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Given evidence that cerebral palsy is not reduced by electronic fetal monitoring, Karin Nelson, Thomas Sartwelle, and Dwight Rouse ask why routine monitoring and related litigation continue to contribute to high rates of caesarean births

Intro While monitoring of the fetal heart rate in labour is recommended, few studies have compared women’s experiences of different forms of monitoring technologies, their impact on labour and perceived risks and benefits. Methods The Women’s experiences of Monitoring Baby (WOMB) study, an Australian national survey, examined experiences of intrapartum fetal monitoring in labour. This study is one of two quantitative analyses of survey responses received. Results We received 861 valid responses. The most common form of monitoring across all hospital settings was wired CTG (53% of total). Women who used wired CTG were more likely to be primiparous (OR = 3.220, [95%CI:2.080–4.987], p  < 0.001), and give birth at a private hospital (OR = 3.017 [95%CI:1.632–5.576], p  < 0.001). Women who were monitored via wired CTG were more likely to use pharmacological pain management, and have an emergency caesarean section ( p  < 0.001), which remained significant when adjusting for epidural. Women who gave birth vaginally were more likely to have been monitored via intermittent auscultation (OR = 3.582, [95%CI:2.007–6.390], p  < 0.001), and to use non-pharmacological techniques such as mobility ( p  < 0.001) and supportive care ( p  < 0.01). Of the women monitored via wired CTG 58% felt that monitoring had a negative impact on their labour. Conclusion This study has substantial implications for research, policy and practice, including the implementation of less invasive and more humanised forms of fetal monitoring. The promotion of freedom of movement and bodily autonomy in labour is essential. This includes implementation of evidence-based practices and information about methods of fetal monitoring that support woman-centred care and optimise physiological processes.

Non-invasive fetal electrocardiography (NIFECG), an emerging technology for fetal health monitoring, has garnered significant attention in recent years. It is considered a promising alternative to traditional Doppler ultrasound methods and has the potential to become the standard approach for fetal monitoring. This paper provides a comprehensive review of the latest advancements in NIFECG technology, including signal acquisition, signal preprocessing, fetal electrocardiogram extraction, and fetal cardiac anomaly classification. Furthermore, the characteristics and limitations of existing NIFECG datasets are analyzed, and improvement suggestions are proposed. Future research directions for NIFECG technology are discussed, with a particular focus on the potential applications of deep learning techniques, multimodal data fusion, and remote monitoring systems. This review offers references and support for advancing the development and application of NIFECG monitoring technology.

Intermittent auscultation (IA) is the technique of listening to and counting the fetal heart rate (FHR) for short periods during active labour and continuous cardiotocography (CTC) implies FHR monitoring for longer periods. Although the evidence suggests that IA is the best way to monitor healthy women at low risk of complications, there is no scientific evidence for the ideal device, timing, frequency and duration for IA. We aimed to give an overview of the field, identify and describe methods and practices for performing IA, map the evidence and accuracy for different methods of IA, and identify research gaps. We conducted a systematic scoping review following the Joanna Briggs methodology. Medline, EMBASE, Cinahl, Maternity & Infant Care, Cochrane Library, SveMed+, Web of Science, Scopus, Lilacs and African Journals Online were searched for publications up to January 2019. We did hand searches in relevant articles and databases. Studies from all countries, international guidelines and national guidelines from Denmark, United Kingdom, United States, New Zealand, Australia, The Netherlands, Sweden, Denmark, and Norway were included. We did quality assessment of the guidelines according to the AGREEMENT tool. We performed a meta-analysis assessing the effects of IA with a Doppler device vs. Pinard device using methods described in The Cochrane Handbook, and we performed an overall assessment of the summary of evidence using the GRADE approach. The searches generated 6408 hits of which 26 studies and 11 guidelines were included in the review. The studies described slightly different techniques for performing IA, and some did not provide detailed descriptions. Few of the studies provided details of normal and abnormal IA findings. All 11 guidelines recommended IA for low risk women, although they had slightly different recommendations on the frequency, timing, and duration for IA, and the FHR characteristics that should be observed. Four of the included studies, comprising 8436 women and their babies, were randomised controlled trials that evaluated the effect of IA with a Doppler device vs. a Pinard device. Abnormal FHRs were detected more often using the Doppler device than in those using the Pinard device (risk ratio 1.77; 95% confidence interval 1.29-2.43). There were no significant differences in any of the other maternal or neonatal outcomes. Four studies assessed the accuracy of IA findings. Normal FHR was easiest to identify correctly, whereas identifying periodic FHR patterns such as decelerations and saltatory patterns were more difficult. Although IA is the recommended method, no trials have been published that evaluate protocols on how to perform it. Nor has any study assessed interrater agreements regarding interpretations of IA findings, and few have assessed to what degree clinicians can describe FHR patterns detected by IA. We found no evidence to recommend Doppler device instead of the Pinard for IA, or vice versa.

Background Newborns are at the greatest risk for dying during the intrapartum period, including labor and delivery, and the first day of life. Fetal heart rate monitoring (FHRM) and partogram use to track labor progress are evidence-based techniques that can help to identify maternal and fetal risk factors so that these can be addressed early. The objective of this study was to assess health worker adherence to protocols for FHRM and partogram use during the intrapartum period, and to assess the association between adherence and intrapartum stillbirth in a tertiary hospital of Nepal. Methods A case-referent study was conducted over a 15-month period. Cases included all intrapartum stillbirths, while 20 % of women with live births were randomly selected on admission to make up the referent population. The frequency of FHRM and the use of partogram were measured and their association to intrapartum stillbirth was assessed using logistic regression analysis. Results During the study period, 4,476 women with live births were enrolled as referents and 136 with intrapartum stillbirths as cases. FHRM every 30 min was only completed in one-fourth of the deliveries, and labor progress was monitored using a partogram in just over half. With decreasing frequency of FHRM, there was an increased risk of intrapartum stillbirth; FHRM at intervals of more than 30 min resulted in a four-fold risk increase for intrapartum stillbirth (aOR 4.17, 95 % CI 2.0–8.7), and the likelihood of intrapartum stillbirth increased seven times if FHRM was performed less than every hour or not at all (aOR 7.38, 95 % CI 3.5–15.4). Additionally, there was a three-fold increased risk of intrapartum stillbirth if the partogram was not used (aOR 3.31, 95 % CI 2.0–5.4). Conclusion The adherence to FHRM and partogram use was inadequate for monitoring intrapartum progress in a tertiary hospital of Nepal. There was an increased risk of intrapartum stillbirth when fetal heart rate was inadequately monitored and when the progress of labor was not monitored using a partogram. Further exploration is required in order to determine and understand the barriers to adherence; and further, to develop tools, techniques and interventions to prevent intrapartum stillbirth. Clinical trial registration ISRCTN97846009 .

Background The Moyo device is an easy-to-use device that allows continuous electronic fetal heart rate monitoring (FHRM). We explored the acceptability of using the Moyo device for continuous intrapartum FHRM in Eastern Uganda. Methods Between November 2023 and August 2024, we introduced the Moyo device for continuous intrapartum FHRM among mothers with high-risk pregnancies at Mbale Regional Referral Hospital in Eastern Uganda. We then conducted 34 in-depth interviews with 14 health workers who had used the Moyo device for continuous FHRM and with 20 mothers on whom the Moyo device was used. Participants were purposively selected and interviewed using a semi-structured interview guide. The interviews were audio recorded and transcribed verbatim. We analyzed data using thematic content analysis in Atlas ti.9 software and presented our findings using Sekhon’s acceptability model. Results Participants perceived the Moyo device as a useful and an easy-to-use tool for intrapartum FHRM. Mothers felt involved in monitoring their babies’ condition, with the freedom to ambulate during labour. Moyo facilitated early detection of fetal distress, and triage of patients awaiting caesarean section in a very busy setting. The facilitators to its use were: adequate staff training, health education and counselling of mothers about the device, and tool attributes such as accuracy, reliability and being user friendly. The barriers included poor health worker attitudes, risk of cross-infection, short battery life and the device alarms that were perceived as disturbances. Conclusion The Moyo device was acceptable to both health workers and mothers, with perceived improvements in both obstetric outcomes and birth experience. When introducing the device, careful attention needs to be paid to the training of both staff and the laboring women. Potential success of large scale roll out is supported by participants’ positive attitudes toward the Moyo and high perceived effectiveness.

Antepartum Cardiotocography (CTG) is a biomedical sensing technology widely used for fetal health monitoring. While the visual interpretation of CTG traces is highly subjective, with the inter-observer agreement as low as 29% and a false positive rate of approximately 60%, the Dawes–Redman system provides an automated approach to fetal well-being assessments. However, it is primarily designed to rule out adverse outcomes rather than detect them, resulting in a high specificity (90.7%) but low sensitivity (18.2%) in identifying fetal distress. This paper introduces PatchCTG, an AI-enabled biomedical time series transformer for CTG analysis. It employs patch-based tokenisation, instance normalisation, and channel-independent processing to capture essential local and global temporal dependencies within CTG signals. PatchCTG was evaluated on the Oxford Maternity (OXMAT) dataset, which comprises over 20,000 high-quality CTG traces from diverse clinical outcomes, after applying the inclusion and exclusion criteria. With extensive hyperparameter optimisation, PatchCTG achieved an AUC of 0.77, with a specificity of 88% and sensitivity of 57% at Youden’s index threshold, demonstrating its adaptability to various clinical needs. Its robust performance across varying temporal thresholds highlights its potential for both real-time and retrospective analysis in sensor-driven fetal monitoring. Testing across varying temporal thresholds showcased it robust predictive performance, particularly with finetuning on data closer to delivery, achieving a sensitivity of 52% and specificity of 88% for near-delivery cases. These findings suggest the potential of PatchCTG to enhance clinical decision-making in antepartum care by providing a sensor-based, AI-driven, objective tool for reliable fetal health assessment.

Fetal monitoring in low-resource settings is often inadequate. A mobile cardiotocograph fetal monitoring device is a digital innovation that could ensure the safety of pregnant women at high risk and their fetuses through early detection and management of fetal distress. Research is scarce on factors that affect the implementation of fetal heart monitoring using the mobile cardiotocograph device in low-resource settings, including Tanzania. This study aimed to explore the barriers and facilitators of fetal monitoring with a mobile cardiotocograph device in Tanzania. We adopted an exploratory qualitative study to analyze the barriers and facilitators of fetal monitoring using the mobile cardiotocograph device in primary healthcare facilities. Seventeen face-to-face in-depth interviews with healthcare providers and seven focus group discussions with women were conducted. Braun and Clarke's thematic analysis guided the data analysis. It included the following steps: familiarizing with data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Three themes emerged as barriers: individual-related ones, including inadequate knowledge and skills to use mobile cardiotocograph devices, institutional barriers attributed to limited referral infrastructures and staff shortage, and community-related barriers, such as myths and misconceptions that limit antenatal care checkups. Individual factors, including motives and desires of healthcare providers and community trust in the healthcare system, support systems related to training and mentorship opportunities for healthcare providers, and the availability of community-based health programs in the respective areas, were revealed as facilitators of mobile cardiotocograph devices. Implementing iCTG in primary healthcare facilities is affected by several factors, from individual to institutional level. Providing user-friendly procedure manuals and training on the functions of the iCTG device and cardiotocograph interpretations could serve as potential solutions to improve the competence and confidence of healthcare providers. Moreover, the availability of supportive infrastructure, adequate human resources for health, and community sensitization were good points to start with when addressing institutional and community barriers. Nevertheless, multistakeholder engagement during the design and implementation of fetal monitoring using a mobile cardiotocograph device is warranted.

Robust evidence to direct management of pregnant women with mild hypertensive disease at term is scarce. We investigated whether induction of labour in women with a singleton pregnancy complicated by gestational hypertension or mild pre-eclampsia reduces severe maternal morbidity. We undertook a multicentre, parallel, open-label randomised controlled trial in six academic and 32 non-academic hospitals in the Netherlands between October, 2005, and March, 2008. We enrolled patients with a singleton pregnancy at 36–41 weeks' gestation, and who had gestational hypertension or mild pre-eclampsia. Participants were randomly allocated in a 1:1 ratio by block randomisation with a web-based application system to receive either induction of labour or expectant monitoring. Masking of intervention allocation was not possible. The primary outcome was a composite measure of poor maternal outcome—maternal mortality, maternal morbidity (eclampsia, HELLP syndrome, pulmonary oedema, thromboembolic disease, and placental abruption), progression to severe hypertension or proteinuria, and major post-partum haemorrhage (>1000 mL blood loss). Analysis was by intention to treat and treatment effect is presented as relative risk. This study is registered, number ISRCTN08132825. 756 patients were allocated to receive induction of labour (n=377 patients) or expectant monitoring (n=379). 397 patients refused randomisation but authorised use of their medical records. Of women who were randomised, 117 (31%) allocated to induction of labour developed poor maternal outcome compared with 166 (44%) allocated to expectant monitoring (relative risk 0·71, 95% CI 0·59–0·86, p<0·0001). No cases of maternal or neonatal death or eclampsia were recorded. Induction of labour is associated with improved maternal outcome and should be advised for women with mild hypertensive disease beyond 37 weeks' gestation. ZonMw.

Qualitative research about women and birthing people’s experiences of fetal monitoring during labour and birth is scant. Labour and birth is often impacted by wearable or invasive monitoring devices, however, most published research about fetal monitoring is focused on the wellbeing of the fetus. This manuscript is derived from a larger mixed methods study, ‘ WO men’s Experiences of M onitoring B aby (The WOMB Study)’, aiming to increase understanding of the experiences of women and birthing people in Australia, of being monitored; and about the information they received about fetal monitoring devices during pregnancy. We constructed a national cross-sectional survey that was distributed via social media in May and June, 2022. Responses were received from 861 participants. As far as we are aware, this is the first survey of the experiences of women and birthing people of intrapartum fetal monitoring conducted in Australia. This paper comprises the analysis of the free text survey responses, using qualitative and inductive content analysis. Two categories were constructed, Tending to the machine , which explores participants’ perceptions of the way in which clinicians interacted with fetal monitoring technologies; and Impressions of the machine , which explores the direct impact of fetal monitoring devices upon the labour and birth experience of women and birthing people. The findings suggest that some clinicians need to reflect upon the information they provide to women and birthing people about monitoring. For example, freedom of movement is an important aspect of supporting the physiology of labour and managing pain. If freedom of movement is important, the physical restriction created by a wired cardiotocograph is inappropriate. Many participants noticed that clinicians focused their attention primarily on the technology. Prioritising the individual needs of the woman or birthing person is key to providing high quality woman-centred intrapartum care. Women should be provided with adequate information regarding the risks and benefits of different forms of fetal monitoring including how the form of monitoring might impact her labour experience.