Intrapartum Asphyxia Research Articles

Understanding the Full Spectrum of Organ Injury Following Intrapartum Asphyxia.

Birth asphyxia is a significant global health problem, responsible for ~1.2 million neonatal deaths each year worldwide. Those who survive often suffer from a range of health issues including brain damage—manifesting as cerebral palsy (CP)—respiratory insufficiency, cardiovascular collapse, and renal dysfunction, to name a few. Although the majority of research is directed toward reducing the brain injury that results from intrapartum birth asphyxia, the multi-organ injury observed in surviving neonates is of equal importance. Despite the advent of hypothermia therapy for the treatment of hypoxic–ischemic encephalopathy (HIE), treatment options following asphyxia at birth remain limited, particularly in low-resource settings where the incidence of birth asphyxia is highest. Furthermore, although cooling of the neonate results in improved neurological outcomes for a small proportion of treated infants, it does not provide any benefit to the other organ systems affected by asphyxia at birth. The aim of this review is to summarize the current knowledge of the multi-organ effects of intrapartum asphyxia, with particular reference to the findings from our laboratory using the precocial spiny mouse to model birth asphyxia. Furthermore, we reviewed the current treatments available for neonates who have undergone intrapartum asphyxia, and highlight the emergence of maternal dietary creatine supplementation as a preventative therapy, which has been shown to provide multi-organ protection from birth asphyxia-induced injury in our preclinical studies. This cheap and effective nutritional supplement may be the key to reducing birth asphyxia-induced death and disability, particularly in low-resource settings where current treatments are unavailable.

Improving Standards of Care in Obstructed Labour: A Criteria-Based Audit at a Referral Hospital in a Low-Resource Setting in Tanzania.

ObjectiveIn low-resource settings, obstructed labour is strongly associated with severe maternal morbidity and intrapartum asphyxia, and consequently maternal and perinatal deaths. This study evaluated the impact of a criteria-based audit of the diagnosis and management of obstructed labour in a low-resource setting.MethodsA baseline criteria-based audit was conducted from October 2013 to March 2014, followed by a workshop in which stakeholders gave feedback on interventions agreed upon to improve obstetric care. The implemented interventions included but were not limited to introducing standard guidelines for diagnosis and management of obstructed labour, agreeing on mandatory review by specialist for cases that are assigned caesarean section, re-training and supervision on use and interpretation of partograph and, strengthening team work between doctors, mid-wives and theatre staff. After implementing these interventions in March, a re-audit was performed from July 2015 to November, 2015, and the results were compared to those of the baseline audit.ResultsTwo hundred and sixty deliveries in the baseline survey and 250 deliveries in the follow-up survey were audited. Implementing the new criteria improved the diagnosis from 74% to 81% (p = 0.049) and also the management of obstructed labour from 4.2% at baseline audit to 9.2% at re-audit (p = 0.025). Improved detection of prolonged labour through heightened observation of regular contractions, protracted cervical dilatation, protracted descent of presenting part, arrested cervical dilation, and severe moulding contributed to improved standards of diagnosis (all p < 0.04). Patient reviews by senior obstetricians increased from 34% to 43% (p = 0.045) and reduced time for caesarean section intervention from the median time of 120 to 90 minutes (p = 0.001) improved management (all p < 0.05). Perinatal outcomes, neonatal distress and fresh stillbirths, were reduced from 16% to. 8.8% (p = 0.01).ConclusionA criteria-based audit proved to be a feasible and useful tool in improving diagnosis and management of obstructed labour using available resources. Some of the observed changes in practice were of modest magnitude implying demand for further improvements, while sustaining those already put in place.

Labouring on decelerations: the fetal peripheral chemoreflex wins.

Recordings of fetal heart rate provide the clinician with the only non‐invasive tool to continuously monitor fetal wellbeing during labour. By far, the most debated component of fetal heart rate monitoring during labour is the significance of fetal heart rate decelerations, which almost invariably occur in association with uterine contractions. Over the years, proposed possible triggers for these reductions in fetal heart rate have included fetal head compression, baroreflexes, chemoreflexes, Bezold–Jarisch reflexes and/or myocardial depression. In this issue of The Journal of Physiology, Lear et al. (2016) propose that a unified understanding of the physiology underlying intrapartum fetal heart decelerations is critical to improve their interpretation. The review reminds us that normal labour is associated with intermittent interruptions of uteroplacental gas exchange, such that ‘technically’ all babies experience some sort of asphyxia to a certain extent during labour. Although intrapartum fetal asphyxia is a term that is often avoided clinically, as it conjures thoughts of injury, it is a biochemical reality and it is useful for clinicians to understand the parameters underlying it. Reviewing and evaluating the available literature, Lear and colleagues suggest that, on balance, typical intrapartum decelerations are most likely the result of transient episodes of fetal hypoxia or fetal asphyxia and the consequent activation of the fetal peripheral chemoreflex response.

A new fetal death classification system

Stillbirth is the mayor contributor to perinatal mortality. To report a system for classification of fetal deaths. Retrospective cohort study of 29,916 births with 258 fetal deaths that occurred in a public hospital. Data were obtained from audit reports of stillbirths. The method for classification “obstetric condition relevant to the death” was applied, based on obstetric and placental pathological findings analyzed exclusively by a single obstetrician and a single pathologist. Ninety two percent of obstetric conditions causing fetal death were identified. The most commonly reported were ascending bacterial infection in 26%, congenital anomalies in 19%, arterial hypertension in 12% and placental pathology in 12%. Fetal growth restriction was identified in 50% of stillbirths. Ninety percent were secondary to a primary obstetric condition and 10% had an unexplained cause. Placental abruption as the final cause of fetal death was identified in 60% of cases with arterial hypertension, 43% of cases with placental pathology and 37% of ascending infections. Fetal deaths occurred during pregnancy in 82% of cases and during labor in 17%. Intrapartum asphyxia occurred in 0.8% of stillbirths and presented in term pregnancies. The “obstetric condition relevant to the death” method for classification of fetal death is effective to identify the originating obstetric cause of stillbirth and reduces the impact of fetal growth restriction and intrapartum asphyxia as the leading causes of death.

Multi Organ Dysfunction in Term Neonates with Perinatal Asphyxia

Introduction: Multiorgan dysfunction (MOD) is one of the four consensus based criteria for the diagnosis of intrapartum asphyxia. The theoretical concept behind MOD is the diving reflex -conservation of blood flow to vital organs at the cost of non-vital organs. The objective of this study was to assess the patterns of involvement of each major organ/system in term asphyxiated neonates.Material and Methods: This was a hospital based prospective study. Sixty term neonates who had suffered perinatal asphyxia were assessed for central nervous system, kidney, cardiovascular system, gastrointestinal system and liver dysfunction. Results: Out of 60 eligible neonates, 57 (95%) had evidence of at least one organ dysfunction. Cardiovascular system involvement (95%) was most common, followed by renal system (37%), hepatic system (22%), central nervous system and hematological system (20% each) and finally, gastrointestinal tract (8%).Conclusion: MOD is frequently associated with perinatal asphyxia with cardiovascular system being the most commonly affected.J Nepal Paediatr Soc 2015;35(3):307-311.

The Association between Hyperlactatemia and Adverse Long-Term Outcome in Infants With Moderate-To-Severe Hypoxic Ischemic Encephalopathy

Abstract BACKGROUND: Hypoxic ischemic encephalopathy (HIE) remains one of the most devastating events in the newborn period. Lactate is invariably produced with hypoxia and poor tissue perfusion. Initial highest lactate in the first hour of life and serial measurements of blood lactate have been found to be important predictors of moderate to severe neonatal encepha-lopathy in cases of intrapartum asphyxia. OBJECTIVES: To examine the association between initial lactate level and the long term adverse outcome in infants with moderate to severe HIE (HIE II/III). We hypothesized that the level and duration to normalize hyperlactatemia in HIE infants can predict long term adverse neurodevel-opmental outcome. DESIGN/METHODS: A retrospective chart and database review for all infants ≥ 35 weeks gestational age treated in the Northern Alberta Neonatal Program with HIE II/III from January 2006 to December 2012 (excluding infants who were growth restricted or with major congenital anomalies). The primary outcome was composite of death or any disability (cerebral palsy, cognitive delay &amp;lt;2SD below the mean, hearing loss and blindness) at 18 months or 3 years of age. Univariate and multivariable regression analyses were used to compare the outcome. RESULTS: Of 167 infants, 106 had initial lactate &amp;gt;5.0mmol/L (63%) and 48 had initial lactate 16mmol/L is significant (P0.0015) for detection of adverse outcome; sensitivity 29.3% and specificity 90.5%. CONCLUSION: Most term/near term infants with HIE II/III had initial lactate &amp;gt; 5mmol/L. Initial lactate &amp;gt;16 mmol/L and duration to normalization of lactate levels was associated with the adverse outcome.

Factors associated with the need for ventilation at birth of neonates weighing ≥2,500 g

OBJECTIVES:Approximately 20-40% of annual global neonatal deaths occur among infants with birthweights ≥2,500 g, and most of these deaths are associated with intrapartum asphyxia in low- and middle-income countries. This study aims to evaluate the peripartum variables associated with the need for resuscitation at birth of neonates weighing ≥2,500 g.METHOD:This case-control retrospective study was performed on data from all public reference maternity units in the state of Ceará, Northeast Brazil, between March 2009 and March 2010. The subjects were singleton neonates without malformations weighing ≥2,500 g, who required positive-pressure ventilation in the delivery room. The controls had a 1-minute Apgar score of ≥8 and did not undergo resuscitation. Variables associated with positive-pressure ventilation in the delivery room were evaluated via conditional multivariate logistic regression.RESULTS:Of the 2,233 live births with birth weights ≥2,500 g, 1-minute Apgar scores ≤7, and no malformations, 402 patients met the inclusion criteria, and they were paired with 402 controls. Risk variables for positive-pressure ventilation at birth were a gestational age <37 weeks (OR: 3.54; 95% CI: 1.14-10.92) and meconium-stained amniotic fluid (8.53; 4.17-17.47). Cervical examination at maternal admission (0.57; 0.38-0.84) and a written follow-up of the labor (0.68; 0.46-0.98) were identified as protective variables.CONCLUSIONS:Significant flaws in obstetric care are associated with the need for positive-pressure ventilation at birth for neonates weighing ≥2,500 g.

Asphyxie perpartum à terme : facteurs de risque de survenue et conséquences à court terme. À propos de 82 cas

Intrapartum asphyxia is a rare yet serious complication during labor with immediate consequences and possible long-term neurological impairment. The international Cerebral Palsy Task Force established criteria that attribute a cerebral palsy to intrapartum asphyxia: metabolic acidemia measured at birth with pH<7and base deficit≥12mmol/L. To determine the risk factors of an intrapartum asphyxia occurring in term live births, to evaluate the short-term consequences. Our retrospective study included all births between 2002and 2010in a level 3maternity of a university hospital center. Inclusion criteria were those of the Cerebral Palsy Task Force associated with a gestational age≥34weeks of gestation. We studied the conventional markers of intrapartum asphyxia: Apgar score at 5minutes, abnormal cardiotogographic recordings whether they occurred after a sentinel hypoxic event or not before and during labor. The duration of expulsive efforts, the amniotic fluid aspects, the delivery mode as well as the preexisting pregnancy pathologies were also evaluated. On the other hand, we studied the short-term consequences at the newborns: death, multiorgan failure and especially the occurring of a neonatal encephalopathy using Sarnat and Sarnat staging. One hundred and twenty-nine newborns (0.43%) out of 29,416live births had a pH<7of whom only 82 (0.27%) presented a real intrapartum asphyxia and were included in this study. A preexisting pregnancy pathology was found in 22% of the women. Hypoxic events were noted in only 9/82of the cases. Abnormal cardiotocographic recordings were present in 97.6% of the cases. The duration of expulsive efforts as well as the amniotic fluid aspects did not interfere with the occurring of a metabolic acidemia. Caesarean rate was at 46.3% and instrumental extraction rate was at 34.1%. Thity-eight newborns (46.3%) were admitted in neonatal intensive care in which we noted 3deaths (3.65%), 2multiorgan failures (2.4%) and 17neonatal encephalopathy (20.7%). The pH value seemed to influence the occurring of an encephalopathy: 50% when pH<6.9vs. 13.6% when pH≥6.9 (P=0.0013), as well as for the base deficit: 50% when BD<-18vs. 15.7% when BD≥-18 (P=0.0068). Apgar score at 5minutes also seemed predictive for a neonatal encephalopathy: 100% when<4, 46% between 4and 6and 11% when>6 (P<0.001). Our results showed an intrapartum asphyxia rate half the one widely recorded of 0.5% of total live births. Our study also validates the commonly used markers to evaluate a high risk of an early neonatal encephalopathy. This study should be continued with the evaluation of hypoxia long-term consequences on the psychomotor development of these kids and especially the occurring of cerebral palsy.

A retrospective review of stillbirths at the national hospital in Timor-Leste.

Timor-Leste has high maternal and infant mortality rates. Estimates of stillbirths are unreliable and limited by poor collection of vital health statistics. Lack of accurate data impedes the development of interventions to address local determinants of stillbirth. This study aimed to identify the rate, timing and causes of stillbirths at National Hospital Guido Valadares in Dili, Timor-Leste, between November 2009 and December 2010, during which data were available. Hospital birth registry and maternal records were retrospectively reviewed to identify stillbirths during the study period. The simplified Cause of Death and Associated Conditions system was utilised to classify stillbirths. One hundred and fifty-three stillbirths were identified, producing a stillbirth rate of 29 per 1000 births. Of stillbirths with known timing, 70 (66.7%) occurred antepartum and 35 (33.3%) intrapartum. Cause of death could not be ascertained in 62.7% of cases due to poor or missing records. Where identified, the three most commonly classified causes of death were intrapartum fetal asphyxia, maternal infection and maternal hypertensive disorder. This study highlights the need for standardised recording and coding of perinatal deaths at HNGV. The high proportion of antenatal death transfers from community health centres demonstrates the need for community and hospital staff training to improve the quality of antenatal and intrapartum obstetric care. A prospective study of stillbirths is recommended to obtain reliable data on the determinants of stillbirths in Timor-Leste. These data would inform evidence-based interventions for the improvement of maternity and obstetric care in community and hospital settings.

Foetal scalp blood sampling during labour for pH and lactate measurements

Second-line methods of foetal monitoring have been developed in an attempt to reduce unnecessary interventions due to continuous cardiotocography (CTG), and to better identify foetuses that are at risk of intrapartum asphyxia. Very few studies directly compared CTG with foetal scalp blood (FBS) and CTG only. Only one randomised controlled trial (RCT) was published in the 1970s and had limited power to assess neonatal outcome. Direct and indirect comparisons conclude that FBS could reduce the number of caesarean deliveries associated with the use of continuous CTG. The main drawbacks of FBS are its invasive and discontinuous nature and the need for a sufficient volume of foetal blood for analysis, especially for pH measurement, resulting in failure rates reaching 10%. FBS for lactate measurement became popular with the design of test-strip devices, requiring <0.5mL of foetal blood. RCTs showed similar outcomes with the use of FBS for lactates compared with pH in terms of obstetrical interventions and neonatal outcomes. In conclusion, there is some evidence that FBS reduces the need for operative deliveries. However, the evidence is limited with regard to actual standards, and large RCTs, directly comparing CTG only with CTG with FBS, are still needed.

Intrapartum asphyxia and hypoxic ischaemic encephalopathy in a public hospital: Incidence and predictors of poor outcome.

To determine the incidence of asphyxia and hypoxic ischaemic encephalopathy (HIE) and predictors of poor outcome in a hospital in a developing country. Neonates of birth weight ≥ 2,000 g who required bag-and-mask ventilation and were admitted with a primary diagnosis of asphyxia from January to December 2011 were included. Medical records were retrieved and maternal and infant data collected and analysed. Infants who had severe HIE and/or died were compared with those who survived to hospital discharge with no or mild to moderate HIE. There were 21 086 liveborn infants with a birth weight of 2 000 g over the study period. The incidence of asphyxia ranged from 8.7 to 15.2/1 000 live births and that of HIE from 8.5 to 13.3/1 000, based on the definition of asphyxia used. In 60% of patients with HIE it was moderate to severe. The overall mortality rate was 7.8%. The mortality rate in infants with moderate and severe HIE was 7.1% and 62.5%, respectively. The odds of severe HIE and/or death were high if the Apgar score was <5 at 10 minutes (odds ratio (OR) 19.1; 95% confidence interval (CI) 5.7-66.9) and if there was no spontaneous respiration at 20 minutes (OR 27.2; 95% CI 6.9-117.4), a need for adrenaline (OR 81.2; 95% CI 13.2-647.7) and a pH of < 7 (OR 5.33; 95% CI 1.31-25.16). Predictors of poor outcome were Apgar score at 10 minutes (p = 0.004), need for adrenaline (p = 0.034) and low serum bicarbonate (p = 0.028). The incidence of asphyxia in term and near-term infants is higher than that reported in developed countries. Apgar score at 10 minutes and need for adrenaline remain important factors in predicting poor outcome in infants with asphyxia.

Role of mitochondria in apoptotic and necroptotic cell death in the developing brain

Hypoxic–ischemic encephalopathy induces secondary brain injury characterized by delayed energy failure. Currently, therapeutic hypothermia is the sole treatment available after severe intrapartum asphyxia in babies and acts to attenuate secondary loss of high energy phosphates improving both short- and long-term outcome. In order to develop the next generation of neuroprotective therapies, we urgently need to understand the underlying molecular mechanisms leading to cell death. Hypoxia–ischemia creates a toxic intracellular environment including accumulation of reactive oxygen/nitrosative species and intracellular calcium after the insult, inducing mitochondrial impairment. More specifically mitochondrial respiration is suppressed and calcium signaling is dysregulated. At a certain threshold, Bax-dependent mitochondrial permeabilization will occur leading to activation of caspase-dependent and apoptosis-inducing factor-dependent apoptotic cell death. In addition, hypoxia–ischemia induces inflammation, which leads to the release of TNF-α, TRAIL, TWEAK, FasL and Toll-like receptor agonists that will activate death receptors on neurons and oligodendroglia. Death receptors trigger apoptotic death via caspase-8 and necroptotic cell death through formation of the necrosome (composed of RIP1, RIP3 and MLKL), both of which converge at the mitochondria.

Intrapartum intrauterine fetal demise with normal umbilical cord blood gas values at birth.

A case is presented in which a fetus was delivered by cesarean section for failure to progress and a “nonreassuring heart rate tracing” in which the Apgar scores were unexpectedly 0 at 1, 5, and 10 minutes. Resuscitation was unsuccessful after 30 minutes. The venous cord gas was normal and the arterial blood gas was not consistent with intrapartum asphyxia. At the time of surgery, the placenta appeared grossly normal. The autopsy was entirely normal. This case raises questions about our understanding of intrauterine fetal demise and suggests an approach to future research.

Scourge of intra-partum foetal death in Sub-Saharan Africa.

Intra-partum foetal death has been variously defined. However, a definition adopted at a technical consultation in 2006 is employed in this review. The quality of intra-partum care is a crucial factor for pregnancy outcome for both mothers and new-borns. Intra-partum stillbirth is defined as late foetal death during labour, which clinically presents as fresh stillbirth. The largest proportion of the world's stillbirths occurs in the late preterm, term and intra-partum periods. The Western Pacific region has the greatest reduction in stillbirth with a 3.8% annual decline between 1995 and 2009; however, the annual decline in the African region is less than 1%. Caesarean delivery is still uncommon, especially in rural areas: 1% of births in rural Sub-Saharan Africa and 5% in rural South Asia are by caesarean delivery; 62% of stillbirths occurred during the intra-partum period; 61.4% of stillbirths are attributable to obstetrical complications. Preventive measures aimed at reducing the incidence of intra-partum foetal death entail all measures aimed at improving quality antenatal care and preventing intra-partum asphyxia. This review discusses intra-partum foetal deaths from a Sub-Saharan African perspective. It explores the contribution of research within the region to identifying its impact on new-born health and potential cost-effective policy interventions.

How an extended perinatal audit may improve perinatal policy

Objective: A perinatal audit has the intention of quality of care improvement based on analysis of perinatal death, with our without analysis of maternal morbidity and/or mortality. Additional analysis of cases of intrapartum asphyxia could provide more insight into ways to improve quality of perinatal care.Methods: Analysis of cases of perinatal death and asphyxia in Jan Yperman Hospital, Ieper, Belgium, in 2012.Results: Three perinatal deaths occurred, none were preventable. Nineteen cases of proven metabolic acidosis have been identified. Three cases are considered possibly preventable, four cases are considered preventable. In three (possibly) preventable cases, foetal monitoring was absent during the active second stage of labour. In two preventable cases, intervention following a significant ST event in the second stage of labour was delayed. In one case intervention was delayed in the first stage of labour, while in another, indicated operative delivery in the second stage was not conducted.Conclusions: Integrating intrapartum asphyxia in the perinatal audit gives an opportunity to identify and eliminate weak points in the perinatal care chain, thereby optimizing quality of care. Lessons learned from our internal audit are the value of foetal monitoring and adequate action on significant ST events during second stage of labour.

A study on early-onset neonatal group B streptococcal infection, Bulgaria, 2007–2011

This study examines neonatal group B streptococcal (GBS) colonization and its relation to early-onset GBS disease (EOGBSD), based upon the experience of leading obstetrics and gynecology centers in Bulgaria. The objectives of the study were to update neonatal colonization rates and to assess relationships between clinically differentiated cases (culture-proven GBS newborns) and risk factors inherent to the infant and mother, using a computerized file. The neonatal GBS colonization rate ranged from 5.48 to 12.19 per 1000 live births. Maternal-fetal infection (MFI, a provisional clinical diagnosis in culture-proven colonized infants with initial signs of infection that is usually overcome with antibiotic treatment) and/or intrapartum asphyxia (IA) have been demonstrated as the most frequent clinical manifestations, with significant correlations for the primary diagnosis, but not affirmative for the final diagnosis at discharge, resulting from adequate treatment of neonates. MFI and IA were significantly related to prematurity, and reciprocally, prematurity was associated with the risk of MFI, indirectly suggesting that preterm birth or PPROM (preterm premature rupture of membranes, an obstetric indication associated with early labor and delivery, one of the major causes of preterm birth) is a substantial risk factor for EOGBSD. The regression analysis indicated that in the case of a newborn with MFI, a birth weight 593.58 g lower than the birth weight of an infant without this diagnosis might be expected. Testing the inverse relationship, i.e., the way birth weight influences a certain diagnosis (logistic regression) established the presence of a relationship between birth weight categories (degree of prematurity) and the diagnosis of MFI. The proportions and odds ratios, converted into probabilities that a baby would develop MFI, indicate the particularly high risk for newborns with extremely low and very low birth weight: extremely low birth weight (≤1000 g), the probability of developing a MFI is 66%; very low birth weight (1001-1500 g), 81%; low birth weight (the birth weight category including premature and small for gestational age term infants: 1501-2500 g), 40%; normal birth weight (term infants) (>2500 g), 32%. In conclusion, the need to introduce separate categories for early- and late-onset GBS disease in the registration nomenclature of neonatal infectious diseases is highlighted by these results. Drawing up intrapartum antibiotic prophylaxis (IAP) guidelines is also strongly recommended.

Comparison of the aetiology of stillbirth over five decades in a single centre: a retrospective study

ObjectiveTo compare the rates and aetiologies of stillbirth over the past 50 years.Study designWe reviewed all autopsy reports for stillbirths occurring between 1989 and 2009 at the McGill University Health...

Has the incidence of hypoxic ischaemic encephalopathy in Queensland been reduced with improved education in fetal surveillance monitoring?

Hypoxic ischaemic encephalopathy (HIE) is secondary to intrapartum asphyxia and the fifth largest cause of death of children under five. Incorrect use and interpretation of intrapartum cardiotocographs has been identified as a contributing factor to the development of HIE. Therefore, RANZCOG introduced the Fetal Surveillance Education Program (FSEP) to improve education and practice of intrapartum care. To investigate the incidence of HIE throughout Queensland between 2003 and 2011 during the introduction and implementation of RANZCOG FSEP. The incidence of HIE admissions at each hospital in Queensland (2003-2011) was collated from Queensland Health Statistics Centre. RANZCOG FSEP provided data regarding course attendees throughout Queensland (2006-2011). Hospitals were grouped into four regions. Statistical analysis was conducted using Stata(TM) (version 12.0) - data appeared to follow a damped harmonic model. The posteducation (2006-2011) HIE rate was significantly lower (P = 0.02) than the pre-education (2003-2005) rate. The final model predicted a stabilisation of HIE occurrence rate at approximately 160 events/100,000 live births by 2012. This rate was stable if the level of education was maintained but rose back to the initial rate of 250 events/100,000 live births if the education participation was discontinued. This study identified a significant reduction in the incidence of HIE--a potentially life-threatening newborn condition--between 2003 and 2011, during and following FSEP implementation. Notwithstanding the inevitable limitations of state-based data collection, these results are encouraging. For such improvements to be sustained, education must reach all staff engaged in intrapartum care and be regularly repeated.

Systemic Effects of Perinatal Asphyxia

Perinatal asphyxia is one of the three most important causes of neonatal mortality and morbidity [1]. It is a major contributor to long term neurodevelopmental sequele in the developing world. During fetal hypoxia-ischemia, ‘diving reflex’ shunts blood from ‘non-vital areas’ such as skin and splanchnic circulation to the ‘vital organs’ like heart, adrenals, and brain to protect them from injury. Thus theoretically, any newborn with neurological injury due to asphyxia should also have derangements of the ‘non-vital organs’ like kidney and gut. However, even in cases of severe intrapartum asphyxia, the involvement of various organs is not consistent and ranges from 70 to 100 % [2, 3]. There could be multiple reasons behind this variation: (a) all organs may not be equally involved due to variable activation of ‘diving reflex’ [4], (b) use of different criteria to define multi-organ dysfunction (MOD) and asphyxia, and (c) variable timing of clinical and laboratory evaluation. The American Congress of Obstetricians and Gynecologists (ACOG) uses MOD as one of the contributory rather than essential criteria to determine the intrapartum timing of insult [5]. Although renal, cardiac, pulmonary, hepatic and gastrointestinal systems could all be affected by perinatal asphyxia, heart and kidneys are the two most important extra-cerebral organs involved. The incidence of renal injury is 50–72 % while cardiac injury has been seen in 29–78 % in various studies. Damage to these organs can be persistent and may predict outcomes [6]. Renal injury in neonatal encephalopathy is associated with more severe brain injury and adverse longterm neurodevelopmental outcome [7]. Hence, it is important to be able to make an early and reliable diagnosis of hypoxicischemic injury to these organs. Cardiac injury has been diagnosed on the basis of clinical grounds, echocardiography, electrocardiography (ECG) and elevation of cardiac enzymes. Echocardiography is most commonly used to assess myocardial dysfunction though Ctroponin-T has emerged as a marker having good correlation with severity and outcome. ECG criteria for cardiac injury in perinatal asphyxia have been described but are cumbersome to apply [8]. Moreover, there are technical difficulties in recording and interpreting ECGs in sick newborns. Traditionally, ECG criteria have used T/QRS ratio and changes in ST segment to evaluate myocardial ischemia in asphyxiated newborns. P-wave dispersion has been used to evaluate the discontinuous propagation of sinus impulse and predict atrial fibrillation in adult patients with anterior wall myocardial infarction [9]. The incidence of atrial fibrillation secondary to intrapartum asphyxia in the newborn is, however, not known. In this issue of the journal, Amoozgar et al. have attempted to understand the changes in P-wave dispersion in asphyxiated neonates [10]. They have also attempted to relate P-wave dispersion with severity of asphyxia, arrhythmias, Apgar scores and C-Troponin I. The research idea is novel as the effects of perinatal asphyxia on cardiac conduction system are not well described. Unfortunately, because of several flaws in design, methodology and analysis, reliable conclusions cannot be drawn from this study. It is not clear if all 4 of the listed criteria had to be met or any one was good enough for a diagnosis of asphyxia. The inclusion criteria for controls mention the requirement of a normal neurological examination at birth and first week. The ECGs were however recorded on day 3. It is not clear if and how many of the ‘enrolled’ infants were subsequently excluded. The authors chose a snapshot window on day 3 of life to look at the ECGs. However, the changes in the ECG are dynamic and may be A. Bhatti Department of Pediatrics, Government Medical College, Jammu, India

Effect of early intervention in the developmental outcome of hypoxic ischemic encephalopathy infants

Background: Neonatal brain injury due to intrapartum asphyxia is a significant cause of cerebralpalsy, mental retardation, and epilepsy. Despite advances in perinatal care over the pastthree decades, the incidence of cerebral palsy attributed to birth asphyxia has not changed. Indeveloping countries, the incidence of post asphyxiate neurological damage is particularly high. Objectives: To study the developmental outcomes of hypoxic ischemicencephalopathy infants by early physiotherapy intervention till one year Methodology: This study had conducted on 48 asphyxiated full term newborn infants who developed HypoxicIschemic Encephalopathy (HIE) admitted in Neonatal Intensive Care Unit (NICU) of Rajah Muthiah Medical College &hospital. The studied infants have classified on the basis of Sarnat and Sarnat staging of HIE into 3 stages, and they were given early intervention. Denver developmental screening test have administered to infants every four months till one year. The level of achievement of various developmental domains in among various stages of HIE early intervention infants were compared. Results: We found improvement in the level of achievement of developmental domains in various stages of birth asphyxia infants with a better outcome in stage I HIE infants. Conclusion: The early interventional program on HIE infants in the neurodevelopmentaloutcome after one year of age investigated in this study was efficacious in infants who participated in thestudy.