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Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial.

https://arctichealth.org/en/permalink/ahliterature63789
Source
Lancet. 2001 Aug 18;358(9281):534-8
Publication Type
Article
Date
Aug-18-2001
Author
I. Amer-Wåhlin
C. Hellsten
H. Norén
H. Hagberg
A. Herbst
I. Kjellmer
H. Lilja
C. Lindoff
M. Månsson
L. Mårtensson
P. Olofsson
A. Sundström
K. Marsál
Author Affiliation
Department of Obstetrics and Gynaecology, University Hospital Lund, Lund, Sweden.
Source
Lancet. 2001 Aug 18;358(9281):534-8
Date
Aug-18-2001
Language
English
Publication Type
Article
Keywords
Acidosis - diagnosis
Cardiotocography
Cesarean Section - statistics & numerical data
Chi-Square Distribution
Comparative Study
Delivery, obstetric - statistics & numerical data
Electrocardiography
Female
Fetal Blood
Fetal Distress - diagnosis
Fetal Monitoring - methods
Heart Rate, Fetal
Humans
Hydrogen-Ion Concentration
Hypoxia, Brain - diagnosis - prevention & control
Pregnancy
Pregnancy outcome
Research Support, Non-U.S. Gov't
Risk factors
Sweden
Umbilical Arteries
Abstract
BACKGROUND: Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone. METHODS: At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH 12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring. FINDINGS: The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording. INTERPRETATION: Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.
Notes
Comment In: Lancet. 2002 Jan 19;359(9302):261-211812592
PubMed ID
11520523 View in PubMed
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Defensive medicine during hospital obstetrical care: a byproduct of the technological age.

https://arctichealth.org/en/permalink/ahliterature198111
Source
Soc Sci Med. 2000 Aug;51(4):523-37
Publication Type
Article
Date
Aug-2000
Author
K L Bassett
N. Iyer
A. Kazanjian
Author Affiliation
BC Office of Health Technology Assessment, Centre for Health Services and Policy Research, University of British Columbia, Vancouver, Canada. bassett@chspr.ubc.ca
Source
Soc Sci Med. 2000 Aug;51(4):523-37
Date
Aug-2000
Language
English
Publication Type
Article
Keywords
British Columbia - epidemiology
Cesarean Section - utilization
Defensive Medicine
Female
Fetal Distress - diagnosis
Fetal Hypoxia - diagnosis
Fetal Monitoring - utilization
Humans
Malpractice
Physician's Practice Patterns - statistics & numerical data
Pregnancy
Abstract
This paper presents an alternative perspective on defensive medicine. Defensive medicine is usually understood as arising from the effect of law on medicine through fear of litigation. Of equal significance, however, is the complementary influence of medicine on law through technological innovation, and, more importantly, the way that medicine and law develop dialectically. Each shapes the other in establishing the standards of care central to both clinical medicine and to actual or potential legal action. Excessive testing owing to fear of litigation indicates that defensive medicine is being practised in a particular setting, but it does not explain why this is so. To understand why defensive medicine occurs and why it is so troubling to clinicians requires an understanding, not only of medical and legal developments, but of a political-economic system and the beliefs and values of a society. Defensive medicine is discussed in relation to hospital obstetrical scenarios commonly associated with fear of litigation: fetal oxygen deprivation ("distress"), which is detected using an electronic fetal monitor, and prolonged labor, known as "dystocia". The material presented is taken from a medical anthropological study of obstetrical care in rural British Columbia, Canada. Litigation fears are shown to result less from rare, albeit often devastating, allegations of malpractice than from doctors adopting a role as "fetal champions", together with the introduction of electronic monitoring technology. The paper concludes by asserting that, rather than being in an adversarial relationship, medical practice and associated litigation primarily work together to reinforce each other, and the social conditions in which defensive medicine occurs.
PubMed ID
10868668 View in PubMed
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Delay in intervention increases neonatal morbidity in births monitored with cardiotocography and ST-waveform analysis.

https://arctichealth.org/en/permalink/ahliterature106074
Source
Acta Obstet Gynecol Scand. 2014 Feb;93(2):175-81
Publication Type
Article
Date
Feb-2014
Author
Jörg Kessler
Dag Moster
Susanne Albrechtsen
Author Affiliation
Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, Clinical Fetal Physiology Research Group, University of Bergen, Bergen, Norway.
Source
Acta Obstet Gynecol Scand. 2014 Feb;93(2):175-81
Date
Feb-2014
Language
English
Publication Type
Article
Keywords
Adult
Apgar score
Cardiotocography
Delivery, Obstetric
Electrocardiography
Female
Fetal Distress - diagnosis - physiopathology
Fetal Hypoxia - diagnosis - physiopathology
Fetal Monitoring - adverse effects - methods - statistics & numerical data
Heart Rate, Fetal - physiology
Humans
Infant, Newborn
Intensive Care Units, Neonatal
Kaplan-Meier Estimate
Logistic Models
Male
Norway
Practice Guidelines as Topic
Pregnancy
Pregnancy, High-Risk - physiology
Prospective Studies
Time Factors
Abstract
To assess the effect of the time interval from indication of hypoxia to delivery on neonatal outcome in high-risk pregnancies monitored with cardiotocography (CTG) and ST-waveform analysis.
Prospective observational study.
University hospital, Norway, 2004-08.
Singleton high-risk births with a gestational age above 35(+6) weeks, monitored with CTG and ST-waveform analysis.
Logistic regression analysis and Kaplan-Meier survival plots.
Neonatal morbidity in relation to the rapidity of intervention.
Of 6010 deliveries monitored with ST-waveform analysis, 1131 (19%) had an indication to intervene for fetal distress according to clinical guidelines. Those fetuses were at increased risk of an adverse neonatal outcome, and if delivered later than 20 min after the indication of hypoxia their risk increased further; i.e. transfer to the neonatal intensive care unit (NICU) from an odds ratio of 1.6 (95% confidence interval 1.2-2.2) to an odds ratio of 3.3 (95% confidence interval 2.5-4.3). The indication-to-delivery interval was longer for neonates with a 5-min Apgar score of
PubMed ID
24251909 View in PubMed
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Explaining variations in cesarean section rates: patients, facilities or policies?

https://arctichealth.org/en/permalink/ahliterature239216
Source
Can Med Assoc J. 1985 Feb 1;132(3):253-6, 259
Publication Type
Article
Date
Feb-1-1985
Author
G M Anderson
J. Lomas
Source
Can Med Assoc J. 1985 Feb 1;132(3):253-6, 259
Date
Feb-1-1985
Language
English
Publication Type
Article
Keywords
Birth rate
Breech Presentation
Cesarean Section - utilization
Dystocia - diagnosis
Female
Fetal Distress - diagnosis
Health Policy
Humans
Ontario
Pregnancy
Reoperation
Statistics as Topic
Abstract
Using overall rates of cesarean section and either rates of diagnosis or rates of cesarean section for the four main indications for this procedure, we analysed the variations among teaching and community hospitals in four of Ontario's six regions. The rates varied substantially in both 1979 and 1982, with the overall rate for cesarean section in 1982 being 17.1 to 21.0 per 100 deliveries in the teaching hospitals and 16.5 to 19.7 in the community hospitals. The rate of diagnosis of dystocia varied up to threefold in the teaching hospitals and up to twofold in the community hospitals. Fetal distress was diagnosed at even more variables rates. The rate of repeat cesarean section varied most in the teaching hospitals, whereas the rate of cesarean section for breech presentation varied significantly in the community and the teaching hospitals in 1982 but only in the community hospitals in 1979. Nearly all the rates increased between 1979 and 1982. Differences in patient characteristics and in availability of resources appeared less important in explaining these rate variations than differences in clinical policy.
Notes
Cites: Science. 1973 Dec 14;182(4117):1102-84750608
Cites: Can Med Assoc J. 1981 Oct 1;125(7):726-307326655
Cites: Am J Obstet Gynecol. 1978 Jul 1;131(5):526-32677195
Cites: N Engl J Med. 1980 Mar 6;302(10):559-636986017
Cites: Br Med J. 1979 Dec 8;2(6203):1488-9526824
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Cites: Can Med Assoc J. 1984 Jul 15;131(2):111-56744157
Cites: Am J Public Health. 1983 Aug;73(8):863-76869639
Cites: JAMA. 1983 Jun 3;249(21):2935-76842808
Cites: N Engl J Med. 1982 Nov 18;307(21):1310-47133068
Cites: Can Med Assoc J. 1978 May 6;118(9):1019-20647577
Cites: Can J Public Health. 1982 Jan-Feb;73(1):47-517074518
Cites: N Engl J Med. 1982 Aug 5;307(6):343-77088099
Cites: Arch Surg. 1982 Jun;117(6):846-537044343
Cites: Am J Obstet Gynecol. 1980 May 15;137(2):235-447377243
Cites: Obstet Gynecol. 1980 Aug;56(2):135-437393501
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Cites: Am J Public Health. 1981 Jun;71(6):591-6007235097
Cites: Can Med Assoc J. 1981 Oct 1;125(7):723-67326654
Cites: Obstet Gynecol. 1982 Jan;59(1):13-207078844
PubMed ID
3967160 View in PubMed
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Fetal health surveillance: antepartum and intrapartum consensus guideline.

https://arctichealth.org/en/permalink/ahliterature160764
Source
J Obstet Gynaecol Can. 2007 Sep;29(9 Suppl 4):S3-56
Publication Type
Article
Date
Sep-2007
Author
Robert Liston
Diane Sawchuck
David Young
Source
J Obstet Gynaecol Can. 2007 Sep;29(9 Suppl 4):S3-56
Date
Sep-2007
Language
English
Publication Type
Article
Keywords
Asphyxia Neonatorum - prevention & control
Canada
Female
Fetal Distress - diagnosis
Fetal Monitoring - standards
Humans
Infant, Newborn
Pregnancy
Prenatal Diagnosis - standards
Quality of Health Care
Risk Management
Abstract
This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum and intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum and intrapartum care in Canada.
Consideration has been given to all methods of fetal surveillance currently available in Canada.
Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered.
A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance both antepartum and intrapartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care.
This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program.
Notes
Comment In: J Obstet Gynaecol Can. 2007 Dec;29(12):972; author reply 97218193502
Erratum In: J Obstet Gynaecol Can. 2007 Nov;29(11):909
PubMed ID
17845745 View in PubMed
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Fetal ST segment heart rate analysis in labor: improvement of intervention criteria using interpolated base deficit.

https://arctichealth.org/en/permalink/ahliterature78058
Source
J Matern Fetal Neonatal Med. 2007 Jan;20(1):47-52
Publication Type
Article
Date
Jan-2007
Author
Mansano Roy Z
Beall Marie H
Ross Michael G
Author Affiliation
Department of Obstetrics and Gynecology, Harbor-UCLA Medical Center, Torrance, California 90509, USA. rmansano@obgyn.humc.edu
Source
J Matern Fetal Neonatal Med. 2007 Jan;20(1):47-52
Date
Jan-2007
Language
English
Publication Type
Article
Keywords
Acidosis - diagnosis - physiopathology
Cesarean Section - statistics & numerical data
Electrocardiography - methods
Female
Fetal Distress - diagnosis
Fetal Monitoring - methods
Heart Rate, Fetal - physiology
Humans
Pregnancy
Pregnancy outcome
Retrospective Studies
Abstract
OBJECTIVE: The addition of ST waveform analysis (STAN, Neoventa, Sweden) to fetal heart rate (FHR) tracings has been demonstrated to improve fetal outcome and reduce operative delivery rates, though the actual level of fetal acidosis at which STAN indicates intervention has not been assessed. We sought to determine if FHR ST segment analysis recommends intervention at appropriate levels of fetal acidosis. METHODS: FHR tracings of 10 acidotic and 10 non-acidotic infants with FHR tracings having a minimum of one STAN flag were retrospectively analyzed. Fetal base deficit (BD) was calculated by interpolation throughout the FHR tracing and STAN 'action' and 'ignore' flags assigned a fetal BD value. A secondary analysis was performed with a revised interpretation of FHR reassuring status. RESULTS: The mean (+/-SD) BD of the first STAN action was significantly greater than the first 'ignore' (4.0+/-2.1 vs. 3.0+/-0.8 mmol/L, p
PubMed ID
17437199 View in PubMed
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[Incidents connected to pregnancy and labor]

https://arctichealth.org/en/permalink/ahliterature58540
Source
Tidsskr Nor Laegeforen. 2001 Nov 10;121(27):3185-7
Publication Type
Article
Date
Nov-10-2001
Author
J. Holmboe
K. Molne
H. Jenssen
Author Affiliation
jorgen.holmboe@helsetilsynet.dep.no
Source
Tidsskr Nor Laegeforen. 2001 Nov 10;121(27):3185-7
Date
Nov-10-2001
Language
Norwegian
Publication Type
Article
Keywords
Diagnostic Errors
English Abstract
Female
Fetal Distress - diagnosis
Humans
Infant mortality
Infant, Newborn
Malpractice - statistics & numerical data
Maternal mortality
Medical Errors - statistics & numerical data
Midwifery - standards
Norway - epidemiology
Obstetric Labor Complications - diagnosis - epidemiology
Obstetrics and Gynecology Department, Hospital - standards
Pregnancy
Pregnancy Complications - diagnosis - epidemiology
Risk Management
Abstract
In the period 1993-2000 the Norwegian Board of Health investigated 70 cases of claimed professional misconduct in relation to pregnancy or delivery. There were two maternal deaths, 38 perinatal deaths and 17 cases of cerebral damage. The Board of Health found reason to criticize midwives in 11 cases, obstetricians in 39 cases, and the hospital for lack of routines in 18 cases. Many of the mishaps were connected to false interpretation of fetal signs of distress (clinical signs or cardiotocography), and the investigation concluded that Caesarean section was delayed too long. The number of patient complaints has been constant through the period, in contrast to the widespread belief that misconduct and complaints are steadily increasing. The health authorities and the Norwegian Association of Gynaecologists have focused on quality and standards in obstetrics through committees for investigation of perinatal deaths, national guidelines in obstetrics, and improved national statistics.
PubMed ID
11876142 View in PubMed
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Inter-observer variation in assessment of 845 labour admission tests: comparison between midwives and obstetricians in the clinical setting and two experts.

https://arctichealth.org/en/permalink/ahliterature58444
Source
BJOG. 2003 Jan;110(1):1-5
Publication Type
Article
Date
Jan-2003
Author
Ellen Blix
Oddvar Sviggum
Karen Sofie Koss
Pål Øian
Author Affiliation
Nordic School of Public Health, Gothenburg, Sweden.
Source
BJOG. 2003 Jan;110(1):1-5
Date
Jan-2003
Language
English
Publication Type
Article
Keywords
Cardiotocography - methods - standards
Diagnostic Tests, Routine - standards
Female
Fetal Distress - diagnosis
Hospitals, Maternity
Humans
Infant, Newborn
Labor, Obstetric
Midwifery - standards
Norway
Observer Variation
Obstetrics - standards
Pregnancy
Research Support, Non-U.S. Gov't
Sensitivity and specificity
Abstract
OBJECTIVE: To assess the inter-observer agreement in assessment of the labour admission test between midwives and obstetricians in the clinical setting and two experts in the non-clinical setting, the inter-observer agreement between two experts in the non-clinical setting and to what degree fetal distress in labour could be predicted by the two experts. DESIGN: Observational study. SETTING: The maternity unit of Hammerfest Hospital, Norway. POPULATION: Eight hundred and forty-five high and low risk women. METHOD: The labour admission test was first assessed by the midwife or obstetrician in the clinical setting, and was later assessed by two experts. The traces were assessed as normal, equivocal or ominous. Weighted kappa (kappaw), proportion of agreement (Pa) and predictive values were calculated. MAIN OUTCOME MEASURES: Weighted kappa, proportion of agreement, sensitivity, positive predictive value and likelihood ratios. RESULTS: Inter-observer agreement between Expert 1 and Expert 2: kappaw 0.38 (CI 0.31-0.46), Pa for reactive labour admission test 0.86 (CI 0.83-0.88) and Pa for equivocal/ominous test 0.33 (CI 0.26-0.40). Agreement between Expert 1 and midwives/obstetricians: kappaw 0.25 (CI 0.15-0.36), Pa for reactive labour admission test 0.89 (CI 0.87-0.91) and Pa for equivocal/ominous labour admission test 0.18 (CI 0.11-0.25). Agreement between Expert 2 and midwives/obstetricians: kappaw 0.28 (CI 0.20-0.37), Pa for reactive labour admission test 0.85 (CI 0.82-0.88) and Pa for equivocal/ominous test 0.20 (CI 0.14-0.26). Totally 5.9% of the newborns had fetal distress. At cutoff equivocal test, sensitivity was 0.22 and 0.31 in the two observers. Positive predictive values were 0.13 and 0.11. Likelihood ratio for a positive test was 2.30 and 1.92 and likelihood ratio for a negative test 0.86 and 0.83. CONCLUSION: A labour admission test is still routine practice in most obstetric units in the Western world when there is little evidence on its benefits. The results from this study may provide some reconsideration for such practice, and for more research.
PubMed ID
12504927 View in PubMed
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Intrapartum monitoring with cardiotocography and ST-waveform analysis in breech presentation: an observational study.

https://arctichealth.org/en/permalink/ahliterature262429
Source
BJOG. 2015 Mar;122(4):528-35
Publication Type
Article
Date
Mar-2015
Author
J. Kessler
D. Moster
S. Albrechtsen
Source
BJOG. 2015 Mar;122(4):528-35
Date
Mar-2015
Language
English
Publication Type
Article
Keywords
Acidosis - blood
Adult
Apgar score
Breech Presentation - diagnosis - physiopathology
Cardiotocography
Delivery, Obstetric
Electrocardiography
Female
Fetal Distress - diagnosis
Fetal Hypoxia - diagnosis
Fetal Monitoring - methods
Gestational Age
Heart Rate, Fetal
Humans
Infant, Newborn
Norway - epidemiology
Practice Guidelines as Topic
Pregnancy
Pregnancy Complications
Pregnancy outcome
Pregnancy, High-Risk
Prevalence
Prospective Studies
Randomized Controlled Trials as Topic
Time Factors
Abstract
To determine the electrocardiographic performance and neonatal outcome of pregnancies with breech presentation and planned vaginal delivery monitored with ST-waveform analysis (STAN).
Prospective observational study.
University hospital, Norway; 2004-2008.
Singleton pregnancies with a gestational age above 35 + 6 weeks, breech presentation, selected for vaginal delivery and monitored with STAN.
Common clinical guidelines for STAN monitoring were used. An experienced neonatologist graded the symptoms of neonatal encephalopathy. The outcome was compared with STAN-monitored high-risk deliveries in a vertex presentation (n = 5569) using logistic regression analysis.
Frequency of ST events, indications of intervention for fetal distress, and neonatal morbidity and mortality.
Breech presentation occurred in 750 of 23,219 (3.2%) deliveries, 625 (83%) of which were selected for vaginal delivery. Intrapartum monitoring by STAN was performed in 433 (69%). Compared with vertex presentations, fetuses in breech presentation had a lower risk of baseline T/QRS rise during labour [odds ratio (OR) = 0.7, 95% confidence interval (95% CI) = 0.7-0.9, P = 0.003] and a higher risk for intervention as a result of preterminal cardiotocogram (OR = 2.9, 95% CI = 1.6-5.9, P = 0.001). The risks of perinatal mortality (OR = 1.8, 95% CI = 0.2-15, P = 0.6), cord metabolic acidosis (OR = 0.8, 95% CI = 0.2-3.2, P = 0.7) and moderate or severe neonatal encephalopathy (OR = 1.8, 95% CI = 0.5-6.2, P = 0.3) did not differ significantly between breech and vertex deliveries.
STAN can be used for the surveillance of breech presentations selected for vaginal delivery with an acceptable neonatal outcome. The electrocardiogram (ECG) pattern during labour varies with the fetal presentation.
Notes
Comment In: BJOG. 2015 Mar;122(4):53525112696
PubMed ID
25040705 View in PubMed
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11 records – page 1 of 2.