Apgar score, meconium and acidaemia at birth in small-for-gestational age infants born at term, and their relation to neonatal neurological morbidity

Summary. Neonatal neurological morbidity was studied in relation to Apgar score, meconium stained amniotic fluid and acidaemia at birth in 247 small-for-gestational age (SGA) maturely born infants. SGA infants, and especially the severely SGA infants and those born abdominally, showed higher rates of neurological morbidity, acidaemia and meconium stained amniotic fluid than appropriate-for-gestational age (AGA) controls. The examined indicators of asphyxia at birth showed slightly higher correlation coefficients with the 'neonatal neurological optimality score'(NNOS) in SGA, than in AGA term infants, but the percentage of explained variance was low, except in the 23 infants born abdominally. In this group poor neurological outcome was restricted to the 14 infants who showed signs of fetal hypoxaemia diagnosed by decelerative fetal heart rate (FHR) patterns. In 11 of them, FHR decelerations occurred antepartum. These FHR abnormalities appear to be better predictors for the neonatal neurological outcome than indicators of asphyxia at birth.     

Apgar score, meconium and acidaemia at birth in relation to neonatal neurological morbidity in term infants

The relation between Apgar score, meconium and acidaemia at birth and neonatal neurological morbidity was investigated in 805 vaginally born term infants whose birthweight was appropriate-for-dates (AFD). Presence or absence of meconium stained amniotic fluid was not related to the neonatal neurological condition. The 1-min and 3-min Apgar scores and the umbilical artery pH were related, but the variances explained in neonatal neurological optimality score were very low (0.9 and 0.5% respectively). Combination of Apgar score and pH slightly increased these percentages to 1.5. The highest frequency of neurologically deviant infants was, on the other hand, found in the group with a normal pH but low Apgar score. It is concluded that in AFD term infants nowadays the predictive value of a low Apgar score, acidaemia at birth and/or presence of meconium for the neonatal neurological morbidity is poor. Most neonatal neurological abnormalities must be due to other factors.     

Apgar score, meconium and acidaemia at birth in relation to neonatal neurological morbidity in term infants

Summary. The relation between Apgar score, meconium and acidaemia at birth and neonatal neurological morbidity was investigated in 805 vaginally born term infants whose birthweight was appropriate-for-dates (AFD). Presence or absence of meconium stained amniotic fluid was not related to the neonatal neurological condition. The 1-min and 3-min Apgar scores and the umbilical artery pH were related, but the variances explained in neonatal neurological optimality score were very low (0·9 and 0·5% respectively). Combination of Apgar score and pH slightly increased these percentages to 1·5. The highest frequency of neurologically deviant infants was, on the other hand, found in the group with a normal pH but low Apgar score. It is concluded that in AFD term infants nowadays the predictive value of a low Apgar score, acidaemia at birth and/or presence of meconium for the neonatal neurological morbidity is poor. Most neonatal neurological abnormalities must be due to other factors.     

Risk factors for meconium aspiration in meconium stained amniotic fluid.

Meconium aspiration syndrome (MAS) is a life-threatening respiratory disease in infants born through meconium stained amniotic fluid (MSAF). The purpose of this study was to determine risk factors for MAS in the newborns of mothers who had meconium stained amniotic fluid in labour. A retrospective study of all full-term pregnancies with MSAF from May 2003 to October 2004 was designed at a teaching hospital. Development of MAS was the primary outcome. Maternal details, mode of delivery and neonatal details (Apgar score, reassuring or non-reassuring fetal heart rate tracing and birth weight) were evaluated. During the study period, there were 2,603 deliveries of whom 302 (11.6%) had MSAF. MAS developed in 64 of these infants (21.1%). Compared with healthy neonates with MSAF, those with MAS had higher rate of non-reassuring fetal heart rate (FHR) tracing, thick meconium and Apgar score < or =5 at 5 min. The neonatal birth weight was lower in the MAS group, maternal age, parity, gestational age and mode of delivery were not significantly different in the two group. We found the severity of meconium, low Apgar score at 5 min and non-reassuring FHR tracing was associated with MAS in MSAF pregnancies.     

Detection of small-for-gestational-age infants with poor perinatal outcomes using individualized growth assessment

OBJECTIVE: Our objective was to evaluate individualized growth assessment using the Rossavik growth model for detection of small-for-gestational-age (SGA) infants with a poor perinatal outcome. METHODS: Rossavik growth models derived from second-trimester ultrasound measurements were used to predict birth characteristics of 47 singleton SGA infants. Individual fetal growth curve standards for head and abdominal circumference, and weight were determined from the data of two scans obtained before 25 weeks' menstrual age and separated by an interval of at least 5 weeks. Comparisons between actual and predicted birth characteristics were expressed by the Growth Potential Realization Index (GPRI) and Neonatal Growth Assessment Score (NGAS). The proportions of perinatal outcomes [mechanical delivery, low Apgar score, abnormal fetal heart rate (FHR) patterns, neonatal acidosis, meconium staining of amniotic fluid, neonatal intensive care unit (NICU) admission and maternal complications] were compared between SGA infants with normal NGAS and those with abnormal NGAS. RESULTS: Of the 47 fetuses studied, 27 had normal growth outcomes at birth and 20 showed evidence of intrauterine growth restriction, based on NGAS. There were significant increases in mechanical deliveries, abnormal FHR patterns and meconium staining of amniotic fluid in cases of growth-restricted neonates, determined using the NGAS classification, when compared with events related to normally grown infants. However, there were no significant differences in low Apgar score, neonatal acidosis, NICU admission and maternal complications between the 2 groups. CONCLUSION: Individualized growth assessment should be useful for detection of SGA infants with poor perinatal outcomes.     

Subclassification of small-for-gestational-age fetus using fetal Doppler velocimetry

Our purpose was to determine whether small-for-gestational-age (SGA) fetus can be divided to subclassified groups using fetal Doppler velocimetry. Fifty-four pregnant women with SGA infant delivered after 37 weeks of gestation were studied. After 24 weeks of gestation, fetal middle cerebral artery puslatility index (MCAPI) and umbilical artery pulsatility index (UAPI) were measured at 2- to 3-week intervals using Doppler ultrasound. Perinatal outcomes [operative delivery due to fetal distress, abnormal fetal heart rate (FHR) pattern, meconium staining, low Apgar score (<7), neonatal acidosis (umbilical artery blood pH <7.15), neonatal intensive care unit (NICU) admission due to neonatal asphyxia, and decreased amniotic fluid] were compared in subclassified SGA groups using fetal Doppler velocimetry. The number of SGA fetuses with normal MCAPI and UAPI (normal SGA group) was 39, and those with significantly low MCAPI but normal UAPI (eventful SGA group) 15, respectively. Birth age and birth weights in the eventful SGA group were significantly earlier and lower than those in the normal SGA group, respectively (p < 0.05, and p < 0.005). There were significant increases in operative deliveries, abnormal FHR patterns and decreased amniotic fluid in eventful SGA group, when compared with events related to normal SGA group. However, there were no significant differences in meconium staining of amniotic fluid, low Apgar score, neonatal acidosis, and NICU admission between the two groups. These results suggest that SGA fetus with abnormally low MCAPI but normal UAPI has more poor perinatal outcomes, compared with that with normal MCAPI and UAPI.     

Comparison of late-second-trimester nonstress test characteristics between small for gestational age and appropriate for gestational age infants

OBJECTIVE: To compare electronic fetal heart rate (FHR) monitoring characteristics between appropriate for gestational age (AGA) fetuses and small for gestational age (SGA) fetuses and to determine whether SGA fetuses have specific abnormalities at second-trimester electronic fetal monitoring (EFM), using nonstress test. METHODS: Among 953 children born from 1993-1996, we identified 500 singleton infants born after 36 weeks' gestation of uncomplicated pregnancies in whom second-trimester (24-27 weeks' gestation) EFM records were obtained. Individual components of FHR patterns (baseline rate, baseline FHR variability, presence of acceleration [at least 10 beats per minute for at least 10 seconds], and periodic or episodic deceleration [at least 25 beats per minute for at least 15 seconds]) and birth characteristics were compared between AGA and SGA infants, or between pregnancies with or without second-trimester decelerations. RESULTS: Among 500 infants, 443 were AGA and 57 SGA; 105 had and 395 did not have second-trimester decelerations. Baseline FHR variability (12.9+/-3.2 beats per minute) in SGA fetuses was significantly higher than variability (10.3+/-3.4 beats per minute) in AGA fetuses (P<.001). Small for gestational age fetuses were significantly more likely to have second-trimester decelerations than AGA fetuses (33.3% vs. 19.4%, P<.05). There were no significant differences in baseline rate and accelerations between AGA and SGA infants. Small for gestational age infants were more frequent in pregnancies with second-trimester decelerations, compared with those without second-trimester decelerations (18.1% vs. 9.6%, P<.05). Baseline FHR variability in pregnancies with second-trimester decelerations was significantly higher than in pregnancies without second-trimester decelerations (12.2+/-3.7 vs. 10.0+/-3.1 beats per minute, P<.001). CONCLUSION: Periodic or episodic decelerations and increased FHR variability during late second-trimester EFM were associated with an increased risk of SGA birth weight.     

Significance of meconium during labor.

Continuous fetal heart rate (FHR) monitoring and routine fetal scalp blood sampling was utilized in the evaluations of 366 fetuses during labor. One hundred and six patients had meconium in the amniotic fluid at some time during labor. A total of 26,110 uterine contractions were monitored during these 366 labors. The incidence of FHR patterns as a percentage of uterine contractions was calculated for the meconium and nonmeconium groups. Although there was a 3 1/2-fold increase in the incidence of low five-minute Apgar scores (less than 7) in the meconium group, signs of fetal distress were, with rare esception, not significantly different from those in the nonmeconium group. The presence of meconium in the amniotic fluid without signs of fetal asphyxia (late decelerations and acidosis) is not a sign of fetal distress and need not be an indication for active intervention. The combination of fetal asphyxia and meconium staining of the amniotic fluid, however, does enhance the potential for meconium aspiration and a poor neonatal outcome. Universal fetal heart rate monitoring and appropriate fetal acid-base evaluation is recommended for following patients with meconium in the amniotic fluid during labor.     

第一产程异常胎心监护图形与新生儿结局的关系

目的　探讨第一产程异常胎心监护图形与新生儿结局的关系。方法　回顾分析 2 0 0 2年 8月至 2 0 0 3年 6月在我院足月单胎头位分娩产妇 ,第一产程中胎心率 (FHR)异常图形 2 1 7例 (观察组 )和FHR正常图形的2 6 9例 (对照组 )的临床资料。结果　第一产程异常FHR图形的发生率为 4 4 7% ,常见类型为轻度变异减速(6 4 5 % )、基线变异减弱 (2 1 6 % )和轻度心动过速 (1 2 0 % )。晚期减速、基线变异减弱和重度变异减速是导致新生儿窒息的危险因素。观察组羊水过少 (5 1 % )、脐带缠绕 (2 2 6 % )、羊水粪染 (1 0 6 % )、新生儿窒息 (6 5 % )、新生儿转入NICU(1 0 1 % )的发生率和剖宫产率 (31 8% )明显高于对照组 (P <0 0 5 )。结论　第一产程异常FHR图形的发生率较高 ,其中晚期减速、基线变异减弱、重度变异减速与新生儿窒息的发生相关 ,其他图形可在严密监护下继续试产     

产程中持续内监护下行羊膜腔输液及羊水置换治疗胎儿窘迫

目的 探讨产程中持续内监护下行羊膜腔输及羊水置换,对治疗胎儿窘迫的意义。方法 对产程中出现频发可变减速合并羊水胎粪污染者１３６例,随机分为观察组与对照组各６８例,观察组在持续内监护下行羊膜腔输液或羊水置换。对照组给予吸氧、改变体位、静脉输液等治疗。结果观察组经羊膜腔输液５００￣１０００ｍｌ,ＶＤ波消失或明显改善者占９１．２％,同时对观察组中４８例羊水Ⅱ度以上粪染者行羊水置换,其中３９例羊水国 清亮     

Impact of being small-for-gestational age on survival and long-term outcome of extremely premature infants born at 23-27 weeks' gestation

AIM: To evaluate factors affecting survival and long-term outcome of extremely premature infants and to determine whether small for gestational age (SGA) status is an additional risk factor. METHODS: Survival was analyzed in 193 infants born between 23 and 27 weeks of gestational age (GA) and compared between SGA (n=43) and appropriate for gestational age (AGA) infants. Long-term outcome was assessed in 123 infants at six years of chronological age by neurological evaluation and cognitive tests. RESULTS: The long-term survival rates were 72.1% for SGA and 84.0% for AGA infants. Significant independent factors affecting survival were GA (OR 1.79 for one week advance, 95% CI 1.36-2.34) and SGA (OR 0.42, 95% CI 0.18-0.997) in comparison with AGA. There were no significant differences in rates of cerebral palsy or mental retardation, 12.0% and 24.0% in SGA, 14.3% and 17.3% in AGA, respectively. Fifty-two percent of SGA and 70% of AGA infants had intact long-term outcome. The perinatal factor found to affect the intact long-term outcome was RDS with surfactant therapy (OR 0.17, 95% CI 0.07-0.45). CONCLUSION: SGA status as well as short gestation had significant effects on survival. Respiratory complications after birth had a larger detrimental effect on long-term outcome than whether the infant was SGA or AGA.     

Antenatal fetal heart rate variation in relation to the respiratory and metabolic status of the compromised human fetus

Three groups of women were delivered by caesarean section before labour: for an abnormal fetal heart rate (FHR) trace (21 cases, group 1), or for maternal deterioration in severe pre-eclampsia without gross fetal heart rate abnormalities (20 cases, group 2), or to avoid mechanical difficulties in labour at term (30 cases, group 3). The mean gestational ages of the first two groups were 32 weeks with a high proportion of infants small-for-gestational-age. In group 1, FHR variation (mean range of pulse intervals) was less than half (20.6 SE 1.2 ms) of the normal value at the same age (44.4 SE 1.5 ms). This was associated with hypoxaemia (mean umbilical artery PO2 of 6 mmHg at delivery), with evidence of compensation shown by an elevated amniotic fluid erythropoietin. The fetuses were hypoglycaemic and had greater umbilical artery blood alanine concentrations, but no large changes in adenine nucleotide or endorphin plasma concentrations. Although there was a minor degree of respiratory acidaemia at birth, there was not significant metabolic acidaemia. The results demonstrate that the reduced variation of 'suboptimal' and 'decelerative' fetal heart rate records is associated with fetal hypoxaemia and evidence of nutritional deprivation, but not with asphyxia.     

Antenatal fetal heart rate variation in relation to the respiratory and metabolic status of the compromised human fetus

Summary. Three groups of women were delivered by caesarean section before labour: for an abnormal fetal heart rate (FHR) trace (21 cases, group 1), or for maternal deterioration in severe pre-eclampsia without gross fetal heart rate abnormalities (20 cases, group 2), or to avoid mechanical difficulties in labour at term (30 cases, group 3). The mean gestational ages of the first two groups were 32 weeks with a high proportion of infants small-for-gestational-age. In group 1, FHR variation (mean range of pulse intervals) was less than half (20·6 SE 1·2 ms) of the normal value at the same age (44·4 SE 1·5 ms). This was associated with hypoxaemia (mean umbilical artery P o₂ of 6 mmHg at delivery), with evidence of compensation shown by an elevated amniotic fluid erythropoietin. The fetuses were hypoglycaemic and had greater umbilical artery blood alanine concentrations, but no large changes in adenine nucleotide or endorphin plasma concentrations. Although there was a minor degree of respiratory acidaemia at birth, there was not significant metabolic acidaemia. The results demonstrate that the reduced variation of 'suboptimal' and 'decelerative' fetal heart rate records is associated with fetal hypoxaemia and evidence of nutritional deprivation, but not with asphyxia.     

羊膜腔输液治疗在产时应用的临床分析

目的 :分析羊膜腔输液 (amnioinfusion,AI)治疗产时羊水过少、胎膜早破和胎粪性羊水的临床意义。方法 :选择产程中发生胎心异常合并羊水过少、胎膜早破和羊水胎粪污染的孕产妇 1 0 1例 ,随机分为治疗组 51例 ,对照组 50例。治疗组在胎心监护下行羊膜腔输液或羊水置换 ;对照组给予吸氧 ,改变体位 ,静滴 5% Na HCO3等治疗。结果 :治疗组经羊膜腔输液 50 0～ 1 0 0 0 ml,胎心可变减速 (variable deceleration,VD)和长时减速 (period long deceleration,PL D)消失或明显改善 44例 ,有效率占 86 .3% ,明显高于对照组 (2 2 % ) ,两组比较差异有显著性 (P<0 .0 1 )。治疗组 1 9例胎粪性羊水行羊水置换 ,有 1 7例羊水转为清亮或 度混浊。治疗组产程时间比对照组缩短 ,治疗组和对照组剖宫产率分别为 1 3.7%和 34.0 % ,新生儿窒息率分别为 3.9%和 42 .0 % ;对照组胎粪吸入性肺炎 9例 ,新生儿死亡 3例 ,治疗组仅一例发生胎粪吸入性肺炎 ,无新生儿死亡。产褥病率两组比较 ,差异无显著性 (P>0 .0 5)。结论 :羊膜腔输液是治疗产时羊水过少、胎膜早破、胎粪性羊水的有效方法     

The role of antepartum testing in the management of postterm pregnancies with heavy meconium in early labor

The documented association between heavy meconium in early labor and increased perinatal morbidity and mortality has alerted physicians to the presence of a potential high-risk fetal condition and to the possible need for immediate fetal blood pH determination. The purpose of this study was to determine whether antepartum fetal assessment can predict whether a postterm fetus with heavy meconium in early labor is at low or high risk for an adverse perinatal outcome. Eight hundred thirty-nine postterm patients were followed with antepartum testing, consisting of twice-weekly fetal heart rate (FHR) testing and ultrasonic amniotic fluid volume estimation. Overall, patients with heavy meconium in early labor had a significantly greater frequency of fetal distress. However, when women with heavy meconium in early labor were separated according to their antepartum testing results, those with normal results were found to have no greater risk for fetal distress or perinatal morbidity than women with normal testing and subsequently clear amniotic fluid. These findings suggest that postterm patients with heavy meconium in early labor and normal antepartum testing can be managed in labor in the same manner as low-risk patients without meconium.     

Long term outcome after umbilical artery acidaemia at term birth: influence of gender and duration of fetal heart rate abnormalities

Objective To study the outcome after acidaemia at term birth, and the relation to gender and duration of pathological fetal heart rate changes.
Design Population based study of 154 infants with umbilical artery pH < 7.05 at term birth. Neonatal outcome and the result of developmental screening at age four years were compared with a control group with pH > 7.10. Fetal heart rate traces in infants with acidaemia were reviewed, and the relation between duration of fetal heart rate changes and outcome was analysed.
Results Of the 154 newborns with acidaemia at birth, 10 had encephalopathy, of which two died and two developed cerebral palsy. Nine of these 10 infants were boys, and eight had pH < 7.00. Male newborns (   n = 39  ) more often had pronounced acidaemia (pH < 7.00) than females (   n = 22  ). Although few infants had severe impairment, infants born with acidaemia significantly more often had speech problems at follow up than controls (19/102 versus 8/98; P = 0.03). In infants with acidaemia, duration of abnormal fetal heart rate changes was significantly associated with neonatal encephalopathy and speech problems at age four years.
Conclusions Acidaemia at term birth was associated with neonatal encephalopathy and with speech problems at four years of age. Boys had more often pronounced acidaemia and a complicated course. A protracted abnormal fetal heart rate trace was associated with poor outcome.     

Tracheal suction in meconium aspiration.

We performed a retrospective study of the morbidity and mortality rates of 125 infants, born through meconium-stained amniotic fluid, and admitted to the newborn intensive-care unit for observation. A comparison was made of maternal age, history of toxemia, type of anesthesia, duration of analgesia, presence of cord complications, abnormalities of fetal heart rate, duration of meconium staining, birth weight, gestational age, 1 and 5 minute Apgar scores, and type of resuscitation between infants who were symptomatic or asymptomatic in the unit. Forty-three developed respiratory distress (symptomatic) and eight died; 82 were asymptomatic. The only difference between the two groups was a history of immediate tracheal suction in the delivery room. Of 97 infants receiving immediate tracheal suction, 27 became symptomatic and one died--an infant with Down's syndrome and endocardial cushion defect. On the other hand, of 28 infants who did not receive immediate tracheal suction, 16 became symptomatic and seven died of massive meconium aspiration pneumonitis (P less than 0.001). We concluded that in infants born through meconium-stained amniotic fluid, immediate tracheal suction is a safe procedure that significantly lowers the morbidity and mortality rates and produces no further respiratory depression of the infant.     

Meconium mineral content in small for gestational age neonates

The mineral concentration of meconia of small for gestational age (SGA) newborns were compared with those of appropriate for gestational age (AGA) newborns of similar gestational ages (GA) to determine whether differences may provide clues of possible nutritional deficits of SGA infants, given that levels of meconium minerals could indicate the use of minerals by the fetus and the sufficiency of the maternal supply of minerals. Twenty-one SGA and 24 AGA newborns were included. Eleven SGA and 15 AGA were < or = 35 weeks GA. Ten SGA and nine AGA infants were > or = 36 weeks GA. All meconia from each neonate was processed and assayed for iron, zinc, copper, manganese, calcium, magnesium, and phosphorus. In the < or = 35-week subgroups, the SGA infants had lower meconium iron and manganese concentrations than that of the AGA. Among > or = 36-week newborns, SGA infants had a higher birthweight-adjusted copper concentration than AGA infants, but no differences were observed for the remaining elements. Lower iron and manganese meconium in < or = 35-week SGA infants may reflect either a greater use or a decreased maternal supply. The higher birthweight-adjusted meconium copper in the > or = 36-week SGA infants may be due to a comparatively reduced fetal use or increased maternal supply. These data may assist in clarifying potential mechanisms affecting intrauterine growth and/or potential nutrient deficits in the neonatal period.     

Fetal tachycardia and meconium staining: A sign of fetal infection

A retrospective study was carried out on 72 liveborn babies in whom perinatal infection was suspected. Twenty-nine of the 72 neonates were effectively infected. Analysis of intrapartum FHR recordings showed that tachycardia (base line FHR above 160 beats/min) during labor, occurred more often among infected babies (P < 0.001). When fetal tachycardia is associated with meconium stained amniotic fluid (MSAF), the relative risk of fetal infection is 51 times as great as in babies without MSAF. Fetal tachycardia is not related to maternal fever nor to prematurity. It is not a sign of limited placental or amniotic fluid infection, but implies infection of the fetus itself. Since most infected babies displayed infectious diarrhea immediately at birth, it is suggested that MSAF may eventually be due to antenatal intestinal infection and intrauterine emission of infected stools. Although great caution is advocated for the management of labor in the presence of fetal tachycardia, MSAF should not be always regarded as a sign of acute fetal distress when antenatal infection of the fetus is suspected.     

Meconium Staining and Its Effect on Hospital Care During the Neonatal Period

Objective: to characterize differences in outcome and course of newborn care between births with meconium-stained amniotic fluid and those with clear amniotic fluid.Design: prospective cohort study complemented by retrospective chart review.Setting: London Health Sciences Centre.Participants: all live singleton births delivered at LHSC between January 1 and December 31, 1996. Excluded were multiple births and elective Caesarean sections.Outcome Measures: degree of resuscitation performed on newborns, Apgar scores, paediatric consultations, transfers from newborn nursery to higher level of care, hospital revisit and readmission rates within 30 days of discharge.Results: there were a total of 126 births associated with thick meconium staining, 194 with thin meconium staining, and 52 with terminal meconium only. Resuscitation efforts were undertaken in 54.0 percent of thick meconium births, 32.5 percent of thin meconium births, 30.8 percent of terminal meconium births and 17.3 percent of births with clear amniotic fluid, a significant difference (p<0.001). One-minute Apgar scores less than 7 occurred in 23.0 percent of thick meconium births, 14.4 percent of thin meconium births 7.7 percent of terminal meconium births and 6.4 percent of births with clear amniotic fluid. Five-minute Apgar scores less than 8 were significantly more common (5.5%) in meconium-stained births of all types (thick, thin, and terminal) than in births with clear amniotic fluid (0.64%; p<0.001). Five percent of infants with meconium staining and 1.6 Percent of infants with clear amniotic fluid required paediatric critical care unit (PCCU) admission: a significant difference (p=0.016). Paediatric consultation rate after transfer from the delivery room was 18.3 percent for infants born with thick meconium, significantly more than the 10.0 percent for infants not born with thick meconium (p=0.014). There was no significant difference in frequency of subsequent visits to the emergency department or readmission rates in the first month after birth by infants who had any degree of meconium staining compared to those who had clear amniotic fluid.Conclusions: presence and degree of meconium-stained amniotic fluid prior to birth predicts an increased likelihood of resuscitative interventions and a possibility of increased intensity of care needed in the first few days of life.