Intrapartum Asphyxia Research Articles

Factors associated with mortality and neurodevelopmental impairment at 12 months in asphyxiated newborns: a retrospective cohort study in rural Tanzania from January 2019 to June 2022

BackgroundWorldwide about 2.3 million newborns still die in the neonatal period and the majority occurs in low- and middle-income countries (LMICs). Intrapartum-related events account for 24% of neonatal mortality. Of these events, intrapartum birth asphyxia with subsequent neonatal encephalopathy is the main cause of child disabilities in LMICs. Data on neurodevelopmental outcome and early risk factors are still missing in LMICs. This study aimed at investigating the factors associated with mortality, risk of neurodevelopmental impairment and adherence to follow-up among asphyxiated newborns in rural Tanzania.MethodsThis retrospective observational cohort study investigated mortality, neurodevelopmental risk and adherence to follow-up among asphyxiated newborns who were admitted to Tosamaganga Hospital (Tanzania) from January 2019 to June 2022. Neurodevelopmental impairment was assessed using standardized Hammersmith neurologic examination. Admission criteria were Apgar score < 7 at 5 min of life and birth weight > 1500 g. Babies with clinically visible congenital malformations were excluded. Comparisons between groups were performed using the Mann-Whitney test, the Chi-square test, and the Fisher test.ResultsMortality was 19.1% (57/298 newborns) and was associated with outborn (p < 0.0001), age at admission (p = 0.02), lower Apgar score at 5 min (p = 0.003), convulsions (p < 0.0001) and intravenous fluids (IV) (p = 0.003). Most patients (85.6%) were lost to follow-up after a median of 1 visit (IQR 0–2). Low adherence to follow-up was associated with female sex (p = 0.005). The risk of neurodevelopmental impairment at the last visit was associated with longer travel time between household and hospital (p = 0.03), female sex (p = 0.04), convulsions (p = 0.007), respiratory distress (p = 0.01), administration of IV fluids (p = 0.04), prolonged oxygen therapy (p = 0.004), prolonged hospital stay (p = 0.0007) and inappropriate growth during follow-up (p = 0.0002).ConclusionsOur findings demonstrated that mortality among asphyxiated newborns in a rural hospital in Tanzania remains high. Additionally, distance from home to hospital and sex of the newborn correlated to higher risks of neurodevelopmental impairment. Educational interventions among the population about the importance of regular health assessment are needed to improve adherence to follow-up and for preventive purposes. Future studies should investigate the role of factors affecting the adherence to follow-up.

Umbilical arterial blood lactate as predictor of early neonatal outcome and evaluation of intrapartum asphyxia

BackgroundPerinatal asphyxia is a leading cause of under-5 mortality and exerts great pressure on the health system. Adequate foetal monitoring in labour is paramount in the early detection of foetal distress to prevent perinatal asphyxia. Several methods of foetal monitoring are in use with varying efficacy. This study investigated the efficacy of umbilical arterial (UA) lactate assay in predicting adverse perinatal outcomes. MethodologyThis was a prospective longitudinal study involving 160 pregnant women in the active phase of labour at term who met the inclusion criteria. They were recruited using a consecutive sampling technique and underwent a cardiotocography. Then they were classified into normal and abnormal cardiotocographic groups. At delivery, the UA blood of all of the babies was collected and assayed for serum lactate, and the levels were correlated with the perinatal outcome. The perinatal outcomes were measured by Apgar scores, admission into the neonatal unit, and hypoxic ischaemic encephalopathy. Analysis was done to determine the sensitivity and specificity of UA lactate in predicting birth asphyxia, hypoxic ischaemic encephalopathy, and neonatal unit admission. ResultsThe mean age ± standard deviation (SD) between the two cardiotocography (CTG) groups, normal years (30.55 ± 5.59) and abnormal years (29.86 ± 5.51), were similar. A critical UA lactate concentration > 9.1 mmol/L predicted Apgar scores < 7 at 5 min with a sensitivity and specificity of 76.47% (CI: 50.1–93.2) and 91.55% (CI: 85.7–95.6%), respectively. Also, the need for neonatal unit admission was predicted at a cut-off point >9.1 mmol/L with a sensitivity of 61.90% (CI: 38.4–81.9) and specificity of 91.30% (CI: 85.3–95.4). Umbilical artery lactate levels > 11.2 mmol/L predicted the development of hypoxic ischaemic encephalopathy in neonates with a sensitivity of 100% (CI: 39.8–100.0) and specificity of 88.39% (CI: 82.3–93.0). ConclusionUmbilical artery lactate correlates with adverse pregnancy outcomes and is an excellent tool for predicting adverse neonatal outcome.

Risk of stillbirth after a previous caesarean delivery: A Swedish nationwide cohort study.

To investigate the risk of stillbirth in relation to (1) a previous caesarean delivery (CD) compared with those following a vaginal birth (VB); and (2) vaginal birth after caesarean (VBAC) compared with a repeat CD. Population-based cohort study. The Swedish Medical Birth registry. Women with their first and second singletons between 1982 and 2012. Multivariable logistic regression models were performed to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CI) of the association between CD in the first pregnancy and stillbirth in the second pregnancy and the association between VBAC and stillbirth. Sub-group analyses were performed by types of CD and timing of stillbirth (antepartum and intrapartum). Stillbirth (antepartum and intrapartum fetal death). Of the 1 771 700 singleton births from 885 850 women, 117 114 (13.2%) women had a CD in the first pregnancy, and 51 755 had VBAC in the second pregnancy. We found a 37% increased odds of stillbirth (aOR 1.37; 95% CI 1.23-1.52) in women with a previous CD compared with VB. The odds of intrapartum stillbirth were higher in the previous pre-labour CD group (aOR 2.72; 95% CI 1.51-4.91) and in the previous in-labour CD group (aOR 1.35; 95% CI 0.76-2.40), although not statistically significant in the latter case. No increased odds were found for intrapartum stillbirth in women who had VBAC (aOR 0.99; 95% CI 0.48-2.06) compared with women who had a repeat CD. This study confirms that a CD is associated with an increased risk of subsequent stillbirth, with a greater risk among pre-labour CD. This association is not solely mediated by increases in intrapartum asphyxia, uterine rupture or attempted VBAC. Further research is needed to understand this association, but these findings might help healthcare providers to reach optimal decisions regarding mode of birth, particularly when CD is unnecessary.

Caffeine Administration in Piglets with Low Birthweight and Low Vitality Scores, and Its Effect on Physiological Blood Profile, Acid-Base Balance, Gas Exchange, and Infrared Thermal Response.

Intrapartum asphyxia, fetal hypoxia, and their consequences (e.g., acidosis, hypercapnia, hypoglycemia, and hypothermia) are the main factors related to physio-metabolic imbalances that increase neonatal mortality in piglets, particularly in piglets with low birthweight and low vitality scores. This study aimed to evaluate the effect of three different doses of caffeine (10, 20, and 30 mg/kg) administered orally to 480 newborn piglets with low birthweight and low vitality scores. Blood gas parameters (pH, pO2, pCO2, and HCO3-), physio-metabolic profile (Ca++, glucose, and lactate), and the thermal response assessed through infrared thermography in four thermal windows (ocular, auricular, snout, and hindlimb) and rectal temperature were evaluated during the first 24 h of life. Doses of 30 mg/kg resulted in significant differences at 24 h for all evaluated parameters, suggesting that caffeine administration improved the cardiorespiratory function and metabolic activity of piglets by reducing acidosis, restoring glycemia, and increasing surface and rectal temperature. In conclusion, caffeine at 30 mg/kg could be suggested as an appropriate dose to use in piglets with low birthweight and low vitality scores. Future research might need to study the presentation of adverse effects due to higher caffeine concentrations.

Cardiotocography, Hypoxia, and Feto-Neonatal Neurological Damage

Complications occurring at any level of fetal oxygen supply can result in hypoxemia, which may ultimately lead to hypoxia/acidosis and neurological damage. Hypoxic-ischemic encephalopathy (HIE) is the short-term neurological dysfunction caused by intrapartum hypoxia/acidosis. This diagnosis requires the presence of several findings, including confirmation of newborn metabolic acidosis, low Apgar scores, early imaging evidence of cerebral edema, and the appearance of clinical signs of neurological dysfunction in the first 48 hours of life. Cerebral palsy (CP) comprises a heterogeneous group of nonprogressive movement and posture disorders, often accompanied by cognitive and sensory impairments, epilepsy, nutritional deficiencies, and secondary musculoskeletal lesions. Although CP is the most common long-term neurological complication associated with intrapartum hypoxia/acidosis, over 80% of cases are caused by other factors. Data on minor long-term neurological deficits are limited, but they suggest that less severe intellectual and motor impairments may result from intrapartum hypoxia/acidosis. Birth asphyxia is a broad term referring to intrapartum asphyxia severe enough to cause neurological damage in some newborns and, rarely, intrapartum or neonatal death. Cerebral palsy and long-term neurological complications such as learning difficulties and motor impairments may have causes other than birth asphyxia. Several intrapartum events can lead to asphyxia (i.e., hypoxia and metabolic acidosis), increasing the likelihood of neurological injury. The cardiotocograph (CTG) is a screening tool used to assess fetal well-being during labor and to identify the possibility of asphyxia. An abnormal CTG, sometimes severe enough to be described as a pathological trace, is commonly referred to as “fetal distress”, although many fetuses with such traces may not have hypoxia and metabolic acidosis. In current practice, these events are appropriately termed “pathological CTG trace” or “acidotic pH” rather than “fetal distress”. Accurate interpretation of the CTG is essential, and it is important to recognize a fetus displaying a pathological CTG in labor, which may imply possible hypoxia and birth asphyxia. Considering the broader clinical context when interpreting the CTG and taking timely and appropriate action based on the findings may help prevent birth asphyxia.

Coagulation parameters in very preterm infants.

The aim of this study was to define normal percentile values of coagulation parameters in preterm infants below 32 weeks of gestational age. This retrospective cohort study was conducted at Istanbul Medical Faculty. Preterm infants who were born prior to 32 weeks of gestation, between 2011 and 2021 were included and evaluated for coagulation parameters. Blood samples obtained through umbilical catheters prior to administration of heparinized flushes/fluids, vitamin K or fresh frozen plasma (FFP). Infants with a major bleeding disorder, intrapartum asphyxia or a history of familial bleeding disorders were excluded. Infants were grouped according to their gestational ages and birth weights: less than 24, 25-26, 27-28, 29-30, 31-32 weeks and <500, 500-749, 750-999, 1000-1249, 1250-1499, more than 1500 g. Third to 97th percentile values of both prothrombin time (PT) and activated partial thromboplastin time (aPTT) were defined. A total of 420 preterm infants were included. The median value and range of gestational age and birth weight of the infants were 29 (22.3-32.9) weeks and 1150 (395-2790) g, respectively. PT values were similar between subgroups according to gestational age but longer in infants with a birth weight less than 1000 g. aPTT values in infants born less than 24 weeks of gestation were found significantly longer. As maturation of the coagulation system increases by gestational age, very preterm infants (<32 gestational week (GW)) are under increased risk of bleeding. Determination of normal percentile distribution of coagulation parameters for preterm infants will shed light on the interpretation of coagulation parameters of these infants and minimize unnecessary FFP administrations.

Silicone breast implants may contribute to early-onset fetal growth restriction.

There are many studies showing that silicone breast implants may affect lactation, but few analyzed whether these implants affect placentation. We observed that many mothers with growth-restricted pregnancies had inflammatory conditions, such as silicone breast implants or giardiasis. This single-center cohort study assessed the prevalence of inflammatory conditions in normotensive growth-restricted singleton pregnancies. Next, we stratified the patients according to the presence or absence of silicone breast implants, to determine whether these implants influence fetal growth restriction onset or severity. Twelve (32%) of the 38 participants underwent cosmetic breast augmentation 4-18years before pregnancy. Half of the patients with and 38% without silicone breast implants had giardiasis. Half of the mothers with and 35% without silicone breast implants had autoantibodies. Silicone breast implants were associated with a 70% increased risk of fetal growth restriction before 32weeks' gestation (95% confidence interval [CI], 1.2-2.5). Fetal growth restriction was diagnosed significantly earlier in mothers with than in those without silicone breast implants, respectively at 27 (95% CI, 25-30) and 30weeks' gestation (95% CI, 29-32). Silicone breast implants also tripled the risk of fetuses being below the third percentile, but the difference was not significant. Our results suggest that the association of inflammatory conditions, such as silicone breast implants, giardiasis, and autoantibodies may contribute to placental insufficiency. Silicone breast implants older than four years increased the risk of early-onset fetal growth restriction. Studies with large samples are needed to validate our findings and define whether silicone-related fetal growth restriction should be included in autoimmune/inflammatory syndrome induced by adjuvants (ASIA) criteria. Key Points • Fetal growth restriction (FGR), responsible for 30% of stillbirths, is the most common cause of prematurity and intrapartum asphyxia. • In this study, including 38 mothers with normotensive FGR, all participants had 2-4 inflammatory conditions, such as giardiasis, sinusitis, candidiasis, dysbiosis, extreme fear or autoantibodies. • Silicone breast implants were associated with a 70% increased risk of fetal growth restriction before 32 weeks' gestation. • FGR was diagnosed at 27 weeks' gestation (95% CI, 25-30) in mothers with and at 30 weeks' gestation (95% CI, 29-32) in mothers without silicone breast implants.

Neonatal serial creatinine levels as an adjunct biomarker in timing of fetal neurologic injury.

To investigate the rise and clearance of newborn creatinine in perinatal asphyxia as an adjunct biomarker to support or refute allegations of acute intrapartum asphyxia. In this retrospective chart review, newborns >35 weeks gestational age were evaluated from closed medicolegal cases of confirmed perinatal asphyxia and reviewed for causation. Data collected included newborn demographic data, patterns of hypoxic ischemic encephalopathy, brain magnetic resonance imaging, Apgar scores, cord and initial newborn blood gases, and serial newborn creatinine levels during the first 96h of life. Newborn serum creatinine values were collected at 0-12, 13-24, 25-48, and 49-96h. Newborn brain magnetic resonance imaging was used to define 3 patterns of asphyxial injury: acute profound, partial prolonged, or Both. Two hundred and eleven cases of neonatal encephalopathy from multiple institutions were reviewed from 1987 to 2019 with only 76 cases having serial creatinine values during the first 96h of life. A total of 187 creatinine values were collected. Partial prolonged and Both had significantly greater degree of metabolic acidosis in the first newborn arterial blood gas in comparison to acute profound. Acute profound and Both had significantly lower 5- and 10- minute Apgar scores in comparison to partial prolonged. Newborn creatinine values were stratified by asphyxial injury. Acute profound injury showed minimally elevated creatinine trends with rapid normalization. Partial prolonged and Both demonstrated higher creatinine trends with delayed normalization. Mean creatinine values were significantly different between the three types of asphyxial injuries within 13-24h of life at the time when creatinine values peaked (p=0.01). Serial newborn serum creatinine levels taken within the first 96h of life can provide objective data of timing and duration of perinatal asphyxia.

EFFECT OF KANGAROO MOTHER CARE ON NEURODEVELOPMENTAL OUTCOME OF BABIES WITH HIE

Intrapartum asphyxia and consequential Hypoxic Ischemic Encephalopathy (HIE) are a common cause of potentially avoidable neonatal brain injury and mortality.HIE occurs in 1.5 per 1000 live births and 2.3 – 26.2 per 1000 live births in developed and developing countries respectively(3,4). Approximately 50% of neonates with severe HIE die, and survivors develop serious and devastating complications including mental retardation, epilepsy, and cerebral palsy. Kangaroo mother care (KMC) is evidence‐based technology that centers on the mother as the primary provider of heat and stimulation resulting in an array of benefits for the newborn. But the data on its effect on neurodevelopmental outcome is very limited especially on babies born with HIE.This study was conducted to compare the effects of KMC and conventional method of care (CMC) on the neurodevelopment of the newborns born with HIE.

Vitality in Newborn Farm Animals: Adverse Factors, Physiological Responses, Pharmacological Therapies, and Physical Methods to Increase Neonate Vigor.

Vitality is the vigor newborn animals exhibit during the first hours of life. It can be assessed by a numerical score, in which variables, such as heart rate, respiratory rate, mucous membranes' coloration, time the offspring took to stand up, and meconium staining, are monitored. Vitality can be affected by several factors, and therapies are used to increase it. This manuscript aims to review and analyze pharmacological and physical therapies used to increase vitality in newborn farm animals, as well as to understand the factors affecting this vitality, such as hypoxia, depletion of glycogen, birth weight, dystocia, neurodevelopment, hypothermia, and finally, the physiological mechanism to achieve thermostability. It has been concluded that assessing vitality immediately after birth is essential to determine the newborn's health and identify those that need medical intervention to minimize the deleterious effect of intrapartum asphyxia. Vitality assessment should be conducted by trained personnel and adequate equipment. Evaluating vitality could reduce long-term neonatal morbidity and mortality in domestic animals, even if it is sometimes difficult with the current organization of some farms. This review highlights the importance of increasing the number of stock people during the expected days of parturitions to reduce long-term neonatal morbidity and mortality, and thus, improve the farm's performance.

Association of Umbilical Cord Lactate Levels and Capillary Ph with Hypoxic-Ischemic Encephalopathy in Neonates Born with Intrapartum Asphyxia

Objective: To estimate the association of umbilical cord lactate levels and pH with Hypoxic-Ischemic Encephalopathy in neonates born with intrapartum asphyxia.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of study: Pediatrics Department, Pak Emirates Military Hospital, Rawalpindi Pakistan, from February 2021 to April 2022.&#x0D; Methodology: The study was conducted on neonates born with suspicion of intrapartum asphyxia at our hospital. Umbilical cord lactate levels and capillary pH were performed within the first 30 minutes of birth. Then, neonates were admitted to the neonatal intensive care unit and followed up for three days to look for the presence and severity of Hypoxic-Ischemic Encephalopathy (HIE). Association was ascertained between raised lactate levels and negative base deficit with HypoxicIschemic Encephalopathy.&#x0D; Results: A total of 1000 neonates were included in the final analysis. From 1000 neonates with intrapartum asphyxia, 790(79%) did not develop any grade of hypoxic-ischemic encephalopathy within the first three days of birth, while 210(21%) developed either Grade-I, II or III encephalopathies. Raised serum lactate and base deficit were significantly associated with the presence and severity of hypoxic-ischemic encephalopathy in neonates born with intrapartum asphyxia (p-value&lt;0.001).&#x0D; Conclusion: Both umbilical artery lactate levels and capillary pH performed within the first 30 minutes of birth were associated with the presence and severity of Hypoxic-Ischemic Encephalopathy in neonates included in our study. These results favour lactate levels as a predictor of Hypoxic-Ischemic Encephalopathy.

Characteristics of Children With Cerebral Palsy in the Post-Therapeutic Hypothermia Era.

Objectives: To explore the profile of children with cerebral palsy secondary to intrapartum asphyxia treated with therapeutic hypothermia after birth and to compare characteristics of children treated with therapeutic hypothermia with mild vs severe cerebral palsy outcome. Study Design: We identified all children treated with therapeutic hypothermia for intrapartum asphyxia in a single-center tertiary-level neonatal intensive care unit from 2008 to 2018 with a cerebral palsy outcome. We collected perinatal and outcome measures from patient charts. We searched the literature for characteristics of children with cerebral palsy prior to therapeutic hypothermia (historical cohort) to compare to our cohort. We subdivided our cohort into mild vs severe cerebral palsy and compared neonatal characteristics to identify predictors of severe phenotype. Results: Thirty of 355 cooled neonates (8%) developed cerebral palsy. More children had spastic quadriparesis and epilepsy, and fewer had visual impairment in the post-therapeutic hypothermia era compared to the historical cohort, but had similar Gross Motor Function Classification System scores. In our cohort, more children had severe (19 of 30, 63%) compared to mild cerebral palsy (11 of 30, 37%). The severe group had higher mean birth weight, lower 5- and 10-minute Apgar scores, and more often white matter injury with associated deep gray matter injury or near-total injury pattern (P < .05). Conclusions: Our data demonstrated more infants with severe rather than mild cerebral palsy in our cohort treated with therapeutic hypothermia. Birthweight, 5- and 10-minute Apgar scores, and magnetic resonance imaging (MRI) findings were significantly different between mild and severe phenotype groups. Our findings can guide clinicians how to better weigh these factors, when counseling parents in the neonatal period.

Characteristics and outcomes of neonates with intrapartum asphyxia managed with therapeutic hypothermia in a public tertiary hospital in South Africa

BackgroundIn randomized clinical trials, therapeutic hypothermia (TH) has been shown to reduce death and/or moderate-to-severe disability in neonates with hypoxic ischemic encephalopathy (HIE) in high-income countries, while this has not consistently been the case in low-and middle-income countries (LMICs). Many studies reporting on outcomes of neonates with HIE managed with TH are those conducted under controlled study conditions, and few reporting in settings where this intervention is offered as part of standard of care, especially from LMICs. In this study we report on short-term outcomes of neonates with moderate-to-severe HIE where TH was offered as part of standard of care.ObjectiveTo determine characteristics and mortality rate at hospital discharge in neonates with moderate-to-severe HIE.MethodsHospital records of neonates with intrapartum asphyxia were reviewed for clinical findings, management with TH (cooled or non-cooled) and mortality at hospital discharge. Inclusion criteria were birthweight ≥ 1800 g, gestational age ≥ 36 weeks and moderate-to-severe HIE. Comparisons were made between survivors and non–survivors in cooled and/or non-cooled neonates.ResultsIntrapartum asphyxia was diagnosed in 856 neonates, with three having no recorded HIE status; 30% (258/853) had mild HIE, and 595/853 (69%) with moderate-to-severe HIE. The overall incidence of intrapartum asphyxia was 8.8/1000 live births. Of the 595 with moderate-to-severe HIE, three had no records on cooling and 67% (399/592) were cooled. Amongst 193 non-cooled neonates, 126 (67%) had documented reasons for not being cooled with common reasons being a moribund neonate (54.0%), equipment unavailability (11.1%), pulmonary hypertension (9.5%), postnatal age > 6 h on admission (8.7%), and improvement in severity of encephalopathy (8.7%). Overall mortality was 29.0%, being 17.0% and 53.4% in cooled and non-cooled infants respectively. On multivariate analysis, the only factor associated with mortality was severe encephalopathy.ConclusionOverall mortality in neonates with moderate-to-severe HIE was 29.0% and 17.0% in those who were cooled. Cooling was not offered to all neonates mainly because of severe clinical illness, equipment unavailability and delayed presentation, making it difficult to assess overall impact of this intervention. Prospective clinical studies need to be conducted in LMIC to further assess effect of TH in short and long-term outcomes.

Review on Prevention of Cerebral Palsy from the Perspective of Social Pediatrics.

Cerebral palsy is a static encephalopathy with multiple etiologies. Several interventions toward perinatal risk factors, intrapartum asphyxia, and head injury or infection have been evaluated in order to deal with irreversible brain damage. Antenatal-intrapartum and neonatal interventions mainly focus on preventing hypoxia, oxidative stress, inflammation, and growth restriction. Among these preventive interventions, magnesium sulfate for neuroprotection of the fetus in women at risk of preterm birth and therapeutic hypothermia (cooling of body or just brain) for newborns with hypoxic-ischemic encephalopathy have effectively reduced cerebral palsy risk. There is still a lack of literature on the effectiveness of preventive interventions toward postnatally acquired brain injury. Social pediatricians are concerned with identifying, reducing, or eliminating risk factors of cerebral palsy and encourage a comprehensive approach to providing integrated and personalized care to children with cerebral palsy with the support of their families and communities.

RETROSPECTIVE STUDY OF RISK FACTORS IN PATIENTS WITH INTRAUTERINE DEATHS AFTER THE STATE OF VIABILITY REFERRED TO THE TERTIARY HEALTH FACILITY IN KODAGU

IUFD is an important indicator of maternal and perinatal Health in a given population. Fetal death from Intra partum asphyxia and Rh is immunization has almost disappeared. Toxaemia and GDM contribute significantly to fetal deaths. There is a significant decline in still birth from unexplained causes. Most frequent reported causes of fetal death earlier were prolapsed of cord, abruptioplacenta, Hydrocephalus and rupture uterus. If the causes of IUFD can be found, an effective strategy for prevention of IUFD can be materialised and complications can be prevented. Methods: Retrospective study in Tertiary Care Hospital. Results: 35 out of 38 of the patients are belong to the age group of 20-30 years. With history of reduced fetal moments, background of pre ecclampsia and anaemia contribute significantly to fetal deaths. Conclusions: to seek treating physicians with history of reduced fetal moments and aggressive treatment of PIH and anaemia can reduce the burden of IUD in this tribal belt. Illiteracy is a big burden to train and educate women to seek good antenatal care and advice. Keywords: Pre Ecclampsia Hypertention(PIH), Intra Uterine Fatal Death(IUFD), Anti Partum Haemorrhage(APH), Macerated Still Birth(MSB), Preterm Labour(PTL), Meconium Stained Liquor (MSL), Gestational Diabetes Mellitus(GDM), Pre matured rupture of Membranes(PROM), Lower Segment caesarean section(LSCS), Pre term death (PTD), Congenital Malformations(CMF).

Moderate to severe neonatal encephalopathy with suspected hypoxic-ischaemic encephalopathy in cooled term infants born in Tygerberg Academic Hospital: Characteristics of fetal monitoring and modifiable factors

&#x0D; Background. In South Africa, in babies &gt;2 500 g, intrapartum asphyxia is the main cause of neonatal death or stillbirth in those who were alive prior to labour. In a developing population, ~60% of neonatal encephalopathy (NE) has evidence of intrapartum hypoxic ischaemia. Therapeutic hypothermia for term babies born with NE can improve neonatal prognosis and long-term survival.&#x0D; Objectives. To identify the healthcare worker- and system-related modifiable factor(s) that were associated with NE in babies of ≥36 weeks’ gestation born at Tygerberg Hospital (a secondary/tertiary referral hospital) between 1 January 2016 and 30 December 2018.&#x0D; Methods. This was an observational cross-sectional study analysing data from the Tygerberg Hospital Hypoxic Ischaemic Encephalopathy database, the electronic labour ward register, the mortality database and clinical data from patient folders.&#x0D; Results. A total of 118 babies were admitted for head cooling, and therefore included in the study. The hospital in-born rate for serious encephalopathy is 5.5/1 000 in singleton live-born babies (9/1 000 rate for live-born deliveries ≥36 weeks). A sentinel event was identified in 19 (16%) cases. Delay in accessing theatre was the main system-related modifiable factor (25/58 or 43% of cases delivered by emergency caesarean delivery). The average decision-to-incision time was 1 hour 40 minutes, while the average bed occupancy in the emergency maternity centre was 102%. Failure to recognise or respond to an abnormal cardiotocograph was the dominant avoidable factor related to healthcare workers in 34 cases (36.4%).&#x0D; Conclusion. Babies born with severe NE place a burden on parents, healthcare staff and resources. Careful intrapartum care, including utilisation of protocols for the use of oxytocin, are imperative. It is recommended that improved access to emergency theatres and appropriately trained staff for maternity units should be a priority for healthcare planners.&#x0D;

Improvement of Umbilical Cord Blood Gas Analysis with Implementation of Clot Catchers.

Umbilical cord blood gas testing is a key component of objective pre- and perinatal evaluation of fetal acid base status to determine presence of intrapartum asphyxia and risk of neonatal encephalopathy. Heparinized cord blood is more likely to form small clots than other blood sources, which can interfere with, or preclude, sample analysis. Cord blood samples are irreplaceable and cannot be recollected, thereby compromising clinical decision-making when analysis is not possible. We evaluated processes to prevent excessive rates of cord blood clotting and quantified their impact on successful testing of blood gas specimens. Verified result and cancellation data were obtained retrospectively from the laboratory information system. Clot catchers were evaluated using noncord remnant specimens. Collection syringes were compared via collection from remnant cord sections. Prior to implementation of any interventions, retrospective analysis indicated a cancellation rate of 18.6% for umbilical cord blood gas specimens (arterial and venous) and 0.7% for noncord blood arterial and venous samples. Clot catchers were validated for clinical use, with a bias of <±4% for all analytes. After clot catchers were implemented for all cord specimens, cancellation rate decreased approximately 5-fold in the first month and remained <5% a year after implementation. A limited comparison of two heparin syringe types revealed a small difference in the overall rate of specimen clotting. Implementation of clot catchers was acceptable for analysis of cord blood samples, and when implemented resulted in a sustained 5-fold decrease in the rate of cord blood gas order cancellation.

Simulation and nurse-mentoring in a statewide nurse mentoring program in Bihar, India: diagnosis of postpartum hemorrhage and intrapartum asphyxia.

Background: Mentoring programs that include simulation, bedside mentoring, and didactic components are becoming increasingly popular to improve quality. These programs are designed with little evidence to inform the optimal composition of mentoring activities that would yield the greatest impact on provider skills and patient outcomes. We examined the association of number of maternal and neonatal emergency simulations performed with the diagnosis of postpartum hemorrhage (PPH) and intrapartum asphyxia in real patients. Methods: We used a prospective cohort and births were compared between- and within-facility over time. Setting included 320 public facilities in the state of Bihar, India May 2015 - 2017. The participants were deliveries and livebirths. The interventions carried out were mobile nurse-mentoring program with simulations, teamwork and communication activities, didactic teaching, demonstrations of clinical procedures and bedside mentoring including conducting deliveries. Nurse mentor pairs visited each facility for one week, covering four facilities over a four-week period, for seven to nine consecutive months. The outcome measures were diagnosis of PPH and intrapartum asphyxia. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Results:Relative to the bottom one-third facilities that performed the fewest maternal simulations, facilities in the middle one-third group diagnosed 26% (incidence rate ratio [IRR] = 1.26, 95% confidence interval [CI]: 1.00, 1.59) more cases of PPH in real patients. Similarly, facilities in the middle one-third group, diagnosed 25% (IRR = 1.25, 95% CI: 1.04, 1.50) more cases of intrapartum asphyxia relative to the bottom third group that did the fewest neonatal simulations. Facilities in the top one-third group (i.e., performed the most simulations) did not have a significant difference in diagnosis of both outcomes, relative to the bottom one-third group. Conclusions: Findings suggest a complex relationship between performing simulations and opportunities for direct practice with patients, and there may be an optimal balance in performing the two that would maximize diagnosis of PPH and intrapartum asphyxia.

P.089 Characteristics of children with cerebral palsy secondary to intrapartum asphyxia in the post-therapeutic hypothermia era

Background: We explored the profile of children with cerebral palsy (CP) secondary to intrapartum asphyxia (IAP), who were treated with therapeutic hypothermia (TH). We compared neonatal characteristics between children treated with TH with a mild vs severe CP. Methods: We collected perinatal and outcome measures of children treated with TH for IAP. We searched the literature for characteristics of children prior to TH to compare to our cohort. We subdivided our cohort into mild vs. severe CP and compared neonatal characteristics to identify predictors of severe phenotype. Results: We found more children with severe (19/30) compared to mild CP (11/30). Post-TH era children leaned towards a more severe phenotype compared to prior to TH. Children with severe CP had significantly higher mean birth weight, lower 5- and 10-minute Apgars, and more often white matter with associated deep gray matter injury or near-total injury pattern on MRI compared to the mild phenotype group (all p&lt;0.05). Conclusions: Our data leaned to a more severe CP in cooled children compared to pre-TH. Birthweight, 5- and 10-minute Apgars and MRI findings were significantly different between our mild vs severe group. Our findings can guide clinicians how to better weigh these factors when counseling parents in the neonatal period.

Neonatal presentations of neuromuscular disorders.

The term 'neuromuscular diseases' defines disorders of the extended motor unit. Newborns with disorders of peripheral nervous system (PNS) (motor neurons, nerve roots, plexuses, peripheral nerves, neuromuscular junction, and skeletal muscles) present most frequently with hypotonia, weakness, contractures, respiratory and feeding difficulties. Challenge in the newborn period is, hypotonia may also occur with more common central causes such as; electrolyte disturbances, sepsis, hypoxic-ischemic encephalopathy (HIE), congestive heart failure, and inborn errors of metabolism. Moreover, newborns with PNS involvement and/or genetic neuromuscular disorders (NMD) can also be prone to intrapartum asphyxia which further masks an underlying condition. This is why, NMD is also described as one of the 'HIE-mimics'. Genetic counseling, individualized treatment strategies, standards of care require accurate diagnosis. Neuromuscular field is moving to screening programs and pre-symptomatic diagnosis with promising disease-modifying treatments. The aim of this paper is to discuss approach to NMD within the newborn period in line with clinical history, examination findings, and diagnostic tests.