Current Women's Health Reviews - Volume 9, Issue 3, 2013

Electronic fetal monitoring (EFM) via cardiotocography was introduced into clinical practice over four decades ago. The intent of fetal monitoring is secondary prevention and early recognition of fetal compromise, including hypoxia and acidosis, so that fetal death can be prevented. Clinical research has failed to show that EFM improves neonatal outcomes including cerebral palsy and has not been shown to be superior to intermittent auscultation. Moreover, EFM is associated with increased rates of operative delivery. Despite the shortcomings of this method of fetal assessment, the use of cardiotocography is widespread in clinical practice. Though largely unchanged in recent decades, a basic understanding of the technology involved in the collection and analysis of the monitoring data is necessary for clinicians to be able to interpret and intervene when indicated. The objective of this review is to provide an overview of basic concepts and technical aspects of commonly employed methods of fetal monitoring.

Electronic fetal monitoring is the recommended method of intrapartum fetal surveillance in high risk pregnancies and the cardiotocography (CTG) forms an integral part of intrapartum care on most modern labour wards. Despite the questions about its efficacy and controversy regarding increased rates of operative delivery associated with its use, continuous CTG remains the predominant method of intrapartum fetal monitoring. Although CTG is sensitive in detecting abnormalities of fetal heart rate (FHR), its specificity for detection of fetal hypoxia is low and therefore confirmatory tests such as fetal scalp blood sampling or analysis of fetal electrocardiography (ECG) become necessary. The intrapartum CTG trace forms a central piece of documentary evidence in litigations related to adverse perinatal outcomes which are alleged to have arisen due to events that took place during the labour and/or delivery of the baby. The main reasons for litigation are not just for recovery of costs determined by injury, pain, loss and future care of a brain damaged child; but the parents also want to know what happened and why, and expect the healthcare staff to be held accountable for their actions. Majority of medico-legal cases have similar problems which can be laid down to a few factors such as - a) inability to interpret FHR trace, b) inappropriate action, c) technical aspects and d) record keeping. Not only can litigations have long-term consequences for the working lives of midwives or obstetricians but they have been influential in changing practice trends such as rising caesarean rates. Unfortunately obstetric litigation with its huge costs is a growing problem and for the foreseeable future, the CTG is here to stay. The best defence against litigation is good clinical practice with adherence to evidence based guidelines and regular mandatory training in the interpretation of CTG for all labour ward staff. There should be a mechanism for the rapid review of adverse obstetric events and dissemination of key learning points to all staff.

The introduction of intrapartum fetal monitoring has failed to achieve one of its major goals - to reduce perinatal morbidity and mortality secondary to intrapartum hypoxic events. Despite this, it remains at common place in labour wards around the world. Although there is now a much greater understanding of fetal physiology and the fetus’ normal adaptation in labour, there continues to be around 500 intrapartum stillbirths in the UK each year, many with avoidable factors that are related to cardiotocograph (CTG) misinterpretation. This review article aims to consider the mechanisms for the control of the fetal heart rate as well as features of a normal CTG. It also discusses the physiology behind abnormal fetal heart rate patterns in labour and by explaining these changes in terms of physiological mechanisms, it is hoped that readers will better understand how the fetus adapts in labour and hence guide appropriately timed intervention rather than intervention based purely upon pattern recognition.

Continuous electronic fetal heart rate monitoring (EFM) using a cardiotocograph (CTG) is associated with a high false positive rate of approximately 60%. Current scientific evidence does not support a significant reduction in perinatal mortality or cerebral palsy, except for a 50% reduction in neonatal convulsions. Recent scientific evidence has questioned the role of ‘peripheral’ tests of fetal wellbeing such as fetal scalp blood sampling (FBS), fetal scalp lactate and fetal pulse oximetry in reducing the false positive rate of CTG. Fetal ECG (ST-Analyzer or STAN) shows promise in reducing neonatal admissions and operative vaginal births. Computerized CTG analysis and Fetal Physiological Score (FPS) may help reduce errors associated with CTG interpretation.

Electronic fetal heart rate monitoring (EFM) in labour began its evolution in 1950s and became commercially available in late 1960s. EFM was introduced to identify those fetuses that were exposed to intrapartum hypoxia and were not able to tolerate ongoing hypoxic stress. Failure of compensatory mechanisms could lead to the development of respiratory and/or metabolic acidosis secondary to the intrapartum hypoxic insult, which if left undetected and treated, may have severe consequences. These include long-term implications such as learning difficulties, cerebral palsy and in some cases, increased risk of perinatal deaths. Use of EFM in high-risk labour has been associated with a significant reduction in fetal mortality rates and early onset neonatal seizures. The purpose of this article is to revisit the relatively uncommon findings of sinusoidal, overshoot and saltatory patterns in a cardiotocograph (CTG), their clinical implications and the approach to managing them in labour.

Substance abuse and addiction are a major burden to society, both in financial costs and public health. Biologic and psychosocial differences in substance misuse exist between sexes. These differences influence the prevalence, presentation, comorbidity, and treatment of substance use disorders and suggest that a tailored and personalized approach should be developed specifically for women. Likewise, mental illness in women who also have a substance use disorder is common. This understudied and undertreated population represents a population that is vulnerable to poor mental and physical health outcomes. This paper will briefly examine the importance of addressing treatment specifically tailored to women and will discuss the further implications of substance abuse in women who have severe mental illness. Future pharmaocologic and psychosocial treatments should be tailored for women, particularly those who are dually diagnosed.

Objective: To determine frequency, transcription and integration rates for high risk Human papillomavirus (HR HPV) types 16 and 18 in neoplastic cervical tissue of women with systemic lupus erythematosus (SLE). Methods: Cervical tissue of cervical intraepithelial neoplasia 1 (CIN 1) or greater severity were obtained from 112 women with SLE. HPV typing and integration was assessed by polymerase chain reaction (PCR) using primers specific for HPV 16 and 18 located in the open reading frames E7, E2, and E5. A commercially available kit was employed for transcriptional analysis of samples positive for HPV DNA types 16 or 18. Results: For the 112 SLE patients, 80.3% of the cervical biopsies were CIN 1 or CIN2 , 15.2% CIN 3, and 4.5% carcinoma in situ/ invasive cancer. HPV DNA 16 and 18 were detected in 20.5%, mostly type 16. Low integration and transcription rates were seen. There was no association of disease severity or immunosuppressive drugs with the presence of HPV DNA or RNA. Conclusion: The paucity of HR HPV along with lack of detectable viral transcripts, are unexpected findings and suggest HPV is latent in CIN lesions in SLE. Host- HPV interactions in this group of immunosuppressed women warrant further study.

Bedside teaching is a commonly used educational tool in obstetrics and gynecology. In this clinical commentary, we analyzed and reviewed strategies for bedside teaching and guidelines for its use, and discussed its advantages and disadvantages. Electronic databases were searched for the period covering the years 2000 to 2012 for studies in the English language with the main outcome measure of the effectiveness of bedside teaching as an educational modality. There are no specific publications in the literature that address this issue in obstetrics and gynecology. Based on the literature in other settings, we infer that bedside teaching in obstetrics and gynecology is an effective teaching tool and should be studied further to determine its optimal usage as a teaching modality. The setting of labor and delivery is the most poignant example of bedside teaching in obstetrics and gynecology.

Objectives: The aim of this study is to deliberate the dynamics of reproductive health care, abortion and the role of nurses in Turkey in a comparative manner. Terms related to reproductive health have been highlighted in order to bring clarity to the conceptual framework of the topic. This topic has always been evaluated in Turkey from a legislative viewpoint and has not primarily been evaluated from the ethical viewpoint. Furthermore, majority of women in Turkey and all around the world might have not made free decision in certain circumstances. When it comes to practice, there are other factors to consider rather than the legal viewpoint such as women can often communicate better with nurses in the health care institutions than others. Methods: A small survey was carried out between September 2011 and December 2012. Initially, we prepared a questionnaire for nurses and we learned their attitudes to the topic. 50 nurses in Ankara in two big hospitals and 50 nurses in Istanbul in two big hospitals were interviewed and asked 11 questions about abortion and the female reproductive health care. Results: It was concluded that abortion has been used as a family planning tool. Women especially from rural areas have not been well educated about reproductive health care and when they have problems they have a tendency to leave the decision to men. Women in rural areas in Turkey cannot access health care service easily because of their socio-economic conditions. Nurses seem to be the center of communication with women in the health care service. Discussion: There is an ongoing debate about reproductive health care problems and abortion as ethical issues in today’s Turkey as well as in today’s globalizing world. Since culture dependent factors are crucially important, nurses should be well educated about cultural values, different attitudes, relevant ethical implications and behavioral reflections. Otherwise, techniques and strategies might be applied but without success or convincing results.