Background: Misinterpretation of the features observed in the cardiotocograph (CTG) may lead to unnecessary intrapartum operative interventions to women due to over-reaction (“pathological” CTG) l or may result in hypoxic-ischaemic encephalopathy (HIE) or perinatal deaths. Physiological interpretation of CTG involves classification of CTG traces based on the type of hypoxic/non-hypoxic stress and determining the fetal responses to stress to individualise care. Aim: To determine the impact of implementing the principles of physiological interpretation of CTG at two premier tertiary referral hospitals specialising in complex obstetric care in the UAE on the rate of intrapartum emergency caesarean sections (EMLSCS) and HIE. Methods: All staff working in the labour and delivery rooms (LDR) at the Burjeel Medical City (BMC) and Burjeel Hospital, Abu Dhabi (BHAD) underwent intense training on the principles of physiological interpretation of CTG in May 2024. This was followed by implementation of International Expert Consensus Guidelines on Physiological Interpretation of CTG produced by > 50 CTG experts from > 20 countries. This was followed by monthly update sessions and “refreshers” on physiological interpretation of CTG to re-enforce knowledge. The rates of EMLSCS and HIE were analysed. Results: The rates of EMLSCS reduced from 37% and 34% from BHAD and BMC, respectively, to 20% at both maternity units within 13 months. There were no cases of HIE due to CTG misinterpretation during the same period. Conclusion: There was a notable reduction (>40%) in the rate of emergency caesarean section at both tertiary referral hospitals providing complex obstetric care within 13 months of implementing the principles of physiological interpretation of CTG. This decrease was accompanied by an absence of HIE due to CTG misinterpretation at both quaternary referral hospitals for over 13 months.

Onset of uterine contractions which become progressively more frequent, intense and last for longer durations as the labor progresses is expected to cause a gradually evolving hypoxic stress to human fetuses. This is because of the repeated constriction of maternal spiral arterioles supplying the placental bed and compression of the umbilical cord as the labor advances. The majority of fetuses are able to mount physiological compensatory responses to protect their high priority central organs by maintaining aerobic metabolism. However, fetuses who are exposed to preexisting compromise such as chronic utero-placental insufficiency, chorioamnionitis or chronic fetal anemia and acidosis may not have sufficient reserves to withstand further hypoxic stress, leading to rapid decompensation and neurological injury or death. Physiological interpretation of fetal heart rate changes involves recognition of specific features of both hypoxic and non-hypoxic stresses on the cardiotocograph (CTG) and determining the fetal compensatory responses to ongoing stress. This approach which is based on the cardinal principle of individualization of care will enable frontline clinicians to differentiate features of compensation from decompensation. Timely interventions to improve intrauterine environment and/or to accomplish urgent birth will help avoid hypoxic ischemic encephalopathy (HIE) and its long term sequalae (cerebral palsy or learning difficulties) and perinatal deaths. Conversely, continuation of labor with careful observation in fetuses with compensated gradually evolving hypoxic stress will help avoid unnecessary intrapartum operative interventions. Emerging evidence suggests reduction in the rates of both HIE and emergency cesarean sections following the implementation of principles of physiological interpretation of CTG.

Uterine contractions cause hypoxic stress to human fetuses by repeatedly occluding maternal spiral arterioles which feed the placental bed and/or compressing the loops of the umbilical cord, interrupting blood flow through the umbilical vessels. For some fetuses, even such transient and repeated interruptions of oxygenation due to ongoing uterine contractions may increase the risk of decompensation in the "high priority" central organs (i.e. heart and the brain). The onset of anaerobic metabolism and resultant production of lactate in the central organs may lead to increased likelihood of fetal neurological injury and/or perinatal death. Therefore, an immediate relaxation of the myometrium by abolishing ongoing uterine contractions may help to rapidly restore oxygenation to fetal central organs. Such timely administration of acute tocolytics would help maintain aerobic metabolism in the high-priority fetal central organs, avoiding the onset of neurological injury and/or perinatal death. Commonly used acute tocolytics include beta-sympathomimetics, nitric oxide donors, oxytocin antagonists, which have different mechanisms of actions, and maternal side-effect profile. The indications include elimination of uterotonic-induced excessive uterine contractions to facilitate normalization of the fetal heart rate so as to allow continuation of labor in anticipation of vaginal birth and for rapidly improving the fetal condition immediately prior to an emergency cesarean section. The latter includes umbilical cord prolapse or chronic hypoxia when a delay in birth is anticipated. This review addresses the indications for acute tocolytics (why), the recommended timing of administration (when), ideal tocolytic (what), route of administration (how), side effects and contraindications (why-not). Based on current evidence, and pharmacokinetics, 250 mcg of subcutaneous terbutaline (or another beta-sympathomimetic such as intravenous fenoterol) is the recommended first line tocolytic, unless there are specific maternal contraindications. In the absence of maternal hypotension, 100 mg of intravenous glyceryl trinitrate (GTN) may be administered as an alternative. Acute tocolytics are not recommended to treat myometrial irritability observed in chorioamnionitis or in acute feto-maternal hemorrhage.

BACKGROUND:Hyoscine butyl bromide (HBB) is a muscarinic receptor antagonist, which inhibits the parasympathetic (cholinergic) activity of the utero-cervical plexus. It has been used to augment the progress of labor. Although, it cannot initiate uterine contractions, in combination with prostaglandins, it may shorten the duration of induction of labor due to its antimuscarinic action on the cervix, if it is administered according to the recently published scientific evidence. OBJECTIVE:To determine the effect of hyoscine butyl bromide used concomitantly with prostaglandins on the time taken to reach 5 cm cervical dilatation in primigravidae. MATERIAL AND METHODS:This is a retrospective cohort study with 98 primigravidae receiving prostaglandins and HBB and 83 primigravidae receiving prostaglandins alone. HBB was administered using the hospital protocol based on the recently published scientific evidence (20 mg given as an infusion over 4 h) if there was no cervical change (dilatation and effacement) after 8 h of insertion of prostaglandin pessary. The time taken to reach 5 cm dilatation and the primary cesarean section rate were analyzed. The Mann-Whitney U Test & the Fisher's Exact Test were used for statistical analysis. RESULTS:The median time to induction was 10 h (interquartile range [IQR]: 7-14, min: 2, max: 23) in women who received hyoscine butyl bromide compared with 19.5 h (IQR: 11.3-24, min: 4, max: 47) in women who did not (Mann-Whitney U Test p < 0.001). The primary cesarean section rate was 24.4% in the HBB group and 31.3% in the control group (Fisher's Exact Test, p > 0.136). There were no statistically significant differences in the gestational ages or birthweights between the two groups. There was no statistically significant difference in the Apgar scores, or adverse maternal and perinatal outcomes between the two groups. CONCLUSION:Administration of 20 mg of hyoscine butyl bromide, diluted in 100 mL of normal saline administered intravenously over 4 h, based on the recently published scientific evidence, concomitantly with vaginal prostaglandins significantly shortened the time to reach 5 cm dilatation. In addition, it was associated with 8% statistically non-significant reduction in the rate of primary cesarean section.

Background: Maternal and perinatal outcomes in both resource-rich and resource-limited healthcare settings depend on patient factors, socio-economic and cultural factors, presence of co-morbidities and timely access to care providers. However, one of the most important variables is the knowledge, skills and competencies of healthcare personnel in recognizing deviations from normal, and then, taking timely and appropriate actions to optimize maternal and perinatal outcomes. In the United Kingdom, despite obstetricians and midwives being mandated to attend a nationally recommended training programme, repeated Each Baby Counts Reports produced by the Royal College of Obstetricians & Gynaecologists (RCOG) has highlighted that substandard care contributed to more than 70% of intrapartum-related deaths and hypoxic-ischemic encephalopathy (HIE), and the Confidential Inquiries into maternal deaths has highlighted substandard care was responsible for approximately half of all maternal deaths in the United Kingdom. Objective: To determine the impact of the SWIFT-M Training Prograame on the rates of emergency caesarean sections and perinatal outcomes after 12 months of commencing training in two cities in the United Arab Emirates. Methodology: The SWIFT-M (Skills-based, Woman & Baby-centered, Innovative. Focused. and Transformational-Multi-professional) Maternity Training Programme was introduced in the United Arab Emirates in February 2025. Midwives, labour ward nurses and obstetricians were trained on SWIFT-M. Outcomes were analysed in two cities by an independent external clinical audit team. Results: The rate of caesarean sections was 50% lower, and there was an approximately a 50% reduction in the hypoxic-ischemic encephalopathy (HIE), neonatal and perinatal mortality rates after 12 months of training staff on SWIFT-M training programme and the introduction of novel tools. Conclusion: There was a demonstrable reduction in the rate of caesarean sections, and the rates of hypoxic-ischemic encephalopathy (HIE), neonatal and perinatal mortality rates after 12 months of SWIFT-M training.

Safe intrapartum care requires masterly observation, timely interventions, verbalization and escalation (MOTIVE) to optimize maternal and perinatal outcomes. In clinical situations where continuation of labor is deemed likely to worsen maternal and perinatal outcomes, emergency cesarean sections, if performed at the right time, have the potential to improve maternal and/or perinatal outcomes, when an immediate and safe spontaneous or operative vaginal birth is not feasible. However, unnecessary emergency cesarean sections for presumed “fetal or obstetrician’s distress” or “delayed progress of labour” may significantly increase the risks of maternal complications such as postpartum hemorrhage, wound infections and sepsis, pain, venous thrombo-embolism as well as long term adverse consequences such as placenta accreta spectrum disorders, uterine rupture and stillbirths. Conversely, the failure to ensure timely interventions due to the misclassification of cardiotocographs (CTG) as “suspicious” may lead to increased risks of hypoxic ischemic encephalopathy (HIE), neonatal encephalopathy (NNE) or perinatal deaths. The Emergency Cesarean Section-Decision Optimizing Tool (EC-DOT) has been developed to promote a systematic, scientific and logical approach prior to finalizing the decision to perform an emergency cesarean section during labor, thereby reducing the likelihood of avoidable harm to women and babies.

Intrauterine resuscitation includes different interventions which aim to improve fetal oxygenation when intrapartum fetal hypoxic stress leading to abnormal CTG features is suspected. Based on the etiology of the hypoxic stress, prompt institution of specific conservative measures, aiming to restore fetal oxygenation and normalize the features of the CTG trace, may reduce the incidence of unnecessary operative deliveries. However, there is paucity of evidence supporting the effectiveness of intrauterine resuscitation measures: based on available data, routine administration of fluid boluses is not recommended and should be limited only to volume-depleted patients, in which intravenous hydration has been associated with potential benefits. Similarly, amnioinfusion and maternal oxygen administration cannot be recommended as previous studies on their efficacy reported conflicting results, and some have suggested that these measures may be potentially harmful. On the other hand, changing maternal position seems to be a potentially useful maneuver with no side effects in cases of supine hypotension syndrome or in cases of suspected sustained umbilical cord compression. Administration of tocolytics for ongoing excessive uterine activity is associated with fetal heart rate improvement; within the most used tocolytic drugs, terbutaline (a beta-agonist) is often recommended as the first-choice agent to be administered for intrapartum acute tocolysis due to its efficacy, ease of administration and side effect profile.

BACKGROUND:Placenta Accreta Spectrum (PAS) disorders has been reported to be associated with a maternal mortality rate of 7-10%, worldwide, and many women who survive, experience life changing morbidity. Triple P procedure (p- perioperative placental localization and incision on the myometrium above the upper border of the placenta; p- pelvic devascularisation; and p-placental non-separation and myometrial excision) was developed in 2010 as a novel conservative alternative to peripartum hysterectomy to avoid severe maternal morbidity and mortality). There have been several modifications to the original Triple P Procedure to achieve "pelvic devascularisation" based on locally available resources. OBJECTIVE:To determine the effectiveness of the Triple P Procedure and its modifications on reducing the blood loss and the rate of peripartum hysterectomy in women who were diagnosed to have placental accreta spectrum (PAS) by reviewing the published literature. MATERIALS AND METHODS:PubMed, Embase and Google Scholar Search searches were made using "Triple P" and "Modified Triple P." Papers selected were assessed independently for content, data extraction and analysis. The following parameters were included for the analysis: total number of cases, total EBL, need for blood transfusion, injury to adjacent pelvic organs (urinary bladder, ureter, bowel), need for embolization, admission to intensive care unit (ICU), post-operative in-patient hospital stay, peripartum Hysterectomy, for "Modified" Triple P Procedure, the nature of the modification.Study characteristics were extracted using a predesigned data extraction table. RESULTS:The literature search identified 6 articles on the Triple P Procedure and 8 articles on the modified Triple P Procedure which were deemed eligible for analysis and comparison, based on the inclusion criteria. 75 patients had the Triple P procedure with an estimated mean blood loss of 2.31 L and a blood transfusion rate of 52%. The bladder injury rate was only 1.3%. None of the patients had a peripartum hysterectomy. Overall, 654 patients had the Modified Triple P procedure with an estimated mean blood loss of 1.4 L and a blood transfusion rate of 64.5%. The mean hospital stay was 3.86 days and 6.1% had a peripartum hysterectomy. CONCLUSION:The Triple P Procedure and the Modified Triple P procedure are associated with lower estimated blood loss as compared to the reported rates with a peripartum hysterectomy. The Triple P Procedure was associated with lower rates of inadvertent injuries to the bladder and ureters as compared to the Modified Triple P Procedure and reported rates with peripartum hysterectomy. Both the Triple P and the Modified Triple P Procedure are associated with very low rates of peripartum hysterectomy (0% and 6.1%, respectively).

OBJECTIVES:Historically, baseline fetal heart rate variability (FHRV) with an amplitude of greater than 25 beats per minute, and lasting for more than 30 min, was defined as the saltatory pattern. Several experimental animal models have reported an association between saltatory pattern and poor perinatal outcomes. However, recent studies have suggested that the classically defined saltatory pattern is very uncommon during labor, and a new CTG pattern, called the "ZigZag" pattern (ZZP), has been reported. ZZP has been defined as a rapid, erratic repetitive oscillations in the FHR with an amplitude of >25 bpm and has been claimed as a potential marker to identify fetuses at risk of intra-partum and perinatal compromise during labour. A recent international expert consensus has recommended that ZZP persisting for >1 min requires an urgent intervention to avoid poor perinatal outcomes. The aim of the present systematic review was to determine the intra-partum and perinatal outcomes of fetuses with the ZZP compared to the control group not showing the ZZP during labor. METHODS:Medline, Embase and Cochrane databases were searched. Inclusion criteria were studies reporting the intra-partum and perinatal outcome of fetuses showing compared to those not showing ZZP during labour. The outcomes observed were operative vaginal delivery, caesarean section, umbilical artery pH<7.1, base excess <-11, mean pH and base excess, admission to neonatal intensive care unit (NICU), abnormal post-natal brain imaging and occurrence of late decelerations later on the CTG trace. Random-effect meta-analyses were used to combine data and results reported as pooled odd ratios (OR) for categorical and pooled mean differences (MD) for continuous variables with their 95 % confidence intervals (CI). RESULTS:Six studies (18,136 fetuses) were included. Fetuses showing ZZP on CTG trace during labor had a higher risk of operative vaginal delivery (OR: 2.22, 95 % CI 1.69-2.91; p<0.001), cesarean delivery (OR: 1.71, 95 % CI 1.37-2.15; p<0.001), umbilical artery pH<7.1 (OR: 2.48, 95 % CI 1.56-3.94; p<0.001), Apgar score <7 at 5 min (OR: 2.13, 955 CI 1.05-4.31; p=0.004) and the occurrence of late decelerations later on during labor (OR: 9.51, 95 % CI 7.80-11.61; p<0.001) compared to those not showing this pattern, while there was no difference in the risk of NICU admission (p=0.209) and respiratory support after birth (p=0.755). Likewise, umbilical artery pH was significantly lower in fetuses showing compared to those not showing ZZP during labour (pooled MD: -0.10, 95 % CI -0.11 to -0.09; p<0.001), while there was no difference in the value of mean base excess between the two groups (p=0.156). CONCLUSIONS:Fetuses showing the ZZP on CTG trace during labour are at higher risk of operative vaginal delivery, caesarean section and adverse intrapartum and perinatal outcomes.