Labor risk assessment in a rural community hospital

Unanticipated perinatal catastrophe in a rural community hospital is responsible for the deaths of many potentially salvageable infants. An intrapartum risk scoring system was designed to help anticipate infants needing skilled resuscitation at the rural community hospital. Thirty-three percent of infants whose mothers scored as high risk (greater than or equal to 10) required resuscitation while only 6% of infants whose mothers scored less than 10 required resuscitation. Sequential Apgar scores of infants in need of resuscitation attended by a skilled resuscitator showed significant improvement compared with Apgar scores of infants not attended by a skilled resuscitator, suggesting at least a short-term benefit for early identification of the infant at risk.     

The partogram's result and neonatal outcome.

The aim was to investigate to what extent low Apgar scores are linked to the partogram's result and, more specifically, if the action line should be set 3 rather than 4 h parallel and right to the alert line. Some 24.0% of all labours evolved left to the alert line and 26.3% of the labours right to the alert line crossed the 4-h action line. An Apgar score of 相似文献   

Immediate neonatal outcomes after elective induction of labor

OBJECTIVE: To examine immediate neonatal outcomes associated with elective labor induction. STUDY DESIGN: Labor inductions occurring at > or = 38 weeks' gestation were examined during a 6-month period at 2 community hospitals. Medical records were reviewed by trained abstractors to determine the reason for induction (elective vs. medical) and maternal characteristics. The need for newborn resuscitation (1-minute Apgar score < 4) was the primary end point. Multiple logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Of the 364 inductions, 54.9% were elective. The odds of a 1-minute Apgar score being < or = 3 were significantly greater when labor was induced for elective reasons than for medical reasons (OR 5.5, 95% CI 1.1-27.9) or was spontaneous (OR 6.5, 95% CI 2.4-17.8), after controlling for mother's age, race and route of delivery. Elective induction was not associated with feal intolerance to labor, a low 5-minute Apgar score or need for admission to a special care nursery. CONCLUSION: An elective abortion induction is an independent risk factor for delivery of an infant requiring immediate attention.     

Neonatal-emergencies: basics in cardiopulmonary resuscitation

The international guidelines for neonatal resuscitation were recently updated by the American Academy of Pediatrics (AAP), the American Heart Association (AHA) and the International Liaison Committee on Resuscitation (ILCOR). The most important steps in resuscitation of the newly born infant are oxygenation and ventilation, including endotracheal intubation. These fundamental techniques will be emphasized and discussed in a problem-oriented approach. The clinical assessment of the newly born infant is based on a triad of respiration, heart rate and color. If indicated, resuscitation has to be initiated approximately 30 s after birth, i. e. prior to determination of the 1 min. Apgar score and umbilical artery pH. The key to successful neonatal resuscitation is establishment of adequate ventilation; it should commence - after oropharyngeal suctioning and ineffective tactile stimulation - when the heart rate drops < 100 bpm. Clinical evidence supporting the hypothesis that ventilation with room air versus 50 or 100 % oxygen is preferable in terms of neurological outcome is still preliminary and requires further investigation. Chest compressions should be administered if the heart rate remains < 60 bpm (or heart rate 60 to 80 bpm and not rising) despite adequate assisted ventilation. There should be a 3 : 1 ratio of compressions to ventilations to achieve approximately 120 events per minute. Moreover, the international guidelines recommend crystalloid volume expanders (normal saline or Ringer's lactate), red blood cells, sodium bicarbonate and naloxone for cardiopulmonary resuscitation of the newly born infant.     

Prospective labor risk assessment in a rural community hospital

This prospective study investigates the utility of a labor risk assessment instrument for the prediction and management of the low Apgar infant in the community hospital setting. Two hundred and fifty patients in labor were managed with a protocol involving initial and ongoing risk assessment throughout the course of labor and delivery. Patients scored as high risk were independently assessed to determine the need for the presence of the resuscitation team at delivery. Twenty-one percent of infants of high-risk mothers required resuscitation, whereas only 8% of infants whose mothers scored as low or moderate risk required resuscitation. A modified ten factor list was developed using multiple logistic regression analysis and clinical experience. This was found to improve predictive power for low Apgar score infants in need of resuscitation within a risk group comprising only 27% of the population. We conclude that this intrapartum scoring system can be readily implemented in a community hospital and is effective in identifying high-risk infants so that resources can be mobilized for appropriate intervention.     

Apgar scores and umbilical arterial pH in preterm newborn infants

One- and five-minute Apgar scores and umbilical cord arterial pH values were compared in preterm newborn infants of various gestational ages. The more premature the infant, the more likely the Apgar score was low in the presence of a pH greater than or equal to 7.25. Conversely, the closer to term, the more frequently an infant with a pH of less than 7.25 had an Apgar score of greater than or equal to 7. Therefore, in preterm infants, there is little congruity between the Apgar score and umbilical cord pH. Based on these findings, it is not appropriate to label preterm newborn infants as asphyxiated based on a low Apgar score.     

The Apgar score, acid-base equilibrium of the umbilical cord vessels and early postnatal adaptation in healthy term newborns

The aim of the study is to establish a correlation between Apgar score, acid-base status (ABS) and blood gases (bg) from cord blood and the early postnatal adaptation in healthy term newborns. The study is prospective and includes 52 babies at term born at the State University Hospital Ma?chin Dom, Sofia during a three month period--03-05, 1998 without evidence of asphyxia before and during delivery. All babies are monitored for Apgar score at minute 1 and 5, ABS and bg from umbilical artery (u.a.) and vein (u.v.) examined at birth, as well as capillary ABS and bg 1 hour after birth. Early postnatal adaptation is judged by a neonatologist in the course of two hours. RESULTS: A significant difference is found between all the examined points in the ABS and the blood gases in samples from umbilical artery and vein (p < 0.05), most significantly differ pH, pO2 and O2 Sat (p < 0.001). There is a correlation between 1 minute Apgar score and ABS and bg from umbilical vessels, babies with 1 minute Apgar score 7 having significantly lower pH from u.a. requiring wider range of resuscitation. Babies with 1 minute Apgar score 9/8 and 5 minute Apgar score 10 have definitely less early adaptational problems. CONCLUSION: The use of a combination of evaluation criteria for the condition of the newborn after birth (Apgar score, ABS and bg from cord blood and strict monitoring of early cardio-pulmonary adaptation) guarantees adequate resuscitation in term babies.     

The Apgar Score: Evolution,Limitations, and Scoring Guidelines

ABSTRACT: The Apgar score has been useful for nearly four decades in focusing on five physiological signs (heart rate, respiratory effort, reflex irritability, muscle tone, color) that denote the condition of an infant during the first critical minutes of life. Before the development of the system, narcotic analgesia and sedation during labor, and general anesthesia for vaginal deliveries were commonly used. Research of the scoring method has focused on the effects of these interventions on the fetus and newborn and has been a major impetus for change in obstetric practices. The Apgar score has been used as a predictive index for neonatal mortality and morbidity and for later neurologic or developmental disability. Both the one- and five-minute scores are predictors of mortality in normal-birthweight infants, whereas in high-risk low-birthweight infants their score is limited. The score is an insensitive predictive index of long-term neurologic or mental handicap, and lacks both sensitivity and specificity to reflect accurately the degree of acidosis. It can be used effectively, however, if these limitations are understood and considered.     

Routine ultrasound screening in the third trimester: a population-based study

BACKGROUND: No population-based study has evaluated the effects of third trimester ultrasound screening on prognosis. OBJECTIVE: To study the effects of routine ultrasound screening in the third trimester on perinatal/infant mortality, prevalence of small for gestational age infants (SGA) and low Apgar score. STUDY DESIGN: Two university clinics using routine ultrasound screening in the third trimester were compared with seven county or district hospitals with no routine screening. Deliveries between 1985 and 1996 were included. In all, 16 municipalities including 56 371 pregnancies with routine screening were compared with 59 municipalities and 153 355 pregnancies without third trimester screening. An observational design was applied, using data stored during pregnancy, delivery, and during the first year (infant mortality) at the Swedish Medical Birth Registry, The National Board of Health and Welfare. Odds ratio with 95% confidence interval was used in the evaluation. End-points included incidence of SGA, perinatal/infant mortality, Apgar score at 5 min, cesarean section and instrumental delivery in areas with versus without routine third trimester screening. RESULTS: No significant difference was seen in the prevalence of the most extreme SGA (< -3 SD from the mean), perinatal complications including cesarean section or instrumental delivery, or perinatal/infant mortality between units with versus without routine ultrasound screening in the third trimester. CONCLUSION: Added to the findings of previous small randomized studies, it seems as if routine third trimester ultrasound screening in an unselected population does not reduce perinatal mortality or early neonatal morbidity, expressed as Apgar scores or SGA.     

Positive changes among very low birth weight infant Apgar scores that are associated with the Neonatal Resuscitation Program in Illinois.

OBJECTIVE: The American Academy of Pediatrics and American Heart Association sponsored Neonatal Resuscitation Program (NRP) was started in Illinois 1987 to standardize knowledge and skills for successful resuscitation to decrease newborn morbidity and mortality. This study evaluated the hypothesis that the statewide NRP in Illinois hospitals was associated with positive outcomes in the Apgar scores among very low birth weight newborns. STUDY DESIGN: A retrospective design was used to compare the (a) different rates of lower (0-6) and higher (7-10) 1- and 5-minute Apgar scores and (b) positive change from a lower 1-minute to a higher 5-minute Apgar score before and after NRP was started. Analyses included maternal characteristics, birth weight groups (grams: 500-749, 750-999, 1000-1249, 1250-1499), and hospital levels (I, II, III). RESULTS: A significantly higher proportion of infants had a higher 1-minute and a higher 5-minute Apgar score after NRP, overall, for Level II and II+ hospitals and for each weight group. Logistic regression indicated that newborns with low 1-minute Apgar scores were 81% more likely to have a higher 5-minute Apgar score after NRP. CONCLUSION: Significant improvement in Apgar score occurred after NRP. Empirical support is demonstrated for the clinical effectiveness of NRP instruction in Illinois hospitals.     

Low 5-minute Apgar score: a population-based register study of 1 million term births.

OBJECTIVE: To determine the rate of 5-minute Apgar scores below 7 in term infants (at least 37 weeks) in Sweden during 1988-1997, evaluate the influence of obstetric risk factors on low 5-minute Apgar scores, and to study the infant prognosis regarding infant mortality, neonatal neurologic morbidity, and outcome. METHODS: Data were collected from the Swedish Medical Birth Registry 1988-1997, and the National Hospital Discharge Registry. Odds ratios (OR) and risk ratios were calculated. RESULTS: Among 1,028,705 term newborns, 7787 (0.76%) had 5-minute Apgar scores below 7. The annual rate of low Apgar scores decreased from 0.77% in 1988 to 0.63% in 1992, but thereafter increased to 0.82% in 1998. The highest OR was found for vaginal breech delivery (OR 6.7), birth weights above 5 kg (OR 6.3), and second born twins (OR 4.1). Primiparity, maternal age, smoking, post-date pregnancy, epidural analgesia, male infant gender, and being born at night, were also significant risk factors for Apgar below 7 at 5 minutes. The infant mortality rate was 48 per 1000 (OR 14.4), and the ORs were 31.4 for a diagnosis with cerebral palsy, 7.9 for epilepsy, and 9.5 for mental retardation. CONCLUSION: Several obstetric risk factors are associated with low 5-minute Apgar score in term infants. Mortality and the risk of severe neurologic morbidity are increased in these infants.     

Obstetric antecedents to apparent stillbirth (Apgar score zero at 1 minute only)

OBJECTIVE: To identify antecedent risk factors for the delivery of an infant with an Apgar score of 0 at 1 minute who is subsequently successfully resuscitated. METHODS: Infants born between January 1986 and February 1999 with 1-minute Apgar score of 0 followed by 5-minute Apgar score above 0 were studied. Each eligible infant was randomly matched with two control infants, born in the same year, with 1-minute Apgar score greater than 0. Hospital records of their mothers were reviewed. The variables were compared between the groups by univariate analysis. Those factors demonstrating significant differences were then analyzed by logistic regression. P <.05 was considered statistically significant. RESULTS: Seventy-four of 81,603 infants (0.9:1000 births) born with an Apgar score of 0 at 1 minute only were compared with 148 control babies. Univariate analysis revealed significant differences between study and control group regarding: gestational age, abruptio placentae, preterm premature rupture of membranes, chorioamnionitis, preeclampsia, small-for-gestational age, male gender, bradycardia, and abnormal fetal heart rate (FHR) other than bradycardia, respectively. Logistic regression of these factors found gestational age, bradycardia, and abnormal FHR to be independent risk factors for the delivery of an apparent stillborn infant. After exclusion of FHR criteria, logistic regression found gestational age (odds ratio [OR] 0.8 per week), male gender (OR 2.5), preeclampsia (OR 3.9), and abruptio placentae (OR 13.6) to be independent risk factors for the delivery of an apparent stillborn infant. CONCLUSION: Preterm birth, male gender, preeclampsia, and abruptio placentae are independently associated with an increased risk of apparent stillbirth.     

Would omitting the assessment of heart rate be harmful to initial neonatal care?

OBJECTIVE: To test the hypothesis that counting heart rate is dispensable and other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth in routine deliveries. METHODS: The database of the Japanese Red Cross Nagoya First Hospital was reviewed for newborn infants whose Apgar scores were marked by trained neonatologists attending delivery. RESULTS: The scores of respiratory effort, muscle tone, and reflex irritability increased parallel to Apgar scores. Heart rate gained higher marks even in lower Apgar scores, whereas color demonstrated lower marks even in higher Apgar scores. Correlation coefficients were higher among respiratory effort, muscle tone, and reflex irritability. In contrast, both heart rate and color exhibited lower correlation coefficients against other components and total Apgar scores. High correlation coefficients were shown between the sum of the four components other than heart rate and the total score. CONCLUSIONS: Heart rate and color play more independent roles in the Apgar score. Heart rate seems to be dispensable and the other components of the Apgar score are satisfactory to evaluate the physical condition of infants shortly after birth, and hence, counting heart rate may be omitted in routine deliveries when a newborn infant is apparently well.     

Impact of anesthetic methods on neonatal outcome in women receiving temporary balloon occlusion of the common iliac artery during cesarean section for placenta accreta

ObjectivePlacenta accreta is associated with significant maternal morbidity and is the leading indication for peripartum hysterectomy. In our institution, occlusion balloon catheters are commonly placed in bilateral common iliac arteries in order to reduce blood loss and facilitate surgery in patients with this obstetric complication. Few studies, however, have evaluated the effect of different anesthetic methods for cesarean hysterectomy on neonatal outcome. In this study, we compared Apgar scores among neonates born to mothers under general anesthesia with those who received regional anesthesia.Case ReportsA retrospective analysis of 19 women with placenta accreta/percreta who underwent cesarean hysterectomy in our hospital, revealed that the 1-minute Apgar score was <7 in 4/12 neonates born to women who underwent general anesthesia and in 1/7 neonates born to mothers who received regional anesthesia. The 5-minute Apgar score was >7 after immediate resuscitation in all neonates. There were no significant differences in demographic data, induction-to-delivery period, or Apgar scores between the general and the regional anesthesia groups.ConclusionWe acknowledge that the retrospective nature of this study makes it difficult to conclude whether the different anesthesia management strategies had an impact on Apgar score; however, according to our clinical observation, regional anesthesia may be a better alternative in the induction-to-delivery period, especially for women with accreta/percreta and in situations in which poor neonatal outcome is expected.     

Computer assessment of the intrapartum cardiotocogram. II. The value of compared with visual assessment

The chief aim of our work has been to create a computer Cardiotocographic Assessment System (CAS) and thus eliminate the intra- and inter-observer variability of the visual assessment of the cardiotocogram (CTG), and to improve the assessment of the CTGs to the standard of the most experienced obstetricians. The purpose of this paper is to present the accuracy of the prediction of fetal outcome obtained by the CAS and to compare it with 4 experienced obstetricians' accuracy. Fifty CTGs from the last 30 min. of labor were assessed as normal or pathological by the computer and by the obstetricians. The condition of the newborn was evaluated from the one-minute Apgar score, the umbilical artery pH and standard base excess, and the need for resuscitation. The accuracy of the CAS was significantly better than the accuracy of the obstetrician obtaining the best result. We conclude that the development of a computer-aided cardiotocographic assessment system is worthwhile.     

Comparison of umbilical artery pH and 5-minute Apgar score in the low-birth-weight and very-low-birth-weight infant

The division between "normal" and low Apgar scores is based largely on data obtained from term newborns and may not apply to the premature infant. Umbilical artery pH has been suggested as a better indicator of intrapartum asphyxia. We examined the charts of 558 infants with birth weights less than or equal to 2500 gm with respect to umbilical artery pH, 5-minute Apgar scores, and birth weight percentiles. A positive correlation between birth weight and 5-minute Apgar score was noted. No such relationship existed between birth weight and umbilical artery pH. Within birth weight groups, small-for-gestational-age infants have higher Apgar scores and lower umbilical artery pH values than their appropriate-for-gestational age counterparts.     

Fused eyelids in the extremely premature infant: multivariate analysis of survival and outcome.

The presence of fused eyelids at birth in the extremely low birthweight infant (less than 1000 gm) is often regarded by physicians as an indication of nonviability. This is especially true for the pediatrician who does not have routine exposure to extremely premature infants and may use the presence of fused eyelids to influence the level of resuscitation afforded the infant in the first crucial minutes following birth. Unfortunately, there are scant data in the literature to guide general pediatricians with regard to this issue. The purpose of this study was to examine, with the aid of multivariate statistical analysis, the survival and combined outcome score in extremely premature infants with and without fused eyelids. The combined outcome was a composite of several outcome variables (intraventricular hemorrhage, bronchopulmonary dysplesia, and retinopathy of prematurity); survival was defined employing the standard definition of neonatal survival, that is, alive at 28 days post natal age. Combined outcome and survival were analyzed with regard to several independent variables (birthweight, gestational age, and 5-minute Apgar scores, mode of delivery, race, sex, and maternal age). A regression analysis was performed to determine the effect of the independent variables on the combined outcome. A separate multivariate logistic regression analysis was employed to determine the effect of the same independent variables on neonatal survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

Influence of presentation on neonatal outcome of vaginally delivered low birthweight infants. A matched pair analysis

Neonatal outcome of 30 low birthweight (800 to 2000 g) breech infants delivered vaginally was compared with a matched sample of vaginally delivered vertex infants. Using a multiple regression analysis, presentation was found to be significantly related only to the Apgar score at 1 minute. No effect of presentation was found on Apgar score at 5 minutes, length of stay in the nursery, need for ventilatory support, or incidence of neonatal death, seizures, or intracranial hemorrhage. Thus, vaginal delivery of low birthweight breech fetuses was associated with short-term infant outcomes comparable to those of similar fetuses delivered vaginally from vertex presentations. The findings suggest that prevailing assumptions about the risks of premature breech vaginal delivery need to be evaluated critically.     

Vaginal breech delivery of selected infants weighing more than 2000 grams. A retrospective analysis of seven years' experience

This retrospective study analyzes 580 term and near-term singleton pregnancies complicated by breech presentation from 1976 through 1982. Vaginal delivery was achieved in 174 patients (30%), 135 of which were selectively allowed a trial of labor. Six infant deaths occurred (1%); all were neonatal deaths directly related to lethal congenital anomalies, for a corrected neonatal mortality rate of 0%. No significant difference was found in the incidence of low Apgar scores, traumatic birth injury, or requirement for neonatal resuscitation between those infants delivered by cesarean section and those delivered vaginally. Although no maternal deaths occurred, cesarean section was associated with a 38-fold increase in significant maternal morbidity. These data suggest that with careful patient selection and fetal monitoring, vaginal delivery of the term or near-term breech infant remains a real alternative to routine cesarean delivery of all breech infants. A selection and management protocol is proposed.     

喉罩通气在新生儿复苏中的应用和评价

目的 初步观察喉罩通气应用于新生儿复苏的可行性、有效性和安全性. 方法将分娩后需正压通气复苏的新生儿369例随机分为喉罩组(205例)及面罩组(164例),比较两种方法的复苏效果及观察喉罩操作时间、一次放置成功率及不良反应等. 结果 (1)两组新生儿生后1 minApgar评分构成差异无统计学意义,生后5 min Apgar评分构成高分者喉罩组明显多于面罩组(x2=-3.39,P=0.001).喉罩总体复苏成功率明显高于面罩组(99.02%和84.15%,x2=28.76,P＜0.01),总体复苏通气时间明显短于面罩组[(36.4±23.7)s和(66.2±35.4)s](t=-8.66,P＜0.01);其中重度窒息患儿喉罩复苏成功率为7/9,面罩组6例均未能成功复苏而需改气管插管;1 minApgar评分4～5分的新生儿喉罩复苏成功率明显高于面罩组(100.00%和42.86%,x2=23.04,P＜0.01),通气时间短于面罩组[(54.6±33.6)s和(136.4±42.0)s](t=-4.45,P＜0.01);1 minApgar评分6～7分的新生儿复苏成功率两组差异无统计学意义.(2)喉罩一次放置成功率98.54%(202/205),放置时间平均为(7.8±2.2)s,不良反应有呕吐(4例)和胃食管反流(3例). 结论喉罩通气操作相对简单,容易掌握,在较重窒息患儿中使用效果优于面罩,可在一定程度上替代气管插管,尤其适于气管插管操作不熟练者使用.