Cesarean Delivery For Fetal Distress Research Articles

Cesarean delivery for fetal distress: rate and risk factors.

The objective of this article was to review the recent English language literature on cesarean delivery for fetal distress to determine its incidence, diagnostic tests, and the contributing factors to this obstetric complications. A PubMed search (1990-2000) with items of "cesarean, fetal distress," "cesarean, non-reassuring fetal heart rate," "cesarean, neonatal acidosis," and "cesarean, umbilical arterial pH," was undertaken. Reports, letters to the editor, focus on anomalous fetuses, and papers not specifically focused on this topic were excluded. Of the 392 articles that the search yielded, 169 met the inclusion criteria. Based on 37 reports with more than 1,000 patients each, the overall risk of prompt cesarean delivery for fetal concern was 3.1% (43,340 of 13,989,74). The risk exceeded 20% in patients with moderate/severe asthma, severe hypothyroidism, severe preeclampsia, and postterm or fetal growth restricted fetuses with abnormal Doppler studies. Use of likelihood ratios suggests that Doppler of the umbilical artery is a superior diagnostic test to amniotic fluid index in identifying parturients at risk for cesarean for non-reassuring fetal heart rate tracing. Although several risk factors increase the need for cesarean delivery for fetal distress, in general, most are unpreventable. Obstetricians & Gynecologists, Family Physicians. After completion of this article, the reader will be able to estimate the incidence of cesarean delivery for non-reassuring fetal heart rate tracing, outline potential diagnostic tests that are useful for the detection of fetal distress, and summarize medical and obstetric conditions that place patients at risk for cesarean delivery for fetal distress.

Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery doppler velocimetry: A randomized controlled clinical trial

Objective: The purpose of this study was to evaluate the ability of two different modes of antepartum fetal testing to screen for the presence of peripartum morbidity, as measured by the cesarean delivery rate for fetal distress in labor. Study Design: Over a 36-month period, all patients who were referred to the Fetal Assessment Unit at BC Women's Hospital because of a perceived increased fetal antepartum risk at a gestational age of ≥32 weeks of gestation were approached to participate in this study. Fetal surveillance of these women was allocated randomly to either umbilical artery Doppler ultrasound testing or nonstress testing as a screening test for fetal well-being. If either the umbilical artery Doppler testing or the nonstress testing was normal, patients were screened subsequently with the same technique, according to study protocol. When the Doppler study showed a systolic/diastolic ratio of >90th percentile or the nonstress testing was equivocal (ie, variable decelerations), an amniotic fluid index was performed, as an additional screening test. When the amniotic fluid index was abnormal (<5th percentile), induction and delivery were recommended. When the Doppler study showed absent or reversed diastolic blood flow or when the nonstress test result was abnormal, induction and delivery were recommended to the attending physician. Statistical comparisons between groups were performed with an unpaired t test for normally distributed continuous variables and χ2 test for categoric variables. Results: One thousand three hundred sixty patients were assigned randomly to groups in the study; 16 patients were lost to follow up. Six hundred forty-nine patients received Doppler testing and 691 received nonstress testing. The mean number of visits for the Doppler test and nonstress test groups was two versus two, respectively. The major indications for fetal assessment included postdates (43%), decreased fetal movement (22%), diabetes mellitus (11%), hypertension (10%), and intrauterine growth restriction (7%). The incidence of cesarean delivery for fetal distress was significantly lower in the Doppler group compared with the nonstress testing group (30 [4.6%] vs 60 [8.7%], respectively; P <.006). The greatest impact on the reduction in cesarean deliveries for fetal distress was seen in the subgroups in which the indication for testing was hypertension and suspected intrauterine growth restriction. Conclusion: Umbilical artery Doppler as a screening test for fetal well-being in a high-risk population was associated with a decreased incidence of cesarean delivery for fetal distress compared to the nonstress testing, with no increase in neonatal morbidity. (Am J Obstet Gynecol 2003;188:1366-71.)

Meconium-Stained Amniotic Fluid in Labor: A Randomized Trial of Prophylactic Amnioinfusion

Puertas, Alberto; Paz Carrillo, M.; Moltó , Luis; Álvarez, Margarita; Sedeño, Salvador; Miranda, José

The Significance of Antenatal Factors in Patients Who Underwent Cesarean Delivery for Fetal Distress

The Significance of Antenatal Factors in Patients Who Underwent Cesarean Delivery for Fetal Distress

The significance of antenatal factors in patients who underwent cesarean delivery for fetal distress

The significance of antenatal factors in patients who underwent cesarean delivery for fetal distress

Relationship between Meconium Staining and Amniotic Fluid Volume in Term Pregnancies

Objective: Our purpose was to evaluate the relationship between meconium-stained amniotic fluid (MEC-AF) and amniotic fluid volume (AFV) and their impact on the risk of cesarean delivery for fetal indications in term pregnancies. Methods: 1,655 live-born singleton gestations delivering at ≧37 weeks within 7 days of sonographic assessment of the amniotic fluid index (AFI) were studied. AFI was categorized as: oligohydramnios (≤5.0 cm); decreased (5.1–8.0 cm); normal (8.1–18.0 cm); increased (18.1–23.9 cm), and polyhydramnios (≧24.0 cm). Frequencies of MEC-AF for each AFV category were stratified by gestational age (GA) and rates of cesarean delivery for fetal indications compared between patients with clear amniotic fluid and those with MEC-AF. Stepwise logistic regression analyses were performed for determinants of MEC-AF and the need for cesarean delivery for fetal indications. Results: The frequency of MEC-AF at birth in term pregnancies was not related to AFV: oligohydramnios (16.7%); decreased (16.7%); normal (20.1%); increased (24.4%), and polyhydramnios (22.1%). The only factor associated with the occurrence of MEC-AF was increasing GA at delivery (p < 0.01). Both MEC-AF (p < 0.02) and decreasing neonatal ponderal index (p < 0.02) were independently associated with cesarean delivery for fetal distress. Conclusions: MEC-AF does not appear to be related to AFV in term pregnancies, and its presence increases the risk of cesarean delivery for fetal distress independent of AFV and neonatal ponderal index.

A benefit-risk assessment of misoprostol for cervical ripening and labour induction.

Misoprostol, a prostaglandin E(1) analogue, is widely used in the US and other countries for cervical ripening and labour induction. Its use for these indications is not approved by the US Food and Drug Administration (FDA). The manufacturer of misoprostol issued a letter to American healthcare providers in August 2000, cautioning against the use of misoprostol in pregnant women and citing a lack of safety data for its use in obstetrical practice. The only FDA-approved indication in the product labelling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory drug use. Multiple trials have proven that when applied vaginally, misoprostol is an effective agent for cervical ripening and labour induction in term pregnancy. The use of oxytocin augmentation is reduced when intravaginal misoprostol is used compared with other agents. Misoprostol use in obstetrics carries the added benefits of temperature stability at room temperature, which is unlike other prostaglandin preparations which require refrigeration or freezing, and reduced cost. However, debate continues regarding the optimal dose, dosage regimen, and route of administration. Uterine contraction abnormalities are often found in association with higher misoprostol doses (50 microg or more) given vaginally or orally. Some trials also indicate increased frequencies of meconium passage, neonatal acidaemia and caesarean delivery for fetal distress in women receiving higher doses of vaginally applied misoprostol. However, most trials fail to demonstrate a significant change in the caesarean delivery rate with the use of misoprostol, although a recent meta-analysis indicated that the use of intravaginal misoprostol is associated with a lowering of the caesarean rate when compared with pooled controls. Low-dose misoprostol (25 microg) is an effective agent for cervical ripening and labour induction when used in a judicious and cautious fashion. There are insufficient data to support the widespread use of oral misoprostol for cervical ripening and labor induction. Some trials suggest that this approach may be effective; however, the ideal dose and administration regimen have yet to be defined.

Amniotomy for Shortening Spontaneous Labour

A substantive amendment to this systematic review was last made on 25 June 1999. Cochrane reviews are regularly checked and updated if necessary.ABSTRACTBackground: Early amniotomy has been advocated as a component of the active management of labour. Several randomised trials comparing routine amniotomy to an attempt to conserve the membranes have been published. Their limited sample sizes limit their ability to address the effects of amniotomy on indicators of maternal and neonatal morbidity.Objectives: To study the effects of amniotomy on the rate of Cesarean delivery and on other indicators of maternal and neonatal morbidity (Apgar less than 7 at 5 minutes, admission to NICU).Search strategy: The register of clinical trials maintained and updated by the Cochrane Pregnancy and Childbirth Group.Selection criteria: All acceptably controlled trials of amniotomy during first stage of labour were eligible.Data collection and analysis: Data were extracted by two trained reviewers from published reports. Trials were assigned methodological quality scores based on a standardised rating system. Typical odds ratios (ORs) were calculated using Peto's method.Main results: Amniotomy was associated with a reduction in labour duration of between 60 and 120 minutes. There was a marked trend toward an increase in the risk of Cesarean delivery: OR = 1.26; 95% Confidence Interval (CI) = 0.96–1.66. The likelihood of a 5‐minute Apgar score less than 7 was reduced in association with early amniotomy (OR = 0.54; 95% CI = 0.30–0.96). Groups were similar with respect to other indicators of neonatal status (arterial cord pH, NICU admissions). There was a statistically significant association of amniotomy with a decrease in the use of oxytocin: OR = 0.79; 95% CI = 0.67–0.92.Reviewers' conclusions: Routine early amniotomy is associated with both benefits and risks. Benefits include a reduction in labour duration and a possible reduction in abnormal 5‐minute Apgar scores. The meta‐analysis provides no support for the hypothesis that routine early amniotomy reduces the risk of Cesarean delivery. Indeed there is a trend toward an increase in Cesarean section. An association between early amniotomy and Cesarean delivery for fetal distress is noted in one large trial. This suggests that amniotomy should be reserved for women with abnormal labour progress.Citation: Fraser WD, Turcot L, Krauss I, Brisson‐Carrol G. Amniotomy for shortening spontaneous labour (Cochrane Review). In: The Cochrane Library, 1, 2001. Oxford: Update Software.MeSH: Amnion/*surgery; Cesarean Section; Female; Human; *Labor; Labor Complications/*prevention &amp; control; PregnancyThe preceding reports are abstracts of regularly updated, systematic reviews prepared and maintained by the Cochrane Collaboration. The full text of the reviews are available in The Cochrane Library (ISSN 1464‐780X).The Cochrane Library is prepared and published by Update Software Ltd. All rights reserved. See www.update‐software.com or contact Update Software, info@update.co.uk, for information on subscribing to The Cochrane Library in your area.Update Software Ltd, Summertown Pavilion, Middle Way, Oxford OX2 7LG, United Kingdom. (Tel: +44 1865 513902; Fax: +44 1865 516918).

Fiberoptic Endotracheal Intubation Through an Ultra-Thin Bronchoscope with Suction Channel in a Newborn with Difficult Airway

Management of the airway may be difficult in newborns with craniofacial and neck malformations (1). Previous experiences with flexible endoscopic intubation in neonates have shown encouraging results, but a number of limitations, such as no directional control at the tip or lack of an operative channel, were also reported (2,3). We describe a successful intubation by a new 2.5-mm fiberoptic bronchoscope with a 1.2-mm suction channel in a newborn with difficult airway. A 2300-g infant, born at 35 wk of gestation after an urgent cesarean delivery for fetal distress, needed cardiopulmonary resuscitation at birth. Endotracheal intubation was achieved only after several attempts with a 3.0-mm tube inserted nasotracheally. On arrival to our unit, physical examination showed dysmorphic face, micrognathia, and arthrogryposis. A gross air leak around the endotracheal tube (ETT) prevented an adequate ventilation of the patient. We decided to explore the patient’s larynx before exchanging the ETT with a larger one, but micrognathia did not allow proper visualization by conventional laryngoscopy. Thus, we inserted a 3.5-mm ETT using a fiberoptic flexible bronchoscope (Richard Wolf-GmbH, Knittlingen, Germany). This endoscope has a 2.5-mm outer diameter, a 1.2-mm instrument channel, an angle of deflection at the tip of 160° up and 130° down, and a working length of 450 mm (Figure 1). During the procedure, we could remove secretions and provide topical anesthesia via the suction channel of the endoscope. No complications were noted.Figure 1: Fiberoptic flexible bronchoscope.We believe this new ultra-thin bronchoscope may be useful in newborns and small infants when a difficult intubation is anticipated or, alternatively, when lower airway evaluation, suctioning, bronchoalveolar lavage, or supplemental oxygen delivery during intubation is required. Paolo Biban MD Simone Rugolotto MD Giuseppe Zoppi MD

Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis

Objective: Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm. Study Design: Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of ≤5.0 cm versus >5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed–effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies. Results: Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of ≤5.0 cm, in comparison with >5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of ≤5.0 cm is also associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 1.7; 95% confidence interval, 1.1-2.6) and an Apgar score <7 at 5 minutes (pooled relative risk, 1.8; 95% confidence interval, 1.2-2.7). A poor correlation between the amniotic fluid index and neonatal acidosis was noted in the only study that examined this end point. More than 23,000 patients are necessary to demonstrate that the incidence of umbilical arterial pH <7.00 is 1.5 times higher among those with oligohydramnios in labor than among those with adequate amniotic fluid index (α = 0.05; β = 0.2) Conclusions: An antepartum or intrapartum amniotic fluid index of ≤5.0 cm is associated with a significantly increased risk of cesarean delivery for fetal distress and a low Apgar score at 5 minutes. There are few reports linking amniotic fluid index and neonatal acidosis, the only objective assessment of fetal well-being. A multicenter study with sufficient power should be undertaken to demonstrate that a low amniotic fluid index is associated with an umbilical arterial pH <7.00. (Am J Obstet Gynecol 1999;181:1473-8.)

Safety of labor epidural anesthesia for women with severe hypertensive disease

Objective: The aim of this study was to determine whether epidural anesthesia during labor increased the frequencies of cesarean delivery, pulmonary edema, and renal failure among women with severe hypertensive disease. Study Design: We performed a secondary retrospective analysis of a subgroup population within a multicenter double-blind trial of low-dose aspirin therapy for women at high risk for development of preeclampsia. Subjects in whom severe hypertensive disease developed were selected. The primary outcomes were the overall frequencies of cesarean delivery among women with severe hypertensive disease who had labor with and without epidural anesthesia. Other maternal and neonatal outcomes were also compared between women who did and did not receive epidural anesthesia. Results: Among the women with severe hypertensive disease (n = 444) 327 had labor. Among the women with severe disease who had labor there was no difference in either the overall cesarean delivery rate (32.1% vs 28.0%; P = .44) or the rate of cesarean delivery for fetal distress or failure to progress (27.8% vs 22.0%; P = .26) between women who did and did not receive epidural analgesia. Women with chronic hypertension were more likely to have a cesarean delivery overall if they received epidural anesthesia, but there was otherwise no difference in the frequencies of cesarean delivery for these indications between women with and without epidural anesthesia within each of the high-risk groups. Pulmonary edema was rare and acute renal failure did not develop in any women. Conclusion: Epidural anesthesia use did not increase the frequencies of cesarean delivery, pulmonary edema, and renal failure among women with severe hypertensive disease. (Am J Obstet Gynecol 1999;181:1096-1101.)

Fetal acoustic stimulation in early labor and pathological fetal acidemia: a preliminary report.

To determine if a nonreactive response to fetal acoustic stimulation in early labor can predict a significantly higher risk of umbilical arterial pH <7.10 or <7.00. Fetal acoustic stimulation was applied to the fetuses of term parturients (gestational age > or =37 weeks) with cervical dilation of < or =5 cm. The responses to stimulation were correlated with cesarean delivery for fetal distress and umbilical arterial pH. Student's t-test, Chi-square, and Fisher exact test were used; P < 0.05 was considered significant. Relative risks (RR) and 95% confidence intervals (CI) were calculated. The study population contained 271 subjects, of which 90% (244) had a reactive response following acoustic stimulation and 10% (27) a nonreactive response. The maternal demographics, time interval from stimulation to delivery (8.3 +/- 8.7 vs. 8.3 +/- 8.4 h; P = 1.00) were similar in the two groups. Compared to those with a reactive response, patients with a nonreactive response had a significantly greater risk for: 1) cesarean delivery for fetal distress (2.0% vs. 11.1%; P = 0.03, RR 4.1, 95% Cl 1.5, 60.5), 2) umbilical arterial pH <7.10 (2.0% vs. 14.8%; P = 0.007, RR 5.0, 95% CI 2.2, 11.6), and 3) umbilical arterial pH <7.00 (0.8% vs. 7%; P = 0.05, RR 5.0, 95% CI 1.8, 15.2). A nonreactive response to fetal acoustic stimulation in early labor is associated with a significantly increased risk for cesarean delivery for fetal distress and neonatal acidosis. This finding extends the potential value of acoustic stimulation as an intrapartum admission screening test.

Labor induction with misoprostol

Misoprostol, a prostaglandin E 1 analog, is widely used in the United States for cervical ripening and labor induction. Its use for these indications is not approved by the US Food and Drug Administration. The only Food and Drug Administration–approved indication in the product labeling is the treatment and prevention of intestinal ulcer disease resulting from nonsteroidal anti-inflammatory use. Multiple trials have proved that misoprostol is an effective agent for cervical ripening and labor induction in term pregnancy; however, investigations continue regarding the optimal dose, dosing regimen, and route of administration. Uterine contraction abnormalities are often found in association with higher misoprostol doses. Some trials also indicate increased frequencies of meconium passage, neonatal acidemia, and cesarean delivery for fetal distress in women receiving higher doses of misoprostol. Overall, most trials fail to demonstrate a significant change in the cesarean delivery rate with the use of this agent. Misoprostol is an effective agent for cervical ripening and labor induction when used in a judicious and cautious fashion. (Am J Obstet Gyneol 1999;181:339-45.)

Does an amniotic fluid index of ≤5 cm necessitate delivery in high-risk pregnancies? A case-control study

Objective: This study was undertaken to determine whether women with high-risk pregnancies and an amniotic fluid index of ≤5 cm require labor induction to prevent adverse perinatal outcomes. Study Design: All women at high risk at ≥34 weeks’ gestation with an amniotic fluid index of ≤5 cm were admitted to the hospital for labor induction. Each woman was compared with the next patient at high risk seen with an amniotic fluid index of >5 cm and the same pregnancy complication. Case patients were also matched with control subjects for maternal race, age, parity, and gestational age. Results: Prospectively, 79 women at high risk with an amniotic fluid index of ≤5 cm were compared with 79 control subjects. There were no statistically significant differences between the 2 groups in the risks of thick meconium ( P = .29), variable decelerations (moderate P = .27, severe P = .37), amnioinfusion ( P = .37), cesarean delivery for fetal distress ( P = .4), and umbilical artery pH <7.10 ( P = .29). Conclusion: High-risk pregnancies with an amniotic fluid index of ≤5 cm appear to carry intrapartum complication rates similar to those of similar high-risk pregnancies with an amniotic fluid index of >5. (Am J Obstet Gynecol 1999;180:1354-9.)

Antenatal testing among 1001 patients at high risk: The role of ultrasonographic estimate of amniotic fluid volume

Objective: Our goal was to compare the accuracy of the amniotic fluid index and the 2-diameter pocket technique with respect to accuracy in predicting an adverse pregnancy outcome among patients at high risk undergoing antenatal testing. Study Design: All women with high-risk pregnancies and intact membranes who underwent antenatal testing during an 18-month period were prospectively enrolled. Ultrasonographic estimates of amniotic fluid volume were performed by means of the amniotic fluid index and the 2-diameter pocket technique. Relative risks with 95% confidence intervals and receiver operator characteristic curves were calculated for patients with an ultrasonographic estimate of oligohydramnios (amniotic fluid index of ≤5 cm or 2-diameter pocket of ≤15 cm 2) versus normal fluid level (amniotic fluid index of >5 cm or 2-diameter pocket of >15 cm 2). Outcome variables studied were intrapartum and neonatal complications. Results: Among 1001 patients the mean (±SD) amniotic fluid index was 10.5 ± 5 cm and the mean (±SD) 2-diameter pocket was 18.7 ± 13.6 cm 2. Significantly more patients (46%) were considered to have oligohydramnios according to the 2-diameter pocket criteria than according to the amniotic fluid index (21%, P < .0001, relative risk 1.7, 95% confidence interval 1.5-1.8). No significant differences in the incidences of nonreactive nonstress test results, meconium-stained amniotic fluid, cesarean delivery for fetal distress, low Apgar scores, or infants with cord pH of <7.10 were observed between the oligohydramnios and normal amniotic fluid groups ( P > .05) when assessed by relative risk with confidence interval and by receiver operator characteristic curves. Conclusions: Current ultrasonographic measurements with the amniotic fluid index and the 2-diameter pocket technique are poor diagnostic tests to determine whether a patient is at high risk for an adverse perinatal outcome. (Am J Obstet Gynecol 1999;180:1330-6.)

Fetal Acoustic Stimulation in Early Labor and Pathologic Fetal Acidemia: A Preliminary Report

Objective: To determine if a nonreactive response to fetal acoustic stimulation in early labor can predict a significantly higher risk of umbilical arterial pH <7.10 or <7.00.Methods: Fetal acoustic stimulation was applied to the fetuses of term parturients (gestational age ≤37 weeks) with cervical dilation of ≤5 cm. The responses to stimulation were correlated with cesarean delivery for fetal distress and umbilical arterial pH. Student's t-test, Chi'Square, and Fisher exact test were used; P < 0.05 was considered significant. Relative risks (RR) and 95% confidence intervals (CI) were calculated.Results: The study population contained 271 subjects, of which 90% (244) had a reactive response following acoustic stimulation and 10% (27) a nonreactive response. The maternal demographics, time interval from stimulation to delivery (8.3 ± 8.7 vs. 8.3 ± 8.4 h; P = 1.00) were similar in the two groups. Compared to those with a reactive response, patients with a nonreactive response had a significantly greater risk for: 1) cesarean delivery for fetal distress (2.0% vs. 11.1%; P = 0.03, RR 4.1, 95% CI 1.5, 60.5), 2) umbilical arterial pH <7.10 (2.0% vs. 14.8%; P = 0.007, RR 5.0, 95% CI 2.2, 11.6), and 3) umbilical arterial pH <7.00 (0.8% vs. 7%; P = 0.05, RR 5.0,95% CI 1.8,15.2).Conclusion: A nonreactive response to fetal acoustic stimulation in early labor is associated with a significantly increased risk for cesarean delivery for fetal distress and neonatal acidosis. This finding extends the potential value of acoustic stimulation as an intrapartum admission screening test.

Management of extremely low birth weight infants: perceptions of viability and parental counseling practices

Objective: To determine physician opinions, parental counseling, and medical practices for extremely low birth weight (LBW) infants. Methods: A retrospective survey was sent in August 1996 to 450 California physicians practicing obstetrics. Results: There was a 41% response rate. The mean thresholds for antenatal steroid administration, cesarean delivery for fetal distress and delivery room resuscitation were gestational age between 23 and 24 weeks and weight close to 500 g. Most obstetricians counsel parents regarding survival, resuscitation, and possible death in the delivery room before delivery of an extremely LBW infant. Just over 60% of obstetricians believe that parents have a role in deciding not to resuscitate an infant born at 22 weeks’ gestation, this decreases to less than 50% at 24 weeks, and decreases further to less than 30% by 26 weeks’ gestation. Just over 40% of obstetricians report their counseling is affected by pediatric opinion, 33% by previous maternal perinatal losses, and less than 20% by maternal drug use or lack of prenatal care, and young maternal age. Language barriers, parental education level, and family insurance affect treatment options in less than 10% of obstetricians. Conclusion: Obstetric opinions about delivery room resuscitation of extremely LBW infants are influenced by birth weight and gestational age thresholds, infant, and parental factors. There is a limited willingness by physicians to allow a parental role in decision making in the delivery room for extremely LBW infants.

Does the prenatal diagnosis of fetal urinary tract anomalies affect perinatal outcome?

A review of the literature is presented. Congenital renal and urinary tract anomalies are described, and the possible consequences of detecting them in utero are discussed. Prenatal detection of lethal anomalies affords the parents the option of terminating the pregnancy. If termination of pregnancy is not an acceptable option for the parents, the antenatal knowledge of lethal fetal anomaly helps the clinician to avoid unnecessary obstetric intervention, e.g., cesarean delivery for fetal distress. In certain cases of nonlethal renal and urinary tract anomalies, antenatal detection may influence both obstetric and postnatal management. It seems reasonable to anticipate that this might improve the prognosis of some children in terms of better preservation of kidney function. However, no scientific evidence is available to support such a statement. There are no randomized trials evaluating the outcome of congenital renal and urinary tract anomalies using different prenatal and postnatal diagnostic and therapeutic approaches. It is hoped that further research will lead to more rational antenatal and postnatal management protocols.

Middle Cerebral Artery Velocimetry: Different Clinical Relevance Depending on Umbilical Velocimetry

Objective: To evaluate the role of cerebral velocimetry as a predictor of perinatal outcome in high-risk pregnancies.Methods: Middle cerebral artery pulsatility index was measured in 576 high-risk pregnancies undergoing umbilical velocimetry. The results of both tests were evaluated with respect to the birth of small for gestational age (SGA) infants and adverse perinatal outcome, defined as perinatal death, cesarean delivery for fetal distress, or low Apgar score.Results: Once umbilical velocimetry was taken into account, cerebral velocimetry did not improve the prediction of fetal growth restriction or adverse perinatal outcome. Neither test was able to predict adverse perinatal outcome in normally grown fetuses. As for SGA fetuses with adverse perinatal outcome, the simultaneous assessment of both umbilical and cerebral velocimetry did not improve diagnostic accuracy (kappa index 0.37 versus 0.41 for umbilical velocimetry only). However, within the group of high-risk pregnancies with abnormal umbilical velocimetry, the risk of being SGA and having an adverse perinatal outcome was doubled (relative risk 2.1, 95% confidence interval 1.1, 4.3) if cerebral velocimetry also was abnormal.Conclusion: The routine use of cerebral velocimetry in high-risk pregnancies adds little information beyond that obtained from umbilical velocimetry; however, it is useful in predicting SGA infants with adverse perinatal outcome when umbilical velocimetry is abnormal.

Does combined spinal-epidural analgesia with subarachnoid sufentanil increase the incidence of emergency cesarean delivery?

The purpose of this review was to determine if patients who receive combined spinal-epidural (CSE) analgesia with subarachnoid sufentanil have an increased incidence of emergency cesarean delivery for fetal distress when compared with patients who receive systemic or no medication (S/NM) for labor analgesia. A retrospective computerized analysis of data on all 2,560 deliveries at Bellevue Woman's Hospital for 14 months summarized practice parameters for 1,240 patients who received regional analgesia (98% CSE analgesia), identified 1,140 patients who received S/NM, and classified the urgency of 479 cesarean deliveries. In the CSE group there were 168 cesarean deliveries (emergency 16, urgent 58, semiurgent 70, and nonurgent 24) as compared with a total of 128 (emergency 16, urgent 43, semiurgent 69, nonurgent 0) in the S/NM group. Scheduled cesarean sections (180) were excluded from the study. The incidence of emergency cesarean delivery in 1,217 patients who received CSE analgesia with subarachnoid sufentanil (10-15 micrograms) compared with 1,140 patients who received S/NM for labor analgesia was 1.3% versus 1.4%, respectively. More importantly, there was no case in which emergency cesarean delivery was required for acute fetal distress in the absence of obstetric factors during the 90 minutes following administration of subarachnoid sufentanil. General anesthesia was required for emergency cesarean delivery in only one patient (6%) in the CSE group, as against eight patients (50%) in the S/NM group who required general anesthesia for emergency cesarean section (P < .05). This experience indicates that patients who receive CSE analgesia do not have a higher incidence of emergency cesarean delivery than patients who have S/NM for labor analgesia. Emergency cesarean section for fetal distress within 90 minutes of the administration of intrathecal sufentanil only occurred in association with obstetric factors. However, caution should be exercised in extrapolating these results to other practice settings, particularly high-risk referral centers.