Cervical dilatation and grade of doctor affects the interval between decision and result of fetal scalp blood sampling in labour

Fetal scalp blood sampling (FSBS) is used to provide information regarding fetal acid–base status during labour. This study assessed the interval between the decision to perform the procedure and obtaining the result and evaluated whether it is affected by cervical dilatation or the experience of the doctor. The median time for FSBS was 10 min. When cervical dilatation was?≤4 cm samples took approximately 30% longer to obtain. After adjustment for dilation, there were no significant differences between different grades of doctors. FSBS is shorter than previously reported; clinicians should be aware that procedures in early labour take longer to complete.     

Interpreting the electronic fetal monitor. Strategies for management

Electronic fetal monitoring offers the practitioner involved in the intrapartum care of women a mechanism to validate the fetus' physiologic adaptation to the labor and delivery experience. Utilizing a predetermined framework for constant assessment of fetal well-being will assist the clinician in the bedside management of these patients. This pathway of reassurance for fetal evaluation is an effective tool in the intrapartum observations of the fetus. If the fetus can demonstrate his physiologic well-being, labor may continue. However, if there are no signs of reassurance, immediate delivery of the fetus should be considered.     

INTERPRETING THE ELECTRONIC FETAL MONITOR Strategies for Management

Electronic fetal monitoring offers the practitioner involved in the intrapartum care of women a mechanism to validate the fetus' physiologic adaptation to the labor and delivery experience. Utilizing a predetermined framework for constant assessment of fetal well-being will assist the clinician in the bedside management of these patients. This pathway of reassurance for fetal evaluation is an effective tool in the intrapartum observations of the fetus. If the fetus can demonstrate his physiologic well-being, labor may continue. However, if there are no signs of reassurance, immediate delivery of the fetus should be considered.     

Timing delivery of the growth-restricted fetus

Intrauterine growth restriction (IUGR) is commonly defined as an estimated fetal weight of less than the 10th percentile. While 70% of these are small for normal reasons and not at risk, 30% are pathologically small at risk for numerous complications including fetal death. In the late preterm IUGR fetus (>34 weeks), prematurity risks less and the risk of fetal demise becomes the primary concern. Pulsed-wave Doppler interrogation of the umbilical and middle cerebral artery is useful in reducing perinatal mortality, however, Doppler changes in these vessels of the IUGR fetus may not occur after 34 weeks gestation. There are no randomized trials addressing the timing of delivery of the IUGR fetus in the late preterm or early-term period. However, retrospective reports show an increase risk of fetal demise. While timing the delivery of the late preterm/early-term IUGR fetus requires consideration of multiple factors (e.g. degree of growth restriction, etiology, amniotic fluid volume, and biophysical and Doppler testing), available data suggests that delivery should occur by 37 to 38 weeks for singleton IUGR fetuses. In twin pregnancies with a co-twin IUGR fetus, chorionicity also impacts timing of delivery, but delivery should occur by 34-36 weeks.     

The effect of insulin on ovine fetal oxygen extraction

Infusion of exogenous insulin (54 +/- 19 mU/kg/hr) to seven fetal lambs caused hyperinsulinism and arterial hypoxemia but not hypoglycemia. We measured the relationship between fetal oxygen delivery and oxygen use for a better understanding of the cause of the observed hypoxemia. Oxygen delivered to the fetus is the product of fetal umbilical venous oxygen content and umbilical blood flow. Both of these quantities decreased as fetal insulin concentration rose. The fall in umbilical blood flow was due to a change in the distribution of cardiac output. Cardiac output rose, but placental perfusion decreased while blood flow to the fetal carcass increased. Oxygen consumption by the ovine fetus increased as insulin concentration rose. Since the delivery of oxygen to the fetus did not increase when its use was rising, fetal extraction of available oxygen increased. Fetal arterial hypoxemia is the result of this increased extraction of available oxygen.     

Delayed interval delivery in multiple gestations

Two multiple pregnancies with delayed delivery after expulsion of dead fetus are presented. Case 1: A woman with a twin pregnancy and one intrauterine fetal death at 20 weeks’ gestation delivered a dead fetus at 27 weeks’ gestation. She delivered a healthy male infant weighing 2430 g at 33 weeks’ gestation (42 d after the delivery of the first twin). Case 2: A woman with quadruplets pregnancy (2 live fetuses, one empty sac, and one fetocide at 7 weeks’ gestation) got a intrauterine fetal death at 21 weeks’ gestation at one fetus among 2 live fetuses and delivered a dead fetus at 24 weeks’ gestation. She delivered a healthy female infant weighing 2110 g at 33 weeks’ gestation (58 d after the delivery of a dead fetus). On the basis of our experience and the review of literature, delayed delivery with careful observation of fetal and maternal condition is recommended for improved survival and decreased morbidity among latter-born siblings. Received: August 1999 / Accepted: 10 January 2000     

The small baby on gestational ultrasound scan

Intrauterine fetal growth restriction is a major cause of perinatal morbidity and mortality in developed countries. Establishing this diagnosis is difficult. When this problem is eventually identified, the management of the affected pregnancy is often challenging. This is because distinguishing the small baby that is constitutionally normal, from the baby with an intrinsic problem, or suffering from placental insufficiency, is difficult. After accurately identifying the fetus at risk of hypoxia from uteroplacental insufficiency, there is the dilemma of determining the optimum time of delivery. The risk of premature delivery has to be weighed against the risk of fetal demise from intrauterine hypoxia. This review outlines the fetal biometric indices by which the diagnosis of a fetus that is ‘small for gestational age’ is made. The place of serial scans for fetal biometry, and the range of functional studies for fetal surveillance are discussed. Factors that should influence the timing of delivery are mentioned and some recent advances in fetal surveillance are highlighted.     

Delayed delivery of second twin after chorioamnionitis and abortion of first twin at 21 weeks gestation

Delayed delivery is a relatively new term used to describe the delivery of one fetus after premature delivery of the first fetus. We describe a case where we used tocolysis and antibiotics to prolong a twin pregnancy for 35 days with excellent fetal outcome, after chorioamnionitis had caused the abortion of the first twin at 21 weeks gestation.     

505例巨大胎儿分析

目的 探讨巨大胎儿的产前诊断及分娩方式,降低母儿并发症。方法 回顾分析５０５例巨大胎儿诊断、分娩方式及并发症,并与单胎正常体重儿分娩情况进行比较。结果 巨大胎儿中双顶径（ＢＰＤ）＋胎骨长度（ＦＬ）〉１６．５ｃｍ者占８８．４６％,剖宫产组较阴道分娩组新生儿窒息率及产伤机会均明显降低,巨大胎儿与正常体重儿相比难产率明显升高。结论 ＢＰＤ＋ＦＬ〉１６．５ｃｍ可做为产前诊断巨大胎儿的一项可靠指标,对巨大胎     

再谈头位阴道助产术

头先露的阴道助产术包括产钳助产术和胎头负压吸引术。在第二产程中判断胎头位置及胎方位是阴道助产成功的关键。胎头最低位置于坐骨棘2 cm以下,胎方位为枕前位者,助产风险相对小。产科医生要严格把握阴道助产的手术指征,并与患者充分沟通。临床医生的判断能力,培训经历以及临床经验是助产成功的重要因素。     

Sinusoidal-like Fetal Heart Rate Tracing in a Case of Acute Fetomaternal Haemorrhage

EDITORIAL COMMENT: This case indicates that when fetomaternal haemorrhage is the cause of critical fetal reserve as observed by cardiotocography the fetus may be doomed in spite of prompt delivery by emergency Caesarean section, although there are reports of successful fetal outcome with immediate delivery in such cases. The moral of this case report is that cardiotocographic evidence of reduced fetal reserve of any degree indicates delivery when the pregnancy is at term, especially when there are other complications, such as fetal growth retardation.     

Cell-free fetal DNA in the cerebrospinal fluid of women during the peripartum period

OBJECTIVE: The purpose of this study was to determine whether cell-free fetal DNA is detectable in the cerebrospinal fluid of women during pregnancy and after delivery. STUDY DESIGN: Cerebrospinal fluid was collected from 39 women who underwent an indicated spinal anesthesia procedure. Twenty-six samples were from women who carried at least 1 male fetus, and 13 samples were from women with only a female fetus. DNA was analyzed with the use of real-time polymerase chain reaction for DYS-1 (which represented male fetal DNA) and beta-globin (which represented maternal and fetal DNA). RESULTS: beta-Globin DNA was detected in all cerebrospinal samples. DYS-1 gene sequences were detected in 4 cerebrospinal fluid samples from women who had male fetuses (2 samples were from women who underwent cesarean delivery of singleton pregnancies, 1 sample was from a triplet pregnancy, and 1 sample was from a woman after delivery). No male DNA was detected in the cerebrospinal fluid of women who carried female fetuses. CONCLUSION: Male fetal cells and/or cell-free fetal DNA is detectable in the cerebrospinal fluid of some pregnant women or some women after delivery.     

Brow and face presentations

Experience with 50 face and 34 brow presentations of the fetus at delivery in the Mayo Clinic agrees with that reported by others. The presence of a small pelvis, a small fetus, a large fetus, cranial abnormalities, placenta previa or a low-lying placenta, and twins seemed to contribute alone or in combination to the occurrence of these deflection attitudes. Premature rupture of membranes, looping of the cord, hydramnios, and pelvic tumors were not as common in this series as in others.The possibility of face or brow presentation should be kept in mind when the fetal head remains high during labor as well as when the fetal cephalic prominence is palpated on the same side as the fetal back. With early recognition and proper management, such a presentation should mean little, if any, additional risk to the mother or fetus. The patient should be given a trial of labor with frequent evaluation of uterine contractions and physical status of mother and fetus, with careful observation of progress during labor. Unless there is arrest of labor or signs of maternal or fetal distress, most of these patients can be expected to be delivered vaginally. Prolonged labor from combined dystocia and uterine inertia was common both in patients with face presentation and in those with brow presentation, but most of these also were delivered vaginally.Manual and forceps rotation or flexion or further extension of the extended fetal head is occasionally successful in converting the presentation to a more favorable one so that subsequent vaginal delivery becomes possible. The most frequent need for cesarean section in this series arose in the primiparas, particularly in those with the fetus in the mentoposterior position.     

A comparison of sheep and human fetal oxygen delivery systems with use of a mathematical model

Human fetal cardiac output measured with ultrasound is only about 60% of that found in the sheep. We modified a previously developed mathematical model of the fetal circulation and oxygen delivery in sheep for the human in order to study several differences. The model predicts that a human fetus can maintain its oxygen delivery with a relatively low cardiac output because of its relatively high fetal hemoglobin concentration, as compared with that of the sheep fetus. Thus an inverse relationship between fetal hemoglobin concentration and fetal cardiac output is suggested. This relationship may be mediated by the influence of red blood cell concentration on blood viscosity. Furthermore, it indicates that fetal anemia should be detectable by ultrasound measurements of increased cardiac output and/or umbilical blood flow. Dynamic responses of the model suggest that the mechanism of late and variable decelerations in the fetal heart rate pattern is mediated via a fall in arterial oxygen tension.     

Twin pregnancy complicated by intrauterine death of one twin

In twin pregnancies single intrauterine death of one fetus is associated with significant morbidity and mortality of the surviving infant. The aims of our retrospective study were to review conditions of twin pregnancies complicated with SIUD in Polish Mother's Memorial Hospital in ?ód? between 1989-1999 and to assess the fetal outcome when conservative management had undergone. In this study we reviewed 30 twin gestations involving the intrauterine death of one fetus. The incidence of preterm delivery among pregnancies with fetal death was 83.3%; Caesarean section was the method of delivery in 53.3% cases. Monochorionic placentation was found in 60%. Conservative management until there is no risk for the fetus is apt.     

Difficult Deliveries in Cesarean Section

Cesarean section rate has been on the rise. It is commonly perceived as a simple and safe alternative to difficult vaginal birth. However, there are situations during C section where delivery of fetus may be difficult. This can cause maternal and fetal complications. To avoid such mishaps, anticipation of potential difficulties and planning in advance can be fruitful. This amounts to mobilization of a good team of anesthetist, assistant and skilled neonatologist. Proper technical skills are needed not only to use the equipment but to deal with such situations for safe delivery of the fetus. The training in technical skills can be imparted through drill protocols under C section skills. This way, one should try and accomplish safe atraumatic fetal delivery.     

Misdiagnosis of a normal fetal platelet count after coagulation of intrapartum scalp samples in autoimmune thrombocytopenic purpura.

Intrapartum fetal scalp sampling for platelet counts in maternal autoimmune thrombocytopenia has been advocated for determining route of delivery. We report a case in which two coagulated scalp samples were believed to indicate a normal fetal platelet count. As a result, vaginal delivery of a severely thrombocytopenic fetus was allowed.     

Doppler blood flow in obstetrics

PURPOSE OF REVIEW: Our review on Doppler ultrasound in obstetrics aims to identify which vessels have a definite clinical role in obstetrics. RECENT FINDINGS: The use of Doppler ultrasonography in the diagnosis and management of the intrauterine growth-restricted fetus improves the perinatal morbidity and mortality. However, the timing of delivery of the intrauterine growth-restricted fetus, based on Doppler ultrasonography, remains the subject of investigation. Robust data exist on the management of fetuses at risk for anemia because of red cell alloimmunization by using the middle cerebral artery peak systolic velocity. Appropriate training for the correct assessment of this vessel is fundamental. Doppler ultrasonography of the umbilical artery is useful in the counseling of patients with pregnancies complicated by twin-twin transfusion syndrome. SUMMARY: Recently, Doppler ultrasonography has been shown to be helpful to the obstetricians in the diagnosis of the IUGR fetus, diagnosis of fetal anemia, twin-twin transfusion syndrome. These are the basis for timing the delivery of the IUGR fetus. However, more data are necessary. Doppler ultrasonography should be used to assess the fetal ductus arteriosus in patients treated with prostaglandin inhibitors. Doppler is also an important part of the fetal echocardiogram.     

Delivery of the macrosomic infant: cesarean section versus vaginal delivery

The macrosomic fetus of a diabetic woman faces increased risk for injury at the time of birth. Cesarean section offers the potential for avoiding trauma to the fetus, but can result in increased morbidity in the mother as compared to vaginal delivery. In this article, the advantages and disadvantages of the 2 routes of delivery for the overgrown fetus of a diabetic mother are discussed. In addition, methods for diagnosing macrosomia by ultrasound are examined, along with the benefits and pitfalls of ultrasonic fetal weight estimation in the setting of diabetes. Finally, management approaches for selecting route of delivery for the macrosomic fetus are described and analyzed.     

产程中的胎儿监护

胎心率受到自主神经系统、化学感受器等多因素影响,是胎儿心脏和延髓对母胎血供、酸中毒和缺氧情况的反映。产时胎心监护用于评估胎儿宫内情况,可分为三级胎心率。根据产时胎心监护对患者进行科学分级管理,将有利于及时识别和处理胎儿宫内缺氧和酸中毒,预防胎儿死亡。