A C TA Obstetricia et Gynecologica
AOGS EDIT ORS M ES SAGE
Laboring on fetal monitoring REYNIR TOMAS GEIRSSON & JENS LANGHOFF-ROOS
DOI: 10.1111/aogs.12409
This issue is on a central issue in modern obstetrical care, fetal monitoring in labor. There is a background in this, namely a conference on the topic held last September 2013 in Malm€ o, Sweden, where some key aspects of modern monitoring methodology were debated. We all monitor the fetus in various ways through the mother’s pregnancy, not least when risk factors for fetal health and even survival are thought to be present. Monitoring intensifies in labor and is applied in some form to most mothers, even those whose risk for something going wrong is perceived as low. As evident from the articles in this issue alone, the scientific background for this extensive use of resources is variably strong and moreover interpretable in different ways. There are the pro’s and con’s, the arguments for and against different methods, when to use them, how to interpret the results, – there are the narrow and broad arguments, the single studies and the combined meta-analytic data. In this field a definite consensus is hard to get, opinions weigh heavily and can apply from the individual case to general principles of use. Yet we all monitor, more or less. We as a journal dedicated to advancement of science, cannot leave the debate as though it was not there, – it is a duty to take part and try to uphold as high a standard in the debate as possible. This is a particular necessity for us, because many of the principles for modern fetal monitoring in pregnancy and labor have emanated from the northern European area where our base is, including from the Nordic countries. Several Nordic pioneer publications and efforts in this field have wielded considerable influence in the last three decades. This includes technology using the ST part of the electronic fetal heart recording, the STAN methodology from Gothenburg in Sweden. Fetal blood sampling with measurements of acid-base status and lactate in labor may also be counted among the many groundbreaking studies on fetal monitoring, such as from the UK, Germany and the Netherlands and of course from a wider international field. We commence the issue on an editorial by one of us who was at the conference and has compiled the issue. Then come three debate-type commentaries (pp. 533– 547), or opinion articles supported by the references which the respective authors have sought out to buttress
their views for and against aspects of fetal monitoring in labor. These center on the two issues of STAN and pH/ base excess measurements and originate from the presentations at the Malm€ o conference. Read them as they come and make up your mind for arriving, we hope, at a rational personal conclusion, which should find its way into revising departmental guidelines and improved application of the techniques. The six authors, Philip Steer, Lone Hvidman, Gerard Visser, Jørg Kessler, Nana Wiberg and Edwin Chandraharan from the UK, Netherlands, Denmark, Norway, and Sweden, are well known researchers within obstetrics and have been among those shaping opinions and taking part in scientific debate in northern Europe, some for a long time. This then followed by a three thorough reviews. The first one by Jan Stener Jørgensen and Tom Weber in Odense and Copenhagen, Denmark (pp. 548–555), on the use of fetal scalp blood sampling in labor, in which both of them strongly believe. Their historical perspective and the overview of the published studies which follows is balanced, and shows that better research to underpin scalp pH measurements in a more solid way would have been needed a long time ago, but on the whole these measurements hold in their opinion a value for helping some women through to safe birth and avoiding instrumental delivery or emergency cesarean section. In this they contradict to some extent the commentary by Chandraharan and Wiberg on pp. 544–547. We also agreed with the Jørgensen and Weber that adding in some data from the Danish Birth Register and a calculation of what would be required in terms of power for a new randomized study would be of use. Lactate measurements in the fetal scalp also need additional appraisal in prospective randomized studies. The next two reviews are on the backgrounds of the STAN-technique, by Per Olofsson in Malm€ o-Lund, Sweden, and his co-workers from Sweden, Norway, Denmark, Portugal and USA (pp. 556–568 and pp. 571–586). These systematic reviews demanded some thought by the editors of the journal, because there is in these a conflict of interest situation for some of the authors, which might be regarded as an adverse issue in principle. We have chosen again to trust the integrity and the stated objectives of
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 529–530
529
Editors Message
the authors, namely to try to give scientific and balanced opinions on the evidence for and against the STAN methodology. It is up to you, the reader, to try form your own opinion on this, but to help with that we have decided with permission to publish some key comments from the reviewers of these articles and also two small “brief commentaries”, one on each article. All of this is really self-explanatory, but should be read and considered by all those involved in fetal monitoring, both on a daily or on a more occasional basis. We hope to have conveyed through this a more balanced view, while at the same time one has to realize that this is not a fully attainable goal. Balancing on a scientific line is always a challenge. The remaining articles on fetal monitoring are unrelated to the Malm€ o conference. The article on maternal body mass index and fetal monitoring by Wayne Cohen of Tucson, USA and Barrie Hayes-Gill in Nottingham, UK (pp. 590–595) and the article by Sarah Rh€ ose and colleagues from Nijmegen, the Netherlands, about intraand inter-observer agreement on non-reassuring fetal traces and the related clinical decision-making (pp. 596– 602), come from centers/countries where there has been a continuing interest in fetal monitoring. This has much relevance to the forgoing contributions. An article on a common end-point in obstetric research, neonatal intensive care admissions, by Melanie Wiegerinck and colleagues at three centers in Amsterdam, the Netherlands (pp. 603–609), fits in a way with the fore-going articles and shows how necessary it is to reach
530
consensus on how this particular and common outcome measure should be used, - if used at all. This is a topic for international discussion through regional and worldwide perinatal medicine organizations. New efforts to arrive at common outcome measures in publications will also be important in this respect. A UK-lead initiative to select and harmonize variables and outcome measures in future obstetric (and gynecologic) studies, - for better comparison and added uniformity in meta-analyses and systematic reviews, has gained approval from editorial boards of leading international journals in obstetrics and gynecology. This will be launched soon, including by this journal, in line with a previous more general appeal (1). June is the month for the NFOG2014 congress in Stockholm, Sweden, the 2-yearly venue for discussing, meeting, listening and socializing of Nordic obstetricians and gynecologists and our guests from several other places, including the Baltic states and other European countries. A few days that are to be looked forward to. The front cover should remind readers in the Nordic countries of this. At AOGS we like to blow the trumpets for news in obstetrics, gynecology and reproductive medicine and at NFOG2014 we get news in plenty as well. Reference 1. Williamson PR, Altman DG, Blazeby JM, Clarke M, Devane D, Gargon E, Tugwell P. Developing core outcome sets for clinical trials: issues to consider. Trials 2012;13:132.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 529–530
AOGS EDIT ORS M ES SAGE
Laboring on fetal monitoring REYNIR TOMAS GEIRSSON & JENS LANGHOFF-ROOS
DOI: 10.1111/aogs.12409
This issue is on a central issue in modern obstetrical care, fetal monitoring in labor. There is a background in this, namely a conference on the topic held last September 2013 in Malm€ o, Sweden, where some key aspects of modern monitoring methodology were debated. We all monitor the fetus in various ways through the mother’s pregnancy, not least when risk factors for fetal health and even survival are thought to be present. Monitoring intensifies in labor and is applied in some form to most mothers, even those whose risk for something going wrong is perceived as low. As evident from the articles in this issue alone, the scientific background for this extensive use of resources is variably strong and moreover interpretable in different ways. There are the pro’s and con’s, the arguments for and against different methods, when to use them, how to interpret the results, – there are the narrow and broad arguments, the single studies and the combined meta-analytic data. In this field a definite consensus is hard to get, opinions weigh heavily and can apply from the individual case to general principles of use. Yet we all monitor, more or less. We as a journal dedicated to advancement of science, cannot leave the debate as though it was not there, – it is a duty to take part and try to uphold as high a standard in the debate as possible. This is a particular necessity for us, because many of the principles for modern fetal monitoring in pregnancy and labor have emanated from the northern European area where our base is, including from the Nordic countries. Several Nordic pioneer publications and efforts in this field have wielded considerable influence in the last three decades. This includes technology using the ST part of the electronic fetal heart recording, the STAN methodology from Gothenburg in Sweden. Fetal blood sampling with measurements of acid-base status and lactate in labor may also be counted among the many groundbreaking studies on fetal monitoring, such as from the UK, Germany and the Netherlands and of course from a wider international field. We commence the issue on an editorial by one of us who was at the conference and has compiled the issue. Then come three debate-type commentaries (pp. 533– 547), or opinion articles supported by the references which the respective authors have sought out to buttress
their views for and against aspects of fetal monitoring in labor. These center on the two issues of STAN and pH/ base excess measurements and originate from the presentations at the Malm€ o conference. Read them as they come and make up your mind for arriving, we hope, at a rational personal conclusion, which should find its way into revising departmental guidelines and improved application of the techniques. The six authors, Philip Steer, Lone Hvidman, Gerard Visser, Jørg Kessler, Nana Wiberg and Edwin Chandraharan from the UK, Netherlands, Denmark, Norway, and Sweden, are well known researchers within obstetrics and have been among those shaping opinions and taking part in scientific debate in northern Europe, some for a long time. This then followed by a three thorough reviews. The first one by Jan Stener Jørgensen and Tom Weber in Odense and Copenhagen, Denmark (pp. 548–555), on the use of fetal scalp blood sampling in labor, in which both of them strongly believe. Their historical perspective and the overview of the published studies which follows is balanced, and shows that better research to underpin scalp pH measurements in a more solid way would have been needed a long time ago, but on the whole these measurements hold in their opinion a value for helping some women through to safe birth and avoiding instrumental delivery or emergency cesarean section. In this they contradict to some extent the commentary by Chandraharan and Wiberg on pp. 544–547. We also agreed with the Jørgensen and Weber that adding in some data from the Danish Birth Register and a calculation of what would be required in terms of power for a new randomized study would be of use. Lactate measurements in the fetal scalp also need additional appraisal in prospective randomized studies. The next two reviews are on the backgrounds of the STAN-technique, by Per Olofsson in Malm€ o-Lund, Sweden, and his co-workers from Sweden, Norway, Denmark, Portugal and USA (pp. 556–568 and pp. 571–586). These systematic reviews demanded some thought by the editors of the journal, because there is in these a conflict of interest situation for some of the authors, which might be regarded as an adverse issue in principle. We have chosen again to trust the integrity and the stated objectives of
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 529–530
529
Editors Message
the authors, namely to try to give scientific and balanced opinions on the evidence for and against the STAN methodology. It is up to you, the reader, to try form your own opinion on this, but to help with that we have decided with permission to publish some key comments from the reviewers of these articles and also two small “brief commentaries”, one on each article. All of this is really self-explanatory, but should be read and considered by all those involved in fetal monitoring, both on a daily or on a more occasional basis. We hope to have conveyed through this a more balanced view, while at the same time one has to realize that this is not a fully attainable goal. Balancing on a scientific line is always a challenge. The remaining articles on fetal monitoring are unrelated to the Malm€ o conference. The article on maternal body mass index and fetal monitoring by Wayne Cohen of Tucson, USA and Barrie Hayes-Gill in Nottingham, UK (pp. 590–595) and the article by Sarah Rh€ ose and colleagues from Nijmegen, the Netherlands, about intraand inter-observer agreement on non-reassuring fetal traces and the related clinical decision-making (pp. 596– 602), come from centers/countries where there has been a continuing interest in fetal monitoring. This has much relevance to the forgoing contributions. An article on a common end-point in obstetric research, neonatal intensive care admissions, by Melanie Wiegerinck and colleagues at three centers in Amsterdam, the Netherlands (pp. 603–609), fits in a way with the fore-going articles and shows how necessary it is to reach
530
consensus on how this particular and common outcome measure should be used, - if used at all. This is a topic for international discussion through regional and worldwide perinatal medicine organizations. New efforts to arrive at common outcome measures in publications will also be important in this respect. A UK-lead initiative to select and harmonize variables and outcome measures in future obstetric (and gynecologic) studies, - for better comparison and added uniformity in meta-analyses and systematic reviews, has gained approval from editorial boards of leading international journals in obstetrics and gynecology. This will be launched soon, including by this journal, in line with a previous more general appeal (1). June is the month for the NFOG2014 congress in Stockholm, Sweden, the 2-yearly venue for discussing, meeting, listening and socializing of Nordic obstetricians and gynecologists and our guests from several other places, including the Baltic states and other European countries. A few days that are to be looked forward to. The front cover should remind readers in the Nordic countries of this. At AOGS we like to blow the trumpets for news in obstetrics, gynecology and reproductive medicine and at NFOG2014 we get news in plenty as well. Reference 1. Williamson PR, Altman DG, Blazeby JM, Clarke M, Devane D, Gargon E, Tugwell P. Developing core outcome sets for clinical trials: issues to consider. Trials 2012;13:132.
ª 2014 Nordic Federation of Societies of Obstetrics and Gynecology, Acta Obstetricia et Gynecologica Scandinavica 93 (2014) 529–530
