High rates of preterm birth and cesarean delivery have been reported in women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. 1 However, studies have inadequate power to assess uncommon outcomes like stillbirth (fetal death ≥24 weeks' gestation). The UK Obstetric Surveillance System reported 3 stillbirths among 247 completed pregnancies in women with confirmed coronavirus disease 2019 (COVID-19) vs the national rate (12.1 per 1000 births vs 4-5 per 1000 births). 2 We assessed the change in stillbirth and preterm delivery rates during the pandemic.

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The fetus is consistently exposed to repeated periods of impaired oxygen (hypoxaemia) and nutrient supply in labour. This is balanced by the healthy fetus's remarkable anaerobic tolerance and impressive ability to mount protective adaptations to hypoxaemia. The most important mediator of fetal adaptations to brief repeated hypoxaemia is the peripheral chemoreflex, a rapid reflex response to acute falls in arterial oxygen tension. The overwhelming majority of fetuses are able to respond to repeated uterine contractions without developing hypotension or hypoxic-ischaemic injury. In contrast, fetuses who are either exposed to severe hypoxaemia, for example during uterine hyperstimulation, or enter labour with reduced anaerobic reserve (e.g. as shown by severe fetal growth restriction) are at increased risk of developing intermittent hypotension and cerebral hypoperfusion. It is remarkable to note that when fetuses develop hypotension during such repeated severe hypoxaemia, it is not mediated by impaired reflex adaptation, but by failure to maintain combined ventricular output, likely due to a combination of exhaustion of myocardial glycogen and evolving myocardial injury. The chemoreflex is suppressed by relatively long periods of severe hypoxaemia of 1.5-2 min, longer than the typical contraction. Even in this setting, the peripheral chemoreflex is consistently reactivated between contractions. These findings demonstrate that the peripheral chemoreflex is an indefatigable guardian of fetal adaptation to labour.

Introduction. One of the limitations reported with cardiotocography is the modest interobserver agreement observed in tracing interpretation. This study compared agreement, reliability and accuracy of cardiotocography interpretation using the International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines. Material and methods. A total of 151 tracings were evaluated by 27 clinicians from three centers where International Federation of Gynecology and Obstetrics, American College of Obstetrics and Gynecology and National Institute for Health and Care Excellence guidelines were routinely used. Interobserver agreement was evaluated using the proportions of agreement and reliability with the j statistic. The accuracy of tracings classified as "pathological/category III" was assessed for prediction of newborn acidemia. For all measures, 95% confidence interval were calculated. Results. Cardiotocography classifications were more distributed with International Federation of Gynecology and Obstetrics (9, 52, 39%) and National Institute for Health and Care Excellence (30, 33, 37%) than with American College of Obstetrics and Gynecology (13, 81, 6%). The category with the highest agreement was American College of Obstetrics and Gynecology category II (proportions of agreement = 0.73, 95% confidence interval 0.70-76), and the ones with the lowest agreement were American College of Obstetrics and Gynecology categories I and III. Reliability was significantly higher with International Federation of Gynecology and Obstetrics (j = 0.37, 95% confidence interval 0.31-0.43), and National Institute for Health and Care Excellence (j = 0.33, 95% confidence interval 0.28-0.39) than with American College of Obstetrics and Gynecology (j = 0.15, 95% confidence interval 0.10-0.21); however, all represent only slight/fair reliability. International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence showed a trend towards higher sensitivities in prediction of newborn acidemia (89 and 97%, respectively) than American College of Obstetrics and Gynecology (32%), but the latter achieved a significantly higher specificity (95%). Conclusions. With American College of Obstetrics and Gynecology guidelines there is high agreement in category II, low reliability, low sensitivity and high specificity in prediction of acidemia. With International Federation of Gynecology and Obstetrics and National Institute for Health and Care Excellence guidelines there is higher reliability, a

Original interpretations of fetal heart rate (FHR) patterns equated FHR decelerations with 'fetal distress', requiring expeditious delivery. This simplistic interpretation is still implied in our clinical guidelines despite 40 years of increasing understanding of the behaviour and regulation of the fetal cardiovascular system during labour. The physiological basis of FHR responses and adaptations to oxygen deprivation is de-emphasised, whilst generations of obstetricians and midwives are trained to focus on, and classify, the morphological appearances of decelerations into descriptive categories, with no attempt to understand how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults, or the patterns that suggest progressive loss of compensation. Consequently, there is a lack of confidence, marked variation in FHR interpretation, defensive practices, unnecessary operative interventions, and a failure to recognise abnormal FHR patterns, resulting in adverse outcomes and expensive litigation. Keywords CTG practice algorithm, deceleration, fetal cardiovascular physiology, intrapartum fetal heart rate monitoring.Please cite this paper as: Ugwumadu A. Are we (mis)guided by current guidelines on intrapartum fetal heart rate monitoring? Case for a more physiological approach to interpretation.

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care-seeking observed in the general UK population during the COVID-19 pandemic. 5,6 However, the absence of data from years before 2019 limits the model's capability to capture seasonality. We cannot rule out that the observed trend was present before the beginning of the pandemic.We believe there is an urgent need to evaluate maternity service delivery, care-seeking, and pregnancy outcomes nationally, so as to plan for both immediate post-pandemic care and future health system shocks.We declare no competing interests.

Bacterial vaginosis (BV) is the most common cause of vaginal discharge in women of childbearing age. In some women it shows a relapsing and remitting course with apparently spontaneous onset and resolution. There are intermediate patterns of vaginal flora in which lactobacilli and other species co-exist. We asked women with recurrent BV to prepare vaginal smears daily, and to record symptoms, time of menstruation, sexual activity and use of douches or medication. We Gram-stained the smears and assigned a Nugent score for BV, and noted the presence of candida, pus cells, sperm and blood. Eighteen women collected daily vaginal smears for up to 10 months. Forty months of slides were collected in total. Bacterial vaginosis arose spontaneously on 23 occasions. We saw candida arise 11 times. Bacterial vaginosis appeared after candida on 9 of these 11 episodes. We saw BV regress spontaneously 13 times. Nine of these resolutions occurred within 48 h of unprotected sexual intercourse: BV only arose on one occasion within 48 h of unprotected intercourse. The intermediate pattern was seen for up to 10 days, and occurred as BV began or resolved in some women, and sometimes resolved without developing into BV. Bacterial vaginosis arose most often in the first 7 days of a menstrual cycle, and resolved spontaneously most often in mid-cycle. In women with recurrent BV, BV arises most often around the time of menstruation and resolves spontaneously in mid-cycle. Recurrences often follow an episode of candidiasis, and BV often regresses after unprotected sexual intercourse.