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A Prospective Cohort Study Describing the Neonatal Outcome of Patient with Different Categories of Intrapartal Traces Among Pregnant Women Delivered at a Tertiary Hospital

Bainary A. Macaurog, MD; Ma. Cristina Pelaez-Crisologo, MD, FPOGS, FPSMFM
Department of Obstetrics and Gynecology, Philippine General Hospital

Background: Continuous electronic fetal monitoring has been under close scrutiny due to lack of consistent interpretation of fetal heart rate tracings, even by perinatologists. In 2008, NICHD revised their definitions, interpretation and research guidelines. ACOG incorporated these guidelines into a 2009 practice bulletin on EFM definitions and the three-tiered fetal heart rate interpretation. After a year of adapting the new classification, the Department of Obstetrics and Gynecology of tertiary hospitals has yet to evaluate locally its use in fetal surveillance during labor and subsequently its value in decision-making. To date, no local study has been published regarding the neonatal outcome of those women whose intrapratal tracings were categorized under the three-tier system.

Objectives: This study aimed to describe the neonatal outcomes of patients with Category I, II, and III traces among pregnant patients admitted in a tertiary hospital. This included APGAR score and disposition of the neonate as primary outcomes.

Methods: This was a prospective cohort study. It was conducted in a tertiary hospital from December 2012 to July 2013. The population consisted of women admitted in the labor room for delivery and underwent intrapartal monitoring and eventually delivered. Inclusions were term or preterm pregnancy ? 34 weeks, singleton pregnancy with no known congenital or lethal fetal anomalies. Exclusions were women with clinically evident chorioamnionitis on admission, multifetal gestations, preterm pregnancy (less than 34 weeks), post-term pregnancy, women who were mentally incapacitated to give consent, and those for outright cesarean section indications. There was no specified number of subjects but all laboring patients who underwent trial of labor in were included. Data was analyzed using descriptive analysis and z-test for proportion. And these data were held confidential. Reading and interpretation of the traces was made by perinatologist fellow on duty. Neonatal outcomes, on the one hand, including the APGAR score were analyzed by pediatrician on duty.

Results: There were a total of 163 subjects included in the study, with age range of 19-33 years old. Subjects were G1P0 to G9P6, with a mean prenatal check-up of 5 times. Among the 163 subjects, 134 had a Category I trace and 17 had Category II traces all through- out their laboring period, and the remainder had combination of category I and II traces. There was no Category III trace observed. For Category I trace, 97.8% of babies had a one minute APGAR score of 7-9, 1.5% had a one minute APGAR score of 4-6, and 0.7% had a one minute APGAR score of 1-3. The five-minute APGAR score with Category I trace were as follows: 99.3% had APGAR score of 7-9, 0.7% had APGAR score of 4-6, but there was none with a five-minute APGAR score of 1-3. Majority (63.4%) of the babies in Category I were direct room-in, 14.9 % were high-risk direct room-in, 10.4% babies were admitted in Neonatal Intensive Care Unit 2 (NICU2) and 11.2% in NICU3. Three (2.2%) of the babies in NICU3 were intubated. For the Category II trace, 100% of babies had one and five minute APGAR score of 7-9. Thirteen (54.2%) of the babies were direct-room in. 37.5% of the babies were admitted in NICU2. One baby (4.2%) was admitted in NICU3 but not intubated. The resuscitative measures done were as follows: tactile stimulation, thermoregulation, suctioning, inhalation, and intubation. Among these measures, suctioning (with a p-value of .02) showed a significant difference between Category I and Category II traces. Category II traces were associated more with abdominal delivery. Spinal anesthesia which was usually used in abdominal deliveries is also significantly different from the two traces, with a p-value of 0.02. Category I traces had a significantly higher morbidity and mortality compared to Category II traces.

Conclusion: There was no significant difference between the one-minute and five-minute APGAR score and disposition of babies between Category I and Category II traces. Abdominal delivery, spinal anesthesia and suctioning were higher in Category II trace than in Category I trace.