A simulation model to study maternal hyperoxygenation during labor

To investigate the effect of maternal hyperoxygenation on fetal oxygenation and fetal heart rate decelerations during labor, using a simulation model. Design Use of a mathematical model that simulates feto–maternal hemodynamics and oxygenation, designed in Matlab R2012a. Setting Clinical and engineering departments in the Netherlands. Methods We simulated variable and late fetal heart rate decelerations, caused by uterine contractions with a different contraction interval. We continuously recorded oxygen pressure in different feto–placental compartments and fetal heart rate, during maternal normoxia and during hyperoxygenation with 100% oxygen. Main outcome measures Changes in oxygen pressure in the intervillous space, umbilical vein and arteries, fetal cerebral and microcirculation as well as fetal heart rate deceleration depth and duration. Results Maternal hyperoxygenation leads to an increase in fetal oxygenation: in the presence of variable decelerations, oxygen pressure in the intervillous space increased 9–10 mmHg and in the cerebral circulation 1–2 mmHg, depending on the contraction interval. In addition, fetal heart rate deceleration depth decreased from 45 to 20 beats per minute. In the presence of late decelerations, oxygen pressure in the intervillous space increased 7–10 mmHg and in the cerebral circulation 1–2 mmHg, depending on the contraction interval. The fetus benefited more from maternal hyperoxygenation when contraction intervals were longer. Conclusions According to the simulation model, maternal hyperoxygenation leads to an increase in fetal oxygenation, especially in the presence of variable decelerations. In addition, in the presence of variable decelerations, maternal hyperoxygenation leads to amelioration of the fetal heart rate pattern

A simulation model to study maternal hyperoxygenation during labor

To investigate the effect of maternal hyperoxygenation on fetal oxygenation and fetal heart rate decelerations during labor, using a simulation model. Design Use of a mathematical model that simulates feto–maternal hemodynamics and oxygenation, designed in Matlab R2012a. Setting Clinical and engineering departments in the Netherlands. Methods We simulated variable and late fetal heart rate decelerations, caused by uterine contractions with a different contraction interval. We continuously recorded oxygen pressure in different feto–placental compartments and fetal heart rate, during maternal normoxia and during hyperoxygenation with 100% oxygen. Main outcome measures Changes in oxygen pressure in the intervillous space, umbilical vein and arteries, fetal cerebral and microcirculation as well as fetal heart rate deceleration depth and duration. Results Maternal hyperoxygenation leads to an increase in fetal oxygenation: in the presence of variable decelerations, oxygen pressure in the intervillous space increased 9–10 mmHg and in the cerebral circulation 1–2 mmHg, depending on the contraction interval. In addition, fetal heart rate deceleration depth decreased from 45 to 20 beats per minute. In the presence of late decelerations, oxygen pressure in the intervillous space increased 7–10 mmHg and in the cerebral circulation 1–2 mmHg, depending on the contraction interval. The fetus benefited more from maternal hyperoxygenation when contraction intervals were longer. Conclusions According to the simulation model, maternal hyperoxygenation leads to an increase in fetal oxygenation, especially in the presence of variable decelerations. In addition, in the presence of variable decelerations, maternal hyperoxygenation leads to amelioration of the fetal heart rate pattern

Interventions for intrauterine resuscitation in suspected fetal distress during term labor: A systematic review

IMPORTANCE: Intrauterine resuscitation techniques during term labor are commonly used in daily clinical practice. Evidence, however, to support the beneficial effect of intrauterine resuscitation techniques on fetal distress during labor is limited and sometimes contradictory. In contrast, some of these interventions may even be harmful. OBJECTIVE: To give insight into the current evidence on intrauterine resuscitation techniques. In addition, we formulate recommendations for current clinical practice and propose directions for further research. EVIDENCE ACQUISITION: We systematically searched the electronic PubMed, EMBASE, and CENTRAL databases for studies on intrauterine resuscitation for suspected fetal distress during term labor until February 2015. Eligible articles and their references were independently assessed by 2 authors. Judgment was based on methodological quality and study results. RESULTS: Our literature search identified 15 studies: 4 studies on amnioinfusion, 1 study on maternal hyperoxygenation, 1 study on maternal repositioning, 1 study on intravenous fluid administration, and 8 studies on tocolysis. Of these 15 research papers, 3 described a randomized controlled trial; all other studies were observational reports or case reports. CONCLUSIONS AND RELEVANCE: Little robust evidence to promote a specific intrauterine resuscitation technique is available. Based on our literature search, we support the use of tocolysis and maternal repositioning for fetal distress. We believe the effect of amnioinfusion and maternal hyperoxygenation should be further investigated in properly designed randomized controlled trials to make up the balance between beneficial and potential hazardous effects

The effect of multiprofessional simulation-based obstetric team training on patient-reported quality of care: a pilot study

Introduction: This study aimed to explore whether multiprofessional simulation-based obstetric team training improves patient-reported quality of care during pregnancy and childbirth. Methods: Multiprofessional teams from a large obstetric collaborative network in the Netherlands were trained in teamwork skills using the principles of crew resource management. Patient-reported quality of care was measured with the validated Pregnancy and Childbirth Questionnaire (PCQ) at 6 weeks postpartum. Before the training, 76 postpartum women (sample I) completed the questionnaire 6 weeks postpartum. Three months after the training, another sample of 68 postpartum women (sample II) completed the questionnaire. Results: In sample II (after the training), the mean (SD) score of 108.9 (10.9) on the PCQ questionnaire was significantly higher than the score of 103.5 (11.6) in sample I (before training) (t = 2.75, P = 0.007). The effect size of the increase in PCQ total score was 0.5. Moreover, the subscales “personal treatment during pregnancy” and “educational information” showed a significant increase after the team training (P < 0.001). Items with the largest increase in mean scores included communication between health care professionals, clear leadership, involvement in planning, and better provision of information. Conclusions: Despite the methodological restrictions of a pilot study, the preliminary results indicate that multiprofessional simulation-based obstetric team training seems to improve patient-reported quality of care. The possibility that this improvement relates to the training is supported by the fact that the items with the largest increase are about the principles of crew resource management, used in the training

Development of the Pregnancy and Childbirth Questionnaire (PCQ):Evaluating quality of care as perceived by women who recently gave birth

Objective To develop an instrument to the assess quality of care during pregnancy and delivery as perceived by women who recently gave birth. Study design Prospective design from focus group interviews to validation of the questionnaire. The focus groups consisted of seven care providers, ten pregnant women and six women who recently gave birth. With the results of the focus group interviews, a draft questionnaire of 52 items was composed and its psychometric properties were tested in a first cohort of 300 women who recently gave birth (sample I) by means of exploratory factor analysis (EFA) and reliability analysis. The final version was further explored by confirmatory factor analyses (CFA) in another sample of 289 women (sample II) with similar characteristics as sample I. Results EFA in sample I suggested an 18-item scale with two components concerning the quality of care during pregnancy: ‘personal treatment’ (11 items, Cronbach's alpha (α) = 0.87) and ‘educational information’ (7 items, α = 0.90); the ‘delivery’ scale showed a single domain (7 items, α = 0.88). CFA in sample II confirmed both factor structures with an adequate model fit. Overall, satisfaction with care was highest among women who only received midwife-led care, while women who were referred to an obstetrician during pregnancy reported less satisfaction. Conclusions The 25-item PCQ, primarily based on the experiences and perceptions of pregnant women and women who recently gave birth, showed adequate psychometric properties evaluating the quality of care during pregnancy and delivery. This user-friendly instrument might be a valuable instrument for future research to further evaluate the quality of care to pregnant women. Keywords: Patient perspective, Satisfaction, Quality of care, Pregnancy, Childbirt

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

OBJECTIVE: Solid 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 DESIGN: We 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. RESULTS: The 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. CONCLUSION: Nationwide 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

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei Objective To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time. Study design Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy. Results During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5–147), and not thereafter. Conclusion The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or implemented, repetitive training sessions every three months seem therefore recommended

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

OBJECTIVE: Solid 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 DESIGN: We 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.RESULTS: The 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.CONCLUSION: Nationwide 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.</p

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial

Does the effect of one-day simulation team training in obstetric emergencies decline within one year? A post-hoc analysis of a multicentre cluster randomised controlled trial. J van de Ven, AF Fransen, E Schuit, PJ van Runnard Heimel, BW Mol, SG Oei Objective To investigate whether the effect of a one-day simulation-based obstetric team training on patient outcome changes over time. Study design Post-hoc analysis of a multicentre, open, randomised controlled trial that evaluated team training in obstetrics (TOSTI study).We studied women with a singleton pregnancy beyond 24 weeks of gestation in 24 obstetric units. Included obstetric units were randomised to either a one-day, multi-professional simulation-based team training focusing on crew resource management in a medical simulation centre (12 units) or to no team training (12 units). We assessed whether outcomes differed between both groups in each of the first four quarters following the team training and compared the effect of team training over quarters. Primary outcome was a composite outcome of low Apgar score, severe postpartum haemorrhage, trauma due to shoulder dystocia, eclampsia and hypoxic-ischemic encephalopathy. Results During a one year period after the team training the rate of obstetric complications, both on the composite level and the individual component level, did not differ between any of the quarters. For trauma due to shoulder dystocia team training led to a significant decrease in the first quarter (0.06% versus 0.26%, OR 0.19, 95% CI 0.03 to 0.98) but in the subsequent quarters no significant reductions were observed. Similar results were found for invasive treatment for severe postpartum haemorrhage where a significant increase was only seen in the first quarter (0.4% versus 0.03%, OR 19, 95% CI 2.5–147), and not thereafter. Conclusion The beneficial effect of a one-day, simulation-based, multiprofessional, obstetric team training seems to decline after three months. If team training is further evaluated or implemented, repetitive training sessions every three months seem therefore recommended