Managing nonreassuring fetal heart rate patterns before cesarean delivery. Compliance with ACOG recommendations.

OBJECTIVE: To determine the rate of compliance with current American College of Obstetricians and Gynecologists (ACOG) recommendations for management of parturients undergoing cesarean delivery for persistent nonreassuring fetal heart rate (FHR) tracings. STUDY DESIGN: We performed a retrospective chart review (July 1995-June 1998) of all parturients who underwent cesarean delivery for nonreassuring FHR tracings. Outcome measures included maneuvers for fetal assessment (scalp stimulation or scalp blood pH) and therapeutic interventions (tocolytic agents for reducing uterine activity or amnioinfusion). Patients with multiple gestations and cesarean delivery for other indications were excluded. Student's t test, chi 2 and Fisher's exact tests were used; odds ratio and 95% confidence interval were calculated. P < .05 was considered significant. RESULTS: Cesarean delivery for persistent nonreassuring FHR patterns included 134 (3.6%) of the 3,671 deliveries during three years. Thirty patients produced intrapartum FHR tracings containing persistent variable decelerations; 12 (40%) of these patients received amnioinfusion. In only 37% (50/134) of cases was there a documented attempt at scalp or acoustic stimulation prior to delivery. Scalp pH was obtained in 15% (15/98) of patients whose cervix was at least 3 cm dilated. Tocolytic agents were used for intrauterine resuscitation in 25% (34/134) of cases; their use varied significantly (P = .006) with the type of FHR abnormality. CONCLUSION: At our tertiary center, ACOG recommendations for management of nonreassuring intrapartum FHR tracings were used in a limited number of cases.

Prenatal care and multiple pregnancy.

Prenatal care of multiple pregnancy presents a variety of nursing challenges. Specialized care, beginning in early pregnancy, can have a significant impact on the outcome for mothers and neonates. Dramatically increasing roles for advanced technology in the care of multifetal pregnancies must be balanced with families' needs for education and support.

Intrapartum care for women with multiple pregnancy.

Intrapartum management of multiple pregnancy presents many challenges for obstetric nurses. Optimal care often is complicated by prematurity, low and very low birth weights, and the unique circumstances of the delivery of multiple neonates. Higher perinatal mortality for multiple pregnancies continues to complicate delivery outcome. Nurses need special knowledge and skills to provide care for women with a variety of high-risk conditions in rapidly changing situations.

Correlation of antepartum uterine activity and cervical change in twin gestation.

OBJECTIVE: To determine the correlation between quantitative measurements of antepartum uterine activity and cervical change twin gestations. METHODS: Forty women from our Twin Clinic constituted the study group. Participants had a cervical examination each week between 20 and 37 weeks gestation and a cervical score (CS) was calculated as follows: CS = cervical length (cms)-cervical dilation (cms) at the internal os. The women also performed blinded home uterine activity monitoring (HUAM) for a mean of 7.0 + 3.0 hrs/wk (+SD). Uterine activity was expressed as mean number of contractions/hour/week gestation based on the average of three independent reviewers. CS was determined by a single clinician unaware of the HUAM recordings. A significant change in the CS was defined as a reduction of at least 0.5 from the preceding week. Correlation coefficients were used to determine the association between uterine activity and change in the cervical score. RESULTS: Twin pregnancy was characterized by a rise from 0.2 + .03 contractions/hr at 20 weeks to 3.2 + 2.4 contractions/hr at 37 weeks gestation. CS fell from a mean of 2.6 + 0.2 at 20 weeks to -2.1 + 0.9 at 37 weeks gestation. There was a significant negative correlation (-0.317, p < .0001) between increasing uterine activity and decreasing CS. There were significantly more (p < .002) contractions during the 7 days preceding a significant reduction in CS (3.3 + 3.5 contractions/hr) than when the CS was unchanged (1.6 +/- 1.5 contractions/hr). CONCLUSIONS: In twin gestations, an increasing frequency of uterine contractions is strongly correlated with quantifiable cervical change between 20-37 weeks gestation. Persistent daytime contraction frequencies of > 3/hr represent a risk factor for cervical dilation and/or effacement.

Prospective determination of chorionicity, amnionicity, and zygosity in twin gestations.

OBJECTIVE: Our purpose was to determine the predictive accuracy of a composite ultrasonographic evaluation for chorionicity, amnionicity, and zygosity in a consecutive series of twins. STUDY DESIGN: One hundred ten consecutive twins were seen for ultrasonography beginning January 1992. Chorionicity, amnionicity, and, zygosity were prospectively assessed with a composite of ultrasonographic findings (placental number, fetal sex, membrane thickness, and "twin peak" sign). Clinical and pathologic confirmation of chorionicity, amnionicity, and zygosity was available on 100 of these twins. RESULTS: The 100 twins had 3.6 +/- 1.6 ultrasonographic scans each (mean +/- SD) with the first performed at 22.6 +/- 6.9 weeks. Chorionicity, amnionicity, and zygosity were each predicted with > or = 91% sensitivity and specificity. In 35 (35%) cases zygosity could not be determined by either ultrasonographic or clinical or pathologic assessment at delivery. CONCLUSION: Chorionicity, amnionicity, and zygosity have important implications for antepartum management and prognosis of twins. By use of a composite of ultrasonographic findings, chorionicity, amnionicity, and zygosity were predicted with excellent reliability when they were prospectively tested in a heterogeneous consecutive series of twins.

Antepartum management of the multiple gestation: the case for specialized care.

Multiple gestations are increasingly more common and represent one of the highest risk conditions faced in pregnancy. The population-attributable fetal and newborn risks of twin and triplet gestations are compelling. This article is dedicated to a discussion of the antepartum management of multiple gestations and a conclusion that specialized care can improve both perinatal morbidity and mortality in these pregnancies. Prenatal care for multiple gestations should be provided by an experienced and dedicated staff that can anticipate and manage the various and complex problems presented by the multifetal gestation. Specialized care for multiple gestations should include components such as consistent evaluation of maternal symptoms and cervical status by a single care-provider, intensive preterm birth prevention education, individualized modification of maternal activity, increased attention to nutrition, ultrasonography, tracking of clinic nonattenders, and a supportive clinical environment. This sort of specialization and individualization of antepartum care for multiple gestations provides the best opportunity to maximize intrauterine fetal growth, identify congenital anomalies, prevent extremely preterm or very low birth weight deliveries, and identify fetal or maternal complications that may necessitate more intensive fetal surveillance or even delivery to reduce adverse perinatal outcome.

Predictive value of antepartum ultrasound examination for anomalies in twin gestations.

The purpose of this study was to evaluate the accuracy of antenatal ultrasonography in the detection of fetal anomalies among twin gestations cared for in a specialized antepartum twin clinic. A retrospective study was performed of 245 consecutive twin gestations followed in our twin clinic. The sensitivity, specificity and diagnostic indices of ultrasound to detect prenatal anomalies in the 490 infants delivered from July 1988 to October 1994 were determined. Fourteen infants had isolated congenital anomalies, and ten had multiple anomalies. The overall prevalence of congenital anomalies was 4.9%. Antepartum ultrasound examination had a sensitivity of 88% and a specificity of 100% for the detection of an anomalous infant, with a positive predictive value of 100% and a negative predictive value of 99%. The sensitivity of ultrasound for each individual anomaly within the cohort was 82%, with 100% specificity, 100% positive predictive value, and 98% negative predictive value. Our conclusions are that serial antepartum ultrasound examination of twins for congenital anomalies in our institution is very specific, with high positive and negative predictive values. The sensitivity, while also excellent, has limitations, which should be discussed with the patient.

Risks of antepartum cervical examination in multifetal gestations.

OBJECTIVE: This study was performed to determine the risks associated with antepartum cervical examination in women with multifetal gestations attending a specialized antepartum Twin Clinic. STUDY DESIGN: Patients followed up in a specialized Twin Clinic from 1988 through 1991 (N = 89) received extensive preterm birth prevention education and routine cervical examination at each clinic visit. Obstetric outcome was compared between these patients and 288 other twin gestations followed up in the high-risk obstetric clinics between 1981 and 1991. In these control twin gestations cervical examination was done for obstetric indications only. RESULTS: Comparisons between the 89 Twin Clinic attendees and the 288 controls followed up in the high-risk obstetric clinic revealed no significant differences in patient demographics, medical complications, or infectious morbidity. Importantly, premature rupture of membranes was significantly less frequent in the Twin Clinic group, who had 7.6 +/- 3.2 (mean +/- SD) cervical examinations per patient. CONCLUSION: Routine cervical examination in multifetal gestations is not associated with increased rates of premature rupture of membranes or other obstetric complications.

Reduction in very low birth weight deliveries and perinatal mortality in a specialized, multidisciplinary twin clinic.

OBJECTIVE: To determine whether a specialized, multidisciplinary twin clinic could reduce rates of very low birth weight (VLBW) and perinatal mortality. Multifetal gestations account for only 1% of all pregnancies, yet are responsible for nearly 10% of all perinatal mortality. Very low birth weight (less than 1500 g) infants are the major contributors to this increased perinatal mortality rate. METHODS: Eighty-nine twin pairs followed in the Twin Clinic since 1988 were compared with 51 contemporary twin pairs who did not attend the Twin Clinic. Patients not attending the Twin Clinic were attended in the high-risk clinic by the obstetric residents and faculty. All maternal transports were excluded. Aspects of prenatal care emphasized in the Twin Clinic that differed from the high-risk clinic included consistent evaluation of maternal symptoms and cervical status by a single certified nurse-midwife, intensive preterm birth prevention education, individualized modification of maternal activity, increased attention to nutrition, and tracking of clinic non-attenders. RESULTS: There were no differences between the groups in demographic characteristics, adequacy of prenatal care, or antepartum complications. However, Twin Clinic attenders had lower rates of VLBW infants, neonatal intensive care unit admission, and perinatal mortality. CONCLUSIONS: These improvements in perinatal outcome for twin gestations are attributed to intensive preterm birth prevention education, individualization of prenatal care, and frequent maternal assessment by a consistent care provider. This approach reduced the rate of very early preterm delivery and its neonatal sequelae.

Quantification of cervical change: relationship to preterm delivery in the multifetal gestation.

Prematurity is the major contributor to the very high perinatal morbidity and mortality associated with multifetal gestations. Antepartum cervical evaluation has been suggested as a way to better define the risk of preterm delivery in multifetal gestations. Weekly digital cervical examinations were performed in 86 twin and 7 triplet gestations that were being monitored in a special antepartum clinic. A cervical score was calculated from each examination by subtracting cervical dilatation in centimeters from cervical length in centimeters. Cervical scores decline gradually with advancing gestation and are influenced by parity and subsequent preterm delivery. Intervals until delivery decrease significantly with lower cervical scores. A cervical score less than or equal to 0 on or before 34 weeks' gestation was strongly predictive of preterm delivery (75%). Only 2 of 78 (2.6%) with a score greater than 0 were delivered within 1 week of the examination. Cervical scoring is a simple, quantifiable, reproducible, and safe method of evaluating preterm delivery risk. An understanding of the prognostic significance of specific cervical scores may be of value in determining the need for obstetric intervention.