Håkan Lilja

Cardiotocography only versus cardiotocography plus ST analysis of fetal electrocardiogram for intrapartum fetal monitoring: a Swedish randomised controlled trial

BACKGROUND Previous studies indicate that analysis of the ST waveform of the fetal electrocardiogram provides information on the fetal response to hypoxia. We did a multicentre randomised controlled trial to test the hypothesis that intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis results in an improved perinatal outcome compared with cardiotocography alone. METHODS At three Swedish labour wards, 4966 women with term fetuses in the cephalic presentation entered the trial during labour after a clinical decision had been made to apply a fetal scalp electrode for internal cardiotocography. They were randomly assigned monitoring with cardiotocography plus ST analysis (CTG+ST group) or cardiotocography only (CTG group). The main outcome measure was rate of umbilical-artery metabolic acidosis (pH <7.05 and base deficit >12 mmol/L). Secondary outcomes included operative delivery for fetal distress. Results were first analysed according to intention to treat, and secondly after exclusion of cases with severe malformations or with inadequate monitoring. FINDINGS The CTG+ST group showed significantly lower rates of umbilical-artery metabolic acidosis than the cardiotocography group (15 of 2159 [0.7%] vs 31 of 2079 [2%], relative risk 0.47 [95% CI 0.25-0.86], p=0.02) and of operative delivery for fetal distress (193 of 2519 [8%] vs 227 of 2447 [9%], 0.83 [0.69-0.99], p=0.047) when all cases were included according to intention to treat. The differences were more pronounced after exclusion of 291 in the CTG+ST group and 283 in the CTG group with malformations or inadequate recording. INTERPRETATION Intrapartum monitoring with cardiotocography combined with automatic ST-waveform analysis increases the ability of obstetricians to identify fetal hypoxia and to intervene more appropriately, resulting in an improved perinatal outcome.

Levels of dimethylarginines and cytokines in mild and severe preeclampsia

Background. The objectives were 1. to evaluate if the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine was altered in mild and severe forms of preeclampsia, and 2. to assess the relationship between dimethylarginines and the cytokine response in preeclampsia.

Changes in the ST waveform of the fetal lamb electrocardiogram with hypoxemia

The ST waveform of the fetal electrocardiogram (ECG) was examined in 10 chronically instrumented fetal lambs from 115 days to term. Averaged ST waveforms were plotted at 5-minute intervals in six fetuses for 2 to 22 days. No diurnal or other rhythms were seen. To correct for changes in signal gain the amplitude of the T wave was measured relative to the amplitude of the QRS complex. The T/QRS ratio was normally less than 0.30. Persistently elevated ST waveforms with a T/QRS range 0.32 to 0.65 preceded fetal death by some days in three fetuses and were associated with anemia and/or hypotension in a further three. In these animals hypoxia produced a further rise in the ST waveform (mean T/QRS, from 0.48 to 0.81) and all died during labor. In lambs with a normal ST waveform there were differences in the response to hypoxia over 1 hour for a similar fall in PO2. In eight experiments the ST segment and T wave increased (mean T/QRS, from 0.17 to 0.59) and promptly reverted to normal with normoxia. There was a significant rise in mean arterial blood pressure, plasma lactate, and glucose and a fall in pH. In four experiments there was little change (mean T/QRS, from 0.19 to 0.25), with a small rise in plasma lactate suggesting that these lambs were able to maintain aerobic myocardial metabolism. Overall there was a strong correlation of the T/QRS ratio to the rate of rise of lactate. These findings complement previous results in the acute fetal lamb preparation and suggest that ST waveform elevation expressed as the T/QRS ratio identifies a change to anerobic myocardial metabolism.

Monocyte chemotactic protein-1 in cervical and amniotic fluid: relationship to microbial invasion of the amniotic cavity, intra-amniotic inflammation, and preterm delivery ☆

OBJECTIVE The purpose of this study was to evaluate the role of monocyte chemotactic protein-1 in cervical and amniotic fluid in women in preterm labor and with preterm premature rupture of membranes. STUDY DESIGN Women with singleton pregnancies (<or=34 weeks) in preterm labor (n=75 women), with preterm premature rupture of membranes (n=47 women), and at term (n=45 women) who were undergoing elective cesarean delivery were included. Cervical and amniotic fluid were sampled. RESULTS Monocyte chemotactic protein-1 in cervical and amniotic fluid was higher in women in preterm labor than in women at term. Cervical monocyte chemotactic protein-1 in women in preterm labor was associated with microbial invasion of the amniotic cavity, intra-amniotic inflammation, delivery within 7 days, and at <or=34 weeks. Amniotic monocyte chemotactic protein-1 correlated to microbial invasion of the amniotic cavity in women with preterm premature rupture of membranes, intra-amniotic inflammation in preterm labor, preterm premature rupture of membranes, delivery within 7 days, and delivery at <or=34 weeks in women in preterm labor. CONCLUSION Monocyte chemotactic protein-1 in cervical and amniotic fluid levels are elevated in preterm labor and preterm premature rupture of membranes and correlate to intra-amniotic infection/inflammation.

Risk factors for obstetric brachial plexus palsy among neonates delivered by vacuum extraction.

OBJECTIVE: The risk of obstetric brachial plexus palsy (OBPP) is increased in infants delivered instrumentally. The aim of this study was to identify risk factors for OBPP and to evaluate the association between possible risk factors linked to the duration of the vacuum extraction procedure and the subsequent risk. METHODS: A population-based retrospective design was adopted. Using a national registry of operative vaginal deliveries linked to the Medical Birth Registry in Sweden, we evaluated by univariate and multiple logistic regression analyses the risk factors for OBPP in 13,716 women delivered by vacuum extraction. The variables assessed in the multiple logistic regression analysis were shoulder dystocia, fetal birth weight of 3,999 g or greater, fundal pressure, number of tractions, vacuum application time, parity, vacuum silicone cup, epidural anesthesia, and fetal head at the level of the ischial spines at vacuum application time. RESULTS: Obstetric brachial plexus palsy was recorded in 153 (1.1%) infants. The following variables increased significantly the risk of OBPP in the newborn: shoulder dystocia (odds ratio 16.0; 95% confidence interval 8.9–28.7), fetal birth weight of 3,999 g or greater (7.1; 4.8–10.5), and administration of fundal pressure (1.6; 1.1–2.3). The probability of the risk of OBPP in vacuum-assisted deliveries increased in relation to vacuum extraction time (minutes). CONCLUSION: Shoulder dystocia in the setting of vacuum extraction is a prominent risk factor for OBPP in the newborn. The risk of OBPP increases with the time required for vacuum extraction. LEVEL OF EVIDENCE: II-3

Decision-making about unwanted pregnancy.

BACKGROUND The aim of the study was to focus on aspects of the decision-making process among women having first and repeat abortion, in comparison with women continuing their pregnancies with or without having experienced abortions. METHODS In a study of 401 pregnant women, (simple random sample) 20-29 years of age, 137 having first abortion (A1), 64 repeat abortion (A2), 142 continuing their pregnancies with no experience of abortion (B1) and 58 continuing, having experienced abortion(s) (B2), were given a questionnaire and were interviewed. RESULTS The pregnancy evoked ambivalent feelings in all groups. One third of the women in the A-groups and about 25% of those in the B-groups had ambivalent feelings. More than half of the women decided to have an abortion upon first finding out they were pregnant, and after a few weeks of thought most of them had decided to have the abortion. More than half of the women having an abortion said it was rather or very difficult to make a decision. Among these subjects, women having had contact with social services found it significantly harder to make this decision. A majority agreed with their partners on having an abortion. A majority did not feel influenced by someone else when deciding about the abortion. However, 10% in the A1-group and 6% in the A2-group felt much or comparatively much influenced by someone else. CONCLUSIONS Counselling seems to be important among a considerable number of women finding it hard to make a decision about abortion. Special attention is required for women feeling influenced by someone else and/or having pronounced social problems.

A comparison of high- versus low-intensity, high-frequency transcutaneous electric nerve stimulation for painful postpartum uterine contractions

Background. Breast‐feeding in the postpartum period is known to induce intense uterine contractions with pain in the lower abdomen. Aims. The primary aim of this study was to compare the effects of high and low intensity, high frequency Transcutaneous Electric Nerve Stimulation (TENS) on pain and discomfort of postpartum uterine contractions. The secondary aim was to evaluate discomfort experienced from the stimulation itself. Methods. Twenty‐one newly delivered women participated in this single‐blind trial, 12 women received high intensity, high‐frequency TENS (HI TENS) and 9 women received low intensity, high‐frequency TENS (LI TENS). The electrodes were placed abdominally on each side of the uterus. Stimulation was done during one minute. Visual analogue scales were used to evaluate the intensity of the pain before and after stimulation. A verbal scale was used to estimate sensation of discomfort before, during and after stimulation. Results. The median decrease in pain ratings before and after treatment by VAS was larger in the HI TENS group −49mm (95% CI −66.5– − 33.2) than in the LI TENS group −21mm (95% CI −39.0– − 20.0). The reduction of pain was most pronounced in the HI TENS group (median difference 28 (95% CI was 14.0–53.0). Furthermore, the HI TENS group experienced significantly less discomfort of the uterine contractions after stimulation (p < 0.01) but they also experienced more discomfort of the stimulation than women in the LI TENS group (p < 0.01). Conclusion. The women treated with HI TENS, experienced significantly less postpartum pain and discomfort to those treated with LI TENS even though the discomfort from the stimulation with HI TENS was greater.

Identification of latent phase factors associated with active labor duration in low-risk nulliparous women with spontaneous contractions.

Objective. The aim of this prospective study was to identify latent phase predictors of active labor duration. Design. Prospective clinical study. Setting. Two delivery units in Sweden. Sample. Healthy nulliparous women with a normal pregnancy, spontaneous onset of active labor at term, and a cervical dilatation of 4 cm or more on admission to the delivery ward (n = 2,072). Methods. The women were asked to answer questions concerning their food and fluid intake, amount of rest and sleep during the preceding 24 hours and to assess their labor pain, sense of security and expectations of the childbirth on a visual analog scale (VAS). Duration and intervals of contractions, cervical dilatation, and position of the fetal head were noted by the midwife. A multiple regression analysis was performed with active labor duration as the outcome variable. Main outcome measure. Predictive factors of active labor duration. Results. Normal food intake during the preceding 24 hours was associated with short labor duration. A long latent phase, low levels of assessed labor pain and few hours of rest and sleep during the preceding 24 hours were significant independent predictors of extended active labor duration, when high birth weight, long contraction intervals, slight cervical dilatation, intact membranes within 2 hours of admission, high maternal age and malposition of the fetal head were controlled for. Conclusion. New findings are that latent phase duration as well as food intake and the amount of rest and sleep during the preceding 24 hours are independent predictors of labor duration.

Women's experiences after early versus postponed oxytocin treatment of slow progress in first childbirth--a randomized controlled trial.

OBJECTIVE The aim was to compare the childbirth experiences of primiparous women with slow labour progress who had received early versus postponed oxytocin augmentation. METHODS The population included healthy primiparous women with slow labour progress after a normal pregnancy and spontaneous onset of active labour at term who had taken part in a randomized controlled trial at two delivery units in Sweden comparing early versus postponed oxytocin augmentation. A total of 536 women were sent the Childbirth Experience Questionnaire (CEQ) one month postpartum. The 22-item questionnaire assesses four domains of the childbirth experience. Main outcomes were the four domains of the CEQ: Own capacity, Professional support, Perceived safety and Participation. RESULTS There were no significant differences between the women in the early and expectant oxytocin treatment groups in any of the four domains; however, operative births were associated with significantly worse childbirth experiences. Almost every third woman in both groups had negative and depressing memories from the childbirth process. CONCLUSIONS Early oxytocin augmentation for slow labour progress does not appear to be more beneficial than expectant management regarding womens perceptions of childbirth one month postpartum. Given the risks for the foetus associated with oxytocin treatment, prudent expectant management seems to be a safe and viable alternative.