Electronic Fetal Monitoring With and Without Pattern Interpretation
NCT ID: NCT03279068
Last Updated: 2020-12-19
Study Results
The study team has not published outcome measurements, participant flow, or safety data for this trial yet. Check back later for updates.
Basic Information
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TERMINATED
637 participants
OBSERVATIONAL
2017-10-06
2019-06-29
Brief Summary
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Historical Western data revealed that implementation of continuous fetal monitoring with pattern interpretation increased rates of cesarean delivery in comparison to intermittent auscultation. However, it is not clear if the inability to interpret a pattern (because of a lack of paper or electronic recording) results in increased or decreased cesarean rates in comparison to pattern interpretation. It is possible that the implementation of pattern interpretation could decrease cesarean delivery rates allowing increased or earlier opportunity for fetal resuscitation for patients with tracing abnormalities which may avert cesarean delivery. The investigators' aim is to assess cesarean delivery rates using electronic fetal monitoring with versus without pattern interpretation in a hospital in a low-middle income country where resources are lacking.
If a decrease in cesarean delivery rate is observed and/or neonatal outcomes are improved, this study may serve as an impetus to encourage electronic fetal monitoring paper-producing companies to subsidize or donate supplies to hospitals in developing countries. Ensuring that fetal status is in fact non-reassuring by fetal heart rate pattern interpretation prior to proceeding with cesarean delivery may decrease the cesarean delivery rate while not compromising fetal outcomes.
Detailed Description
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The International Federation of Gynecology and Obstetrics (FIGO), of which ACOG is a member, produced several documents in 2015 to address Consensus Guidelines for Intrapartum Fetal Monitoring. The document addressing CTG for an international audience provides the same guidelines for interpretation of fetal heart tracing patterns as ACOG, and very similar recommendations for management based on slightly different categorization terminology. Both the ACOG Practice Bulletin and the FIGO Consensus Guideline addressing intrapartum fetal monitoring describe fetal heart rate patterns including baseline rate, variability, accelerations, and decelerations. Specifically, they address the various types of decelerations, some of which are benign, and others which are ominous for fetal well-being, as well as the importance of variability in assessing fetal well-being. For example, moderate baseline variability reflects the oxygenation of the central nervous system and reliably predicts the absence of ongoing hypoxic injury and metabolic acidemia at the time it is observed.
An alternative method for intrapartum fetal monitoring is via intermittent auscultation (IA). IA is a technique by which the fetal heart rate is appreciated by a stethoscope, fetoscope, or handheld Doppler to assess the fetal heart rate over established periods of time during different stages of labor, but does not produce a continuous numerical output of the fetal heart rate. As such, certain features of a fetal heart rate pattern cannot be evaluated by IA, including fetal heart rate variability or the different types of decelerations. According to the FIGO Guidelines on Intermittent Auscultation, "Based on expert opinion, IA should be recommended in all labors in settings where there is no access to CTG monitors or to the resources necessary for using them. When the resources for CTG monitoring are available, intermittent auscultation may be used for routine intrapartum monitoring in low-risk cases. However, approximately half of the panel members believe that continuous CTG should be the option during the second stage of labor, although there is no direct scientific evidence to support this." In settings where CTG is available, the conditions required to use IA are stringent and even preclude patients who don't deliver within 1 hour of pushing. Furthermore, management of abnormal findings on IA includes proceeding to CTG if it is available. These provisions to using IA convey the implication that it is preferred to have CTG available for use, if possible. It is important to note that electronic fetal monitoring without paper or the ability to interpret a pattern, is not the same as IA or electronic fetal monitoring as described above. Therefore, there is no set of guidelines to interpret and manage patients monitored with continuous monitoring without pattern interpretation.
In many developing countries, hospitals have the ability to provide intrapartum electronic fetal monitoring. At Ayder Referral Hospital, a teaching hospital for Mekelle University, labor and delivery is equipped with electronic CTG monitors that display fetal heart rate in real time, and potentially have the ability to record on paper. Secondary to limited number of CTG monitors, EFM is reserved for use for patients who are considered "high risk," and IA is used to monitor patients who are "low risk." "High risk" patients are those who have maternal conditions or fetal conditions that prompt higher level of fetal monitoring, such as pre-eclampsia, history of prior cesarean delivery, or concerns regarding fetal well-being. However, at this hospital, as in many other hospitals in sub-Saharan Africa, paper strip supplies were depleted and have not been replenished. Thus, patients are currently monitored intrapartum with a live feedback of fetal heart rate, but with no ability to interpret fetal heart rate pattern. Management of patients in this setting is based on real-time fetal heart rates that are continuously observed, which is an intermediate entity of fetal monitoring for which there are no established recommendations for management. Neither the ACOG Bulletin nor the FIGO Consensus Guidelines address CTG/EFM without pattern interpretation.
In a setting such as Ayder Referral Hospital in Mekelle, making efforts to minimize the cesarean delivery rate while optimizing neonatal outcomes is paramount for many reasons. In Mekelle, personal and socioeconomic implications of a major surgery such as cesarean delivery are considered seriously, and refusal of cesarean delivery is higher in many developing countries in comparison to resource-rich countries. Furthermore, performance of a cesarean delivery in a patient population that has a high aversion to cesarean delivery puts these patients at risk of avoiding a subsequent delivery in a hospital to avoid a repeat cesarean section, which can have dire consequences. Preventing adverse fetal outcome is equally as important as preventing unnecessary cesarean section, as resources available for neonatal resuscitation are limited in comparison to developed countries.
While there is a lack of data regarding the use of EFM without pattern interpretation, the investigators' hypothesis is that the implementation of EFM with pattern interpretation will result in a decrease in cesarean delivery rates without altering neonatal outcomes. This hypothesis arises from anecdotal experience. Providers at Ayder Referral Hospital and the principal investigator's observation of the intrapartum management on Labor and Delivery noted that several of the cesarean deliveries that occurred may have been averted given the opportunity for intrauterine resuscitation.
This prospective cohort study comparing current standard of care at Ayder Referral Hospital (EFM without pattern interpretation for high risk obstetric patients) with EFM as per ACOG and FIGO recommendations (with pattern evaluation) may reveal a change in cesarean delivery rate and/or neonatal outcomes.
Conditions
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Keywords
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Study Design
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COHORT
PROSPECTIVE
Study Groups
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Without Pattern Interpretation
All women who are admitted for labor at Ayder Referral Hospital in Mekelle, Ethiopia will be asked to participate and a physician will obtain consent. If an indication arises and they are designated to receive EFM per previously established standard practice at Ayder Hospital, then their patient information will be collected. Patients who require EFM will be asked to provide basic health and demographic information, along with collection of information on labor and delivery course, post-partum outcome, and neonatal outcomes. The investigators estimate enrollment of up to 1800 patients which will result in at least 300 patients who will require EFM.
No interventions assigned to this group
With Pattern Interpretation
All women who are admitted for labor at Ayder Referral Hospital in Mekelle, Ethiopia will be asked to participate and a physician will obtain consent. If an indication arises and they are designated to receive EFM per previously established standard practice at Ayder Hospital, then their patient information will be collected.
Their labor will be managed as in Phase 1 except that EFM will be interpreted and managed as per ACOG/FIGO guidelines using paper on which fetal heart tracings will be recorded. All other aspects of their care will proceed as per standard at Ayder Referral Hospital.
Patients who require EFM will be asked to provide basic health and demographic information, along with collection of information on labor and delivery course, post-partum outcome, and neonatal outcomes. The investigators estimate enrollment of up to 1800 patients which will result in at least 300 patients who will require EFM.
Teaching and EFM Paper
Data will be collected for patients receiving EFM without pattern interpretation as the first phase of the study, as this is the current practice at Ayder Hospital. Then, the second phase will involve a week of teaching sessions regarding interpretation and management of EFM as per ACOG and FIGO guidelines. For the third phase of this study, paper will be provided for the use of EFM with pattern interpretation for all patients receiving EFM.
Interventions
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Teaching and EFM Paper
Data will be collected for patients receiving EFM without pattern interpretation as the first phase of the study, as this is the current practice at Ayder Hospital. Then, the second phase will involve a week of teaching sessions regarding interpretation and management of EFM as per ACOG and FIGO guidelines. For the third phase of this study, paper will be provided for the use of EFM with pattern interpretation for all patients receiving EFM.
Other Intervention Names
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Eligibility Criteria
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Inclusion Criteria
* Women admitted for labor to Ayder Referral Hospital in Mekelle, Ethiopia.
* Pregnant women aged 18 years or older.
* Receiving EFM for intrapartum management.
* Patients assigned to receive EFM will be designated by the current protocol regarding "high risk" vs. "low risk" patients at Ayder Referral Hospital as per discretion of the supervising provider in Labor and Delivery.
Exclusion Criteria
* Pregnant women under 18 years of age.
* Low risk women who are undergoing IA.
18 Years
FEMALE
No
Sponsors
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University of Illinois at Chicago
OTHER
Responsible Party
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Abida Hasan
Maternal Fetal Medicine Fellow
Principal Investigators
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Abida Hasan, MD
Role: PRINCIPAL_INVESTIGATOR
University of Illinois, Maternal Fetal Medicine Fellow
Locations
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Ayder Referral Hospital, Mekelle University
Mek'ele, Tigray, Ethiopia
Countries
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References
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American College of Obstetricians and Gynecologists. Practice bulletin no. 116: Management of intrapartum fetal heart rate tracings. Obstet Gynecol. 2010 Nov;116(5):1232-40. doi: 10.1097/AOG.0b013e3182004fa9.
Ayres-de-Campos D, Spong CY, Chandraharan E; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Cardiotocography. Int J Gynaecol Obstet. 2015 Oct;131(1):13-24. doi: 10.1016/j.ijgo.2015.06.020. No abstract available.
Lewis D, Downe S; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Intermittent auscultation. Int J Gynaecol Obstet. 2015 Oct;131(1):9-12. doi: 10.1016/j.ijgo.2015.06.019. No abstract available.
Malek J. Responding to refusal of recommended cesarean section: Promoting good parenting. Semin Perinatol. 2016 Jun;40(4):216-21. doi: 10.1053/j.semperi.2015.12.009. Epub 2016 Jan 21.
Ohel I, Levy A, Mazor M, Wiznitzer A, Sheiner E. Refusal of treatment in obstetrics - A maternal-fetal conflict. J Matern Fetal Neonatal Med. 2009 Jul;22(7):612-5. doi: 10.1080/14767050802668698.
Ugwu NU, de Kok B. Socio-cultural factors, gender roles and religious ideologies contributing to Caesarian-section refusal in Nigeria. Reprod Health. 2015 Aug 12;12:70. doi: 10.1186/s12978-015-0050-7.
Ajah LO, Ibekwe PC, Onu FA, Onwe OE, Ezeonu TC, Omeje I. Evaluation of Clinical Diagnosis of Fetal Distress and Perinatal Outcome in a Low Resource Nigerian Setting. J Clin Diagn Res. 2016 Apr;10(4):QC08-11. doi: 10.7860/JCDR/2016/17274.7687. Epub 2016 Apr 1.
Ayres-de-Campos D, Arulkumaran S; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Physiology of fetal oxygenation and the main goals of intrapartum fetal monitoring. Int J Gynaecol Obstet. 2015 Oct;131(1):5-8. doi: 10.1016/j.ijgo.2015.06.018. No abstract available.
Boyle A, Reddy UM, Landy HJ, Huang CC, Driggers RW, Laughon SK. Primary cesarean delivery in the United States. Obstet Gynecol. 2013 Jul;122(1):33-40. doi: 10.1097/AOG.0b013e3182952242.
Ayres-de-Campos D, Arulkumaran S; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Introduction. Int J Gynaecol Obstet. 2015 Oct;131(1):3-4. doi: 10.1016/j.ijgo.2015.06.017. No abstract available.
Visser GH, Ayres-de-Campos D; FIGO Intrapartum Fetal Monitoring Expert Consensus Panel. FIGO consensus guidelines on intrapartum fetal monitoring: Adjunctive technologies. Int J Gynaecol Obstet. 2015 Oct;131(1):25-9. doi: 10.1016/j.ijgo.2015.06.021. No abstract available.
Other Identifiers
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2017-0723
Identifier Type: -
Identifier Source: org_study_id