Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants

Information dissemination and the cesarean birth rate. The Illinois experience

A study was initiated to investigate the impact of information dissemination in Illinois upon the projected rise in the cesarean birth rate over the period from 1986 through 1988. The total cesarean birth rate in Illinois had not changed significantly during this period, whereas the rate of vaginal births after cesarean sections (VBAC) increased by 58.4% (p < .001). Information dissemination may have contributed to stemming an increase in the cesarean birth rate in Illinois while promoting VBAC deliveries.

Appropriateness of intrapartum fetal heart rate management and risk of cerebral palsy

Cerebral palsy affects 2 in 1000 infants in the United States, and the intrapartum period is frequently scrutinized as the etiologic source. In a matched group of 49 infants with cerebral palsy at 1 year of age and 49 controls, no difference in the incidence of inappropriate intrapartum fetal heart rate pattern management was detected. This supports the conclusions of others that the intrapartum period is an infrequent source of cerebral palsy.

Integrating research activities, practice changes, and monitoring and evaluation: a model for academic health centers

A study undertaken by the Joint Commission in 1986 proposed that some research activities at academic health centers (AHCs) be used to fulfill monitoring and evaluation requirements. This paper presents a framework for such use of research activities. To fulfill the monitoring and evaluation standards, AHCs and their medical staff departments must conduct planned and systematic quality assurance activities, and research and subsequent practice changes must be documented. In addition, particular research activities should correspond to the ten steps of the Joint Commission model of the monitoring and evaluation process. It is critical that research result in specific actions to improve care, along with follow-up monitoring and, when necessary, follow-up action.

Why have we failed to reduce the frequency of cerebral palsy?

OBJECTIVE

To review the data on children with cerebral palsy in relation to quality of obstetric care.

DATA SOURCES AND STUDY SELECTION

In our Institute, a regular Medline print-out, certain key journals and Current Contents are perused to create an updated computerised file of publications on the epidemiological, aetiological and other aspects of cerebral palsy. For this study we reviewed data from the Western Australian Cerebral Palsy Register, more than 150 publications from which studies were chosen for sound methodology in countries with modern obstetric practices, and recent population data on cerebral palsy.

DATA EXTRACTION AND SYNTHESIS

Three major areas were studied to see: (i) if the prevalence of cerebral palsy has fallen with increasing use of obstetric and neonatal interventions aimed at reducing birth asphyxia; (ii) if there is any evidence that cerebral palsy is caused by birth asphyxia; and (iii) if there is any evidence that intrapartum fetal monitoring or caesarean section reduces the prevalence of cerebral palsy.

CONCLUSIONS

We concluded that: cerebral palsy proportions are not falling in spite of significant increases in obstetric and neonatal interventions aimed at reducing asphyxia; cerebral palsy proportions in low birthweight infants are rising in most developed countries, coincident with increases in the neonatal survival of low birthweight babies; few cases of cerebral palsy seem to be caused by birth asphyxia and those that are may not have been preventable by obstetric care; and parents will continue to sue if obstetricians keep promising perfection from obstetric care in the face of 2.0-2.5 cases of cerebral palsy per 1000 children born.

Labor and delivery characteristics and the risk of germinal matrix hemorrhage in low birth weight infants

To assess the influence of labor and delivery events on the risk of germinal matrix hemorrhage in preterm newborns, we conducted a review of data collected on 449 babies who weighed 1.5 kg or less. Babies delivered vaginally were more likely to have germinal matrix hemorrhage than were babies delivered abdominally (odds ratio, 2.5; 95% confidence interval, 1.4,3.3). Among babies delivered vaginally, the risk of germinal matrix hemorrhage was increased by 39% if labor lasted more than 12 hours. Among babies delivered abdominally, the occurrence of any labor was accompanied by a 150% increased risk of germinal matrix hemorrhage. The only indication for abdominal delivery associated with an increased risk of germinal matrix hemorrhage was impending amnionitis (odds ratio, 2.6; 95% confidence interval, 1.2,5.7), whereas the only indication associated with a decreased risk was preeclampsia (odds ratio, 0.2; 95% confidence interval, 0.6). Epidural and local anesthesia were associated with a reduced risk of germinal matrix hemorrhage among babies delivered abdominally. We conclude that delivery practices, or their indications, appear to influence the risk of germinal matrix hemorrhage in low birth weight babies.