks: a comparison between an active and a more conservative management

Objective: To compare perinatal mortality and short-term morbidity in extremely preterm infants with fetal distress due to placental insufficiency in two centers with different management attitude. Design: Retrospective cohort study in two university hospitals of all infants with fetal growth retardation due to placental insufficiency resulting in signs of fetal distress at 26 through 31 weeks gestational age, during the years 1984 through 1989. Center A followed a conservative management: in some cases the risk of major handicaps or mortality was estimated so high, based on antenatally estimated fetal weight and gestational age, that the decision was taken to abstain from treatment. In all other cases cesarean section took place, but only if fetal distress was obvious. Center B used a more active management: cesarean section was performed in all cases, sometimes with only minor changes in fetal heart rate variability. Results: Overall survival differed significantly: 55% (center A) versus 72% (center B), largely due to antenatal mortality in center A. Discharge survival rate of liveborn infants was 81% in center A and 72% in center B. More than half of the postnatal mortality was attributed to respiratory causes in both centres. An active management showed a tendency to a higher incidence of short-term morbidity. Conclusion: Selection by antenatal prediction of postnatal mortality using estimated fetal weight fails. Even in the group with the lowest birthweight postnatal mortality did not surpass 50%. Early intervention may be associated with higher short-term morbidity. Long-term follow-up of these children is needed to discriminate between both policies with regard to further development of surviving infants.

Maternal brain death during pregnancy

A case of a 36-year-old woman diagnosed brain dead secondary to pneumococcal meningitis at 27 weeks of gestation is presented. In spite of aggressive therapy, supportive intensive care was possible for only 36 h. Signs of fetal distress appeared and a cesarean section was performed. The complexity of supportive care and its ethical implications are discussed.

Clinical significance of creatine kinase isoenzymes for fetal asphyxia in women at labor.

Creatine kinase-brain isoenzyme activity (CK-BB) was measured longitudinally in the serum of 31 pregnant women in the first stage of labor (early and advanced), at delivery, and 1, 6 and 24 h after delivery, in the umbilical cord and in the serum of their neonates on the first day of life. There was no increase in serum CK-BB values of mothers that delivered normally (n = 15) or had an elective cesarean section (n = 5). Pregnant women with signs of fetal distress had an increase in CK-BB levels in the first stage of labor (mean +/- SD 4.5 +/- 4.9 U/l, p < 0.03) and 6 h after delivery (12 +/- 4 U/l, p < 0.0001). Neonates with intrauterine stress also had an increase in their CK-BB to 144 +/- 116 U/l at 6 h of life, in comparison with babies born without signs of stress. It appears that CK-BB during labor and in the first hours of life may be indicative of intrauterine stress.

Prepartum transabdominal amnio-infusion for severe oligohydramnios.

Transabdominal amnio-infusion preceding labor induction was evaluated as a means of avoiding fetal distress and cesarean delivery in patients with oligohydramnios. A preliminary study was performed in 8 consecutive term or post-term pregnancies complicated by severe oligohydramnios (amniotic fluid index less than or equal to 1 cm) with unripe cervices (Bishop's score less than or equal to 3). Warm saline was injected through a spinal needle under ultrasound control. Vaginal delivery occurred in 7 cases; cesarean section was performed in one patient for failure to progress. There was no meconium aspiration and no sign of fetal distress.

How Much of Neonatal Encephalopathy Is due to Birth Asphyxia?

In the literature on neonatal encephalopathy, the pervasive assumption is that once infants with major malformations or infections have been excluded, most of the remaining cases are due to birth asphyxia. Assessing the proportion of neonatal encephalopathy that is due to asphyxia during birth is difficult because of problems in defining asphyxia and neonatal encephalopathy and in recognizing the cause of neonatal neurologic illness. Available evidence indicates that neonatal neurologic signs are not strongly related to obstetric complications, signs of fetal distress, or biochemical markers usually considered to indicate perinatal asphyxia. Most studies that have sought positive evidence of independent markers of intrapartum asphyxia have found them to be absent in a large majority of neurologically symptomatic neonates. We conclude that the proportion of neonatal encephalopathy that is asphyxial in origin is not known but warrants examination, especially in view of the probable need in the near future to identify, on the basis of evidence available in the first hour or so of life, suitable candidates for clinical trials of powerful but risky treatments of birth asphyxia.

Safety of term vaginal breech delivery

Of 247 women who were pregnant of one healthy child in breech presentation at term, 13 (5.3%) were delivered by a primary cesarean section. The other 234 (94.7%) were allowed to attempt vaginal birth. In these women, the only factor to determine the possibility of a vaginal delivery was normal progression of labor during the first stage, without secondary arrest or signs of fetal distress. 109 Women (44.1%) were delivered spontaneously according to Bracht, 87 (35.2%) had an assisted breech delivery, and 38 (15.4%) underwent a secondary cesarean section. There were two perinatal deaths (0.8%). One of them was directly related to the trial of labor. Two children with a birth trauma had an uneventful recovery. The 1 min Apgar score in all breech delivery groups was more often lower than in a control group of children, who were born spontaneously at term in vertex presentation. However, the 5 min Apgar score and the mean umbilical artery pH were within normal limits in all groups. The secondary cesarean section rate was inversely related to vaginal parity of the mother, and directly related to the newborns' birth weight. There was no relation between the secondary cesarean section rate and the type of breech presentation. It is concluded, that a trial of labor in carefully selected patients with a child in breech presentation at term is a safe procedure, that can be successfully completed in almost 80% of cases. In retrospect, low vaginal parity and high birth weight of the newborn have a negative influence on normal progression of labor.

Pre‐ and Perinatal Factors in Febrile Convulsions

In a community based study, 110 children with febrile convulsions (FC) were identified prospectively. Pre- and perinatal risk factors were compared with 213 age and sex matched controls sampled from the community. During pregnancy, proteinuria and preeclampsia/eclampsia occurred more often in mothers of cases. Premature birth and bilirubinemia greater than 200 mumol/l were also more common in cases. There were no differences between cases and controls in occurrence of chronic illnesses in mothers, parents age at birth, birth order, and factors occurring during delivery such as type of anesthesia, occurrence of acute or elective cesarean section, use of vacuum extraction, mode of presentation, signs of fetal distress in amnion fluid, umbilical problems, abnormalities of fetal heart rate or duration of delivery. Perinatal asphyxia was uncommon and there was no difference between cases and referents. Occurrence of complications during the first neonatal week did not differ between groups.

The role of epidural anesthesia in trial of labor.

In 1988, the American College of Obstetricians and gynecologists (ACOG) decided that vaginal delivery after a previous cesarean delivery (trial of labor, TOL) was an acceptable alternative to elective repeat cesarean delivery. ACOG stated that there appears to be no absolute contraindication to epidural anesthesia for labor during TOL. The concern is that should there be a uterine rupture, would the epidural anesthesia mask the abdominal pain? The incidence of complete rupture with trial of labor is reported to be 0.3-0.5%. In our review of 10,967 patients undergoing TOL, only 22% of complete ruptures presented with abdominal pain; 76% presented with signs of fetal distress diagnosed by continuous electronic fetal monitoring. Thus abdominal pain is an unreliable sign of complete uterine rupture. There have been no reports of epidural anesthesia delaying the diagnosis of uterine rupture. In the review of 10,967 patients undergoing TOL, there were no maternal deaths and only nine fetal deaths secondary to complete uterine rupture. The literature strongly suggests that epidural anesthesia is safe in TOL even when oxytocin is used for augmentation of labor.

The influence of increased seismic activity on pregnancy outcome

The influence of increased seismic activity on pregnancy outcome was evaluated. A significant increase in delivery rate was noted during the 48 hours following an earthquake on all instances. In two out of five events, a significant increase in premature delivery rate was noted (p < 0.05). Possible signs of fetal distress in utero were documented following these events.

Cardiotocography in cows: A method for monitoring calves during delivery

Fetal ECG-electrodes and an intrauterine catheter were inserted into 15 Holstein-Friesian cows during their first stage of labor to make a cardiotocogram. Simultaneously, fetal heart rate and intrauterine pressure were recorded until completion of fetal expulsion. Immediatly post partum the viability of the calf was assessed by clinical evaluation and measurements of blood pH, base excess (BE) and pCO 2. Fetal heart rate patterns and their changes were evaluated according to standards used in human medicine. Basal fetal heart rate (90 to 120) in 10 calves gradually increased towards the end of parturition, with a marked loss of variability. Decelerations, coinciding with periods of increased intrauterine pressure, occurred in all cows. When decelerations occurred beyond the end of a contraction the calf was born in a poor condition. Accelerations were only recorded in two cows. Many of the fetal heart rate changes observed were similar to those which in human cardiotocography are considered to be signs of fetal distress. Further investigation is needed to establish the predictive value of fetal heart rate patterns in cows, which would be a welcome addition to improved fetal diagnostics during parturition.

The Effect of Dihydralazine on Blood Velocity in Branches of the Uterine Artery in Pregnancy Induced Hypertension

Dihydralazine is frequently used in severe pregnancy induced hypertension (PIH). Little is known about its effect on the human uteroplacental circulation. In this study, Doppler ultrasound recordings were made from branches of the uterine artery in 5 women with PIH and blood pressure (BP) greater than or equal to 150/100 who received either 7.5 or 10 mg dihydralazine, as repeated intravenous doses of 2.5 mg, before obtaining near-normal/normal BP values. The measurements started 5-10 min prior to the injections and continued as undisrupted as possible during injections and the subsequent 30 min. When the reduction in BP was obtained, the median blood velocity was reduced by 23% (range 10-29%). A/B ratio was calculated at the same time as an indicator of peripheral vascular resistance. The ratio increased, compared with pre-experiment values, in 3 subjects (5, 26 and 31%) but decreased in 2 (4 and 6%). Maternal tachycardia was noted in all but one woman. Continuous fetal heart rate (FHR) recording showed no signs of fetal distress. The uteroplacental circulation does not seem to benefit from the vasodilatory effects of dihydralazine, the response to the decreased perfusion pressure being a reduction in blood velocity and unchanged peripheral resistance.

Ultrasound Doppler evaluation of uteroplacental and fetoplacental circulation in pre-eclampsia.

Blood flow velocity waveforms (FVW) were recorded weekly from the umbilical and arcuate arteries in 58 hospitalised women with a pregnancy complicated by pre-eclampsia. The maximum velocity waveform was analysed for pulsatility index (PI) and the results from the final antenatal examination were related to the outcome of pregnancy. The umbilical artery FVW was abnormal in 36% of the pre-eclamptic pregnancies, as was the arcuate artery FVW in 42%. No difference in FVW was found between mild and severe pre-eclampsia. Abnormal FVW in the umbilical artery was associated significantly both with intra-uterine growth retardation (IUGR) (P less than 0.001) and with signs of fetal distress (FD) (P less than 0.05). Abnormal arcuate artery FVW was associated with FD (P less than 0.05), but not with IUGR. The outcome of pregnancy was related to Placenta Waveform Class, which was derived from the blood velocity on both maternal and fetal sides of placenta. The results suggest that ultrasound Doppler examination of the umbilical artery is a useful aid in monitoring pregnancies complicated by pre-eclampsia, but that arcuate artery examination needs further evaluation.

Cardiopulmonary Bypass During Pregnancy: A Case Report

(J. Extra-Corpor. Technol 20(2):67-71, 39 references) Reported cases of the pregnant patient during cardiopulmonary bypass are rare but not unique. This case report of the pregnant patient during cardiopulmonary bypass is unique for two reasons. First, the patient was also a Jehovah’s Witness and refused blood products. Secondly, this case report provides a literature review and specific cardiopulmonary bypass considerations pertinent to the perfusionist. Recent literature reports that heart surgery is relatively safe during pregnancy. It is important to monitor fetal heart rate during the procedure not only to determine fetal distress but also to further knowledge in the area by documenting effects. The perfusion circuit must be prepared for the increased blood volume of the patient and still maintain minimal priming volumes. Uterine blood flow is not autoregulated so it is important to maintain adequate cardiac output or blood flow and perfusion pressure during the operation. A cardiac index of 3 liters per minute per meter squared and mean blood pressure of 60 mmHg during our case gave us no signs of fetal distress. The pregnant patient should be maintained at normothermia and bypass times should be kept to a minimum.

Maternal Posture in Second Stage and Fetal Acid Base Status

The effect of position during the second stage on outcome was studied in 58 women, with no exclusions because of pregnancy complications or signs of fetal distress, who were randomly allocated to have the second stage conducted in either the dorsal or 15 degrees lateral tilt position. All the women were of parity 0 or 1 and the two groups were well matched except for gestational age at delivery. There were no differences in clinical outcome between the two groups, but overall the dorsal group had lower cord artery pH values (P less than 0.05), higher PCO2 (P less than 0.01) and a greater base deficit, but not significantly so. pH and base deficit were similar in both groups where the second stage did not last greater than 15 min. Thereafter, there was a trend to decreasing pH and increasing base deficit with increasing length of second stage in the dorsal group, but not in the tilt group though this did not reach statistical significance. Low Apgar scores, complicated pregnancy and first pregnancy were each associated with significantly lower pH levels. Prolonged placement of the patient in the flat dorsal position should be avoided in second stage, though a suitable alternative under the conditions described has not been defined.

Predisposing factors in the formation of true knots of the umbilical cord-analysis of morphometric and perinatal data

Fifty-four umbilical cords with a true knot were analysed and compared to 108 normal cords. True knots were found in 1.22% of births. They occurred at a significantly higher rate in longer cords (P < 0.00001), in male fetuses (P < 0.05) and in multiparous women (P < 0.003). Signs of fetal distress were observed more frequently in female fetuses, especially in those with longer cords. A true knot seems to disrupt the significant correlation (P < 0.007) between cord length and birth weight that we observed in controls. The present study reviews the literature on the subject and suggests a possible mechanism for true knot formation.

Maternal perception of fetal movements: the optimal duration of a recording period

A regular count of perceived fetal movements by the mother has been proposed as a screening method for the early recognition of fetal distress. Absence or a strongly decreased number of fetal movements during a particular period is considered as a sign of fetal distress. In the study presented, the optimal duration of a recording period for the maternal perception of fetal movements was examined. 186 pregnant patients at gestational ages of 32 and 38 weeks were asked to mark each perceived fetal movement on a time axis for two continuous hours. From these patients an ‘optimal’ group of 143 pregnancies was selected to constitute the study group. A window technique was applied to the 2 h recordings, searching for periods in which 0, 1 or 2 fetal movements were noted. 23% of the recordings at 32 weeks and 14% at 38 weeks showed absence of fetal movements for at least 30 min. At both 32 weeks and 38 weeks there was absence of fetal movements for more than 1 h in only 1.5% of the recordings. The findings are in agreement with the fetal behavioural state concept. A recording time of 1 h exceeds the normal duration of a fetal quiet-sleep state and minimizes the risk of unjustified suspicion of fetal distress.

Cardiotocographic findings in abruptio placentae

The findings in cardiotocograms of 18 patients with placental abruption were analysed. Eleven out of 16 cases monitored during the 2-h period preceding delivery had five or more contractions in 10 min, with a mean of 5.6. Signs of fetal distress in heart rate recordings in the same period were found in 14 monitored cases. The diagnostic value of the cardiotocogram, especially the interpretation of tocograms in placental abruption, is stressed.

Neonatal Outcome in Cesarean Section under General Anesthesia, Related to Gestational Age, Induction-Delivery and Uterus-Delivery Intervals

Neonatal outcome after cesarean section under general anesthesia may be influenced by several factors. Two of these are the interval between anesthesia induction and delivery and the interval between uterine incision and delivery. The present authors evaluated the relationship between both factors and the Apgar scores of newborn infants delivered by cesarean section at various gestational ages. The study comprised 568 cesarean deliveries that were performed and under general anesthesia without any sign of fetal distress before operation. Of the 568 women, 216 had elective operations, and 352 had nonelective cesarean deliveries.

Significance of meconium during labour and its correlation with umbilical cord blood studies.

Continuous intrapartum fetal heart rate (FHR) monitoring with external cardiotocograph, and umbilical cord blood acid base analysis was done in 210 patients. One hundred cases who had meconium stained liquor formed the study group and 110 cases who had clear liquor formed the control group. There was higher incidence of low Apgar score (0–7) at one minute in study group as compared to the control, but no significant difference was found in the Apgar score at five minutes. There was significantly higher incidence of low Apgar score (0–7) in neonates with thick meconium as compared to controls at one and five minutes. The frequency of abnormal fetal heart rate patterns in both the groups showed no significant variation. The duration of exposure to meconium had no influence on the fetal outcome. Appearance of meconium alone did not seem to be a definitive sign of fetal distress warranting immediate delivery, but thick meconium with ominous fetal heart rate pattern, was significantly predictive of fetal distress. Presence of meconium was found to be indication for intense fetal monitoring in labour.