Influence of elective cesarean section and breech delivery on neonatal neurological condition

Fifty-three infants born after elective cesarean section (CS), and 28 infants born vaginally in breech presentation were compared with 45 full-term controls. A quantitative neurological assessment consisting of 31 items was performed on days 1, 2 and 5 after birth. A tonus score, an excitability score and the number of optimal responses were calculated. A follow-up examination was done at 6 months of age, with a standardized neurological and developmental examination. The results showed that infants born after elective CS in both vertex and breech presentation had significantly reduced number of optimal responses during the first five days after delivery, compared to controls. They were more hypotonic and less excitable than the control infants during the first 2 days. There were no significant differences in neurological results between infants born after CS with general or epidural anaesthesia. The infants born in vaginal breech presentation showed no differences neurologically as compared to the controls on the first day. On days 2 and 5, however, they were less excitable and showed a reduced number of optimal responses. There were few differences in neurological condition between the infants born after elective CS and the infants born vaginally in breech presentation. Growth, psychomotor development and neurological status at 6 months did not differ significantly between the three groups. Our findings indicate that infants born after elective CS and vaginal breech presentation have a delayed neurological adaptation during their first days of life. These differences did not affect the physical well-being of the infants, which showed normal growth, neurology and development at the follow-up at 6 months of age.     

Postdelivery head bleeding in hemophilic neonates. Causes and management

During a 12-month period, four of the five infants with hemophilia known to have been born in Arkansas were examined for head bleeding. Three of the infants had had traumatic delivery, with use of low forceps in two and vacuum extraction in one. In the fourth patient, hemophilia was prenatally diagnosed, and vaginal delivery resulted in cephalohematoma. Diagnosis was delayed in three patients, including one with a family history of hemophilia. Central nervous system bleeding may be more common in hemophilic neonates than has been presumed. Pregnancy management should include consideration of family history of bleeding disorders and carrier testing in appropriate cases. In confirmed carriers, prenatal diagnosis is justified to allow choice of the least traumatic delivery method. Any term neonate with intracranial hemorrhage should be treated as being possibly hemophilic until proved otherwise.     

Posterior fossa hemorrhage in the term newborn: report of two cases.

Two term newborn infants born by frank breech delivery had posterior fossa hemorrhage diagnosed by CT scan within the first 72 hours of life and underwent successful surgical drainage of hematoma. Previously reported cases with long-term postoperative survival have included 12 term newborns with good outcome in nine. Most remaining reported examples of posterior fossa hemorrhage in newborns have been from autopsy reports on premature infants. It is suggested that operative intervention is often indicated in cases of early neonatal posterior fossa hemorrhage and that additional data on long-term outcome of operative intervention as well as outcome in nonoperated cases are needed. One of the two cases reported here and one previously reported presented with onset of seizures as the initial clinical manifestation.     

Role of asphyxia and slow intrauterine growth in morbidity among breech delivered infants

The outcome of breech delivery was evaluated by a neonatal neurological score and a follow-up examination at 18 months of age. The subjects were 132 children identified by ultrasound to be in breech presentation in the 33rd gestational week. 62 were born in breech presentation, while 70 turned to vertex presentation. During the early neonatal period, a neurological score was obtained based on the results of 29 items concerning posture, muscle tone, reflexes and reactions. Although there was no difference, in neurological score or in general development when the entire breech and vertex groups were compared, the SGA (small-for-gestational age) infants and the infants with low Apgar scores of the breech group had the poorest neurological scores. The contribution of certain maternal and fetal factors to postnatal condition was evaluated by a multiple linear regression analysis. Within the breech group, relationships were found between the neurological score and the variables intrauterine growth, fetal sex, and low Apgar score. A major part (66%) of the variation in neurological score was explained by the combination of these variables. These factors should therefore be taken into consideration when deciding on the mode of delivery in breech presentation.     

Posterior fossa hemorrhage in newborns following vaccum extractor delivery]

AIM: To emphasize the risk of posterior fossa hemorrhage in newborns following vacuum extraction. PATIENTS AND METHODS: Over a period of 26 months (September 1996-December 1998), seven patients who underwent delivery with the vacuum extractor had symptoms of brain stem compression, related to posterior fossa hemorrhage. They were referred to the neonatal intensive care unit. Some parameters had been analyzed: gestational period, delivery circumstances, gestational age, parameters of newborn, indications of vacuum extraction and other paraclinical investigations (biological and radiological). RESULTS: Ultrasound scan revealed intracranial hemorrhage in five cases of seven; mean time of diagnosis was 10 hours of age. All patients presented symptoms of brain stem compression. Mean period of follow-up was 22 months: six of seven patients had a normal neurodevelopment. One patient had a cerebellar ataxia, another one a palsy of the IIIrd cranial nerve. CONCLUSION: Analyses of posterior fossa by ultrasound scan should be made for newborns delivered by vacuum extractor, especially if they had symptoms of brain stem compression.     

Incidence, severity, and timing of subependymal and intraventricular hemorrhages in preterm infants born in a perinatal unit as detected by serial real-time ultrasound

Real-time ultrasound scans were performed on 66 low-birth-weight infants within the first six hours of life (mean, two hours), and then at 12, 24, 48, and 72 hours, and thereafter at weekly intervals. All of the infants were born in a perinatal unit. The incidence of intraventricular hemorrhage and subependymal hemorrhage was 31%. Eight of 20 infants had small hemorrhages (Papile, grades I and II); seven infants sustained grade III hemorrhages, and five infants sustained grade IV hemorrhages. All hemorrhages occurred in the first 72 hours of life; 25% were diagnosed with the first scan (ie, within the first six hours of life). The infants especially at risk were those less than 29 weeks' gestation. Five infants developed progressive posthemorrhagic ventriculomegaly that subsided spontaneously by age 8 weeks. The mortality in the study group was only 4.5%.     

Ultrasonographic evaluation of breech presentation as a risk factor for hip dysplasia

In order to gain more information of breech position as a risk factor for congenital hip dysplasia or dislocation, the hips of 408 newborns delivered in the breech position were examined by ultrasound. Clinical examination was performed by both experienced paediatricians and orthopaedic surgeons. The infants were re-examined by ultrasound at 2–3 months of age. Twenty-five newborns (6.1%) had neonatal hip instability. Breech presentation as a risk factor was confirmed, with first borns, breech position with extended knees, and high birthweight as special high-risk groups. Ultrasound showed subluxation in most of the unstable hips. The main benefit of using ultrasound was that direct visualization permitted more reliable evaluation, especially when the clinical findings were uncertain. Normal ultrasound findings in false positive and uncertain Ortolani tests reduced the frequency of unnecessary treatment. Because ultrasound was used in follow-up, the need of radiography was reduced. There were no late-detected cases of hip dysplasia or dislocation, indicating that routine follow-up is not necessary in breech infants with normal hips at birth, provided that the neonatal screening is optimal.     

Decreased Incidence of Intraventricular Hemorrhage in Infants of Opiate Dependent Mothers

ABSTRACT. The incidence of intraventricular hemorrhage (IVH) in infants born to opiate dependent mothers was compared to infants whose mothers denied the use of addicting substances. The two groups were comparable in birth weight, gestational age, 1 and 5 min Apgar scores, and sex distribution. The incidence of breech presentations, PROM, and type of anesthesia at delivery were similar. However, more infants in the control group were delivered by cesarean section. The incidence of IVH was 52% in the controls and 23% in the opiate infants ( p <0.05). Neonatal risk factors such as use of ventilators, incidence of pneumothorax, administration of pressor and sedative drugs, acidosis, use of alkali therapy and volume expanders, fluid therapy in the first three days and transfers to other hospitals were the same.     

The 'breech head' and its relevance.

Eight infants had scaphocephaly with prominent occipital shelving. This abnormal head shape is identified as a postural deformation associated with breech intrauterine position, and it is noted to resolve during infancy with no apparent residual impairment in most cases. At the same time, the "breech head," as we have designated this unusual head form, may occur in the setting of a primary problem in fetal morphogenesis, and it may be itself a factor contributing to birth injury during vaginal delivery of the breech infant.     

The influence of prenatal breech presentation on neonatal leg posture

The aim of our study was to examine the effect of prenatal breech presentation on postnatal leg posture. Twelve infants were born after breech presentation and nine infants after cephalic presentation participated. At 2, 4, 6, 12 and 18 weeks postnatal age leg posture was examined during general movements in supine and vertical position.

Results

Transient differences in hip posture between the groups were observed during the first 6 weeks postnatal age, with significantly more hip flexion and less hip extension in the breech group. For knee extension, differences between the groups were not statistically significant.Changing from supine to vertical position, the breech group demonstrated a significant increase in hip extension, with no significant changes in hip posture for the cephalic group. For both groups the vertical condition resulted in a significant increase in knee extension. Continuity from pre- to postnatal life was found for hip posture in both groups and for knee extension only in the breech group.

Conclusions

Significant differences between breech and cephalic-born infants were found during the first 6 weeks after birth and mainly concerned hip posture and not knee posture. An increase in gravitational force has more impact on leg posture in the breech than in the cephalic group. The observed differences in hip posture between the studied groups were found to be transient, however, in the long term subtle differences still remain between the groups.     

Fetal breech presentation predisposes to subsequent development of septic arthritis of the hip

We postulated a link between breech presentation and septic arthritis of the hip. To examine the potential association between these 2 relatively uncommon entities, we used the Patient Administration Systems and Biostatistics Activity (PASBA) database, which contains coded information derived from hospitalizations and ambulatory encounters at U.S. military hospitals worldwide. Among a cohort of nearly 1 million infants born in a 14-year period, 3.37% were found to be in the breech presentation. The rate of septic arthritis of the hip or pelvis during the first year of life among these breech infants was approximately 1/8000, providing a relative risk of 4.1 (95% confidence interval, <1.4-11.7) compared with the rate among nonbreech infants. Fetal breech presentation predisposes to the development of septic hip during the first year of life.     

The value of EEG and cerebral evoked potentials in the assessment of neonatal intracranial hemorrhage

The EEG, visual and auditory evoked potentials (VEP, AEP) were evaluated in 16 full-term newborn infants who had intracranial hemorrhage documented by computerized tomography (CT). Three of them had supratentorial, three, supra- and infratentorial hemorrhage, while the other ten had infra- or peri-tentorial bleeding. Three died during the neonatal period. Eight of the 13 surviving infants were neurologically normal and five were abnormal at the time of the follow-up. Those who had normal or mildly abnormal background EEGs all developed normally, while those whose neonatal EEG was severely abnormal subsequently developed neurological sequelae irrespective of the extent of intracranial hemorrhage. The EEG, VEP or AEP is of little value in the diagnosis of intracranial bleeding but the EEG is valuable in assessing the degree of associated parenchymatous damage and is of great prognostic significance.The authors are grateful to Professors Suzuki, Wada and Kageyama for their continued interest and encouragement     

Decreased incidence of intraventricular hemorrhage in infants of opiate dependent mothers

The incidence of intraventricular hemorrhage (IVH) in infants born to opiate dependent mothers was compared to infants whose mothers denied the use of addicting substances. The two groups were comparable in birth weight, gestational age, 1 and 5 min Apgar scores, and sex distribution. The incidence of breech presentations, PROM, and type of anesthesia at delivery were similar. However, more infants in the control group were delivered by cesarean section. The incidence of IVH was 52% in the controls and 23% in the opiate infants (p less than 0.05). Neonatal risk factors such as use of ventilators, incidence of pneumothorax, administration of pressor and sedative drugs, acidosis, use of alkali therapy and volume expanders, fluid therapy in the first three days and transfers to other hospitals were the same.     

Subependymal germinal matrix hemorrhage in full-term neonates

A population of healthy, full-term newborn infants was studied in order to obtain documentation of the prevalence of intracranial hemorrhage. Cerebral ultrasonography was performed within 72 hours of birth on 505 healthy newborn infants, 37 weeks of gestation or greater. Sonographic abnormalities were detected in 23 (4.6%) neonates. Bilateral subependymal germinal matrix hemorrhage occurred in 14 and unilateral hemorrhage in five infants. Other abnormalities detected included agenesis of the corpus callosum in two infants, a cyst involving the subependymal germinal matrix in one (presumably the result of a previous subependymal hemorrhage), and mild ventricular dilation of unknown etiology in one. Newborns with subependymal hemorrhage were compared with newborns without hemorrhage in order to determine whether any significant differences existed between the two populations. No significant differences existed between infants with and without subependymal hemorrhage with regard to gender, obstetrical presentation, use of forceps, birth trauma, Apgar scores, need for resuscitation, maternal age and parity, and neonatal clinical problems. Infants with subependymal hemorrhage were of significantly lower gestational age and birth weight; the overall difference in weight was attributable to lower weight in female infants with subependymal hemorrhage. Significantly more infants with subependymal hemorrhage were small for gestational age, vaginally delivered, and black.     

Ocular outcomes in low birth weight premature infants with intraventricular hemorrhage

PURPOSE: To study ocular outcomes in very low birth weight premature infants with intraventricular hemorrhage. METHODS: Parents of 490 consecutive very low birth weight (less than 1500 g) premature infants who were discharged from the neonatal intensive care unit of our hospital between 1994 and 1996 were asked to enroll their child/children in this cross-sectional study. Sixty infants (12%) were recruited and had complete masked ophthalmologic examinations at 12 months corrected gestational age. The medical records of each infant were reviewed after the eye examination was complete. The occurrence of intraventricular hemorrhage and other perinatal comorbidities was documented. Ocular outcomes of infants with no or low-grade (grades I-II) hemorrhages were compared with those of infants with high-grade (grades III-IV) intraventricular hemorrhage. RESULTS: Of the 60 infants examined, 17 (28%) had neonatal intraventricular hemorrhage. Eleven (18%) had high-grade intraventricular hemorrhage, and 49 (82%) had no or low-grade hemorrhage. Of the 11 infants with high-grade intraventricular hemorrhage, 8 (73%) had strabismus compared with 7 (14%) of 49 infants with no or low-grade hemorrhages who developed strabismus (P<0.001). The high-grade group also had a larger proportion of infants with ocular motility defects (P=0.008), nystagmus (P<0.001), optic nerve atrophy (P<0.001), and abnormal retinal findings (P=0.039). Additionally, these infants were more likely to have stage 3 or worse retinopathy of prematurity (P=0.003). CONCLUSIONS: These results confirm the findings of our earlier retrospective study, and suggest that the occurrence of high-grade intraventricular hemorrhage in the early postnatal period places these infants at significant risk for adverse ocular outcomes. These infants require close ophthalmologic surveillance.     

Randomized indomethacin trial for prevention of intraventricular hemorrhage in very low birth weight infants

We admitted 48 preterm neonates (600 to 1250 gm birth weight, normal 6-hour echoencephalograms) to a randomized prospective indomethacin or placebo trial for the prevention of neonatal intraventricular hemorrhage. Beginning at 6 postnatal hours, indomethacin or placebo was administered intravenously every 12 hours for a total of five doses. Cardiac ultrasound studies to assess the status of the ductus arteriosus were performed at 6 postnatal hours and on day 5. Urinary output, serum electrolytes, and renal and clotting functions were monitored. No differences in birth weight, gestational age, Apgar scores, or ventilatory needs were noted between the two groups. Six infants given indomethacin had intraventricular hemorrhage, compared to 14 control infants (P = 0.02). The indomethacin-treated group had significant decreases in serum prostaglandin values 30 hours after the initiation of therapy. The overall incidence of patent ductus arteriosus was 82% at 6 postnatal hours; 84% of the indomethacin-treated infants experienced closure of the ductus, compared to 60% of the placebo-treated patients. Closure of the ductus was not related to incidence of intraventricular hemorrhage. We speculate that indomethacin may provide some protection against neonatal intraventricular hemorrhage by acting on the cerebral microvasculature.     

Hip joint instability in breech pregnancy

222 consecutive fetuses found by ultrasound to be in breech presentation in the 33rd gestational week were followed with repeated examinations in weeks 35 and 38. Ninety-one of these fetuses persisted in breech presentation until delivery, while cephalic version occurred in 131. The frequency of hip joint instability was 21% in the breech delivered group and 1.5% in the vertex delivered group. The position of the fetal legs was established at each ultrasound examination. The intrauterine fetal attitude was classified as extended when the fetuses had extended knees and maximally flexed hips at all ultrasound examinations. This occurred in 30 breech delivered fetuses, 47% of which developed hip joint instability. Only 8% of the breech born infants with flexed legs in utero developed hip joint instability. It is concluded that instability of the hip joint is a consequence of the intrauterine attitude, rather than of the breech delivery per se.     

单胎濒死儿发生的围生期危险因素分析

目的 探讨单胎濒死儿发生的围生期危险因素,为濒死儿综合诊治提供依据。 方法 该研究为病例对照研究。选取2006年1月—2015年12月在复旦大学附属妇产科医院出生的154例胎龄≥28周、1 min Apgar评分为0~1分的单胎新生儿为病例组（濒死组）,按1∶4比例随机选取616例同期出生的单胎非濒死儿（1 min Apgar评分>1分）为对照组,采用单因素分析和多因素logistic回归分析评估濒死儿发生的围生期危险因素。 结果 濒死组胎龄和出生体重均显著低于对照组（P<0.05）。濒死组胎儿水肿、脐带脱垂、羊水Ⅲ度污染、胎盘早剥、臀位、重度子痫前期、母亲产时全麻、产前胎心监护异常、产前胎动减少发生比例显著高于对照组（P<0.05）。多因素logistic回归分析显示母亲产时全麻（OR=34.520）、产前胎动减少（OR=28.168）、胎盘早剥（OR=15.641）、羊水Ⅲ度污染（OR=6.365）、产前胎心监护异常（OR=5.739）、臀位（OR=2.614）是濒死儿发生的危险因素（P<0.05）,胎龄较大（OR=0.686）是濒死儿发生的保护因素（P<0.05）。 结论 临床需对产前胎心监护异常、胎动减少、早产、胎盘早剥、臀位、羊水Ⅲ度污染、全麻手术的产妇引起重视,做好新生儿复苏准备,防范濒死儿的发生。     

Hip Joint Instability in Breech Pregnancy

ABSTRACT. 222 consecutive fetuses found by ultrasound to be in breech presentation in the 33rd gestational week were followed with repeated examinations in weeks 35 and 38. Ninety-one of these fetuses persisted in breech presentation until delivery, while cephalic version occurred in 131. The frequency of hip joint instability was 21% in the breech delivered group and 1.5% in the vertex delivered group. The position of the fetal legs was established at each ultrasound examination. The intrauterine fetal attitude was classified as extended when the fetuses had extended knees and maximally flexed hips at all ultrasound examinations. This occurred in 30 breech delivered fetuses, 47% of which developed hip joint instability. Only 8% of the breech born infants with flexed legs in utero developed hip joint instability. It is concluded that instability of the hip joint is a consequence of the intrauterine attitude, rather than of the breech delivery per se.     

Thalamic hemorrhage with intraventricular hemorrhage in the full-term newborn

Intraventricular hemorrhage is an uncommon problem in the full-term newborn. In a review of 19 full-term infants with intraventricular hemorrhage diagnosed on computed tomography prior to 1 month of age, thalamic hemorrhage associated with the intraventricular hemorrhage was documented in 12 infants. Thus, thalamic hemorrhage appears to the most common source of intraventricular hemorrhage in this age group, particularly in infants who had uneventful birth histories and in whom clinical abnormalities (signs of increased intracranial pressure, seizures, altered level of consciousness) developed after the first week of life. The majority of these infants had predisposing factors for cerebral venous infarction such as sepsis, cyanotic congenital heart disease, and coagulopathy. The clinical appearance and outcome for infants with thalamic hemorrhage/intraventricular hemorrhage were similar to those in infants with intraventricular hemorrhage originating from other sites, except for an increased incidence of cerebral palsy in infants with thalamic hemorrhage/intraventricular hemorrhage. Definitive diagnosis was made on the basis of characteristic radiologic abnormalities.