A randomised controlled trial of admission electronic fetal monitoring in normal labour

AIM: To test the hypothesis that the use of admission Electronic Fetal Monitoring (EFM) for healthy pregnant women in spontaneous labour would result in an increase in continuous EFM when compared to women who have had no admission EFM. DESIGN: A randomised controlled trial. SETTING: The Midwives Birth Unit in Glasgow Royal Maternity Hospital, a major urban teaching hospital with approximately 5000 births per year. PARTICIPANTS: Healthy pregnant women admitted in normal labour, deemed low risk based on the midwives' birth unit admission criteria. INTERVENTION: Women were randomly allocated either to receive a routine 20-minute period of EFM at the time of admission (control group), or to receive no routine admission EFM (study group). OUTCOME MEASURES: Primary study outcomes, use of continuous EFM; and use of EFM additional to the admission test. Secondary outcomes: artificial rupture of membranes, use of fetal scalp electrode, fetal blood sample, syntocinon, epidural analgesia, number of vaginal examinations, rate of transfer to labour ward, and reason for transfer. KEY FINDINGS: There was no statistically significant difference between the groups for use of continuous monitoring, but significantly more women in the control group did receive additional EFM. There was no statistically significant difference between groups for any of the interventions studied. CONCLUSION: The use of admission EFM did not in itself lead to a cascade of intervention. Other factors including setting of care and philosophy of caregivers may have an effect on the rate of intervention in labour.     

Monitoring the fetus in labor: evidence to support the methods

Electronic fetal monitoring (EFM) was implemented across the United States in the 1970s. By 1998, it was used in 84% of all U.S. births, regardless of whether the primary caregiver was a physician or a midwife. Numerous randomized trials have agreed that continuous EFM in labor increases the operative delivery rate, without clear benefit to the baby. Intermittent auscultation (IA) is safe and effective in low-risk pregnancies and may play a role in helping birth remain normal. Clinicians and educators are encouraged to reconsider the use of IA in the care of healthy childbearing women.     

Fetal heart rate auscultation: current and future practice

Intermittent auscultation (IA) has been reported as equivalent to electronic fetal monitoring (EFM) as a fetal surveillance method in terms of neonatal outcomes based on randomized controlled trials and meta-analyses. Despite recommendations to include IA as a primary method for fetal evaluation, EFM use predominates. Understanding the equipment, method, benefits and limitations, and strategies for implementing IA may assist nurses in providing informed choices for low-risk pregnant women.     

Are Routine Interventions Necessary in Normal Birth?

Routine interventions during labor and birth, such as perineal shaving and enemas before vaginal delivery, continuous intrapartum electronic fetal monitoring (EFM), and episiotomy are prevalent in Taiwan, but they may not always be necessary. Numerous studies investigating these interventions have failed to find absolute benefits for women with uncomplicated and low-risk pregnancies. No evidence-based benefits support routine perineal shaving or enemas during labor for reducing the risk of perineal wound infection or neonatal infection. The use of EFM is associated with an increased rate of operative interventions (vacuum, forceps, cesarean delivery) but does not result in a significant decrease in the incidence of perinatal death or cerebral palsy. Routine episiotomy does not have demonstrable advantages over restrictive episiotomy in the frequency or severity of perineal damage or pelvic relaxation.     

A Randomized Trial of Electronic Fetal Monitoring in Preterm Labor: Mothers'Views

ABSTRACT: To determine if perceptions of preterm labor and birth differed between women who were monitored by electronic fetal monitoring (EFM) or by periodic auscultation, 135 subjects were randomly assigned to one of two treatment groups on admission to a tertiary perinatal care setting. The first group received external monitoring by continuous Doppler and tocodynamometer when membranes were intact, and with an internal fetal scalp electrode and pressure catheter once membranes were ruptured. The second group received periodic monitoring with a DeLee fetoscope or amplified Doppler. All women were cared for on a one-to-one basis by expert study nurses. Subjects completed a questionnaire about their labor experience during their postpartum hospital stay. There was no statistically significant difference between the two groups on the study measures [T2(7,81) = 13.65; F = 1.82; P > 0.05]. Forty-four percent of the variance in women's global evaluation of labor was explained by their perceptions of nursing support. These findings suggest that mothers' perceptions of their preterm labor are less influenced by the technologic interventions used than by the supportive care received from nurses.     

RESPONSES OF LABORING WOMEN TO FETAL HEART RATE MONITORING

Authors of 13 studies agreed that women generally felt positively about the method of fetal monitoring they experienced during labor, whether intermittent auscultation (AUS) or electronic fetal monitoring (EFM). Advantages and disadvantages of both AUS and EFM are discussed. Limitations of the research are discussed, and clinical suggestions are given for ways the nurse-midwife can accent the advantages and minimize the disadvantages of whatever method is chosen.     

ST-analysis in electronic foetal monitoring is cost-effective from both the maternal and neonatal perspective

Objective: Electronic foetal monitoring (EFM) together with non-invasive ST-analysis (STAN) has been suggested as a superior technique to EFM alone for foetal surveillance to prevent metabolic acidosis. This study aims to compare the cost-effectiveness of these two techniques from both maternal (short term) as neonatal (long term) perspective to guide clinical decision-making.

Methods: We created two models: a maternal model, focused on the difference in mode of delivery as most important outcome, and a neonatal Markov model focused on the differences in metabolic acidosis – and its relationship to cerebral palsy (CP) – as the most relevant outcome to estimate the long-term cost-effectiveness. The cost to prevent one instrumental delivery was estimated in the maternal model. The costs to prevent one metabolic acidosis and the costs per quality adjusted life years were calculated in the neonatal model.

Results: The average costs of STAN are only €34 higher when compared to EFM alone. From maternal perspective the cost of preventing one instrumental delivery was estimated at €2602. From neonatal perspective the cost to prevent one case of metabolic acidosis was €14 509. Over the long term, STAN becomes a dominant (cost saving) strategy if?>1% of the patients exposed to metabolic acidosis acquire CP.

Conclusions: Our study suggests that STAN, when compared to EFM alone, can be a cost-effective strategy from both a maternal and neonatal perspective.     

To stay or not to stay: are fears about shorter postnatal hospital stays justified?

Common concerns raised during a Ministerial Review of Birthing Services in Victoria, Australia about the potential detrimental effects of shorter hospital stays after birth were examined in a study of women's actual experiences of and opinions about their hospital stays. Just under one in four women left hospital within five days of the birth, with the greater majority staying five days or more. Satisfaction with length of stay was high in the sample, with 82% of women feeling their stay had been about right, 11% feeling it had been too long and only 7% of women feeling their stay had been too short. A number of the concerns about the consequences of shorter lengths of stay were not borne out. Women who left hospital earlier than the traditional 5-7 day stay were not less likely to breast feed, nor were they more likely to be depressed 8-9 months after the birth. They were also much more likely to feel confident about looking after their baby when they went home than women who stayed five days or more. Implications for further research and for policy development concerning length of stay are considered.     

Maternal attitudes to fetal monitoring

During a randomized clinical trial concerning alternative methods of intrapartum fetal surveillance (electronic fetal monitoring (EFM) and auscultation (AUS)) an investigatory interview was carried out. Out of 655 expecting mothers the antepartum preference of EFM was 39.5%, of AUS 32.3% and 28.1% were undecided (UD). EFM was especially preferred by obstetrical high-risk patients. Reasons for preference of AUS were a natural childbirth, a non-technological milieu, and the lack of supposed discomfort from sensors and belts. The pregnant women found as major advantages of EFM continuous observation and the possibility of quick intervention. Postpartum 385 patients were again interviewed. The majority upheld the original preference if that method was used. If the non-preferred method had been applied many would stick to the primary preference although a tendency to prefer the experienced method was seen. The patients who antepartum preferred AUS, but had EFM, became more positive toward the method, and a significantly increased number were positively influenced by the EFM signal/trace and found the method promoting their partner's involvement in labor. Enforced immobility, however, was a major disadvantage as well as the technical milieu. If EFM is to be accepted by a majority of women giving birth it is necessary to increase the pregnant women's knowledge of the method and to take milieu factors into consideration in order to reduce the intrinsic depersonalization of EFM.     

Fetal Surveillance and Monitoring: Legal Issues Revisited

The issue of obstetric litigation and electronic fetal monitoring (EFM) is revisited. The controversy in the medical literature that suggests that we are in an era fraught with both medical and legal dilemmas in the use of EFM is explored. The role of the nurse expert, the standard of care, and case studies are presented that demonstrate the need for obstetric nurses to be competent in EFM, the physiology and pathophysiology of labor, and the standard of care to which they are held accountable. Suggestions are made for risk management in the intrapartum setting.     

Early pregnancy complications

The early pregnancy period can be complicated by a range of symptoms varying from nausea, vomiting, vaginal spotting and pelvic pain, to more severe conditions such as hyperemesis gravidarum, early embryonic demise, mental health problems and either molar or ectopic pregnancies. Some of these conditions require hospital admission and multidisciplinary team management, whilst others can be managed in an outpatient setting after the appropriate investigations. Complications early on in the pregnancy can be distressing, therefore women who experience such symptoms require close monitoring, reassurance and information on how to access help. Early pregnancy units have been specifically designed to serve patients with complications in early pregnancy and the health professionals are trained to support women during their treatment, whilst helping these patients make informed decisions about their care. This review summarises the key presentations, investigations and management of the most common complications that can arise in early pregnancy.     

Postpartum health, service needs, and access to care experiences of immigrant and Canadian-born women

OBJECTIVE: To describe immigrant women's postpartum health, service needs, access to services, and service use during the first 4 weeks following hospital discharge compared to women born in Canada. DESIGN: Data were collected as part of a larger cross-sectional study. SETTING: Women were recruited from 5 hospitals purposefully selected to provide a diverse sample. PARTICIPANTS: A sample of 1,250 women following vaginal delivery of a healthy infant; approximately 31% were born outside of Canada. MAIN OUTCOME MEASURES: Self-reported health status, postpartum depression, postpartum needs, access to services, service use. RESULTS: Immigrant women were significantly more likely than Canadian-born women to have low family incomes, low social support, poorer health, possible postpartum depression, learning needs that were unmet in hospital, and a need for financial assistance. However, they were less likely to be able to get financial aid, household help, and reassurance/support. There were no differences between groups in ability to get care for health concerns. CONCLUSIONS: Health care professionals should attend not only to the basic postpartum health needs of immigrant women but also to their income and support needs by ensuring effective interventions and referral mechanisms.     

Effect of dialysis on fetal heart rate: is inpatient admission for fetal monitoring necessary?

Objective: Pregnant patients receiving hemodialysis (HD) have long hospital stays for the purpose of electronic fetal monitoring (EFM) during HD, which allows for monitoring of fetal well-being. However, more frequent dialysis allows for smaller fluid shifts, preventing maternal hypotension. Our aim was to determine differences in rates of EFM abnormalities during HD versus non-stress testing (NST) off dialysis for gravid women with renal failure.

Methods: Retrospective cohort study over a 13-year period (2000–2013) identified five patients with renal failure in pregnancy. EFM tracings were reviewed during HD (cases) and routine inpatient NST off HD (controls). Standardized nomenclature was used to identify EFM abnormalities. The rate of abnormalities per hour of EFM was calculated. Kruskal–Wallis test was used and statistical significance was set at p?Results: There were no significant differences in late decelerations (p?=?0.2) between cases and controls. Significantly fewer variable decelerations (p?=?0.01) and contractions (p ≤0.001) were noted during dialysis compared to controls. Significantly more prolonged decelerations (p?=?0.02) were noted during HD compared to controls.

Conclusion: There may be no fetal benefit of EFM during HD for gravid women with renal disease attributed to hypertensive and diabetic nephropathy. There may be cost savings by shifting HD to the outpatient setting.     

Aspects of FHR tracings as warning signals

We have reviewed several different groups of common clinical problems with an eye toward their effects on FHR tracings. Although argument exists in the literature concerning the universal applicability of continuous EFM, most authors agree that continuous EFM is desirable, if not imperative, within these subgroups. Schifrin said, "It appears that potential benefits accrue when EFM and scalp sampling are employed with understanding and adequate training." With appropriate training, EFM and pH analysis can help the clinician to quickly and accurately assess fetal condition and to make necessary decisions regarding labor and delivery. The interpretation of fetal monitoring patterns necessitates consideration of gestational age and maternal condition as a starting point in analysis. The many other components of fetal-maternal interactions that occur with labor and delivery can be assessed satisfactorily only in this light.     

Randomised trial of expectant versus surgical management of spontaneous miscarriage

Thirty-five women with retained products of conception after spontaneous miscarriage were randomised to expectant ( n =19) or surgical ( n =16) management, respectively. Women were reviewed at one week, two weeks and six months. There were no significant differences in the number of days of pain, bleeding, sick leave or return to normal periods. Nine of twelve women from the expectant group and six of nine from the surgical group who attempted to conceive did so by six months. All 16 women were satisfied with conservative management. This study provides further reassurance when considering expectant management for spontaneous miscarriage both in the short and medium term.     

Comparison of two successive policies of cervical cerclage for the prevention of pre-term birth.

The percentage of women receiving cervical cerclage increased from 5% to 18% between two periods at Haguenau maternity hospital, according to a new policy for the prevention of pre-term birth. A parallel reduction of premature deliveries by about a half was observed in the relevant group of women. This suggests that cerclage might be employed on another basis than is currently the case, and that a randomized trial is urgently needed to define its indications more precisely.     

Continuous Electronic Fetal Monitoring: Contradictions Between Practice and Research

The reliability, validity, and efficacy of electronic fetal monitoring (EFM) remain matters of controversy. In fact, several professional organizations, including the American College of Obstetricians and Gynecologists, have endorsed the use of intermittent auscultation for low-risk pregnant women. Nevertheless, in 1996, 83% of laboring women in the United States are monitored electronically. Nurses should encourage healthy, low-risk pregnant women to weigh carefully decisions about the use of EFM.     

Does admission to hospital for bed rest prevent disease progression or improve fetal outcome in pregnancy complicated by non-proteinuric hypertension?

OBJECTIVE: To test whether a policy of admission to hospital for rest is of value in the management of women with non-proteinuric hypertension during pregnancy. DESIGN: A randomized controlled trial. SETTING: Harare Maternity Hospital, Zimbabwe. SUBJECTS: 218 (28 first pregnancies) women with non-proteinuric hypertension and a singleton pregnancy at between 28 and 38 weeks gestation allocated to rest in hospital or routine outpatient care. INTERVENTION: Admission to hospital for rest. Encouraged to rest in bed although voluntary ambulation around the ward was allowed. The women in the control group were encouraged to continue normal activity at home, to check urine each day for proteinuria. All the women were reviewed weekly. MAIN OUTCOME MEASURES: Disease progression was assessed by the development of severe hypertension (greater than or equal to 160/110 mmHg), development of proteinuria, need for induction of labour and number of infants born preterm (less than 37 weeks). Fetal outcome was assessed by birthweight, number of infants small-for-gestational age (SGA), and the number of infants requiring admission to the neonatal unit and their length of stay. RESULTS: The hospital rest group had a decreased risk of developing severe hypertension (blood pressure greater than or equal to 160/110 mmHg [odds ratio 0.47, 95% CI 0.26-0.83]). No differences were found in fetal growth or neonatal morbidity. The mean antenatal stay in hospital was 22.2 (SD 16.5), and 6.5 (SD 7.9) days in the rest and control groups, respectively. CONCLUSIONS: Hospital admission for bed rest decreased the risk of developing severe hypertension but no improvement in fetal growth or neonatal morbidity was observed. Fetal monitoring at home and continued outpatient antenatal care provided a safe, alternative policy to hospital admission.     

Whither electronic fetal monitoring?

Largely based on promising animal studies, continuous electronic fetal monitoring (EFM) was introduced into clinical practice in the early 1970s. After almost 20 years of experience, it is now apparent that the anticipated benefits of this technology have not materialized. Undesirable side effects of EFM include inappropriate operative intervention for some patients and increased liability for physicians and hospitals, resulting in an increase in the costs of obstetric services. After reviewing several research studies, The American College of Obstetricians and Gynecologists concluded that EFM and intermittent auscultation are equivalent methods for intrapartum assessment. We have developed a protocol for the performance of intermittent auscultation, including indicated responses to different levels of bradycardia. This protocol has allowed us to substitute auscultation for EFM in a high percentage of patients using existing nursing personnel. Laboring patients should, at a minimum, receive information on both intermittent auscultation and EFM to enable them to make an informed choice of method for intrapartum fetal assessment.