Einführung der S3 Leitlinie „Vaginale Geburt am Termin“ – Wie hat
                    sich die subpartuale fetale Überwachung verändert?

Rebecca Felicitas Adams; Sven Schiermeier

doi:10.1055/a-2678-7980

Zeitschrift für Geburtshilfe und Neonatologie, Table of Contents

Z Geburtshilfe Neonatol
DOI: 10.1055/a-2678-7980

Originalarbeit

Einführung der S3 Leitlinie „Vaginale Geburt am Termin“ – Wie hat sich die subpartuale fetale Überwachung verändert?

Introduction of the S3 guideline “Vaginal Birth at Term” – What has changed in intrapartum fetal monitoring?

Authors

Rebecca Felicitas Adams

¹Humanmedizin, Universität Witten/Herdecke, Witten, Germany (Ringgold ID: RIN12263)

²Frauenklinik und Geburtshilfe, Marien Hospital Witten, Witten, Germany
Sven Schiermeier

²Frauenklinik und Geburtshilfe, Marien Hospital Witten, Witten, Germany

Abstract

Zusammenfassung

Hintergrund

Hintergrund Die subpartuale fetale Überwachung wird in der Geburtsmedizin intensiv diskutiert. Studien haben gezeigt, dass das CTG zu nicht immer notwendigen Interventionen wie operativen und vaginal-operativen Eingriffen führen kann. Darum wird in der 2021 erschienenen AWMF-S3-Leitlinie „Vaginale Geburt am Termin“ erstmals die strukturierte intermittierende Auskultation im Niedrigrisikokollektiv empfohlen.

Material und Methoden

In einer retrospektiven Querschnittsstudie wurden alle deutschen Geburtskliniken (n=616) mithilfe eines Online-Fragebogens befragt, ob sie die intermittierende Auskultation bei Niedrigrisikoschwangeren einsetzen, sowie Gründe dafür und dagegen. Die Antwortrate lag bei 16% (n=96). Ergebnisse 22% (n=21) der Kliniken gaben an, die intermittierende Auskultation immer oder manchmal zu nutzen. Es zeigte sich ein signifikanter Zusammenhang zwischen einer durch die S3-Leitlinie bewirkten Veränderung in den Kliniken und der Anwendung der intermittierenden Auskultation (X2=12,95, df=2, p=0,001). Faktoren wie die 1-zu-1 Betreuung zu>95%, der hebammengeleitete Kreißsaal und die Differenzierung des Risikostatus beeinflussten die Anwendung der intermittierenden Auskultation nicht signifikant.

Schlussfolgerung

Die Leitlinie hat nicht dazu geführt, dass die intermittierende Auskultation als Überwachung im Niedrigrisikokollektiv eingesetzt wird. Erforderlich sind die klare Niedrigrisiko-Definition, die Sicherstellung der 1-zu-1 Betreuung, Qualifikation des Personals und eine rechtlich sichere Dokumentation sowie aktuelle Studien zum Vergleich der Vor- und Nachteile der intermittierenden Auskultation vs. CTG-Überwachung.

Abstract

Background

Subpartum fetal monitoring is a debated topic in obstetrics. Studies have shown that CTG monitoring can lead to not always necessary interventions such as C-sections and vaginal-operative deliveries. Therefore, the 2021 AWMF S3 guideline “Vaginal Birth at Term” recommends structured intermittent auscultation instead of CTG monitoring in low-risk pregnancies for the first time.

Materials and Methods

In a retrospective cross-sectional study, all German maternity clinics (n=616) were asked using an online questionnaire whether they use intermittent auscultation for low-risk pregnancies as well as reasons for and against it. The response rate was 16% (n=96). Results 22% (n=21) of clinics reported using intermittent auscultation always or sometimes. A significant correlation was found if changes had occurred and the application of intermittent auscultation (X2=12.95, df=2, p=0.001). Other factors such as the availability of one-to-one care (>95%), midwife-led delivery rooms, and differentiation between high- and low-risk pregnancies had no significant influence on the use of intermittent auscultation.

Summary

The guideline has not led to the use of intermittent auscultation for monitoring in low-risk pregnancies. Clear low-risk definition, one-to-one care, qualified staff and updated studies on intermittent auscultation vs. CTG are needed.

Schlüsselwörter

Kardiotokogramm (CTG) - Geburtshilfe - intermittierende Auskultation - Fetale Überwachung

Keywords

cardiotocogram (CTG) - obstetrics - intermittent auscultation - fetal surveillance

Full Text

References

Literatur
1 Ben M'Barek I, Ben M'Barek B, Jauvion G. et al. Large-scale analysis of interobserver agreement and reliability in cardiotocography interpretation during labor using an online tool. BMC Pregnancy Childbirth 2024; 24: 136
2 Hernandez Engelhart C, Gundro Brurberg K, Aanstad KJ. et al. Reliability and agreement in intrapartum fetal heart rate monitoring interpretation: A systematic review. Acta Obstet Gynecol Scand 2023; 102: 970-985
3 Hruban L, Spilka J, Chudáček V. et al. Agreement on intrapartum cardiotocogram recordings between expert obstetricians. J Eval Clin Pract 2015; 21: 694-702
4 Heelan-Fancher L, Shi L, Zhang Y. et al. Impact of continuous electronic fetal monitoring on birth outcomes in low-risk pregnancies. Birth 2019; 46: 311-317
5 Paterno MT, McElroy K, Regan M. Electronic Fetal Monitoring and Cesarean Birth: A Scoping Review. Birth 2016; 43: 277-284
6 Deutsche Gesellschaft für Gynäkologie und Geburtshilfe e.V. DGfH. Vaginale Geburt am Termin. S3-Leitlinie der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe e.V., Deutschen Gesellschaft für Hebammenwissenschaft. In. AWMF. 015/083 2021
7 (NICE) NIfHaC-E. Intrapartum Care. Care of healthy woman and their babies during childbirth. Clinical guideline [CG 190]. In. London; 2014 updated 02/2017
8 Rosset IK, Lindahl K, Blix E. et al. Recommendations for intrapartum fetal monitoring are not followed in low-risk women: A study from two Norwegian birth units. Sex Reprod Healthc 2020; 26: 100552
9 Levett K, Fox D, P. B et al. Differences in women’s experiences of labour according to type of fetal monitoring: a quantitative analysis of an Australian national survey,. PREPRINT (Version 1), available at Research Square 2024 https://doi.org/10.21203/rs.3.rs-4604217/v1]
10 Chuey M, De Vries R, Dal Cin S. et al. Maternity Providers’ Perspectives on Barriers to Utilization of Intermittent Fetal Monitoring: A Qualitative Study. J Perinat Neonatal Nurs 2020; 34: 46-55
11 Maude RM, Skinner JP, Foureur MJ. Putting intelligent structured intermittent auscultation (ISIA) into practice. Women Birth 2016; 29: 285-292
12 Jepsen I, Blix E, Cooke H. et al. The overuse of intrapartum cardiotocography (CTG) for low-risk women: An actor-network theory analysis of data from focus groups. Women Birth 2022; 35: 593-601
13 Hodnett ED, Gates S, Hofmeyr GJ. et al. Continuous support for women during childbirth. Cochrane Database Syst Rev 2013; 7: Cd003766
14 Kashanian M, Javadi F, Haghighi MM. Effect of continuous support during labor on duration of labor and rate of cesarean delivery. Int J Gynaecol Obstet 2010; 109: 198-200
15 Knape N, Mayer H, Schnepp W. et al. The association between attendance of midwives and workload of midwives with the mode of birth: secondary analyses in the German healthcare system. BMC Pregnancy Childbirth 2014; 14: 300
16 Page L, McCourt C, Beake S. et al. Clinical interventions and outcomes of One-to-One midwifery practice. J Public Health Med 1999; 21: 243-248
17 Alfirevic Z, Devane D, Gyte GM. et al. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2017; 2: Cd006066
18 DGGG, DHV. Berlin, 25.08.2020 – DHV und DGGG fordern Korrekturen am Gesetzentwurf für die 1 : 1-Betreuung in der klinischen Geburtshilfe. Geburtshilfe Frauenheilkd 2020; 80
19 Romano AM, Buxton M. A Multimethod Improvement Project to Strengthen Intermittent Auscultation Practice Among Nurse-Midwives and Nurses. J Midwifery Womens Health 2020; 65: 362-369
20 DGGG, DHV. Vaginale Geburt am Termin. Leitlinienreport der S3-Leitlinie. AWMF 015/083 (S3). In; 2020
21 (NICE) NIfHaC-E. Fetal monitoring in labour. NG 229. In. London; 2022
22 Phillips K, Sanders J, Warren LE. UK student midwives’ theoretical knowledge, confidence, and experience of intermittent auscultation of the fetal heart rate during labour: An online cross-sectional survey. Midwifery 2024; 132: 103952
23 Lawrence A, Lewis L, Hofmeyr GJ. et al. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev 2013; Cd003934 10.1002/14651858.CD003934.pub4
24 Watson K, Mills TA, Lavender T. Experiences and outcomes on the use of telemetry to monitor the fetal heart during labour: findings from a mixed methods study. Women Birth 2022; 35: e243-e252
25 Fox D, Maude R, Coddington R. et al. The use of continuous foetal monitoring technologies that enable mobility in labour for women with complex pregnancies: A survey of Australian and New Zealand hospitals. Midwifery 2021; 93: 102887
26 Nazir L, Lakhta G, Anees K. et al. Admission Cardiotocography as a Predictor of Low Apgar Score: An Observational, Cross-Sectional Study. Cureus 2021; 13: e14530
27 Kumar N, Yadav M. Role of admission cardiotocography in predicting the obstetric outcome in term antenatal women: A prospective observational study. J Mother Child 2022; 26: 43-49
28 Oluwasomidoyin OB, Emmanuel AU, Folasade AB. Admission Cardiotocography and Neonatal Outcomes at a Tertiary Health Facility in Southwestern Nigeria. Ann Afr Med 2024; 23: 154-159
29 Devane D, Lalor JG, Daly S. et al. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev 2017; 1: Cd005122
30 Parts L, Holzmann M, Norman M. et al. Admission cardiotocography: A hospital based validation study. Eur J Obstet Gynecol Reprod Biol 2018; 229: 26-31