Acta Paediatr 81: 797-801. 1992
Neurological adaptation of infants delivered by emergency or elective cesarean section G Otamiri, G Berg', 0 Finnstrom, I Leijon
'
Departments of Paediatrics and ObstetricslGynaecoIogy University Hospital. Linkoping, Sweden ~
Otamiri G, Berg G, Finnstrom 0,Leijon I. Neurological adaptation of infants delivered by emergency or elective cesarean section. Acta Paediatr 1992;81:797-801. Stockholm. ISSN 0803-5253 The effects of intrapartal asphyxia on neonatal neurological condition have been studied in 17 full-term infants delivered by emergency cesarean section and in 30 full-term infants delivered by elective cesarean section used as controls. A neurol?gical examination consisting of 3 1 items was performed on days I , 2 and 5 after birth. A tonus score, an excitability score as well as the number of optimal responses were calculated. A follow-up examination was done at six months of age with a standardized neurological and developmental examination. The results showed that infants born after emergency cesarean section were significantly more hypotone the first two days after delivery than the infants in the elective cesarean section group. In regard to individual neurological items, significant differences were found between the emergency and elective cesarean section in reaction to sound, rooting, patellar, Moro and stepping reflexes with weaker reactions in the elective cesarean section group. Growth, psychomotor development and neurological status at six months did not differ significantly between the groups. Our findings indicate that full-term infants born after emergency cesarean section due to mild intrapartal asphyxia have a delayed neurological adaptation as expressed by poor muscular tonus during their first days of life compared with infants born after elective cesarean section. 0 Elective cesarean section, emergency cesarean section, full-term infants, intrapartal asphyxia, neurological function, psychomotor development Ingemar Leijon, Department of Paediatrics, University Hospital, S-581 85 Linkoping. Sweden
Fetal distress, as an indication for cesarean section (CS), accounts for a large proportion of CS deliveries (1). Acute intrapartal asphyxia might disturb the immediate postnatal adaptation regarding both cardio-respiratory and neurological functions. However, it is difficult to evaluate the isolate effect of asphyxia, since the delivery per se, regardless of asphyxia, has an effect on neurological condition (2). Comparing two groups of CS infants, one born after emergency CS because of intrapartal asphyxia and one after elective CS would provide the chance to evaluate the asphyctic effect, although the CS itself both affects the respiratory function (3-8) and delays the neurological adaptation (9). Clinically, intrapartal asphyxia was diagnosed (by fetal heart rate changes) by cardiotocography (CTG) and/or pH measurements from the fetal scalp. The clinical situation with CTG changes were the basis for diagnosing intrapartal asphyxia in this study. The aim of the present study was to examine the effect of intrapartal asphyxia at full-term age on (i) the neonatal neurological adaptation and (ii) to evaluate any long-term effects of asphyxia on the infants through a follow-up examination of development and neurology at six months of age.
Material and methods The study was performed at the Departments of Paediatrics and Obstetrics/Gynaecology at the University Hospital, Linkoping, between February 1987 and December 1988. The total number of deliveries in the hospital during this period was 4,120. During this time 1 1.5% of all mothers were delivered by CS, 60% of them electively. Primiparae as well as multiparae who fulfilled the following criteria were included in the study: Elective CS group The elective CS group (controls) consisted of 30 mothers and their infants. Pregnant women with medical indications for elective CS were selected according to the following inclusion criteria provided they accepted participating in the study. 0 0
0 0 0
Medically uneventful pregnancy, with gestational age confirmed by early ultrasound examination. Delivery at full-term age (after 37 completed weeks). Normal fetal growth and no suspicion of fetal disease. Single birth. Indications for CS being feto-pelvic disproportion,
798
G Oramiri er at.
ACTA PEDJATR 81 (1992)
previous CS, placenta praevia or humanitarian (that is CS because of fear of vaginal child birth). No labour activity at the time of surgery.
maternal age, parity, marital status and educational level between the groups.
Of the 30 mothers delivered by elective CS, 5 had breech presentation. The indication for CS was fetopelvic disporportion in 16 cases, CS in earlier pregnancy in 10 cases and placenta praevia in 1 case. In the remaining 3 cases the indication was humanitarian (fear of vaginal child birth). In the elective CS group 8 women were operated upon in general anaesthesia and 22 in epidural or spinal anaesthesia. In both groups premedication with 0.5 mg atropine was used. General anaesthesia was administered with thiopental and pankuron as induction and later fentanyl was used. In women receiving epidural or spinal anaes: thesia, bupivacaine was used as the local anaesthetic.
Neonatalcare Fathers were always present at delivery except when the mothers received general anaesthesia. All mothers, except those who received general anaesthesia, had early skin-to-skin contact with their infants. Conventional rooming-in service was practised at the maternity ward for all groups. As long as the mother was confined to bed the staff took responsibility for the care of the baby.
0
Emergency CS group Seventeen mothers and their full-term single infants (after 37 completed weeks) delivered by emergency CS section were studied. The indication was fetal distress during labour, as assessed by CTG and/or fetal scalp pH. Furthermore, the first four criteria as described above for the elective CS were followed. In the emergency CS group 13 women were operated upon in general anaesthesia, 3 in epidural anaesthesia and 1 in spinal anaesthesia. All mothers who accepted taking part in this study were included. There were no drop-outs. Assessment of intrapartal asphyxia All women in the emergency CS group had normal pregnancies up to delivery. Door-test (that is initial CTG registration when entering the delivery ward) was normal in all pregnancies. During labour the women were followed with repeated CTG registrations and continuous registrations after the first ominous fetal heart rate pattern was noted. The following CTG patterns were considered signalling asphyxia: “silent pattern” with tachycardia, late decelerations in the first stage of labour, variable decelerations with confirmed low (
Neurological adaptation of infants delivered by emergency or elective cesarean section G Otamiri, G Berg', 0 Finnstrom, I Leijon
'
Departments of Paediatrics and ObstetricslGynaecoIogy University Hospital. Linkoping, Sweden ~
Otamiri G, Berg G, Finnstrom 0,Leijon I. Neurological adaptation of infants delivered by emergency or elective cesarean section. Acta Paediatr 1992;81:797-801. Stockholm. ISSN 0803-5253 The effects of intrapartal asphyxia on neonatal neurological condition have been studied in 17 full-term infants delivered by emergency cesarean section and in 30 full-term infants delivered by elective cesarean section used as controls. A neurol?gical examination consisting of 3 1 items was performed on days I , 2 and 5 after birth. A tonus score, an excitability score as well as the number of optimal responses were calculated. A follow-up examination was done at six months of age with a standardized neurological and developmental examination. The results showed that infants born after emergency cesarean section were significantly more hypotone the first two days after delivery than the infants in the elective cesarean section group. In regard to individual neurological items, significant differences were found between the emergency and elective cesarean section in reaction to sound, rooting, patellar, Moro and stepping reflexes with weaker reactions in the elective cesarean section group. Growth, psychomotor development and neurological status at six months did not differ significantly between the groups. Our findings indicate that full-term infants born after emergency cesarean section due to mild intrapartal asphyxia have a delayed neurological adaptation as expressed by poor muscular tonus during their first days of life compared with infants born after elective cesarean section. 0 Elective cesarean section, emergency cesarean section, full-term infants, intrapartal asphyxia, neurological function, psychomotor development Ingemar Leijon, Department of Paediatrics, University Hospital, S-581 85 Linkoping. Sweden
Fetal distress, as an indication for cesarean section (CS), accounts for a large proportion of CS deliveries (1). Acute intrapartal asphyxia might disturb the immediate postnatal adaptation regarding both cardio-respiratory and neurological functions. However, it is difficult to evaluate the isolate effect of asphyxia, since the delivery per se, regardless of asphyxia, has an effect on neurological condition (2). Comparing two groups of CS infants, one born after emergency CS because of intrapartal asphyxia and one after elective CS would provide the chance to evaluate the asphyctic effect, although the CS itself both affects the respiratory function (3-8) and delays the neurological adaptation (9). Clinically, intrapartal asphyxia was diagnosed (by fetal heart rate changes) by cardiotocography (CTG) and/or pH measurements from the fetal scalp. The clinical situation with CTG changes were the basis for diagnosing intrapartal asphyxia in this study. The aim of the present study was to examine the effect of intrapartal asphyxia at full-term age on (i) the neonatal neurological adaptation and (ii) to evaluate any long-term effects of asphyxia on the infants through a follow-up examination of development and neurology at six months of age.
Material and methods The study was performed at the Departments of Paediatrics and Obstetrics/Gynaecology at the University Hospital, Linkoping, between February 1987 and December 1988. The total number of deliveries in the hospital during this period was 4,120. During this time 1 1.5% of all mothers were delivered by CS, 60% of them electively. Primiparae as well as multiparae who fulfilled the following criteria were included in the study: Elective CS group The elective CS group (controls) consisted of 30 mothers and their infants. Pregnant women with medical indications for elective CS were selected according to the following inclusion criteria provided they accepted participating in the study. 0 0
0 0 0
Medically uneventful pregnancy, with gestational age confirmed by early ultrasound examination. Delivery at full-term age (after 37 completed weeks). Normal fetal growth and no suspicion of fetal disease. Single birth. Indications for CS being feto-pelvic disproportion,
798
G Oramiri er at.
ACTA PEDJATR 81 (1992)
previous CS, placenta praevia or humanitarian (that is CS because of fear of vaginal child birth). No labour activity at the time of surgery.
maternal age, parity, marital status and educational level between the groups.
Of the 30 mothers delivered by elective CS, 5 had breech presentation. The indication for CS was fetopelvic disporportion in 16 cases, CS in earlier pregnancy in 10 cases and placenta praevia in 1 case. In the remaining 3 cases the indication was humanitarian (fear of vaginal child birth). In the elective CS group 8 women were operated upon in general anaesthesia and 22 in epidural or spinal anaesthesia. In both groups premedication with 0.5 mg atropine was used. General anaesthesia was administered with thiopental and pankuron as induction and later fentanyl was used. In women receiving epidural or spinal anaes: thesia, bupivacaine was used as the local anaesthetic.
Neonatalcare Fathers were always present at delivery except when the mothers received general anaesthesia. All mothers, except those who received general anaesthesia, had early skin-to-skin contact with their infants. Conventional rooming-in service was practised at the maternity ward for all groups. As long as the mother was confined to bed the staff took responsibility for the care of the baby.
0
Emergency CS group Seventeen mothers and their full-term single infants (after 37 completed weeks) delivered by emergency CS section were studied. The indication was fetal distress during labour, as assessed by CTG and/or fetal scalp pH. Furthermore, the first four criteria as described above for the elective CS were followed. In the emergency CS group 13 women were operated upon in general anaesthesia, 3 in epidural anaesthesia and 1 in spinal anaesthesia. All mothers who accepted taking part in this study were included. There were no drop-outs. Assessment of intrapartal asphyxia All women in the emergency CS group had normal pregnancies up to delivery. Door-test (that is initial CTG registration when entering the delivery ward) was normal in all pregnancies. During labour the women were followed with repeated CTG registrations and continuous registrations after the first ominous fetal heart rate pattern was noted. The following CTG patterns were considered signalling asphyxia: “silent pattern” with tachycardia, late decelerations in the first stage of labour, variable decelerations with confirmed low (
