The Dublin randomized controlled trial of intrapartum fetal heart rate monitoring

Epidural analgesia and fetal heart rate abnormalities

Lumbar epidural analgesia is frequently associated with fetal heart rate abnormalities. Fluid preloading prior to the procedure significantly reduces the incidence of abnormal fetal heart rate patterns (p = 0.02). The mechanisms of these changes are discussed and the importance of maternal hypotension is evaluated. Fluid preloading and continuous electronic fetal monitoring should be considered routine for all women undergoing this procedure.

The predictive value of abnormal fetal heart rate patterns in early labour

An abnormal early intrapartum cardiotocogram was found to have a sensitivity of 26.4% and a positive predictive value of 28.3% for the detection of fetal acidaemia at birth and a sensitivity of 27.3% and a positive predictive value of 3.3% for the prediction of 5-minute Apgar scores below 7. The presence of meconium in the liquor amnii improved the predictive properties of the test. Although an abnormal early intrapartum feta heart rate pattern indicated a higher risk group, the majority of patients with abnormal early intrapartum cardiograms had a favourable outcome. A normal pattern does not exclude an adverse outcome.

Induction of labour: does internal tocography result in better obstetric outcome than external tocography

A prospective randomized study was undertaken to evaluate the benefit of intrauterine catheters in induced labour. Two hundred and thirty nine women who had induced labour were studied. The patients in one group had intrauterine catheters inserted and oxytocin was titrated to achieve the 75th percentile of uterine activity observed in spontaneous normal labour according to parity. Contractions were assessed by external tocography in the other group and oxytocin was titrated to achieve 6 to 7 contractions per 15 minutes each lasting > 40 seconds. Mean maximum dose of oxytocin, mode of delivery, Apgar score < 7 at 5 minutes, cord arterial blood pH < 7.15 and admission to neonatal intensive care unit did not differ significantly in the 2 groups. In conclusion, women who had intrauterine catheters did not have a shorter duration of labour, lower dose of oxytocin, fewer operative deliveries or fewer babies in poor condition at birth compared with those who had external tocography in induced labour.

Simulated home delivery in hospital: a randomised controlled trial

OBJECTIVES

To compare the outcome of two methods of maternity care during the antenatal period and at delivery. One was to be midwife-led for both antenatal care and delivery, the latter taking place in rooms similar to those in one's own home to simulate home confinement. The other would be consultant-led with the mothers labouring in the delivery suite rooms with resuscitation equipment for both mother and baby in evidence, monitors present and a delivery bed on which both anaesthetic and obstetric procedures could be easily and safely carried out.

DESIGN

Randomised controlled trial.

SETTING

Leicester Royal Infirmary Maternity Hospital.

SUBJECTS

Of 3510 women who were randomised, 2304 were assigned to the midwife-led scheme and 1206 were assigned to the consultant-led scheme.

MAIN OUTCOME MEASURES

Complications in the antenatal, intrapartum and postpartum periods were compared as was maternal morbidity and fetal mortality and morbidity. Satisfaction of the women with care over different periods of the pregnancy and birth were assessed.

RESULTS

There were few significant differences in antepartum, intrapartum and postpartum events between the two groups. There was no difference in the percentage of mothers and babies discharged home alive and well. Generally higher levels of satisfaction with care antenatally and during labour and delivery were shown in those women allocated to midwife care.

Communicating the significance of the fetal heart rate record to the user

Fetal heart rate (FHR) records should be presented as measurements derived from numerical analysis. Such analysis requires computerized systems. The Oxford system is the longest established and most tested of the systems available. It could provide the basis for a standardized approach to the numerical analysis of antepartum FHR records. Intrapartum FHR monitoring is of uncertain clinical value. It is premature to recommend standards for numerical analysis to upgrade the present methods of data presentation during labour. Once the patterns of abnormality are better defined numerically such standards will be mandatory because intrapartum FHR records cannot be interpreted reliably by eye.

Intrapartum fetal heart rate assessment: monitoring by auscultation or electronic means

OBJECTIVE

Our purpose was to assess the frequency with which auscultation could be used as the primary mode of fetal assessment during labor in a busy labor and delivery suite by means of published criteria.

STUDY DESIGN

During a 3-month period, 862 patients in labor with live fetuses between 24 and 43 weeks of gestation were available for auscultation in the prospective study. Auscultation was initiated during a contraction and extended for 30 seconds after uterine activity ceased. It was repeated every 15 minutes in the first stage and every 5 minutes in the second stage of labor.

RESULTS

In 420 patients this modality was not begun because of inability of the nurses to meet 1:1 staffing requirements. In 19 patients auscultation was not performed because of obesity (12) or patient refusal (7). Of the 423 assessed by auscultation 392 were unable to complete monitoring caused by the frequency requirement (n = 212) or the recording criteria (n = 163). Of the 31 patients where auscultation was successfully completed, there was a 1:1 nurse ratio during the entire labor.

CONCLUSIONS

Auscultation with stringent evaluation and recording frequency is not feasible under normal labor and delivery room conditions unless 1:1 nursing care is always available.

The effect of parental age, birth order and other variables on early childhood mortality: a Caribbean example

The 4275 births to women of native ancestry that took place on the island of St Barthélemy, French West Indies between 1878 and 1970 were analyzed according to the sex of the child, the year of birth, maternal age, maternal parity, paternal age and the number of children the father already had to determine the effects of these variables on rates of perinatal death, death before age 1 and death before age 5. The year of birth, the number of children the father already had, and maternal parity influenced death before age 1 and death before age 5. The sex of the child also influenced the probability of dying in the first year of life but not the first 5 yr of life when the other variables were controlled. Perinatal deaths were influenced only by the sex of the child, but even this effect disappeared when the other variables were controlled.

Evaluation of care for the preterm infant: review of literature on follow-up of preterm and low birthweight infants. Report from the collaborative Project on Preterm and Small for Gestational Age Infants (POPS) in The Netherlands

Since the introduction of neonatal intensive care in the 1960s, mortality in very preterm and very low birthweight infants has been decreasing steadily. Consequently, interest in the outcome of surviving infants is growing. Restriction of health care resources has stressed the need for information concerning the effect of individual treatment components on mortality and morbidity. Concern about the quality in apparently normal survivors has been increasing as well. The current flood of papers on these subjects illustrates the interest in these issues. The first part of this paper reviews the methodology used in follow-up studies in the past decades. It aims at methodological problems that hamper comparison between studies and preclude unequivocal conclusions. New treatment techniques seldom were but should be evaluated by randomised trials. To monitor the combined effects of changing obstetric and neonatal techniques on perinatal outcome, studies in geographically defined populations are recommended using data from early pregnancy until at least preschool age. Comparability of outcomes could be enhanced by international agreement on standardisation of assessment methods and outcome measures. In the second part the results concerning gestational age- and birthweight-specific mortality, impairments and disabilities and the risk factors for such disorders are discussed. Increased survival of even the tiniest infants is clearly established. This increase in survival has not yet been accompanied by an apparent increase in major morbidity. However, many minor impairments are reported, occurring often in combination and predisposing these children to deviations of normal development. Important changes in the manifestation of brain damage appear to occur during development. These findings stress the importance of long-term follow-up studies.

Fetal heart rate variability and behavioral state: analysis by power spectrum

OBJECTIVE

We attempted to determine the relationship between the fetal heart rate power spectrum and fetal state.

STUDY DESIGN

Interbeat intervals, electrocortical activity, and fetal breathing movements were recorded from five near-term fetal lambs. Interbeat intervals were taken from epochs of low-voltage electrocortical activity with breathing, low-voltage electrocortical activity without breathing, and high-voltage electrocortical activity without breathing. Power spectral techniques were applied to determine the underlying frequencies contributing to fetal heart rate variability. Spectral analysis was also performed on fetal breathing data from three animals.

RESULTS

Significant differences were found between low-voltage electrocortical activity with breathing and high-voltage electrocortical activity without breathing at 0.62 Hz and from 1.09 to 1.56 Hz. There was no clear relationship between the breathing and heart rate spectra.

CONCLUSIONS

Fetal heart rate is mediated by both state and respiratory variables. The respiratory component is not strictly related to respiratory rate.

Perinatal cerebrovascular disease in the neonate. Parenchymal ischemic lesions in term and preterm infants

Acute cerebrovascular injury in term and preterm infants is a cause of significant morbidity. Treatment efforts in the past have focused on attempts to prevent such injury by interceding during labor in term infants and improving neonatal care in preterm infants. Epidemiologic studies suggest that these strategies have had little impact. A new strategy--drug treatment of acute ischemic brain injury--is on the horizon. The recognition and prognostication in ischemic neonatal brain injury takes on a new importance in this light.

Falling incidence of hypoxic-ischaemic encephalopathy in term infants

OBJECTIVE

To examine trends in the incidence of hypoxic-ischaemic encephalopathy over a 13-year period.

DESIGN

A retrospective analysis of medical records of all infants admitted in the years 1976-1980 and 1984-1988.

SETTING

A large non-teaching district health authority in central England.

SUBJECTS

Infants admitted to a district general hospital neonatal unit with clinical features of hypoxic-ischaemic encephalopathy.

MAIN OUTCOME MEASURES

Incidence of three grades of hypoxic-ischaemic encephalopathy, handicap and mortality.

RESULTS

During the first 5-year period the overall incidence of hypoxic-ischaemic encephalopathy was 7.7 per 1000 live births with 2.6 per 1000 live births being severely affected (grades II and III). In the second 5-year period the overall incidence was 4.6 per 1000 live births with 1.8 per 1000 live births being severely affected. The difference in the overall rate is statistically significant. Of the infants with severe encephalopathy 61% had Apgar scores below 4 at 1 min and 60% were born by instrumental or operative delivery.

CONCLUSIONS

The fall in incidence of hypoxic-ischaemic encephalopathy has occurred during a period of falling perinatal mortality rate. It was instructive to find that infants born vaginally and without obstetric intervention formed a larger fraction of the severely affected infants in the later period.

Relation between cerebral oxidative metabolism following birth asphyxia, and neurodevelopmental outcome and brain growth at one year

Studies of cerebral oxidative metabolism were carried out by phosphorous magnetic resonance spectroscopy during the first week of life in 52 infants with clinical and/or biochemical evidence of birth asphyxia. 15 infants died and the 37 survivors were assessed by a wide range of neurodevelopmental tests at one year of age. The minimum recorded values for cerebral phosphocreatine/inorganic phosphate concentration ratio (an index of oxidative metabolism) were related to outcome. The results showed a significant relation between the extent of derangement of oxidative metabolism and the severity of adverse outcomes, including death, neurodevelopmental impairment and reduced head growth.

Does oxytocin augmentation increase perinatal risk in primigravid labor?

To assess the influence of high-dose oxytocin augmentation of spontaneous labor, a consecutive series of 30,874 primigravid term deliveries were analyzed for adverse perinatal outcome. In spite of a longer mean duration of labor, the frequencies of asphyxial perinatal death, neonatal seizures, and abnormal neonatal neurologic behavior were not significantly increased in 14,119 (45%) oxytocin-treated patients. There was no case of uterine rupture in any primigravid labor during the study. These results from 13 years of clinical practice provide reassurance about maternal and fetal safety if oxytocin is used as part of a protocol of active management to correct dystocia when spontaneous primigravid labor with vertex presentation fails to progress.

The accuracy of auscultatory detection of fetal cardiac decelerations: a computer simulation

To evaluate current practices of auscultation for the detection of decelerations, we used a computer to generate contractions and late decelerations and perform the counting. The baseline rate ranged from 110 to 180 beats/min. The duration of the deceleration ranged from 1 to 2 minutes, and the amplitude of the deceleration ranged from 10 to 90 beats/min. The onset of the decelerations ranged from 0.4 to 0.7 of the length of the contraction. Counting was begun at 80%, 100%, and 120% of the contraction length. The duration of counting varied between 15 and 60 seconds. A multicount algorithm obtained three 10-second counts separated by 5 seconds. Results were classified by the ability to detect rates below 120, 100, or 80 beats/min (threshold determination) or 20 and 25 beats/min below the baseline rate (subtraction determination). The baseline rate and deceleration amplitude had the greatest effect on accuracy. The higher the baseline rate and the smaller the deceleration amplitude, the less accurate was detection. Multiple counts were more accurate than the single-count strategy, and subtraction detection was more accurate than threshold detection. The effects of counting error are briefly described. This model, which requires clinical confirmation, nevertheless emphasizes the potential inaccuracies of many popular schemes of auscultatory surveillance, even for the detection of prolonged or sustained decelerations. Certain modifications of auscultatory practice may improve the accuracy of this technique.

Outcome of the second labour in patients whose first labour was prolonged: the Dublin experience

This observational study examined the outcome of the second delivery in patients whose first labour was prolonged. The onset of labour was defined as that time when the diagnosis of labour was made on admission to the delivery unit. The first labour was defined as prolonged when delivery occurred more than 12 h later. The study was confined to those patients (n = 66) who had a prolonged first labour with a single, live fetus and cephalic presentation during 1984-1987 and who had a subsequent labour. Sixty-one of the 66 patients (92%) delivered vaginally, and 5 were delivered by emergency caesarean section. Forty-six (70%) delivered within 6 h of admission. Although all 66 had received oxytocin in their first labour, only 8 (12%) required oxytocin in their second labour. Fourteen (82.4%) of the 17 patients with a previous caesarean section had a vaginal delivery. These results indicate that compared to the first labour the duration of the second labour and the oxytocin requirements in the second labour were significantly reduced. These findings are reassuring for patients who have had a long difficult first labour.

Recommendations for the management of low risk obstetric patients

Specific interventional procedures have enjoyed widespread popularity in the United States in the routine management of low risk obstetric patients without the benefit of clinical studies attesting to their utility. A review of the literature was conducted to survey obstetric practice with regard to amniotomy, intravenous fluids, third stage administration of oxytocics, episiotomy and continuous fetal monitoring.

Electronic fetal heart monitoring, auscultation, and neonatal outcome

In a large randomized, controlled study of fetal heart rate monitoring with either continuous electronic fetal heart monitoring or auscultation at specified intervals, only one pattern of deviation in the fetal heart rate correlated significantly with neonatal neurologic examinations at 0 to 48 hours and 72 hours to 1 week: late decelerations in stage 1 and in stage 2. Other variables from labor and delivery, specifically, duration of labor after hospital admission, failure of labor to progress, number of fetal scalp pH values, and presence of meconium were important predictors of neonatal outcome in the regression analyses. The fetal heart rate deviations did contribute significantly to the percent variance accounted for in the regression analyses with neonatal outcomes of Apgar scores at 1 and 5 minutes and serial neonatal neurologic examinations.

Fetal acidosis in labour: a prospective study on the effect of parity

The effect of parity on intrapartum fetal scalp pH was investigated in 6466 patients in labour with a live fetus who were delivered in 1987. 350 (5.4%) required fetal scalp blood sampling for pH (FBS), 236 primigravidae (10.4%) and 114 multigravidae (2.7%) (P less than 0.001). Fetal acidosis (pH less than 7.20) was detected in 35 patients, 27 primigravidae (11.4%) and 8 multigravidae (7.0%) (P less than 0.001). The incidence of intrapartum acidosis in the 2275 primigravidae and the 4191 multigravidae was 1.2 and 0.2% respectively (P less than 0.001). The two deaths from birth asphyxia and three cases of neonatal seizures occurred in primigravidae. In primigravidae requiring FBS, fetal acidosis was not associated with the use of oxytocin or with increased duration of labour. Neonatal seizures were more common overall in primigravidae than in multigravidae and more common in patients requiring FBS than in those not requiring FBS (P less than 0.05). The higher incidence of FBS, fetal scalp acidosis and neonatal seizures in primigravidae has important implications for intrapartum fetal monitoring.

Hospital setting and fetal death during labor among women at low risk

Intrapartum fetal death in low-risk women at term is a rare obstetric outcome. This is difficult to study because few data sets contain an adequate number of cases for meaningful analysis. This study used data from the 1980 National Natality Survey and National Fetal Mortality Survey, merged with an American Hospital Association annual survey for the same year, to determine whether the frequency of intrapartum fetal death in low-risk women varied by the hospital setting for birth. Stratified analysis was used to assess the relation of level of hospital for delivery with intrapartum fetal death, with control for potential confounding factors. As the level of available perinatal technology decreased, the frequency of intrapartum fetal death increased (odds ratio, 2.0 for Level II and 3.3 for Level I, as compared with Level III hospitals). Even when early neonatal deaths were considered, perinatal mortality remained lowest at Level III facilities (odds ratio, 1.6 for Level II and 2.7 for Level I, as compared with Level III hospitals). The components of intrapartum surveillance that are most effective in the reduction of perinatal mortality have not been identified.

The second stage of labour: durational dilemmas

The optimal management of prolonged second stage of labour remains a confused area of thought and action. This confusion is particularly evident when epidural analgesia is also being used. A review of the literature indicates that prolonged duration of the second stage, i.e. from full dilation of the cervix until delivery, with or without epidural analgesia, has little adverse effect on perinatal outcome. More attention should be paid to the expulsive phase of the second stage and greater efforts made to reduce unnecessary interventions.

The fetal heart rate trace is normal, isn't it? Observer agreement of categorical assessments

The limitations of the kappa statistic method to measure inter-observer variation of categorical assessments are shown by means of a hypothetical example. Another method for assessing the inter-observer variation of categorical variables, the proportion of agreement, is used for the same example, and reasons why it is preferable to the kappa statistic are given. Since this method allows measurement of the inherent difficulty of carrying out a particular assessment, it has wide applicability in the introduction of new technology. If a proportion of agreement study shows poor inter-observer agreement for a new method, the technology must either be improved or abandoned.

The work of the National Perinatal Epidemiology Unit. One example of technology assessment in perinatal care

This article describes one approach to assessing the effects of perinatal care--that adopted by the National Perinatal Epidemiology Unit in Oxford, England. The unit's research has been based primarily on a combination of simple, descriptive analyses of observational data and statistically robust analyses of evidence derived from randomized controlled trials.

Birth asphyxia and hypoxic-ischaemic encephalopathy: incidence and severity

Clinically significant birth asphyxia was assessed over a 3-year period in a tertiary referral hospital in Nigeria. The overall incidence was 26.5/1000 live births of whom 12.1/1000 showed severely abnormal features comprising persistent seizures and coma. There was no appreciable difference in incidence for the consecutive years of the study. There was a marked involvement of infants who had suffered intrauterine growth retardation: 51 (30.7%) of these were asphyxiated, whereas only 3% were large for gestational age. The Apgar scoring system seemed not to have compared well with the clinical presentation of hypoxic-ischaemic encephalopathy from birth asphyxia. Much needs to be done to improve health care delivery and reduce the incidence of birth asphyxia.

What is fetal distress?

Fetal distress is a widely used but poorly defined term. This confusion of definition compounds the difficulty of making an accurate diagnosis and initiating appropriate treatment. The fetus reacts at the onset of asphyxia with a remarkable series of responses, primarily a complexly regulated redistribution of blood flow that serves to limit the deleterious effects of oxygen limitation in vital organs. This enables the fetus to survive asphyxia intact unless the insult is profound or prolonged. The most common asphyxial stresses imposed on the fetus during labor are insufficiency of uterine blood flow, or insufficiency of umbilical blood flow, and occasionally decrease in uterine arterial oxygenation. Each of these stresses produces characteristic fetal heart rate patterns: late decelerations, variable decelerations, or prolonged bradycardia. There is strong evidence that the presence of normal fetal heart rate variability represents normal central nervous system integrity, including adequate oxygenation. A decrease or loss of variability in the presence of these patterns is a sign that the physiologic compensations are overwhelmed as a result of the severity of asphyxia. Knowledge of the fetal responses to asphyxia, together with the known evolution of fetal heart rate patterns during asphyxia, should allow a more accurate definition of the onset of unacceptable asphyxia, and more rational management and timing of intervention.

'Normal but dead': perinatal mortality in non-malformed babies of birthweight 2.5 kg and over in the northern region in 1983

The case notes relating to 75 of the 91 perinatal deaths of nonmalformed babies of birthweight greater than or equal to 2.5 kg born in the Northern Region in 1983 were examined. The major groups involved antepartum deaths of unknown cause (40%), and deaths due to intrapartum anoxia or trauma (35%). A case-control study compared each of the 75 cases with two controls matched for place of birth, obtained by taking the next two babies born in the same maternity unit (excluding perinatal deaths, birthweight less than 2.5 kg, and malformations). Four factors were found to be significantly associated with risk of perinatal death in this group: primigravidity, parity greater than or equal to 3, not booked for antenatal care by 20 weeks, and corrected birthweight less than 3.2 kg (adjusted for gestation). Two further factors were related only to the risk of perinatal death consequent upon intrapartum events: labour post-term and malpresentation in labour. All four factors relevant to the whole group remained independently associated with risk of perinatal death after multivariate analysis by two techniques. Adjusted odds ratios (95% CI) were estimated as: primigravidity 2.1 (1.1 to 4.1); parity three or more 5.7 (1.9 to 17); not booked for antenatal care by 20 weeks 15.7 (3.0 to 81); and corrected birthweight less than 3.25 kg 2.5 (1.3 to 4.6). An avoidable factor, as defined, was detected in 50% of deaths. In 30% of deaths there was an avoidable factor (grade 2) such that absence may have been expected to lead to a different outcome had all other factors remained equal. Of the avoidable factors detected, 61% related to intrapartum management, as did 76% of the grade 2 factors. Most of these involved failure to respond to evidence of fetal distress in labour. The defined group constituted 21% of all perinatal deaths, suggesting that this is an important category, particularly as their potential for normal survival should otherwise have been high.

Assessment of cardiotocographs

In recent years advances in medical electronic equipment for monitoring, diagnosis and treatment of patients have led to a large increase in the number and variety of instrumentation available to the medical profession. There is a considerable amount of duplication of equipment and in the absence of readily available information buyers are unlikely to make informed decisions about the ideal instrument for their particular circumstances. One method of increasing the users' awareness is a comparative, independent assessment of equipment, with the results disseminated to the interested parties. This paper describes the essential qualities of cardiotocographs: how they are assessed as part of the UK Department of Health's evaluation programme and the measures to inform users of the latest evaluation information.

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

In a multicenter, randomized clinical trial, we assessed the early neurologic development of 93 children born prematurely whose heart rates were monitored electronically during delivery and compared it with that of 96 children born prematurely whose heart rates were periodically monitored by auscultation. All the children were singletons with cephalic presentation, and all weighed less than or equal to 1750 g at birth. The mental and psychomotor indexes of the Bayley Scales of Infant Development (standardized mean score +/- SD, 100 +/- 16) and a formal neurologic examination were administered at three follow-up visits (at 4, 8, and 18 months of age, corrected for gestational age). At 18 months, the mean mental-development scores in the groups receiving electronic fetal monitoring and periodic auscultation were 100.5 +/- 2.4 and 104.9 +/- 1.8, respectively (P greater than 0.1). The mean psychomotor-development scores in the two groups at 18 months were 94.0 +/- 2.4 and 98.3 +/- 1.8, respectively (P greater than 0.1). The incidence of cerebral palsy was higher in the electronically monitored group--20 percent as compared with 8 percent in the group that was monitored by auscultation (P less than 0.03). In the electronic-fetal-monitoring group (but not in the periodic-auscultation group), the risk of cerebral palsy increased with the duration of abnormal fetal-heart-rate patterns, as assessed by retrospective review (chi 2 trend = 12.71, P less than 0.001). The median time to delivery after the diagnosis of abnormal fetal-heart-rate patterns was 104 minutes with electronic fetal monitoring, as compared with 60 minutes with periodic auscultation. We conclude that as compared with a structured program of periodic auscultation, electronic fetal monitoring does not result in improved neurologic development in children born prematurely.

Cesarean section in the United States: has it changed since 1979?

From 1965 to 1979 the cesarean section rate in the United States increased 264 percent. An analysis in 1979 identified several contributing factors, including fear of malpractice suits, the custom of repeat cesareans and operative delivery for breech-presenting infants, increased diagnoses of dystocia and fetal distress, physician training, economic incentives, and the concept of "premium babies." From 1979 to 1987 the cesarean section rate increased 48.8 percent to an annual rate of 24.4 percent. Current analysis finds the same factors still interacting to continue the upward trend. Growing use of vaginal birth after a previous cesarean, increased recognition of the imprecision of electronic fetal monitoring, greater public awareness, and professional peer review activities are beginning to slow the rate of increase.

Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring

In a randomised trial involving 13,079 liveborn children intrapartum care by electronic fetal heart rate monitoring, with scalp blood sampling when indicated, was associated with a 55% reduction in neonatal seizures. Reassessment, when aged 4, of the 9 children in the intensively monitored group and 21 in the control group who survived after neonatal seizures showed that 3 such children in each group had cerebral palsy. A fourth child in the intensively monitored group with cerebral palsy had had transient abnormal neurological signs during the neonatal period. 8 other children in the intensively monitored group and 7 in the control group who had not had abnormal neurological signs in the neonatal period also had cerebral palsy. 16 (78%) of the total of 22 cases of cerebral palsy had not shown clinical signs suggestive of intrapartum asphyxia. Thus, compared with intermittent intrapartum monitoring, intensive monitoring has little, if any, protective effect against cerebral palsy.