Preventable brain injury in term labour

Abstract

The Editors (Nov 24, 2018, p 2238)1The LancetAddressing preventable stillbirth and brain injury.Lancet. 2018; 392: 2238Scopus (2) Google Scholar discuss preventable brain injury in term labour and highlight errors in interpreting, or failing to act on, abnormal cardiotocography results as a major modifiable risk factor. However, they did not mention the limitations of cardiotocography as a test to prevent intrapartum brain injury. In 1968, Benson,2Benson RC Scubeck F Deutschberger J Weiss W Berendes H Fetal heart rate as a predictor of fetal distress. A report from the collaborative project.Obstet Gynecol. 1968; 32: 259-266Google Scholar a pioneer in the development of cardiotocography, stated that cardiotocography is clinically useful at predicting intrapartum brain injury only at the extremes, with a normal trace usually indicating a normal fetus and a pathological trace indicating a fetus needing urgent delivery. According to a systematic review,3Alfirevic Z Devane D Gyte GM Cuthbert A Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labor.Cochrane Database Syst Rev. 2017; (CD006066.)Google Scholar the value of cardiotocography does not accurately predict fetal brain injury in mature babies, and there have been calls for its withdrawal.4Whittle M Is it time to abandon cardiotocographic ECG analysis?.Lancet. 2000; 355: 422Google Scholar In a 2013 case-control study5Hayes BC McGarvey C Mulvany S et al.A case-control study of hypoxic-ischaemic encephalopathy in newborn infants at >36 weeks gestation.Am J Obstet Gynecol. 2013; 208: 29.e1-29.e19Google Scholar of intrapartum brain injury in Dublin, electronic monitoring of the fetal heart was done for 48 968 (90%) of 54 409 low-risk mothers in labour at term (9250 [17%] of 48 968 intermittent monitoring and 39 718 [73%] of 48 968 continuous monitoring), and in 27 366 (69%) of 39 718 continuous monitoring cases, the trace was deemed unsatisfactory or non-reassuring. 73 babies with intrapartum brain injury had undergone continuous monitoring of fetal heart rate during labour, with a normal trace in six (8%) babies and an unsatisfactory or non-reassuring trace in the remaining 67 (92%) babies (ie, one case of intrapartum brain injury for every 403 unsatisfactory or non-reassuring traces). This result means that an abnormal cardiotocography in term labour had a 99·8% false positive rate in predicting intrapartum brain injury, which is surely a relevant factor in why so many unsatisfactory traces are not acted on in labour wards. However, the central problem is that, in the Dublin study,5Hayes BC McGarvey C Mulvany S et al.A case-control study of hypoxic-ischaemic encephalopathy in newborn infants at >36 weeks gestation.Am J Obstet Gynecol. 2013; 208: 29.e1-29.e19Google Scholar a baby born with intrapartum brain injury will usually have had a heart rate trace that was unsatisfactory or non-reassuring, with changes that were no different from the thousands of other non-reassuring traces in the study.5Hayes BC McGarvey C Mulvany S et al.A case-control study of hypoxic-ischaemic encephalopathy in newborn infants at >36 weeks gestation.Am J Obstet Gynecol. 2013; 208: 29.e1-29.e19Google Scholar The rate of cerebral palsy in normally formed mature infants, with a birthweight of more than 2·5 kg, is the same as it was 30 years ago, at approximately one case per 1000 livebirths.6Nelson KB Dambrosia JM Ting TY Grether JK Uncertain value of electronic fetal monitoring in predicting cerebral palsy.N Engl J Med. 1996; 334: 613-618Google Scholar The rate of intrapartum brain injury has not decreased in more than 30 years, despite almost universal monitoring of the fetal heart rate in labour and a tripling of the rate of caesarean sections.7Curtis PD Matthews TG Clarke TA et al.Neonatal seizures: the Dublin Collaborative Study.Arch Dis Child. 1988; 63: 1065-1068Google Scholar, 8Gale C Statnikov Y Jawad S Uthaya SN Modi N Brain Injuries Expert Working GroupNeonatal brain injuries in England: population-based incidence derived from routinely recorded clinical data held in the National Neonatal Research Database.Arch Dis Child Fetal Neonatal Ed. 2018; 103: F301-F306Google Scholar Midwives and obstetricians are being personally and professionally held accountable for failing to identify at-risk infants with use of a very limited test, which has never been shown to be able to prevent the bulk of intrapartum brain injury. TM is a retired consultant neonatologist. We declare no competing interests. Addressing preventable stillbirth and brain injuryNearly three-quarters of stillbirths, neonatal deaths, and severe brain injuries in the UK that resulted from incidents occurring during term labour might have been averted with different care. These are the stark findings of the second Each Baby Counts report from the Royal College of Obstetricians and Gynaecologists, released on Nov 13. Full-Text PDF