- pH less than 7.20 Pathological value. Indication for fetal extraction by the quickest route, in this case a cesarean section. - pH between 7.20-7.25 Prepathological value. Repeat microtome in 15-20 min. - pH greater than 7.25. Value within the limits of normality. Observation.

- pH less than 7.20 Pathological value. [HIDDEN], in this case a cesarean section.
- pH between 7.20-7.25 Prepathological value. Repeat microtome in 15-20 min.
- pH greater than 7.25. Value within the limits of normality. Observation.

Woman 40 weeks gestation in labor with 6 cm dilation. She presents a decelerative fetal pattern in cardiotocographic recordings, so it is decided to perform a fetal blood smear to assess fetal well-being. Result 7.22. The correct conduct is:

Severe acidosis. Urgent cesarean section.

Pre-pathological value repeat microtome 15-20 minutes.

Moderate acidosis. Repeat microtome in 1-2 hours.

Value in normal limits, leave natural evolution of labor.

Repeat at the time of possible error in obtaining the shot.

[Pre-pathologic-pathologic cardiotocographic pattern in second stage of labor. Analysis of the incidence of acidosis and recommendations for fetal blood gas analysis].

Fetal heart rate (FHR) patterns from 746 consecutive, documented vaginal deliveries within a 1 year period were reported on using the Hammacher Score. Characteristic FHR patterns were described and the frequency of acidosis calculated. FHR score, the single FHR parameters, baseline (BL), floatingline (FL) and oscillation type (OT) and the acid-base balance of the neonate were submitted to a correlation analysis according to Spearman. FHR patterns reported as ominous (FHR score > or = 5) were observed in 25.9% and were associated with a frequency of acidosis (pHUA < or = 7.20) of 38.1% Suspicious fetal heart rate patterns (FHR score 3-4) were seen in 60%, here the frequency of acidosis was 8.5%. With the inclusion of decelerations by the parameter FL an increased frequency of acidosis of 29% was registered only when 4 points were allocated. Total FHR score and the score parameter baseline (BL) correlated closest with the pH changes at the end of birth. Tachycardic FHR patterns showed the highest frequency of acidosis (55%) and ominous tracings (83%). The commonest FHR pattern, normocardia with decelerations (48%) exhibited only a low frequency of acidosis (8%) and ominous tracings (15%) with an average pH value of 7.27 +/- 0.08. To prevent an unnecessary operative delivery in the presence of an ominous FHR finding, whether in the late first stage or early second stage when birth is not imminent, a fetal blood analysis should be carried out. With a suspiciously assessed fetal heart rate pattern the fetal blood analysis will only rarely reveal a severe acidosis (pHUA < or = 7.10).

[Reference values range of the fetal oxygen saturation and its dispersal during labor without cardiotocographic evidence for fetal distress].

The objective of this study is to establish the reference values range of the fetal oxygen saturation during the first and the second period of labor and their dispersal according to the extent of cervical dillatation in cases with normal FHR--absence of fetal hypoxia and asphyxia of the newborn. This is a prospective study which involves 94 women with normal FHR. All of the newborns are with umbilical artery pH values greater than 7.15 and 5 min Apgar score greater than 7; there was no necessity for any reanimation procedures, assisted ventilation or intensive care treatment. The fetal oxygen saturation (SpO2) is monitored by fetal pulseoxymeter Nellcor N 400, fetal sensors FS - 14. Cardiotocographic monitoring is carried out simultaneously. Blood is obtained from the fetal scalp during labor for blood gas and pH analysis, and umbilical artery pH as well as the Apgar score of the newborn are determined. The average monitoring time during the first period of labor is 107.19+/-29.49 min. with reliability of the recordings 86.54+/-6.10%. The average monitoring time for the second period of labor is 36.72+/-8.31 min. with reliability of the recordings 75.42 +/-9.61%. The mean SpO2 values are 48.71+/-5.52% during the first period and 47.30+/-4.62% during the second period of labor. The reference SpO2 values ranging between the 25-th and 75-th percentile in fetuses with normal FHR are 46-52 % for the first and 44-50 % for the second period. The results for fetal SpO2 during the different stages of cervical dillatation are as follows: for 4-5 cm - 49.49+/-5.12%, for 6-7 cm - 48.76+/-5.42%, for 8-9 cm - 48.39+/-5.49%. The fetal SpO2 dispersal during cervical dillatation of 4-5, 6-7 and 8-9cm accordingly demonstrates a nonsignificant decrease of SpO2 for the different groups (p>0.05). The fetal SpO2 dispersal between the first and the second period of labor also demonstrates decrease of SpO2 values and shows a minor statistically significant difference (p < 0.05 - Repeated measures ANOVA), which is considered to be within the normal range and does not reflect on the newborn's well-being.

Recognition and significance of maternogenic fetal acidosis during intensive monitoring of labor.

FHR monitoring and microanalysis of fetal blood are mutually complementary procedures, and optimal knowledge of the fetal state is achieved by making use of both, the former for the preliminary screening of all cases at risk and the latter for the purpose of deciding on obstetric management where pathological changes are evident in the FHR. The major difficulty in obtaining a precise value for the fetal acid-base balance lies in the occurence of "falsely abnormal" cases, i.e. cases in which the fetal pH falls during labor but the clinical condition at birth is good (APGAR greater than or equal to 7). In our own series the incidence of such cases among fetuses at risk was 11.2% (Tab. I). In the majority of these cases the fetal acidosis is thought to be a result of increased metabolic acidosis in the mother (maternogenic fetal metabolic acidosis). The importance of the maternogenic fetal acidosis during labor lies in the fact that unless it is recognised, rapid extraction of the fetus will appear necessary on clinical grounds, although it is in fact unnecessary, since this form of acidosis has no adverse effect on the fetus. Various parameters have been proposed for the differential diagnosis of the maternogenic fetal acidosis. These include the feto-maternal difference in base deficit (F/M deltaBD), the materno-fetal differences in pHqu 40 (M/F deltapHqu 40) the materno-fetal difference actual pH (M/F actual deltapH), and the materno-fetal difference in base deficit of the extra-cellular fluid (M/F deltaBDHb5). A critical analysis of these parameters has been carried out on the results of microtests performed during a 5 year period (1968-1972) at the First Clinic of Obstetrics and Gynecology of Milan University. The cases comprised 59 regarded as normal (normal course of pregnancy, spontaneous commencement of labor at term, clear amniotic fluid, regular FHR, spontaneous birth, APGAR at 90 sec between 8 and 10, weight at birth greater than 2500 g), and 335 considered to be at risk (maternal disease, presence of meconium stained amniotic fluid and/or abnormal changes in FHR). In all of these cases the FHR was recorded by cardiotokography, and the tracings were interpreted according to HON. Microsamples of blood were taken from both mother and fetus during labor and the following determinations were carried out: actual pH, pHqu 40, Hb concentration, hemoglobin oxygen saturation, base deficit Hb5 (BDHb5). The maternofetal differences were then calculated. The same determinations were carried out on samples of maternal blood and of arterial and venous cord blood taken immediately after delivery. The clinical condition of the infant was evaluated by the APGAR score at 90 seconds after birth.

[Fetal monitoring during the active second stage of labor].

To determine the best way of fetal monitoring during the active second stage of labor. Articles were searched using PubMed and Cochrane library. Active phase of labor begins with the onset of maternal pushing. It is characterised by frequent and prolonged uterine contractions as well as maternal bearing down efforts. Altogether those mechanical forces lead to an intrauterine pressure increase up to 250 mm Hg and to a marked reduction in placental perfusion. A prolonged period of expulsion will lead to an impairment of fetal oxygenation as well as a rise in carbon dioxide level. Melchior's FHR classification is specific of the active second stage of labor and described five fetal heart rate patterns: from type 0 to type 4. A reduction in pH and a rise in lactate and P(CO2) values occurred as one progresses from type 0 to type 4 (NP4). During the active phase of labor every method has a significant rate of signal loss. Loss of sensor contact occurred in up to 64% of time with oximetry, 35 to 48% of recordings obtained via external Doppler sensors have more than 20% of signal loss. Even 8 to 11% of recordings obtained via scalp sensors have more than 20% of signal loss. Fetal scalp blood sampling does not allow a continuous recording of fetal well-being and is difficult to perform during this stage. No method has a 100% sensitivity to detect metabolic acidosis. Normal FHR of 1.3% are coupled with an acidosis. Even ST analysis exhibited a small but real false negative rate (NP4). Active second phase of labor is at high risk of fetal acidosis, and required a close follow-up of the FHR. The length of maternal bearing down efforts should be matched to the fetal heart rhythm Melchior's classification pattern. Optimal length of bearing down efforts could be 30 min for type 0, 20 min for type 1 and 10 min for type 2, 3 or 4 (NP4).

pH measurement from the fetus during labor--a task for the midwife?

After theoretical education on the development of fetal acidosis and the fetal blood sampling technique, 12 midwives in a training program carried out or assisted in 40 fetal blood sampling procedures. Sampling was possible at a cervical dilatation of 1.5 cm. 11/12 midwives were successful in their first sampling attempt. The instrument used for analysis was an automated microprocessor device with a minimum sampling volume of 15 microliter of blood. There was a statistically highly significant correlation between the results obtained with the instrument tested and the reference device (r = 0.9; n = 36). 82% of the measurements fell within +/- 0.04 pH units of the reference device. With the instrument placed in the labor room, and using the current technique with very small blood samples, it is possible to obtain a fetal pH value within 10 minutes after the development of a pathological fetal heart rate pattern.

Fetal heart rate pattern interpretation in the second stage of labor using the five-tier classification: impact of the degree and duration on severe fetal acidosis.

The aim of this study was to clarify the association between fetal heart rate (FHR) tracing interpretation levels in the second stage of labor and poor fetal acid-base balance. The database at one tertiary hospital in Nagoya, Japan, was retrospectively reviewed for women with singleton fetuses in cephalic presentation and vaginal labor at ≥37 + 0 gestational weeks between 1 June 2011 and 30 April 2012. Continuous FHR tracings in the second stage of labor were subdivided into 15-min intervals, each of which we called a window, from the beginning of labor through delivery, and were assessed according to the five-tier classification proposed by the Japan Society of Obstetrics and Gynecology, in which level 1 is normal, level 2 is subnormal, and levels 3-5 are abnormal patterns. In total, 777 parturient women were eligible for the study protocol. The numbers of women with maximal levels of 1, 2, 3, 4, and 5 were 3, 77, 341, 349, and 7, respectively. No cases of severe fetal acidosis (pH < 7.0 or base excess <-12 mmol/L) were recorded when the maximal levels were below 3. Both the pH and base excess of the umbilical artery decreased with higher levels of FHR tracings interpretation (P < 0.001). Both the summations of level-4 windows and level-3 and level-4 windows were significantly higher in women with severe fetal acidosis than in women without (P < 0.001), indicating that the duration of abnormal levels is associated with severe fetal acidosis. Both the degree and duration of FHR tracing abnormalities correlate with severe fetal acidosis.

The effect of labor on the normal values of umbilical blood acid-base status.

Although several investigators have attempted to define the normal values of umbilical cord blood pH and gases, there is considerable controversy about the optimal cutoff values to diagnosis intrauterine asphyxia. A possible reason for this might be that several studies have included data from fetuses born after different duration of labor. To determine the effect of labor and the duration of second stage on labor on umbilical arterial acid-base status at birth in healthy term infants. Umbilical artery acid-base status was determined in patients (n = 356) who met the following criteria: 1) singleton term pregnancy with no significant medical, obstetric, or neonatal complications; 2) vertex presentation if delivered vaginally; 3) neither regional nor general anesthesia applied if delivered vaginally; 4) no use of oxytocin; 5) normal fetal heart rate patterns; 6) clear amniotic fluid; 7) Apgar scores at 1 and 5 min > or = 7; 8) appropriate fetal weight for gestational age. Patients were divided into three groups. A-patients delivered by cesarean section (CS) in the absence of labor (n = 135); B-patients delivered by CS during first stage of labor (n = 62); C-patients with vaginal birth (n = 159). A Kruskal-Wallis ANOVA with post-hoc procedures and stepwise multiple regression analysis were performed. 1) There were significant differences in cord arterial acid-base values between study groups (pH: no labor CS, 7.27 +/- 0.05 vs labor CS, 7.26 +/- 0.05 vs vaginal birth, 7.24 +/- 0.07, p < 0.00001). 2) There was a significant fall in cord arterial pH and bicarbonate concentrations with increased duration of second stage of labor in newborns born vaginally (pH: duration of second stage, 1-30 min, 7.25 +/- 0.07 vs 31-60 min, 7.22 +/- 0.06 vs > 61 min, 7.21 +/- 0.07, p < 0.05). 3) Analysis of confounding variables which could influence the cord pH such as parity, use of vacuum, gestational age, maternal age, and birth weight by stepwise multiple regression analysis indicated that only the duration of second stage of labor pain had a significant relationship with cord blood pH. There is a significant fall in umbilical artery pH and bicarbonate with the presence of labor and increased duration of second stage of labor in healthy term neonates. This should be taken into consideration in evaluating neonatal well-being by cord blood pH and acid-base measurements.

Clinical usefulness of pulse oximetry in the fetus with non-reassuring heart rate pattern?

The objective of this study was the evaluation of intrapartum pulse oximetry as an indicator of fetal distress and the condition of the newborn during clinical routine surveillance in an University Perinatal Center. Between 1998 and 1999 pulse oximetry (SpO2) was used additionally to routine fetal monitoring by electronic fetal heart rate tracing (CTG) and fetal blood sampling (FBA) in 128 cases with nonreassuring heart rate pattern. Cut off values were FIGO Score < 8 for the heart rate pattern and for fetal blood sampling during labor results of < 7.25 (preacidosis). The condition of the newborn was defined by the APGAR score with the cut off < 7 at 1 minute, while the biochemical status was evaluated by means of arterial blood sampling of the umbilical artery directly after birth using a pH of < 7.20 to verify acidosis. Predictive values of critically low SpO2 values (< 30%) for at least 10 minutes as well as corresponding sensitivities and specificities were calculated together with 95% confidence intervals to identify fetal distress or a depressed condition of the newborns. Of 128 fetuses included in this study 66 (52%) were born spontaneously, 23 (18%) were born by operative vaginal delivery and 39 (31%) by means of cesarean section. The high rate of cesarean section was due to cephalopelvic disproportion in 29 cases. Fetal outcome was evaluated with a clinical score: mean APGAR score value 8.5 SD +/- 1. The mean value of the pH in the umbilical artery was 7.23 +/- 0.04. During a SpO2 monitoring period of 18,381 minutes we analyzed a contact time of 63%. Comparing SpO2 values of < 30% with preacidosis in the fetal blood sampling, we found a positive predictive value of merely 0.17 (95% CI: 0.00-0.64). Of 9 preacidotic cases during delivery only 1 was indicated by a saturation value below 30% (sensitivity 0.11, 95% CI: 0.00-0.48). The specificity and negative predictive value were calculated as 0.83 (95% CI: 0.65-0.94) and 0.76 (95% CI: 0.58-0.89) respectively. Of eleven cases with acidosis in the blood of the umbilical cord artery, pH < 7.20, only 2 were indicated by a SpO2 values below 30%. Which is equivalent to a sensitivity of 0.18 (95% CI: 0.03-0.52). Results of a receiver operator curve analysis showed no substantial deviation from the diagonal. The area under the curve was 0.62, the 95% CI (0.47-0.76) indicating no significant discrimination. Three of 49 fetuses with SpO2 recording during the last 10 minutes were born in clinical depressed status (APGAR < 7). None was indicated by a SpO2 value below 30%. Fetal distress and impaired condition of the newborn are not identified or predicted during routine application of SpO2 monitoring in the fetus during labor with adequate safety.

Impaired validity of the new FIGO and Swedish CTG classification templates to identify fetal acidosis in the first stage of labor.

Cardiotocography (CTG) is the main method of intrapartum fetal surveillance. In 2015 a new guideline was introduced by the International Federation of Gynecology and Obstetrics (FIGO), FIGO-15. In Sweden it was adjusted to SWE-17, replacing the previous national template, SWE-09. This study, conducted at one university hospital and one regional hospital in southern Sweden, evaluated the diagnostic validity of these three templates to detect fetal acidosis during the first stage of labor. A total of 73 neonates with pH <7.1 in umbilical cord artery or vein at cesarean delivery during the first stage of labor were identified retrospectively. For each acidotic neonate, three non-acidemic neonates, with a pH ≥7.2 in cord artery and vein, and Apgar scores ≥9 at five and ten minutes, in all 219 neonates, were selected. The CTG tracings before birth in acidemic neonates, and tracings at the same cervical dilatation in the non-acidemic neonates, were independently assessed by three professionals from the obstetric staff, blinded to group and clinical data. Based on their categorizations of the included variables (baseline, variability, accelerations, decelerations and contraction rate), each CTG tracing was systematically classified according to the three templates. The sensitivity and specificity to identify acidemia by the classification pathological were determined for each template. Interobserver agreement in the assessments of tracings as pathological or not was analyzed, using free-marginal Kappa index. The sensitivity for patterns classified as pathological to identify acidemia was similar for FIGO-15 (71%) and SWE-17 (77%, <ip</i = .13), and the specificity was 97% for both. SWE-09 had a significantly higher sensitivity (95%, <ip</i < .001) albeit with a lower specificity (90%, <ip</i < .001) than the other two templates. Among acidemic neonates, the fraction of tracings classified as normal was higher with SWE-17 (9.6%) than with SWE-09 (0%; <ip</i = .01) and FIGO-15 (1.4%; <ip</i = .06). For tracings from neonates with acidemia, agreement for three independent assessors was strong (κ 0.85) with SWE-09, and weak for FIGO-15 (κ 0.47), and SWE-17 (κ 0.51). For tracings from neonates without acidemia, the agreement was almost perfect for FIGO-15 (κ 0.91), strong withSWE-17 (κ 0.90) and moderate with SWE-09 (κ 0.78). The ability of FIGO-15 and SWE-17 to identify fetal acidosis is considered insufficient. The combination of a high sensitivity and a high specificity makes SWE-09 the most discriminatory template during the first stage of labor.

[Lowering the cesarean section rate by exclusion of cardiotocographically suspected acidosis using fetal blood gas analysis].

In 871 deliveries out of a total of 3980 effected during 1980-1982 at the Winterthur Gynaecological Hospital, we found it necessary to perform one or several microanalyses of blood (blood gas analyses) sub partu. Among these, we found retrospectively that in 22 cases the microanalysis of the blood gas had prevented us from performing caesarean section which would have seemed necessary if we had relied on the cardiotocographical findings alone. Micro-analysis of blood gas made it possible to exclude the presence of pre-acidosis or acidosis which would have made Caesarean section imperative; in all these cases, normal delivery via the vagina was achieved, and in no case did this result in severe acidosis. All newborn had a 5-minute Apgar score of 7 and higher. We can conclude from these results, therefore, that the indication for an immediate termination of delivery via Caesarean section should not depend solely on a pathological cardiotocogram; the final decision should be arrived at only after micro-analyses of blood gas have confirmed the presence of foetal pre-acidosis or acidosis.

Earlier and improved screening for impending fetal compromise.

The use of pH and base excess (FSSPHBE) from fetal scalp sampling (FSS) was abandoned when cardiotocography (CTG) was believed to be sufficiently accurate to direct patient management. We sought to understand the fetus' tolerance to stress in the 1st stage of labor and to develop a better and earlier screening test for its risk for developing acidosis. To do so, we investigated sequential changes in fetal pH and BE obtained from FSS in the 1st stage of labor as part of a research protocol from the 1970s. We then examined the utility of multiple of the median (MoM's) conversion of BE and pH values, and the capacity of Fetal Reserve Index (FRI) scores to be a proxy for such changes. We then sought to examine the predictive capacity of 1st stage FRI and its change over the course of the first stage of labor for the subsequent development of acidosis risk in the 2nd stage of labor. Using a retrospective research database evaluation, we evaluated FSSPHBE data from 475 high-risk parturients monitored in labor and their neonates for 1 h postpartum.We categorized specimens according to cervical dilatation (CxD) at the time of FSSPHBE and developed non-parametric, multiples of the median (MOMs) assessments. FRI scores and their change over time were used as predictors of FSSPHBE. Our main outcome measures were the changes in BE and pH at different cervical dilatations (CxD) and acidosis risk in the early 2nd stage of labor. FSSPHBE worsens over the course of the 1st stage. The implications of any given BE are very different depending upon CxD. At 9 cm, -8 Mmol/L is 1.1 MOM; at 3 cm, it would be 2.0 MOM. The FRI level and its trajectory provide a 1st stage screening tool for acidosis risk in the second stage. Fetal acid-base balance ("reserve") deteriorates beginning early in the 1st stage of labor, irrespective of whether the fetus reaches a critical threshold of concern for actual acidosis. The use of MoM's logic improves appreciation of such information. The FRI and its trajectory reasonably approximate the trajectory of the FSSPHBE and appears to be a suitable screening test for early deterioration and for earlier interventions to keep the fetus out of trouble rather than wait until high risk status develops.

Cardiotocography

Updated 2015 FIGO Intrapartum Fetal Monitoring Guidelines FIGO has recently modified the guidelines on intrapartum fetal monitoring, proposing the following interpretation: Normal: No hypoxia or acidosis; no intervention necessary to improve fetal oxygenation state. Baseline 110–160bpm Variability 5–25bpm No repetitive decelerations (decelerations are defined as repetitive when associated with >50% contractions) Suspicious: Low probability of hypoxia/acidosis, warrants action to correct reversible causes if identified, close monitoring or adjunctive methods. Lacking at least one characteristic of normality, but with no pathological features. Pathological: High probability of hypoxia/acidosis, requires immediate action to correct reversible causes, adjunctive methods, or if this is not possible expedite delivery. In acute situations, delivery should happen immediately. Baseline <100bpm Reduced or increased variability or sinusoidal pattern

Fetal distress

Signs and symptoms Generally it is preferable to describe specific signs in lieu of declaring fetal distress that include: Decreased movement felt by the mother Meconium in the amniotic fluid ("meconium stained fluid") Non-reassuring patterns seen on cardiotocography: increased or decreased fetal heart rate (tachycardia and bradycardia), especially during and after a contraction decreased variability in the fetal heart rate late decelerations Biochemical signs, assessed by collecting a small sample of baby's blood from a scalp prick through the open cervix in labor fetal metabolic acidosis elevated fetal blood lactate levels (from fetal scalp blood testing) indicating the baby has a lactic acidosis Some of these signs are more reliable predictors of fetal compromise than others. For example, cardiotocography can give high false positive rates, even when interpreted by highly experienced medical personnel. Metabolic acidosis is a more reliable predictor, but is not always available.

[Usefulness of the examination of fetal blood oxygen saturation (FSpO2) and fetal heart rate (FHR) as a prognostic factor of the newborn outcome].

Cardiotocography has become the standard for fetal monitoring in labor. False-positive findings during electronic fetal heart rate monitoring may were not associated with neonatal acidemia. Because of the poor specificity of fetal heart rate monitoring in predicting fetal distress, new methods are being investigated as a way to improve the accuracy of assessing the infant's condition during labor. The aim of this study was to determinate the efficiency of fetal blood oxygen saturation (FSpO2) and computer analysis of the fetal heart rate (Co-CTG) in the late 1-st stage of labor as a prognostic factor of newborn acidemia. Total 62 subjects were studied. During labors and deliveries fetal oxygen saturation was continuously recorded, with use of Nellecor N-400 fetal pulse oximeter and continous CTG were performed by Hewlett Packard 50A. Transdermal fetal oxygen saturation measurements and CTG results obtained during the labors was analyzed using MONAKO system (ITAM Zabrze). The results were compared with the values of pH and base deficit in the umbilical artery measured just after delivery. The sensitivity, specificity, negative, positive predictive values and Youden factor based on FHR and FSpO2, for prognosis of neonatal acidosis were: 65%, 80%, 16%, 97.5% 60% and 0.135 respectively FHR; and 100%, 60%, 100%, 96.8% and 0.968 respectively FSpO2. 1. The examination of fetal blood oxygen saturation in the labor is a useful prognostic factor of the newborn outcome. 2. The best predictive value for intrapartum fetal asphyxia with metabolic acidosis was found when fetal pulse oximetry is added to cardiotocography.

Cardiotocography

In a study by Tarvonen et al. (2019), it was demonstrated that the occurrence of saltatory pattern (already with the minimum duration of 2 minutes) in CTG tracings during labor was associated with fetal hypoxia indicated by high umbilical vein (UV) blood erythropoietin (EPO) levels and umbilical artery (UA) blood acidosis at birth in human fetuses. As saltatory patterns preceded late decelerations of fetal heart rate (FHR) in the majority of cases, saltatory pattern seems to be an early sign of fetal hypoxia. According to the authors, awareness on this gives obstetricians and midwives time to intensify electronic fetal monitoring and to plan possible interventions before fetal asphyxia occurs.

Obstentrics_Williams

If repeat test >6, observe and repeat per protocol Repeat testing same day; if biophysical profile score :;6, deliver Deliver AFV = amnionic fluid volume; NST = nonstress test. Reproduced with permission from Manning FA, Morrison I, Harman CR, et al: Fetal assessment based on fetal biophysical profile scoring: experience in 19,221 referred high-risk pregnancies. II. An analysis of false-negative fetal deaths, Am J Obstet Gynecol. 1987 Oct;157(4 Pt 1 ):880-884. I. ):J0 downstream impedance (Chap. 10, p. 213). For growth 7.30 7.25 0E:J E:J= 7.20 7.10 7.05 FIGURE 17-9 Mean umbilical vein pH (±2 SD) obtained by cordocentesis in relation to fetal biophysical profile score category. (Data from Manning, 1993.) API determination for which �5 cm was considered abnormal (Chap. 11, p. 230). his abbreviated biophysical proile required approximately 10 minutes to perform, and they concluded that it was a superb antepartum surveillance method because there were no unexpected fetal deaths.

Ultrasound Biophysical Profile -- Potential Diagnosis

Diagnosis and management must take into consideration maternal and fetal risk factors. A biophysical profile can only diagnose oligohydramnios or polyhydramnios. Otherwise, it is an indicator of fetal wellbeing reflecting the blood pH. A score of 8 to 10 is normal and provides reassurance that the risk of fetal asphyxia within 1 week is extremely low. Rates of this study being a false negative range from fetal death rates of 0.55 per 1000 to 0.83 per 1000. [2] A score of 6 is considered either equivocal or abnormal. If oligohydramnios is diagnosed, the study should be repeated in 24 hours or the patient should possibly be induced if at term. If the score is 6 and all the points off relate to fetal movement, this is more reassuring, but the study should be repeated in a short interval. A score of 2 to 4 is not reassuring, and the recommendation is to either move toward labor induction or cesarean section depending on what is most prudent. A score of 0 indicates impending fetal asphyxia and delivery should be by urgent cesarean section at a hospital with NICU capability.

[Evolution of indications for cesarean section between 1991 and 2000 in materials from the Pathology Clinic in the Department of Pregnancy and Labor, Pomeranian Medical University in Szczecin].

The present study was designed to analyze retrospectively the course of 2693 pregnancies and deliveries between 1999 and 2000 at the Department of Pathology of Pregnancy and Labor, Pomeranian Academy of Medicine in Szczecin. Attention was focused on the frequency of cesarean sections including preventive and urgent cases, obstetric and paraobstetric pathologies complicating pregnancy, perinatal and maternal mortality. The efficacy of diagnosing fetal distress in pregnancy and labor by continuous fetal monitoring with cardiotocography versus ultrasonography, in particular umbilical artery Doppler velocimetry, was studied. The material consisted of 2693 pregnant women (1476 (54.8%) primiparous and 1217 (45.2%) multiparous) aged 15-46 years, and their 2802 newborns. Gestational age varied between 23 and 43 weeks. Two groups were formed: I--1268 women delivering by cesarean section between 1991 and 1995; II--1425 women delivering by cesarean section between 1996 and 2000. In 1995/1996, complete ultrasonography supplemented with umbilical artery Doppler flow and intrauterine invasive intervention (cordocentesis, amnioinfusion, amnioreduction, intrauterine fetal blood transfusion) were introduced, as well as screening for diabetes in pregnancy and immunological tests for anticardiolipin antibodies. At that time, the Program of Improved Prenatal Care in Poland was fully implemented. Moreover, the Intensive Therapy of Newborns Uni was established at the Department of Pathology of Pregnancy and Labor. Depending on the moment the decision to perform cesarean section was taken, the prospective group was divided into two groups: antenatal (group P--1036 gravida) and intranatal (group S--1657 parturients). Depending on indications for cesarean section, urgent (N) were distinguished from preventive (Pr) cases. CTG interpretation was performe using qualitative and semi-quantitative Fischer's method. CTG recordings during labor were interpreted according to the qualitative method proposed by FIGO in 1987. An analysis of PI, S/D, RI, and flow curve (absence (AEDF) or reversion (REDF) of end-diastolic umbilical artery blood flow) in umbilical artery Doppler velocimetr was performed. A decrease of more than two standard deviations from average valu for several pregnancy time intervals was regarded as pathological. The absence (AEDF) or reversion (REDF) of end-diastolic umbilical artery blood flow was considered to be a high risk factor. The status of newborns was assessed using 5 min Apgar score and parameters o acid-base equilibrium in umbilical artery blood. The following conclusions were drawn: 1. Analysis of cases during the last decade of the 20th century revealed: --increased rate of cesarean sections with a shift in indications from urgent to preventive; --increase in obstetric risk associated with higher percentage of complication during pregnancy; --higher percentage of cesarean sections in premature labor; --correlation between premature labor and increased risk of poor newborn statu --decrease in perinatal mortality of newborns. 2. Analysis of methods for antepartum fetal monitoring revealed: --abnormal CTG patterns and abnormal blood flow in umbilical artery with ab sence or reversion of end-diastolic blood flow the coexistence of which were diagnostically effective for prediction of poor newborn status. 3. Analysis of fetal monitoring methods revealed: --normal intrapartum CTG patterns and normal antepartum blood flow in umbilical artery were markers of good newborn status; --abnormal CTG patterns and abnormal blood flow in umbilical artery had lim ited predictive value regarding poor newborn status. 4. Evolution of indications for cesarean section was multifactorial in character. New and more effective methods for fetal monitoring are needed.

["Quantitative cardiotocography"--clinical practice guideline].

The "quantitative cardiotocography" method provides important information about the condition of the fetus during labor, non-invasively and in real time. Since the forecast pH-results are being updated every 5 (five) minutes, significant differences in the readings for pH can be observed. In certain cases this can hamper the evaluation of fetal condition and lead to contradictions. Such inconveniences can be easily avoided by using the arithmetic average value of the last 6 forecast results for pH, generated by the quantitative cardiotocography software. Another inconvenience of the "quantitative cardiotocography" method lies in the fact that the components involved in the formation of CTG-score seem to be unequal in terms of potential for evaluating the fetal condition. Based on that, we believe that clinical practice guideline is needed. We developed such guideline based on two main criteria: the arithmetic average value over the last 6 (six) pH estimates; which components of the CTG-score are involved in the formation of the pH forecast readings. Our previous studies demonstrated that in 85% of all cases, the actual pH value of the newborn was in the range of -0037/+0046 from the average arithmetic value of the last six (6) pH estimates before the delivery. Based on this variability in the pH forecast results we defined three groups of findings--normal (pH 7.350 to 7.237), suspect (pH of 7.237 to 7.137) and abnormal (pH < 7.137). In another study, we differentiated several varieties of CTG-score (with very high, high, satisfactory and low predictive value), depending on the observed deviations between forecast and actual pH results. pH forecast results should always be assessed together with the composition of the CTG-score. This can be achieved by using the presented clinical guideline, which also contains recommendations for adopting specific obstetric behavior, based on the "quantitative cardiotocography" readings. In future studies we will investigate if it is possible the presented clinical practice guideline to replace fetal blood sampling for intrapartal assessment of the fetal condition. Further clinical studies will clarify whether the use of this clinical guideline could lead to a reduction in the incidence of metabolic acidosis in newborns or change the percentage of operative deliveries compared with the cases where classical indirect cardiotocography was used.

The effect of labor on maternal and fetal vitamins C and E.

This study was conducted to compare maternal and fetal plasma, amniotic fluid, and chorioamnion levels of vitamins C and E in term (>38 weeks' gestation) subjects undergoing elective repeat cesarean section (CS) without labor with values of subjects of similar gestational age and dietary intake undergoing labor and vaginal delivery (VD). Healthy women undergoing elective repeat CS (n = 5) or uncomplicated VD (n = 5) at term (>38 weeks' gestation) were studied. For CS patients, maternal and fetal (cord) blood, amniotic fluid, and chorioamnion samples were collected at time of surgery. For VD patients, maternal blood and amniotic fluid were obtained at 5 cm cervical dilation and fetal cord blood and chorioamnion were collected at delivery. Each patient completed a nutritional questionnaire. Plasma and membrane vitamin E concentrations were determined by reversed-phase high-performance liquid chromatography and standardized to cholesterol or membrane protein, respectively. Vitamin C was determined with the use of the 2,4-DNPH method. Dietary intakes for vitamins C and E as well as maternal and fetal vitamin E plasma concentrations were similar for CS and VD patients. In both groups, maternal levels were higher than fetal levels(P <.05). Chorioamnion membrane vitamin E measurements in both groups were similar. Vitamin C concentrations in CS and VD patients were highest in amniotic fluid, lower in fetal plasma, and lowest in maternal plasma. However, mean vitamin C concentrations in maternal plasma, amniotic fluid, and fetal plasma of VD patients were significantly lower, being only 20% +/- 6%, 29% +/- 11%, and 22% +/- 2% of values obtained from CS patients. During labor in healthy women at term, uterine contractile activity may generate reactive oxygen species (ROS) through the process of repetitive ischemia and reperfusion. With the significant depletion of vitamin C during labor, we speculate that water-soluble vitamin C scavenges ROS in the aqueous phase and recycles lipid-soluble vitamin E to combat ROS-induced tissue damage.

[A comparative study of the prognostic pH values of the fetus in utero, generated by the "quantitative cardiotocography" computer method, and the actual pH values measured immediately after delivery].

The presented methodology for quantitative evaluation of the cardiotocographic (CTG) findings unconditionally provides essential opportunities for improving the diagnostic potential in modern obstetric practice. Current literature data concerning the clinical application of this method are scarce. Credible clinical trials are needed to determine what is the correlation between estimated and actual values of the studied variables. A prospective study on 110 pregnant women was performed. All patients were monitored via indirect cardiotocography. The recordings were stored and analyzed by the computerized method for "quantitative cardiotocography". We compared the last prognostic fetal pH value, generated by the "quantitative cardiotocography" software during labor, with the actual pH measured from the umbilical artery (UA) of the newborn. For each of the stored CTG recordings we quantified the difference between the last forecast and the actual pH of the newborn. In 82% of these cases this difference was in range of -0081/+0074 from the projected results. However during the study we discovered that there is a significantly better correlation between the arithmetic average of the last 6 (six) predicted results and the actual pH of the newborn. In 85% of these cases the difference between forecast and actual pH values lies a in range of -0037/+0046. Using the arithmetic average of the last 6 (six) predicted results for pH leads to a significant increase in the clinical value of the "quantitative cardiotocography". More studied are needed if we are to find opportunities to further reduce the existing prediction variability.

Obstentrics_Williams

Because the biophysical proile is labor intensive and requires a person trained in sonography, Clark and coworkers (1989) used an abbreviated biophysical proile as a irst-line screening test in 2628 singleton pregnancies. Speciically, a vibroacoustic nons tress test was performed twice weekly and combined with TABLE 17-3. Interpretation of Biophysical Profile Score 10 Normal, nonasphyxiated fetus 8/10 (Normal AFV) Normal, nonasphyxiated fetus 8/8 (NST not done) 8/10 (Decreased AFV) Chronic fetal asphyxia suspected 6 Possible fetal asphyxia o to 2 Almost certain fetal asphyxia If amnionic fluid volume abnormal, deliver If normal fluid at >36 weeks with favorable cervix, deliver If repeat test :;6, deliver If repeat test >6, observe and repeat per protocol Repeat testing same day; if biophysical profile score :;6, deliver Deliver AFV = amnionic fluid volume; NST = nonstress test.

Postterm pregnancy

Baby Reduced placental perfusion – Once a pregnancy has surpassed the 40-week gestation period, doctors closely monitor the mother for signs of placental deterioration. Toward the end of pregnancy, calcium is deposited on the walls of blood vessels, and proteins are deposited on the surface of the placenta, which changes the placenta. This limits the blood flow through the placenta and ultimately leads to placental insufficiency, and the baby is no longer properly nourished. Induced labor is strongly encouraged if this happens. Oligohydramnios – Low volume of amniotic fluid surrounding the fetus. It is associated with complications such as cord compression, abnormal heart rate, fetal acidosis, and meconium amniotic fluid. Meconium aspiration syndrome – Respiratory compromise secondary to meconium present in infant's lungs. Macrosomia – Estimated fetal weight of ≥ 4.5 kg. It can further increase the risk of prolonged labor and shoulder dystocia.

Maternal and fetal plasma levels of free corticosteroids in pathological deliveries.

Does intrauterine acidosis induce increased steroid secretion? The concentration of free steroids (CS) increases in both fetal and maternal plasma during labor and delivery. Fetal levels are higher after vaginal than after cesarean section. These differences may indicate an important role of the fetal adrenal gland in the induction of labor or they may reflect merely the fetal response to the stress of delivery. During incrased intrauterine stress steroid secretion is increased as shown here. We examined 41 mothers and their infants during pathological labor. Pathology was assessed from fetal acidosis and/or a clinically obstetric disease of the mother or fetus. The 41 cases included 9 cesarean sections, 8 forceps deliveries; 24 spontaneous deliveries of which 7 were premature. At the time of delivery the pH and CS level were determined in maternal and umbilical vessels in all cases. During spontaneous labor blood samples were also taken during the different stages of labour. A competetive protein binding assay with transcortin without fractionation of the steroids was used. Progesteron was determined by the same assay. The level of this hormone, however, remains unchanged and hence any changes reflect changes in CS. The levels of CS were correlated with the pH values and compared to previously obtained normal values. During pathological deliveries CS levels in both mother and fetus are normal as long as there is no acidosis (Fig. 1). If acidosis is present the CS level in the umbilical artery is usually higher than normal. In 13 out of 18 vaginal deliveries the CS level was above normal, in the other 5 at the upper limit of normal (Fig. 1 and 2). At the same time the a--v difference becomes smaller and sometimes even negative. No changes were noted in maternal and umbilical venous blood (Tab. I and II). Similar dependence on the pH was found for cesarean sections (Tab. III). In premature deliveries without acidosis in the umbilical artery the CS levels were lower in both mother and fetus (Tab. I). These results indicate that the fetal adrenal gland reacts to acidosis, i.e., intrauterine stress, with increased corticosteroid secretion. This rise depends on the pH of fetal blood and not on the type of delivery (Fig. 3).

Severe variable decelerations and fetal pulse oximetry during the second stage of labor.

The aim of the study was to investigate the usefulness of fetal pulse oximetry in cases of severe variable decelerations in the second stage of labor. It is a prospective study including 58 patients. Thirty-eight patients (group A) had a normal uncomplicated labor and 20 patients (group B) developed severe variable decelerations during the second stage of labor. All patients were primiparous with normal pregnancies and had electronic fetal monitoring of labor in conjunction with fetal pulse oximetry. An estimation of fetal pH and base deficit was performed at delivery in all patients. There was no statistically significant difference in relation to maternal age and gestational age between the two groups. Group A patients did not delivered neonates with metabolic acidosis. Six out of 20 (group B) patients delivered neonates with a pH <7.10 despite a fetal pulse oximetry reading of >30%. It appears that fetal pulse oximetry is not capable of detecting pre-acidotic or acidotic fetuses during the second stage of labor in patients with severe variable decelerations and the management of such patients should be supported by fetal scalp pH when indicated or otherwise the obstetrician should expedite delivery either with assisted operative delivery or cesarean section. Fetal heart rate monitoring was introduced into clinical practice over 30 years ago. It continues to be the predominant method of intrapartum fetal surveillance despite worries about its accuracy and efficacy.

Intrapartum surveillance of IUGR fetuses with cardiotocography and fetal pulse oximetry.

To investigate the efficacy and safety of intrapartum fetal pulse oximetry, as a predictor of metabolic acidosis at birth of fetuses with intrauterine growth retardation (IUGR). We studied 18 IUGR fetuses (group I) and a control group of 30 appropriate for gestational age (AGA) fetuses (group II) during labor. Both groups had abnormal fetal heart rate tracings and were monitored simultaneously throughout labor with cardiotocography and fetal pulse oximetry. Apgar scores, pH and base excess of fetal blood obtained from the umbilical artery after delivery were compared in both groups. The Fetal Surveillance Unit of the 2nd Department of Obstetrics and Gynecology, Aretaieion Hospital, Medical School, Athens University. In IUGR fetuses, when their oxygen saturation value (FSPO2) was less than 34%, cord artery pH was 7.10 +/- 0.04, base excess -13 +/- -1 mmol/l and Apgar scores < or =5 at the 5th min, and when FSPO2 was over 35%, artery pH was 7.29 +/- 0.08, base excess -8 +/- -2 mmol/l and Apgar scores > or =7 at the 5th minute. In cases of drops of FSPO2)below 30% for more than 2 min, labor was completed operatively and cord pH was 7.00 +/- 0.04, base excess -15 +/- -2 mmol/l and Apgar scores < or =5 at the 5th minute. In AGA fetuses, when FSPO2 was over 30%, artery pH was over 7.20, base excess <-11 mmol/l and Apgar scores > or =9 at the 5th minute; in contrast, when FSPO2 was <30% for 2 min, a cesarean section was performed and cord pH was < or =7.02, base excess > or =-13 mmol/l and Apgar scores < or =4 at the 5th minute. In IUGR fetuses, FSPO2 values less than 34% represent an acidotic status, while values of > or =35% are well tolerated. Fetal pulse oximetry proved reliable, according to umbilical cord blood measurements and Apgar scores, reducing cesarean deliveries in cases of nonreassuring cardiotocographic patterns in IUGR fetuses.

[Determination of the mean pH of fetal blood during the pushing phase of labor].

The pH of the fetus and mother in the phase of pressing in 100 normal deliveries, which served as the control group, was analysed. An average decrease of the pH by 0.07 in both the fetus and the mother was recorded, starting from the full opening of the cervix until the termination of labour. This result is evaluated by the determination of the pH in 121 cases of disturbed pregnancies, singling out 9.9% of fetus in preacidosis and 11.6% of fetus in acidosis, which is significantly higher than in the control group. It is pointed out that the detection of acute fetal suffering in labour should not be limited to the time of opening only but that it should be carried out also in the phase of pressing.

Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect.

To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair. We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15). Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32-68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7-40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7-40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17-56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80-99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0-15%) had acidosis but normal Apgar scores. Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.

Fetal blood sampling in labor.

Cardiotocography is the most widely used method to monitor fetal well-being during labor. It has been shown that this technology is affected by a large intra and interobserver variability, that reduces its reliability. Moreover, it should be remembered that CTG is in condition to detect early fetal heart rate patterns that may indicate fetal hypoxaemia but it is not able to assess precisely the level of fetal compromise. This assessment can be done by examining fetal blood for pH that can be easily obtained in labor. If present, the level of acidemia, is established by measuring the pH which can be of practical use in clinical management. Values above 7.24 are considered normal, and pH values lower than 7.20 are expression of fetal acidemia requiring a quick delivery. The technique of FBS can be easily performed with very few complications. The main indication is one of the abnormal or suspicious CTG patterns. By using FBS is a complementary diagnostic tool to CTG it is possible to reduce the number of false positive thus reducing the number of unnecessary obstetrical interventions.

Manual fetal stimulation during intrapartum fetal surveillance: a randomized controlled trial.

Manual fetal stimulation, either by mechanical manipulation or by stimulation of the fetal scalp, is known to evoke a fetal heart response in a normal fetus. This study aimed to assess the clinical effectiveness of manual fetal stimulation in the assessment of fetal well-being during labor vs no stimulation among women with a singleton pregnancy and to investigate the maternal and neonatal outcomes in the 2 groups. This was a randomized controlled trial conducted in the department of obstetrics and gynecology at a tertiary care teaching hospital between 2014 and 2016. The inclusion criteria included women with a singleton pregnancy at ≥37 weeks of gestation with cephalic presentation in labor having one of the following abnormalities on fetal heart tracing: fetal heart rate of <110 bpm or >160 bpm, variable decelerations, late decelerations, and minimal or absent beat-to-beat variability. The exclusion criteria included women requiring immediate cesarean delivery, conditions that would preclude a vaginal delivery, and intrauterine fetal demise or a major fetal congenital abnormality. The women were followed up in labor and randomized to either the manual stimulation group or the no stimulation group when one of the cardiotocography abnormalities were present. In the manual stimulation group, the fetus was stimulated abdominally by holding the head in the palm of 1 hand when the cervical dilatation was <3 cm or vaginally by pinching the scalp of the fetus when the cervical dilatation was ≥3 cm. After delivery, a cord blood sample was collected and pH estimated. Mother and baby were followed up until discharge, and mode of delivery, cord blood pH at birth, Apgar scores at 1 minute and 5 minutes, neonatal intensive care unit admissions, and duration of stay were the outcomes studied. Data were entered and compiled as frequency and percentage for categorical variables. For continuous variables, data were calculated using mean and standard deviation. The chi-square test was used for assessing the association between the intervention and fetal and maternal outcomes. A total of 327 women were included in the trial, of whom 164 were in the manual fetal stimulation group (group 1) and 163 were in the "no stimulation" group (group 2). The cesarean delivery rates were 25.61% in group 1 and 30.67% in group 2 (P=.308). The mean cord blood pH levels at birth were 7.267±0.027 in group 1 and 7.265±0.024 in group 2 (P=.479), and the Apgar scores at 1 minute and 5 minutes (P=.169 and P=.423, respectively, between the 2 groups) were not found to be statistically different among the 2 groups. There was no considerable change in fetomaternal outcomes with manual fetal stimulation in women having nonreassuring cardiotocographic changes in labor.

Fetal monitoring in labor: are accelerations good enough?

To investigate whether accelerations of the fetal heart rate in response to scalp stimulation (the scalp stimulation test) before fetal scalp blood sampling (FBS) are such a good predictor of fetal well-being as to render the FBS unnecessary. A retrospective observational study. Cardiotocograms (CTG) from 54 fetuses during labor in whom 70 FBS procedures were performed, were analysed by an investigator blinded to the outcome, to determine whether accelerations were present in response to fetal scalp stimulation during vaginal examination (VE) prior to the FBS. This was compared with the pH obtained at FBS in a 2 x 2 table. The primary outcome measure was the false negative rate of the scalp stimulation test. There were accelerations at 48 VEs before FBS (n = 70). In five cases there was fetal acidosis (pH<or=7.20). Three of these five fetuses had accelerations at VE, giving a false negative rate of 6.25%. These data do not support previous reports that accelerations in response to fetal scalp stimulation before FBS exclude fetal acidosis when the CTG is suspicious and FBS is otherwise indicated. A larger sample may help answer this question.

Root Cause Analysis and Medical Error Prevention -- Function -- Case Example 3

A 26-year-old primigravida woman with labor pains was admitted to a busy hospital's labor and delivery suite at 39 weeks of gestation. There were no associated high-risk factors. The patient was admitted to the labor ward and managed according to routine protocol. She progressed in spontaneous labor, but the cardiotocograph showed prolonged fetal bradycardia lasting for 3 and a half minutes at 4 centimeters (cm) cervical dilatation. The fetal bradycardia did not resolve with initial conservative measures.