Maternal position during labor: effects on fetal oxygen saturation measured by pulse oximetry
Objective
To determine the effects of maternal left lateral, right lateral, and supine positions during labor on fetal oxygen saturation measured by pulse oximetry. Methods:Fetal oxygen saturation measured by pulse oximetry was obtained in 15 laboring women randomly and successively adopting left lateral, supine, and right lateral positions for 10 minutes each. Repeated measures analysis of variance was used for statistical analysis.
Results
Changes in fetal oxygen saturation were observed in different maternal positions. The supine position was associated with a lower fetal oxygen saturation than the left lateral position. One supine hypotensive syndrome occurred and was associated with a drop in fetal oxygen saturation.
Conclusion
Maternal supine position during labor is associated with a lower fetal oxygen saturation than the left lateral position.
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Fetal Heart Rate Auscultation, 4th Edition
2024, Nursing for Women's HealthIntermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women’s Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.
Fetal Heart Rate Auscultation, 4th Edition
2024, JOGNN - Journal of Obstetric, Gynecologic, and Neonatal NursingIntermittent auscultation (IA) is an evidence-based method of fetal surveillance during labor for birthing people with low-risk pregnancies. It is a central component of efforts to reduce the primary cesarean rate and promote vaginal birth (American College of Obstetricians and Gynecologists, 2019; Association of Women’s Health, Obstetric and Neonatal Nurses, 2022a). The use of intermittent IA decreased with the introduction of electronic fetal monitoring, while the increased use of electronic fetal monitoring has been associated with an increase of cesarean births. This practice monograph includes information on IA techniques; interpretation and documentation; clinical decision-making and interventions; communication; education, staffing, legal issues; and strategies to implement IA.
Heterogeneity in management of category II fetal tracings: data from a multihospital healthcare system
2023, American Journal of Obstetrics and Gynecology MFMElectronic fetal monitoring is widely used to identify and intervene in suspected fetal hypoxia and/or acidemia. Category II fetal heart rate tracings are the most common class of fetal monitoring in labor, and intrauterine resuscitation is recommended given the association of category II fetal heart rate tracings with fetal acidemia. However, limited published data are available to guide intrauterine resuscitation technique selection, leading to heterogeneity in the response to category II fetal heart rate tracings.
This study aimed to characterize approaches to intrauterine resuscitation in response to category II fetal heart rate tracings.
This was a survey study administered to labor unit nurses and delivering clinicians (physicians and midwives) across 7 hospitals in a Midwestern healthcare system spanning 2 states. The survey posed 3 category II fetal heart rate tracing scenarios (recurrent late decelerations, minimal variability, and recurrent variable decelerations) and asked participants to select first- and second-line intrauterine resuscitation management strategies. The participants were asked to quantify the level of influence certain factors have on their choice using a scale from 1 to 5. Intrauterine resuscitation strategy selection was compared by clinical role and hospital type (nurses vs delivering clinicians and university-affiliated hospital vs non–university-affiliated hospital).
Of 610 providers invited to take the survey, 163 participated (response rate of 27%): 37% of participants from university-affiliated hospitals, 62% of nurses, and 37% of physicians. Maternal repositioning was the most selected first-line strategy, regardless of the type of category II fetal heart rate tracing. First-line management varied by clinical role and hospital affiliation for each fetal heart rate tracing scenario, particularly for minimal variability, which was associated with the most heterogeneity in the first-line approach. Previous experience and recommendations from professional societies were the most influential factors in intrauterine resuscitation selection overall. Of note, 16.5% of participants reported that published evidence did not influence their choice at all. Participants from a university-affiliated hospital were more likely than participants from a non–university-affiliated hospital to consider patient preference when selecting an intrauterine resuscitation technique. Nurses and delivering clinicians differed significantly in the rationale for management choices: nurses were more often influenced by advice from other healthcare providers on the team (P<.001), whereas delivering clinicians were more influenced by literature (P=.02) and ease of technique (P=.02).
There was significant heterogeneity in the management of category II fetal heart rate tracing. In addition, motivations for choice in intrauterine resuscitation technique varied by hospital type and clinical role. These factors should be considered when creating fetal monitoring and intrauterine resuscitation protocols.
Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) – Maternal postures during the second stage of labour, delivery techniques and perineal protection
2020, Gynecologie Obstetrique Fertilite et Senologiedécrire l’influence des postures maternelles lors du second stade du travail sur le déroulement du travail, le mode d’accouchement et la morbidité maternelle et néonatale. Décrire les différentes techniques de l’accouchement par voie basse spontanée et leur influence sur la morbidité maternelle et néonatale. Décrire les différentes techniques de protection périnéale.
Revue systématique de la littérature par consultation des banques de données Medline, Cochrane et des recommandations internationales.
Il n’existe pas de posture particulière ayant fait preuve de sa supériorité (Niveau de preuve [NP] NP2). En l’absence de contre-indication et sous réserve d’une surveillance maternelle et fœtale préservée, il est recommandé d’encourager les femmes à adopter les postures qu’elles jugent les plus confortables lors du second stade du travail (Avis d’experts (AE)). Il n’existe pas de données suffisantes dans la littérature permettant de recommander une technique de dégagement de la tête et des épaules fœtale. Il n’existe pas de données suffisantes dans la littérature permettant de recommander l’utilisation de la manœuvre de Ritgen (grade B), le massage périnéal (grade C) ou l’application de compresses chaudes (AE). L’expression abdominale doit être abandonnée (grade B).
Le second stade du travail est un moment crucial du travail pouvant entraîner une morbidité maternelle et néonatale importante. Il est nécessaire de prendre le plus grand soin à la surveillance et à la prise en charge des parturientes et notamment en termes de protection périnéale. L’influence des techniques non médicamenteuses sur le déroulement du second stade du travail doit être étudiée.
To assess maternal postures during the second stage of labour on course of labour, mode of delivery and maternal and neonatal morbidity. To describe the different techniques of spontaneous vaginal delivery and their influence on maternal and neonatal morbidity. To describe the different perineal protection techniques.
Systematic review of the literature through consultation of Medline, Cochrane databases and international recommendations.
There is no particular posture that has demonstrated its superiority (Level of Evidence (LE) 2). In case of no contraindication and permanent maternal and fetal monitoring, it is recommended to encourage women to adopt the postures they consider most comfortable during the second stage of labour (Consensus agreement). There is insufficient evidence in the literature to recommend a technique for fetal head and shoulders delivery. There is not enough data in the literature to recommend the use of Ritgen maneuver (grade B), perineal massage (grade C) or hot compresses (Consensus agreement). The abdominal expression must be abandoned (grade B).
The second stage of labour is a crucial time in labour that can lead to significant maternal and neonatal morbidity. It is necessary to take the greatest possible care in the supervision and management of women, especially for the perineal protection. The influence of non-medicinal techniques on the course of the second stage of labour should be studied.
Effect of anaesthesia on neonatal outcome
2020, Anesthesie et ReanimationTout traitement qui peut modifier la perfusion placentaire, l’oxygénation fœtale ou agir directement sur le fœtus peut théoriquement modifier les outcomes fœtaux. Il est possible de prédire les effets de l’anesthésie sur le pronostic fœtal si on tient compte de plusieurs marqueurs : Score d’Apgar, gazométrie détaillée (pH mais aussi réserve alcaline, lactates), scores comportementaux (Sarnat et NACS). Une acidose métabolique sévère avec un score de Sarnat 3 est de mauvais pronostic neurologique. Des enregistrements EEG et IRM sont nécessaires pour compléter le pronostic. Pratiquement toutes les molécules d’anesthésie franchissent le placenta. Cependant, leurs effets néonataux sont modestes et sans conséquences immédiates. Seule des perfusions prolongées de propofol et de rémifentanil peuvent affecter la vitalité fœtale immédiate. Certaines techniques, en particulier la rachianesthésie, peuvent induire une baisse de la perfusion placentaire et donc une acidose métabolique chez le fœtus. Les vasopresseurs corrigent cette hypoperfusion. Parmi eux, seule l’éphédrine a un effet métabolique chez le fœtus. À très forte dose, elle peut induire une acidose qui se corrigera rapidement après la naissance. En soit, l’analgésie neuraxiale obstétricale comprenant des anesthésiques locaux à faible dose et des additifs divers (morphiniques, clonidine, dexmédétomidine) sont sans effet direct sur le pronostic fœtal. Si la pression artérielle maternelle est maintenue proche de 90 % des valeurs basales au cours d’une césarienne, le pronostic fœtal n’est pas modifié par la technique d’anesthésie. L’injection de morphiniques en intrathécal peut provoquer une hypertonie utérine avec bradycardie fœtale, mais sans effet sur le pronostic fœtal. Une PCA intraveineuse aux morphiniques aux doses recommandées a peu d’effets néonataux. L’oxygénation maternelle et la bascule de la table opératoire à 15 ° n’améliorent que rarement l’oxygénation fœtale.
Any therapeutic that can modify placental perfusion, foetal oxygenation or act directly on the foetus can theoretically affect foetal outcomes. It is possible to predict the effects of anaesthesia on foetal prognosis using the following markers: Apgar score, detailed arterial gas measurement (pH, base excess, lactate), behavioural scores (Sarnat and NACS). Severe metabolic acidosis with Sarnat score = 3 is associated with poor neurological prognosis. EEG recording and MRI examination are required to complete the prognosis assessment. Almost all of the anaesthetic drugs do cross the placental barrier. However, their neonatal effects are modest and do not lead to immediate consequences on foetal vitality. Only prolonged infusion of propofol and remifentanil can affect immediate foetal vitality. Some anaesthetic techniques, in particular spinal anaesthesia, can induce a decrease in placental perfusion and consequently metabolic acidosis in the foetus. Infusion of vasopressors corrects this state of hypoperfusion. Of these, only ephedrine has metabolic effect in the foetus. At very high doses, it can induce acidosis which will be corrected spontaneously and quickly after birth. In itself, obstetric neuraxial analgesia with low dose of local anaesthetics and various adjuvants (morphine, clonidine, dexmedetomidine) do not have any direct effect on foetal prognosis. If maternal blood pressure is kept around 90% of basal values during caesarean section, the foetal prognosis will not be affected by the anaesthesia technique. Injection of intrathecal opioid may cause uterine hypertonia with foetal bradycardia without any consequence on the foetal prognosis. Intravenous PCA with opioids at recommended doses has little neonatal effect. Maternal oxygenation and tilting of the operating table to 15 ° rarely improve foetal oxygenation.
Response to category II tracings: Does anything help?
2020, Seminars in PerinatologyElectronic fetal monitoring (EFM) is the most commonly used tool to screen for intrapartum fetal hypoxia. Category II EFM is present in over 80% of laboring patients and poses a unique challenge to management given the breadth of EFM features that fall within this category. Certain Category II patterns, such as recurrent late or recurrent variable decelerations, are more predictive of neonatal acidemia than others. A key feature among many published algorithms for Category II management is the use of intrauterine fetal resuscitation techniques including maternal oxygen administration, amnioinfusion, intravenous fluid bolus, discontinuation of oxytocin, and tocolytic administration. The goal of intrauterine resuscitation is to prevent or reverse fetal hypoxia. This is most likely to be successful if the etiology of the Category II EFM pattern is identified and targeted resuscitative measures are performed.