Effect of maternal hyperoxygenation on neonatal outcomes among women in labour with pathological cardiotocography: an open-label randomized controlled trial.

BACKGROUND: Hyperoxygenation has shown promise in improving suspicious fetal heart patterns in women in labor. However, the effect of hyperoxygenation on neonatal outcomes in women in labor with pathologic fetal heart rate tracing has not been studied. OBJECTIVE: This study aimed to evaluate the effect of fractional inspiration of oxygen of 80% compared with fractional inspiration of oxygen of 40% on neonatal outcomes in women with pathologic fetal heart rate tracing. STUDY DESIGN: This randomized, open-label, parallel arm, outcome assessor-blinded clinical trial was conducted in a large tertiary care university hospital. Singleton parturients aged ≥18 years at term gestation in active labor (cervical dilatation of ≥6 cm) with pathologic fetal heart rate tracing were recruited in the study. Pathologic fetal heart rate tracing was defined according to the International Federation of Gynecology and Obstetrics 2015 guidelines. The International Federation of Gynecology and Obstetrics classifies fetal heart rate tracings into 3 categories (normal, suspicious, and pathologic) based on rate, variability, and deceleration. Women in the intervention arm received oxygen at 10 L/min via a nonrebreathing mask, and those in the usual care arm received oxygen at 6 L/min with a simple face mask. Oxygen supplementation was continued until cord clamping. The primary outcome measure was a 5-minute Apgar score. The secondary outcome measures were the proportion of neonatal intensive care unit admission, umbilical cord blood gas variables, level of methyl malondialdehyde in the cord blood, and mode of delivery. RESULTS: Overall, 148 women (74 women in the high fractional inspiration of oxygen arm and 74 in the low fractional inspiration of oxygen arm) with pathologic fetal heart rate tracing were analyzed. The demographic data, obstetrical profiles, and comorbidities were comparable. The median 5-minute Apgar scores were 9 (interquartile range, 8-10) in the hyperoxygenation arm and 9 (interquartile range, 8-10) in the usual care arm (P=.12). Furthermore, the rate of neonatal intensive care unit admission (9.5% vs 12.2%; P=.6) and the requirement of positive pressure ventilation (6.8% vs 8.1%; P=.75) were comparable. Concerning cord blood gas parameters, the hyperoxygenation arm had a significantly higher base deficit in the umbilical vein and lactate level in the umbilical artery. The cesarean delivery rate was significantly lower in women who received hyperoxygenation (4.1% [3/74]) than in women who received normal oxygen supplementation (25.7% [19/74]) (P=.00). In addition, umbilical vein malondialdehyde level in the umbilical vein was lower in the hyperoxygenation group (8.28±4.65 µmol/L) than in the normal oxygen supplementation group (13.44±8.34 µmol/L) (P=.00). CONCLUSION: Hyperoxygenation did not improve the neonatal Apgar score in women with pathologic fetal heart rate tracing. In addition, neonatal intensive care unit admission rate and blood gas parameters remained comparable. Therefore, the results of this trial suggest that a high fractional inspiration of oxygen supplementation confers no benefit on neonatal outcomes in women with pathologic fetal heart rate tracings and normal oxygen saturation.

Trends in Apgar scores and umbilical artery pH: a population-based cohort study on 10,696,831 live births in Germany, 2008-2022.

Low Apgar scores and low umbilical arterial (UA) blood pH are considered indicators of adverse perinatal events. This study investigated trends of these perinatal health indicators in Germany. Perinatal data on 10,696,831 in-hospital live births from 2008 to 2022 were obtained from quality assurance institutes. Joinpoint regression analysis was used to quantify trends of low Apgar score and UA pH. Additional analyses stratified by mode of delivery were performed on term singletons with cephalic presentation. Robustness against unmeasured confounding was analyzed using the E-value sensitivity analysis. The overall rates of 5-min Apgar scores < 7 and UA pH < 7.10 in liveborn infants were 1.17% and 1.98%, respectively. For low Apgar scores, joinpoint analysis revealed an increase from 2008 to 2011 (annual percent change (APC) 5.19; 95% CI 3.66-9.00) followed by a slower increase from 2011 to 2019 (APC 2.56; 95% CI 2.00-3.03) and a stabilization from 2019 onwards (APC - 0.64; 95% CI - 3.60 to 0.62). The rate of UA blood pH < 7.10 increased significantly between 2011 and 2017 (APC 5.90; 95% CI 5.15-7.42). For term singletons in cephalic presentation, the risk amplification of low Apgar scores was highest after instrumental delivery (risk ratio 1.623, 95% CI 1.509-1.745), whereas those born spontaneous had the highest increase in pH < 7.10 (risk ratio 1.648, 95% CI 1.615-1.682).          Conclusion: Rates of low 5-min Apgar scores and UA pH in liveborn infants increased from 2008 to 2022 in Germany. What is Known: • Low Apgar scores at 5 min after birth and umbilical arterial blood pH are associated with adverse perinatal outcomes. • Prospective collection of Apgar scores and arterial blood pH data allows for nationwide quality assurance. What is New: • The rates of liveborn infants with 5-min Apgar scores < 7 rose from 0.97 to 1.30% and that of umbilical arterial blood pH < 7.10 from 1.55 to 2.30% between 2008-2010 and 2020-2022. • In spontaneously born term singletons in cephalic presentation, the rate of metabolic acidosis with pH < 7.10 and BE < -5 mmol/L in umbilical arterial blood roughly doubled between the periods 2008-2010 and 2020-2022.

Neonatal morbidity and mortality in birth centers in the United States 2018-2021: An observational study of low-risk birthing individuals.

BACKGROUND: Many studies reporting neonatal outcomes in birth centers include births with risk factors not acceptable for birth center care using the evidence-based CABC criteria. Accurate comparisons of outcomes by birth setting for low-risk patients are needed. METHODS: Data from the public Natality Detailed File from 2018 to 2021 were used. Logistic regression, including adjusted and unadjusted odds ratios, compared neonatal outcomes (chorioamnionitis, Apgar scores, resuscitation, intensive care, seizures, and death) between centers and hospitals. Covariates included maternal diabetes, body mass index, age, parity, and demographic characteristics. RESULTS: The sample included 8,738,711 births (8,698,432 (99.53%) in hospitals and 40,279 (0.46%) in birth centers). There were no significant differences in neonatal deaths (aOR 1.037; 95% CI [0.515, 2.088]; p-value 0.918) or seizures (aOR 0.666; 95% CI [0.315, 1.411]; p-value 0.289). Measures of morbidity either not significantly different or less likely to occur in birth centers compared to hospitals included chorioamnionitis (aOR 0.032; 95% CI [0.020, 0.052]; p-value < 0.001), Apgar score < 4 (aOR 0.814, 95% CI [0.638, 1.039], p-value 0.099), Apgar score < 7 (aOR 1.075, 95% CI [0.979, 1.180], p-value 0.130), ventilation >6 h (aOR 0.349; [0.281,0.433], p-value < 0.001), and intensive care admission (aOR 0.356; 95% CI [0.328, 0.386], p-value < 0.001). Birth centers had higher odds of assisted neonatal ventilation for <6 h as compared to hospitals (aOR 1.373; 95% CI [1.293, 1.457], p-value < 0.001). CONCLUSION: Neonatal deaths and seizures were not significantly different between freestanding birth centers and hospitals. Chorioamnionitis, Apgar scores < 4, and intensive care admission were less likely to occur in birth centers.

Effect of anesthesia administration method on apgar scores of infants born to women undergoing elective cesarean section.

BACKGROUND: Neonatal health at delivery as measured by apgar scores is an important outcome. This study was done to assess the impact of anesthesia on Apgar 1-minute and 5-minute scores of infants delivered through elective cesarean section in Zimbabwe. METHODS: We carried out a secondary analysis of data from the Efficacy of Tranexamic Acid in Preventing Postpartum Hemorrhage (ETAPPH) clinical trial in Zimbabwe. Outcomes measured were infant Apgar scores at 1 and 5 min, exposure was the administration of either a general (intravenous propofol/ketamine/sodium thiopental) or spinal (hyperbaric bupivacaine 0.5%) anesthesia for anesthesia during the elective cesarean section procedure. Marginal Structural Logistic Modelling (MSM) using an unstabilized Inverse Probability Treatment Weight (IPTW) estimator was used to assess the relationship between anesthetic administration method and infant Apgar scores. RESULTS: Four hundred and twenty-one (421) women who had an elective caesarean section in the ETAPPH study had their infants assessed for Apgar scores. Comparing general anesthesia to spinal anesthesia, spinal anesthesia was related to good Apgar scores at 1-minute (adjusted odds ratio [aOR] = 4.0, 95% Confidence Interval = 1.5-10.7, sensitivity analysis E-value = 3.41). Spinal anesthetic administration was also related to good Apgar scores at 5 min (adjusted odds ratio [aOR] = 6.2, 95% Confidence Interval = 1.6-23.1, sensitivity analysis E-value = 4.42). CONCLUSIONS: When providing anesthesia for patients undergoing elective cesarean section, care should be taken on the method of administration of anesthetic agents. General anesthesia tends to depress Apgar scores at 1 min, although most neonates recover and have better scores at 5 min. Spinal anesthesia should be the first choice whenever possible. TRIAL REGISTRATION: The clinical trial from which data of this study was abstracted was registered under clinical trials registration number NCT04733157.

Neonatal outcomes of births in freestanding birth centers and hospitals in the United States, 2016-2019.

BACKGROUND: Births in freestanding birth centers have more than doubled between 2007 and 2019. Although birthing centers, which are defined by the American College of Obstetricians and Gynecologists as ". . . freestanding facilities that are not hospitals," are being promoted as offering women fewer interventions than hospitals, there are limited recent data available on neonatal outcomes in these settings. OBJECTIVE: To compare several important measures of neonatal safety between 2 United States birth settings and birth attendants: deliveries in freestanding birth centers and hospital deliveries by midwives and physicians. STUDY DESIGN: This is a retrospective cohort study using the United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, and Division of Vital Statistics natality online database for the years 2016 to 2019. All term, singleton, low-risk births were eligible for inclusion. The study outcomes were several neonatal outcomes including neonatal death, neonatal seizures, 5-minute Apgar scores of <4 and <7, and neonatal death in nulliparous and in multiparous women. Outcomes were compared between the following 3 groups: births in freestanding birth centers, in-hospital births by a physician, and in-hospital births by a midwife. The prevalence of each neonatal outcome among the different groups was compared using Pearson chi-squared test, with the in-hospital midwife births being the reference group. Multivariate logistic regression models were performed to account for several potential confounding factors such as maternal prepregnancy body mass index, maternal weight gain, parity, gestational weeks, and neonatal birthweight and calculated as adjusted odds ratio. RESULTS: The study population consisted of 9,894,978 births; 8,689,467 births (87.82%) were in-hospital births by MDs and DOs, 1,131,398 (11.43%) were in-hospital births by midwives, and 74,113 (0.75%) were births in freestanding birth centers. Freestanding birth center deliveries were less likely to be to non-Hispanic Black or Hispanic, less likely to women with public insurance, less likely to be women with their first pregnancy, and more likely to be women with advanced education and to have pregnancies at ≥40 weeks' gestation. Births in freestanding birth center had a 4-fold increase in neonatal deaths (3.64 vs 0.95 per 10,000 births: adjusted odds ratio, 4.00; 95% confidence interval, 2.62-6.1), a more than 7-fold increase in neonatal deaths for nulliparous patients (6.8 vs 0.92 per 10,000 births: adjusted odds ratio, 7.7; 95% confidence interval, 4.42-13.76), a more than 2-fold increase in neonatal seizures (3.91 vs 1.94 per 10,000 births: adjusted odds ratio, 2.19; 95% confidence interval, 1.48-3.22), and a more than 7-fold increase of a 5-minute Apgar score of <4 (194.84 vs 28.5 per 10,000 births: adjusted odds ratio, 7.46; 95% confidence interval, 7-7.95). Compared with hospital midwife deliveries, hospital physician deliveries had significantly higher adverse neonatal outcomes (P<0.001). CONCLUSION: Births in United States freestanding birth centers are associated with an increased risk of adverse neonatal outcomes such as neonatal deaths, seizures, and low 5-minute Apgar scores. Therefore, when counseling women about the location of birth, it should be conveyed that births in freestanding birth centers are not among the safest birth settings for neonates compared with hospital births attended by either midwives or physicians.

Paracetamol preceding very preterm birth: Is it safe?

INTRODUCTION: The use of paracetamol for pain relief in pregnancy is common. However, the influence of paracetamol on the perinatal adaptation of high-risk infants has not been studied. These data are important for safety, since another inhibitor of prostaglandin synthesis is harmful to infants born very preterm and increases serious morbidity. We studied whether the use of paracetamol had an adverse influence on neonatal adaptation and the outcomes of infants during the first hospitalization. MATERIAL AND METHODS: We studied the patient records of high-risk mothers and their infants born before 32 weeks of gestation for multiple variables over a period of 84 months in Oulu University Hospital, a regional tertiary care hospital caring for high-risk deliveries and providing neonatal intensive care. In a matched cohort setting, the exposition was defined as paracetamol use <24 h before childbirth. The controls had consumed no paracetamol up to 1 week before delivery. Infants with major anomalies were excluded. The primary outcome was defined as the need for early interventional treatments for the preterm infants. Outcomes during the first hospitalization were also studied. RESULTS: Altogether, 170 fetuses from 149 mothers were exposed to paracetamol during the study period. The control population, delivering during the same period, consisted of 118 non-exposed fetuses from 104 mothers. Among them, the mothers were pairwise matched according to their medications, amniotic fluid leakage time, clinical infections, and delivery mode. After matching, 72 mothers/group remained, resulting in 88 paracetamol-exposed infants and 85 controls. No perinatal adverse reactions were detected. There were no differences in either circulatory support during the first postnatal day or in the risk for major diseases during the first hospitalization. Paracetamol-exposed infants needed fewer acute delivery room therapies (51.1% vs 65.9%, mean difference -14.89; 95% confidence interval -0.29 to -0.003). Maternal total paracetamol dose in the 1 week before delivery correlated positively with Apgar scores. CONCLUSIONS: Antenatal paracetamol given within 24 h before birth had no adverse effects on extremely or very preterm infants. The long-term safety of paracetamol and the potential acute benefits for preterm infants during perinatal transition remain to be proven in larger, prospective settings.

Continuing epidural analgesia during the second stage and ACOG definition of arrest of labor on maternal-fetal outcomes.

BACKGROUND: Despite an increase in the rates of epidural labor analgesia, continuation of epidural labor analgesia in the second stage of labor (CEADSSOL) was interrupted by care providers due to fears of increased risk of operative delivery and adverse neonatal outcomes. Therefore, we evaluated the effect of CEADSSOL and the newer American College of Obstetricians and Gynecologists (ACOG) definition of arrest of labor on the length of secondary stage of labor, newborn outcomes, and mode of delivery. METHODS: This is a retrospective cohort study. Data collection began during March 2014 and ended in May 2015, 1 year after implementation of both interventions. The primary outcome was the length of secondary stage of labor, mode of delivery and neonatal outcome (Apgar < 7, at 5 minutes). The implementation of continuing epidural analgesia during the second stage of labor was performed with 0.08%-0.15% ropivacaine and 0.1-0.2 µg/mL sufentanil. RESULTS: There were a total 10 414 deliveries during the study period. The length of the second stage of labor has no significant differences among groups. The cesarean delivery rate decreased 4.1% (36% vs 40.1%, P = .0038). Moreover, no significant difference was found in neonatal Apgar scores less than 7 at 5 minutes between two phases. Maternal outcomes remained unchanged. Post-intervention neonatal parameters including NICU admissions (P < .001), incidences of antibiotics usage (P < .0001), intubation (P = .0003), and 7 days mortality (P = .0020) were remarkably reduced compared to pre-interventions. CONCLUSION: The important finding of this study was the improvement in neonatal outcomes by implementing two simultaneous interventions without a cost of increased operative delivery.

Peritoneal adhesions do not increase intra-operative organ injury or adverse neonatal outcomes during a repeated cesarean delivery.

PURPOSE: To examine whether the presence of peritoneal adhesions at the second cesarean delivery (CD), attributable to the first CD, are associated with maternal intra-operative organ injury and adverse neonatal outcomes. METHODS: A retrospective cohort study was conducted, comparing severe maternal intra-operative organ injury and adverse neonatal outcomes, between women with and without peritoneal adhesions. All women with two CDs during the follow-up period were included. Women with adhesions diagnosed during the first CD, history of other abdominal or pelvic surgery, pelvic infection or pelvic inflammatory disease, endometriosis, uterine Mullerian anomalies and newborns with known chromosomal or structural abnormalities were excluded, resulting in 7925 women. Intra-operative peritoneal organ injury was defined as a composite of bladder injury, ureteral injury, small bowel injury or hysterectomy. The examined adverse neonatal outcomes were low 1 and 5 min Apgar scores, intrapartum death (IPD) and postpartum death (PPD). Multivariate logistic regression was performed. RESULTS: Peritoneal adhesions at the second CD, attributable to the first CD were diagnosed in 32.6% of patients (n = 2581). The presence of peritoneal adhesions was not found to be independently associated with intra-operative organ injury nor with 5 min Apgar scores, IPD and PPD. Second CDs complicated with adhesions were found to be associated with low (< 7) 1 min Apgar scores (adjusted OR 1.38, CI 1.20-1.58, p < 0.001). CONCLUSION: Adhesions attributable to a previous CD do not seem to increase the risk for intra-operative organ injury and adverse neonatal outcomes. These findings may assist in reassuring patients who are facing a second CD.

Towards scheduled pre-parturient caesarean sections in bitches.

Elective caesarean section (CS) is the safest means of delivering the litter in bitches in specific situations. Timeously performing elective pre-parturient CSs at a fixed time would be convenient and prevent emergency CSs and foetal demise. This review proposes a method of performing elective pre-parturient CSs which is safe for both the bitch and puppies. Brachycephaly, small litters and large litters, preceding litter delivered by CS and trial of labour after a preceding CS are identified as factors increasing the need for CS whereas emergency CS is identified as factor increasing foetal demise. The first day of cytological dioestrus more precisely predicts the day of onset of spontaneous parturition than the first day of the LH surge or the dates during oestrus on which progesterone (P4) first exceeds 6 nM or 16 nM. Foetal biparietal diameter at the time of onset of spontaneous parturition varies too much to accurately predict readiness for CS. During the last few days of gestation, P4 with cut-off concentrations at 15.8, 8.7 and 3.18 nM, but not plasma cortisol concentrations, hold promise as predictors of onset of parturition and when to perform pre-parturient CSs. A protocol associating medetomidine hydrochloride as premedicant with propofol as induction agent and sevoflurane as maintenance is safe for scheduled CS and yields good maternal and puppy survival rates at delivery, 2 hr and 7 days after CSs. Clinicians have to pay attention to the haematocrit of bitches at the time of cervical dilatation which is at the lower end of the normal reference ranges for non-pregnant dogs and to the decline in haematocrit during CS (as a proxy for blood loss) which is approximately 7% for both parturient (open cervix) and pre-parturient (closed cervix) CSs. Pre-parturient CSs can be scheduled and performed 57 days after onset of cytological dioestrus with puppy survival rates of 99%. Collectively, these studies provide a protocol to safely perform elective CSs in a large proportion of the obstetric population at a convenient time of the day but more research is required with larger numbers to establish whether this practice is routinely safe and safe in all breeds.

Types of intrapartum hypoxia on the cardiotocograph (CTG): do they have any relationship with the type of brain injury in the MRI scan in term babies?

Electronic foetal monitoring using cardiotocography is aimed at the timely recognition and management of foetal hypoxia. The primary objective of this study was to examine whether a relationship exists between the types of foetal hypoxia (acute, subacute, evolving, chronic), as identified on cardiotocography and the nature of hypoxic ischaemic encephalopathy, as observed on MRI scans after birth. We conducted a retrospective study of 16 babies born (out of 52,187 births) at St George's Hospital in London during 2006-2017 with a postnatal diagnosis of HIE. Of the 16 babies, only 11 had both MRI scans and CTG traces available. Of those, 9 showed evidence of intrapartum hypoxia on CTG, but only 6 demonstrated evidence of HIE on MRI. Those with acute hypoxia showed abnormalities in the basal ganglia and thalami. A gradually evolving hypoxia or subacute hypoxia was associated with lesions in myelination and cerebral cortex.Impact StatementWhat is already known on this subject? It has been reported that inter-observer agreement for CTG interpretation is low (30%) when pattern recognition based guidelines are used (Rhöse et al. 2014; Reif et al. 2016), even amongst 'experts' (Hruban et al. 2015). Furthermore, it has been shown that CTG traces do not reliably predict neonatal encephalopathy (Spencer et al. 1997).What do the results of this study add? Our study indicates that if 'types of intrapartum hypoxia' are used for interpretation, then inter-observer agreement increases to 81%, from the reported 30% when traces are classified into 'normal, suspicious and pathological' using guidelines based on 'pattern recognition'. Furthermore, our study shows a good correlation between the type of intrapartum hypoxia observed on CTG trace and the nature of injury observed on the MRI.What are the implications of these findings for clinical practise and/or further research? Improving inter-observer agreement of CTGs with the use of pattern recognition in combination with the good correlation to MRI scan findings ultimately leads to better management and post-natal outcomes. This is evidenced by the fact that after the introduction of physiology-based CTG interpretation and mandatory competency testing on CTG interpretation for all staff in 2010, St. George's Maternity Unit has half the nationally reported rate of cerebral palsy.

Adverse pregnancy outcomes and multiple nuchal cord loops.

PURPOSE: To evaluate the effects of nuchal cord and the number of loops during labor and delivery on delivery outcomes among women with singleton pregnancy who delivered vaginally. METHODS: This retrospective cohort study included 42,798 women with singleton, vertex, and vaginal deliveries at 24-43 weeks of gestation. We analyzed delivery outcomes based on the number of nuchal cord loops. RESULTS: A total of 42,798 deliveries met the inclusion criteria, of which, 3809 (8.9%) had nuchal cord with 1 loop at delivery, 1035 (2.42%) had 2 loops, and 258 (0.6%) had 3 loops. Nuchal cord with 3 loops compared to no nuchal cord has been associated with higher incidence of intrauterine fetal death (1.9%), Apgar scores less than 7 at 1 and 5 min (7.4%, 2.3%), and higher rate of operative vaginal deliveries (17.5%). Nuchal cord with 2 or 3 loops was associated with higher incidence of intrauterine growth restriction (10.2%, 11.6%).  In a multiple logistic regression model, nuchal cord with 3 loops was an independent risk factor for operative vaginal delivery and Apgar score less than 7 in 1 min. CONCLUSIONS: In the case of vaginal delivery in the presence of nuchal cord, as the number of nuchal cord loops increased, so did the number of adverse delivery outcomes. While 3 loops were associated with higher incidence of intrauterine fetal death, intrauterine growth restriction, increased operative vaginal deliveries, and low Apgar scores, 1 loop was not associated with adverse perinatal outcomes.

Lower Apgar scores and Caesarean sections are related to attention-deficit/hyperactivity disorder.

AIM: We examined the associations between prenatal, birth-related and newborn risk factors and attention-deficit/hyperactivity disorder (ADHD). METHODS: In this population-based study, 10 409 subjects diagnosed with ADHD by 31 December 2011 and 39 124 controls, born between 1 January 1991 and 31 December 2005, were identified from Finnish nationwide registers. Perinatal data were obtained from the Birth Register. Conditional logistic regression was used to examine the associations after controlling for confounders. RESULTS: Lower Apgar scores were associated with a higher risk of ADHD, with odds ratios of 1.12 (95% confidence intervals 1.06-1.19) for one-minute Apgar scores of 7-8, 1.17 (95% CI 1.02-1.35) for scores of 5-6 and 1.41 (95% CI 1.18-1.68) for scores of 0-4, compared to Apgar scores of 9-10. Elective Caesarean sections were associated with an increased risk of ADHD with an adjusted odds ratio of 1.15 (95% CI 1.05-1.26). Other identified risk factors were breech presentation, induced labour and admission to a neonatal intensive care unit. Low umbilical artery pH did not increase the risk of ADHD. CONCLUSION: Elective Caesareans and perinatal adversities leading to lower Apgar scores increased the risk of ADHD. Future research to identify the mechanisms behind these findings is warranted.

The effect of labor epidural analgesia on maternal-fetal outcomes: a retrospective cohort study.

PURPOSE: To evaluate the impact of labor epidural analgesia on maternal-fetal safety outcomes in a signal Chinese academic medical center. METHODS: A single-intervention impact study was conducted at The Second Affiliated Hospital, Wenzhou Medical University. The study period was divided into three phases: (1) baseline phase: from January 1 and June 30, 2009 when no analgesic method was routinely employed during labor; (2) phase-in period: the epidural analgesia was implemented 8 a.m.-5 p.m. during weekdays; and (3) the post-No Pain Labor N'Delivery phase when the labor epidural was applied 24 h a day, 7 days a week, from June 1, 2010 and June 30, 2011. The maternal-fetal safety outcomes of delivery were compared between the different periods. RESULTS: There were 15,415 deliveries with 42.3% of nulliparous parturients in the 31-month study period. As the primary outcomes, the labor epidural analgesia rate increased from 0 to 57%, the vaginal delivery rate increased, and cesarean delivery rate decreased by 3.5% after full implementation. As the secondary outcomes, the rate of episiotomy and severe perineal injury after the implementation periods were significant decreased. The rate of postpartum oxytocin administration was decreased by 17.8%. No significant difference between the baseline and implementation periods was found in the rate of postpartum hemorrhage, Apgar scores less than 7 at both 1 and 5 min, 7-day mortality, and the overall neonatal intensive care unit admission rate. CONCLUSION: Implementation of labor epidural analgesia increased the vaginal delivery rate and use of labor epidural analgesia is safe to parturients and fetus.

Maternal and perinatal outcomes in pregnancies with multiple sclerosis: a case-control study.

OBJECTIVE: To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center. METHODS: We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ2 tests. Logistic regression models were constructed to determine independent effects. RESULTS: Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models. CONCLUSION: MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

Assessment of oxidative stress markers in cord blood of newborns to patients with oxytocin-induced labor.

AIM: We aimed to measure the extent of oxidative stress experienced during labor by the neonates of pregnant women undergoing induced or spontaneous birth and to compare the effects of induced labor on fetal well-being. METHODS: Sixty-four healthy pregnant women referring to the Department of Gynecology and Obstetrics, Dicle University Medical Faculty between October 2010 and May 2011 were included in this comparative study. Pregnant women undergoing induced labor by oxytocin were group 1 and those without labor induction were group 2. Post-partum Apgar score was calculated at 1 and 5 min and measurements of weight and height of the neonates were carried out. After the fetal cord was clamped, 5 cm3 blood was drawn into a plain tube without anticoagulant. The samples were centrifuged at 5000 r.p.m. for 5 min. Separated sera were transferred to Eppendorf tubes and were stored at -80 C° until the analysis time. RESULTS: The complete blood counts and biochemistry results indicated that there were no statistically significant differences in regards to diseases between the two groups. Nitric oxide and asymmetrical dimethylarginine values of the two groups were not significantly different; however, there were statistically significant differences in the malondialdehyde, paraoxonase, total antioxidative status, and total oxidative status values of the two groups (respectively, P = 0.005, P = 0.006, P = 0.008, and P = 0.007). CONCLUSION: We observed that oxytocin-induced labor increases stress markers but does not affect Apgar scores. Oxidative stress in pregnant women may trigger antioxidative mechanisms. Prospective studies in larger cohorts are needed to better understand the impact of oxytocin-induced labor on pregnant women and neonates.

Apgar Scores Are Associated with Attention-Deficit/Hyperactivity Disorder Symptom Severity.

OBJECTIVE: Adverse events during pregnancy and delivery have been linked to attention-deficit/hyperactivity disorder (ADHD). Previous studies have investigated Apgar scores, which assess the physical condition of newborns, in relation to the risk of developing ADHD. We propose to go one step further and examine if Apgar scores are associated with ADHD symptom severity in children already diagnosed with ADHD. METHOD: ADHD symptoms severity, while off medication, was compared in 2 groups of children with ADHD: those with low (≤6, n = 52) and those with higher (≥7, n = 400) Apgar scores sequentially recruited from the ADHD clinic. RESULTS: Children with low Apgar at 1 minute after birth had more severe symptoms as assessed by the externalizing scale of the Child Behaviour Checklist, the Conners' Global Index for Parents, and the DSM-IV hyperactivity symptoms count (P = 0.02, <0.01, <0.01, respectively). CONCLUSION: Low 1-minute Apgar scores are associated with a significant increase in ADHD symptom severity. These findings underline the importance of appropriate pregnancy and perinatal care.

Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting.

OBJECTIVE: The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub-Saharan African setting. METHODS: A prospective cohort study of 1010 women of less than 17 weeks of gestation was conducted at two antenatal clinics in Accra, Ghana, between July 2012 and March 2014. Information about hypertensive disorders was available for analysis on 789 pregnancies. The main outcomes were pre-term birth, birthweight, Apgar scores, small for gestational age and mortality. Relative risk (RR, 95% confidence interval (CI)) for the association between hypertensive disorders of pregnancy and perinatal outcomes was assessed using logistic regression adjusting for potential confounders. RESULTS: A total of 88.7% of women remained normotensive, 7.5% developed pregnancy-induced hypertension, 2.0% had chronic hypertension, and 1.7% developed (pre-)eclampsia. No adverse effects were observed in women with pregnancy-induced hypertension. Women with chronic hypertension were more likely to have a lower gestational age at delivery (38.0 ± 2.3 weeks vs. 39.0 ± 1.9 weeks, P = 0.04) and higher risk of pre-term delivery (aRR 4.63, 95% CI 1.35-15.91). Women with pre-eclampsia had emergency Caesarean section significantly more often (88.9% vs. 50%, P = 0.04), with a higher risk for low birthweight infants (aRR 7.95, 95% CI 1.41-44.80) and a higher risk of neonatal death (aRR 18.41, 95% CI 1.20-283.22). CONCLUSION: Comparable to high-income countries, in Accra hypertensive disorders during pregnancy were associated with increased risk of adverse perinatal outcomes necessitating maternal and newborn care.

Using adrenaline during neonatal resuscitation may have an impact on serum cardiac troponin-T levels.

AIM: It has been suggested that serum cardiac troponin-T (cTnT) can predict the severity of neonatal hypoxic-ischaemic encephalopathy. We evaluated whether cTnT was better correlated with adrenaline during cardiopulmonary resuscitation (CPR) than with the severity of the insult itself, based on the Apgar scores. METHODS: Serum cTnT was analysed in 47 asphyxiated newborn infants treated with hypothermia. Blood samples and resuscitation data were collected from medical records, and multiple linear regressions were used to evaluate the effect of the treatment and the Apgar scores on cTnT levels. RESULTS: The infants were divided into three groups: the no CPR group (n = 29) just received stimulation and ventilation, the CPR minus adrenaline group (n = 9) received cardiac compression and ventilation and the CPR plus adrenaline group (n = 9) received complete CPR, including adrenaline. In the univariate analysis, the five and ten-minute Apgar scores were significantly lower in the CPR plus adrenaline group and the cTnT was significantly higher. Multiple regression analysis showed significantly higher cTnT values in the CPR plus adrenaline group, but no significant relationship between cTnT and the Apgar scores. CONCLUSION: Although cTnT correlated with the severity of the insult in neonatal hypoxic-ischaemic encephalopathy, the levels may have been affected by adrenaline administered during CPR.

Correlation of cardiotocography with combined APGAR scores and diagnostic performance of umbilical cord parameters in predicting low combined APGAR scores - A prospective Cohort study.

Objectives: Combined Apgar score includes utilization of interventions such as Continuous positive airway pressure, Oxygen, Mask and Bag ventilation, I ntubation and ventilation, Ne onatal chest compression, Drugs, and newborn assessment. It has been proposed as a substitute for conventional Apgar score which is the gold standard for evaluating newborns right after birth but is impacted by medical interventions and preterm. Combined Apgar scores were examined to check for correlation with CTG tracing and umbilical cord blood parameters which gives an objective assessment of fetal hypoxia, in response to the demand for a more accurate tool for evaluating the neonate and to be used for medico-legal purposes. The study's objectives were to (1) determine the association of combined Apgar scores with suspicious and pathological CTG (2) the association of umbilical cord parameters with low combined Apgar scores and the diagnostic performance of these parameters in predicting low combined Apgar scores. Study design: A prospective observational cohort study was conducted in a tertiary care center in East India. 2350 consecutive laboring mothers who had completed 34 weeks of gestation underwent cardiotocography according to institutional protocol and those with suspicious and pathological CTG who delivered within 1 h of abnormal CTG were recruited. Arterial blood was analyzed and the newborn was evaluated immediately after delivery with a combined Apgar scoring system. Results: Of the 2350 women, 50.7 % and 49.3 %, respectively, exhibited suspicious and abnormal CTG tracings. CTG was reported to have low diagnostic accuracy and specificity, with a sensitivity of 66.7 % and 88.9 %, respectively, in detecting combined Apgar at 1 and 5 min. The combined Apgar score at five minutes showed a strong association with acidosis. There was a statistically significant correlation between low combined Apgar and excess lactate and base at one and five minutes. With 100 % sensitivity and 95 % specificity, high lactate levels > 4.1 mM/L were found to predict newborn encephalopathy. Conclusion: Umbilical cord blood parameters were found to be correlated with low combined Apgar scores. Combined Apgar scores may be a more useful tool for neonatal assessment and long-term morbidity of newborns. Additional research is required to determine whether it can take the role of conventional Apgar scores in clinical practice.

Umbilical arterial blood lactate as predictor of early neonatal outcome and evaluation of intrapartum asphyxia.

Background: Perinatal asphyxia is a leading cause of under-5 mortality and exerts great pressure on the health system. Adequate foetal monitoring in labour is paramount in the early detection of foetal distress to prevent perinatal asphyxia. Several methods of foetal monitoring are in use with varying efficacy. This study investigated the efficacy of umbilical arterial (UA) lactate assay in predicting adverse perinatal outcomes. Methodology: This was a prospective longitudinal study involving 160 pregnant women in the active phase of labour at term who met the inclusion criteria. They were recruited using a consecutive sampling technique and underwent a cardiotocography. Then they were classified into normal and abnormal cardiotocographic groups. At delivery, the UA blood of all of the babies was collected and assayed for serum lactate, and the levels were correlated with the perinatal outcome. The perinatal outcomes were measured by Apgar scores, admission into the neonatal unit, and hypoxic ischaemic encephalopathy. Analysis was done to determine the sensitivity and specificity of UA lactate in predicting birth asphyxia, hypoxic ischaemic encephalopathy, and neonatal unit admission. Results: The mean age ± standard deviation (SD) between the two cardiotocography (CTG) groups, normal years (30.55 ± 5.59) and abnormal years (29.86 ± 5.51), were similar. A critical UA lactate concentration > 9.1 mmol/L predicted Apgar scores < 7 at 5 min with a sensitivity and specificity of 76.47% (CI: 50.1-93.2) and 91.55% (CI: 85.7-95.6%), respectively. Also, the need for neonatal unit admission was predicted at a cut-off point >9.1 mmol/L with a sensitivity of 61.90% (CI: 38.4-81.9) and specificity of 91.30% (CI: 85.3-95.4). Umbilical artery lactate levels > 11.2 mmol/L predicted the development of hypoxic ischaemic encephalopathy in neonates with a sensitivity of 100% (CI: 39.8-100.0) and specificity of 88.39% (CI: 82.3-93.0). Conclusion: Umbilical artery lactate correlates with adverse pregnancy outcomes and is an excellent tool for predicting adverse neonatal outcome.