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Intrapartum Monitoring with Cardiotocography and Stwaveform DOI: 10.1111/1471-0528.12989 www.bjog.org Intrapartum monitoring with cardiotocography and ST-waveform analysis in breech presentation: an observational study J Kessler,a,b D Moster,c,d,e S Albrechtsena,b a Department of Obstetrics and Gynaecology, Haukeland University Hospital, Bergen, Norway b Department of Clinical Science, Research Group for Pregnancy, Fetal Development and Birth, University of Bergen, Bergen, Norway c Department of Health Registries, Norwegian Institute of Public Health, Bergen, Norway d Department of Paediatrics, Haukeland University Hospital, Bergen, Norway e Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway Correspondence: Dr J Kessler, Department of Obstetrics and Gynaecology, Haukeland University Hospital, 5021 Bergen, Norway. Email: [email protected] Accepted 29 May 2014. Published Online 18 July 2014. Objective To determine the electrocardiographic performance and Results Breech presentation occurred in 750 of 23 219 (3.2%) neonatal outcome of pregnancies with breech presentation and deliveries, 625 (83%) of which were selected for vaginal delivery. planned vaginal delivery monitored with ST-waveform analysis Intrapartum monitoring by STAN was performed in 433 (69%). (STAN). Compared with vertex presentations, fetuses in breech presentation had a lower risk of baseline T/QRS rise during Design Prospective observational study. labour [odds ratio (OR) = 0.7, 95% confidence interval (95% Setting University hospital, Norway; 2004–2008. CI) = 0.7–0.9, P = 0.003] and a higher risk for intervention as a result of preterminal cardiotocogram (OR = 2.9, 95% CI = 1.6– Population Singleton pregnancies with a gestational age above 5.9, P = 0.001). The risks of perinatal mortality (OR = 1.8, 95% 35 + 6 weeks, breech presentation, selected for vaginal delivery CI = 0.2–15, P = 0.6), cord metabolic acidosis (OR = 0.8, 95% and monitored with STAN. CI = 0.2–3.2, P = 0.7) and moderate or severe neonatal Methods Common clinical guidelines for STAN monitoring were encephalopathy (OR = 1.8, 95% CI = 0.5–6.2, P = 0.3) did not used. An experienced neonatologist graded the symptoms of differ significantly between breech and vertex deliveries. neonatal encephalopathy. The outcome was compared with Conclusion STAN can be used for the surveillance of breech STAN-monitored high-risk deliveries in a vertex presentation presentations selected for vaginal delivery with an acceptable (n = 5569) using logistic regression analysis. neonatal outcome. The electrocardiogram (ECG) pattern during Main outcome measure Frequency of ST events, indications of labour varies with the fetal presentation. intervention for fetal distress, and neonatal morbidity and Keywords Breech presentation, fetal electrocardiogram (ECG), mortality. intrapartum monitoring, neonatal outcome, ST-waveform analysis. Please cite this paper as: Kessler J, Moster D, Albrechtsen S. Intrapartum monitoring with cardiotocography and ST-waveform analysis in breech presentation: an observational study. BJOG 2014; DOI: 10.1111/1471-0528.12989. mode of delivery.6 In contrast with the recommendations Introduction – of the Cochrane review,7 several national guidelines8 10 still The Term Breech Trial (TBT) revealed an increased mortal- support the option of vaginal delivery for breech presenta- ity in participants randomised to planned vaginal delivery tion at term. relative to elective caesarean section.1 This study resulted in Cardiotocography (CTG), which is the basic method of changes to the management of breech presentation at term, surveillance of high-risk labour, is hampered by a high sen- with elective caesarean delivery being recommended in sitivity and low specificity for the detection of intrapartum – most countries.2 4 The TBT has since been criticised for hypoxia. As a result of the risk of cord compression and methodological flaws,5 and long-term follow-up of the cord prolapse in breech presentations, continuous elec- infants has not confirmed that the outcome differs with the tronic fetal monitoring is essential in order to reveal fetal ª 2014 Royal College of Obstetricians and Gynaecologists 1 Kessler et al. hypoxia in a timely manner. The use of ST-waveform Piper’s forceps were used liberally for the delivery of the af- analysis (STAN) of the fetal electrocardiogram (ECG) as an tercoming head. A paediatrician was present at delivery. In adjunct to CTG has been found to reduce the frequency of cases with ruptured membranes, a fetal electrode was vaginal operative deliveries, the necessity of fetal blood attached at the onset of active labour. If the CTG was nor- sampling and the frequency of neonate transferral to the mal, the fetal membranes were kept intact. Amniotomy was neonatal intensive care unit (NICU).11 The largest rando- not performed unless CTG abnormalities occurred. The mised controlled trials have also demonstrated a decreased fetal electrode was most often attached to the fetal buttock, frequency of cord metabolic acidosis.12,13 in some cases to the foot. In order to enable an ECG analy- Despite being a common indication for electronic fetal sis analogous to that for cephalic presentation, the recorded monitoring, breech presentation was an exclusion criterion ECG had to be mirror imaged by activation of the ‘Breech in all but one14 of the five randomised trials on CTG and mode’ in the monitoring device. The diagnosis and inter- STAN.12,13,15,16 A total of 55 cases with breech presentation vention in cases of suspected intrapartum hypoxia were were randomised in the Plymouth study,14 30 of these to based on the clinical guidelines for monitoring with CTG CTG and STAN. Thus, the evidence from randomised trials and STAN.18 CTG classification was conducted according supporting the use of the method in breech presentation is to the International Federation of Gynaecology and Obstet- almost negligible. The aim of the present study was there- rics.19 CTG abnormalities were then related to the occur- fore to investigate the fetal ECG waveform pattern and to rence of ST events (Table 1) to determine whether or not evaluate the neonatal outcome of pregnancies with breech to intervene. presentation selected for vaginal delivery, monitored with If hypoxia is indicated during the first stage of labour, STAN. clinical guidelines18 recommend intrauterine resuscitation as the first measure and, if not successful, an operative Materials and methods intervention should be performed and delivery accom- plished within 20 minutes. Immediate delivery is warranted This was a prospective observational study of all singleton if hypoxia is indicated during the second stage.18 pregnancies with a gestational age above 35 + 6 weeks with An adverse neonatal outcome was defined as follows: a planned vaginal delivery that were monitored by STAN perinatal mortality, cord metabolic acidosis [arterial pH between 1 January 2004 and 31 December 2008. STAN mon- (pHartery) < 7.05 and base deficit in the extracellular fluid 20,21 itoring was restricted to high-risk deliveries as defined by (BDecf) > 12 mmol/l ], cord acidosis at delivery [either 17 local guidelines. The study protocol was assessed by the moderate (pHartery < 7.15, <10th percentile) or severe 22 regional ethics committee (REK Vest, 129.08) and defined as (pHartery < 7.05, <2.5th percentile) ], a 5-minute Apgar a quality improvement project which, according to Norwe- score of <7, transfer to the NICU, and moderate or severe gian law on medical research, does not require written neonatal encephalopathy (NE). NE was graded according patient consent for their involvement. The study population to Sarnat and Sarnat23 by an experienced neonatologist, as consisted of pregnancies with a fetus in breech presentation; described elsewhere.17 those with cephalic presentation served as a reference. The The occurrence of ST interval changes, the risk of ST sig- overall results on the maternal and neonatal outcome of the nal disturbance and the risk of adverse outcome were com- study population have been published elsewhere.17 pared with those for a reference population using logistic Women with a fetus in breech presentation were selected regression analysis. The characteristics of the study and to undergo a planned vaginal delivery according to the fol- background were evaluated using Pearson’s chi-squared test lowing local guidelines: 1 The estimated fetal weight did not exceed 4500 g (indi- vidual assessment between 4000 and 4500 g according to Table 1. Clinical guidelines for the use of cardiotocography (CTG) pelvic size and obstetric history). and ST-waveform analysis; recommendations for intervention 2 Computed tomography (CT) pelvimetry was performed according to CTG abnormalities and ST events ≥ ≥ [conjugata vera 11.5 cm, sum of outlet 32.5 cm Intermediary Abnormal Preterminal (sagittal outlet + intertuberous + interspinous diame- CTG CTG CTG ters)] in nulliparous women or those with a large discor- dance between previous birthweight and estimated fetal Episodic T/QRS rise >0.15 >0.10 Immediate weight in the current pregnancy. delivery Epidural anaesthesia was advised for all women in the Baseline T/QRS rise >0.10 >0.05 study population. All deliveries were performed by, or Biphasic ST Three biphasic Two biphasic under the supervision of, a senior consultant. The shoul- events events ders and arms were delivered by Løvset’s manoeuvre. 2 ª 2014 Royal College of Obstetricians and Gynaecologists Intrapartum monitoring and breech presentation and Student’s t-test. The level of statistical significance for The distribution of indications to intervene in cases of all statistical tests was set at P < 0.05. suspected hypoxia, as given by the STAN clinical guidelines, also varied with the type of fetal presentation. Interventions Results as a result of baseline T/QRS rise occurred less often in breech presentation, whereas hypoxia was more frequently A breech presentation occurred in 750 of 23 219 (3.4%) indicated by a preterminal CTG. The distribution of indica- deliveries. Among these, 625 (83%) were selected for tions for intervention was not influenced by birthweight, attempted vaginal delivery, 433 (69%) of which were mon- gestational age at delivery or fetal sex (Table 3).
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