Intra-uterine Fetal Brain Activity Monitoring.
Intra-uterine Fetal Brain Activity Monitoring.
Fetal cardiac monitoring is used during labor. Fetal decelerations may imply fetal hypoxia
 and distress. Brain activity monitoring is not used to evaluate fetal distress during labor.
 In this study the investigators intend to use an EEG based algorithm to evaluate and monitor
 fetal brain activity during the 2nd stage of labor.
Fetal heart rate (FHR) monitoring is commonly used in order to reduce fetal intrapartum
 asphyxia or any associated long-term disabilities. The electronic fetal monitoring (EFM) was
 first described by Hon and others during the 1960s (1) (2) and introduced into clinical
 practice before any clear evidence of benefits had been demonstrated.

 The EFM records the fetal heart rate, and characteristics such as baseline, accelerations,
 decelerations and variability are constantly evaluated in order to assess the hypoxic
 condition of the fetus and to identify fetal distress.

 Nevertheless, most of the studies (3-5) demonstrated that abnormal patterns of the fetal
 heart rate are of low predictive value for intrapartum fetal hypoxia or metabolic acidosis.
 Among high-risk pregnant woman, the probability of fetal metabolic acidosis in the presence
 of repeated, variable decelerations is 25%, and 48% in the presence of late decelerations
 (6). According to the Cochrane review (7) EFM didn't decrease the rates of cerebral palsy
 (CP), asphyxias complications or perinatal morbidity. The positive predictive value of
 non-reassuring FHR patterns for the prediction of CP among singleton newborns with birth
 weight of 2500 grams or more is only 0.14% (8).

 Hypoperfusion to a certain brain areas involves the rapid loss of brain function due to
 disturbances in brain blood supply. EEG shows typical changes in brain ischemia. These
 changes include: attenuation of faster waves, particularly in the beta and alpha frequency
 bands; enhancement of slower waves, mainly in the delta frequency band; regional attenuation
 without delta enhancement (RAWOD) and reduction of variability in the EEG signal (9).
 However, reaching effective sensitivity and specificity in immediate brain ischemia detection
 on the basis of EEG changes is still considered a challenge, as it depends on the presence of
 a skilled expert in neurophysiology to analyses raw EEG data in real-time.

 The investigators developed a unique platform algorithm, which analyses EEG data, and
 recognizes patients suffering from brain ischemia (stroke), based on the phenomena of
 interhemispheric decreased synchronization. Interhemispheric synchronization is the measure
 of correlation in EEG activity between ipsilateral and contralateral hemispheres, where
 values range between 1 (complete synchronization) and 0 (no synchronization). Increased
 synchronization means greater correlation between related ipsilateral and contralateral
 activities and vice versa for decreased synchronization. Normal brains should have a high
 correlation/ synchronization. Once brain ischemia occurs and the hemisphere is damaged, the
 interhemispheric synchronization decreases. In a recent study, we have shown the decrease in
 synchronization when a certain part of the brain is anaesthetized, causing a lesion similar
 to brain ischemia, and the recovery of synchronization, when the anesthesia recovered2. In
 another study, the investigators have tested the reliability of the algorithm in patients
 undergoing mechanical thrombectomy for acute stroke. In the study patients with acute stroke
 admitted to neuro angio intervention undergone short EEG test for 5 minutes. At the end of
 the procedure patients underwent a second short EEG test. In the test the interhemispheric
 synchronization were analyzed. It was shown that patients admitted to the neuro-angio
 intervention, who had brain tissue that might be salvable, had an average synchronization of
 0.8. If the procedure succeeded and there was a clinical improvement - the synchronization
 remained high. If the procedure did not succeed, or succeed without clinical improvement, the
 synchronization decreased to an average of 0.65. Importantly, patients who were not
 candidates for neuro intervention, because they didn't have salvable brain, their index of
 synchronization was low to begin with (figure 1a and 1b). This preliminary assay proves the
 ability of the synchronization index to detect brain hypoperfusion that occurs, for example,
 in stroke.

 The objective of this proof of concept study is to test whether there is a correlation
 between the EEG index of interhemispheric synchronization, to the umbilical PH of the newborn
 and to the gold standard fetal heart rate monitor.
Inclusion Criteria:

 -  Vaginal delivery course.

 -  Patient with epidural anesthesia.

 -  Continous fetal heart-rate monitoring.

 -  Singleton pregnancy.

 -  Term pregnancy.

 Exclusion Criteria:

 -  Suspected Chorioamnionitis.

 -  No epidural anesthesia.

 -  Multiple pregnancy.

 -  Fetal abnormality with emphasis on brain abnormalities.

 -  Preeclampsia.

 -  Patients refusing continous fetal heart-rate monitoring.

 -  Patients in need of a scalp electrode for fetal monitoring.

 -  Patients that received Dolestine during labor.

 -  Patients with Hepatitis B, Hepatitis C and HIV carriers or any other vertically
 transmitted pathogenic agent.