Telephone transmission of fetal monitor data

A telephone system was established to transmit fetal monitor data to a tertiary center from small rural hospitals with limited experience in interpreting such tracings. This type of program fosters sound obstetric management and appropriate therapeutic intervention of monitored patients in rural areas. We believe that similar service can be established by other tertiary hospitals.     

Guidelines for the provision of psychological evaluations for infertile patients at the University of Connecticut Health Center

OBJECTIVE: Because of the psychologically demanding nature of infertility treatment, it has been recommended that psychological services be made available to infertile patients. However, no specific guidelines for the scope or usage of those services has been proposed. Our objective was to formulate guidelines to be used at our institution to provide psychological evaluations to infertility patients. DESIGN: The guidelines were formulated through discussions between the division psychologist and attendings and then presented to and modified by the University Ethics, Risk Management, Legal, and Institutional Review Board departments. SETTING: The University of Connecticut Health Center Division of Reproductive Endocrinology and Infertility provides tertiary level care to infertility patients. Services include assisted reproductive technologies and donor gamete programs. Surrogate parenting is not a provided service. RESULTS: Guidelines for the provision and use of psychological services for infertility patients were formulated. CONCLUSIONS: These guidelines are preliminary in nature and intended to provide a starting point for discussion among physicians, nurses, and mental health professionals regarding the psychological needs of infertility patients.     

Xerox telecopier transmission of fetal monitor tracings: a 4-year experience.

A telephone consultation system using the Xerox 400 Telecopier has been established to transmit fetal monitor data to a tertiary center from regional hospitals with limited experience in interpreting this data. This report reviews a 4-year experience with this consultative device, discusses both the advantages and disadvantages of such a program, and recommends the establishment of similar services in other tertiary centers. We believe that the establishment of such services can be of diagnostic and therapeutic benefit to inexperienced medical personnel when first confronted with the concept of fetal monitoring. Hopefully, by so doing, hospital use of fetal monitoring will increase.     

Evaluation of the accuracy of a new ultrasonic fetal heart rate monitor

An indirect Doppler fetal monitoring system has been developed and validated by computer comparison of simultaneous fetal heart rate (FHR) with Doppler and scalp ECG of high-risk patients during labor. The difference in measurement of FHR averaged 0.3 b.p.m., and 93 per cent of the Doppler FHR measures were within 10 b.p.m. of the ECG FHR. If interinstrument difference is discounted, 96 per cent were within 10 b.p.m. All types of decelerations and variability were well approximated. Doppler FHR from the instrument described may be relied upon as valid clinical information and may be obtained from over 90 per cent of labor patients with 93 per cent accuracy.     

Acceleration of the fetal heart rate.

Acceleration of the fetal heart rate during contractions was usually followed by deceleration, and evidence is presented to show that it results from increased sympathetic drive and may be associated with fetal tissue hypoxia. However, the presence of accelerations are not serious and merely warn the obstetrician of the possibility of the occurrence of subsequent decelerations. The mechanism thought most likely to produce accelerations is uterine compression of the umbilical vein during contractions.     

An improved data display system for fetal heart rate monitoring.

Fetal heart rate (FHR) monitor records, particularly those derived from external sensors, may contain artifactual information closely resembling true FHR patterns. Additional machine-determined information may be used to help discriminate these data. Present commercial systems for indicating potentially artifactual FHR modify the FHR display, and this tends to cause the physician to ignore the absence of data or annoy him by obliterating some useful as well as potentialy useless information. Therefore, we chose to put the information that the data may be artifactual on another channel and allow the physician, rather than the instrument, to modify the interpretation of the FHR as necessary. A computer study was made of the characteristics of FHR beat-to-beat changes during poor signal to determine the most appropriate criteria for indicating when the FHR record is highly likely to be artifactual. Unphysiologic, erratic FHR changes are easily flagged by the presence of 3 serial beat-to-beat changes greater than 25 beats/min. Clinical testing demonstrated that this system allows the physician to better discriminate between valid and invalid data and increases the amount of usable data, particularly in active patients.     

Intrapartum fetal heart rate monitoring. I. Classification and prognosis of fetal heart rate patterns.

A total of 1,996 direct fetal heart rate (FHR) tracings in labor were analyzed using the first and last 30 minutes of monitoring in order to evaluate individual FHR characteristics as to their ability to predict the fetal status. Comparisons were made between individual FHR characteristics occurring alone ("uncomplicated") and those occurring in association with others ("complicated") in predicting fetal status as judged by 1 and 5 minute Apgar scores. These comparisons were made separately for the first 30 minutes and the last 30 minutes of monitoring.     

'False' fetal heart rate recording caused by interaction of an infusion pump and a fetal monitor

The authors describe 4 cases of falsely recorded fetal heart rate pattern due to technical failure. Interaction of a fetal monitor and an infusion pump may lead to a 'false' fetal heart rate tracing, suggesting fetal compromise and masking the actual cardiac activity. The limits of indirect fetal monitoring are stressed.     

The effect of maternal hypothermia on the fetal heart rate.

Fetal bradycardia is a recognized response to maternal hypothermia but has not previously been reported in conjunction with diabetes. A 30-year-old insulin-dependent diabetic was admitted at 35 weeks gestation for control of her diabetes. She developed maternal hypothermia and hypoglycemia and the fetal heart rate fell to 100 beats per minute (b.p.m.). However, the fetal heart rate gradually returned to normal after rewarming the patient.     

Maternal self-administered fetal heart rate monitoring and transmission from home in high-risk pregnancies.

OBJECTIVES: To evaluate the feasibility of high-risk pregnancy surveillance by patient-directed fetal heart rate monitoring and transmission, and to assess patient satisfaction with this technology. METHODS: Thirty-six women with high-risk pregnancies performed daily non-stress tests at home and transmitted the data to our perinatal care center by telephone. At each transmission, patients were asked by a physician about perceived fetal movements and uterine contractions and given the results. If the tracing was unsatisfactory, further evaluation was performed. In addition, patients completed a questionnaire on quality of life and anxiety state before and after the study. RESULTS: All patients were able to perform the tests and transmissions. The quality of recorded data was significantly correlated with maternal body mass index, but not with gestational age at the time of monitoring or birth weight. Thirty-nine of the total 562 tracings (6.9%) were inconclusive or non-reassuring. After repeated testing, 32 of them (82%) were considered normal, and seven patients (18%) were referred for additional in-hospital evaluation. Of this group, four were discharged for further surveillance with routine home monitoring and the remaining three were hospitalized for continued evaluation. There were no significant immediate adverse maternal or neonatal outcomes as a result of the monitoring. Patient satisfaction was high. CONCLUSIONS: Daily home FHR monitoring in high-risk patients is safe and feasible at all gestational ages, based on this initial pilot evaluation. It is easily and reliably performed and accepted by patients with a high level of satisfaction.     

The effect of drugs on fetal heart rate variability.

Baseline FHR variability has been quantitated into the mathematical indices of differential index (short-term variability) and interval index (long-term variability). Normal values have been determined. The effect that drugs used during labor have on FHR baseline variability has been evaluated. A clinically meaningful change in variability has been observed following low-dose administration of Demerol, morphine, Nisentil, Phenergan, and Vistaril. A statistically significant increase in variability has been observed following administration of magnesium sulfate.     

The effect of maternal exercise on fetal heart rate.

One hundred and ninety-three women with uncomplicated pregnancies and 44 with high-risk pregnancies participated in a 5-minute exercise stress test on a bicycle ergometer. All women were in the third trimester of pregnancy. Measurements of fetal heart rate were made at intervals of 2, 4, 6, 8, 10, 12, 16, 20, 25 and 30 minutes. Fetal heart rate was then compared in terms of maternal age, parity, consumption of cigarettes, exercise intensity, history of activity, cardiotocography score, maternal heart rate at rest, maternal heart rate after exercise, fetal sex and birth weight. In low-risk pregnancies an increase in fetal heart rate from 143 (124-171) beats per minute (bpm) to 148 (116-191) bpm was noted after exercise while, in the high-risk pregnancy group, a transient decrease from 148 (115-170) bpm to 141 (70-180) bpm was observed. There were also 10 cases of significant bradycardia in the high-risk pregnancy group. We conclude that the effect of maternal exercise on fetal heart rate is dependent on many variables. A fetal bradycardia following exercise is more likely to occur in high-risk pregnancies. The use of fetal heart rate variation with exercise could be a useful prognostic factor in pregnancy.     

The fetal autonomic nervous system, the fetal heart rate and the beat-to-beat irregularity.

In the exteriorized fetal lamb an experimental study on the influence of the fetal autonomic nervous system upon the heart rate pattern is described by means of blockage of the cholinergic, alpha-adrenergic and beta-adrenergic system. The alpha-adrenergic system proved to have no effect upon heart rate. The beta-adrenergic system had a positive chronotropic effect and the parasympathetic system had a negative chronotropic effect. Beat-to-beat irregularity was independent of a functional alpha-adrenergic system, but at a high basic heart rate disappeared completely after cholinergic blockage and at a low rate after beta-adrenergic blockage. It is concluded that most probably the beat-to-beat irregularity is the result of the competition of the enhancing influence of the beta-adrenergic system and the inhibiting influence of the cholinergic system on fetal heart rate.     

An assessment of the first decade's experience with antepartum fetal heart rate testing

The utility of antepartum fetal heart rate (APFHR) monitoring (nonstress test and the contraction stress test) was evaluated for a 10-year interval from 1974 through 1983. The number of high-risk patients evaluated increased from 2.9 to 25.1% of all deliveries. The decade's perinatal mortality rate differed from 22.4 per 1000 in the nontested population to 11.8 per 1000 in the tested population; the stillbirth rate differed from 11.1 per 1000 to 5.4 per 1000 uncorrected, 2.2 per 1000 corrected, and perinatal morbidity also differed from 26.1 per 1000 to 24.9 per 1000 (NS). Improvement statistics appear to plateau by the fourth year. An abnormal APFHR test was associated with a lethal congenital anomaly in 2.54% of patients (versus 0.5 to 1.5% in the general population). Evaluation for the presence of congenital anomalies appears to be indicated in the fetus with an abnormal APFHR test. A lower stillbirth rate occurred within 4 days of a normal APFHR test (0.027%) compared with a test interval of 5 to 7 days (0.11%). Thus, APFHR testing performed twice weekly may offer a better outcome for the fetus at risk than once weekly testing. This report confirms that the chief value of APFHR testing is its ability to identify the normal healthy fetus. These tests are somewhat less accurate at identification of the sick fetus. The nonstress test and contraction stress test were found to be of similar clinical predictive value.     

Predictive value of a fetal heart rate acceleration at the time of fetal blood sampling in labour.

It has been suggested that the fetal heart rate response to fetal stimulation in labour is an indication of fetal condition. This study was designed to evaluate scalp stimulation at the time of fetal blood sampling. All labours requiring fetal scalp pH measurement during one year at the John Radcliffe Maternity Hospital were reviewed to determine the association between pH result and the fetal heart rate response to the first scalp blood sample. Sixty-nine (50%) cases showed an acceleration and none had a scalp blood pH less than 7.20. Six (8.7%) of the cases which did not show an acceleration of the fetal heart rate had a pH less than 7.20 and this group had a greater incidence of analgesia usage and twice as many caesarean sections (39%). The detection rate for non-acidaemia using a fetal heart rate acceleration at the time of fetal blood sampling was 52 percent but the specificity and positive predictive value were both 100 percent. The false negative rate was 91 percent. Thus, whilst an acceleration was reassuring, the absence of an acceleration at the time of fetal blood sampling was not a good predictor of fetal acidaemia. These results are compared with the data from four other published reports.