Compromised Baby

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• Cerebral Palsy
• Asphyxiating Conditions
• Electronic Fetal Monitoring (EFM)
• Abandon EFM?
• Fetal Biophysical Profile
• Fetal Biophysical Profile predictive
• APGAR Score
• Umbilical Cord Blood Gas Analysis
• Medicolegal Issues
• International Consensus

Controlled studies, improved epidemiologic and statistical techniques, and an increase in biological information on mechanisms of fetal and neonatal brain injury or maldevelopment have led to a better, although still imperfect, understanding of the cause of developmental disabilities. The role of asphyxia during the birth process is smaller than was once believed. Intrauterine exposure to infection, autoimmune and coagulation disorders, and problems specific to multiple pregnancies are risk factors for cerebral palsy. Electronic fetal monitoring and other observations during birth are unsatisfactory management guides, having enormously high rates of false-positive identification. There is no evidence that caesarean section can prevent cerebral palsy in term infants.

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Asphyxiating Conditions 

Unique Identifier 98400587
Author Nelson KB; Grether JK
Institution Neuroepidemiology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland, USA.
Title Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight [see comments]
Source Am J Obstet Gynecol 1998 Aug;179(2): p507-13
ISSN 0002-9378
Abstract

OBJECTIVE: Our purpose was to examine the association of cerebral palsy with conditions that can interrupt oxygen supply to the fetus as a primary pathogenetic event.
STUDY DESIGN: A population-based case-control study was performed in four California counties, 1983 through 1985, comparing birth records of 46 children with disabling spastic cerebral palsy without recognized prenatal brain lesions and 378 randomly selected control children weighing > or = 2500 g at birth and surviving to age 3 years.
RESULTS: Eight of 46 children with otherwise unexplained spastic cerebral palsy, all eight with quadriplegic cerebral palsy, and 15 of 378 controls had births complicated by tight nuchal cord (odds ratio for quadriplegia 18, 95% confidence interval 6.2 to 48). Other potentially asphyxiating conditions were uncommon and none was associated with spastic diplegia or hemiplegia. Level of care, oxytocin for augmentation of labor, and surgical delivery did not alter the association of potentially asphyxiating conditions with spastic quadriplegia. Intrapartum indicators of fetal stress, including meconium in amniotic fluid and fetal monitoring abnormalities, were common and did not distinguish children with quadriplegia who had potentially asphyxiating conditions from controls with such conditions.
CONCLUSION: Potentially asphyxiating conditions, chiefly tight nuchal cord, were associated with an appreciable proportion of unexplained spastic quadriplegia but not with diplegia or hemiplegia. Intrapartum abnormalities were common both in children with cerebral palsy and controls and did not distinguish between them.

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Electronic Fetal Monitoring (EFM)

Section I. Screening
Part F. Prenatal Disorders

Intrapartum Electronic Fetal Monitoring

This guideline is a portion of a larger document that cannot be downloaded efficiently as a single HTML file. See other guidelines from the U.S. Preventive Services Task Force to read the complete document.

RECOMMENDATION

Routine electronic fetal monitoring for low-risk women in labor is not recommended. There is insufficient evidence to recommend for or against intrapartum electronic fetal monitoring for high-risk pregnant women.

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Abandon EFM? 

Unique Identifier 20227603
Author Parer JT; King T
Institution Department of Obstetrics, Gynecology, and Reproductive Sciences, and the Cardiovascular Research Institute, University of California San Francisco, 94143-0550, USA.
Title Fetal heart rate monitoring: is it salvageable?
Source Am J Obstet Gynecol 2000 Apr;182(4): p982-7
ISSN 0002-9378
Abstract

Fetal heart rate monitoring was introduced in the 1960s. After a number of randomized controlled trials in the mid 1980s, doubt arose regarding the efficacy of fetal heart rate monitoring in improving fetal outcome. The potential reasons why fetal heart rate monitoring has not been shown to be efficacious are
(1) use of an outcome measure that is not related to variant fetal heart rate monitoring patterns, (2) lack of standardized interpretation of fetal heart rate patterns,
(3) disagreement regarding algorithms for intervention of specific fetal heart rate patterns, and
(4) the inability to demonstrate the reliability, validity, and ability of fetal heart rate monitoring to allow timely intervention. A recent National Institutes of Health committee proposed detailed, quantitative, standardized definitions of fetal heart rate patterns, which can serve as a basis for determining whether fetal heart rate monitoring is reliable and valid. In this article we examine reasons why fetal heart rate monitoring did not live up to its original expectations and why the randomized controlled trials did not demonstrate efficacy, and we make suggestions for determining whether electronic fetal heart rate monitoring should be abandoned.

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Fetal Biophysical Profile 

Unique Identifier 20055267
Author Manning FA
Institution Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, Bronx, New York, USA.
Title Fetal biophysical profile.
Source Obstet Gynecol Clin North Am 1999 Dec;26(4): p557-77, v
ISSN 0889-8545
Abstract

This article begins with an outline of the theoretic basis of the fetal biophysical profile, the method for the biophysical profile score (BPS), and the timing and frequency of testing. The article further discusses the clinical management based on test scores; modified methods of the BPS; and clinical application, predictive accuracy, and impact on outcome of BPS. The authors specifically examine the relationship between BPS and cerebral palsy. They conclude with a discussion of adult sequelae and fetal adaptation to asphyxia.

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Fetal Biophysical Profile predictive

Unique Identifier 98239034
Author Manning FA; Bondaji N; Harman CR; Casiro O; Menticoglou S; Morrison I; Berck DJ
Institution Department of Obstetrics and Gynecology, University of Manitoba, Winnipeg, Canada.
Title Fetal assessment based on fetal biophysical profile scoring. VIII. The incidence of cerebral palsy in tested and untested perinates.
Source Am J Obstet Gynecol 1998 Apr;178(4): p696-706
ISSN 0002-9378
Abstract

OBJECTIVE: The intent of this comparative clinical study was fourfold: (1) to determine the incidence of cerebral palsy in a large obstetric population, (2) to compare the incidence of cerebral palsy in patients at high risk referred for and managed according to the fetal biophysical profile score result with the incidence among unreferred and untested patients, (3) to determine the relationship, if any, between the last fetal biophysical profile score and the incidence of cerebral palsy, and (4) to categorize cases of cerebral palsy according to the clinical parameters and the probable time and nature of the damaging insult.
STUDY DESIGN: In this retrospective 5-year comparative study (1987 to 1991) the incidence of cerebral palsy was determined by analysis of International Classification of Diseases, Ninth Revision, -coded related medical services. The clinical records were then sought and reviewed in cases and obstetric, neonatal, and postnatal clinical data were abstracted. Cross-correlation with partial registries was done to confirm completeness of capture of cases. The population of referred high-risk patients who received serial fetal biophysical profile scoring and were managed according to test results was determined by review of a prospective computer-stored database and by review of patient log books. The population of untested patients was calculated as the residual of total cases minus tested cases. The rate of cerebral palsy for all patients and for the tested and untested population was calculated and compared. The tested and untested perinates were compared for birth age, weight, and assigned timing or etiology of cerebral palsy. In the tested population the distribution of test results by last recorded biophysical profile score was determined and the relationship between the last test result and cerebral palsy and predictive accuracy parameters of the fetal biophysical profile score were calculated.
RESULTS: The incidence of cerebral palsy among the 84,947 live births was 3.68 per 1000 live births (313 cases). The rate of cerebral palsy in the 26,290 referred high-risk tested patients was 1.33 per 1000 (35 cases) compared with a rate of 4.74 per 1000 live births in the 58,657 untested mixed low-risk/high-risk patients (278 cases). These differences were highly significant. A significant declining trend in the annual incidence of cerebral palsy was observed in the total population and the untested population, whereas the rate in the tested population remained relatively constant over the 5-year study interval. The differences in the cerebral palsy rate between the tested and untested population were not related to differences in gestational age, birth weight, or assigned timing or etiology category. In the tested population the relationship between the incidence of cerebral palsy and the last test fetal biophysical profile score was inverse, exponential, and highly significant.
CONCLUSIONS: Antepartum assessment by fetal biophysical profile scoring is associated with a significant reduction in the incidence of cerebral palsy compared with untested patients. The relationship between the last test score and the incidence of cerebral palsy is inverse and exponential, suggesting that antenatal asphyxia is an important and potentially avoidable cause of cerebral palsy.

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APGAR Score 

Unique Identifier 96262057
Title Use and abuse of the Apgar score. Committee on Fetus and Newborn, American Academy of Pediatrics, and Committee on Obstetric Practice, American College of Obstetricians and Gynecologists.
Source Pediatrics 1996 Jul;98(1): p141-2
ISSN 0031-4005
Abstract

This is a revised statement published jointly with the American College of Obstetricians and Gynecologists that emphasizes the appropriate use of the Apgar Score. The highlights of the statement include: (1) the Apgar Score is useful in assessing the condition of the infant at birth; (2) the Apgar score alone should not be used as evidence that neurologic damage was caused by hypoxia that results in neurologic injury or from inappropriate intrapartum treatment; and (3) an infant who has had "asphyxia" proximate to delivery that is severe enough to result in acute neurologic injury should demonstrate all of the following: (a) profound metabolic or mixed acidemia (pH < 7.00) on an umbilical arterial blood sample, if obtained, (b) an Apgar score of 0 to 3 for longer than 5 minutes, (c) neurologic manifestation, eg, seizure, coma, or hypotonia, and (d) evidence of multiorgan dysfunction.

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Umbilical Cord Blood Gas Analysis 

Unique Identifier 20055275
Author Thorp JA; Rushing RS
Institution St. Luke's Hospital of Kansas City, Missouri, USA.
Title Umbilical cord blood gas analysis.
Source Obstet Gynecol Clin North Am 1999 Dec;26(4): p695-709
ISSN 0889-8545
Abstract

Umbilical cord blood gas and pH values should always be obtained in the high-risk delivery and whenever newborn depression occurs. This practice is important because umbilical cord blood gas analysis may assist with clinical management and excludes the diagnosis of birth asphyxia in approximately 80% of depressed newborns at term. The most useful umbilical cord blood parameter is arterial pH. Sampling umbilical venous blood alone is not recommended because arterial blood is more representative of the fetal metabolic condition and because arterial acidemia may occur with a normal venous pH. A complete blood gas analysis may provide important information regarding the type and cause of acidemia and sampling the artery and vein may provide a more clear assessment. The sampling technique is simple and easily mastered by any treatment person in the delivery room. Preheparinized syringes ensure a consistent dose and amount of heparin. Depending on how normality is defined and on the population studied, normal ranges for umbilical cord blood gas values vary (see Table 1). In general, the lower range for normal arterial pH extends to at least 7.10 and that for venous pH to at least 7.20. Many different factors during pregnancy, labor, and delivery can affect cord blood gases. Umbilical blood sampling for acid-base status at all deliveries cannot be universally recommended because many facilities do not have the capabilities to support such a practice and in doing so may impose an excessive financial burden. Considering the costs, the accumulated published data, and the nonspecificity of electronic fetal monitoring in the evaluation of fetal oxygenation, it may be more rational to implement universal cord blood gas analysis. Care providers and institutions with the logistical capabilities in place should consider the cost efficacy of routine cord blood gas analysis because it is the gold standard assessment of uteroplacental function and fetal oxygenation/acid-base status at birth.

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Medicolegal Issues 

Unique Identifier 97307901
Author Perlman JM
Institution Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas 75235-9063, USA.
Title Intrapartum hypoxic-ischemic cerebral injury and subsequent cerebral palsy: medicolegal issues.
Source Pediatrics 1997 Jun;99(6): p851-9
ISSN 0031-4005

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International Consensus

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