Implementation of a fetal ultrasound telemedicine service: women's views and family costs.

BACKGROUND: The complexity of fetal medicine (FM) referrals that can be managed within obstetric units is dependent on the availability of specialist ultrasound expertise. Telemedicine can effectively transfer real-time ultrasound images via video-conferencing. We report the successful introduction of a fetal ultrasound telemedicine service linking a specialist fetal medicine (FM) centre and a remote obstetric unit. METHODS: Over a four-year period from October 2015, all women referred for FM consultation from the obstetric unit were seen via telemedicine, excluding cases where invasive testing, intrauterine therapy or cardiac anomalies were anticipated. The outcomes measured included the indication for FM referral; scan duration and image and sound quality during the consultation. Women's perceptions of the telemedicine consultation and estimated costs to attend the FM centre were measured by a structured questionnaire completed following the first telemedicine appointment during the Phase 1 of the project. RESULTS: Overall, 297 women had a telemedicine consultation during Phase 1 (pilot and evaluation) and Phase 2 (embedding and adoption) of the project, which covered a 4 year period 34 women completed questionnaires during the Phase 1 of the study. Travel to the telemedicine consultation took a median (range) time of 20 min (4150), in comparison to an estimated journey of 230 min (120,450) to the FM centre. On average, women would have spent approximately £28 to travel to the FM centre per visit. The overall costs for the woman and her partner/ friend to attend the FM centre was estimated to be £439. Women were generally satisfied with the service and valued the opportunity to have a FM consultation locally. CONCLUSIONS: We have demonstrated that a fetal ultrasound telemedicine service can be successfully introduced to provide FM ultrasound of sufficient quality to allow fetal diagnosis and specialist consultation with parents. Furthermore, the service is acceptable to parents, has shown a reduction in family costs and journey times.

The effect of maternal epidural analgesia on fetal oxygen saturation.

OBJECTIVE: To observe fetal arteriolar oxygen saturation during maternal epidural analgesia. DESIGN: An observation study of 27 epidural top-ups. SETTING: Labour ward, St James's University Hospital and Leeds General Infirmary, Leeds University, UK. SAMPLE: Seventeen fetuses in uncomplicated labour monitored with a N400 fetal pulse oximeter. OUTCOME MEASURE: A change in fetal pulse oximetry reading following epidural analgesia. RESULTS: There is no change in fetal oxygen saturation following an uncomplicated epidural top-up (F = 0.93; df 35 and 784). CONCLUSION: An uneventful maternal epidural has no measurable effect on fetal oxygen saturation measured with a N400 pulse oximeter.

Taking account of vaginal bleeding in screening for Down's syndrome.

OBJECTIVE: To derive a method for revising the risk of Down's syndrome in maternal serum marker screening when there is vaginal bleeding. The effect on screening performance of routinely allowing for the presence or absence of bleeding in all women is also assessed. DESIGN: Overview of published studies on the rate of reported vaginal bleeding in pregnancies with Down's syndrome, on the rate according to maternal age and on the association of bleeding with alpha-fetoprotein (AFP) level. The publications are supplemented with data on unconjugated oestriol (uE3), human chorionic gonadotrophin (hCG) and AFP levels in a consecutive series of screened women. SETTING: Routine Down's syndrome screening tests carried out on women having antenatal care at the St James's University Hospital, Leeds. SUBJECTS: Eight hundred and nine screened women. RESULTS: In five studies the rate of vaginal bleeding in Down's syndrome pregnancies was 1.7 times that in unaffected pregnancies on average. In three studies, the vaginal bleeding rate increased proportionally by 2.2% on average for each year of maternal age. Three studies and our own data were consistent with a 10% increase in the mean AFP level associated with vaginal bleeding, but it did not appear to materially alter uE3 and hCG levels or the standard deviations and correlation coefficients for any of the three analytes. An individual woman's risk was calculated by multiplying her age-specific odds of Down's syndrome by two likelihood ratios, one relating to the vaginal bleeding itself and one from the marker levels. Routine allowance for the presence or absence of vaginal bleeding was estimated to increase the detection rate by less than 1%. CONCLUSION: Our method is of clinical value in revising the risk when there is concern that vaginal bleeding might be responsible for a negative maternal serum Down's syndrome screening result. A policy of routinely incorporating information on vaginal bleeding in risk estimation for all women would have too small an effect on overall screening performance to recommend it.

Fetal pulse oximetry: a new method of monitoring the fetus.

Experimental pulse oximetry devices, similar to the existing systems used in adult and neonatal monitoring, can be used on the fetus to provide safe, and rapid information about oxygenation. They have been calibrated using fetal lambs and validated in human cross-sectional studies. Experiments have shown that fetal oxygen saturation decreases during normal labour, and drops after a uterine contraction especially with oxytocin-induced tachysystole. When the mother is given oxygen the fetal oxygen saturation increases. Readings are effected by caput and movement, and trends seem to be more meaningful than absolute values. Pulse oximetry can predict fetal outcome and a normal oxygen saturation result is specific for a good outcome perhaps even if the CTG is abnormal. However the technique is still experimental and there is insufficient data to support its use as a replacement for fetal blood sampling or a discriminator for an abnormal fetal heart trace.

Clinical value of antenatal fetal pulse oximetry.

The aim of this prospective observational study was to see if high quality fetal pulse oximetry signals can be obtained from the fetus before labour. It was carried out in Labour Ward, Clarendon Wing, Leeds General Infirmary and St. James Hospital, Leeds. We studied Caucasian term fetuses antenatally and 20 fetuses during labour. Antenatal fetal oxygen saturation was measured using a sensor passed through the cervix onto the membranes covering the fetus before the onset of labour. The quality of these signals was compared to data obtained from 20 fetuses monitored during active labour after amniotomy. High quality pulse oximetry signals were obtained for less than 1% of the monitoring time before the onset of labour (95% CI 0-2.5%). High quality data was seen 38.6% of the time once the membranes were ruptured and the head descendend into the pelvis. With present technology fetal pulse oximetry will not contribute to antenatal fetal assessment.