Bethany Sabol

Acidemia in neonates with a 5-minute Apgar score of 7 or greater - What are the outcomes?

BACKGROUND The Apgar score is universally used for fetal assessment at the time of birth, whereas, the collection of fetal cord blood gases is performed commonly in high-risk situations or in the setting of Apgar scores of <7, which is a less standardized approach. It has been well-established that neonatal acidemia at the time of delivery can result in significant neonatal morbidity and death. Because of this association, knowledge of the fetal acid-base status and detection of acidemia at the time of delivery can serve as a sensitive and useful component in the assessment of a neonates risk. Umbilical cord blood gas analysis is an accurate and validated tool for the assessment of neonatal acidemia at the time of delivery. Because the collection of fetal cord blood gases is not a standardized practice, it is possible that, with such a varied approach, some cases of neonatal acidemia are not detected, particularly in the setting of reassuring Apgar scores. OBJECTIVE In a setting of universally obtained cord blood gases, we sought to identify the rates of acidemia and associated factors in neonates with 5-minute Apgar scores of ≥7. STUDY DESIGN This retrospective cohort study identified all term, singleton, nonanomolous neonates with 5-minute Apgar scores of ≥7. The incidence of umbilical artery pH ≤7.0 or ≤7.1 and base excess ≤-12 mmol/L or ≤-10 mmol/L were examined overall and in association with obstetric complications and adverse neonatal outcomes. Chi-squared tests were used to compare proportions, and multivariable logistic regression was used to control for potential confounders. RESULTS In this cohort, the incidence of an umbilical artery pH of ≤7.0 was 0.5%, of a pH ≤7.1 was 3.4%, of a base excess ≤-12 mmol/L was 1.4%, and of ≤-10 mmol/L was 4.0%. Rates of neonatal acidemia were greater in the setting of meconium (4.3% vs 3.2%; P<.001), placental abruption (13.2% vs 3.4%; P<.001), and cesarean deliveries (5.8% vs 2.8%; P<.001), despite normal 5-minute Apgar scores. Additionally, umbilical artery pH ≤7.0 was associated with an increased risk of respiratory distress syndrome (adjusted odds ratio, 6.5; 95% confidence interval, 2.9-14.3) and neonatal intensive care unit admission (adjusted odds ratio, 10.8; 95% confidence interval, 6.8-17.4). Base excess of ≤-12 mmol/L was also associated with an increased risk of neonatal sepsis (adjusted odds ratio, 4.7; 95% confidence interval, 1.9-12.1). Finally, when examined together, neonates with both a pH of ≤7.0 and base excess of ≤-12 mmol/L continued to demonstrate an increased risk of neonatal intensive care unit admission and respiratory distress syndrome, with adjusted odds ratios of 9.6 and 6.0, respectively. This risk persisted in neonates with a pH of ≤7.1 and base excess of ≤-10 mmol/L as well, with adjusted odds ratios of 4.5 and 1.1, respectively. CONCLUSION Because neonates with reassuring Apgar scores have a residual risk of neonatal acidemia that is associated with higher rates of adverse outcomes, the potential utility of obtaining universal cord blood gases should be further investigated.

Vaginal birth after cesarean: an effective method to reduce cesarean.

Cesarean deliveries represent almost one third of US births. Given that repeat cesarean is the most common single indication for cesarean, trial of labor after cesarean (TOLAC) with subsequent vaginal birth after cesarean (VBAC) is an important mechanism to reduce the overall cesarean rate. The 2010 National Institutes of Health Conference found that one of the biggest barriers to VBAC is the lack of patient access to TOLAC. Many women who currently deliver by repeat cesarean would be candidates for a TOLAC. This manuscript will summarize the evidence on VBAC to help clinicians identify candidates, provide evidence-based counseling, and guide management of TOLAC.

Racial and Ethnic Differences in Pregnancy Outcomes in Women With Chronic Hypertension

INTRODUCTION: This study evaluates the association between race and ethnicity and obstetric outcomes in women with chronic hypertension. METHODS: A retrospective cohort study of African American, Hispanic, Asian, and white California residents who delivered live, singleton, nonanomalous neonates from 2005 to 2008. The data consisted of birth records linked to hospital discharge data; chronic hypertension was identified by International Classification of Diseases, 9th Revision codes. Univariate and multivariable analyses were conducted to examine the association between chronic hypertension and preeclampsia, gestational diabetes, preterm delivery, birth weight, intrauterine fetal demise, neonatal death, and postneonatal death. RESULTS: After accounting for education level, socioeconomic status, maternal age, and parity, African American, Hispanic, and Asian women with chronic hypertension were significantly more likely than whites to develop preeclampsia and deliver preterm (P<.001). African American women had a significantly elevated risk of intrauterine fetal demise (P<.001) and postneonatal death (P<.05). Hispanic and Asian women were significantly more likely to develop gestational diabetes (P<.001). There were no significant differences in neonatal death (Table 1). Mean birth weights were significantly less for each race and ethnicity: African American (2,891 g), Hispanic (3,053 g), and Asian (2,933 g) when compared with whites (3,221 g) (P<.001). Table 1 Perinatal Outcomes by Race and Ethnicity in Women With Chronic Hypertension (Sabol, p. 168–9S) CONCLUSION: Racial and ethnic disparities affect maternal and neonatal outcomes in women whose pregnancies are complicated by chronic hypertension. Whether this represents disparities in quality of care compared with biologic differences requires further investigation.

Growth restriction: identifying fetuses at risk

Abstract Purpose: Examine risks of intrauterine growth restriction (IUGR) and composite perinatal outcomes with estimated fetal weights (EFW) 10–20th%, and compare outcomes using umbilical artery Doppler (UAD). Materials and methods: Retrospective, cohort evaluating ultrasound (US) EFW 10–20th%, between 2002 and 2012. Cases were identified with EFW % 10–20. Controls, EFW >20th% were obtained for each case, matched by gestational age, and US date. Unadjusted and adjusted logistic regression was used for outcomes. Results: Seven hundred and sixty-seven cases met criteria with matched controls. Fetuses having EFW 10–20th% (GA 33.6 ± 3.7 weeks) had increased IUGR on follow up ultrasound (OR 26.5[10.2–68.7], p < .01), small for gestational age (SGA) (OR 9.2 [6.9–12.3], p < .01), neonatal intensive care unit (NICU) admissions (OR 2.4 [1.6–3.6], p < .01), and composite perinatal morbidity (OR 7.8 [6.0–10.1], p < .01) on adjusted analyses. Abnormal UAD in cases had greater rates of 5 min Apgar <7, NICU admission and composite morbidity (p < .05). Conclusions: Pregnancies with EFW 10–20th% at the time of initial US are at increased risk for developing IUGR and being SGA at birth, with more NICU admissions and composite perinatal outcomes; abnormal UAD evaluation in cases conveyed further increase in outcomes.

Quality Improvement and Patient Safety on Labor and Delivery

There has been an emphasis on redesigning our health care system to eliminate medical errors and create a culture of safety. The American College of Obstetrics and Gynecologists defines a culture of safety as an environment in which all care providers are empowered to identify errors, near misses, risky behaviors and broader systems issues while engaging in active collaboration to improve and resolve processes and system failures. This article reviews key components that promote a culture of safety and help to implement safer, more effective, evidence-based quality care on labor and delivery units.

The Hard Work of Improving Outcomes for Mothers and Babies: Obstetric and Perinatal Quality Improvement Initiatives Make a Difference at the Hospital, State, and National Levels

Quality improvement efforts are an increasingly expanding focus for perinatal care providers across the United States. From successful hospital-level initiatives, there has been a growing effort to use and implement quality improvement work in substantive and meaningful ways. This article summarizes the foundations of maternal-focused, birth-focused, and neonatal-focused quality improvement initiatives to highlight the underpinnings and potential future directions of current state-level perinatal quality care collaboratives.

Intrauterine Fetal Demise and Postneonatal Death Stratified by Maternal Education Level and Gestational Age [152]

INTRODUCTION: To evaluate the association between maternal education and the rates of intrauterine fetal demise and postneonatal death stratified by gestational age in a cohort of otherwise healthy women. METHODS: A retrospective cohort study was conducted using 2005 U.S. national linked birth certificate and death certificate data. Maternal education was defined as less than or equal to some level of high school education compared with college education or beyond. Intrauterine fetal demise was defined as death occurring at or after 20 weeks of gestation. Postneonatal death was defined as death from day 29 to 365 of life. Results were expressed as number of deaths per 10,000 live births. RESULTS: Overall, perinatal death rates per 10,000 were at least double in women receiving a high school education or less compared with the more educated cohort. Specifically, the rate of intrauterine fetal demise was 0.0029 compared with 0.0018 (P<.001), neonatal death was 0.0021 compared with 0.0012 (P<.001), postneonatal death was 0.0028 compared with 0.0011 (P<.001), and infant death was 0.0049 compared with 0.0024 (P<.001). However, when examined by week of gestation, although the rates of intrauterine fetal demise and postneonatal death were greater at every gestational age in those with a high school education or less, rates of neonatal death and infant death were quite similar between the two educational groups. CONCLUSION AND IMPLICATION: Rates of intrauterine fetal demise and post neonatal death were greater for every gestational age in less educated women when compared with their more educated cohort. Given that rates of neonatal death were approximately the same regardless of level of education brings up an interesting discrepancy. Environmental factors, inability to navigate the health care system, or lack of education in prenatal and postnatal care may all be contributing factors and would require further investigation.