scholarly journals Bayes Theorem and Protopathic Bias: Methodological Concerns When Addressing the Impact of Fetal Heart Rate Patterns on the Cesarean Section Rate

2020 ◽  
Vol 10 (03) ◽  
pp. e342-e345
Author(s):  
Jacques Balayla ◽  
Ariane Lasry ◽  
Yaron Gil ◽  
Alexander Volodarsky-Perel
Keyword(s):  
Heart Rate ◽  
Caesarean Section ◽  
Fetal Heart Rate ◽  
Predictive Power ◽  
Fetal Heart ◽  
Caesarean Section Rate ◽  
Bayes Theorem ◽  
The Poor ◽  
Clinical Scenarios ◽  
The Impact

AbstractOver the last 30 years, the caesarean section rate has reached global epidemic proportions. This trend is driven by multiple factors, an important one of which is the use and inconsistent interpretation of the electronic fetal monitoring (EFM) system. Despite its introduction in the 1960s, the EFM has not definitively improved neonatal outcomes, yet it has since significantly contributed to a seven-fold increase in the caesarean section rate. As we attempt to reduce the caesarean rates in the developed world, we should consider focusing on areas that have garnered little attention in the literature, such as physician sensitization to the poor predictive power of the EFM and the research method biases that are involved in studying the abnormal heart rate patterns—umbilical cord pH relationship. Herein, we apply Bayes theorem to different clinical scenarios to illustrate the poor predictive power of the EFM, as well as shed light on the principle of protopathic bias, which affects the classification of research outcomes among studies addressing the effects of the EFM on caesarean rates. We propose and discuss potential solutions to the aforementioned considerations, which include the re-examination of guidelines with which we interpret fetal heart rate patterns and the development of noninvasive technologies that evaluate fetal pH in real time.

scholarly journals Continued versus discontinued oxytocin stimulation in the active phase of labour (CONDISOX): double blind randomised controlled trial

BMJ ◽  
2021 ◽  
pp. n716
Author(s):  
Sidsel Boie ◽  
Julie Glavind ◽  
Niels Uldbjerg ◽  
Philip J Steer ◽  
Pinar Bor
Keyword(s):  
Caesarean Section ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Controlled Trial ◽  
Caesarean Section Rate ◽  
Active Phase ◽  
Double Blind ◽  
Oxytocin Infusion ◽  
Randomised Controlled ◽  
Reduced Risk

Abstract Objective To determine whether discontinuing oxytocin stimulation in the active phase of induced labour is associated with lower caesarean section rates. Design International multicentre, double blind, randomised controlled trial. Setting Nine hospitals in Denmark and one in the Netherlands between 8 April 2016 and 30 June 2020. Participants 1200 women stimulated with intravenous oxytocin infusion during the latent phase of induced labour. Intervention Women were randomly assigned to have their oxytocin stimulation discontinued or continued in the active phase of labour. Main outcome measure Delivery by caesarean section. Results A total of 607 women were assigned to discontinuation and 593 to continuation of the oxytocin infusion. The rates of caesarean section were 16.6% (n=101) in the discontinued group and 14.2% (n=84) in the continued group (relative risk 1.17, 95% confidence interval 0.90 to 1.53). In 94 parous women with no previous caesarean section, the caesarean section rate was 7.5% (11/147) in the discontinued group and 0.6% (1/155) in the continued group (relative risk 11.6, 1.15 to 88.7). Discontinuation was associated with longer duration of labour (median from randomisation to delivery 282 v 201 min; P<0.001), a reduced risk of hyperstimulation (20/546 (3.7%) v 70/541 (12.9%); P<0.001), and a reduced risk of fetal heart rate abnormalities (153/548 (27.9%) v 219/537 (40.8%); P<0.001) but rates of other adverse maternal and neonatal outcomes were similar between groups. Conclusions In a setting where monitoring of the fetal condition and the uterine contractions can be guaranteed, routine discontinuation of oxytocin stimulation may lead to a small increase in caesarean section rate but a significantly reduced risk of uterine hyperstimulation and abnormal fetal heart rate patterns. Trial registration ClinicalTrials.gov NCT02553226 .

scholarly journals A before and after study of the impact on obstetric and perinatal outcomes following the introduction of an educational package of fetal heart rate monitoring education coupled with umbilical artery lactate sampling in a low resource setting labor ward in South Africa

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Emma R. Allanson ◽  
Robert C. Pattinson ◽  
Elizabeth A. Nathan ◽  
Jan E. Dickinson
Keyword(s):  
Heart Rate ◽  
Cesarean Section ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Perinatal Outcomes ◽  
Heart Rate Monitoring ◽  
Post Intervention ◽  
Fetal Heart Rate Monitoring ◽  
Resource Setting ◽  
The Impact

Abstract Introduction Rates of cesarean section (CS) are increasing and abnormal fetal heart rate tracing and concern about consequent acidosis remain one of the most common indications for primary CS. Umbilical artery (UA) lactate sampling provides clinicians with point of care feedback on CTG interpretation and intrapartum care and may result in altered future practice. Materials and methods From 3rd March - 12th November 2014 we undertook a before and after study in Pretoria, South Africa, to determine the impact of introducing a clinical package of fetal heart rate monitoring education and prompt feedback with UA cord lactate sampling, using a hand-held meter, on maternal and perinatal outcomes. Results Nine hundred thirty-six consecutive samples were analyzed (pre n = 374 and post n = 562). There was no difference in mean lactate (4.6 mmol/L [95%CI 4.4–4.8] compared with 4.9 mmol/L [95%CI 4.7–5.1], p = 0.089). Suspected fetal compromise was reduced in the post-intervention period: 30·2% vs 22·1%, aOR 0·71, 95% CI 0·52–0·96, p = 0·027. Cesarean section rates were significantly reduced in the univariate analysis: pre- 40·3% vs post-intervention 31·6% (p = 0·007). This reduction remained significant when adjusted for previous cesarean section, primiparity, maternal HIV infection and preterm birth (aOR 0·72, 95%CI 0·54–0·98, p = 0·035). Neonatal outcomes did not differ between the two groups. Conclusion The introduction of a clinical practice package of fetal heart rate monitoring education combined with routine UA cord lactate sampling has the potential to reduce the cesarean section rate without increasing adverse neonatal outcomes in a low-resource setting.

scholarly journals Fetal heart rate patterns in patients with thick meconium staining of amniotic fluid and its association with perinatal outcome

2017 ◽  
Vol 6 (3) ◽  
pp. 1030 ◽  
Author(s):  
Dharna Desai ◽  
Nandita Maitra ◽  
Purvi Patel
Keyword(s):  
Heart Rate ◽  
Amniotic Fluid ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Caesarean Section Rate ◽  
Mode Of Delivery ◽  
Birth Asphyxia ◽  
Neonatal Morbidity ◽  
P Value ◽  
Meconium Staining

Background: This study assesses the role of abnormal fetal heart rate tracing patterns in patients with thick meconium staining of the amniotic fluid and its association with perinatal outcomes.Methods: Prospective unmatched case-control study on 2 groups of 136 subjects each- cases had thick MSAF and controls had clear liquor with abnormal fetal heart rate tracings on cardiotocography.Results: Gestational age (GA) >40 weeks, was found to have a significant association with MSAF (p value 0.01556 CI 95%). Premature Rupture of membranes at term (PROM) showed a significant association with MSAF with an OR of 2.25 (95% CI 1.37, 3.7); Post datism had significantly higher odds for being a risk factor for MSAF with an OR (3.194) (CI 95% 1.003-10.165). MSAF was not found to be significantly associated with abnormal trace on CTG. Neonatal morbidity (MAS, birth asphyxia, sepsis, HIE) had statistically higher odds in cases 1.669 (0.884-3.150) as compared to controls.Conclusions: No particular cardio-tocograph pattern can be considered to have a poor prognostic value in the presence of thick MSAF and the decision to deliver and the mode of delivery should be based on the overall assessment and the stage and progress of labor. While management should be individualized, a higher Caesarean section rate in thick MSAF can be justified to ensure a better outcome for the neonate even in the presence of a normal CTG trace.

scholarly journals Neonatal Mortality is Modulated by Gestational Age, Birthweight and Fetal Heart Rate Abnormalities in the Low Resource Setting in Tanzania – a Five Year Review 2015-2019

2021 ◽  
Author(s):  
Aisa Shayo ◽  
Pendo Mlay ◽  
Emily Ahn ◽  
Hussein Kidanto ◽  
Michael Espiritu ◽  
...  
Keyword(s):  
Heart Rate ◽  
Mortality Rate ◽  
Neonatal Mortality ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Delivery Room ◽  
Moderate Hypothermia ◽  
Neonatal Mortality Rate ◽  
Low Resource ◽  
The Impact

Abstract Background Neonatal mortality (NM) remains a significant problem in low resource settings. Birth asphyxia (BA) and prematurity contribute significantly to NM. The study objectives were to determine first, the overall NM as well as yearly neonatal mortality rate from 2015 to 2019. Second, the impact of decreasing GA (<37 weeks) and BW (<2500 grams) on NM. Third, the contribution of intrapartum and delivery room (DR) factors and in particular fetal heart rate abnormalities (FHRT) on NM <7 days. Methods Retrospective cohort study. Labor and delivery room data were obtained from 2015 to 2019 and included BW, GA, fetal heart rate (FHRT) abnormalities, bag mask ventilation (BMV) during resuscitation, initial temperature, antenatal steroids use. Outcome was binary i.e. either death < 7 days or survival. Analysis included t tests, odds ratios (OR) and multiple logistic regression Results The overall neonatal mortality rate was 18/1000 livebirths over the five years. NM was significantly higher for newborns <37 versus ≥37 weeks, OR 10.5 (p<0.0001) and BW <2500 versus ≥2500g OR 9.9 (p<0.0001). For infants <1000g / <28 weeks, the neonatal mortality rate was ~ 588/1000 livebirths. Variables associated with NM included BW - odds of death decreased by 0.55 for every 500g increase in weight, by 0.89 for every week increase in GA, NM increased 6.8-fold with BMV, 2.6-fold with abnormal FHRT, 2.2 fold with no antenatal corticosteroid (ACS), 2.6-fold with moderate hypothermia (all <0.0001). Conclusion NM rates was predominantly modulated by decreasing BW and GA, with smaller/ less mature newborns 10-fold more likely to die. NM in term newborns is strongly associated with FHRT abnormalities and when coupled with respiratory depression suggests BA. In smaller newborns, lack of ACS and moderate hypothermia were additional contributing factors. A composite perinatal approach is essential to achieve a sustained reduction in NM.

scholarly journals Effects of Three Different Stimulations (Acupuncture, Moxibustion, Acupuncture Plus Moxibustion) of BL.67 Acupoint at Small Toe on Fetal Behavior of Breech Presentation

2007 ◽  
Vol 35 (01) ◽  
pp. 27-33 ◽  
Author(s):  
Isabella Neri ◽  
Viviana De Pace ◽  
Paolo Venturini ◽  
Fabio Facchinetti
Keyword(s):  
Heart Rate ◽  
Fetal Heart Rate ◽  
Fetal Heart ◽  
Stress Test ◽  
Breech Presentation ◽  
Cardiovascular Effects ◽  
Acupuncture And Moxibustion ◽  
Small Series ◽  
Fetal Movements ◽  
The Impact

The aim of the study was to evaluate cardiovascular effects and fetal behavior during moxibustion, acupuncture or acupuncture plus moxibustion applied on the BL.67 acupoint of women (beside the outer corner of the 5th toenail) in fetal breech presentation. During the acupoint stimulation (20 min, two times a week), the women were submitted to computerized non-stress test. Fourteen cases were treated by both acupuncture and moxibustion, 15 cases by moxibustion and 10 cases by acupuncture. In 56% of cases, fetal position was converted from breech position to cephalic one; the success share was 80% for moxibustion, 28% for acupuncture, 57% for acupuncture plus moxibustion; the conversion, on average, was achieved after 3 sessions. Statistical analysis indicated that acupuncture plus moxibustion was able to reduce fetal heart rate during the application of stimuli while acupuncture and moxibustion separately did not affect such parameter. Moreover, moxibustion and acupuncture with moxibustion reduced fetal movements while acupuncture only appears ineffective. The present study suggests that fetal movements were reduced by both acupuncture plus moxibustion and moxibustion and that fetal heart rate was reduced just by acupuncture plus moxibustion. The mechanisms leading the effect on fetal heart rate and fetal movements remain to be clarified. Even though further studies are needed, such preliminar report mainly investigated the impact of different stimula on the BL.67 acupoint. Unfortunately these small series of data do not allow us to draw any conclusion about the effectiveness of the different treatments.

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