Patient preferences for disposable and reusable vaginal specula and their willingness to compromise in the era of climate change: A cross-sectional study.

OBJECTIVE: To evaluate patient satisfaction on gynaecological examination with metal, plastic and biobased plastic vaginal specula, and to investigate whether patients are willing to compromise on comfort for a more sustainable healthcare system. DESIGN: Cross-sectional study: population-based survey. SETTING: Gynaecological outpatient clinics in five Dutch hospitals. POPULATION: Patients during general gynaecology consultation hours. METHODS: A survey containing two questions about patient demographics, four about comfort and five about sustainability and healthcare was distributed. MAIN OUTCOME MEASURES: Comfort score (scale 1-10). SECONDARY OUTCOMES: (1) temperature, size and ease of insertion, (2) willingness to compromise for a more sustainable healthcare system. RESULTS: In all, 196 patients completed the survey. Biobased plastic vaginal specula scored significantly higher on comfort than the metal ones (mean 8.03 ± 1.65 versus 7.26 ± 1.51 respectively; P < 0.001). The biobased plastic vaginal speculum is significantly the most comfortable on temperature, whereas the metal speculum is the least comfortable (P < 0.007). Most patients are willing to compromise on comfort or are open to the reuse of disposables to contribute to a more sustainable healthcare. The majority of patients (77%) urge healthcare organisations to combat climate change. CONCLUSIONS: There is a small but statistically significant difference in favour of a biobased plastic speculum regarding comfort score, although it might be questioned whether this is clinically relevant. Furthermore, patients are willing to compromise on comfort for a more sustainable healthcare, which should be a contributing factor in speculum selection.

The effect of intrauterine resuscitation by maternal hyperoxygenation on perinatal and maternal outcome: a randomized controlled trial.

BACKGROUND: Maternal hyperoxygenation is widely used during labor as an intrauterine resuscitation technique. However, robust evidence regarding its beneficial effect and potential side effects is scarce, and previous studies show conflicting results. OBJECTIVE: To assess the effect of maternal hyperoxygenation upon suspected fetal distress during the second stage of term labor on fetal heart rate, neonatal outcome, maternal side effects, and mode of delivery. MATERIALS AND METHODS: In a single-center randomized controlled trial in a tertiary hospital in The Netherlands, participants were randomized in case of an intermediary or abnormal fetal heart rate pattern during the second stage of term labor, to receive either conventional care or 100% oxygen at 10 L/min until delivery. The primary outcome was the change in fetal heart rate pattern. Prespecified secondary outcomes were Apgar score, umbilical cord blood gas analysis, neonatal intensive care unit admission, perinatal death, free oxygen radical activity, maternal side effects, and mode of delivery. We performed subgroup analyses for intermediary and abnormal fetal heart rate, and for small for gestational age fetuses. RESULTS: From March 2016 through April 2018, a total of 117 women were included. Fetal heart rate patterns could be analyzed in 71 women. Changes in fetal heart rate (defined as improvement, equal, or deterioration) in favor of maternal hyperoxygenation were significant (odds ratio, 5.7; 95% confidence interval, 1.7-19.1) using ordinal logistic regression. Apgar score, umbilical cord blood gas analysis, free oxygen radicals, and mode of delivery showed no significant differences between the intervention and control group. Among women with an abnormal fetal heart rate, there were fewer episiotomies on fetal indication in the intervention group (25%) than in the control group (65%, P < .01). CONCLUSION: Maternal hyperoxygenation has a positive effect on the fetal heart rate in the presence of suspected fetal distress during the second stage of labor. There was no significant difference in the mode of delivery or neonatal outcome; however, significantly fewer episiotomies on fetal indication were performed following maternal hyperoxygenation in the subgroup with abnormal fetal heart rate pattern.

Correction to: Intrauterine resuscitation during the second stage of term labour by maternal hyperoxygenation versus conventional care: study protocol for a randomised controlled trial (INTEREST O2).

Following publication of the original article [1], the authors noticed that the sample size for the study group was incorrectly reported in the Methods section.

Intrauterine resuscitation during the second stage of term labour by maternal hyperoxygenation versus conventional care: study protocol for a randomised controlled trial (INTEREST O2).

BACKGROUND: Perinatal asphyxia is, even in developed countries, one the major causes of neonatal morbidity and mortality. Therefore, if foetal distress during labour is suspected, one should try to restore foetal oxygen levels or aim for immediate delivery. However, studies on the effect of intrauterine resuscitation during labour are scarce. We designed a randomised controlled trial to investigate the effect of maternal hyperoxygenation on the foetal condition. In this study, maternal hyperoxygenation is induced for the treatment of foetal distress during the second stage of term labour. METHODS/DESIGN: This study is a single-centre randomised controlled trial being performed in a tertiary hospital in The Netherlands. From among cases of a suboptimal or abnormal foetal heart rate pattern during the second stage of term labour, a total of 116 patients will be randomised to the control group, where normal care is provided, or to the intervention group, where before normal care 100% oxygen is supplied to the mother by a non-rebreathing mask until delivery. The primary outcome is change in foetal heart rate pattern. Secondary outcomes are Apgar score, mode of delivery, admission to the neonatal intensive care unit and maternal side effects. In addition, blood gas values and malondialdehyde are determined in umbilical cord blood. DISCUSSION: This study will be the first randomised controlled trial to investigate the effect of maternal hyperoxygenation for foetal distress during labour. This intervention should be recommended only as a treatment for intrapartum foetal distress, when improvement of the foetal condition is likely and outweighs maternal and neonatal side effects. TRIAL REGISTRATION: EudraCT, 2015-001654-15; registered on 3 April 2015. Dutch Trial Register, NTR5461; registered on 20 October 2015.

Practice variation in the management of intrapartum fetal distress in The Netherlands and the Western world.

OBJECTIVE: Solid evidence on the effect of intrauterine resuscitation on neonatal outcome is limited, and superiority of one intervention over the others is not clear. We therefore surveyed the clinical practice variation in fetal monitoring and the management of fetal distress during labor, in Dutch labor wards. In addition, we have compared recommendations from international guidelines. STUDY DESIGN: We conducted a survey among all 86 Dutch hospitals, using a questionnaire on fetal monitoring and management of fetal distress. In addition, we requested international guidelines of 28 Western countries to study international recommendations regarding labor management. RESULTS: The response rate of the national survey was 100%. Labor wards of all hospitals use CTG for fetal monitoring, 98% use additional fetal scalp blood sampling, and 23% use ST-analysis. When fetal distress is suspected, oxytocin is discontinued and tocolytic drugs are applied in all hospitals. Nearly all hospitals (98%) use maternal reposition for fetal resuscitation, 33% use amnioinfusion, and 58% provide maternal hyperoxygenation. Management is mainly based on the Dutch national guideline (58%) or on local guidelines (26%). Eight international guidelines on fetal monitoring were obtained for analysis. Fetal scalp blood sampling facilities are recommended in all the obtained guidelines. Use of ST-analysis is recommended in three guidelines and advised against in three guidelines. Five guidelines also advised on intrauterine resuscitation: discontinuation of oxytocin and use of tocolytic drugs was advised in all guidelines, amnioinfusion was recommended in two guidelines and advised against in two guidelines, whereas maternal hyperoxygenation was recommended in two guidelines and advised against in one guideline. CONCLUSION: Nationwide clinical practice, and recommendations from international guidelines agree on the use of fetal scalp blood sampling in addition to cardiotocography during labor. The opinion on the use of ST-analysis differs per clinic and per guideline. Discontinuation of oxytocin, administration of tocolytic drugs and maternal repositioning are rather uniform, on national and international level. However, there is a large variation in the use of amnioinfusion and maternal hyperoxygenation, which may be explained by the contradictory recommendations of the different guidelines.

Interventions for Intrauterine Resuscitation in Suspected Fetal Distress During Term Labor: A Systematic Review.

IMPORTANCE: Intrauterine resuscitation techniques during term labor are commonly used in daily clinical practice. Evidence, however, to support the beneficial effect of intrauterine resuscitation techniques on fetal distress during labor is limited and sometimes contradictory. In contrast, some of these interventions may even be harmful. OBJECTIVE: To give insight into the current evidence on intrauterine resuscitation techniques. In addition, we formulate recommendations for current clinical practice and propose directions for further research. EVIDENCE ACQUISITION: We systematically searched the electronic PubMed, EMBASE, and CENTRAL databases for studies on intrauterine resuscitation for suspected fetal distress during term labor until February 2015. Eligible articles and their references were independently assessed by 2 authors. Judgment was based on methodological quality and study results. RESULTS: Our literature search identified 15 studies: 4 studies on amnioinfusion, 1 study on maternal hyperoxygenation, 1 study on maternal repositioning, 1 study on intravenous fluid administration, and 8 studies on tocolysis. Of these 15 research papers, 3 described a randomized controlled trial; all other studies were observational reports or case reports. CONCLUSIONS AND RELEVANCE: Little robust evidence to promote a specific intrauterine resuscitation technique is available. Based on our literature search, we support the use of tocolysis and maternal repositioning for fetal distress. We believe the effect of amnioinfusion and maternal hyperoxygenation should be further investigated in properly designed randomized controlled trials to make up the balance between beneficial and potential hazardous effects.

A simulation model to study maternal hyperoxygenation during labor.

OBJECTIVE: To investigate the effect of maternal hyperoxygenation on fetal oxygenation and fetal heart rate decelerations during labor, using a simulation model. DESIGN: Use of a mathematical model that simulates feto-maternal hemodynamics and oxygenation, designed in Matlab R2012a. SETTING: Clinical and engineering departments in the Netherlands. METHODS: We simulated variable and late fetal heart rate decelerations, caused by uterine contractions with a different contraction interval. We continuously recorded oxygen pressure in different feto-placental compartments and fetal heart rate, during maternal normoxia and during hyperoxygenation with 100% oxygen. MAIN OUTCOME MEASURES: Changes in oxygen pressure in the intervillous space, umbilical vein and arteries, fetal cerebral and microcirculation as well as fetal heart rate deceleration depth and duration. RESULTS: Maternal hyperoxygenation leads to an increase in fetal oxygenation: in the presence of variable decelerations, oxygen pressure in the intervillous space increased 9-10 mmHg and in the cerebral circulation 1-2 mmHg, depending on the contraction interval. In addition, fetal heart rate deceleration depth decreased from 45 to 20 beats per minute. In the presence of late decelerations, oxygen pressure in the intervillous space increased 7-10 mmHg and in the cerebral circulation 1-2 mmHg, depending on the contraction interval. The fetus benefited more from maternal hyperoxygenation when contraction intervals were longer. CONCLUSIONS: According to the simulation model, maternal hyperoxygenation leads to an increase in fetal oxygenation, especially in the presence of variable decelerations. In addition, in the presence of variable decelerations, maternal hyperoxygenation leads to amelioration of the fetal heart rate pattern.

Does arterial shear explain the magnitude of flow-mediated dilation?: a comparison between young and older humans.

Flow-mediated dilatation (FMD) has become a commonly applied approach for the assessment of vascular function and health in humans. Recent studies emphasize the importance of normalizing the magnitude of FMD to its apparent eliciting stimulus, the postdeflation arterial shear. However, the relationship between shear stress and the magnitude of FMD may differ between groups. The aim of this study was to examine the relationship between the brachial FMD and four different indexes of postdeflation shear rate (SR) in healthy children (n = 51, 10 +/- 1 yr) and young (n = 57, 27 +/- 6 yr) and older (n = 27, 58 +/- 4 yr) adults. SR was calculated from deflation (time 0) until 9 s (peak), 30 s (0-30), 60 s (0-60), or until the time-to-peak diameter in each individual (0-ttp). Edge detection and wall tracking of high resolution B-mode arterial ultrasound images were used to calculate the conduit artery diameter. In young adults, the brachial artery FMD demonstrated a significant correlation with the area under the SR curve (SR(AUC)) 0-30 s (r(2) = 0.12, P = 0.009), 0-60 s (r(2) = 0.14, P = 0.005), and 0-ttp (r(2) = 0.14, P = 0.005) but not for the peak SR(AUC) 0-9 s (r(2) = 0.04, P = 0.12). In children and older adults, the magnitude of the brachial artery FMD did not correlate with any of the four SR(AUC) stimuli. These findings suggest that in young subjects, postdeflation SR(AUC) correlates moderately with the magnitude of the FMD response. However, the relationship between FMD and postdeflation shear appears to be age dependent, with less evidence for an association in younger and older subjects. Therefore, we support presenting SR(AUC) stimuli but not normalizing FMD responses for the SR(AUC) when using this technique.

The impact of baseline diameter on flow-mediated dilation differs in young and older humans.

Flow-mediated dilation (FMD) has become a commonly applied approach for the assessment of vascular function and health, but methods used to calculate FMD differ between studies. For example, the baseline diameter used as a benchmark is sometimes assessed before cuff inflation, whereas others use the diameter during cuff inflation. Therefore, we compared the brachial artery diameter before and during cuff inflation and calculated the resulting FMD in healthy children (n=45; 10+/-1 yr), adults (n=31; 28+/-6 yr), and older subjects (n=22; 58+/-5 yr). Brachial artery FMD was examined after 5 min of distal ischemia. Diameter was determined from either 30 s before cuff inflation or from the last 30 s during cuff inflation. Edge detection and wall tracking of high resolution B-mode arterial ultrasound images was used to calculate conduit artery diameter. Brachial artery diameter during cuff inflation was significantly larger than before inflation in children (P=0.02) and adults (P<0.001) but not in older subjects (P=0.59). Accordingly, FMD values significantly differed in children (11.2+/-5.1% vs. 9.4+/-5.2%; P=0.02) and adults (7.3+/-3.2% vs. 4.6+/-3.3%; P<0.001) but not in older subjects (6.3+/-3.4% vs. 6.0+/-4.2%; P=0.77). When the diameter before cuff inflation was used, an age-dependent decline was evident in FMD, whereas FMD calculated using the diameter during inflation was associated with higher FMD values in older than younger adults. In summary, the inflation of the cuff significantly increases brachial artery diameter, which results in a lower FMD response. This effect was found to be age dependent, which emphasizes the importance of using appropriate methodology to calculate the FMD.