Sodium dichloroacetate stimulates cardiac mitochondrial metabolism and improves cardiac conduction in the ovine fetus during labor.

Previous studies in our laboratory have suggested that the increase in stillbirth in pregnancies complicated by chronic maternal stress or hypercortisolemia is associated with cardiac dysfunction in late stages of labor and delivery. Transcriptomics analysis of the overly represented differentially expressed genes in the fetal heart of hypercortisolemic ewes indicated involvement of mitochondrial function. Sodium dichloroacetate (DCA) has been used to improve mitochondrial function in several disease states. We hypothesized that administration of DCA to laboring ewes would improve both cardiac mitochondrial activity and cardiac function in their fetuses. Four groups of ewes and their fetuses were studied: control, cortisol-infused (1 g/kg/day from 115 to term; CORT), DCA-treated (over 24 h), and DCA + CORT-treated; oxytocin was delivered starting 48 h before the DCA treatment. DCA significantly decreased cardiac lactate, alanine, and glucose/glucose-6-phosphate and increased acetylcarnitine/isobutyryl-carnitine. DCA increased mitochondrial activity, increasing oxidative phosphorylation (PCI, PCI + II) per tissue weight or per unit of citrate synthase. DCA also decreased the duration of the QRS, attenuating the prolongation of the QRS observed in CORT fetuses. The effect to reduce QRS duration with DCA treatment correlated with increased glycerophosphocholine and serine and decreased phosphorylcholine after DCA treatment. There were negative correlations of acetylcarnitine/isobutyryl-carnitine to both heart rate (HR) and mean arterial pressure (MAP). These results suggest that improvements in mitochondrial respiration with DCA produced changes in the cardiac lipid metabolism that favor improved conduction in the heart. DCA may therefore be an effective treatment of fetal cardiac metabolic disturbances in labor that can contribute to impairments of fetal cardiac conduction.

Fetal Heart Rate Extraction Based on Wavelet Transform to Prevent Fetal Distress In Utero.

In order to improve the effective extraction of fetal heart rate and prevent fetal distress in utero, a study of fetal heart rate feature extraction based on wavelet transform to prevent fetal distress in utero was proposed. This paper adopts a fetal heart rate detection method based on the maximum value of the binary wavelet transform modulus. The method is simulated by the Doppler fetal heart signal obtained from the clinic. Compared with the original curve, the transformed curve can roughly see the change rule of the original signal and identify the peak point of the signal, but due to the large disturbance of the peak point, the influence on the computer processing is also great. The periodicity of the transformed signal is greatly enhanced, making it easier to deal with the computation. A total of 300 pregnant women with full-term fetal heart monitoring from January 2018 to January 2020 were selected as the research subjects and divided into the observation group and the control group. The observation group consisted of 100 patients with abnormal fetal heart monitoring, and the control group consisted of 200 patients with normal fetal heart monitoring. The uterine contractions and fetal heart rate were recorded, and the incidence of fetal distress, cesarean section, neonatal asphyxia, and amniotic fluid and fecal contamination were observed. The incidence of fetal distress, cesarean section, neonatal asphyxia, and amniotic fluid fecal stain in the observation group were significantly higher than those in the control group. Fetal heart monitoring can accurately judge the situation of the fetus in pregnant women and timely diagnose the abnormal fetal heart rate, which has a better effect on the prognosis of perinatal infants and can reduce their mortality. It can effectively solve the problems existing in the autocorrelation algorithm and extract the fetal heart rate more accurately. It is an effective improved scheme of fetal heart rate extraction. It is very helpful in preventing fetal distress in utero.

Resilience and Stress during Pregnancy: A Comprehensive Multidimensional Approach in Maternal and Perinatal Health.

This narrative review addresses resilience and stress during pregnancy, which is part of a broader concept of maternal health. Pregnancy and postpartum are opportune periods for health promotion interventions, especially because the close contact of the women with health professionals. In this way, it can be considered a useful window of opportunity to identify women at higher risk for adverse outcomes. Integrated health is a concept that aims at providing comprehensive care related to the promotion of individuals' physical, mental, and social well-being. In this context, stress during pregnancy has been targeted as a remarkable condition to be addressed whether due to individual issues, social issues, or specific pregnancy issues, since it is directly and indirectly associated with pregnancy complications. Stress is associated with preterm birth, postpartum depression, anxiety, child neurodevelopment, and fetal distress. The way that an individual faces a stressful and adverse situation is called resilience; this reaction is individual, dynamic, and contextual, and it can affect maternal and fetal outcomes. Low resilience has been associated with poorer pregnancy outcomes. The social context of pregnancy can act as a protective or contributory (risk) factor, indicating that environments of high social vulnerability play a negative role in resilience and, consequently, in perceived stress. A given stressor can be enhanced or mitigated depending on the social context that was imposed, as well as it can be interpreted as different degrees of perceived stress and faced with a higher or lower degree of resilience. Understanding these complex mechanisms may be valuable for tackling this matter. Therefore, in the pregnancy-puerperal period, the analysis of the stress-resilience relationship is essential, especially in contexts of greater social vulnerability, and is a health-promoting factor for both the mother and baby.

The CErebro Placental RAtio as indicator for delivery following perception of reduced fetal movements, protocol for an international cluster randomised clinical trial; the CEPRA study.

BACKGROUND: Routine assessment in (near) term pregnancy is often inaccurate for the identification of fetuses who are mild to moderately compromised due to placental insufficiency and are at risk of adverse outcomes, especially when fetal size is seemingly within normal range for gestational age. Although biometric measurements and cardiotocography are frequently used, it is known that these techniques have low sensitivity and specificity. In clinical practice this diagnostic uncertainty results in considerable 'over treatment' of women with healthy fetuses whilst truly compromised fetuses remain unidentified. The CPR is the ratio of the umbilical artery pulsatility index over the middle cerebral artery pulsatility index. A low CPR reflects fetal redistribution and is thought to be indicative of placental insufficiency independent of actual fetal size, and a marker of adverse outcomes. Its utility as an indicator for delivery in women with reduced fetal movements (RFM) is unknown. The aim of this study is to assess whether expedited delivery of women with RFM identified as high risk on the basis of a low CPR improves neonatal outcomes. Secondary aims include childhood outcomes, maternal obstetric outcomes, and the predictive value of biomarkers for adverse outcomes. METHODS: International multicentre cluster randomised trial of women with singleton pregnancies with RFM at term, randomised to either an open or concealed arm. Only women with an estimated fetal weight ≥ 10th centile, a fetus in cephalic presentation and normal cardiotocograph are eligible and after informed consent the CPR will be measured. Expedited delivery is recommended in women with a low CPR in the open arm. Women in the concealed arm will not have their CPR results revealed and will receive routine clinical care. The intended sample size based on the primary outcome is 2160 patients. The primary outcome is a composite of: stillbirth, neonatal mortality, Apgar score < 7 at 5 min, cord pH < 7.10, emergency delivery for fetal distress, and severe neonatal morbidity. DISCUSSION: The CEPRA trial will identify whether the CPR is a good indicator for delivery in women with perceived reduced fetal movements. TRIAL REGISTRATION: Dutch trial registry (NTR), trial NL7557 . Registered 25 February 2019.

Tocolysis and the risk of nonreassuring fetal status among pregnant women in labor: Findings from a population-based retrospective cohort study.

The purpose of this study was to evaluate the association between tocolysis for preterm uterine contraction and the risk of nonreassuring fetal status.This was a retrospective cohort study using data from the Taiwan National Health Insurance Research Database. Pregnant women were enrolled if they delivered a baby during January 1, 2003 to December 31, 2011. The occurrence of the nonreassuring fetal status was compared between pregnant women with and without tocolytic treatment for preterm uterine contraction. Multivariable logistic regression models with adjusted cofounders were used to evaluate the association between tocolysis and the risk of nonreassuring fetal status.Of 24,133 pregnant women, 1115 (4.6%) received tocolytic treatment during pregnancy. After adjusting for covariates, pregnant women receiving tocolysis more than one time during pregnancy were found to have significantly higher risk of the nonreassuring fetal status when compared with pregnant women who did not receive tocolysis for uterine contraction (Odds Ratio = 2.70, 95% Confidence Interval: 1.13-6.49).Pregnant women with more frequent tocolysis for preterm uterine contraction during pregnancy had an increased risk of nonreassuring fetal status. Close evaluation of dose and duration of tocolytic treatment is necessary for pregnant women with preterm uterine contraction.

Local adaption of intrapartum clinical guidelines, United Republic of Tanzania

Problem Gaps exist between internationally derived clinical guidelines on care at the time of birth and realistic best practices in busy, low-resourced maternity units. Approach In 2014­2018, we carried out the PartoMa study at Zanzibar's tertiary hospital, United Republic of Tanzania. Working with local birth attendants and external experts, we created easy-to-use and locally achievable clinical guidelines and associated in-house training to assist birth attendants in intrapartum care. Local setting Around 11 500 women gave birth annually in the hospital. Of the 35­40 birth attendants employed, each cared simultaneously for 3­6 women in labour. At baseline (1 October 2014 to 31 January 2015), there were 59 stillbirths per 1000 total births and 52 newborns with an Apgar score of 1­5 per 1000 live births. Externally derived clinical guidelines were available, but rarely used. Relevant changes Staff attendance at the repeated trainings was good, despite seminars being outside working hours and without additional remuneration. Many birth attendants appreciated the intervention and were motivated to improve care. Improvements were found in knowledge, partograph skills and quality of care. After 12 intervention months, stillbirths had decreased 34% to 39 per 1000 total births, while newborns with an Apgar score of 1­5 halved to 28 per 1000 live births. Lessons learnt After 4 years, birth attendants still express high demand for the intervention. The development of international, regional and national clinical guidelines targeted at low-resource maternity units needs to be better attuned to input from end-users and the local conditions, and thereby easier to use effectively

Discontinuation of intravenous oxytocin in the active phase of induced labour.

BACKGROUND: In most Western countries, obstetricians and midwives induce labour in about 25% of pregnant women. Oxytocin is an effective drug for this purpose, but associated with serious adverse effects of which uterine tachysystole, fetal distress and the need for immediate delivery are the most common. Various administration regimens such as reduced or pulsatile dosing have been suggested to minimise these. Discontinuation in the active phase of labour, i.e. when contractions are well-established and the cervix is dilated at least 5 cm is another method which may reduce adverse effects. OBJECTIVES: To assess whether birth outcomes can be improved by discontinuation of intravenous (IV) oxytocin, initiated in the latent phase of induced labour, once active phase of labour is established. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (31 January 2018), Scopus, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) (23 January 2018) together with reference checking, citation searching, and contact with study authors to identify additional studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing discontinued IV with continuous IV oxytocin in the active phase of induced labour.No exclusion criteria were applied in terms of parity, maternal age, ethnicity, co-morbidity status, labour setting, gestational age, and prior caesarean delivery.Studies comparing different dosage regimens are outside the scope of this review. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. MAIN RESULTS: We found 10 completed RCTs involving 1888 women. One additional trial is ongoing. The included trials were conducted in hospital settings between February 1998 and January 2016, two in Europe (Denmark, and Greece), two in Turkey, and one each in Israel, Iran, USA, Bangladesh, India, and Thailand. Most trials included full-term singleton pregnancies with a fetus in vertex presentation. Some excluded women with cervical priming prior to induction and some excluded women with a history of prior caesarean delivery. When reported, the average age of the women ranged from 22 to 31 years, nulliparity from 45% to 68%, and pre-pregnancy body mass index from 22 to 32.Many of the included trials had design limitations and were judged to be at either high or unclear risk of bias across a number of 'Risk of bias' domains.Four trials included a Consort flow diagram. In three, this gave details of participants delivered before the active phase of labour, and treatment compliance for those who reached that stage. One Consort diagram only provided the latter information. The data in many of the trials without such a flow diagram were implausibly compliant with treatment allocation, suggesting that there had been silent post randomisation exclusions of women delivered before the active phase of labour. We therefore conducted a secondary analysis (not in our protocol) of caesarean section among women who reached the active phase of labour and were therefore eligible for the intervention.Our analysis by 'intention-to-treat' found that, compared with continuation of IV oxytocin stimulation, discontinuation of IV oxytocin may reduce the caesarean delivery rate, risk ratio (RR) 0.69, 95% confidence interval (CI) 0.56 to 0.86, 9 trials, 1784 women, low-level certainty. However, restricting our analysis to women who reached the active phase of labour (using 'reached active phase' as our denominator) suggests there is probably little or no difference between groups (RR 0.92, 95% CI 0.65 to 1.29, 4 trials, 787 women, moderate-certainty evidence).Discontinuation of IV oxytocin probably reduces the risk ofuterine tachysystole combined with abnormal fetal heart rate (FHR) compared with continued IV oxytocin (RR 0.15, 95% CI 0.05 to 0.46, 3 trials, 486 women, moderate-level certainty). We are uncertain about whether or not discontinuation increases the risk of chorioamnionitis (average RR 2.32, 95% CI 0.99 to 5.45, 1 trial, 252 women, very low-level certainty). Discontinuation of IV oxytocin may have little or no impact on the use of analgesia and epidural during labour compared to the use of continued IV oxytocin (RR 1.04 95% CI 0.95 to 1.14, 3 trials, 556 women, low-level certainty). Intrapartum cardiotocography (CTG) abnormalities (suspicious/pathological CTGs) are probably reduced by discontinuing IV oxytocin (RR 0.65, 95% CI 0.51 to 0.83, 7 trials, 1390 women, moderate-level certainty). Compared to continuing IV oxytocin, discontinuing IV oxytocin probably has little or no impact on the incidence of Apgar < 7 at five minutes (RR 0.78, 95% CI 0.27 to 2.21, 4 trials, 893 women, low-level certainty), or and acidotic cord gasses at birth (arterial umbilical pH < 7.10), (RR 1.03, 95% CI 0.50 to 2.13, 4 trials, 873 women, low-level certainty).Many of this review's maternal and infant secondary outcomes (including maternal and neonatal mortality) were not reported in the included trials. AUTHORS' CONCLUSIONS: Discontinuing IV oxytocin stimulation after the active phase of labour has been established may reduce caesarean delivery but the evidence for this was low certainty. When restricting our analysis to those trials that separately reported participants who reached the active phase of labour, our results showed there is probably little or no difference between groups. Discontinuing IV oxytocin may reduce uterine tachysystole combined with abnormal FHR.Most of the trials had 'Risk of bias' concerns which means that these results should be interpreted with caution. Our GRADE assessments ranged from very low certainty to moderate certainty. Downgrading decisions were based on study limitations, imprecision and indirectness.Future research could account for all women randomised and, in particular, note those who delivered before the point at which they would be eligible for the intervention (i.e. those who had caesareans in the latent phase), or because labour was so rapid that the infusion could not be stopped in time.Future trials could adopt the outcomes listed in this review including maternal and neonatal mortality, maternal satisfaction, and breastfeeding.

Late preterm and early term: when to induce a growth restricted fetus? A population-based study.

PURPOSE: (1) Compare fetal and neonatal morbidity and mortality associated with induction of labor (IOL) versus expectant management (EM) in women with isolated fetal growth restriction (FGR) between 340/7 and 386/7 weeks; (2) Determine optimal gestational age for delivery of such fetuses. MATERIALS AND METHODS: A retrospective population based cohort study of 2232 parturients with isolated FGR, including two groups: (1) IOL (n = 1428); 2) EM (n = 804). RESULTS: IOL group had a lower stillbirth and neonatal death rates (p = .042, p < .001), higher 1 and 5 min Apgar scores and a higher vaginal delivery rate compared to the EM group. In the late preterm period, EM was associated with increased rate of low 1 and 5 min Apgar scores, nonreassuring fetal heart rate tracing (NRFHR), stillbirth and neonatal death rate (p = .001, p = .039). In the early term cohort, EM was associated with a higher rate of NRFHR and low 1 min Apgar scores (p = .003, p = .002). IOL at 37 weeks protected from stillbirth but not from adverse composite neonatal outcomes. CONCLUSIONS: IOL of FGR fetuses at 37 weeks had a protective effect against stillbirth. In addition, at late preterm, it is associated with lower rates of stillbirth, neonatal death, and NRFHR.

Crecimiento fetal: evidencias actuales / Fetal growth: current evidence

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Decision-to-delivery interval: Is 30 min the magic time? What is the evidence? Does it work?

Emergency caesarean section is required when delivery can reduce the risk to the life of the mother or foetus. When a caesarean section is indicated for foetal compromise, a decision-to-delivery interval of 30 min (or less) has been suggested as the ideal time frame within which an obstetric team should achieve delivery. In theory, a short decision-to-delivery interval may minimise intra-uterine hypoxia and improve neonatal outcome. Current medical evidence does not support this time frame. There are certain indications for caesarean section that necessitate a much shorter decision-to-delivery interval, but evidence suggests that the majority of neonates may be safely delivered within a longer interval of time. Current tools available for the diagnosis of foetal distress are imperfect, and the concept of foetal distress is poorly defined. Future research should focus on finding accurate means of diagnosing foetal distress in labouring women and establishing universally agreed evidence-based decision-to-delivery targets without compromising maternal or foetal safety.

Evaluación del riesgo fetal en las pacientes cesareadas con el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva / Evaluating the fetal risk in patients diagnosed with fetal distressing status with intrauterine revival

Fundamento: el término sufrimiento fetal impreciso e inespecífico, tiene bajo valor predictivo, incluso en poblaciones de alto riesgo.Objetivo: evaluar el riesgo fetal en las pacientes cesareadas con el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva.Métodos: se realizó un estudio cuasiexperimental para dos grupos en las pacientes cesareadas con el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva, en el Hospital Universitario Ana Betancourt de Mora en el período del 1 junio de 2014 al 1 de febrero de 2015.Resultados: se asoció el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva y las condiciones del cordón umbilical con odss ratio 1,3. La probabilidad del diagnóstico de estado fetal intranquilizante con reanimación intraútero fue 5,6 veces más para las pacientes con enfermedad hipertensiva en el embarazo. La probabilidad fue 4,3 veces para la diabetes. No se asoció el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva y la anestesia neuroaxial.Conclusiones: los factores de riesgo fetal de las pacientes cesareadas con el diagnóstico de estado fetal intranquilizante con reanimación intraútero efectiva fueron: enfermedad hipertensiva en el embarazo, diabetes, alteraciones del cordón umbilical y la anestesia neuroaxial fue independiente del riesgo fetal de las pacientes(AU)

Background: the term fetal imprecise suffering, predictive value has softly, even in populations of tall risk.Objective: to evaluate the fetal risk in patients who underwent Cesarean sections and diagnosed with fetal distressing status with effective intrauterine revival.Methods: a quasi-experimental accomplished study was conducted for two groups in patients diagnosed with fetal distressing status with intrauterine revival at Ana Betancourt de Mora hospital from June 1st, 2014 to February 1st, 2015.Results: the fetal distressing status was associated with effective intrauterine revival and the conditions of the umbilical cord with odss ratio 1.3. The probability of the diagnosis of fetal distressing status with intrauterine revival was 5.6 times more for patients with hypertensive disease in pregnancy. Probability was 4.3 times for diabetes. The diagnosis of fetal distressing status was not associated with effective intrauterine revival and the neuroaxial anesthesia.Conclusions: fetal risk factors of patient cesareans with the diagnosis of fetal distressing status with revival the intrauterine cashes they went: disease hipertensive in pregnancy, diabetes, alterations of the umbilical cord and anesthesia the neuroaxial was independent of fetal risk of patients(AU)

Computerized data-driven interpretation of the intrapartum cardiotocogram: a cohort study.

INTRODUCTION: Continuous intrapartum fetal monitoring remains a significant clinical challenge. We propose using cohorts of routinely collected data. We aim to combine non-classical (data-driven) and classical cardiotocography features with clinical features into a system (OxSys), which generates automated alarms for the fetus at risk of intrapartum hypoxia. We hypothesize that OxSys can outperform clinical diagnosis of "fetal distress", when optimized and tested over large retrospective data sets. MATERIAL AND METHODS: We studied a cohort of 22 790 women in labor (≥36 weeks of gestation). Paired umbilical blood analyses were available. Perinatal outcomes were defined by objective criteria (normal; severe, moderate or mild compromise). We used the data retrospectively to develop a prototype of OxSys, by relating its alarms to perinatal outcome, and comparing its performance against standards achieved by bedside diagnosis. RESULTS: OxSys1.5 triggers an alarm if the initial trace is nonreactive or the decelerative capacity (a nonclassical cardiotocography feature), exceeds a threshold, adjusted for preeclampsia and thick meconium. There were 187 newborns with severe, 613 with moderate and 3197 with mild compromise; and 18 793 with normal outcome. OxSys1.5 increased the sensitivity for compromise detection: 43.3% vs. 38.0% for severe (p = 0.3) and 36.1% vs. 31.0% for moderate (p = 0.06); and reduced the false-positive rate (14.4% vs. 16.3%, p < 0.001). CONCLUSIONS: Large historic cohorts can be used to develop and optimize computerized cardiotocography monitoring, combining clinical and cardiotocography risk factors. Our simple prototype has demonstrated the principle of using such data to trigger alarms, and compares well with clinical judgment.

Effects of delayed cord clamping on the third stage of labour, maternal haematological parameters and acid-base status in fetuses at term.

OBJECTIVE: To compare the time in the third stage of labour, differences in maternal hematologic parameters 48h after birth and acid-base status in the umbilical cord between the early cord clamping (ECC) and delayed cord clamping (DCC). STUDY DESIGN: 97 healthy pregnancies at term and a spontaneous vertex delivery at Clinic University Hospital "Virgen de la Arrixaca" (Murcia, Spain), were randomized to ECC group (<10s post-delivery) or to DCC group (2min post-delivery). Duration of the third stage of labour was measured. Samples for acid-base status were taken both from the umbilical artery and vein. Blood samples were taken from the mothers 48h after birth. RESULTS: No statistical differences were found in the time of the third stage of labour (p=0.35). No statiscally significant differences were found between the number of red cells (p=0.25), hemoglobin (p=0.08) or hematocrit (p=0.15) in mothers. Umbilical acid-base status or gas analysis did not show any differences between the two groups CONCLUSIONS: Delayed cord clamping does not affect significantly the time of the third stage of labour. It does not show either any effect on the hematological parameters in the mother 48h after birth.

Factors leading to cesarean section delivery at Felegehiwot referral hospital, Northwest Ethiopia: a retrospective record review.

BACKGROUND: Cesarean section is the commonest obstetric operative procedure worldwide. When used appropriately cesarean sections can improve infant and/or maternal outcomes. However, when used inappropriately the potential harm may exceed the potential benefit of cesarean section. Appreciating the limited information in this area the current study assessed the rate and factors associated with cesarean section in Felegehiwot referral hospital, Bahir Dar, northwest Ethiopia. METHOD: The study was a retrospective analysis of eligible patient records that included 2967 pregnant women who had underwent either cesarean or vaginal delivery from July 1, 2012 to June 31, 2013. The data were double entered to EPI-INFO 3.5.2 and analyzed with SPSS. Binary logistic regression model was fitted to identify independent factors associated with cesarean section. RESULT: The proportion of women who underwent cesarean section in this study was 25.4%. Obstructed labor (30.7%), fetal distress (15.9%) and abnormal presentation (13.4%) were the major obstetric indications for cesarean section. The odd of undergoing cesarean section was higher among mothers in rural residence (AOR = 1.63, 95% CI: 1.21, 2.20), mothers reported to have pregnancy risk factors (AOR = 2.31, 95% CI: 1.74, 3.07) and lower among mothers in age category of 15-19 (AOR = 0.63, 95% CI: 0.43, 0.93). CONCLUSION: Obstetric factors occurring around birth, including obstructed labor and fetal distress were the main reasons leading to Cesarean Section rather than background characteristics assumed to be a risk. The results imply that there is a need for timely and accurate screening of women during obstetric care and, decision to perform cesarean section should be based on clear, compelling and well-supported justifications.

Evaluation of the quality of guidelines for the management of reduced fetal movements in UK maternity units.

BACKGROUND: The development of evidence-based guidelines is a key step in ensuring that maternity care is of a universally high standard. To influence patient care national and international guidelines need to be interpreted and implemented locally. In 2011, the Royal College of Obstetricians and Gynaecologists published guidelines for the management of reduced fetal movements (RFM), which can be an important symptom of fetal compromise. Following dissemination it was anticipated that this guidance would be implemented in UK maternity units. This study aimed to assess the quality of local guidelines for the management of RFM in comparison to published national standards. METHODS: Cross-sectional survey of maternity unit guidelines for RFM. The guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool and scored by two independent investigators. Two national guidelines were used as standards to evaluate unit guidelines. RESULTS: Responses were received from 98 units (42%); 12 units had no guideline. National guidelines scored highly using the AGREE II tool but there was wide variation in the quality of individual maternity unit guidelines, which were frequently of low quality. No guidelines incorporated all the recommendations from the national guideline. Maternity unit guidelines performed well for clarity and presentation but had low scores for stakeholder involvement, rigour of development and applicability. CONCLUSIONS: In contrast to national evidence based guidance the quality of maternity unit guidelines for RFM is variable and frequently of low quality. To increase quality, guidelines need to include up to date evidence and audit standards which could be taken directly from national evidence-based guidance. Barriers to local implementation and resource implications need to be taken into consideration. Training may also improve the implementation of the guideline. Research is needed to inform strategies to realize the benefits of clinical guidance in practice.

Manejo de las circulares de cordón en el expulsivo / Nuchal cord management during expulsión

La presencia de circulares de cordón se encuentra en alrededor de 21-35% de los partos. Los resultados de las investigaciones sobre los efectos perinatales de las circulares son heterogéneos, no existiendo un criterio unificado en cuanto a su manejo en el parto. Esta revisión bibliográfica tiene como objetivo conocer las distintas formas de actuación ante la presencia de circulares de cordón en el expulsivo y la evidencia científica que éstas presentan. Encuestas anónimas realizadas a matronas muestran un alto porcentaje de manejo activo de la circular, coincidiendo con la práctica mayoritaria enseñada durante su formación. Sin embargo, el manejo activo de la circular no está exento de riesgos, por lo que se desarrollan alternativas a su gestión, como el manejo pasivo o la maniobra de Somersault

The presence of nuchal cords is around 21-35% at birth. Research results on the perinatal effect are heterogeneous, with no unified criteria in their management during delivery. This review aims to analyse different practices in the presence of nuchal cord during expulsion and their scientific evidence. Anonymous surveys carried out on midwives show a high percentage of nuchal cord active management, which turns out to be the most frequent approach learnt during their training. However, nuchal cord active management presents risks. Consequently, alternatives have been developed such as the passive management or the Somersault maneuver