Diogo Ayres-de-Campos

Evaluation of interobserver agreement of cardiotocograms.

Objective: To evaluate interobserver agreement in visual analysis of each cardiotocographic event. Methods: Three experts independently divided 16 antepartum and 17 intrapartum cardiotocograms into baseline segments, accelerations and decelerations, according to the FIGO guidelines. Baseline segments were further classified as having normal, reduced or increased variability and decelerations as early, late and variable. Uterine activity was divided into tonus and contractions. Agreement was assessed by the proportions of agreement (pa) with 95% confidence intervals. Results: Reproducibility in assessment of baseline segments with normal variability, accelerations and uterine activity was acceptable (pa = 0.56–0.71) whereas that of other segments was not (pa = 0.14–0.45). Conclusions: Analysis of most cardiotocographic events is poorly reproducible, even when experts use the FIGO guidelines. This may be explained by some still ambiguous guidelines, by eyeball limitations in evaluation of subtle events, and by the incapacity of busy clinicians to assess complex and multiple cardiotocographic events in a systematic and disciplined fashion.

Variations in policies for management of the third stage of labour and the immediate management of postpartum haemorrhage in Europe

Background  The EUropean Project on obstetric Haemorrhage Reduction: Attitudes, Trial, and Early warning System (EUPHRATES) is a set of five linked projects, the first component of which was a survey of policies for management of the third stage of labour and immediate management of postpartum haemorrhage following vaginal birth in Europe.

Inconsistencies in classification by experts of cardiotocograms and subsequent clinical decision

Inter‐observer agreement in the interpretation according to the FIGO guidelines of 33 cardiotocographic tracings by experts and subsequent clinical decision was evaluated, using the kappa statistic (K) and the proportions of agreement (Pa). Overall agreement in the classification of tracings was fair (K = 0.48) and was better for normal (Pa = 0.62), than for suspicious (Pa = 0.42) or pathologic tracings (Pa = 0.25). Overall agreement on clinical decision was slightly higher (K = 0.59), but mostly was centred on the decision to take ‘no action’ (Pa = 0.79). Experts especially disagreed over the decisions to ‘monitor closely’ (Pa = 0.14) or to ‘intervene immediately’ (Pa = 0.38). These limitations should be taken into account in clinical audits and in medical jurisprudence.

FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography

The purpose of this chapter is to assist in the use and interpretation of intrapartum cardiotocography (CTG), as well as in the clinical management of specific CTG patterns. In the preparation of these guidelines, it has been assumed that all necessary resources, both human and material, required for intrapartum monitoring and clinical management are readily available. Unexpected complications may occur during labor, even in patients without prior evidence of risk, so maternity hospitals need to ensure the presence of trained staff, as well as appropriate facilities and equipment for an expedite delivery (in particular emergency cesarean delivery). CTG monitoring should never be regarded as a substitute for good clinical observation and judgement, or as an excuse for leaving the mother unattended during labor.

Linear and nonlinear fetal heart rate analysis of normal and acidemic fetuses in the minutes preceding delivery

Linear and nonlinear fetal heart rate (FHR) indices, namely mean FHR, interval index (II), very low, low and high frequencies, approximate (ApEn) and sample entropy (SampEn), were computed, immediately before delivery, in the initial and final FHR tracing segments, from 48 normal, 10 mildly acidemic and 10 moderate-to-severely acidemic fetuses. Progression of labor was associated with a significant increase in linear frequency domain indices whereas nonlinear indices were significantly decreased. Moderate-to-severe fetal acidemia was associated with a significant decrease in nonlinear indices. The best discrimination between moderate-to-severe acidemic fetuses and the remaining cases was obtained combining II and ApEn(2,0.15), with a specificity of 71% and a sensitivity of 80%. These findings support the hypothesis of increased autonomic nervous system activity in the final minutes of labor and of decreased central nervous system activity, both in the final minutes of labor and in moderate-to-severe acidemic fetuses.

The limits of agreement and the intraclass correlation coefficient may be inconsistent in the interpretation of agreement.

OBJECTIVE To compare the interpretation of agreement in the prediction of neonatal outcome variables, using the limits of agreement (LA) and the intraclass correlation coefficient (ICC). STUDY DESIGN AND SETTING Three obstetricians were asked to predict neonatal outcomes independently based on the evaluation of intrapartum cardiotocographic tracings. Interobserver agreement was assessed with the LA and the ICC, and the results obtained were interpreted by six clinicians and six statisticians on a scale that established agreement as very poor, poor, fair, good, or very good. RESULTS Interpretation of the LA results was less consensual than the ICC results, with proportions of agreement of 0.36 (95% confidence interval [CI]: 0.28-0.44) vs. 0.63 (95% CI: 0.54-0.73), respectively. LA results suggested a fair to good agreement among obstetricians, whereas interpretation of ICC results suggested a poor to fair agreement. LA results were more plausible with reality, suggesting that obstetricians predicted neonatal outcomes better than randomly generated values, whereas it was not always the case with the ICC. CONCLUSIONS LA and ICC can provide inconsistent results in agreement studies. Accordingly, in the absence of better strategies to assess agreement, both should be used for this purpose, but their results need to be interpreted with caution keeping their respective limitations in mind.

Prediction of neonatal acidemia by computer analysis of fetal heart rate and ST event signals

OBJECTIVE The objective of the study was to evaluate the accuracy of computer analysis of fetal heart rate (FHR) and ST event signals in prediction of neonatal acidemia. STUDY DESIGN One hundred forty-eight FHR tracings were evaluated to identify red alerts provided by the system, based on automated analysis of FHR and ST event signals, and compared with the occurrence of umbilical artery acidemia (pH < or =7.05). RESULTS The presence of red alerts obtained sensitivity of 1.00 (95% confidence interval [CI], 0.56-1.00), specificity of 0.94 (95% CI, 0.89-0.97), positive predictive value (PPV) of 0.47 (95% CI, 0.22-0.72), negative predictive value (NPV) of 1 (95% CI, 0.96-1.00), positive likelihood ratio (PLR) of 17.6 (95% CI, 9.0-34.5), and negative likelihood ratio (NLR) of 0. When limiting analysis to red alerts that did not include ST data, sensitivity was 0.57 (95% CI, 0.20-0.88), specificity was 0.97 (95% CI, 0.92-0.99), PPV was 0.50 (95% CI, 0.17-0.82), NPV was 0.98 (95% CI, 0.93-0.99), PLR was 20.14 (95% CI, 6.3-64.2), and NLR was 0.44 (95% CI, 0.19-1.04). CONCLUSION Computer analysis of FHR and ST event signals provide higher accuracy in predicting neonatal academia.

Maternal Healthcare in Migrants: A Systematic Review

Pregnancy is a period of increased vulnerability for migrant women, and access to healthcare, use and quality of care provided during this period are important aspects to characterize the support provided to this population. A systematic review of the scientific literature contained in the MEDLINE and SCOPUS databases was carried out, searching for population based studies published between 1990 and 2012 and reporting on maternal healthcare in immigrant populations. A total of 854 articles were retrieved and 30 publications met the inclusion criteria, being included in the final evaluation. The majority of studies point to a higher health risk profile in immigrants, with an increased incidence of co-morbidity in some populations, reduced access to health facilities particularly in illegal immigrants, poor communication between women and caregivers, a lower rate of obstetrical interventions, a higher incidence of stillbirth and early neonatal death, an increased risk of maternal death, and a higher incidence of postpartum depression. Incidences vary widely among different population groups. Some migrant populations are at a higher risk of serious complications during pregnancy, for reasons that include reduced access and use of healthcare facilities, as well as less optimal care, resulting in a higher incidence of adverse outcomes. Tackling these problems and achieving equality of care for all is a challenging aim for public healthcare services.

Omniview-SisPorto 3.5 - a central fetal monitoring station with online alerts based on computerized cardiotocogram+ST event analysis.

Visual analysis of cardiotocograms is poorly reproducible and is currently recognized as the main weakness of the STAN methodology. The Omniview-SisPorto 3.5 program is the most recent version of a central monitoring system that provides visual and sound alerts, based on computer analysis of cardiotocographic and ST event features. This paper describes the programs main characteristics and provides an overview of the systems online alerts. Omniview-SisPorto 3.5 is the first central monitoring system to incorporate computerized analysis of cardiotocographic and ST event features, providing health professionals with online alerts for minor and major changes in monitored signals. The system is currently undergoing extensive clinical evaluation.

Twenty-five years after the FIGO guidelines for the use of fetal monitoring: Time for a simplified approach?

Twenty‐five years after the FIGO Workshop that produced the “Guidelines for the use of fetal monitoring,” these remain the only broad international consensus effort in this field. Documents of a similar nature have been produced by national institutions, with subsequent updates of the initial concepts. The 3‐class classification system has now been adopted by all the major guidelines, and while there are numerous similar features, and indeed many ideas were inspired by the FIGO guidelines, many key aspects still lack consensus. Making guidelines simpler and more objective may be an important step to guarantee a wide application and assimilation of the recommendations, as well as an enhanced reproducibility and increased memory retention.