Low birthweight breech infant: short-term and long-term outcome by method of delivery

The effect of the delivery method on the short-term and long-term morbidity and mortality of the very low birthweight breech-presenting infants was evaluated. Although some previous studies question the benefit of cesarean section for the premature breech infants, the mortality rate and the incidence of birth injuries were significantly lower in the abdominally delivered group than in those delivered vaginally. The long-term follow-up clearly demonstrates that the vaginally delivered infants had a substantially higher incidence of cerebral palsy, visual damage, deafness, and severe developmental delay. It is concluded that cesarean section may be the preferred delivery method for the breech-presenting infants weighing 1000 to 1999 gm, offering a better quality of life.

Cerebral handicap in full-term newborns related to late pregnancy and/or labor

The improving results of modern obstetrics, anesthesiology and immediate pediatric care have to be assessed. Clinical methods are available, providing guidelines for a simple neuro-sensorial assessment of the full-term newborn. When abnormalities are detected at the first assessment, the newborn will be assessed daily or every other day, as the symptomatology often rapidly changes. Based on these repeated evaluations, a gradation of 3 levels of severity is established, by the end of the first week: mild (1) includes tone abnormalities and hyperexcitability but no seizures and no CNS depression; moderate (2) includes CNS depression +/- isolated seizures; severe (3) includes coma and repeated seizures. Though this gradation represents an empirical cut-off in a continuum of signs and symptoms indicating brain dysfunction at birth, correlations with late outcome are reasonably good. Individual prognosis is out of our reach, specially in grade 2 infants. However, as a group estimation of late outcome, this gradation is satisfactory. Neurobehavioral competence in the full-term newborn is such that one assessment performed within normal limits in the first 3 days allows a reasonable prediction of a normal outcome, no matter how dreadful the pregnancy and/or delivery has been. Therefore neurological assessment of the full-term newborn in the first week of life can be considered as a good marker for the quality of perinatal care, and good feed-back information for the obstetrical staff.(ABSTRACT TRUNCATED AT 250 WORDS)

Cause and effect of obstetric (neonatal) brachial plexus palsy

We have studied the causes and outcome of obstetric brachial plexus palsy in all children born in Malmö during the 10-year period 1973-1982. Forty-eight of 25,736 live-born children (0.19%) were neonatally diagnosed as having a brachial plexus paresis. Twenty-five percent of these, i.e., one child in 2,000 liveborn, had a persistent palsy. The obstetric history was characterized by high birthweight, vertex presentation with shoulder dystocia and multiparity; and in two cases the mother had two children with brachial palsy. The children who recovered totally did so during the first few months. The prognosis for the more common upper brachial plexus, or Erb's, was more favorable than that for entire brachial plexus palsy. All the children with persistent palsy were afflicted with considerable reduction in arm function, resulting in varying degrees of handicap, such as not being able to use the palsied arm at all or not being able to perform certain tasks--writing properly, playing a musical instrument, doing the hair, wearing clothing with shoulder straps, etc. We wish to point out that, in several cases, obstetric brachial plexus palsy results in a lifelong handicap and that prevention and therapy are essential both in obstetric and in pediatric management.

Fractured clavicle in newborns

A five year retrospective study was undertaken to determine the incidence and associated factors of fractured clavicle in newborns. The time period 1.1.1980 to 12.31.1984 was studied with the finding of 60 cases of fractured clavicle (1% of total vaginal births no. 5,847). An extensive neonatal and maternal chart review found birth weight, gestational age, and prolonged 2nd stage in primiparous patients as predisposing factors. The level of obstetrical experience and difficulty of delivery were also statistically significant. There was no increase in operative deliveries. Most of the cases of fractured clavicles were not appreciated at time of delivery by the delivering physician. One case ended in neurological injury with an Erb's palsy with partial resolution at two week follow-up. Fractured clavicle occurs in a certain high risk population, most cases of which ended up with no long term problems.

Rotational delivery with Kielland's forceps

A retrospective study over 15 months showed that 10.7% of primigravid women and 1.6% of multigravid women were delivered by Kielland's forceps: a total of 145 babies. The successful vaginal delivery rate for attempted Kielland's forceps was 96.7%. The neonatal outcome was good and there were no perinatal deaths. Traumatic injuries were present in 7.6% of babies and were minor. The data show that even in the presence of fetal distress, Kielland's forceps can be safely employed for rotational delivery from the mid-pelvic cavity. This approach can avoid some caesarean sections without undue risk to the baby, the caesarean rate being 9.5%. As 10.7% of primigravid women required rotational delivery with Kielland's forceps, it is desirable that primigravid women should be cared for by obstetricians who are skilled in the use of the instrument, in order to maintain a low caesarean section rate in this group, with a good neonatal outcome.

Shoulder dystocia: a fetal-physician risk

Trauma that occurs as a result of shoulder dystocia is an important cause of neonatal morbidity. If the occurrence of severe shoulder dystocia, resulting in fetal asphyxia and trauma, could be accurately predicted from maternal risk factors, then a cesarean section would be indicated to prevent the poor outcome. The information available in the obstetric literature, however, is contradictory regarding whether shoulder dystocia can be predicted. In the present study, the patients at greatest risk of shoulder dystocia (all 394 mothers delivering neonates with birth weights greater than or equal to 4000 gm over a 2-year period) were examined. A three-way discriminant analysis was used to determine if a model could be developed that could effectively predict those patients who would be included in each of the groups of no shoulder dystocia, shoulder dystocia without trauma (29 patients), and shoulder dystocia with trauma (20 patients). Three factors, including birth weight, prolonged deceleration phase, and length of second stage labor, were found individually to contribute significantly to the classification. However, when examined in detail, it was noted that while 94% of cases with no shoulder dystocia would be detected, only 16% of the cases of shoulder dystocia with trauma would be predicted by this model. We conclude that in the group of pregnancies delivering neonates greater than or equal to 4000 gm, the occurrence of shoulder dystocia cannot be predicted from clinical characteristics or labor abnormalities, and that the occurrence of shoulder dystocia is not evidence of medical malpractice.

Vacuum extraction versus forceps delivery: indications and complications, 1979 to 1984

Two hundred fifty-six vacuum extractions and 300 randomly chosen forceps deliveries were analyzed retrospectively. Vacuum extraction use increased from 0.3 to 3.1%, while forceps use declined from 10.1 to 4.9% over a five-year period. No differences were found in indications for vacuum extraction and forceps, but the preapplication position differed (occiput posterior or transverse in 81.2% in the vacuum group and 27% in forceps patients). Preapplication station also differed, with 59.8% of vacuum extraction at +1 or higher stations, compared with 9% of forceps. Under these conditions we found less maternal trauma, similar failure rates (3.9 versus 2%), and no difference in maternal morbidity. There was a higher incidence of shoulder dystocia and neonatal jaundice in the vacuum group, but cephalohematoma frequency did not differ significantly (3.9% vacuum extraction, 4.3% forceps). Cosmetic injuries (ecchymoses, abrasions) were more likely with vacuum extraction than with forceps (44.1 versus 29.5%). One death occurred in each group. Vacuum extraction replaced midforceps in our institution in the study period. We consider vacuum extraction a useful technique to teach house staff in view of today's decreasing instrumental delivery rate.

Prognosis of perinatal brain damage: a prospective study of a one year birth cohort of 12,000 children

The prognosis of perinatal brain damage was studied prospectively in a one year birth cohort of 12,000 children born in Northern Finland in 1966. Children were included in the study if they had an Apgar score of 0 at 1 min or less than 5 at 15 min, convulsions during the neonatal period, or a diagnosis of asphyxia, brain injury or intraventricular haemorrhage, but did not have CNS malformation, chromosomal aberrations or hereditary CNS degeneration. There were 233 children, 19.3 per thousand, of which 134, 58.0% were boys. Eighty-four, 36.4% died during the first 28 days and 7 children died before the age of 14 years, 6 of the latter group being handicapped. There were 44 children, 29.9% who had mental retardation, IQ less than 71, epilepsy or cerebral palsy. With regard to these children 13 had normal school performance, but there were 12 other children in the perinatal brain damage group who needed special education, two of them because of deafness. Perinatal brain damage accounted for 57.5% of all neonatal deaths, 30% of admissions to a special nursery and 12.5% of mental retardation (IQ less than 71), epilepsy and cerebral palsy at the age of 14.

Mid-cavity occipitoanterior forceps delivery--Laufe and Barnes forceps compared

Laufe forceps are divergent forceps designed to reduce compressive forces upon the fetal skull during delivery from the pelvic outlet. Here we have undertaken a retrospective matched analysis in which Laufe (N = 75) and Barnes (N = 75) forceps were used for occipitoanterior mid-cavity forceps delivery. Our aim was to compare fetal and maternal outcome following use of these 2 types of forceps in the mid-pelvis. Fetal morbidity, categorized by trauma, low Apgar score or jaundice, was present in 31 of 75 infants delivered by Laufe forceps and in 47 of 75 infants delivered by Barnes forceps (p less than 0.01). Overall, maternal morbidity was statistically similar between the 2 groups although perineal trauma was more frequent in the Laufe group (p less than 0.05). We concluded that there appeared to be an improved fetal outcome following occipitoanterior mid-cavity delivery using Laufe forceps compared with Barnes forceps. These initial findings imply that in situations of fetal compromise, where forceps delivery from an occipitoanterior position in the mid-cavity is indicated, that Laufe forceps might be chosen.

Relation of private or clinic care to the cesarean birth rate

The rising rate of cesarean births in the United States has been the focus of academic attention as well as attention from the media during the past decade. Although there is a consensus about the indications for cesarean delivery that have led to the increased rate (dystocia, malpresentation, fetal distress, and previous cesarean delivery), the influence of other key factors, such as whether the patient received care from a private physician or through a hospital clinic, has not been established. In a review of 65,647 deliveries in four Brooklyn hospitals between 1977 and 1982, we found that private physicians performed significantly more cesarean sections than house officers and attending physicians. Private patients giving birth to their first child were significantly more likely than clinic patients to undergo cesarean delivery if dystocia, malpresentation, or fetal distress was diagnosed, and private patients with one or more previous deliveries were significantly more likely to undergo cesarean delivery if dystocia or malpresentation was diagnosed. Private patients had fewer perinatal deaths, which were concentrated among infants with birth weights under 2000 g, but the infants of private patients had a significantly higher rate of low Apgar scores and birth injuries than the infants of clinic patients.

Midforceps deliveries: long-term outcome of infants

Infants delivered by midforceps between 1976 and 1982 were evaluated for evidence of developmental delay or neurological deficit by chart review. The 110 infants who were followed for at least 2 years were compared to a matched group of infants delivered by cesarean section. The cesarean section group was matched for the immediate indication for delivery (dystocia or fetal distress), birth weight, gestational age, sex, and race. There was no significant difference in abnormal outcomes in the two groups.

Results of a five-year prospective study using a feto-pelvic scoring system for term singleton breech delivery after uncomplicated pregnancy

Two hundred and twenty-six term singleton breech deliveries were managed prospectively during a 5-year period according to Westin's feto-pelvic scoring system based on X-ray pelvimetry, estimated fetal weight, type of breech, and outcome of previous vaginal deliveries. The vaginal delivery rate was 45.1% and cesarean section rate 54.9%. 81.5% of cesarean sections could be planned in advance, based on the scoring system. Corrected neonatal mortality was nil and persistent morbidity was 0.4% for the whole material. Asphyxia, defined as 5 min Apgar score less than 7, occurred in only 1% of cases, evenly distributed among vaginal and planned cesarean deliveries. It was possible by means of the scoring system to identify a group of women who could give birth vaginally, without any mortality or persistent morbidity.

Risk factors for shoulder dystocia

The risk factors associated with the occurrence of shoulder dystocia were examined in the general obstetrical population of women delivering vaginally. An increasing incidence of shoulder dystocia was found as infant birth weight increased. Although one-third of shoulder dystocia occurred in pregnancies at 42 + weeks, except for those resulting in infants weighing 4500 + g, the vast majority was unaffected by shoulder dystocia. The incidence of shoulder dystocia in nondiabetic gravidas delivering an infant weighing 4000 to 4499 and 4500 + g vaginally was 10.0 and 22.6%, respectively. Within the 4000- to 4499-g group, no labor abnormality was clearly predictive; however, in the heaviest birth weight group, an arrest disorder heralded a shoulder dystocia in 55.0% of cases. Diabetics experienced more shoulder dystocia than nondiabetics. Among them, 31% of vaginally delivered neonates weighing 4000 + g experienced shoulder dystocia. Nevertheless, the risk factors of diabetes and large fetus (4000 + g) could predict 73% of shoulder dystocia among diabetics; large fetus along flagged 52% of shoulder dystocia in nondiabetics. Cesarean section is recommended as the delivery method for diabetic gravidas whose estimated fetal weight is 4000 + g. If others confirm the risk, the authors advise serious consideration of cesarean section for gravidas who are carrying fetuses estimated to be 4500 + g and who experience an abnormal labor.

[Child development after abdominal version of the fetus from breech presentation to vertex presentation near term]

The prospective study presented here describes the results of follow-up examinations of the developmental stage of 116 children born between 1977 and 1980 in whom abdominal version of the foetus from breech presentation to vertex presentation was performed near term. The children were examined according to the Denver Developmental Screening Test at the age of 2 to 5 3/4 years in various fields (social contacts, minor motor functions and adaptation, speech and major motor functions). Children with abnormal findings were subjected to special examinations. Those with disturbed development were re-examined after one year. In the entire group of children there were four with psychomotor retardation of speech, and two further children with minimal cerebral motor disturbances. The children had been detected early during infancy. These results, classified as secondary morbidity (disturbances of speech and minimal cerebral motor disturbances) were analysed taking into account the results of version (successful and unsuccessful version) and other obstetric factors (course of pregnancy and birth, method of delivery, biochemical examinations during and after birth, age of mother and socioeconomic status of parents).

Brachial plexus birth palsy: a 10-year report on the incidence and prognosis

Sixty-one cases of brachial plexus birth palsies were documented in 30,451 live births at Kaiser Foundation Hospital, San Francisco, between January 1972 and December 1982, for an incidence of 2.0/1,000 births. Thirty-eight patients were evaluated in follow-up ranging from 1 year to 11 years 6 months. Associated birth traumas include facial palsy, clavicle fracture, arm ecchymosis, and cephalohematoma. The prognosis was excellent, with full recovery in 95.7% of cases. The presence of a palsy did not preclude the development of dominant use of the extremity. Right-handedness was noted in 73% of right-sided palsies. This study showed that the incidence of palsies has not declined in the past 10 years. Risk factors and associated birth injuries were similar to those in other reports. The severity of palsies has lessened, and early recovery is usual.

Birth trauma: incidence and predisposing factors

The authors retrospectively studied 13,870 singleton full-term consecutive live births at a major teaching hospital and assessed the frequency of brachial plexus injury, clavicular fracture, and facial nerve injury in newborns delivered from January 1974 through December 1977 and from January 1979 through September 1981. Predisposing factors relating to mechanical birth trauma were defined, and a risk assessment profile was developed to identify the fetus at risk. Mechanical injuries were identified according to the International Classification of Diseases codes 761. The incidence of selected birth injuries in the study group were: brachial plexus injury, 2.6 per 1000 or 1 in 385 single full-term live births; fractured clavicle, 2.0 per 1000 or 1 in 495 single full-term live births; and facial nerve injury, 7.5 per 1000 or 1 in 133 single full-term live births. There were 162 full-term infants born with 168 injuries relevant to this study. Of the six infants who incurred more than one injury, three had a combined fractured clavicle-brachial plexus injury, and three had facial nerve-branchial plexus injuries. Logistic regression analysis of fetal, maternal, and intrapartum complications in labor and delivery revealed that midforceps , shoulder dystocia, low forceps, infants greater than 3500 g, and second stage labor exceeding 60 minutes were the predominant events associated with fetal injury. The authors then applied a risk assessment profile to successfully identify over 50% of the injured and 84% of the uninjured groups. From their results, the authors suggest that obstetricians should alert the pediatricians when these predisposing factors exist to aid in the recognition and early treatment of these birth injuries.

Changing patterns of birth asphyxia and trauma over 20 years

Comparison of birth asphyxia and trauma in the same obstetric service during periods 18 years apart shows some reassuring and some disquieting findings. Liberalized cesarean sections, electronic monitoring of fetal heart in labor, and replacement of opiate sedation by epidural anesthesia have had their effect. There has been dramatic reduction in perinatal death and neonatal encephalopathy due to birth asphyxia and trauma and only rarely do affected infants now develop permanent cerebral injury. Severe birth asphyxia, defined by need for prolonged ventilation, has, however, remained unchanged in frequency. Unexpectedly, fractures and paralyses have dramatically increased. The major hazard today for the term infant is the use of midforceps, which has become much more common in parallel with the increased use of pain relief by continuous epidural anesthesia.

[Clavicular fractures in the newborn infant]

The frequency of the fracture of clavicle in liveborn infants delivered in the Obstetric Department of the School of Medicine of Sassari was retrospectively evaluated for the years 1977, 1978 and 1979. Moreover, all the fractured live infants born in 1980 were prospectively identified and compared to a group of unmatched controls, which included the live infant born immediately before and that born immediately after the index case. The same procedure was adopted when the fracture was identified in two infants born consecutively. The following variables were studied: date and hour of delivery, sex, birthweight, gestational age, type of labour, presentation and mode of delivery, Apgar at one minute, parity of the mother. There were 108 cases and 194 controls. The frequency of the fracture of clavicle showed a linear increase from 2.2/100 live births in 1977 to 4.8/100 live births in 1980; males were slightly more affected than females and the right clavicle was more frequently fractured than the left one (67% for the four years altogether). In the prospective study the only statistically significant differences between cases and controls were found for birthweight (less than 0.001) and mode of delivery (P less than 0.025): cases weighed more and were more frequently born by instrumental delivery (vacuum or forceps) than controls; none of the fractured infants was born by caesarean section. One of the fractured infants was affected by osteogenesis imperfecta and two other presented a transitory paresis of the omolateral brachial plexus; in the remaining cases the prognosis was good.