Edwin Chandraharan

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.

The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta

The reported maternal mortality for morbidly adherent placenta ranges from 7% to 10% worldwide. Current treatment modalities for this potentially life‐threatening condition include radical approaches such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re‐implantation (for placenta percreta infiltrating these organs), and conservative measures such as compression sutures with balloon tamponade and the placenta remaining in situ. However, both conservative and radical measures are associated with significant maternal morbidity and mortality. The present article describes the Triple‐P procedure—which involves perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; pelvic devascularization; and placental non‐separation with myometrial excision and reconstruction of the uterine wall—as a safe and effective alternative to conservative management or peripartum hysterectomy.

Use of the "obstetric shock index" as an adjunct in identifying significant blood loss in patients with massive postpartum hemorrhage.

To establish the normal range for the “obstetric shock index” (OSI) after birth and to determine its usefulness as an aid to estimate blood loss in postpartum hemorrhage (PPH).

Outcome of the management of massive postpartum hemorrhage using the algorithm "HEMOSTASIS".

To evaluate whether the algorithm “HEMOSTASIS” (help; establish etiology; massage the uterus; oxytocin infusion and prostaglandins; shift to operating theater; tamponade test; apply compression sutures; systematic pelvic devascularization; interventional radiology; subtotal/total abdominal hysterectomy) was of value in the systematic management of postpartum hemorrhage (PPH).

Misidentification of maternal heart rate as fetal on cardiotocography during the second stage of labor: the role of the fetal electrocardiograph

Objective: To identify the incidence of fetal heart rate (FHR) accelerations in the second stage of labor and the role of fetal electrocardiograph (ECG) in avoiding misidentification of maternal heart rate (MHR) as FHR. Design: Retrospective observational study. Setting: University hospital labor ward, London, UK. Sample: Cardiotocograph (CTG) tracings of 100 fetuses monitored using external transducers and internal scalp electrodes. Methods: CTG traces that fulfilled inclusion criteria were selected from an electronic FHR monitoring database. Main outcome measures: Rate of accelerations during external and internal monitoring as well as decelerations for a period of 60 minutes prior to delivery were determined. The role of fetal ECG in differentiating between MHR and FHR trace was explored. Results: Decelerations occurred in 89% of CTG traces during the second stage of labor. Accelerations indicating possible recording of FHR or MHR were found in 28.1 and 10.9% of cases recorded by an external ultrasound transducer as well as internal scalp electrode, respectively. Accelerations coinciding with uterine contractions occurred only in 11.7 and 4% of external and internal recording of FHR, respectively. Absence of ‘p‐wave’ of the ECG waveform was associated with MHR trace. Conclusion: Decelerations were the commonest CTG feature during the second stage of labor. The incidence of accelerations coinciding with uterine contractions was less than half in fetuses monitored using a fetal scalp electrode. Analysing the ECG waveform for the absence of ‘p‐wave’ helps in differentiating MHR from FHR.

FIGO consensus guidelines on placenta accreta spectrum disorders: Conservative management,

1Department of Obstetrics and Gynecology, Bordeaux University Hospital, Bordeaux, France 2Department of Obstetrics and Gynecology, Trousseau Hospital AP-HP, Paris, France 3Department of Obstetrics and Gynecology, St George’s University Hospitals NHS Foundation Trust, London, UK 4Department of Obstetrics and Gynecology, CEMIC University Hospital, Buenos Aires, Argentina 5EGA Institute for Women’s Health, Faculty of Population Health Sciences, University College London, London, UK

Fetal scalp blood sampling should be abandoned: FOR: FBS does not fulfil the principle of first do no harm

EDWIN CHANDRAHARAN, LEAD CONSULTANT LABOUR WARD, ST GEORGE’S UNIVERSITY HOSPITALS NHS FOUNDATION TRUST, LONDON, UK ....................................................................................................................................................................... F scalp blood sampling (FBS) was developed as a complementary test to a Pinard’s stethoscope in 1962 by Erich Saling, 6 years before the introduction of the cardiotocograph (CTG) into clinical practice. Unfortunately, no randomised controlled trials were performed to determine its presumed efficacy in improving perinatal outcomes or reducing operative interventions during labour. The normal values currently used were obtained by sampling only 77 fetuses and therefore, they are not scientifically valid. Not only the area of the scalp sampled is least vascular, and so has been shown to be useless in determining fetal oxygenation (O’Connor et al. Lancet 1979:314;8149), results are also affected by caput and moulding. Due to centralisation of the blood during hypoxic stress, from a physiological point of view, it is nonsensical to sample a peripheral tissue (scalp). As in adults, only an arterial blood sample and not a capillary blood sample should be taken to estimate the pH. Contamination with the alkaline amniotic fluid or meconium (bile acids) can alter the results leading to false reassurance or unnecessary interventions, respectively. In addition, significant differences were observed from two scalp blood samples taken from the same fetus at the same time (O’Brien et al. Eur J Obstet Gynecol Reprod Biol 2013;167:142– 5).

Should national guidelines continue to recommend fetal scalp blood sampling during labor

Abstract Intrapartum fetal scalp blood sampling (FBS) (pH or lactate) has not been shown to reduce emergency cesarean sections or operative vaginal births or improve long-term perinatal outcomes. In contrast, it is associated with rare but potentially very serious complications such as leakage of cerebro-spinal fluid (CSF) and perinatal hemorrhagic shock. Therefore, it does not fulfill the “First Do No Harm” principle and its use during labor should be critically re-evaluated.

Fetal scalp blood sampling during labor: an appraisal of the physiological basis and scientific evidence

Fetal cardiotocography is characterized by low specificity; therefore, in an attempt to ensure fetal well‐being, fetal scalp blood sampling has been recommended by most obstetric societies in the case of a non‐reassuring cardiotocography. The scientific agreement on the evidence for using fetal scalp blood sampling to decrease the rate of operative delivery for fetal distress is ambiguous. Based on the same studies, a Cochrane review states that fetal scalp blood sampling increases the rate of instrumental delivery while decreasing neonatal acidosis, whereas the National Institute of Health and Clinical Excellence guideline considers that fetal scalp blood sampling decreases instrumental delivery without differences in other outcome variables. The fetal scalp is supplied by vessels outside the skull below the level of the cranial vault, which is likely to be compressed during contractions. The self‐regulated redistribution of oxygenated blood from peripheral to central organs causes peripheral ischemia, thus theoretically bringing into question the scalp capillary bed as representative of the central circulation.

Safety of vaginal delivery among dichorionic diamniotic twins over 10 years in a UK teaching hospital

To determine whether vaginal delivery among dichorionic diamniotic twins remains a safe option following full implementation of the European Working Time Directive in the UK.