Perinatal antecedents of cerebral palsy.

The dramatic reduction in perinatal morbidity and mortality over the last decade has not been accompanied by any diminution in the incidence of cerebral palsy. We investigated retrospectively the relationship of certain perinatal events to the subsequent development of cerebral palsy in 75 infants. Cerebral palsy occurred in association with acute intrapartum asphyxia in 8% and traumatic delivery in 11%. Thirty-five percent of cases were associated with chronic fetal distress, defined by a unique fetal heart rate (FHR) pattern consisting of a normal baseline rate with persistently absent variability and mild variable decelerations with overshoot. This pattern was found frequently in association with postmaturity, meconium staining, intrauterine growth retardation, and neonatal seizures. Acid-base studies, when available, did not reveal acidosis. Twenty-seven percent of the cases involved a combination of chronic fetal distress, acute intrapartum fetal asphyxia, and/or traumatic delivery. We postulate that antenatal intermittent umbilical cord compression secondary to oligohydramnios results in repetitive transient central nervous system ischemia, insufficient to cause death, but resulting in a characteristic FHR pattern and impaired neurologic development. If these data are confirmed, this FHR pattern may be an important marker for the development of subsequent neurologic handicap or other adverse outcome.

Fetal cardiac asystole during labor.

A review of 14 cases of fetal cardiac asystole greater than two seconds during labor revealed two distinct patterns. Type 1 episodes developed without warning in eight apparently healthy fetuses at the nadir of a variable deceleration. These episodes were both preceded and followed by normal to increased variability, stable baseline heart rate, and less dramatic variable decelerations. Analysis of the fetal electrocardiogram (ECG) complexes during the asystole revealed a normal QRS complex, either biphasic or absent P-waves, and occasional ventricular extrasystoles. One of eight fetuses in this group died; the remainder were delivered in good condition and required minimal resuscitation. The mechanism of type 1 episodes appears to be an exuberant vagal response to umbilical cord compression. Rapid intervention probably is not warranted. Type 2 episodes developed in seriously asphyxiated infants and frequently were preceded by absent variability and, usually, severe decelerations. The fetal ECG pattern during the episode revealed bradycardia with sinus rhythm. Five of the six infants with type 2 episodes died either in utero or in the neonatal period. Despite the ominous portent of type 2 patterns, rapid delivery appears to be indicated.

Fetal heart rate patterns preceding death in utero.

Four cases of intrauterine fetal demise in term infants are presented. From these cases and other published reports, a sequence of fetal heart rate changes preceding intrapartum death is presented. Late or variable decelerations, if unrelieved or uncorrected, lead to baseline heart rate changes of tachycardia and loss of variability reflecting loss of fetal reserve and fetal distress. This is followed by an unstable heart rate, a sinusoidal pattern, or a rapidly changing fetal heart rate. The final event is a profound bradycardia just prior to fetal demise.

Is any pregnancy low risk?

The standards of reproductive potential have not yet been defined. Should we accept a perinatal mortality of 5 to 10 per 1000 in the low-risk population if we have methods available to lower the rate to 1 to 2 per 1000?

Intrapartum, atraumatic, non-asphyxial intracranial hemorrhage in a full-term infant.

BACKGROUND: Intracranial hemorrhage in a full-term infant is uncommon, is usually subarachnoid in type, and is usually associated with operative vaginal delivery or asphyxia. CASE: A 15-year-old primigravid woman at 37 weeks' gestation developed a prolonged second stage of labor associated with persistent occiput posterior position. With the onset of pushing, baseline fetal heart rate (FHR) decreased and variability increased. Thirty minutes before vaginal delivery, sudden fetal tachycardia (up to 210 beats per minute) was observed, with absent variability and minimal decelerations. At birth, the infant was apneic and hypotonic, but lacked biochemical evidence of acidemia or asphyxia; seizures developed in the early neonatal period. Subarachnoid hemorrhage was demonstrated by computed tomography of the head. CONCLUSION: The occiput posterior position, marked molding, and prolonged labor with compulsive pushing may be associated with an increased risk of adverse outcome, even unrelated to the details of delivery. The change in FHR pattern, to a lowered baseline rate and increased variability, suggests increased intracranial pressure. The sudden change to fetal tachycardia with absent variability before delivery suggests intracranial hemorrhage or injury.

The effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid index.

OBJECTIVE: To determine the effect of fetal acoustic stimulation on fetal swallowing and amniotic fluid (AF) index in an attempt to understand the potential mechanism for fetal compromise following fetal acoustic stimulation. METHODS: Fetal swallowing movements and AF index were assessed in 90 full-term fetuses before and after fetal acoustic stimulation. Fetal swallowing movements were identified on a video monitor and measured in terms of the percentage of time they occurred during 30 minutes of observation. The fetal heart rate was recorded 30 minutes before and 30 minutes after fetal acoustic stimulation. RESULTS: The mean (+/- standard deviation) percentage of time spent by the fetus in swallowing increased from 16.1 +/- 6% before to 44.3 +/- 10.3% after stimulation (P < .005). The AF index decreased from 14.6 +/- 8.4 cm before acoustic stimulation to 12.8 +/- 6.8 cm afterward (not statistically significant). Seven of 17 patients (41%) with borderline AF indexes developed oligohydramnios after the fetal acoustic stimulation; two of these demonstrated persistent variable decelerations that required obstetric intervention. CONCLUSIONS: Fetal acoustic stimulation is associated with increased fetal swallowing activity, which can lead to diminution of AF volume. The AF index should be assessed in fetuses before acoustic stimulation and if the volume is low, acoustic stimulation should be used with extreme caution.

Routine fetal heart rate monitoring in the antepartum period.

A total of 4517 successful antepartum nonstress tests (NST) was performed on 2003 high- (28%) and low- (72%) risk obstetric patients. Most patients were monitored from 32 to 34 weeks' gestation onward. A reactive NST was defined as 2 accelerations in 10 minutes--15 beats/min minimum amplitude; 15 seconds minimum duration. The test was repeated at the next visit in low-risk patients with reactive NST or in 1 week in high-risk patients with this response. Nonreactive tests were followed immediately by a stress test in high-risk patients, but only after repeat nonreactive NST within 24 hours in low-risk patients. About 88% of low-risk and 86% of high-risk patients demonstrated ractive NST only. Late decelerations during subsequent stress testing or labor, low Apgar scores, and perinatal deaths were more common in low-risk pregnancies than in high-risk pregnancies and more common in those with nonreactive NST than in those with reactive NST. High-risk/reactive NST babies, however, fared better than low-risk/nonreactive NST babies. Of the 16 perinatal deaths 6 died antepartum, 2 died in labor, and 8 died as neonates. Presumed asphyxia accounted for 6 deaths while significant anomaly accounted for 5; sepsis and trauma accounted for 2 each. In only 2 instances was a reactive NST followed by a death from apparent asphyxia. Routine NST testing appears to improve the resolution of maternal risk classification and may contribute to better perinatal outcome.

Contraction stress test for antepartum fetal evaluation.

The contraction stress test (CST) was used to attempt determination of fetal reserve prior to labor by evaluating the response of the fetal heart rate to spontaneous or induced uterine contractions. Testing was performed by using an external fetal heart rate monitor and tocograph. The CST was employed 189 times in 120 high-risk patients who either had hypertensive disorder of pregnancy or had completed at least 42 weeks of gestation. Testing was begun as early as 34 weeks' gestation and repeated at weekly intervals; it was not used in the clinical management of the patient. The maximum number of tests performed on one patient was 8. A negative CST appears to be a most reliable guide to the ability of the fetus to tolerate labor if it ensues within 1 week. A positive test suggests that the fetus is at increased risk, but death is not necessarily imminent. Results of the present study warrant use of the CST in controlled studies to determine its effect in improving perinatal outcome.

Nonimmunologic hydrops fetalis.

Eight cases of nonimmunologic hydrops fetalis (HF) were seen at Cedars-Sinai Medical Center over a 3.5-year period. The etiology of the HF included 2 cases of fetal-maternal hemorrhage and 1 each of sacral teratoma, tachyarrhythmia, diaphragmatic hernia, neuroblastoma, and heart disease. For 1 infant, the cause was never found. These cases involved various diagnostic and therapeutic dilemmas. Only 4 were anticipated ant partum by ultrasound scanning. Two of the 8 fetuses died in utero, whereas 4 others died in the neonatal period. Earlier diagnosis and evaluation are likely to improve these outcomes.

Cirrhosis and fetal hyperbilirubinemia.

A case of fulminating liver failure during pregnancy, resulting from maternal cirrhosis in which fetal distress developed during labor and the mother died post partum, is presented. The effects of maternal unconjugated bilirubin levels and the possibility of kernicterus developing in utero are discussed.

Fetal arrhythmia.

Seven human fetuses with intermittently recurring cardiac arrhythmias of ectopic origin were studied intensively during labor and the early neonatal period. Neonatal outcome, judged by Apgar scores and neonatal acid-base parameters, was favorable in all 7 patients. Three of the seven arrhythmias reverted spontaneously to sinus rhythm within 72 hours, and six of the seven resolved by 5 days of age. One neonate, with supraventricular tachycardia, developed congestive heart failure, necessitating digitalization, but was free of symptoms at 6 weeks and showed no evidence of congenital heart disease. The literature on fetal cardiac arrhythmias is reviewed. A number of etiologic mechanisms and several methods of pharmacologic therapy of these irregularities have been proposed. These cases suggest, however, that fetal arrhythmias of ectopic origin need not represent signs of fetal distress or cardiac anomaly and may be inocuous. Evidence to date indicates that in utero pharmacologic treatment of fetal arrhythmias is not indicated.

Update on external cephalic version performed at term.

External cephalic version under tocolysis at term was investigated during a prospective study at the Los Angeles County/University of Southern California Medical Center from October 1, 1979 to March 16, 1983. Two hundred twelve patients were considered for attempted version. Forty-one patients were excluded, and 23 patients as previously reported were randomized to the control group. The procedure was successful in 73% (108 of 148). Of the 102 successful versions observed until delivery (six lost to follow-up), 93% (95 of 102) presented in labor with a vertex presentation; seven fetuses reverted to abnormal lies. The cesarean section rate in the success group with a vertex presentation was 24% (23 of 95).

Intrapartum electronic fetal heart rate monitoring versus intermittent auscultation: a meta-analysis.

OBJECTIVE: To use a meta-analysis of all published randomized trials to determine whether the use of continuous electronic fetal heart rate monitoring (EFM) as the main method of intrapartum fetal surveillance is associated with improved pregnancy outcome compared to intermittent auscultation. DATA SOURCES: We used the MEDLINE data base and reference lists of articles to identify all published randomized trials of EFM versus intermittent auscultation. METHODS OF STUDY SELECTION: A total of nine randomized trials published in peer-review journals were identified. The selection criterion was the use of EFM or intermittent auscultation as the main intrapartum fetal surveillance technique. DATA EXTRACTION AND SYNTHESIS: A total of 18,561 patients were included in the nine published randomized trials, 9398 in the EFM group and 9163 in the auscultation group. Measures of pregnancy outcome included cesarean delivery, cesarean for suspected fetal distress, overall use of forceps or vacuum, use of forceps or vacuum for suspected fetal distress, overall perinatal mortality, and perinatal mortality due to fetal hypoxia (intrapartum or early neonatal death) attributable to the method of intrapartum monitoring. The meta-analysis showed that the patients monitored electronically had a significantly higher overall cesarean rate (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.17-2.01), higher cesarean rate for fetal distress (OR 2.55, 95% CI 1.81-3.53), overall increased use of forceps or vacuum (OR 1.23, 95% CI 1.02-1.49), increased use of forceps or vacuum for suspected fetal distress (OR 2.50, 95% CI 1.97-3.18), and decreased perinatal mortality due to fetal hypoxia (OR 0.41, 95% CI 0.17-0.98). CONCLUSION: Electronic fetal monitoring is associated with increased rates of surgical intervention and decreased perinatal mortality due to fetal hypoxia.

Polemics in perinatology: the abortion thing.

PIP: This article discusses the debate over abortion in a vary informal and literary style. While is may have a grand image, do not think it is lacking in substance for all the important arguments and positions are considered. It is admitted early on in the essay that this issue is partially over fundamental differences in view points. This is reflected in the choice of words used by members of both sides. Antiabortionists call themselves "pro life" or "right-to-life" advocates, while proabortionists call themselves "pro-choice" advocates. Clearly the debate is over the legal status of abortion, not over whether some people think life is important or not, we all think life is important. And no one is anti-choice, we all want to be given freedom to chose how we live. The issue is about the legal status of abortion and the author makes this fact quite clear. The author also points out that no one wants to see "back-ally" abortions destroy the bodies and lives of women, yet that is what will happen if abortion is criminalized. The author also points out that some antiabortionists seem to be unconcerned with the physical and psychological suffering of women that goes along with having an abortion. They seem more concerned with the doctors and the fetuses. Ultimately the author concludes that policy makers must consider the abortion issue in terms of its sociological effect. It is better to eliminate unwanted pregnancies than to give abortions, yet our President wants to deny us of both.^ieng

The ABCs of electronic fetal monitoring.

There have been too many surrogates used to define fetal asphyxia and too many surrogates used to time fetal injury. Low Apgar scores and the need for prolonged resuscitation, by themselves, are inadequate criteria for the diagnosis of perinatal asphyxia or subsequent neurologic handicap. Even with the addition of a low cord pH and seizures, it is not possible to infer neurologic handicap. Furthermore, acidosis and depression at birth (which should be referred to as "perinatal asphyxia") cannot measure the duration and extent of any prenatal asphyxial encounter. Nor can we use the absence of one or more of these signs to exclude perinatal asphyxia as the cause of injury. We cannot refer to fetal asphyxia and injury therefrom without defining our criteria and describing the model of asphyxia being invoked. Because ischemia to the brain and other organs (that is, localized asphyxia), not systemic global asphyxia, appears to be the major precursor of human fetal injury it seems unreasonable to insist on systemic fetal asphyxia at any time to validate the timing or mechanism of fetal injury. Most hypoxic newborn infants are not injured and most injured newborn infants are not hypoxic. Furthermore, that a baby is injured as a result of hypoxia during labor does not mean that the hypoxia was preventable. FHR patterns, properly interpreted, may be one of the most reliable determinants of subsequent neurologic outcome and depending on the circumstances may provide insight into the timing and mechanism of neurologic injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Community-based perinatal research.

A program of clinical perinatal research was established in a community-based hospital in collaboration with private-practice obstetricians and their patients. This longitudinal study, undertaken to investigate the value of a circulating placental protein as an indicator of fetal compromise, enrolled 200 unselected pregnant patients. The project required collection of five blood samples at 16, 20, 24, 28, and 32 weeks' gestation in addition to a level II ultrasound examination at 32 weeks. Baseline and interim prenatal visit data were collected, as were maternal and neonatal data upon delivery. Patients who participated were invariably enthusiastic about their involvement. The physicians and their staff were also generally pleased. We infer from these and other studies a need to provide enhanced educational, participatory opportunities to all pregnant women. We conclude that properly conducted, reasonably funded projects that offer no direct benefit to the patient or physician can be successfully carried out with physicians and their private patients in community hospitals. The potential benefits of developing such extended resources can only enhance medical care and foster satisfaction and cooperation among physicians and patients.

Anencephalic infants: life expectancy and organ donation.

Between 1978 and 1982, 205 anencephalic infants weighing more than 2,500 g were born alive in California. Although typically none were offered significant support, almost 9% lived more than one week. It seems reasonable to assume that modern intensive care would have increased survival times dramatically. In fact, preliminary data from centers specializing in neonatal organ transplantation demonstrate that seven to 14 days of ventilatory support can be accomplished for anencephalic infants without occurrence of brainstem death. Given these data and medical information that clearly establishes anencephalic infants as a "special case" of children who have not suffered brain death but could reasonably be used as organ donors, we believe that parents who wish to do so should be allowed to continue ventilatory support for their anencephalic children for whatever period of time is necessary to find organ recipients and arrange for organ donation. Arbitrary cutoff points for intensive care and artificial criteria for brain death should not be necessary to allow the use of anencephalic infants as organ donors. We believe that current laws should be changed to permit this scenario.

Fetal heart rate patterns and the timing of fetal injury.

We studied the nonstress test (NST) results and other perinatal features of 44 children with cerebral palsy, who had fetal heart rate (FHR) patterns during labor suggesting preexisting injury. This was a retrospective, descriptive study. All fetuses persistently showed absent variability and small, variable decelerations, with overshoot from the onset of monitoring during labor. During the initial NST, 84.1% of fetuses revealed normal reactive NST patterns (three with decelerations). Six fetuses (15.9%) had nonreactive NST results (three with decelerations). The conversion of the reactive NST to a pattern of persistently absent variability often occurred during advanced pregnancy (average estimated gestational age 40 weeks), in association with decreased amniotic fluid (AF) volume (70.5%) and maternal complaints of decreased fetal movement (52.4%). FHR decelerations consistent with acute fetal distress were uncommon during early labor but occurred in about half of cases in advanced labor. All but one neonate had low Apgar scores at birth, but acidosis occurred in about one third of infants. Seizures developed in about half the infants, usually in the first day. Follow-up studies revealed a high incidence of mental retardation, microcephaly, and seizure activity in addition to cerebral palsy, regardless of the presence of perinatal acidosis. The results of this retrospective study of a limited population base suggest that fetal neurologic injury preceding labor may develop late in pregnancy, and that decreased AF volume appears to be a significant risk factor. FHR patterns may provide clues to the presence and timing of fetal neurologic injury.

Medicolegal ramifications of electronic fetal monitoring during labor.

Fetal heart rate patterns play a significant role in the modern day obstetric care. They also play a significant role in medicolegal allegations of negligence when the fetus suffers injury. Proper interpretation of the fetal monitor tracing is only one factor in the evaluation of the reasonableness of obstetric care. Appropriate care and optimal defense both derive from reasonable interpretation of pertinent clinical data, including the monitor strip, along with timely pursuit of a thoughtful, properly annotated, plan of care.