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.     

Are histopathologic chorioamnionitis and funisitis associated with metabolic acidosis in the preterm fetus?

OBJECTIVE: Perinatal infection increases the risk of neonatal neurologic injury. Our objective is to determine whether histologically confirmed chorioamnionitis and funisitis is associated with fetal metabolic acidosis. STUDY DESIGN: This is a retrospective cohort study of all infants 34 weeks or less born at a single tertiary hospital admitted to the neonatal intensive care unit (NICU) between April 1999 and September 2002. Maternal and neonatal records and placental pathology reports were reviewed. RESULTS: There were 392 infants at 23 to 34 weeks' gestational age admitted to the NICU during this period of whom 354 had placental pathology reported; 259 infants had umbilical cord gases available. These neonates were placed into 3 groups: group 1 (208 infants) had no signs of placental infection, group 2 (59 infants) had isolated chorioamnionitis, and group 3 (87 infants) had both chorioamnionitis and funisitis. The gestational age (30.2 +/- 2.8, 28.3 +/- 3.4, 27.8 +/- 2.8 weeks, P < .01) and birth weight (1358 +/- 520, 1242 +/- 547, 1103 +/- 381 g, P < .01) were significantly higher in group 1. There was an increase in neurologic morbidity in groups 2 and 3 (25.2%, 34.4%, 43.7%), which was not significant when corrected for gestational age. Groups 2 and 3 had a small but significant increase in umbilical arterial pH (7.25 +/- 0.10, 7.29 +/- 0.10, 7.30 +/- 0.08, P < .01) and base excess (-3.5 +/- 3.6, -2.2 +/- 3.6, -2.3 +/- 2.7 mmol/L, P = .02). When a single pathologist reviewed all placentas with any inflammation and staged them on the basis of the degree of the fetal inflammatory response, no relationship was found between the degree of fetal inflammation and umbilical arterial pH (stage 1, 7.27 +/- 0.09; stage 2, 7.30 +/- 0.09; stage 3, 7.30 +/- 0.08; P = .41) or base excess (stage 1, -2.82 +/- 3.47 mmol/L; stage 2, -1.95 +/- 3.17 mmol/L; stage 3, -2.23 +/- 3.07 mmol/L; P = .62). When stepwise multiple linear regression was performed, neither histologic chorioamnionitis nor histologic funisitis were associated with a change in umbilical cord pH or base excess. CONCLUSION: Intrauterine infection, as confirmed by histologic chorioamnionitis and funisitis, is not associated with fetal metabolic acidosis. Intrauterine infection may represent a nonhypoxic form of encephalopathy that produces neurologic morbidity by a mechanism independent of hypoxia-ischemia leading to metabolic acidosis.     

Incidence of meconium aspiration syndrome in term meconium-stained babies managed at birth with selective tracheal intubation.

The delivery room management of infants born through meconium stained amniotic fluid (MSAF) remains controversial. The aim of this prospective study was to evaluate maternal and neonatal characteristics of MSAF infants and the incidence of meconium aspiration syndrome (MAS) in routine delivery room management which reserved selective intubation for depressed/asphyxiated babies. Between October 1993 and September 1997, a consecutive sample of 3745 full-term infants was analyzed. Of these, 361 were MSAF infants. No significant difference in maternal age, parity, gestational age, sex, low 1 and 5 minute Apgar scores, metabolic acidemia, or need for endotracheal intubation was found between MSAF and non-MSAF infants. Only one of the MSAF infants (0.28%), who needed intubation, developed MAS. Identification of postterm pregnancy and prenatal asphyxia is the best prevention of MAS.     

Meconium stained amniotic fluid in very low risk pregnancies at term gestation

Objective: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. Methods: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30 921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. Results: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group ( ) compared with women with clear AF ( ). Conclusions: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.     

Incidence of and factors associated with meconium staining of the amniotic fluid in a Nigerian University Teaching Hospital.

This study was conducted to determine the incidence of meconium staining of the amniotic fluid (MSAF) and its associated factors in a Nigerian teaching hospital. Perinatal data on 80 consecutive live, singleton infants of booked mothers born through meconium-stained liquor from March - June 2003 were analysed and compared with babies born through clear liquor. The incidence of MSAF was 20.4% for 393 deliveries. The rate increased with gestational age: no case was found below 37 weeks (p = 0.001). Primiparity, prolonged rupture of fetal membranes and obstructed labour were more often associated with MSAF (p = 0.005, p = 0.0013 and p = 0.0000002, respectively) as were tachycardia or bradycardia and low Apgar scores (p = 0.0000001 and p = 0.046, respectively). It is concluded that meconium-staining is common. It is related to gestational maturity and stressful peripartum conditions and associated with adverse symptomatology in the fetus and newborn.     

Have the year 2000 neonatal resuscitation program guidelines changed the delivery room management or outcome of meconium-stained infants?

OBJECTIVE:To study the impact of neonatal resuscitation program (NRP) guidelines on delivery room (DR) management of infants born through meconium-stained amniotic fluid (MSAF).STUDY DESIGN:A retrospective study of all term (>or=37 weeks) infants born through MSAF was performed. Patients were divided into two periods: pre year 2000 NRP and post year 2000 NRP. Meconium consistency, APGAR scores and intubation (INT) for suctioning and respiratory outcome were recorded. Groups were analyzed using chi (2) tests and stepwise logistic regression.RESULTS:The incidence of MSAF remained constant in period 1 (13.6%) and period 2 (13.1%) while the proportion of infants intubated fell from 67 to 41% (p<0.001). The incidence of meconium aspiration and nonspecific respiratory distress did not differ between groups.CONCLUSIONS:Since the implementation of year 2000 NRP guidelines, the rate of DR INT for tracheal suctioning has fallen significantly without a change in overall respiratory complications. Results of this study support the efficacy of year 2000 NRP recommendations.     

Meconium-stained amniotic fluid and its association with obstetric infections

Meconium-stained amniotic fluid (MSAF) complicates the intrapartum course of 1.5% to 18% of pregnancies. In addition to predisposing to the meconium aspiration syndrome, MSAF is also an established risk factor for neonatal sepsis and for intrapartum and postpartum maternal infection. Meconium enhances the growth of bacteria in amniotic fluid by serving as a growth factor, inhibits the bacteriostatic properties of amniotic fluid, and antagonizes host defense systems such as phagocytosis, thus explaining the association between MSAF and intrauterine infection. Other evidence suggests that the presence of intraamniotic infection may actually cause passage of meconium in utero by inducing fetal enteritis and gastrointestinal hypermotility. Prophylactic intravenous ampicillin-sulbactam has been shown to be effective in significantly decreasing the rate of chorioamnionitis in patients with MSAF. Additional investigation is necessary to determine the optimal prophylactic antibiotic(s) and method of drug administration in patients with MSAF.     

Placental histologic patterns and neonatal seizure,in preterm premature rupture of membrane

Objective: To investigate the relationship between placenta and perinatal outcomes, in preterm infants born to mothers with preterm premature rupture of fetal membrane (PPROM).

Methods: We report detailed histology of placentas and perinatal outcomes of infants from 79 PPROM pregnancies. Placental histologic pattern and adverse perinatal outcomes were assessed by logistic regression, adjusting for gestational age at birth, birth weight and interval from rupture of membrane to delivery.

Results: Mean gestational age at membrane rupture was 29.5?±?3.4 weeks. The incidence of histologic chorioamnionitis (HCA), fetal inflammatory response (FIR) and vascular thrombotic abnormalities in placental histologic examination were 63.3, 25.3 and 78.5%, respectively. Neonates with FIR showed significantly higher incidence of periventricular leukomalacia (PVL) (85% versus 59.3%, p?=?0.0364) at brain ultrasonography, than neonates without FIR, in univariate analysis, but not in logistic regression analysis. In logistic regression analysis, the odds ratio of low Apgar score at 1?min in the neonates with clinical chorioamnionitis was 5.009 (95% CI, 1.242–20.195). The odds ratio of neonatal seizure in the neonates with FIR and vascular thrombotic problem was 7.486 (95% CI, 1.617–34.653).

Conclusions: Our findings support the association between FIR with vascular thrombotic problem in placenta and neonatal seizure, in pregnancies with PPROM.     

Meconium-stained amniotic fluid

Passage of meconium usually occurs within 48 hours after birth. However, some fetuses may pass meconium in-utero leading to meconium staining of amniotic fluid (MSAF). The vast majority of fetuses pass meconium in-utero due to the physiological maturation of the fetal gut with advancing gestation leading to normal defaecation in utero. However, clinicians need to exclude ‘non-physiological’ causes of MSAF, especially an ongoing hypoxia or chorioamnionitis, to improve perinatal outcomes. Meconium aspiration syndrome (MAS) is a potentially serious fetal condition with increased risk of severe morbidity and mortality. The use of the cardiotocograph (CTG), timely recognition of ongoing hypoxia or infection, consideration of the overall clinical picture and avoidance of injudicious use of oxytocin may help avoid poor perinatal outcomes and resultant medico-legal consequences.     

Impact of subclinical chorioamnionitis on maternal and neonatal outcomes

BACKGROUND: Chorioamnionitis is considered to be one of the main causes of preterm labor and has been associated with an adverse perinatal outcome in preterm infants. The controversy about the benefits/risks of delaying labor is a critical issue concerning the management of chorioamnionitis. METHODS: The database between July 2001 and March 2006 was reviewed for women with singleton pregnancies between 22 and 28 weeks of gestation and with chorioamnionitis diagnosed on admission by amniotic fluid neutrophil elastase level. Women were classified according to the severity of chorioamnionitis (group A, amniotic fluid neutrophil elastase level of 0.15-1 microg/ml; B, 1-10 microg/ml; and C, > or = 10 microg/ml). During expectant management, serum C-reactive protein levels monitored the remission and aggravation of chorioamnionitis. Following deliveries, placentas were examined for histologic chorioamnionitis. RESULTS: One hundred women were enrolled (group A, 38; B, 34; C, 28). The latency period until delivery was significantly longer in group A than in groups B and C. C-reactive protein levels just before delivery were higher than those on admission in 61% of the overall cases. Histologic chorioamnionitis and funisitis were manifested in 90.4% and 65.5%, respectively. Intrauterine fetal demise (4 cases) and neonatal and postneonatal deaths during admission (10 cases) were observed. Bronchopulmonary dysplasia was the most common major morbidity noted in groups B and C. CONCLUSION: Chorioamnionitis could be controlled but is hard to cure. Higher levels of amniotic fluid neutrophil elastase are associated with a shorter interval from admission to delivery in women with subclinical chorioamnionitis.     

Indomethacin activity in the fetal vasculature of normal and meconium exposed human placentae

OBJECTIVE: To study the effect of indomethacin on the vasculature of isolated perfused human placental cotyledon in normal and meconium pretreated placentae. STUDY DESIGN: Isolated placental cotyledons were dually perfused and fetal perfusion pressure was used as an index of vascular resistance. Meconium-stained amniotic fluid (MSAF) was collected from patients after artificial rupture of membranes, diluted 1:2, 1:4, 1:16 and 1:32 and a spectrophotometric determination of meconium concentration in amniotic fluid was performed. Only MSAF with an optical density of 20.0 units per gram was used in this study. In five placentae, the effect of indomethacin (100 microg/ml continuous perfusion from the fetal site) on basal pressure of the fetal-placental vasculature was established. In five more placentae, the effect of indomethacin on MSAF-induced vasoconstriction was established when a bolus injections of 1 ml MSAF was made into the fetal circulation. The statistical significance of response to MSAF injection was determined by paired t-test and ANOVA repeated measurements. RESULTS: A significant vasoconstrictor response to MSAF was achieved in normal placentae. Bolus injections of MSAF into the fetal circulation resulted in a significant increase in perfusion pressure (P=0.0026). Indomethacin was capable of significantly reducing the basal perfusion pressure (P=0.03). Significant attenuation of vasoconstrictor response to MSAF occurred in the presence of indomethacin (P=0.0016). CONCLUSION: Indomethacin causes a significant reduction in basal pressure of fetal placental vasculature in the human placental circulation in vitro and is capable of attenuating the vasoconstrictory activity of MSAF. The mechanism of such activity may be explained partially by the inhibitory effect of indomethacin on the PG-mediated pathways.     

Incidence of chorioamnionitis in patients with meconium-stained amniotic fluid

Objective: The goal of this study was to determine if meconium staining of the amniotic fluid (MSAF) is a marker for chorioamnionitis.Methods: In a retrospective, case-control investigation, we studied 100 patients with MSAF. Each patient was matched with a control who delivered during the same period but did not have MSAF. Subjects and controls were matched for age, parity, gestational age, mode of delivery, duration of rupture of membranes (ROM), length of internal monitoring, and number of examinations before and after ROM. The incidence of chorioamnionitis in controls and study patients was compared. The diagnosis of chorioamnionitis was based on clinical examination.Results: Thirteen of the 200 patients [6.5%, 95% confidence interval (CI), 2.5-10.5%] developed chorioamnionitis. Of the 100 women with MSAF, 10 (10%, 95% CI, 4-16) were infected compared with only 3 controls (3%, 95% CI, 0-6, P = 0.04). The odds ratio (OR) for this comparison was 3.3, and the 95% CI was 1.02-10.63.Conclusions: MSAF is associated with an increased frequency of chorioamnionitis. Several factors could explain this association. Infection may cause fetal stress, leading to the release of meconium. MSAF may enhance the growth of bacteria by providing a rich medium of essential nutrients or growth stimulants. MSAF also may impair the host immune system so that chemotaxis or phagocytosis is diminished, thus allowing accelerated growth of microorganisms.     

Intrapartum and postdelivery management of infants born to mothers with meconium-stained amniotic fluid: evidence-based recommendations

The article reviews and critically evaluates the available evidence to determine whether the current recommendations for the management of infants born through meconium stained amniotic fluid (MSAF) should be maintained. Authors provide evidence-based recommendations regarding the benefits of amnioinfusion prior to delivery, oral suctioning of the newborn prior to delivery of the shoulder, and the practice of routine endotracheal suctioning of the newborn born through MSAF in preventing meconium aspiration syndrome (MAS). Authors also discuss the gaps in knowledge in all the above interventions to prevent MAS.     

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.     

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.     

The value of cord blood interleukin-6 levels for predicting chorioamnionitis, funisitis and neonatal infection in term premature rupture of membranes

OBJECTIVE: The objective was to determine whether the interleukin-6 (IL-6) level in umbilical cord blood can be used for the prediction of histologic chorioamnionitis, funisitis, fetal membrane cultures and neonatal infection. STUDY DESIGN: A case-control study was conducted on 30 controls (control group) and on 40 women with term premature rupture of the membranes (PROM group). The interleukin-6 concentration of cord blood was measured. Fetal membranes and newborn blood were cultured. Placentas were examined for histologic chorioamnionitis and funisitis. Receiver operator curve analysis was used to obtain a cut-off value of interleukin-6 concentration for predicting histological and clinical infection. RESULTS: The mean interleukin-6 level in cord blood was significantly higher in the PROM group (p=0.01). Histological chorioamnionitis and positive placental cultures were significantly higher in the PROM group (p=0.006 and 0.02, respectively). The PROM group had seven (17.5%) cases of funisitis and positive newborn blood cultures while neither was observed in the control group. A cord blood interleukin-6 level >29 pg/ml was found to have 84% sensitivity and 72.5% specificity for predicting positive placental cultures and 74.1% sensitivity and 76.7% specificity for identifying cases of histologic chorioamnionitis. For predicting funisitis and positive newborn cord blood cultures a cord blood interleukin-6 level >39 pg/ml has 100% sensitivity and 81% specificity. CONCLUSION: Cord blood interleukin-6 level can be a tool for the evaluation of the extent of maternal-fetal infection and guides proper planning of the treatment.     

The relationship among inflammatory lesions of the umbilical cord (funisitis), umbilical cord plasma interleukin 6 concentration, amniotic fluid infection, and neonatal sepsis

OBJECTIVE: The purpose of this study was to determine whether funisitis (inflammation of the umbilical cord detected by histologic examination of the placenta) is associated with changes in the umbilical cord plasma concentration of interleukin 6, microbial invasion of the amniotic cavity, and neonatal sepsis. STUDY DESIGN: The relationship among the presence of funisitis, interleukin 6 concentrations in umbilical cord plasma at birth, the results of amniotic fluid culture performed within 3 days of birth, and the occurrence of congenital neonatal sepsis was examined in 315 consecutive singleton preterm births (20-35 weeks' gestation). Funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton jelly. The interleukin 6 concentration was measured with a specific immunoassay. Amniocentesis was performed in 106 patients within 3 days of birth. Amniotic fluid was cultured for aerobic and anaerobic bacteria and for mycoplasmas. RESULTS: (1) Funisitis was present in 25% of patients (78/315). (2) Patients with funisitis had a significantly higher median cord plasma interleukin 6 and a lower gestational age at birth than did those without funisitis (cord interleukin 6: median, 52.4 pg/mL; range, 0.9-19,230 pg/mL; vs median, 4.6 pg/mL; range, 0-18,108 pg/mL; gestational age: median, 31.1 weeks' gestation; range, 21.0-35.0 weeks' gestation; vs median, 32.9 weeks' gestation; range, 21.4-35.0 weeks' gestation; P<.001 for each comparison). (3) A cord plasma interleukin 6 of > or =17.5 pg/mL had a sensitivity of 70% and a specificity of 78% in the identification of funisitis. (4) Microbial invasion of the amniotic cavity and clinical chorioamnionitis were more common among patients with funisitis than among those without funisitis (positive amniotic fluid culture: 53% [20/38]; vs. 12% [8/68]; clinical chorioamnionitis: 18% [14/78]; vs. 4% [9/237]; P<.001 for each comparison). (5) Neonates with funisitis had a significantly higher rate of congenital sepsis than did those without this lesion (12% [8/66] vs. 1% [3/216]; P<.001); this difference remained significant after adjustment for gestational age at birth (odds ratio, 7.2; 95% confidence interval, 1.8-29.0). CONCLUSION: (1) Umbilical cord plasma interleukin 6 concentrations were higher in neonates born with funisitis than in those without this lesion. (2) Funisitis is associated with amniotic fluid infection, congenital neonatal sepsis, and the fetal inflammatory response syndrome.     

Meconium stained fluid: approach to the mother and the baby

Meconium aspiration syndrome (MAS) is a common problem that most pediatricians will encounter in the delivery room and normal newborn nursery. Approximately 13% of all live births are complicated by meconium stained amniotic fluid (MSAF). MAS is defined as respiratory distress in an infant born through MSAF whose symptoms cannot be otherwise explained. Optimal care for an infant born through MSAF involves cooperation between the obstetrician and pediatrician, each with separate but imperative roles.     

A fetal response to chorioamnionitis is associated with early survival after preterm birth

OBJECTIVE: The purpose of this study was to determine, in a large preterm cohort (20-34 completed weeks of gestation), the incidence of histologic chorioamnionitis and the incidence of a histologic fetal response to chorioamnionitis (umbilical vasculitis with or without funisitis) in neonatal survivors (to 28 days) and perinatal deaths. STUDY DESIGN: Placental histopathology was reviewed (n=3928 reports). In a subset of this cohort (n=2076 reports), evidence of a histologic fetal response was compared in neonatal survivors and perinatal deaths. RESULTS: The incidence of histologic chorioamnionitis ranged from 66% at 20 to 24 weeks of gestation (n=261 neonates) to 16% at 34 weeks (n=770 neonates). The overall incidence was 31% (n=3928 neonates). At 25 to 29 weeks of gestation, neonatal survivors had a higher incidence of histologic chorioamnionitis (P=.02; 95% CI, 1.02-1.21). In addition, neonatal survivors had a higher incidence of a histologic fetal response to chorioamnionitis at 25 to 29 weeks of gestation (P=.01; 95%CI, 0.33-0.86) and 30 to 34 weeks of gestation (P=.02; 95%CI, 0.18-0.85). CONCLUSION: Histologic chorioamnionitis is inversely related to gestational age. Both histologic chorioamnionitis and a histologic fetal response to chorioamnionitis were observed to be more common in preterm survivors of the neonatal period.     

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.