Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography （CTG） has been a major driv...Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography （CTG） has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about signifcant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [defnitions of fetal heart rate （FHR） parameters, CTG recording speed, 3-tier systems, etc .] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefning the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography （ECG） is discussed. The FHR decelerations are often deterministic （center-stage） in CTG interpretation and 3-tier categorization. It is discussed if their scientifc and physiological classifcation （avoiding framing and confirmation biases） may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG （STAN） have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable （overcome human factors） and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often diffcult and resource-intensive.展开更多
Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a ...Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system(CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specifi c period of time. The resulting profi le provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus(DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.展开更多
Approximately 303,000 women die annually while giving birth, worldwide, and more than 99% of the deaths occur in developing countries. In Zambia, a developing country situated in sub-Saharan Africa, most of the matern...Approximately 303,000 women die annually while giving birth, worldwide, and more than 99% of the deaths occur in developing countries. In Zambia, a developing country situated in sub-Saharan Africa, most of the maternal mortalities occur during the intrapartum and immediate postpartum periods, arising from postpartum hemorrhage, sepsis, obstructed labor, and hypertensive disorders. <span style="font-family:Verdana;">Aim:<span style="font-family:Verdana;"> The aim of this study was to assess the quality of intrapartum services provided in health facilities in the country. <span style="font-family:Verdana;">Methodology:<span style="font-family:Verdana;"> Guided by a descriptive <span style="font-family:Verdana;">cross sectional<span style="font-family:Verdana;"> design, data were collected from 264 women in labor using a World Health Organization validated observation checklist. Convenience sampling was used to recruit the women, while multistage sampling was used to select four health facilities. The Social Package for Social Sciences, version 23 was used to analyze the data. <span style="font-family:Verdana;">Results:<span style="font-family:Verdana;"> One health facility met the World Health Organization 80% minimum standard in four out of the five categories used to measure quality in intrapartum care, while the other three met the minimum standard in one category each. <span style="font-family:Verdana;">Conclusion:<span style="font-family:Verdana;"> Low numbers of midwives, inadequate supplies <span style="font-family:Verdana;">and<span style="font-family:Verdana;"> equipment were major obstacles to following national and international agreed standards for providing optimal care during <span style="font-family:Verdana;">intrapartum<span style="font-family:Verdana;"> period. <span style="font-family:Verdana;">Recommendations:<span style="font-family:Verdana;"> There is <span style="font-family:Verdana;">need<span style="font-family:Verdana;"> for local and national stakeholders in Zambia to urgently address the structural barriers that were observed, as well as invest in sufficient numbers of adequately trained and motivated midwives.展开更多
The anesthesia ex utero intrapartum treatment (EXIT) procedure is a specialized surgical procedure used to deliver babies who have airway compression due to cystic adenomatoid malformation, bronchopulmonary sequestrat...The anesthesia ex utero intrapartum treatment (EXIT) procedure is a specialized surgical procedure used to deliver babies who have airway compression due to cystic adenomatoid malformation, bronchopulmonary sequestration, cervical teratomas, or other congenital conditions. EXIT is erroneously known as a routine cesarean section (CS), but is rather an extension of CS with discernible differences. The procedure creates an opening in the anesthetized abdomen of the mother and uterus. Once EXIT is complete, the remainder of the CS proceeds. EXIT is much more complex than a routine CS, as it requires coordination between the mother and a multidisciplinary team of surgical and neonatal personnel. This review highlights current anesthetic concepts during the EXIT procedure.展开更多
Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates ...Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.展开更多
Aim&objective The diagnosis of foetal distress in a clinical setting is based on foetal cardiotocography findings during labour.This study aims to analyse the total deceleration area(TDA)on intrapartum cardiotocog...Aim&objective The diagnosis of foetal distress in a clinical setting is based on foetal cardiotocography findings during labour.This study aims to analyse the total deceleration area(TDA)on intrapartum cardiotocogram which will predict neonatal acidemia at bith.Materials&methods The study participants included women in labour having intrapartum foetal distress(National Institute of Child Halth and Human Development criteria category II and persistent category II on cardiotocogram),who had the 30-min traces(prior to delivery/decision to delivery)and foetal umbilical cord blood gas analysis at delivery.The TDA was calculated and analysed against the cord blood pH obtained at delivery.The deceleration area is calculated as the width of the widest aspect of deceleration(below baseline)measured in minutes which is multiplied by the maximum depth below the baseline and divided by two.TDA is the summation of all the deceleration areas in the last 30 min before delivery.Results A total of 168 participants were analysed.There were 42 cases and 146 controls in the study.The mean TDA in the case and control group was 254.62 missed beats and 165 missed beats,respectively.It was observed that an intrapartum TDA of 2195 missed beats was associated with neonatal acidemia at birth and with an area under curve of 0.6576(95%CI 0.5305 to 0.7847)with a positive predictive value of 83.78%.Conclusion In this study,an intrapartum TDA of≥195 missed beats was significantly associated with neonatal acidemia at birth.The calculation of TDA has simplified intrapartum foetal monitoring.展开更多
INTRODUCTION The incidence of fetal cardiac tumor was about 0.14% as determined by fetal echocardiography. It was extremely difficult to deal with the fetus when the severe circulatory instability was induced by a car...INTRODUCTION The incidence of fetal cardiac tumor was about 0.14% as determined by fetal echocardiography. It was extremely difficult to deal with the fetus when the severe circulatory instability was induced by a cardiac tumor in the womb. It was reported that ex utero intrapartum treatment （EXIT） procedure solved the problems of fetal airway or pulmonary lesion during delivery to avoid hypoxia after birth. The goal of EXIT is to maintain placental circulation while steps are taken to optimize the transition of the baby from fetal to neonatal life. This study introduced the experience of EXIT procedure to solve the problems of fetal circulation induced by a fetal cardiac tumor.展开更多
Background To determine whether ex utero intrapartum treatment (EXIT) is an appropriate approach for managing fetuses antenatally diagnosed with giant congenital omphaloceles. Methods We retrospectively reviewed patie...Background To determine whether ex utero intrapartum treatment (EXIT) is an appropriate approach for managing fetuses antenatally diagnosed with giant congenital omphaloceles. Methods We retrospectively reviewed patients with omphaloceles who underwent either an EXIT procedure or a traditional repair surgery. Basic and clinical parameters including gender, gestational age, birth weight, maternal blood loss, operative times and operative complications were analyzed. During the 6–12-month follow-ups, postoperative complications including bowel obstruction, abdominal infections, postoperative abdominal distension were monitored, and survival rate was analyzed. Results A total of seven patients underwent the EXIT procedure and 11 patients underwent the traditional postnatal surgery. We found no differences in maternal age, gestational age at diagnosis, gestational age at delivery and birth weight between the two groups. In the EXIT group, the average operation time for mother was 68.3 ± 17.5 minutes and the average maternal blood loss was 233.0 ± 57.7 mL. The operation time in the EXIT group (22.0 ± 4.5 minutes) was shorter than that in the traditional group (35 ± 8.7 minutes), but the length of hospital stay in the EXIT group (20.5 ± 3.1 days) was longer than that in the traditional group (15.7 ± 2.5 days,P < 0.05). During the follow-up, one patient in the EXIT group had an intestinal obstruction, one developed abdominal compartment syndrome and one died in the traditional group. Conclusions In our experience, EXIT is a safe and effective procedure for the treatment of giant congenital omphaloceles. However, more experience is needed before this procedure can be widely recommended.展开更多
目的探讨产时超声指导在产妇体位矫正胎方位中的应用价值。方法130例非枕前位产妇,随机分为对照组和观察组,每组65例。对照组采用常规操作助产,观察组采用全程超声指导产妇体位矫正胎方位。对比两组胎方位矫正成功率、剖宫产率、活跃期...目的探讨产时超声指导在产妇体位矫正胎方位中的应用价值。方法130例非枕前位产妇,随机分为对照组和观察组,每组65例。对照组采用常规操作助产,观察组采用全程超声指导产妇体位矫正胎方位。对比两组胎方位矫正成功率、剖宫产率、活跃期、第一产程、第二产程、不良分娩结局发生情况、新生儿质量。结果观察组胎方位矫正成功率84.62%高于对照组的50.77%,剖宫产率30.77%低于对照组的52.31%,差异有统计学意义(P<0.05)。观察组活跃期(3.47±0.42)h、第一产程(11.32±2.04)h、第二产程(1.18±0.12)h均短于对照组的(4.83±0.53)、(14.51±2.32)、(2.23±0.18)h,差异有统计学意义(P<0.05)。观察组新生儿窒息、产后2 h出血、胎儿窘迫、软产道撕裂发生率分别为0、6.15%、0、4.62%,低于对照组的7.69%、18.46%、6.15%、15.38%,差异有统计学意义(P<0.05)。两组新生儿出生后5 min Apgar评分<4分、4~7分、>7分占比对比差异不显著(P>0.05)。结论产时超声指导产妇体位矫正胎方位可以有效缩短产程,降低剖宫产率,改善不良分娩结局,确保母婴安全性,提高新生儿质量,值得推荐。展开更多
文摘Intrapartum fetal monitoring has been criticized for the lack of evidence of improvement in fetal outcome despite causing increased operative intervention. Paradoxically, cardiotocography （CTG） has been a major driver for litigation for neonatal neurological injury. This analytical review tries to explore why extensive clinical studies and trials over 50 years have failed to demonstrate or bring about signifcant improvement in intrapartum fetal monitoring. There seems a need for significant reform. International congruence on most aspects of CTG interpretation [defnitions of fetal heart rate （FHR） parameters, CTG recording speed, 3-tier systems, etc .] is highly desirable to facilitate future meaningful clinical studies, evaluation and progress in this field. The FHR changes are non-specific and poor surrogate for fetal well-being. As a compromise for maintaining low false-negative results for fetal acidemia, a high false-positive value may have to be accepted. The need for redefning the place of adjuvant tests of fetal well-being like fetal blood sampling or fetal electrocardiography （ECG） is discussed. The FHR decelerations are often deterministic （center-stage） in CTG interpretation and 3-tier categorization. It is discussed if their scientifc and physiological classifcation （avoiding framing and confirmation biases） may be best based on time relationship to uterine contractions alone. This may provide a more sound foundation which could improve the reliability and further evolution of 3-tier systems. Results of several trials of fetal ECG （STAN） have been inconclusive and a need for a fresh approach or strategy is considered. It is hoped that the long anticipated Computer-aided analysis of CTG will be more objective and reliable （overcome human factors） and will offer valuable support or may eventually replace visual CTG interpretation. In any case, the recording and archiving all CTGs digitally and testing cord blood gases routinely in every delivery would be highly desirable for future research. This would facilitate well designed retrospective studies which can be very informative especially when prospective randomised controlled trials are often diffcult and resource-intensive.
文摘Intrapartum maternal normoglycemia seems to play an important role in the prevention of adverse perinatal, maternal and neonatal outcomes. Several glucose monitoring protocols have been developed, aiming to achieve a tight glucose monitoring and control. Depending on the type of diabetes and the optimal or suboptimal glycemic control, the treatment options include fasting status of the parturient, frequent monitoring of capillary blood glucose, intravenous dextrose infusion and subcutaneous or intravenous use of insulin. Continuous glucose monitoring system(CGMS) is a relatively new technology that measures interstitial glucose at very short time intervals over a specifi c period of time. The resulting profi le provides a more comprehensive measure of glycemic excursions than intermittent home blood glucose monitoring. Results of studies applying the CGMS technology in patients with or without diabetes mellitus(DM) have revealed new insights in glucose metabolism. Moreover, CGMS have a potential role in the improvement of glycemic control during pregnancy and labor, which may lead to a decrease in perinatal morbidity and mortality. In conclusion, the use of CGMS, with its important technical advantages compared to the conventional way of monitoring, may lead into a more etiological intrapartum management of both the mother and her fetus/infant in pregnancies complicated with DM.
文摘Approximately 303,000 women die annually while giving birth, worldwide, and more than 99% of the deaths occur in developing countries. In Zambia, a developing country situated in sub-Saharan Africa, most of the maternal mortalities occur during the intrapartum and immediate postpartum periods, arising from postpartum hemorrhage, sepsis, obstructed labor, and hypertensive disorders. <span style="font-family:Verdana;">Aim:<span style="font-family:Verdana;"> The aim of this study was to assess the quality of intrapartum services provided in health facilities in the country. <span style="font-family:Verdana;">Methodology:<span style="font-family:Verdana;"> Guided by a descriptive <span style="font-family:Verdana;">cross sectional<span style="font-family:Verdana;"> design, data were collected from 264 women in labor using a World Health Organization validated observation checklist. Convenience sampling was used to recruit the women, while multistage sampling was used to select four health facilities. The Social Package for Social Sciences, version 23 was used to analyze the data. <span style="font-family:Verdana;">Results:<span style="font-family:Verdana;"> One health facility met the World Health Organization 80% minimum standard in four out of the five categories used to measure quality in intrapartum care, while the other three met the minimum standard in one category each. <span style="font-family:Verdana;">Conclusion:<span style="font-family:Verdana;"> Low numbers of midwives, inadequate supplies <span style="font-family:Verdana;">and<span style="font-family:Verdana;"> equipment were major obstacles to following national and international agreed standards for providing optimal care during <span style="font-family:Verdana;">intrapartum<span style="font-family:Verdana;"> period. <span style="font-family:Verdana;">Recommendations:<span style="font-family:Verdana;"> There is <span style="font-family:Verdana;">need<span style="font-family:Verdana;"> for local and national stakeholders in Zambia to urgently address the structural barriers that were observed, as well as invest in sufficient numbers of adequately trained and motivated midwives.
文摘The anesthesia ex utero intrapartum treatment (EXIT) procedure is a specialized surgical procedure used to deliver babies who have airway compression due to cystic adenomatoid malformation, bronchopulmonary sequestration, cervical teratomas, or other congenital conditions. EXIT is erroneously known as a routine cesarean section (CS), but is rather an extension of CS with discernible differences. The procedure creates an opening in the anesthetized abdomen of the mother and uterus. Once EXIT is complete, the remainder of the CS proceeds. EXIT is much more complex than a routine CS, as it requires coordination between the mother and a multidisciplinary team of surgical and neonatal personnel. This review highlights current anesthetic concepts during the EXIT procedure.
文摘Purpose: We propose that using remifentanil in ex utero intrapartum treatment (EXIT) procedures reduces the need for maternal exposure to general anesthesia. Using remifentanil along with spinal anesthesia eliminates the fetal and maternal risks associated with inhalational general anesthesia, allows the mother to be awake, and obviates the need for and costs associated with general anesthesia and a second anesthesia team. Materials and Methods: We performed a retrospective review of all sequential patients undergoing ex utero intrapartum treatment procedure at our hospital from 1/1/2009 to 11/1/2010. All procedures were performed under regional neuraxial analgesia, using nitroglycerine as a tocolytic agent and remifentanil for analgesia. Variables included indication, time to secured fetal airway, complications, estimated blood loss, need for additional anesthetics, participating personnel, and survival. Results: All five of our ex utero intrapartum treatment procedures were successfully completed with combined spinal epidural remifentanil anesthetic. No patient was required additional alternative anesthetic. There were no complications with mother or fetus. Indications for procedure were arthyrogryposis (n = 3), fetal goiter, and micrognathia. Average time to secured airway was 10.25 minutes. Average estimated blood loss was 1010 ml. All five mothers were conscious during their procedure. Conclusions: We report the largest series of ex utero intrapartum treatment procedures performed with remifentanil regional anesthesia. We found that the combined use of nitroglycerin and regional remifentanil anesthesia is a safe alternative to the pediatric otolaryngologist for performing ex utero intrapartum treatment procedures without the risks of general anesthesia, allowing the mother to be awake for the delivery, and reducing the cost of providing care.
文摘Aim&objective The diagnosis of foetal distress in a clinical setting is based on foetal cardiotocography findings during labour.This study aims to analyse the total deceleration area(TDA)on intrapartum cardiotocogram which will predict neonatal acidemia at bith.Materials&methods The study participants included women in labour having intrapartum foetal distress(National Institute of Child Halth and Human Development criteria category II and persistent category II on cardiotocogram),who had the 30-min traces(prior to delivery/decision to delivery)and foetal umbilical cord blood gas analysis at delivery.The TDA was calculated and analysed against the cord blood pH obtained at delivery.The deceleration area is calculated as the width of the widest aspect of deceleration(below baseline)measured in minutes which is multiplied by the maximum depth below the baseline and divided by two.TDA is the summation of all the deceleration areas in the last 30 min before delivery.Results A total of 168 participants were analysed.There were 42 cases and 146 controls in the study.The mean TDA in the case and control group was 254.62 missed beats and 165 missed beats,respectively.It was observed that an intrapartum TDA of 2195 missed beats was associated with neonatal acidemia at birth and with an area under curve of 0.6576(95%CI 0.5305 to 0.7847)with a positive predictive value of 83.78%.Conclusion In this study,an intrapartum TDA of≥195 missed beats was significantly associated with neonatal acidemia at birth.The calculation of TDA has simplified intrapartum foetal monitoring.
文摘INTRODUCTION The incidence of fetal cardiac tumor was about 0.14% as determined by fetal echocardiography. It was extremely difficult to deal with the fetus when the severe circulatory instability was induced by a cardiac tumor in the womb. It was reported that ex utero intrapartum treatment （EXIT） procedure solved the problems of fetal airway or pulmonary lesion during delivery to avoid hypoxia after birth. The goal of EXIT is to maintain placental circulation while steps are taken to optimize the transition of the baby from fetal to neonatal life. This study introduced the experience of EXIT procedure to solve the problems of fetal circulation induced by a fetal cardiac tumor.
基金supported by Grants from the National Natural Science Foundation of China(Nos.81270441,81401240)
文摘Background To determine whether ex utero intrapartum treatment (EXIT) is an appropriate approach for managing fetuses antenatally diagnosed with giant congenital omphaloceles. Methods We retrospectively reviewed patients with omphaloceles who underwent either an EXIT procedure or a traditional repair surgery. Basic and clinical parameters including gender, gestational age, birth weight, maternal blood loss, operative times and operative complications were analyzed. During the 6–12-month follow-ups, postoperative complications including bowel obstruction, abdominal infections, postoperative abdominal distension were monitored, and survival rate was analyzed. Results A total of seven patients underwent the EXIT procedure and 11 patients underwent the traditional postnatal surgery. We found no differences in maternal age, gestational age at diagnosis, gestational age at delivery and birth weight between the two groups. In the EXIT group, the average operation time for mother was 68.3 ± 17.5 minutes and the average maternal blood loss was 233.0 ± 57.7 mL. The operation time in the EXIT group (22.0 ± 4.5 minutes) was shorter than that in the traditional group (35 ± 8.7 minutes), but the length of hospital stay in the EXIT group (20.5 ± 3.1 days) was longer than that in the traditional group (15.7 ± 2.5 days,P < 0.05). During the follow-up, one patient in the EXIT group had an intestinal obstruction, one developed abdominal compartment syndrome and one died in the traditional group. Conclusions In our experience, EXIT is a safe and effective procedure for the treatment of giant congenital omphaloceles. However, more experience is needed before this procedure can be widely recommended.
文摘目的探讨产时超声指导在产妇体位矫正胎方位中的应用价值。方法130例非枕前位产妇,随机分为对照组和观察组,每组65例。对照组采用常规操作助产,观察组采用全程超声指导产妇体位矫正胎方位。对比两组胎方位矫正成功率、剖宫产率、活跃期、第一产程、第二产程、不良分娩结局发生情况、新生儿质量。结果观察组胎方位矫正成功率84.62%高于对照组的50.77%,剖宫产率30.77%低于对照组的52.31%,差异有统计学意义(P<0.05)。观察组活跃期(3.47±0.42)h、第一产程(11.32±2.04)h、第二产程(1.18±0.12)h均短于对照组的(4.83±0.53)、(14.51±2.32)、(2.23±0.18)h,差异有统计学意义(P<0.05)。观察组新生儿窒息、产后2 h出血、胎儿窘迫、软产道撕裂发生率分别为0、6.15%、0、4.62%,低于对照组的7.69%、18.46%、6.15%、15.38%,差异有统计学意义(P<0.05)。两组新生儿出生后5 min Apgar评分<4分、4~7分、>7分占比对比差异不显著(P>0.05)。结论产时超声指导产妇体位矫正胎方位可以有效缩短产程,降低剖宫产率,改善不良分娩结局,确保母婴安全性,提高新生儿质量,值得推荐。
