Adverse outcome of pregnancy and the quality of obstetric care

Substandard care in delivery-related asphyxia among term infants: prospective cohort study

OBJECTIVE

To assess substandard care factors in the case of delivery-related asphyxia.

DESIGN

Prospective cohort study.

SETTING

Catchment area of the Neonatal Intensive Care Unit (NICU) of the University Medical Center Utrecht; a region in the middle of the Netherlands covering 13% of the Dutch population.

POPULATION

Term infants, without congenital malformations, who died intrapartum or were admitted to the Neonatal Intensive Care Unit due to asphyxia.

METHODS

During a two-year period, cases were prospectively collected and audited by an expert panel.

MAIN OUTCOME MEASURES

Substandard care factors.

RESULTS

37 735 term infants without congenital malformations were born. There were 19 intrapartum deaths, and 89 NICU admissions of which 12 neonates died. In 63 (58%) cases a substandard care factor was identified that was possibly (n= 47, 43%) or probably (n= 16, 15%) related to perinatal death or NICU admission. In primary care, substandard care factors were mainly the low frequency of examination during labor and delay in referral to secondary care. In secondary care, misinterpretation of cardiotocography and failure to respond adequately to clinical signs of fetal distress were the most common substandard care factors.

CONCLUSIONS

Substandard care is present in a substantial number of cases with delivery-related asphyxia resulting in perinatal death or NICU admission. Improving the organization of obstetric care in the Netherlands as well as training of obstetric caregivers might reduce adverse outcomes.

Nighttime delivery and risk of neonatal encephalopathy

OBJECTIVE

The objective of the study was to determine the relationship between nighttime delivery and neonatal encephalopathy (NE).

STUDY DESIGN

The design of the study was a retrospective population-based cohort of 1,864,766 newborns at a gestation of 36 weeks or longer in California, 1999-2002. We determined the risk of NE associated with nighttime delivery (7:00 (PM) to 6:59 (AM)).

RESULTS

Two thousand one hundred thirty-one patients had NE (incidence 1.1 per 1000 births). Nighttime delivery was associated with increased NE (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.20), birth asphyxia (OR, 1.18; 95% CI, 1.08-1.29), and neonatal seizures (OR, 1.17; 95% CI, 1.07-1.28). In adjusted analyses, nighttime delivery was an independent risk factor for NE (OR, 1.10; 95% CI, 1.01-1.21), as were severe intrauterine growth retardation (OR, 3.8; 95% CI, 3.1-4.8); no prenatal care (OR, 2.0; 95% CI, 1.4-2.9); primiparity (OR, 1.5; 95% CI, 1.4-1.7); advanced maternal age (OR, 1.3; 95% CI, 1.16-1.45); and infant male sex (OR, 1.3; 95% CI, 1.2-1.4).

CONCLUSION

Future studies of time of delivery may generate new strategies to reduce the burden of NE.

Early-onset neonatal seizures: types, risk factors and short-term outcome

In a large majority of term newborns, early-onset neonatal seizures (EONS) are believed to relate to perinatal risk factors.

AIM

To identify risk factors for EONS.

METHODS

Among a cohort of 1293 newborns admitted over a period of 2 years to the neonatal intensive care unit of Tikur Anbasa Hospital, Addis Ababa, 93 had seizures. The case control study method was used to identify risk factors associated with EONS. Univariate analysis was used to further examine risk factors after adjusting for the effect of severe perinatal asphyxia (Apgar < or = 3).

RESULTS

A total of 78 (85%) term newborns had EONS. Hypoxic-ischaemic encephalopathy (OR 3.46, 95% CI 2.74-7.42) and shock (OR 2.53, 95% CI 1.51-4.76) were significantly associated with EONS. Multifocal clonic (66%) followed by focal clonic (22%) were the most common types of EONS. Nine (11%) of the newborns with EONS died. During follow-up, 37 (53%) of the 69 surviving newborns with EONS had psychomotor delay with or without neurological deficit.

CONCLUSION

Hypoxic-ischaemic encephalopathy and shock are important causes of EONS.

Risk of cerebral palsy in multiple pregnancies

Multiple compared with singleton gestations have a five- to tenfold increased risk of CP. The increased risk associated with MC placentation has been variously ascribed to transfer of thromboplastin or thromboemboli from the dead to the surviving fetus, exsanguination of the surviving fetus into the low pressure reservoir of the dead fetus, or hemodynamic instability with bidirectional shunting of blood between the two fetuses. An increased risk of CP in assisted reproductive technology gestations is to be expected because of the higher proportion of preterm births. The increase in risk of CP associated with monochorionic placentation will not be observed except for the minority of assisted reproductive technology gestations that undergo monozygotic splitting.

Intrapartum complications associated with malformations of cortical development

Birth asphyxia can be an early sign of cerebral palsy, the effect of an antenatal anomaly rather than its cause. The objective of this study was to evaluate the occurrence of intrapartum complications in patients with malformation of cortical development. The data were retrospectively assessed and compared with a control group of children with idiopathic epilepsy. Intrapartum complications were reported in 22 (31.5%) patients, as opposed to only 2 in the control group (p < 0.001). Patients with cortical malformations frequently present intrapartum complications, which could lead to the misdiagnosis of hypoxic-ischemic encephalopathy.

Risk of cerebral palsy in multiple pregnancies

Multiple compared with singleton gestations have a five- to tenfold increased risk of CP. The increased risk associated with MC placentation has been variously ascribed to transfer of thromboplastin or thromboemboli from the dead to the surviving fetus, exsanguination of the surviving fetus into the low pressure reservoir of the dead fetus, or hemodynamic instability with bidirectional shunting of blood between the two fetuses. An increased risk of CP in assisted reproductive technology gestations is to be expected because of the higher proportion of preterm births. The increase in risk of CP associated with monochorionic placentation will not be observed except for the minority of assisted reproductive technology gestations that undergo monozygotic splitting.

Time of birth and risk of intrapartum and early neonatal death

BACKGROUND

Previous studies have found that infants born at night and during weekends and holidays have an increased risk of perinatal mortality. However, these associations may be confounded by the distribution of high-risk deliveries according to time of birth.

METHODS

We undertook a population-based cohort study of 694,888 singleton births without elective cesarean section in Sweden between 1991 and 1997. We estimated relative risks of intrapartum and early neonatal death according to the hour, day and month of delivery. Estimated risk ratios were adjusted for gestational age, birth weight for gestational age, malformations, induction of labor, breech presentations and year of birth.

RESULTS

Infants of high-risk deliveries were more often delivered during daytime (8:00 am to 7:59 pm). Compared with infants born during daytime, infants born at night were at increased risk of early neonatal death (adjusted risk ratio = 1.28; 95% confidence interval = 1.13-1.46), but not intrapartum death (1.05; 0.71-1.54). If this association is causal, 12% of early neonatal deaths can be attributed to the increased risk among nighttime births. There was no association of weekend or holiday births with risks of intrapartum or early neonatal death.

CONCLUSIONS

Infants born at night may be at increased risk of early neonatal death.

Prenatal and perinatal determinants of neonatal seizures occurring in the first week of life

To evaluate prenatal and perinatal risk factors for early neonatal seizures, we conducted a case-control study including 100 newborns with neonatal seizures in the first week of life and 204 controls randomly selected from a list of healthy newborns born in the same hospital during the study period. Generalized tonic seizures were the most common seizures observed (29%), although the majority of newborns (71%) experienced more than one type of seizure. The most frequent presumed etiology of neonatal seizures was hypoxic-ischemic encephalopathy (30%). A history of epilepsy in first-degree relatives was found only for cases. Neonatal seizures were found to be associated with maternal disease in the 2 years before pregnancy, mother's weight gain > 14 kg during pregnancy, placental pathology, preeclampsia, low birthweight, low gestational age, and jaundice in the first 3 days of life. The need for cardiopulmonary resuscitation was found only for cases (37%). The causal pathways for neonatal seizures often begin before birth, and some of the factors identified may be preventable.

Demographic and intrapartum characteristics of term pregnancies with early-onset neonatal seizures

OBJECTIVE

To compare the demographic and intrapartum factors of term pregnancies in which early-onset neonatal seizures developed with the characteristics of a large, unselected control population.

STUDY DESIGN

Pregnancies delivered at term (gestational age > or = 37 weeks) in one birthing unit between 1984 and 1995 with a discharge diagnosis of neonatal seizures were identified. Maternal and neonatal charts of these patients were reviewed to confirm the diagnosis of early-onset seizure (EOS) which was defined as a clinical or EEG-diagnosed seizure within 72 hours of life. Demographic and intrapartum factors were compared between these EOS cases and all singleton term pregnancies delivered over the same time period in which there was no EOS. A regression model was then developed to determine factors predictive of EOS.

RESULTS

Of 80,561 total deliveries during the 11-year study period, there were 64,340 control and 62 EOS (0.1%) deliveries. Regression modeling identified NICU admission, depressed 1- and 5-minute Apgar scores, and neonatal intubation as predictors of EOS, but not operative vaginal, vaginal breech, or cesarean delivery.

CONCLUSION

Depressed condition at birth and/or the requirement for NICU care was the most important risk associated with early seizures in term infants.

The continuing fall in incidence of hypoxic-ischaemic encephalopathy in term infants

OBJECTIVE

To examine trends in incidence of hypoxic-ischaemic encephalopathy in term infants over a twenty-one year period.

DESIGN

A retrospective analysis of medical records of all term infants admitted to a neonatal unit with hypoxic-ischaemic encephalopathy during the years 1992-1996 (period C) and a comparison with data from the years 1976-1980 (period A) and 1984-1988 (period B) from the same unit (previously published).

SETTING

A District Health Authority in Central England serving a population of about 450,000.

SAMPLE

All term infants admitted with clinical features of hypoxic-ischaemic encephalopathy.

MAIN OUTCOME MEASURES

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

RESULTS

In each five year period there were similar numbers of births. Over the time-span of this study the stillbirth rate and neonatal mortality rate has consistently fallen. The overall incidence of hypoxic-ischaemic encephalopathy in term infants was significantly lower (P < 0.001; OR 0.42 CI 0.29-0.59) in the present study period (C) compared with the earlier study period B (1.9 vs 4.6 per 1,000 total live births). The fall in moderately and severely affected infants between the present and the first study period was significant (1.2 vs 2.6 per 1,000 total live births, P < 0.001: OR 0.46 CI 0.29-0.72). The number of deaths and the incidence of cerebral palsy in survivors fell progressively over the 21 years spanned by this study.

CONCLUSION

This study shows that the incidence of hypoxic-ischaemic encephalopathy and its sequelae in term infants has fallen significantly. The use of cardiotocography and caesarean section rates have risen but the relative contributions of changes in clinical practice are uncertain.

Fetal distress

The term 'fetal distress' should be replaced by 'suspected fetal compromise' because the diagnosis of 'fetal distress' is often unproven. Cardiotocography remains the cornerstone of making the diagnosis, but as a test it is renowned for its high sensitivity and low specificity. It has reduced intrapartum fetal mortality but not long-term neonatal morbidity or the incidence of cerebral palsy. There is no doubt that when obvious signs of fetal compromise, such as late decelerations in the presence of intrauterine growth retardation and oligohydramnios, are present, the diagnosis of fetal compromise is relatively simple. Often, however, the subtle signs of fetal compromise are missed; these are a change in the grade of meconium in the amniotic fluid, a rising base-line fetal heart rate, the absence of accelerations, the presence of 'atypical' variable decelerations or a combination of the above. To date, there is no test available to replace the cardiotocograph, although fetal pulse oximetry is the most promising adjunctive test. Above all, no test result obtained in isolation must detract from the whole clinical picture.

Numbers of deaths related to intrapartum asphyxia and timing of birth in all Wales perinatal survey, 1993-5

OBJECTIVES

To investigate the relation between the timing of birth and the occurrence of death related to an intrapartum event.

DESIGN

Analysis of 107,206 births to Welsh residents in 1993-5, including 608 cases of stillbirth and 407 of neonatal death identified in the all Wales perinatal survey, the cause of death classified with the clinicopathological system.

SUBJECTS

79 normally formed babies stillborn or who died in the neonatal period, birth weight > 1499 g, for whom cause of death was related to an intrapartum event.

MAIN OUTCOME MEASURES

Relative risk of death due to an intrapartum event according to the hour, day, and month of birth.

RESULTS

Mortality was higher in babies born between 9.00 pm and 8.59 am than in those born between 9.00 am and 8.59 pm; relative risk (95% confidence interval) 2.18 (1.37 to 3.47). July and August births also had a higher death rate than births in other months; relative risk 1.99 (1.23 to 3.23). Weekened births had a higher death rate but it was not significant.

CONCLUSIONS

The excess of deaths at night and during months when annual leave is popular may indicate an overreliance on inexperienced staff at these times. Errors of judgement may also be related to physical and mental fatigue, demanding a more disciplined systematic approach at night. Mistakes may be ameliorated by increasing shiftwork, but shifts should be carefully designed to avoid undue disruption of circardian rhythms. In addition, greater supervision by senior staff may be required at night and during summer months.

Risk factors for cerebral palsy: a case-control study in Greece

The purpose of this study was to investigate the relation between a series of maternal, antenatal, perinatal, socioeconomic and environmental variables and the occurrence of cerebral palsy (CP) in a setting different from those in which previous analytic epidemiologic studies had been undertaken. The study was of case-control design and included 103 children with cerebral palsy born between 1984 and 1988 and residents of the Greater Athens area at any time during 1991 and 1992. Controls were chosen among the neighbors of the index case or were healthy siblings of children with neurological diseases other than CP seen by the same neurologists as the children with CP; a total of 254 control children were eventually included. Statistical analysis was done by modeling the data through unconditional logistic regression. Statistically significant (p < 0.05) risk factors of potential causal importance were: twin membership (OR = 10.2), gestational age (OR = 0.5 per 4 weeks), birth weight conditional on gestational age (OR = 0.9 per 100 g), congenital malformations (OR = 7.5), unhealthy placenta (OR = 6.6), placenta previa (6 cases, no controls), abnormal amniotic fluid (OR = 3.6), head circumference more than 36 cm (OR = 9.0), general anesthesia during labor (OR = 4.3), forceps delivery (OR = 6.8), and birth trauma (OR = 11.5). Among children with no identifiable prenatal risk factors there was no excess prevalence of one or more perinatal risk factors in CP cases compared to controls, which implies that the latter factors impart their effect through interactions with co-existing prenatal or other risk factors.

Case-control study of intrapartum care, cerebral palsy, and perinatal death

OBJECTIVE

To investigate the relation between suboptimal intrapartum obstetric care and cerebral palsy or death.

DESIGN

Case-control study.

SETTING

Oxford Regional Health Authority.

SUBJECTS

141 babies who subsequently developed cerebral palsy and 62 who died intrapartum or neonatally, 1984-7. All subjects were born at term of singleton pregnancies and had no congenital anomaly. Two controls, matched for place and time of birth, were selected for each index case.

MAIN OUTCOME MEASURES

Adverse antenatal factors and suboptimal intrapartum care (by using predefined criteria).

RESULTS

Failure to respond to signs of severe fetal distress was more common in cases of cerebral palsy (odds ratio 4.5; 95% confidence interval 2.4 to 8.4) and in cases of death (26.1; 6.2 to 109.7) than among controls. This association persisted even after adjustment for increased incidence of a complicated obstetric history in cases of cerebral palsy. Neonatal encephalopathy is regarded as the best clinical indicator of birth asphyxia; only two thirds (23/33) of the children with cerebral palsy in whom there had been a suboptimal response to fetal distress, however, had evidence of neonatal encephalopathy; these 23 formed 6.8% of all children with cerebral palsy born to residents of the region in the four years studied.

CONCLUSION

There is an association between quality of intrapartum care and death. The findings also suggest an association between suboptimal care and cerebral palsy, but this seems to have a role in only a small proportion of all cases of cerebral palsy. The contribution of adverse antenatal factors in the origin of cerebral palsy needs further study.

Long-term outcome of infants born preterm

This chapter outlines some of the many long-term health problems to be expected in surviving preterm children. They have higher rates of sensorineural impairments (such as cerebral palsy, and visual, auditory and intellectual impairments) and sensorineural disabilities from these impairments, than children born at term. In addition, they grow poorly and have higher rates of other health problems, including poorer respiratory health in early childhood. There is little doubt that preterm children contribute disproportionately to the prevalence of health problems in childhood. However, there are still many gaps in our knowledge of the outcome for preterm survivors, particularly regarding outcome in adulthood. Obstetricians and neonatologists working in intensive care, as well as parents, want to know the long-term outcome for preterm children born today, not that of children born a generation ago when fewer preterm children (particularly those of extremely low birthweight) survived. Despite the many problems, the conclusion is that most preterm children are as healthy as term children, suffering only usual childhood illnesses; we feel confident that the majority make, and will continue to make, useful contributions to their families and the societies in which they live.

The paradox of electronic fetal monitoring: more data may not enable us to predict or prevent infant neurologic morbidity

Electronic fetal heart rate monitoring has been used to identify periods of fetal risk, with the hope that clinical intervention would avoid the potential for perinatal death or neurologic damage. A literature review of 10 infant studies failed to document fetal heart rate patterns associated with neurologic injury or protocols for intervention to avoid neurologic injury. A separate analysis of fetal heart rate patterns from 55 brain-damaged infants failed to find consistent patterns that foreshadowed the observed brain injury. These findings should not be surprising, because the majority of infant brain damage occurs outside the intrapartum period and because electronic monitoring may identify times of fetal risk but was never expected to identify brain damage.

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.

A case-control study of intrapartum stillbirths

OBJECTIVE

To determine antenatal and intrapartum risk factors for intrapartum stillbirths in a total population.

DESIGN

Matched case-control study.

SETTING

Western Australia 1980-1983.

SUBJECTS

Intrapartum stillbirths of > or = 1000 g birthweight (cases) and liveborn infants (controls) individually matched for year of birth, plurality, sex and birthweight of infant and race of mother.

RESULTS

Intrapartum stillbirths were more likely than controls to have had placental abruption (OR = 9.55, CI = 2.09-43.69), fetal distress (OR = 4.64, CI = 1.92-11.19), cord prolapse (OR = 10.00, CI = 1.17-85.60) and unhealthy placentas (OR = 2.26, CI = 1.13-4.52), and more likely to have been born by vaginal breech manoeuvre (OR = 3.51, CI = 1.40-8.80) and emergency caesarean section (OR = 2.15, CI = 1.13-4.10); mothers of intrapartum stillbirths were less likely to have had no labour (OR = 0.14, CI = 0.04-0.55) and to have been delivered normally (OR = 0.20, CI = 0.10-0.40). Mothers of cases born by emergency caesarean section had longer labours than mothers of controls born by this method. All intrapartum stillbirths with breech presentation were born by vaginal breech manoeuvre compared with only 53% of the controls; the remainder of the controls were born by caesarean section.

CONCLUSIONS

Results indicate that little could have been done early in pregnancy to prevent the intrapartum stillbirths as no antenatal risk factors predicted these deaths. Most of the risk factors identified related to labour and delivery problems. Considering cases born by emergency caesarean section, delivery of the mother earlier in labour may have prevented some of the deaths.

Chronic mental illness and perinatal outcome

A retrospective review of pregnant women admitted to a state psychiatric facility and to an acute university psychiatric unit compares various characteristics of the two populations. No major significant differences were noted in demographic, psychiatric, or obstetric characteristics. It was hypothesized that the patients from the state facility would have a better perinatal outcome secondary to an opportunity for closer prenatal follow-up. No differences were noted in perinatal outcomes between the two facilities. Significantly poorer perinatal outcomes were noted in the combined group of psychiatric patients when compared were noted in the combined group of psychiatric patients when compared with the state of Oregon's birth-outcome statistics. The importance of prenatal care in this high-risk population is discussed, and specific recommendations are offered.

Perinatal substance abuse

This article reviews medical, obstetrical, and neonatal complications of perinatal substance abuse. The psychological and social issues commonly encountered in drug-abusing pregnant women are also discussed. Treatment considerations that take into account the complex biopsychosocial parameters are presented.

Dyskinetic and dystonic cerebral palsy and birth

Two hundred and nineteen cases of the dyskinetic and dystonic forms of cerebral palsy which were seen in the course of three decades at a single clinic have been analysed. Fifty-seven patients had kernicterus. In the remaining 162, 71% of whom were born at term, birthweight was below the expected mean in two-thirds. There was no relationship between birth weight, or abnormal birth, or asphyxia, and the ultimate clinical severity of the children. We conclude that abnormal birth and asphyxia are not direct causes of the cerebral damage, but are expressions of a pre-existing condition resulting in susceptibility to the stress of birth, whether it is normal or abnormal.

The safety of team midwifery: the first decade of the Monash Birth Centre

OBJECTIVE

To review the safety of team midwifery care, in terms of perinatal mortality, for pregnant women assessed at their first visit as being at low risk of complications.

DESIGN

A cohort study.

SETTING

Team midwifery unit (Birth Centre) in a tertiary hospital.

PATIENTS

All women who made a booking and met the selection criteria at their first antenatal visit (3085), excluding those with spontaneous or induced fetal loss before 20 weeks (89) and those who withdrew at their own request to seek an alternative form of care (138); the 2858 remaining women gave birth to 2874 infants.

MAIN OUTCOME MEASURES

Perinatal mortality rate; and birthweight specific perinatal mortality ratio with reference values being specific rates for birthweight in Victoria for 1984-1985.

RESULTS

The perinatal mortality rate was 7.7 per 1000 births (95% confidence interval [CI] 4.8-11.6) for the whole cohort; for women beginning labour in the Birth Centre it was 1.3 per 1000 births (95% CI, 0.3-3.9). The birthweight standardised perinatal mortality ratio was 80 (95% CI, 50-122).

CONCLUSION

Within this setting, with explicit criteria for booking and referral, and a framework for consultation, team midwifery care is as safe as the standard maternity care provided within the State.

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.

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.

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.

Antenatal and perinatal care in southern Italy. I. The mothers' reports

A population-based cross-sectional study of antenatal and perinatal care was performed in Campania, a region of southern Italy. One thousand three hundred women who had given birth in 1982 were interviewed. The number of antenatal visits was very low, less than 1% of the mothers having attended more than three times during pregnancy. The women at high obstetric risk did not attend more than those at low risk and certain aspects of their antenatal care were unsatisfactory. The place of birth was similar for high risk and low risk mothers, with 40% delivering in small private facilities (with few neonatal resuscitation facilities and often with inadequate infant transport services). The labour was induced or accelerated in 60% of the mothers. The organisation of perinatal care did not take into account many of the needs of the mothers such as presence of a relative at delivery, ambulation during labour, early relationship with the newborn, rooming-in, or encouragement to breastfeed.

Perinatal mortality in southern Italy

Perinatal deaths occurring in the Campania region of southern Italy in 1982 were analysed. The perinatal mortality rate was 17.6 per thousand (stillbirth rate 8.3, early neonatal mortality rate 9.3). Compared with Swedish data, our deaths excess does not seem attributable to an unfavourable birthweight distribution, but to high birthweight mortality rates in every birthweight category and particularly in the normal birthweight group (greater than 2500 g). This group of newborns, representing about 94% of the births, contributes 45.4% of perinatal deaths; this situation is not common in developed countries, where the normal birthweight newborns form a much smaller proportion of perinatal deaths. The analysis of the causes of perinatal mortality, even though autopsies are rarely executed in Campania, shows a high prevalence of events which should be prevented by good antenatal and perinatal care.

The pregnant psychiatric inpatient: a missed opportunity

The authors describe a group of pregnant psychiatric patients admitted to a psychiatric service in an urban hospital. A high rate of involuntary admission (44%), homelessness (36%), and substance abuse (64%) was noted. In this group of high-risk obstetric patients, we identified risk factors associated with noncompliance with ongoing prenatal care. Brief psychiatric hospitalization can be an important aspect in improving obstetric outcome by providing an opportunity to collect obstetric information and promote ongoing prenatal care.

The Green Bay cesarean section study. I. The physician factor as a determinant of cesarean birth rates

This study was designed to identify the determinants of cesarean birth rates. The study population included all 1030 cesarean deliveries performed on singleton pregnancies by 11 obstetricians practicing at two Green Bay hospitals from 1986 through 1988; 1076 control patients with vaginal deliveries were selected for comparison purposes. The 1030 cesarean deliveries represented 14% of the 7335 singleton deliveries that occurred during the study period. Individual physician cesarean rates ranged from 5.6% to 19.7%. Cesarean rates for physician groups ranged from 9.8% to 18%. The variances in cesarean rates among individual and groups of physicians were not attributable to patient obstetric risk factors, socioeconomic status, service status, or duration of the physician's practice. Higher cesarean rates did not result in better neonatal outcome. Individual physician practice style was the only apparent determinant of cesarean rates for the 11 obstetricians. Current cesarean rates can be substantially reduced without sacrificing fetal and newborn safety.

Birth asphyxia and obstetric care in Curaçao Netherlands Antilles

Out of the 223 fetal and neonatal deaths that occurred on the island of Curaçao in a 2-year period (1984-1985), 35 were due to birth asphyxia (15.7%). In order to evaluate the quality of obstetric care, the circumstances surrounding each asphyxiated death were scrutinized. On the whole, patients' compliance with antenatal care was satisfactory. However, when the woman presented in labor the attending physician or midwife often lacked information on maternal antecedents and the course of pregnancy. Inadequate intrapartum surveillance together with failure to respond appropriately to abnormalities in labor constituted the principle factors which were associated with asphyxiated deaths. In addition, asphyxial conditions during labor were often preceded by inappropriate administration of oxytocic agents.

Birth asphyxia and the intrapartum cardiotocograph

The intrapartum cardiotocographs (CTGs) of 38 severely asphyxiated, term infants, born during a 17-month period, and those of 120 healthy term infants acting as controls were independently reviewed by three investigators who were unaware of the clinical outcome. Inter-observer agreement was good (Kappa statistic = 0.74, P less than 0.0001). The investigators found that cardiotocographic abnormalities were present in 33 of the asphyxiated infants (87%) and in 35 of the controls (29%) and predicted that the abnormalities were severe enough to lead to significant fetal metabolic acidosis at delivery in 23 asphyxiated infants (61%) and in 11 controls (9%). The differences between the two groups were highly significant (P less than 0.001). Using the traditional diagnostic criteria for fetal distress, the investigators found that fetal blood sampling was indicated in 58% of cases in the asphyxia group and in 20% of controls but was only performed in 16% of asphyxiated infants and in 8% of controls. Furthermore, the median response times of delivery suite staff for abnormal fetal heart rate patterns were similar whether the FHR changes, classified using Krebs' CTG scoring system, were moderate or severe: 80 min and 90 min, respectively. These findings suggest that interpretation of the intrapartum CTG continues to pose major problems for practising obstetricians.

'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.

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.

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.