The effect of initiating neuraxial analgesia service on the rate of cesarean delivery in Hubei, China: a 16-month retrospective study.

BACKGROUND: No Pain Labor &Delivery (NPLD) is a nongovernmental project to increase access to safe neuraxial analgesia through specialized training. This study explores the change in overall cesarean delivery (CD) rate and maternal request CD(MRCD) rate in our hospital after the initiation of neuraxial analgesia service (NA). METHODS: NA was initiated in May 1st 2015 by the help of NPLD. Since then, the application of NA became a routine operation in our hospital, and every parturient can choose to use NA or not. The monthly rates of NA, CD, MRCD, multiparous women, intrapartum CD, episiotomy, postpartum hemorrhage (PPH), operative vaginal delivery and neonatal asphyxia were analyzed from January 2015 to April 2016. RESULTS: The rate of NA in our hospital was getting increasingly higher from 26.1% in May 2015 to 44.6% in April 2016 (p < 0.001); the rate of CD was 48.1% (3577/7360) and stable from January to May 2015 (p>0.05), then decreased from 50.4% in May 2015 to 36.3% in April 2016 (p < 0.001); the rate of MRCD was 11.4% (406/3577) and also stable from January to May 2015 (p>0.05), then decreased from 10.8% in May 2015 to 5.7% in April 2016 (p < 0.001). At the same time, the rate of multiparous women remained unchanged during the 16 month of observation (p>0.05). There was a negative correlation between the rate of NA and rate of overall CD, r = - 0.782 (95%CI [- 0.948, - 0.534], p<0.001), and between the utilization rate of NA and rate of MRCD, r = - 0.914 (95%CI [- 0.989, - 0.766], p<0.001). The rates of episiotomy, PPH, operative vaginal delivery and neonatal asphyxia in women who underwent vaginal delivery as well as the rates of intrapartum CD, neonatal asphyxia, and PPH in women who underwent CD remained unchanged, and there was no correlation between the rate of NA and anyone of those rates from January 1st 2015 to April 30th 2016 (p>0.05). CONCLUSIONS: Our study shows that the rates of CD and MRCD in our department were significantly decreased from May 1st 2015 to April 30th 2016, which may be due to the increasing use of NA during vaginal delivery with the help of NPLD.

Factores asociados a epilepsia en niños en México: un estudio caso-control / Factors associated with epilepsy in children in Mexico: A case-control study

Resumen: Introducción: La epilepsia es la enfermedad neurológica crónica más común en el mundo. En México es considerada dentro de las principales enfermedades vinculadas a la mortalidad por enfermedades no infecciosas de la población infantil. El objetivo del estudio fue identificar los factores asociados a epilepsia en niños derechohabientes del Instituto Mexicano del Seguro Social (IMSS), en Acapulco, México. Métodos: Estudio de casos y controles realizado entre abril de 2010 y abril de 2011. Fueron seleccionados 118 casos de la consulta externa de neurología pediátrica, con criterios diagnósticos de epilepsia de acuerdo a la Liga Internacional Contra la Epilepsia, con máximo dos años de evolución. Los controles fueron seleccionados de las Unidades de Medicina Familiar de donde procedieron los casos. En una encuesta a las madres, se obtuvo información sobre antecedentes heredofamiliares, prenatales, perinatales y posnatales. El análisis bivariado y multivariado se realizó mediante el procedimiento de Mantel-Haenszel. Resultados: Tres factores estuvieron asociados con la epilepsia: el antecedente familiar de epilepsia en familiares de primer grado (Razón de Momios ajustada (RMa) 2.44, IC95% 1.18 - 5.03), la asfixia al nacimiento (RMa 2.20, IC95% 1.16-34.18) y la infección de la vía urinaria en la etapa prenatal (RMa, 1.80 IC95% 1.0 - 3.24). Conclusiones: La asfixia al nacimiento y el reporte de infecciones de vías urinarias durante la gestación fueron factores asociados a epilepsia independientemente del antecedente de epilepsia en familiares de primer grado.

Abstract: Background: Epilepsy is the most common chronic neurological disease in the world. In Mexico, epilepsy is among the diseases more related to mortality due to non-infectious diseases in children. The objective of the study was to identify the factors associated with epilepsy in children entitled to the Mexican Social Security Institute (IMSS), in Acapulco, Mexico. Methods: We carried out a case-control study from April 2010 to April 2011. We selected 118 cases from the database of outpatient pediatric neurology with epilepsy diagnostic with two year of evolution according to the International League Against Epilepsy criteria. We selected 118 controls from the same Medical Units where cases were detected. Data collected throughout an interview with the mothers included information on history of epilepsy among relatives, prenatal, perinatal and postnatal history. Bivariate and multivariate analysis was performed using Mantel-Haenszel process. Results: Multivariate analysis identified three factors associated with epilepsy: family history of epilepsy in first-degree relatives (adjusted Odds ratio (ORa) 2.44, 95%CI 1.18 -5.03), birth asphyxia (ORa 2.20, 95%CI 1.16-34.18), and urinary tract infection in the prenatal stage (ORa, 1.80, 95%CI 1.0 - 3.24). Conclusions: Preventing birth asphyxia and urinary tract infections during pregnancy reduces the risk of epilepsy regardless of the history of epilepsy in first-degree relatives.

[Factors associated with epilepsy in children in Mexico: A case-control study]. / Factores asociados a epilepsia en niños en México: un estudio caso-control.

BACKGROUND: Epilepsy is the most common chronic neurological disease in the world. In Mexico, epilepsy is among the diseases more related to mortality due to non-infectious diseases in children. The objective of the study was to identify the factors associated with epilepsy in children entitled to the Mexican Social Security Institute (IMSS), in Acapulco, Mexico. METHODS: We carried out a case-control study from April 2010 to April 2011. We selected 118 cases from the database of outpatient pediatric neurology with epilepsy diagnostic with two year of evolution according to the International League Against Epilepsy criteria. We selected 118 controls from the same Medical Units where cases were detected. Data collected throughout an interview with the mothers included information on history of epilepsy among relatives, prenatal, perinatal and postnatal history. Bivariate and multivariate analysis was performed using Mantel-Haenszel process. RESULTS: Multivariate analysis identified three factors associated with epilepsy: family history of epilepsy in first-degree relatives (adjusted Odds ratio (ORa) 2.44, 95%CI 1.18 -5.03), birth asphyxia (ORa 2.20, 95%CI 1.16-34.18), and urinary tract infection in the prenatal stage (ORa, 1.80, 95%CI 1.0 - 3.24). CONCLUSIONS: Preventing birth asphyxia and urinary tract infections during pregnancy reduces the risk of epilepsy regardless of the history of epilepsy in first-degree relatives.

Assessment of knowledge on neonatal resuscitation amongst health care providers in Kenya.

INTRODUCTION: Competence in neonatal resuscitation, which represents the most urgent pediatric clinical situation, is critical in delivery rooms to ensure safety and health of newly born infants. The challenges experienced by health care providers during this procedure are unique due to different causes of cardio respiratory arrest. This study aimed at assessing the knowledge of health providers on neonatal resuscitation. METHODS: Data were gathered among 192 health providers drawn from all counties of Kenya. The clinicians were asked to complete questionnaires which were in two parts as; demographic information and assessment of their knowledge by different scenarios which were formatted in the multiple choice questions. Data were analyzed using SPSS version 15.0 for windows. The results are presented using tables. RESULTS: All the participants were aged 23 years and above with at least a certificate training. Most medical providers had heard of neonatal resuscitation (85.4%) with only 23 receiving formal training. The average duration of neonatal training was 3 hours with 50% having missed out on practical exposure. When asked on steps of resuscitation, only 68 (35.4%) of the participants scored above 85%. More than 70% of them considered their knowledge about neonatal resuscitation inadequate and blamed it on inadequate medical training programs. CONCLUSION: Health providers, as the key personnel in the management of neonatal resuscitation, in this survey seem to have inadequate training and knowledge on this subject. Increasing the duration and quality of formal training should be considered during the pre-service medical education to ensure acceptable neonatal outcome.

Reducing intrapartum-related deaths and disability: can the health system deliver?

BACKGROUND: Each year 1.02 million intrapartum stillbirths and 904,000 intrapartum-related neonatal deaths (formerly called "birth asphyxia") occur, closely linked to 536,000 maternal deaths, an estimated 42% of which are intrapartum-related. OBJECTIVE: To summarize the results of a systematic evidence review, and synthesize actions required to strengthen healthcare delivery systems and home care to reduce intrapartum-related deaths. METHODS: For this series, systematic searches were undertaken, data synthesized, and meta-analyses carried out for various aspects of intrapartum care, including: obstetric care, neonatal resuscitation, strategies to link communities with facility-based care, care within communities for 60 million non-facility births, and perinatal audit. We used the Lives Saved Tool (LiST) to estimate neonatal deaths prevented with relevant interventions under 2 scenarios: (1) to address missed opportunities for facility and home births; and (2) assuming full coverage of comprehensive emergency obstetric care and emergency newborn care. Countries were first grouped into 5 Categories according to level of neonatal mortality rate and examined, and then priorities were suggested to reduce intrapartum-related deaths for each Category based on health performance and possible lives saved. RESULTS: There is moderate GRADE evidence of effectiveness for the reduction of intrapartum-related mortality through facility-based neonatal resuscitation, perinatal audit, integrated community health worker packages, and community mobilization. The quality of evidence for obstetric care is low, requiring further evaluation for effect on perinatal outcomes, but is expected to be high impact. Over three-quarters of intrapartum-related deaths occur in settings with weak health systems marked by low coverage of skilled birth attendance (<50%), low density of skilled human resources (<0.9 per 1000 population) and low per capita spending on health (

Fetal health surveillance: antepartum and intrapartum consensus guideline.

OBJECTIVE: This guideline provides new recommendations pertaining to the application and documentation of fetal surveillance in the antepartum and intrapartum period that will decrease the incidence of birth asphyxia while maintaining the lowest possible rate of obstetrical intervention. Pregnancies with and without risk factors for adverse perinatal outcomes are considered. This guideline presents an alternative classification system for antenatal fetal non-stress testing and intrapartum electronic fetal surveillance to what has been used previously. This guideline is intended for use by all health professionals who provide antepartum and intrapartum care in Canada. OPTIONS: Consideration has been given to all methods of fetal surveillance currently available in Canada. OUTCOMES: Short- and long-term outcomes that may indicate the presence of birth asphyxia were considered. The associated rates of operative and other labour interventions were also considered. EVIDENCE: A comprehensive review of randomized controlled trials published between January 1996 and March 2007 was undertaken, and MEDLINE and the Cochrane Database were used to search the literature for all new studies on fetal surveillance both antepartum and intrapartum. The level of evidence has been determined using the criteria and classifications of the Canadian Task Force on Preventive Health Care. SPONSOR: This consensus guideline was jointly developed by the Society of Obstetricians and Gynaecologists of Canada and the British Columbia Perinatal Health Program (formerly the British Columbia Reproductive Care Program or BCRCP) and was partly supported by an unrestricted educational grant from the British Columbia Perinatal Health Program.

A randomised clinical trial on cardiotocography plus fetal blood sampling versus cardiotocography plus ST-analysis of the fetal electrocardiogram (STAN) for intrapartum monitoring.

BACKGROUND: Cardiotocography (CTG) is worldwide the method for fetal surveillance during labour. However, CTG alone shows many false positive test results and without fetal blood sampling (FBS), it results in an increase in operative deliveries without improvement of fetal outcome. FBS requires additional expertise, is invasive and has often to be repeated during labour. Two clinical trials have shown that a combination of CTG and ST-analysis of the fetal electrocardiogram (ECG) reduces the rates of metabolic acidosis and instrumental delivery. However, in both trials FBS was still performed in the ST-analysis arm, and it is therefore still unknown if the observed results were indeed due to the ST-analysis or to the use of FBS in combination with ST-analysis. METHODS/DESIGN: We aim to evaluate the effectiveness of non-invasive monitoring (CTG + ST-analysis) as compared to normal care (CTG + FBS), in a multicentre randomised clinical trial setting. Secondary aims are: 1) to judge whether ST-analysis of fetal electrocardiogram can significantly decrease frequency of performance of FBS or even replace it; 2) perform a cost analysis to establish the economic impact of the two treatment options. Women in labour with a gestational age > or = 36 weeks and an indication for CTG-monitoring can be included in the trial. Eligible women will be randomised for fetal surveillance with CTG and, if necessary, FBS or CTG combined with ST-analysis of the fetal ECG. The primary outcome of the study is the incidence of serious metabolic acidosis (defined as pH < 7.05 and Bdecf > 12 mmol/L in the umbilical cord artery). Secondary outcome measures are: instrumental delivery, neonatal outcome (Apgar score, admission to a neonatal ward), incidence of performance of FBS in both arms and cost-effectiveness of both monitoring strategies across hospitals. The analysis will follow the intention to treat principle. The incidence of metabolic acidosis will be compared across both groups. Assuming a reduction of metabolic acidosis from 3.5% to 2.1 %, using a two-sided test with an alpha of 0.05 and a power of 0.80, in favour of CTG plus ST-analysis, about 5100 women have to be randomised. Furthermore, the cost-effectiveness of CTG and ST-analysis as compared to CTG and FBS will be studied. DISCUSSION: This study will provide data about the use of intrapartum ST-analysis with a strict protocol for performance of FBS to limit its incidence. We aim to clarify to what extent intrapartum ST-analysis can be used without the performance of FBS and in which cases FBS is still needed. TRIAL REGISTRATION NUMBER: ISRCTN95732366.

[Assessment of blood flow in the middle cerebral artery and the umbilical artery in fetuses with umbilical venous pulsations]. / Ocena przeplywu krwi w testnicy srodkowej mózgu i tetnicy pepowinowej u plodów z rozpoznana pulsacja w zyle pepowinowej.

OBJECTIVES: Umbilical venous pulsation is an important sign of hemodynamic compromise, especially during fetal heart failure and asphyxia. DESIGN: The aim of this study was to determine of the blow flow in the middle cerebral artery and the umbilical artery in fetuses with umbilical venous pulsations. MATERIALS AND METHODS: The investigation included 18 fetuses with signs of the intrauterine growth restriction and umbilical venous pulsations after 28th weeks of gestation. We evaluated cerebral-placental ratio (CPR) and pulsation index (PI) in the middle cerebral artery (MCA) and the umbilical artery (UA). RESULTS: We observed brain sparring effect in all cases of analyzing fetuses. There were 77,8% of abnormal flow pattern in umbilical artery. 13 fetuses had a single pulsation pattern in umbilical vein and another 5 had double pulsation pattern. CONCLUSIONS: The coexistence of umbilical vein pulsation and abnormal flow pattern in umbilical artery is closely related to increased perinatal mortality.

Perinatal risk management: obstetric methods to prevent birth asphyxia.

Because obstetric care frequently is associated with the potential for liability, the purpose of this article is to familiarize the reader with perinatal risk management using the concept of foreseeability of harm and its potential application to obstetric care. At the same time, this article introduces the concept of notice, and explains the critical conduct intervals that are used to gauge how well the health care teams handle obstetric emergencies. The focus then shifts to incorporate these concepts into several maternal-child health quality management programs. It is hoped that this article will result in an improvement of perinatal outcome for pregnant women and their unborn children.

Clinical risk management in newborn and neonatal resuscitation.

This chapter aims to provide an overview of aspects of risk management as they might be applied to the practice of resuscitation of the newborn using general principles of risk management and specific standards where they apply. Section 1 considers the matter of hazard and risk and how they may be classified. Figures are presented to provide a clinical perspective on resuscitation with a discussion on the hierarchy of clinical risks operating upon the baby. Section 2 centres on a discussion of those aspects that operate to modify the risks to the baby during a resuscitation, including environmental considerations (location, clinical setting and equipment); staffing issues (establishment, competency, induction and training) and logistics (process, communication and documentation). Section 3 debates the place of cord gases in the context of the diagnosis of perinatal hypoxaemia.

Cardiotocography and medicolegal issues.

Obstetric litigation is on the increase. A review of litigation cases reveals that the majority of claims relating to the intrapartum period arise because the cardiotocograph- (CTG) was misinterpreted or because inappropriate action was taken in the presence of fetal heart rate abnormalities. Compulsory education and training in the interpretation of CTGs and in best practice are key factors in minimizing the threat of litigation. Newer methods, such as pulse oximetry or fetal electrocardiogram waveform analysis, can act as adjuncts to CTG and help to avoid birth asphyxia and hence litigation.

[Cesarean section on demand--an equivalent alternative to spontaneous delivery?]. / Die Wunschsectio--Eine gleichwertige Alternative zur Spontangeburt?

Due to advances in perioperative management, surgical techniques as well as anaesthesia, caesarean section has become a very safe intervention for mother and child. In certain high-risk situations, an early delivery by caesarean section can prevent serous morbidity and mortality of the fetus and newborn. It has been postulated that a planned caesarean section is a true alternative to vaginal birth, and in the absence of a specific medical reason the woman's demand may be an indication for the operation. A critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.critical review of studies based on large regional perinatal datasets shows that the risk for minor as well as serious complications in the mother and the newborn is increased after planned caesarean section. Serious consequences for subsequent pregnancies like uterine rupture or placenta praevia, which may be associated with accreta or abruptio of the placenta, are of major concern. On the other hand, trauma to the pelvic floor with urinary or anal incontinence is more frequent after vaginal birth. The balance of these risks including the very rare cases of severe intrapartal asphyxia, which might be prevented by a planned caesarean section, must be carefully evaluated together with the patient on an individual basis. These risks must be carefully balanced and the final decision about the type of delivery requires a detailed informed consent.

Monitoring the fetus in labor: evidence to support the methods.

Electronic fetal monitoring (EFM) was implemented across the United States in the 1970s. By 1998, it was used in 84% of all U.S. births, regardless of whether the primary caregiver was a physician or a midwife. Numerous randomized trials have agreed that continuous EFM in labor increases the operative delivery rate, without clear benefit to the baby. Intermittent auscultation (IA) is safe and effective in low-risk pregnancies and may play a role in helping birth remain normal. Clinicians and educators are encouraged to reconsider the use of IA in the care of healthy childbearing women.

Noninvasive assessment of cerebral oxidative metabolism in the human newborn.

Magnetic resonance spectroscopy (MRS) and near infrared spectroscopy (NIRS) permit direct observations within the human brain of a number of metabolites important in cerebral oxidative metabolism. MRS identifies high energy phosphorus metabolites such as phosphocreatine and ATP, which are products of oxidative phosphorylation and of the anaerobic accumulation of lactate. NIRS makes it possible to measure cerebral haemodynamics and oxygen delivery and to detect changes in the redox state of mitochondrial cytochrome oxidase. Studies in the brain of newborn infants after perinatal asphyxia have shown a delayed reduction in high energy phosphorus metabolites and an accumulation of lactate. Haemodynamic abnormalities frequently precede the delayed failure of energy metabolism. NIRS and MRS provide unique information on deranged cerebral energy metabolism following hypoxia-ischaemia and will guide the introduction of new cerebroprotective interventions.

Risk assessment in birth asphyxia.

In developing countries the need for a risk approach in neonatology is obvious because of a high birth rate, high neonatal mortality rate, and limited availability of resources. Quantification of risk, with selected antepartum, intrapartum factors, clinical, and post-mortem findings was done by calculating odds ratio, attributable risk, and 95 per cent confidence limits in 1811 babies, 541 of which were asphyxiated. Primigravidity, history of perinatal death, pregnancy induced hypertension, and antepartum haemorrhage carried higher risk. Abnormal fetal heart rate and meconium passage in amniotic fluid correctly predicted high risk of birth asphyxia. Decreasing risk in premature/low birth weight babies without increase in abdominal deliveries suggested that caesarean sections were unnecessary in preterm deliveries. Clinical monitoring of asphyxiated newborns was adequate enough.