External cephalic version for breech presentation before term

What to do when it is breech? A state-of-the-art review on management of breech presentation

Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.

Use of external cephalic version for breech presentation at term: A national survey of Norwegian birth units

INTRODUCTION

International guidelines recommend that external cephalic version (ECV) be offered to all women with single fetuses in breech presentation at term. In Norway, ECV is not offered routinely; the national clinical guidelines advice that birth units capable of offering ECV for breech pregnancies make their own practice decisions. This study was performed to determine the extent to which Norwegian birth units offer ECV to pregnant women with fetuses in breech presentations at term, and to identify factors that might influence the use of ECV.

MATERIAL AND METHODS

A survey of all 39 obstetric birth units providing ECV in Norway was conducted using a self-reporting questionnaire about ECV availability, attitudes, clinical procedures, perceived competence, and outcome expectations.

RESULTS

Chief obstetricians from all birth units responded. Twenty-six (67%) respondents reported that their units offered ECV for breech presentation at term to a large degree. Thirty-one (80%) respondents reported a large degree of competence in performing ECV. Thirty-three (85%) units followed local ECV procedures. Nineteen (49%) units provided standardized information about the procedure to pregnant women. The respondents had different views about who should be offered ECV, and varying knowledge about ECV outcomes.

CONCLUSIONS

The majority of Norwegian birth units offer ECV to pregnant women with fetuses in breech position to a large extent. However, the survey results reveal challenges related to ECV information provision to pregnant women, determination of women's eligibility for ECV attempts, and familiarity and agreement with the knowledge base regarding ECV.

External cephalic version in the outpatient clinic

The continuous increase in the rates of cesarean section worldwide is concerning. Breech presentation is one of the major indications for cesarean section in most countries. External cephalic version (ECV) can reduce cesarean rates by approximately two-thirds in term breech pregnancies. After introduction of ultrasonography and cardiotocography before and after the procedure, ECV has become much safer. As a result, over-night fasting, intravenous access, and preoperative laboratory tests are no longer recommended as the patient's risk of requiring emergency cesarean section is very low. We have been running the largest ECV clinic in South Korea since 2008, and ECV trials in the outpatient clinic were started in 2015. We want to share our experiences running the ECV clinic for 15 years managing more than 2000 patients.

Smoke or smokeless moxibustion treatment for breech presentation: A three-arm pilot trial

AIMS

We conducted a pilot trial to compare the effects of smoke and smokeless moxibustion with a control as a possible supplement to external cephalic version (ECV) for converting breech to cephalic presentation and increasing adherence to cephalic position, and to assess their effects on the well-being of the mother and child.

METHODS

We used a quasi-experimental design with 3 arms: a smoke moxibustion (SM) (n = 20) and smokeless moxibustion (SLM) (n = 20) groups (20-min acupoint BL67 stimulation once or twice daily for 10-14 days), and a control group (n = 20). The participants had singleton breech presentations between 33 and 35 gestation weeks. The primary outcome was cephalic presentation at the conclusion of intervention. The secondary outcomes were cephalic presentation at birth and effects on mother and child well-being.

RESULTS

At the conclusion of intervention, cephalic presentation was higher in the SLM (60.0%) than the control groups (25.0%), Relative Risk 2.40, 95% Confidence Interval [1.04-5.56]; there was no significant difference for SM. At birth, there were no significant differences in cephalic presentation or well-being.

CONCLUSION

SLM treatment showed an increasing trend towards cephalic presentation at the conclusion of intervention. Although significant differences were not observed at birth possibly due to the small samples and non-randomization, moxibustion was safe, and not associated with perinatal morbidity and mortality. A randomized controlled trial with a larger sample is warranted to ascertain SLM treatment as a possible ECV supplement for converting and increasing adherence to cephalic position.

External cephalic version at 38 weeks' gestation at a specialized German single center

Introduction

Cesarean section (CS) rates are increasing worldwide. One constant indication is the breech presentation at term. By offering external cephalic version (ECV) and vaginal breech delivery CS rates can be further reduced.

Objective

This study aimed to analyze the ECV at 38 weeks of gestation with the associate uptake rate, predicting factors, success rate, and complications at a tertiary healthcare provider in Germany specializing in vaginal breech delivery.

Methods

We conducted a prospective cohort study with retrospective data acquisition. All women with a singleton fetus in breech presentation presenting after 34 weeks of gestation for counseling between 2013 and 2017 were included. ECV impact factors were analyzed using logistic regression.

Results

A total of 1,598 women presented for breech birth planning. ECV was performed on 353 patients. The overall success rate was 22.4%. A later week of gestation (odds ratio [OR] 1.69), an abundant amniotic fluid index (AFI score) (OR 5.74), fundal (OR 3.78) and anterior (OR 0.39) placental location, and an oblique lie (OR 9.08) were significantly associated with successful ECV in our population. No major complications were observed. The overall vaginal delivery rates could be increased to approximately 14% with ECV.

Conclusion

The demand for alternative birth modes other than CS for breech birth is high in the area of Frankfurt, Germany. Our study offers evidence of the safety of ECV at 38 weeks. Centers with expertise in vaginal breech delivery and ECV can reduce CS-rates. To further establish vaginal breech delivery and ECV as alternate options, the required knowledge and skill should be implemented in the revised curricula.

Current Approach for External Cephalic Version in Germany

Introduction Fetal breech presentation at terms occurs in 3 - 6% of pregnancies. External cephalic version can reduce the number of cesarean sections and vaginal breech deliveries. Different approaches are used to carry out external cephalic version. This study looked at the different approaches used in Germany and compared the approach used with the recommendations given in German and international guidelines. Material and Methods An anonymized online survey of 234 hospitals in Germany was carried out in 2018. In addition to asking about hospital structures, questions also focused on how external version was carried out in practice (preparations, tocolysis, anesthetics, etc.), on relative and absolute contraindications and on the success rate. Results 37.2% of the hospitals approached for the survey participated in the study. Of these, 98.8% performed external version procedures. The majority of participating hospitals were university hospitals (26.4%) and maximum care hospitals (35.6%) with an average number of more than 2000 births per year (60.9%). External cephalic version is the preferred (61.7%) obstetrical procedure to deal with breech presentation, rather than vaginal breech birth or primary cesarean section. 45.8% of respondents carry out external version procedures on an outpatient basis, and 42.1% of hospitals perform the procedure as an inpatient intervention, especially from the 37th week of gestation. Prior to performing an external version procedure, 21.6% of surveyed institutions carry out a vaginal examination to evaluate possible fixation of the fetal rump. 95.5% of institutions used fenoterol for tocolytic therapy; the majority using it for continuous tocolysis (70.2%). 1 - 3 attempts at external version (8.4%) were usually carried out by a specific senior physician. In most cases, no analgesics were administered. The reported rate of emergency cesarean sections was very low. The most common indication for emergency C-section was pathological CTG (56,7%). The assessment of relative and absolute contraindications varied, depending on the surveyed hospital. 67.5% asked patients to empty their bladders before carrying out external version, while 10.8% carried out external version when the bladder was filled. The reported success rate was more than 45%. After successful version, only 14.8% of hospitals arranged for patients to wear an abdominal binder. For 32.4%, the decision to apply an abdominal binder was taken on a case-by-case basis. Conclusion The approach used in Germany to carry out external cephalic version is based on the (expired) German guideline on breech presentation. Based on the evidence obtained, a number of individual recommendations should be re-evaluated. More recent international guidelines could be useful to update the standard procedure.

Comparison of blogshots with plain language summaries of Cochrane systematic reviews: a qualitative study and randomized trial

Background

Cochrane, an organization dedicated to the production and dissemination of high-quality evidence on health, endeavors to reach consumers by developing appropriate summary formats of its systematic reviews. However, the optimal type of presentation of evidence to consumers is still unknown.

Objective

The aim of this study was to investigate consumer preferences for different summary formats of Cochrane systematic reviews (CSRs), using both qualitative and quantitative approaches.

Methods

Initially, we conducted three focus groups with medical students (n = 7), doctors (n = 4), and patients (n = 9) in 2017 to explore their health information search habits and preferences for CSR summary formats. Based on those findings, we conducted a randomized trial with medical students at the University of Split School of Medicine, Croatia, and with patients from three Dalmatian family practices to determine whether they prefer CSR blogshots (n = 115) or CSR plain language summaries (PLSs; n = 123).

Results

Participants in the focus groups favored brief and explicit CSR summary formats with fewer numbers. Although we found no difference in participants’ preferences for a specific summary format in the overall sample, subgroup analysis showed that patients preferred blogshots over PLSs in comparison to medical students (P = 0.003, eta squared effect size η² = 0.04).

Conclusion

CSR summaries should be produced in a format that meets the expectations and needs of consumers. Use of blogshots as a summary format could enhance the dissemination of CSRs among patients.

Trial registration

The trial was registered in ClinicalTrials.gov, NCT03542201. Registered on May 31st 2018.

Reviving external cephalic version: a review of its efficacy, safety, and technical aspects

Currently, the rate of cesarean sections being performed in Korea is approximately 40%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries. Breech presentation at term is an important indication for cesarean section among other factors, including medicolegal concerns and pregnancies in women of advanced maternal age. Term breech presentation is associated with a higher fetal mortality rate than that associated with a cephalic presentation. Therefore, in Korea, most of these women deliver by cesarean section to avoid the complications of vaginal breech delivery. However, cesarean section is itself associated with considerable obstetric morbidity and sometimes, mortality. External cephalic version (ECV) is a useful method to reduce the cesarean section rate in women with breech presentation and therefore to reduce the incidence of breech presentation at delivery. Studies have shown that routine use of ECV reduces the cesarean section rate by approximately two-thirds in term pregnancies with breech presentation. ECV is accepted as a safe, efficacious, and cost-effective method and is recommended by both the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists in all pregnancies with term breech presentation, if not contraindicated. In Korea, although most clinicians are aware of the option of ECV, their relative lack of experience in performing the procedure and fear of complications render them hesitant to perform ECV. This review is aimed at guiding obstetricians by describing the efficacy, safety concerns, and technical aspects of this procedure.

Maternal and perinatal outcomes in external cephalic version: prognostic factors for the success of the technique

Background We aimed to analyze the success rate of external cephalic version (ECV) for breech presentations performed in our center between March 2011 and March 2016. We evaluated factors related to a successful ECV, delivery mode, complications and newborn status after ECV. Methods Analysis of assembled data of 327 consecutive ECVs in the third trimester was done. Results The total success rate was 56.6%. After a successful ECV, 85.9% of the fetuses were delivered vaginally. Logistic regression analysis of background factors leading to a successful ECV showed that tocolysis with ritodrine and anterior placenta were each significantly correlated with the rate of successful version. No severe complications were registered during the ECVs, and all babies had normal Apgar scores at delivery. Conclusion These findings suggest that attempting an ECV in breech presentations, once or even twice, seems to be an appropriate management given that a successful ECV decreases the rate of cesarean section in this group of patients and by doing so, it might also decrease the risk of cesarean sections in future pregnancies.

Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway

BACKGROUND

In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable.

MATERIAL AND METHODS

Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries.

RESULTS

Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head.

CONCLUSION

All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits.

Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews

BACKGROUND

Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB.

OBJECTIVES

We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update.

METHODS

We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI.

MAIN RESULTS

We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB.

OUTCOME

preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions.

OUTCOME

perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources.

OUTCOMES

preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm.

AUTHORS' CONCLUSIONS

Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.

National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births-Supporting Intended Vaginal Births

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.

Applying the Newman-Peacock Prognostic System to a Portuguese Obstetrical Population - A Useful Tool?

BACKGROUND

 External cephalic version (ECV) is a maneuver that enables the rotation of the non-cephalic fetus to a cephalic presentation. The Newman-Peacock (NP) index, which was proposed by Newman et al. in a study published in 1993, was described as a prediction tool of the success of this procedure; it was validated in a North-American population, and three prognostic groups were identified.

PURPOSE

 To evaluate the value of the NP score for the prediction of a successful ECV in a Portuguese obstetrical population, and to evaluate maternal and fetal safety.

METHODS

 We present an observational study conducted from 1997-2016 with pregnant women at 36-38 weeks of pregnancy who were candidates for external cephalic version in our department. Demographic and obstetrical data were collected, including the parameters included in the NP index (parity, cervical dilatation, estimated fetal weight, placental location and fetal station). The calculation of the NP score was performed, and the percentages of success were compared among the three prognostic groups and with the original study by Newman et al. The performance of the score was determined using the Student t-test, the Chi-squared test, and a receiver operating characteristic (ROC) curve.

RESULTS

 In total, 337 women were included. The overall success rate was of 43.6%. The univariate analysis revealed that multiparity, posterior placentation and a less engaged fetus were factors that favored a successful maneuver (p < 0.05). Moreover, a higher amniotic fluid index was also a relevant predictive factor (p < 0.05). The Newman-Peacock score had a poorer performance in our population compared with that of the sample of the original study, but we still found a positive relationship between higher scores and higher prediction of success (p < 0.001). No fetal or maternal morbidities were registered.

CONCLUSIONS

 The Newman-Peacock score had a poorer performance among our population compared to its performance in the original study, but the results suggest that this score is still a useful tool to guide our clinical practice and counsel the candidate regarding ECV.

Fetal heart rate abnormalities during and after external cephalic version: Which fetuses are at risk and how are they delivered?

BACKGROUND

Fetal heart rate abnormalities (FHR) during and after external cephalic version (ECV) are relatively frequent. They may raise concern about fetal wellbeing. Only occasionally they may lead to an emergency cesarean section.

METHODS

Prospective cohort study in 980 women (> 34 weeks gestation) with a singleton fetus in breech presentation. During and after external cephalic version (ECV) FHR abnormalities were recorded. Obstetric variables and delivery outcome were evaluated. Primary outcome was to identify which fetuses are at risk for FHR abnormalities. Secondary outcome was to identify a possible relationship between FHR abnormalities during and after ECV and mode of delivery and fetal distress during subsequent labor.

RESULTS

The overall success rate of ECV was 60% and in 9% of the attempts there was an abnormal FHR pattern. In two cases FHR abnormalities after ECV led to an emergency CS. Estimated fetal weight per 100 g (OR 0.90, CI: 0.87-0.94) and longer duration of the ECV-procedure (OR 1.13, CI: 1.05-1.21) were factors significantly associated with the occurrence of FHR abnormalities. FHR abnormalities were not associated with the mode of delivery or the occurrence of fetal distress during subsequent labor.

CONCLUSIONS

FHR abnormalities during and after ECV are more frequent with lower estimated fetal weight and longer duration of the procedure. FHR abnormalities during and after ECV have no consequences for subsequent mode of delivery. They do not predict whether fetal distress will occur during labor.

TRIAL REGISTRATION

The Eindhoven Breech Intervention Study, NCT00516555 . Date of registration: August 13, 2007.

Amnioinfusion for women with a singleton breech presentation and a previous failed external cephalic version: a randomized controlled trial

PURPOSE

Our trial aimed to assess the effectiveness of amnioinfusion for a second attempt at external cephalic version (ECV).

MATERIAL AND METHODS

This open randomized controlled trial was planned with a sequential design. Women at a term ≥36 weeks of gestation with a singleton fetus in breech presentation and a first unsuccessful ECV were recruited in two level-3 maternity units. They were randomly allocated to transabdominal amnioinfusion with a 500-mL saline solution under ultrasound surveillance or no amnioinfusion before the second ECV attempt. Trained senior obstetricians performed all procedures. The primary outcome was the cephalic presentation rate at delivery. Analyses were conducted according to intention to treat (NCT00465712).

RESULT

Recruitment difficulties led to stopping the trial after a 57-month period, 119 women were randomized: 59 allocated to amnioinfusion + ECV and 60 to ECV only. Data were analyzed without applying the sequential feature of the design. The rate of cephalic presentation at delivery did not differ significantly according to whether the second version attempt was or was not preceded by amnioinfusion (20 versus 12%, p = .20). Premature rupture of the membranes occurred for 15% of the women in the amnioinfusion group.

CONCLUSION

Amnioinfusion before a second attempt to external version does not significantly increase the rate of cephalic presentation at delivery.

Global Burden, Epidemiologic Trends, and Prevention of Intrapartum-Related Deaths in Low-Resource Settings

Intrapartum-related neonatal deaths include live-born infants who die in the first 28 days of life from neonatal encephalopathy or die before onset of neonatal encephalopathy and have evidence of intrapartum injury. A smaller portion of the population in poorer countries has access to basic obstetric and postnatal care causing neonatal mortality rates to be higher. Presence of a skilled birth attendant and provision of basic emergency obstetric care can reduce intrapartum birth asphyxia by 40%. With the announcement of Sustainable Development Goals and global Every Newborn Action Plan, there is hope that interventions around continuum of care will save lives.