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Resident evaluation of intrapartum fetal heart-rate tracings: can they predict acidosis?
In-house Versus Out-of-House Call: A Comparison of Obstetric Procedure Rates Manish Gopal, MD Thomas Jefferson University Hospital, Philadelphia, PA
Richa Singhal, MD, Christina Mitchell, AB, Jennifer Culhane, PhD, Kelly Farley McCollum, MPH, Jay Goldberg, MD PURPOSE: Prior studies have implicated out-of-house physician call status as a factor in higher cesarean delivery rates. This study was performed to evaluate the effect of inhouse versus out-of-house nighttime call coverage on obstetric practice. METHODS: A retrospective analysis was performed on deliveries at Thomas Jefferson University Hospital that occurred between 5 PM and 7 AM in 1996 and 1997. Included were deliveries of the faculty group, which equally shared inhouse and out-of-house call coverage. Clinic patients and private patients whose physicians did not do inhouse calls were excluded. Thus, patients included had an equal chance of having their infant delivered by an inhouse or out-of-house physician. Patient demographics and obstetric outcomes were analyzed with respect to call status by ANOVA and 2. RESULTS: Of 1577 deliveries occurring between 5 PM and 7 AM, 230 eligible deliveries were identified, 120 with inhouse and 110 with out-of-house call coverage. Demographics, including maternal age, race, gestational age, and birth weight, did not statistically differ between the groups. A comparison of inhouse and out-of-house deliveries yielded rates for episiotomy (28.3% and 30.0%, respectively), nonoperative vaginal delivery (61.6%, 60.0%), cesarean delivery (26.7%, 21.8%), and operative vaginal delivery (15.9%, 23.3%). A 2 analysis of the two groups showed no statistically significant differences. CONCLUSIONS: The call status of physicians, whether inhouse or out-of-house, did not affect episiotomy, cesarean delivery, or operative vaginal delivery rates.
Intrapartum Fetal Heart-Rate Tracings to Predict Neonatal Death Due to Hypoxic Ischemic Encephalopathy Keith Williams, MD Yale School of Medicine, New Haven, CT
France Galerneau, MD OBJECTIVE: To determine which intrapartum FHR parameters in the presence of severe neonatal acidosis (pH ⬍ 7.0) predict the development of neonatal death secondary to hypoxic ischemic encephalopathy (HIE).
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STUDY DESIGN: The intrapartum FHR tracings of six term neonates who died secondary to complications of HIE were compared with six matched neonates with similar pH and gestational age who survived. All patients had at least 2 hours of intrapartum fetal heart rate patterns available for review. We compared the fetal heart rate parameters of bradycardia, variable and late deceleration variability, accelerations, baseline fetal heart rate, and the duration of the fetal heart rate abnormality. Comparison between the groups was done using 2 analysis for proportions and Student t tests for continuous data. Multiple logistic regression analysis was done to assess the role of significant intrapartum fetal heart rate parameters to predict neonatal death. RESULTS: Neonates who died secondary to HIE showed a 50% incidence of bradycardia, and a doubling of the duration of fetal heart rate abnormality (Table 1). Multiple logistic regression analysis revealed that neonatal death was predicted by bradycardia, odds ratio 0.51 (95% CI 0.27, 0.83, P ⬍ .05), and duration of FHR abnormality, odds ratio 2.5 (95% CI 1.7, 7.5, P ⬍ .01). Table 1. Incidence of
Died (6)
Did not die (6)
Bradycardia Variable decelerations Late decelerations Minimal variability Accelerations Duration of abnormality
3 (50%) 2 (33%) 3 (50%) 5 (83%) 1 (17%) 49 ⫾ 12
6 (100%) 2 (33%), NS 3 (50%), NS 3 (50%) 1 (17%), NS 24 ⫾ 14 (.01)
CONCLUSIONS: The duration of abnormal fetal heart rate pattern and not the degree of metabolic acidosis correlates best with neonatal death secondary to HIE. Patients with bradycardia were less likely to die secondary to HIE. This may be related to the acuteness of change in FHR that elicits a prompt intervention.
Resident Evaluation of Intrapartum Fetal Heart-Rate Tracings: Can They Predict Acidosis? Keith Williams, MD Yale School of Medicine, New Haven, CT
Richard Benoit, MD, Ebenezer Babalola, MD, and France Galerneau, MD OBJECTIVE: To assess the ability of resident physicians to evaluate nonreassuring intrapartum fetal heart rate (FHR) tracings to predict the degree of neonatal acidosis as defined by the pH and base deficit. STUDY DESIGN: The final 2 hours of 14 nonreassuring FHR tracings were reviewed by a group of ten obstetric residents.
OBSTETRICS & GYNECOLOGY
The residents then categorized the predicted pH and base deficit into one of the four categories ⬎7.25, 7.25 to ⬎7.10, 7.10 to ⬎7.0, and 7.0 or into the four categories of base deficit of ⫺6, ⬎⫺6 to ⫺12, ⬎⫺12 to ⫺16, and ⬎⫺16. Comparison between the 4 years of residents was done using 2 analysis. The significance level was set at the P ⬍ .05 level. RESULTS: Ten residents participated in this review. The incidence of the correct prediction of both pH and base deficit categories was 38.5% (Table 1). In 80% of cases when pH and base deficit were incorrect, the predicted pH or base deficit was lower than the actual pH or base deficit. There was no significant difference between the years of training and prediction of pH or base deficit.
uterine pressure catheter. Data were analyzed using the Student t test and 2, where applicable. RESULTS: Sixty-seven women consented to participate in the study. Mean phosphorus levels were 3.67 mg/dL in the control group and 3.75 mg/dL in the dysfunctional contraction group (P ⫽ .58). Changes in serum phosphorus from admission to complete cervical dilation were 0.17 mg/dL in the control group and 0.13 mg/dL in the dysfunctional contraction group (P ⫽ .82). There were no statistically significant differences in mean calcium levels between the groups. CONCLUSIONS: There appears to be no association between hypophosphatemia and dysfunctional uterine contractions.
Table 1. Resident years
Accuracy of pH
Accuracy of base deficit
1 2 3 4
39.2% 28.6% 35.7% 46.4%
47% 36.9% 35.7% 50%
Ketorolac Versus Hydrocodone for Postpartum Pain* Clint M. Cormier, MD LSUHSC-Shreveport, Shreveport, LA
CONCLUSIONS: The ability to accurately predict pH and base deficit based on the clinical scenario and fetal heart rate tracings is limited in a resident training program and is not improved by increased years of resident training.
Is Hypophosphatemia Associated With Dysfunctional Uterine Contractions? Jason D. Wright, MD Washington University School of Medicine, St. Louis, MO
Angela Chaudhari, MD, and Yoel Sadovsky, MD OBJECTIVE: Muscle dysfunction, characteristic of transient heart failure, respiratory depression, and respiratory muscle weakness, has been attributed in some patients to hypophosphatemia. Hypotonic uterine contractions are the leading cause of dysfunctional labor. We hypothesized that hypophosphatemia depresses uterine muscle contractility and leads to clinically significant dysfunctional labor. METHODS: Serum samples for phosphorus and total calcium levels were collected prospectively from term laboring parturients. Samples were obtained upon admission and at the time of complete cervical dilation or when dysfunctional uterine contractions were identified. A dysfunctional contraction pattern was defined as fewer than four contractions in a 20-minute period or as less than 180 Montevideo units in women with a
VOL. 101, NO. 4 (SUPPLEMENT), APRIL 2003
Michael J. Lucas, MD, and Lisa Philibert OBJECTIVE: To compare the efficacy of oral ketorolac with oral hydrocodone for the treatment of pain in patients who have undergone vaginal delivery. METHODS: Women presenting in labor were randomized to receive ketorolac 10 mg orally or hydrocodone 10 mg orally immediately after delivery, and then repeated doses every 4 – 6 hours as requested by the patient. Patients rated pain intensity before the first dose and then at 30 minutes, 1 hour, and hourly thereafter for 6 hours on a scale from 1 to 10. Pain was then rated every 2 hours until 24 hours from the first dose. Laboratory changes were recorded before and at 6 and 24 hours after the first dose was given. RESULTS: Seventy patients were randomized, 55 of whom delivered vaginally and were included in this study. Two of these withdrew from the study voluntarily after it was begun. Of the remaining 53, 27 were assigned to ketorolac and 26 were assigned to hydrocodone. Important demographic and clinical characteristics were similar in the groups. The mean pain scores were similar at every time interval. The average number of doses required in the first 24 hours had no statistical difference. There were no statistically significant differences in the measured laboratory values between the two groups at any of the time interavals. CONCLUSIONS: Oral ketorolac is as effective as oral hydrocodone in relieving pain in the first 24 hours after delivery. The potential adverse affects of ketorolac do not appear to be significant after vaginal delivery.
*This document includes a discussion of use of a product that is unapproved by the United States Food and Drug Administration.
TUESDAY POSTERS
67S
Richa Singhal, MD, Christina Mitchell, AB, Jennifer Culhane, PhD, Kelly Farley McCollum, MPH, Jay Goldberg, MD PURPOSE: Prior studies have implicated out-of-house physician call status as a factor in higher cesarean delivery rates. This study was performed to evaluate the effect of inhouse versus out-of-house nighttime call coverage on obstetric practice. METHODS: A retrospective analysis was performed on deliveries at Thomas Jefferson University Hospital that occurred between 5 PM and 7 AM in 1996 and 1997. Included were deliveries of the faculty group, which equally shared inhouse and out-of-house call coverage. Clinic patients and private patients whose physicians did not do inhouse calls were excluded. Thus, patients included had an equal chance of having their infant delivered by an inhouse or out-of-house physician. Patient demographics and obstetric outcomes were analyzed with respect to call status by ANOVA and 2. RESULTS: Of 1577 deliveries occurring between 5 PM and 7 AM, 230 eligible deliveries were identified, 120 with inhouse and 110 with out-of-house call coverage. Demographics, including maternal age, race, gestational age, and birth weight, did not statistically differ between the groups. A comparison of inhouse and out-of-house deliveries yielded rates for episiotomy (28.3% and 30.0%, respectively), nonoperative vaginal delivery (61.6%, 60.0%), cesarean delivery (26.7%, 21.8%), and operative vaginal delivery (15.9%, 23.3%). A 2 analysis of the two groups showed no statistically significant differences. CONCLUSIONS: The call status of physicians, whether inhouse or out-of-house, did not affect episiotomy, cesarean delivery, or operative vaginal delivery rates.
Intrapartum Fetal Heart-Rate Tracings to Predict Neonatal Death Due to Hypoxic Ischemic Encephalopathy Keith Williams, MD Yale School of Medicine, New Haven, CT
France Galerneau, MD OBJECTIVE: To determine which intrapartum FHR parameters in the presence of severe neonatal acidosis (pH ⬍ 7.0) predict the development of neonatal death secondary to hypoxic ischemic encephalopathy (HIE).
66S
TUESDAY POSTERS
STUDY DESIGN: The intrapartum FHR tracings of six term neonates who died secondary to complications of HIE were compared with six matched neonates with similar pH and gestational age who survived. All patients had at least 2 hours of intrapartum fetal heart rate patterns available for review. We compared the fetal heart rate parameters of bradycardia, variable and late deceleration variability, accelerations, baseline fetal heart rate, and the duration of the fetal heart rate abnormality. Comparison between the groups was done using 2 analysis for proportions and Student t tests for continuous data. Multiple logistic regression analysis was done to assess the role of significant intrapartum fetal heart rate parameters to predict neonatal death. RESULTS: Neonates who died secondary to HIE showed a 50% incidence of bradycardia, and a doubling of the duration of fetal heart rate abnormality (Table 1). Multiple logistic regression analysis revealed that neonatal death was predicted by bradycardia, odds ratio 0.51 (95% CI 0.27, 0.83, P ⬍ .05), and duration of FHR abnormality, odds ratio 2.5 (95% CI 1.7, 7.5, P ⬍ .01). Table 1. Incidence of
Died (6)
Did not die (6)
Bradycardia Variable decelerations Late decelerations Minimal variability Accelerations Duration of abnormality
3 (50%) 2 (33%) 3 (50%) 5 (83%) 1 (17%) 49 ⫾ 12
6 (100%) 2 (33%), NS 3 (50%), NS 3 (50%) 1 (17%), NS 24 ⫾ 14 (.01)
CONCLUSIONS: The duration of abnormal fetal heart rate pattern and not the degree of metabolic acidosis correlates best with neonatal death secondary to HIE. Patients with bradycardia were less likely to die secondary to HIE. This may be related to the acuteness of change in FHR that elicits a prompt intervention.
Resident Evaluation of Intrapartum Fetal Heart-Rate Tracings: Can They Predict Acidosis? Keith Williams, MD Yale School of Medicine, New Haven, CT
Richard Benoit, MD, Ebenezer Babalola, MD, and France Galerneau, MD OBJECTIVE: To assess the ability of resident physicians to evaluate nonreassuring intrapartum fetal heart rate (FHR) tracings to predict the degree of neonatal acidosis as defined by the pH and base deficit. STUDY DESIGN: The final 2 hours of 14 nonreassuring FHR tracings were reviewed by a group of ten obstetric residents.
OBSTETRICS & GYNECOLOGY
The residents then categorized the predicted pH and base deficit into one of the four categories ⬎7.25, 7.25 to ⬎7.10, 7.10 to ⬎7.0, and 7.0 or into the four categories of base deficit of ⫺6, ⬎⫺6 to ⫺12, ⬎⫺12 to ⫺16, and ⬎⫺16. Comparison between the 4 years of residents was done using 2 analysis. The significance level was set at the P ⬍ .05 level. RESULTS: Ten residents participated in this review. The incidence of the correct prediction of both pH and base deficit categories was 38.5% (Table 1). In 80% of cases when pH and base deficit were incorrect, the predicted pH or base deficit was lower than the actual pH or base deficit. There was no significant difference between the years of training and prediction of pH or base deficit.
uterine pressure catheter. Data were analyzed using the Student t test and 2, where applicable. RESULTS: Sixty-seven women consented to participate in the study. Mean phosphorus levels were 3.67 mg/dL in the control group and 3.75 mg/dL in the dysfunctional contraction group (P ⫽ .58). Changes in serum phosphorus from admission to complete cervical dilation were 0.17 mg/dL in the control group and 0.13 mg/dL in the dysfunctional contraction group (P ⫽ .82). There were no statistically significant differences in mean calcium levels between the groups. CONCLUSIONS: There appears to be no association between hypophosphatemia and dysfunctional uterine contractions.
Table 1. Resident years
Accuracy of pH
Accuracy of base deficit
1 2 3 4
39.2% 28.6% 35.7% 46.4%
47% 36.9% 35.7% 50%
Ketorolac Versus Hydrocodone for Postpartum Pain* Clint M. Cormier, MD LSUHSC-Shreveport, Shreveport, LA
CONCLUSIONS: The ability to accurately predict pH and base deficit based on the clinical scenario and fetal heart rate tracings is limited in a resident training program and is not improved by increased years of resident training.
Is Hypophosphatemia Associated With Dysfunctional Uterine Contractions? Jason D. Wright, MD Washington University School of Medicine, St. Louis, MO
Angela Chaudhari, MD, and Yoel Sadovsky, MD OBJECTIVE: Muscle dysfunction, characteristic of transient heart failure, respiratory depression, and respiratory muscle weakness, has been attributed in some patients to hypophosphatemia. Hypotonic uterine contractions are the leading cause of dysfunctional labor. We hypothesized that hypophosphatemia depresses uterine muscle contractility and leads to clinically significant dysfunctional labor. METHODS: Serum samples for phosphorus and total calcium levels were collected prospectively from term laboring parturients. Samples were obtained upon admission and at the time of complete cervical dilation or when dysfunctional uterine contractions were identified. A dysfunctional contraction pattern was defined as fewer than four contractions in a 20-minute period or as less than 180 Montevideo units in women with a
VOL. 101, NO. 4 (SUPPLEMENT), APRIL 2003
Michael J. Lucas, MD, and Lisa Philibert OBJECTIVE: To compare the efficacy of oral ketorolac with oral hydrocodone for the treatment of pain in patients who have undergone vaginal delivery. METHODS: Women presenting in labor were randomized to receive ketorolac 10 mg orally or hydrocodone 10 mg orally immediately after delivery, and then repeated doses every 4 – 6 hours as requested by the patient. Patients rated pain intensity before the first dose and then at 30 minutes, 1 hour, and hourly thereafter for 6 hours on a scale from 1 to 10. Pain was then rated every 2 hours until 24 hours from the first dose. Laboratory changes were recorded before and at 6 and 24 hours after the first dose was given. RESULTS: Seventy patients were randomized, 55 of whom delivered vaginally and were included in this study. Two of these withdrew from the study voluntarily after it was begun. Of the remaining 53, 27 were assigned to ketorolac and 26 were assigned to hydrocodone. Important demographic and clinical characteristics were similar in the groups. The mean pain scores were similar at every time interval. The average number of doses required in the first 24 hours had no statistical difference. There were no statistically significant differences in the measured laboratory values between the two groups at any of the time interavals. CONCLUSIONS: Oral ketorolac is as effective as oral hydrocodone in relieving pain in the first 24 hours after delivery. The potential adverse affects of ketorolac do not appear to be significant after vaginal delivery.
*This document includes a discussion of use of a product that is unapproved by the United States Food and Drug Administration.
TUESDAY POSTERS
67S