Introduction: There are more deliveries in India than any country in the world, according to World Health Report. Review of seven articles published in The Journal of Obstetrics and Gynecology of India suggests that the perinatal mortality (PNM) in the country is 92/1,000 (16,339/177,998) births and the cause is asphyxia in about one fourth of the cases.
Methods: We reviewed the evidencebased guidelines on intrapartum fetal surveillance from four countries (UK, USA, Canada, and Australia/New Zealand).
Results: Overall there were 72 recommendations and whether they were level A, B, C, or D varied significantly (p=0.021) for the four national guidelines. The composite summary of these recommendations indicates that no single guideline is comprehensive, the composite may be better than any singular.
Conclusion: Each country needs its own recommendations to ameliorate the PNM. Accounting for the varied setting childbirths occurring in the country, a national guideline for clinicians in India may decrease the PNM secondary to asphyxia.
Keywords : intrapartum, fetal, surveillance, national, guidelines
According to the World Health Report 2005, there are more live births (25 million/year) in India than in any other country, including China (19 million/year).Comparing China to India, the stillbirth rate (19 vs. 39/1,000 births, respectively), death of newborn ≤1 week (16 vs. 33/1,000 births), and ≤4 weeks (21 vs. 43/1,000 births) of birth rates are twice as high in India1. Incontestably, there are numerous, complex, and unavoidable reasons for the higher mortality in India, but we sought a two-step explanation that might ameliorate the perinatal outcome.
First, we reviewed every obstetric publication in The
Journal of Obstetrics and Gynecology of India that
appeared between 2000 and 2006 and available at their
web site. Such a review provided us with the potential
causes for the perinatal mortality (PNM) in India. Since there are no national guidelines in India regarding
intrapartum surveillance of fetus, we appraised the
national guidelines2,3,4,5 from four countries to provide a
simplified starting point for possible endeavors.
From the official website (http://www.journal-obgynindia.com/index.htm), we were able to print 321 obstetric articles that were published over 7 years. Review of these publications was notable for seven publications6,7,8,9,10,11,12 that focused on the rate as well as the causes of the PNM (Table 1). The cohorts of the seven articles gave birth to their children between 1991 and 2002. The authors reviewed their institution’s data for the preceding 1 to 10 years. These publications described their experience from 2,000 to 70, 000 deliveries. The stillbirth rate varied from 22 to 74/1,000 deliveries, with an overall rate of 59/1,000 (10,531/177,998); the corresponding numbers for the PNM were from 56 to 107/1,000, with an overall rate of 92/1,000 (16,339/177,998). It does not seem that adverse outcome decreased with later publications, suggestive that these outcomes did not improve recently. Asphyxia as the cause of the PNM varied from 3 to 44%, with an overall rate of 28%.
Admittedly, these seven publications merely suggest the
rate and causes of the PNM in India and that a national
survey or a multicenter study would provide a more
accurate assessment of the likelihood and the etiology of
these deaths. Meanwhile, it could be beneficial to
determine how clinicians could decrease asphyxia as the
potential etiology of PNM in India.
Evidence-Based Guidelines
American College of Obstetrician and Gynecologists (ACOG) practice bulletins are one of the most influential publications for clinicians involved with childbirth in the USA13. These evidence-based guidelines are the results of reviews of all publications in English language on the topic, objective evaluation of each reference, and a condensed synthesis of recommendations from the literature. These suggestions are categorized as levels A, B, C, D, and E (Table 2). The stated purpose of these guidelines is to optimize the outcomes, decrease the costs of healthcare, and diminish the potential liability13.
Interestingly, there are guidelines on intrapartum fetal evaluation from Australia, Canada, and UK. Although they were published in different years and did not use identical references, these guidelines are similar in that they are evidence-based synthesis from English language articles, with the stated purpose of improving outcomes. Thus, it seems reasonable to review these four national guidelines to determine the similarities and differences and to allow national societies of other countries adopt these recommendations to the unique situations of childbirth in their country.
Four National Guidelines on Intrapartum
Fetal Surveillance
While ACOG had six recommendations on the topic,
Australian New Zealand College of Obstetricians and
Gynecologists (Royal ANZCOG) had 13, Royal College
of Obstetricians and Gynecologists (RCOG) 16, and
Society of Obstetricians and Gynecologists of Canada
(SOGC) 37. Chi square test for trend indicates that
among the 72 recommendations from these organizations, the types of recommendations varied
significantly (p=0.021; Fig. 1). Since simple tabulation of
the recommendations is not very useful clinically, we
synthesized them by segregating them into 13
categories—competency, equip-ment, prenatal course,
admission for labor, continuous vs. intermittent
auscultation, nonreassuring fetal heart rate (FHR), fetal
blood sampling, expedited delivery, operative delivery,
umbilical arterial/venous pH, adverse outcomes, audit
and risk management, and future technology.
Competency
Of the 72 recommendations, 8 (11%) focused on the competency of providers and all of them were level C. One of these eight suggestions was from RANZCOG and the rest from RCOG. They indicate that it is the institute’s responsibility that healthcare providers have an understanding not only of maternalfetal pathophysiology, but also have competence in the various intrapartum surveillance methods (RANZCOG). RCOG suggestions include an awareness of chain of command when an abnormal FHR is noted, common terminology to be used, and annual training for healthcare providers. This training should be provided by the trusts, not the providers, and should focus on intermittent auscultation (IA), electronic fetal monitoring (EFM), and how to document and store the ACOG, American College of Obstetricians and Gynecologists; RAZCOG, Royal Australian New Zealand College of Obstetricians and Gynaecologists; RCOG, Royal College of Obstetrician and Gynaecologists; SOGC, Society of Obstetrics and Gynaecologists of Canada.
information. It is noteworthy that neither ACOG nor
SOGC made any recommendations on this topic.
Equipment
Regarding equipment, both RANZCOG and SOGC had one level C recommendation and they focused on the paper speed during EFM. The national society in Australia and New Zealand specified the speed to be 1cm/min in both countries because many health professionals move between the two countries. They acknowledge that one paper speed is not superior to another. SOGC, on the other hand, suggests that all clinicians be aware of the paper speed, so as to avoid misinterpretation. The Canadian society does not suggest a uniform paper speed. RCOG and ACOG do not have any recommendations regarding EFM equipment.
Prenatal Course
There were two level C recommendations, one each from RANZCOG and RCOG, which suggest that prior to presenting in labor, patients should be informed about the two techniques to monitor fetuses during labor. While RANZCOG specifies that during the prenatal course patients should have information about IA and EFM, RCOG encourages clinicians to provide women with evidence-based information so they can make informed decisions.
Upon Admission
Once the parturient is admitted, there were five recommendations that are applicable. SOGC specifies that in active labor, women receive continuous, close oneto-one support and this is categorized as a level A recommendation. RCOG suggests that prior to starting any type of monitoring, maternal and fetal pulse should be palpated simultaneously so the two can be differentiated (level C). RANZCOG, SOGC, and RCOG indicate that there is insufficient evidence about the usefulness of fetal admission testing with cardiotocography (CTG) in lowrisk women. RANZCOG acknowledges that admission tests may have potential minor benefit but are linked to an increase in minor intervention (level B). RCOG simply does not support the role of admission tests and considers this to be a level B recommendation. Lastly, SOGC considers that there is insufficient information about admission tests and further research needs to be done on the topic (level C).
IA versus EFM
Of the 72 recommendations in the four guidelines, 29% (21) focused on the two methods of monitoring the fetus during labor. To begin with, RCOG notes that regardless of the technique selected to assess fetal well-being, the same level of care should be provided (level C). RANZCOG specifies that at least one of these techniques should be used for fetal surveillance with all admissions (level C).
For low-risk or healthy parturients, IA is recommended by RCOG, RANZCOG, and SOGC. It is notable that this is one of the few times three different national organizations made similar recommendations and categorized it as level A. Though the three guidelines do not define what a low-risk patient is, they do provide the indications for EFM. Thus, we can infer what patient can be monitored with IA.
The recommendations describe the nuances of IA. To begin with, IA should be done with audible Doppler and not a Pinard stethoscope (level A by RANZCOG). The auscultation episode should commence toward the end of a contraction and continue for ≤30 seconds after the contraction has finished. FHR should be auscultated at least every 15-30 minutes in the active phase of the first stage of labor, at least every 5 minutes in the second stage of labor, and toward the end for ≤30 seconds after each contraction during active pushing in the second stage of labor. Interestingly, while RANCOG and RCOG agree on how frequently IA should be done, they classify it as level C and A, respectively.
If intrapartum complications occur in a low-risk patient, it should be documented contemporaneously in the maternal notes, signed, the time noted (level C, RCOG), and to ensure fetal well-being, EFM utilized (level B, RANZCOG). IA should also be abandoned if the baseline is <100 bpm or >160 bpm or if there is evidence on auscultation of any decelerations (level A, RCOG). All four national guidelines recommend that for highrisk parturients, EFM should be used (level B for ACOG, RANZCOG, RCOG, and level C for SOGC). Antepartum and intrapartum risk factors that require EFM are listed in Table 3 and are composite of suggestions by RANZCOG, RCOG, and SOGC. ACOG does not specify the indications for EFM. Pregnancies at risk for neonatal death, cerebral palsy, or neonatal encephalopathy should be monitored by EFM (level C, SOGC).
These guidelines also suggest that the timing of EFM patterns should be determined in association with uterine contractions. The contraction frequency, duration, intensity, and resting tone should be assessed and documented. Abdominal palpation, a tocodynamometer, or an intrauterine pressure catheter may be used to facilitate the assessment (level C, SOGC). To optimize outcomes, practitioners should use standard terminology when describing fetal heart characteristics of an EFM record (level C, SOGC). The frequency of reviewing the EFM records is every 15 minutes in the active phase of labor and at least every 5 minutes in the second stage of labor (level C SOGC).
Lastly, it should be noted that RCOG provides detailed level suggestions about utilizing EFM and what they should include. The inclusions are as follows: conduct of EFM; date and time clocks on the EFM machine; tracing labeled with the mother’s name, date, and hospital number; intrapartum events that may affect the FHR noted contemporaneously on the EFM tracing, signed, dated, and timed (e.g., vaginal examination, fetal blood sample, sitting for an epidural); any member of the staff asked to provide an opinion on a tracing noting their findings on both the tracing and maternal case notes, together with date, time, and signature; following the birth, caregiver note signed with the date, time, and mode of birth on the EFM tracing; and the EFM tracing should be stored securely with the maternal notes at the end of the monitoring process.
Nonreassuring FHR
There are seven recommendations on the management of nonreassuring FHR and most (71%; 5/7) are level A. If FHR is considered to be abnormal with IA, EFM, scalp pH or delivery should be considered (level A, SOGC). When the FHR pattern is considered abnormal, immediate management includes identification of reversible causes of the abnormality, initiation of appropriate action—correction of maternal hypotension, cessation of oxytocin and/or tocolytics, and initiation or maintenance of continuous EFM. If FHR abnormalities persist, consider delivery. These are level A recommendation by RANZCOG.
For recurrent variable decelerations, amnioinfusion should be considered because it decreases the rate of emergency cesarean delivery (level A, ACOG). In the presence of abnormal FHR patterns and uterine hypercontractility (not secondary to oxytocin infusion) tocolytics should be considered. A suggested regimen is subcutaneous terbutaline 0.25 mg (level A, RCOG).
The two level B recommendations from RCOG are:
during the episodes of abnormal FHR patterns, when the
mother is lying supine, she should adopt the left-lateral
position, and in cases of hypercontractility in association
with oxytocin infusion and with suspicious or
pathological CTG, the oxytocin infusion should be
decreased or discontinued.
Expedited Delivery
There are two recommendations regarding the conditions that should prompt expedited delivery—one from RANCOG, which is level B, and from RCOG, which is level A. The recommendation from Australia and New Zealand states that delivery should be expedited if significant acidosis is suspected or there is clear evidence of serous fetal compromise, or CTG abnormalities are of a degree requiring further assessment, but FBS is contraindicated, clinically inappropriate, or not feasible. The recommendation in the UK is that in cases of suspected or confirmed acute fetal compromise, delivery should be accomplished as soon as possible, accounting for the severity of FHR abnormality and relevant maternal factors. The accepted standard has been that, ideally, this should be accomplished ≤30 minutes. Neither SOGC nor ACOG make any recommendations on this topic.
Operative delivery
There is only recommendation on this topic and it does not focus on the indication or the manner on how to conduct it. The level A recommendation by ACOG is that use of EFM is linked with operative delivery, which includes not only vaginal but also cesarean.
Umbilical acid-base analysis
The two recommendations on this topic are from RCOG, who suggest that acid-base status should be analyzed from the umbilical artery as well as vein (level B). Although the samples can be analyzed in other situations, they should be obtained when emergency cesarean section is performed, instrumental vaginal delivery is performed, a fetal blood sample has been performed in labor, or if the condition at birth is poor (level C).
Adverse outcomes—Cerebral palsy and neonatal death
Since the purpose of the intrapartum surveillance is to avoid these two adverse outcomes, it is interesting to note that there are five recommendations, two (40%) of which are level A. The false rate of EFM for predicting adverse outcomes is high, and the use of EFM does not result in a reduction of cerebral palsy rates. Both of these recommendations are level A and from ACOG. The reinterpretation of FHR tracing, when aware of the neonatal outcome, is not reliable (level B, ACOG).
As alluded to previously, continuous intrapartum EFM is
recommended for pregnancies when there is increased
risk of perinatal death, cerebral palsy, or neonatal
encephalopathy (level C, SOGC and level B, RCOG).
Lastly, if fetal death is suspected despite the presence of
an apparently recordable FHR, then fetal viability should
be confirmed with real-time ultrasound assessment (level
C, RCOG).
Audit and risk management
Neither ACOG nor SOGC provide recommendations but the other two national societies do. All health professionals should participate in regular multidisciplinary clinical audits focusing on maternal and perinatal outcomes in relation to intrapartum fetal surveillance (level C, RANZCOG). RCOG describes the absolute outcome measures of fetal/neonatal hypoxia to be collected at a local and regional level: perinatal deaths, cerebral palsy, and neurodevelopmental disability (level B, RCOG). The intermediate fetal/neonatal measures of fetal hypoxia to be collected should be umbilical artery acid-base status, Apgar score at 5 minutes, and neonatal encephalopathy (level B, RCOG). The maternal outcome measures that should be collected include the rates of operative vaginal and cesarean deliveries (level C, RCOG). Additionally, RCOG recommends that a tracer system should be developed to ensure that CTG removed for any purpose (e.g., risk management, teaching purpose) can always be located (level C). Lastly, EFM traces should be kept for ≥25 years (level C, RCOG).
Future technology
Only SOGC made any recommendations about the role
of newer technology in intrapartum surveillance.
According to them the use of computer-based
algorithms alone to interpret FHR patterns is not
recommended as a standard of care at the present time
(level D). The fetal pulse oximetry as an adjunct to EFM
in patients with nonreassuring FHR status is also not
recommended as a standard of care at the present time.
Moreover, near-infrared spectroscopy as an adjunct to
EFM is currently not recommended as there is
insufficient evidence to assess its efficacy in fetal
surveillance. Although all three of these are level D
recommendations, SOGC considers not using ST
waveform analysis technology as a standard of care at
this time as a level C recommendation.
Further study on pulse oximetry, ST waveform analysis,
and near-infrared technology in clinical research
settings is encouraged by SOGC and this is a level B
recommendation
