Treatment Of Fetal Distress Research Articles

Monitoring intrapartum fetal heart rates by mothers in labour in two public hospitals: an initiative to improve maternal and neonatal healthcare in Liberia

BackgroundIn low-resource settings with few health workers, Fetal Heart Rate (FHR) monitoring in labour can be inconsistent and unreliable. An initiative to improve fetal monitoring was implemented in two public hospitals in rural Liberia; the country with the second lowest number of midwives and nurses in the world (1.007 per 10,000 of the population). The initiative assessed the feasibility of educating women in labour to monitor their own FHR and alert a midwife of changes detected.MethodsFour hundred seventy-four women admitted in labour without obstetric complications were approached. Four hundred sixty-one consented to participate (97%) and 13 declined. Those consenting were trained to monitor their FHR using a sonicaid for approximately 1 minute immediately following the end of every uterine contraction and to inform a midwife of changes. If changes were confirmed, standard clinical interventions for fetal distress (lateral tilt, intravenous fluids and oxygen) were undertaken and, when appropriate, accelerated delivery by vacuum or Caesarean section. Participants provided views on their experiences; subsequently categorized into themes. Neonatal outcomes regarding survival, need for resuscitation, presence of birth asphyxia, and treatment were recorded.ResultsFour hundred sixty-one out of 474 women gave consent, of whom 431 of 461 (93%) completed the monitoring themselves. Three hundred eighty-seven of 400 women who gave comments, reported positive and 13 negative experiences. FHR changes were reported in 28 participants and confirmed in 26. Twenty-four of these 26 FHR changes were first identified by mothers. Fetal death was identified on admission during training in one mother. Thirteen neonates required resuscitation, with 12 admitted to the neonatal unit. One developed temporary seizures suggesting birth asphyxia. All 26 neonates were discharged home apparently well. In 2 mothers, previously unrecognized obstetric complications (cord prolapse and Bandl’s ring with obstructed labour) accompanied FHR changes. Resuscitation was needed in 8 neonates without identified FHR changes including one of birth weight 1.3 Kg who could not be resuscitated. There were no intrapartum stillbirths in participants.ConclusionsWomen in labour were able to monitor and detect changes in their FHR. Most found the experience beneficial. The absence of intrapartum stillbirths after admission and the low rate of poor neonatal outcomes are promising and warrant further investigation.

How Malpractice Cases Can Drive Your Safety Agenda [18B

INTRODUCTION: Malpractice data is a valuable tool to understand the complexities of alleged medical error. The Comparative Benchmark System (CBS) is a national database with over 350,000 medical professional liability (MPL) claims from more than 400 hospitals and 165,000 physicians across the country. Communication was identified as a factor in 30 percent of 23,658 medical malpractice cases filed between 2009-2013 in CBS, and 1,056 or 5 percent of these cases involved obstetrics. METHODS: Applying a Clinical Coding Taxonomy to MPL cases provides insight into specific factors driving patient harm and financial loss. Analysis of OB communication claims identified that communication failures occur among providers and/or between providers and patients, and failure types vary during throughout management of pregnancy, labor, and delivery. RESULTS: Identified communication failures: Antepartum -35 percent of cases involve communication failures (lab results): 63 percent are provider to provider; 57 percent are provider to patient. Intrapartum – 41 percent of cases involve communication failures in labor management and treatment of fetal distress (handoffs): 79 percent are provider to provider; 32 percent are provider to patient. Second stage or Delivery - 35 percent of cases involving the performance of the delivery involve communication issues (failure to escalate): 73 percent are provider to provider; 43 percent are provider to patient. CONCLUSION: Using malpractice claims to identify the need to improve the communication skills of providers can improve care and potentially reduce future malpractice claims.

Possible treatment of fetal distress without caesarean delivery

Possible treatment of fetal distress without caesarean delivery

The added predictive value of biphasic events in ST analysis of the fetal electrocardiogram for intrapartum fetal monitoring.

To study the predictive value of biphasic ST-events for interventions for suspected fetal distress and adverse neonatal outcome, when using ST-analysis of the fetal electrocardiogram (FECG) for intrapartum fetal monitoring. Prospective cohort study. Three academic hospitals in Sweden. Women in labor with a high-risk singleton fetus in cephalic position beyond 36weeks of gestation. In women in labor who were monitored with conventional cardiotocography, ST-waveform analysis was recorded and concealed. Traces with biphasic ST-events of the FECG (index) were compared with traces without biphasic events of the FECG. The ability of biphasic events to predict interventions for suspected fetal distress and adverse outcome was assessed using univariable and multivariable logistic regression analyses. Interventions for suspected fetal distress and adverse outcome (defined as presence of metabolic acidosis (i.e. umbilical cord pH <7.05 and base deficit in extracellular fluid >12mmol), umbilical cord pH <7.00, 5-min Apgar score <7, admittance to neonatal intensive care unit or perinatal death). Although the presence of biphasic events of the FECG was associated with more interventions for fetal distress and an increased risk of adverse outcome compared with cases with no biphasic events, the presence of significant (i.e. intervention advised according to cardiotocography interpretation) biphasic events showed no independent association with interventions for fetal distress [odds ratio (OR) 1.71, 95% confidence interval (CI) 0.65-4.50] or adverse outcome (OR 1.96, 95% CI 0.74-5.24). The presence of significant biphasic events did not discriminate in the prediction of interventions for fetal distress or adverse outcome. Therefore, biphasic events in relation to ST-analysis monitoring during birth should be omitted if future studies confirm our findings.

Intervention for Fetal Distress Among Obstetricians, Registered Nurses, and Residents

To explore the factors possibly associated with the intrapartum management of nonreassuring fetal status and the factors affecting the decision to expedite delivery for fetal distress among different obstetric health care providers. In a cross-sectional study, a standardized hypothetical clinical scenario of management of fetal distress was presented by a study investigator to labor and delivery personnel, including faculty obstetricians, residents, and registered nurses (N=52). An intervention index was calculated for each faculty by dividing the number of cesarean and operative deliveries for nonreassuring fetal status by the actual number of laboring patients supervised by each faculty in 2008. Selection of the timing of delivery and characterization of nonreassuring fetal heart rate patterns was not different among the different providers (P=.3). However, compared with residents, registered nurses notified the attending obstetricians at an earlier stage and in response to different fetal heart rate tracing scenarios suggestive of fetal distress (P<.001). Personal or professional experience, type of clinical practice, and psychological traits did not affect the management of the standardized clinical scenario or the intervention index (P=.3-.9). Different providers practicing in the same environment may develop a similar approach in the setting of nonreassuring fetal status that overcomes individual differences and follows the current guidelines on electronic fetal monitoring. II.

Sublingual compared with vaginal misoprostol for labour induction at term: a randomised controlled trial

To compare the efficacy and safety of 50 microg of sublingual misoprostol with 25 microg of vaginal misoprostol administered for labour induction at term. Design Double-blinded, randomised controlled trial. Setting University Hospital, Kaunas, Lithuania. Sample A total of 140 women at term with indications for labour induction. Methods Women were randomised to receive either 50 microg of sublingual misoprostol with vaginal placebo (n = 70) or sublingual placebo with 25 microg of vaginal misoprostol (n = 70) every 4 hours (maximum six doses). Main outcome measures The number of women delivering vaginally within 24 hours of labour induction. Results Fifty-eight women (83%) in the sublingual misoprostol group and 53 (76%) in the vaginal misoprostol group delivered vaginally within 24 hours [relative risk (RR) 1.1, 95% confidential interval (CI) 0.9-1.3]. However, the induction to vaginal delivery time was significantly shorter in the sublingual group (15.0 +/- 3.7 hours) compared with the vaginal group (16.7 +/- 4.1 hours, P = 0.03). The incidence of tachysystole was more than three-fold higher in the sublingual than in the vaginal group (14 versus 4.3%; RR 3.3, 95% CI 0.9-11.6), but this was not statistically significant. There were no significant differences in the incidence of hypertonus or hyperstimulation syndrome, mode of delivery, interventions for fetal distress or neonatal outcomes between the two groups. Conclusion A 50 microg of sublingual misoprostol 4 hourly for labour induction at term seems to have similar efficacy as 25 microg of vaginal misoprostol. Further studies on safety with larger numbers of women need to be conducted before routine sublingual misoprostol use in this setting.

Routine cesarean delivery does not improve the outcome of infants with gastroschisis

Background/Purpose The optimal mode of delivery for infants with gastroschisis is controversial. The authors compared the outcomes of infants with gastroschisis born vaginally (VD) or by cesarean section (CS). Methods A retrospective analysis of infants with gastroschisis born between 1990 and 2000 was performed. Assessment included patient demographics, respiratory distress, method of closure, number of surgeries, presence of atresia, feeding parameters, parenteral nutrition days (TPN), time to full feeding (FPO), mortality, and length of stay (LOS). Subgroup analyses were performed for those infants requiring cesarean section for fetal distress. Student’s t test/analysis of variance (ANOVA) or χ 2/Fisher’s Exact tests were used for statistical analysis. Logistic and linear regression analyses were also performed. Results One hundred thirteen patients were studied (82 VD and 31 CS). No statistical difference existed between the VD and CS groups for perinatal complications, method of closure, number of surgeries (1.6 each), TPN (40.6 v 46.0 days), FPO (40.4 v 47.1 days), mortality (9.7 v 6.5%) and LOS (53.4 v 61.7 days). CS was associated with increased stenosis (25.8 v 4.9%; P = .003), gastrointestinal dysfunction (25.8 v 11.0%; P = .049), and respiratory distress (16.1 v 3.7%; P = .035). Many of these differences did not persist when infants undergoing CS for fetal distress were excluded from the analysis. However, regression analysis identified CS as an independent risk factor for the development of respiratory distress at birth (odds ratio, 7.11; CI, 1.06 to 47.7), with a trend to increased gastrointestinal dysfunction (odds ratio, 4.35; CI, 0.77 to 24.61). Conclusions The routine use of CS for infants with gastroschisis is not supported by our results because equivalent outcomes were observed with both modes of delivery. CS may be a necessary intervention for fetal distress.

Sublingual misoprostol for the induction of labor at term

Objective: To evaluate the efficacy, safety, and patient acceptability of sublingual misoprostol compared with an equivalent dose administered orally for labor induction at term. Study Design: One hundred women with medical or obstetric indications for induction of labor after 37 weeks of gestation and unfavorable cervices were randomized to receive 50 μg of misoprostol either orally or sublingually. The dose was repeated every 4 hours to a maximum of 5 doses if indicated. Previous cesarean delivery was a criteria for exclusion. Our primary outcome measure was the number of patients who went on to have a vaginal delivery within 24 hours of the induction. The need for oxytocin, mode of delivery, number of cesarean deliveries for fetal distress, uterine hyperstimulation rates, and neonatal outcomes were secondary outcome measures. Patient acceptability was assessed by questionnaires completed after delivery. Results: Significantly more patients were delivered of infants within 24 hours (73.8% versus 45.7%; relative risk, 1.6; 95% confidence interval, 1.1 to 2.4) and the induction to delivery intervals were significantly shorter (20 hours versus 28.3 hours; mean difference, 8.3 hours; 95% confidence interval, 1.2 to 15.4) in the sublingual group compared with the oral group. There was 1 case of uterine hyperstimulation in the sublingual group. There were no significant differences in the mode of delivery, interventions for fetal distress, or neonatal outcomes in the 2 groups. The satisfaction rates were 82.5% and 85.7% in the oral and sublingual groups respectively, and 9.5% of patients thought that the sublingual tablets did not dissolve completely. Conclusion: There has been no previous report in the literature of misoprostol given sublingually for labor induction. Sublingual misoprostol seems to have better efficacy than oral misoprostol, seems to be acceptable to patients, and is an option to be considered to induce labor at term. (Am J Obstet Gynecol 2002;186:72-6.)

Prophylactic intrapartum amnioinfusion: a controlled retrospective study of 135 cases

Objective: To show that intrapartum prophylactic amnioinfusion (AI) in case of oligohydramnios or particulate meconiumstained amniotic fluid could be beneficial. Study design: From the first March 1993 until the 30th June 1995, 4031 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (71 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2) (64 patients) were included. Each group was compared to an historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age and duration of labor. Statistical analysis was performed using the Student's t-test and the Fisher's exact test when appropriate with a level of significance of P less than 0.05. Results: The mean infused volume was 893 ml in G1 and 734 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (11.3 vs. 24.5%; P < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (12.5 vs. 23.43%; P < 0.05). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also could not find any significant difference between G2 and CG2 (1.6 vs. 9.4%; P = 0.05). No neonatal or maternal adverse effect happened in this short study. Comment: AI is easy to perform during labour in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic AI performed in case of oligohydramnios and abnormal fetal heart rate.

The élims-501 electric stimulator for prophylaxis and treatment of fetal distress

The élims-501 electric stimulator for prophylaxis and treatment of fetal distress

Perinatal asphyxia: A Bayesian analysis of prediction and prevention

SummaryThe value of routine intrapartum cardiotocography has yet to be proved despite widespread use. The confounding effects of treatment paradox and relative risk assessment are possible reasons for this.The pattern of management within 10000 consecutive deliveries was examined, using an ‘independence Bayes' probability model to demonstrate changing relationships between test results, obstetric intervention and neonatal outcome.The incidence of birth asphyxia in the Prince of Wales hospital decreased by 33 percent between 1985 and 1986. This is shown to have been associated with improvements in the selection of patients for intrapartum cardiotocography and for elective caesarean section, and with an increased rate of intervention for fetal distress. The incidence of fetal distress also decreased, suggesting that factors other than intervention in response to fetal distress were partly responsible for improved perinatal outcome. A higher than expected incidence of asphyxia where delivery was by emergency...

Placental transfer of 14C-hexoprenaline

The placental transfer of a single intravenous injection of 14C-hexoprenaline was studied in eight pregnant New Zealand white rabbits. Maternal and fetal blood was sampled intermittently for 60 minutes after the injection. An initial rapid decrease in the levels of 14C-hexoprenaline in maternal blood was followed by a second slower phase, whereas fetal levels remained insignificant. The conclusion, therefore, is that the rapid improvement in fetal heart rate after the administration of a single maternal intravenous injection of hexoprenaline in the treatment of fetal distress is due to the action on the uterus and/or on maternal cardiovascular function, and not to direct stimulation of the fetus.

Estriol in pregnancy: VI. Experience with unconjugated plasma estriol assays and antepartum fetal heart rate testing in diabetic pregnancies

The reliability of daily unconjugated plasma estriol (E3) as a first-line test for fetal surveillance in the management of diabetic pregnancies was assessed. Seventy consecutive insulin-dependent diabetic women admitted in late pregnancy were followed up with daily 8 am unconjugated plasma E3 assays and weekly antepartum fetal heart rate testing (AFHRT). There were no perinatal deaths, and only two neonates developed the respiratory distress syndrome. The mean gestational age at delivery was 38 weeks. Pregnancies continued until elective delivery at 38 weeks and development of a mature amniotic fluid lecithin/sphingomyelin (L/S) ratio (n = 40) unless spontaneous labor began earlier (n = 20) or early delivery was indicated for either maternal reasons (n = 3) or presumed fetal distress (n = 7). Intervention for fetal distress took place when plasma E3 levels had fallen by 40% or more from the highest mean of three consecutive preceding values (significant drop) and both a nonstress test (NST) and a contraction stress test (CST) were abnormal irrespective of the L/S ratio (n = 2) or, in the presence of a mature L/S ratio, when either plasma E3 levels had fallen significantly or AFHRT was abnormal (n = 5). Five patients without a mature L/S ratio and a significant fall in plasma E3 with a reactive NST were not delivered. Only 14 (1.2%) of the 1,180 plasma E3 assays in 12 (17%) of the 70 patients represented a significant drop and fetal distress was documented in two of these 12 pregnancies, the only two in which both NST and CST were abnormal. In 18 of the 70 patients in whom 317 NSTs were performed, 26 NSTs (8.2%) were nonreactive initially, but 18 of these 26 NSTs were either reactive when repeated within hours or followed by negative CSTs. Documented fetal distress was found to occur 1 day after a reactive NST and a normal plasma E3 but was indicated in time for successful intervention by both tests. These data indicate that: (1) daily unconjugated plasma E3 assays constitute a reliable first-line test of fetal status in diabetic pregnancies, (2) a single daily plasma E3 at 8 a.m. suffices, (3) the 40% limit for a significant drop appears to be sensitive enough to detect fetal distress, (4) AFHRT, if done daily, may be used in lieu of daily plasma E3 determinations, and (5) both plasma E3 assays and AFHRT render false abnormal results. By combining both biophysical and biochemical testing, it is possible to virtually eliminate the need for unwarranted intervention and unnecessary prematurity.

Oxygen administration during labor

Seventy women were given 100 per cent oxygen to breathe for varying lengths of time during labor. Fetal pH and blood gas changes were observed using the Saling technique of scalp sampling. The overall mean increment of pO2 in fetal capillary blood was 3.5 mm. Hg. However, a negative regression was observed (i.e., in general, the lower the initial fetal pO2, the greater the increment). In a control group of 33 mothers who breathed only room air, no significant change in fetal pO2 was noted. Umbilical vein pO2 values were significantly greater in the oxygenated group than the controls, while umbilical artery values remained stable in both groups. pH, pCO2, and base deficits did not change with oxygen inhalation. It would seem that oxygen administration is warranted as an adjunct in the treatment of fetal distress.