How does electronic fetal heart rate monitoring affect labor and delivery outcomes?

Continuous electronic fetal monitoring (EFM) reduces the risk of neonatal seizure by 50% compared with intermittent auscultation (IA) (strength of recommendation [SOR]: A, systematic review of randomized controlled trials [RCTs]). EFM increases the incidence of cesarean section by 66% and the incidence of operative vaginal delivery by 16% (SOR: A, systematic review of RCTs). It has no effect on the rates of cerebral palsy or neonatal mortality (SOR: A, systematic review of RCTs). An estimate from a Cochrane meta-analysis suggests that a cohort of 628 women receiving EFM could expect to experience 1 less neonatal seizure and 11 more cesarean sections compared with IA controls

A reverse-engineered pitch on defensive versus evidence-based medical technology: Liability risk and electronic fetal monitoring in low-risk births

This pitching research letter (PRL) describes the application of the pitching research template introduced by Faff (2015, 2021) to a reverse-engineering process in the practice of electronic fetal monitoring (EFM) as a form of defensive medicine with regard to the field of medical technology. The pitch structure underlines a succinct and streamlined approach to recapitulate key components of scientific studies that form the basis upon which a researcher’s scientific or seminal research work is assembled

Exploring Nursing Students\u27 Perceptions of Electronic Fetal Monitoring App

Within the healthcare realm, innovative technology has become an integral part of teaching in today’s nursing education, specifically computer-generated teaching applications. A new application that combines both nursing simulation and teaching methods regarding electronic fetal monitoring and fetal heart rhythms was developed at the University of Tennessee in fall 2014.This application was created in collaboration with both the College of Engineering and the College of Nursing. The Electronic Fetal Monitoring App displays instructor-created fetal heart rate (FHR) and maternal contraction patterns to simulate a monitor enabling live- feed interpretation in the classroom or simulation setting. It also has the potential to be saved and recreated for further simulated learning experiences. With current nursing education using processes such as application involvement and simulation in the clinical environment, the evolvement and merger of simulation and technology applications has the potential to exponentially benefit patient outcomes. Therefore, with the creation of a novel simulation application incorporated into the classroom setting, the purpose of this qualitative descriptive study is to explore nursing students’ learning experiences, attitudes, perceptions, and opinions regarding a fluid, dynamic, instructor-manipulated EFM application

Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour

Background Cardiotocography (CTG) records changes in the fetal heart rate and their temporal relationship to uterine contractions. The aim is to identify babies who may be short of oxygen (hypoxic) to guide additional assessments of fetal wellbeing, or determine if the baby needs to be delivered by caesarean section or instrumental vaginal birth. This is an update of a review previously published in 2013, 2006 and 2001. Objectives To evaluate the effectiveness and safety of continuous cardiotocography when used as a method to monitor fetal wellbeing during labour. Search methods We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 November 2016) and reference lists of retrieved studies. Selection criteria Randomised and quasi‐randomised controlled trials involving a comparison of continuous cardiotocography (with and without fetal blood sampling) with no fetal monitoring, intermittent auscultation intermittent cardiotocography. Data collection and analysis Two review authors independently assessed study eligibility, quality and extracted data from included studies. Data were checked for accuracy. Main results We included 13 trials involving over 37,000 women. No new studies were included in this update. One trial (4044 women) compared continuous CTG with intermittent CTG, all other trials compared continuous CTG with intermittent auscultation. No data were found comparing no fetal monitoring with continuous CTG. Overall, methodological quality was mixed. All included studies were at high risk of performance bias, unclear or high risk of detection bias, and unclear risk of reporting bias. Only two trials were assessed at high methodological quality. Compared with intermittent auscultation, continuous cardiotocography showed no significant improvement in overall perinatal death rate (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.59 to 1.23, N = 33,513, 11 trials, low quality evidence), but was associated with halving neonatal seizure rates (RR 0.50, 95% CI 0.31 to 0.80, N = 32,386, 9 trials, moderate quality evidence). There was no difference in cerebral palsy rates (RR 1.75, 95% CI 0.84 to 3.63, N = 13,252, 2 trials, low quality evidence). There was an increase in caesarean sections associated with continuous CTG (RR 1.63, 95% CI 1.29 to 2.07, N = 18,861, 11 trials, low quality evidence). Women were also more likely to have instrumental vaginal births (RR 1.15, 95% CI 1.01 to 1.33, N = 18,615, 10 trials, low quality evidence). There was no difference in the incidence of cord blood acidosis (RR 0.92, 95% CI 0.27 to 3.11, N = 2494, 2 trials, very low quality evidence) or use of any pharmacological analgesia (RR 0.98, 95% CI 0.88 to 1.09, N = 1677, 3 trials, low quality evidence). Compared with intermittent CTG, continuous CTG made no difference to caesarean section rates (RR 1.29, 95% CI 0.84 to 1.97, N = 4044, 1 trial) or instrumental births (RR 1.16, 95% CI 0.92 to 1.46, N = 4044, 1 trial). Less cord blood acidosis was observed in women who had intermittent CTG, however, this result could have been due to chance (RR 1.43, 95% CI 0.95 to 2.14, N = 4044, 1 trial). Data for low risk, high risk, preterm pregnancy and high‐quality trials subgroups were consistent with overall results. Access to fetal blood sampling did not appear to influence differences in neonatal seizures or other outcomes. Evidence was assessed using GRADE. Most outcomes were graded as low quality evidence (rates of perinatal death, cerebral palsy, caesarean section, instrumental vaginal births, and any pharmacological analgesia), and downgraded for limitations in design, inconsistency and imprecision of results. The remaining outcomes were downgraded to moderate quality (neonatal seizures) and very low quality (cord blood acidosis) due to similar concerns over limitations in design, inconsistency and imprecision. Authors' conclusions CTG during labour is associated with reduced rates of neonatal seizures, but no clear differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing. However, continuous CTG was associated with an increase in caesarean sections and instrumental vaginal births. The challenge is how best to convey these results to women to enable them to make an informed decision without compromising the normality of labour. The question remains as to whether future randomised trials should measure efficacy (the intrinsic value of continuous CTG in trying to prevent adverse neonatal outcomes under optimal clinical conditions) or effectiveness (the effect of this technique in routine clinical practice). Along with the need for further investigations into long‐term effects of operative births for women and babies, much remains to be learned about the causation and possible links between antenatal or intrapartum events, neonatal seizures and long‐term neurodevelopmental outcomes, whilst considering changes in clinical practice over the intervening years (one‐to‐one‐support during labour, caesarean section rates). The large number of babies randomised to the trials in this review have now reached adulthood and could potentially provide a unique opportunity to clarify if a reduction in neonatal seizures is something inconsequential that should not greatly influence women's and clinicians' choices, or if seizure reduction leads to long‐term benefits for babies. Defining meaningful neurological and behavioural outcomes that could be measured in large cohorts of young adults poses huge challenges. However, it is important to collect data from these women and babies while medical records still exist, where possible describe women's mobility and positions during labour and birth, and clarify if these might impact on outcomes. Research should also address the possible contribution of the supine position to adverse outcomes for babies, and assess whether the use of mobility and positions can further reduce the low incidence of neonatal seizures and improve psychological outcomes for women

Intrapartum fetal heart rate monitoring: using audit methodology to identify areas for research and practice improvement

The purpose of the study was to explore the fetal heart rate monitoring practices of midwives and doctors to determine compliance with an evidence-based guideline for fetal heart rate monitoring endorsed by one New Zealand (NZ) District Health Board (DHB). A retrospective audit of 193 randomly selected medical records was undertaken over six months (July-December 2006). The audit revealed deficiencies in choice of fetal heart rate monitoring modality, monitoring technique, documentation, communication and use of a standardised approach and language for interpreting cardiotocograph (CTG) traces especially the description and categorisation of the four main fetal heart rate features. Multidisciplinary education and a standardised template for reporting CTG's were key recommendations

Team-Based Care To Support Physiologic Birth: A Review Of Literature

Abstract Introduction: Physiologic birth practices support the normal processes of childbirth, are associated with improved outcomes, and can prevent unnecessary intervention. Defensive maternity practice contributes to the overuse of medical interventions and decrease in physiologic birth practices. Team-based maternity care has been studied as a method to improve safety through improved communication and teamwork skills. The purpose of this literature review was to explore whether team-based care can be used as a strategy to promote physiologic birth through decreasing defensive maternity practices. Methods: The search engines OVID, CINAHL, Pub Med, Google Scholar and the Cochrane Library were used to identify relevant studies for the review. Search terms included, physiologic birth, team-based maternity care, defensive maternity practice, electronic fetal monitoring (EFM), and cesarean delivery. Intermittent auscultation (IA) was considered proxy for physiologic birth practice and was examined in the research comparing IA to EFM. The data were organized according to major content area then synthesized to summarize the state of the science and implications for practice and future research. Results: EFM in low risk pregnancies was not associated with improved outcomes and is associated with increased cesarean rates. Overuse of EFM was associated with fear of litigation as was increased cesarean rates. Team-based care was associated with improved communication. There was some evidence suggesting that team-based care supports physiologic maternity practices. Discussion: A team based-care model may provide a forum to discuss and implement practices that support physiologic birth care. Professional organizations should partner to examine how they can encourage maternity professionals to support physiologic birth. Future research is necessary to evaluate the efficacy of these strategies

Characteristics of Heart Rate Tracings in Preterm Fetus

We thank K. Shashok for translating the original manuscript into English.Background and Objectives: Prematurity is currently a serious public health issue worldwide, because of its high associated morbidity and mortality. Optimizing the management of these pregnancies is of high priority to improve perinatal outcomes. One tool frequently used to determine the degree of fetal wellbeing is cardiotocography (CTG). A review of the available literature on fetal heart rate (FHR) monitoring in preterm fetuses shows that studies are scarce, and the evidence thus far is unclear. The lack of reference standards for CTG patterns in preterm fetuses can lead to misinterpretation of the changes observed in electronic fetal monitoring (EFM). The aims of this narrative review were to summarize the most relevant concepts in the field of CTG interpretation in preterm fetuses, and to provide a practical approach that can be useful in clinical practice. Materials and Methods: A MEDLINE search was carried out, and the published articles thus identified were reviewed. Results: Compared to term fetuses, preterm fetuses have a slightly higher baseline FHR. Heart rate is faster in more immature fetuses, and variability is lower and increases in more mature fetuses. Transitory, low-amplitude decelerations are more frequent during the second trimester. Transitory increases in FHR are less frequent and become more frequent and increase in amplitude as gestational age increases. Conclusions: The main characteristics of FHR tracings changes as gestation proceeds, and it is of fundamental importance to be aware of these changes in order to correctly interpret CTG patterns in preterm fetuses