Course and predictive value of fetal heart rate parameters.

The present study concerns the developmental character of the fetal heart rate (FHR) pattern and the implications of predicting the perinatal outcome. Data from 443 patients undergoing 2193 nonstress tests were analyzed retrospectively. We found a significant increase of accelerations more than 15 beats/min, of accelerations associated with fetal movements, of fetal movements registered by the tocotransducer, the frequency of oscillations, and of the Fischer score values throughout gestation. The number of short FHR decreases and the mean baseline level declined throughout gestation. A long duration of absent or reduced baseline variability registered even 6 weeks before delivery was associated with low Apgar score values. Late decelerations and contractions registered early in pregnancy were also correlated to a poor outcome. Tachycardia and a low number of accelerations were only correlated to a poor perinatal outcome shortly before the delivery. Fetal movements not associated with FHR accelerations were an early indicator of a poor neonatal outcome. Scoring systems did not generally improve the predictive value of FHR patterns.

Management of twin pregnancy: the vaginal route is still safe.

To investigate the effect of method of delivery on the outcome of twin pregnancies, we reviewed all deliveries at our institution over the 10 years from 1976 to 1985. Two hundred six pairs were delivered, with a mean gestational age of 34 weeks (range 20 to 43 weeks) and a mean weight of 2116 gm (range 220 to 3800 gm). The mean gestational age at diagnosis of the twin pregnancy was 23 weeks. Nineteen (4.6%) infants were stillborn, and 36 (8.7%) died in the neonatal period. Cesarean section was used to deliver both twins in 66 cases. The method of delivery for the remaining 142 cases was vaginal-vertex, 85 (61%), vaginal-breech, 40 (29%), cesarean section, 13 (9%), and version and extraction, 2 (1%). The four most common indications for cesarean section for both twins were previous cesarean section, breech presentation, abnormal labor, and fetal distress. The indications for the 13 cesarean sections after vaginal delivery of twin A were fetal distress, cord prolapse, high presenting part, and footling breech. The impact of the method of delivery was investigated by comparing outcome variables between twin pairs. No significant differences were noted for perinatal mortality, need for resuscitation, duration of newborn hospital stay, and trauma. There were significant differences in the 1- and 5-minute Apgar scores in the vaginal delivery group. These differences were clinically minor, tending toward mild acidemia, and were unaffected by route or method of delivery.

Antepartum fetal surveillance in the patient with decreased fetal movement.

Whenever a patient has the subjective perception of decreased fetal movement, prompt evaluation in the form of antepartum fetal surveillance has been undertaken. The purpose of this report is to describe our experience with 489 pregnant women who came between Jan. 1 and Dec. 31, 1985 to our Antepartum Fetal Surveillance Clinic with this complaint alone or in association with another indication for fetal surveillance. Overall, 838 nonstress tests were performed, and the results were reactive, 93.2%; nonreactive, 6.8%; and fetal heart rate decelerations, 6.1%. Comparison of the first nonstress test results between those with decreased fetal movement alone or in combination with another diagnosis demonstrated a similar incidence of nonreactivity and fetal heart rate decelerations. In those patients whose indication was decreased fetal movement alone, there was a 3.7 times greater likelihood of diminished amniotic fluid volume. When the last test within 7 days of delivery was analyzed, the decreased fetal movement alone group had a lower incidence of cesarean delivery, cesarean delivery for fetal distress, and Apgar scores less than 7 than patients with an additional indication for testing. In summary, decreased fetal movement continues to be an acceptable indication for fetal surveillance. Based on our retrospective experience, the most reasonable approach appears to be a combination of nonstress test and amniotic fluid volume assessment. Unless the patient has additional indications for fetal surveillance, the patient with decreased fetal movement with a reactive nonstress test and a normal amniotic fluid volume does not appear to warrant additional testing.