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Cesarean delivery of full-term infants: Identification of those at high risk for requiring resuscitation
Volume 106 Number 3
Clinical and laboratory observations
tcPcoe mm Hg
Respiratory rate Change
63.2 + 17.7 41.7 _+ 3,5 53.5 _+ 13.7
477
Heart rate
Per minute
Change
Per minute
Change
-4,8 • 6.2
56.8 +_ 15.6
-11.5 _+ 9.9~"
144.0 • 31.0
-0.7 + 7.1
0 • 1,0
44.0 +_ 11.4
--4,8 +_ 2,3w
111.6 _+ 17.2
-2.8 _+ 5.0
-1 _+ 1.4
69.0 +_ 19.5
-5.5 _+ 7.6
129.0 +_ 23.5
-0.2 _+ 3.9
Cesarean delivery of full-term infants." Identification of those at high risk for requiring resuscitation Shirley Press, M.D., Carlos Teilechea, M.D., and Samson Pregen, M.D. M i a m i , Florida
ALMOST 90% OF INFANTS born by cesarean delivery weight >2500 gin. The most frequent reasons for these deliveries are previous cesarean delivery, fetal distress, fetopelvic disproportion, breech presentation, and failure of labor to progress.t-~ Currently, there are no standard conventions concerning attendance of a physician to care for the infant at cesarean deliveries. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have published guidelines stating that each institution should develop a list of maternal and fetal complications that require the presence in the delivery room of an individual qualified in newborn infant resuscitation. 4 Cesarean delivery is included in their sample list. Their guidelines also state that the person who resuscitates the infant should be specifically trained and immediately available in the hospital at all times. This individual may be a physician, nurse anesthetist, nurse, nurse-midwife, or respiratory therapist? From the Department of Pediatrics. University of Miami School of Medicine. Submitted for publication June 4, 1984; accepted A~ug. 17, 1984. Reprint requests: Shirley Press, M.D., Department of Pediatrics, University of Miami School of Medicine (R-131), P.O. Box 016960, Miami, FL 33101.
To identify prior to cesarean delivery those newborn infants at high risk for requiring resuscitation, a prospective study was undertaken. The need for medical intervention or treatment was analyzed with respect to the reasons for cesarean birth.
METHODS Between December 1, 1981, and September 1, 1983, data were collected regarding 377 full-term neonates born by cesarean delivery. All deliveries were attended by one of us. The infants were born to private patients at North Miami General Hospital. Fourteen different obstetricians delivered the babies. The population was heterogeneous with respect to age and race. The information obtained included identification of the attending pediatrician and obstetrician, reason for the cesarean delivery, treatment of the infant, Apgar scores and outcome. When there was more than one reason for the cesarean delivery, the one judged to be most important was recorded. Fetal distress overrode all other reasons. An exception was made in the categories of maternal disease and failure of lab0i" to progress because they were thought to be of equal significance. Infants of <37 weeks gestational age were not considered. Dystoeia. Dystocia is characterized by abnormal progress in labor. ~ Because of this broad definition, dysto-
4 78
Clinical and laboratory observations
The Journal of Pediatrics March 1985
Table I. Reason for cesarean delivery
Repeat cesarean delivery Fetopelvic disproportion Fetal distress Breech presentation Failure of labor to progress Maternal disease Maternal disease and failure of labor to progress Other abnormal presentations Fetal conditions Total
n
%
111 76 66 41 28 28 9
29.4 20.2 17.5 10.9 7.4 7.4 2.4
9 _~9 377
2.4 2.4 100.0
cia was not used in this study as a reason for cesarean delivery. Instead, failure of labor to progress, fetopelvic disproportion, and malpresentations other than breech were selected as more specific. Failure of labor to progress. The fourteen obstetricians involved in this study had different criteria for failure of labor to progress. Generally, this was labor lasting longer than 8 to 12 hours without progression in Friedman's category of the latent phase of labor. Friedman's category of secondary arrest of dilation was also included in the definitions. Fetopelvic disproportion. Fetopelvic disproportion included abnormalities of the birth canal, in the soft tissues and in the bony pelvis. The size of the pelvis and its relationship to the size of the fetal head was judged clinically. X-ray pelvimetry was used when the maternal pelvis was clinically too small, malpresentation was suspected, or in cases of arrested labor. If fetopelvic disproportion was not seen on the radiographs in the cases of arrested labor, the diagnosis of failure of labor to progress was recorded. Fetal distress. Fetal monitoring was done only in selected patients. The definition of fetal distress used in this study included late or severe variable decelerations of fetal heart rate to <100/min. The presence of meconiumstained amniotic fluid was considered to be suggestive, although not indicative, of fetal distress when seen before delivery. If meconium staining was discovered at delivery, the original reason for the cesarean delivery, rather than fetal distress, if present, was re.corded. Meconium-stained amniotic fluid dictated mandatory direct laryngoscopy, tracheal intubation, and deep tracheal suctioning. Tracheal intubation, In general, neonates, other than those with meconium staining, required tracheal intubation when the 1-minute Apgar score was --<4. Infants with hypoventilation who did not respond to suctioning, oxygen,
and manual bag-and-mask ventilation also required tracheal intubati0n, as did those whose clinical condition rapidly deteriorated to respiratory failure. Routine care. Routine care consisted of stimulation and or nasopharyngeal suctioning with or without administration of oxygen. Manual ventilation was done with a standard resuscitation bag (Puritan manual resuscitator, Puritan-Bennett Corp., Kansas City, Mo.) and mask. RESULTS Cesarean delivery constituted 23.5% of all deliveries at North Miami General Hospital during the 21-month study period. One of us was in attendance at 85.1% of the cesarean deliveries performed. The remainder were attended by other pediatricians, based on parental selection. There were nine different categories for the election of cesarean deliveries. Maternal disease included abruptio placenta, herpes simplex, placenta previa, prolonged rupture of membranes (>48 hours), prolapsed cord, preeclampsia, and vaginal bleeding (Table I). Included in the category of maternal disease and failure of labor to progress were prolonged rupture of membranes and preeclampsia. Abnormal presentations other than breech comprised face, hyperextended head, and transverse lie. The fetal conditions were postmaturity, Rh incompatibility, and twins. The most common reason for cesarean delivery was repeat operation. Previous cesarean section, fetopelvic disproportion, fetal distress, breech presentation, and failure of labor to progress made up the reasons for 85.4% of these deliveries. In the groups with breech presentation and failure of labor to progress, none of the infants required tracheal intubation (Table II). Only one (0.9%) of those in the repeat cesarean group needed resuscitation. Infants delivered because of fetal distress and fetopelvic disproportion had the highest rates of tracheal intubation, 36.4% and 13.2%, respectively. Of these, 25.0% and 20.0%, respectively, required prolonged (>5 minutes) tracheal intubation. No infants required external cardiac massage or resuscitative drug therapy. The overall rate of tracheal intubation for all the full-term cesarean-delivered neonates was 10.9%. In the one infant born because of repeat cesarean delivery who required tracheal intubation, meconiumstained amniotic fluid was seen only after surgery had begun; there was no evidence of fetal distress prior to operation. No infant died in the delivery room; there were two subsequent deaths, both from persistent fetal circulation
Volume 106 Number 3
479
Clinical a n d laboratory observations
T a b l e II. Intervention in the delivery room
Reason for cesarean delivery
Repeat cesarean delivery Fetopelvic disproportion Fetal distress Breech presentation Failure of labor to progress Maternal disease Maternal disease and failure o f labor to progress Other abnormal presentations Fetal conditions
Routine care + manual ventilation
Routine care + naloxone
Tracheal suction +_ manual ventilation +_ naloxone
Tracheal intubation +_ manual ventilation +_ naloxone
Tracheal intubation + manual ventilation + resuscitative drug therapy
n
Routine care
111 76 66 41 28 28 9
108 60 29 38 25 25 7
1
0
1
1
0
2 4 0 0
l 2 1 0
3 7 2 3
10 24 0 0
0 0 0 0
1 1
0 1
0 0
2 0
0 0
9 9
5 7
2 0
0 0
0 0
2 2
0 0
secondary to meconium aspiration. Both infants had fetal distress and required tracheal intubation in the delivery room. The neonatal mortality was 0.6% among all the full-term cesarean-delivered infants in this study: DISCUSSION At Present there is no standard practice o r policy as to whether an individual competent in neonatal resuscitation should be present at all cesarean deliveries. North Miami General Hospital, and many others, requires a qualified pediatrician to be present at all cesarean deliveries. We believed it important to be a b l e to identify prior to cesarean delivery those full2term infants at h i g h r i s k for resuscitation. An occasiona ! neonate at low risk will require resuscitation, as may some infants delivered vaginally. The rate of tracheal intubation i n the repeat cesarean group was lower than for infants born vaginally in our hospital, but there are no reported data to confirm this as standard. This report is intended to help pediatricians and hospitals decide which cesarean deliveries in full-term pregnancies must be attended because of the high risk for requiring resuseita-
tion, when it is impractical to have physicians in attendance for all cesarean births. Based on our data, we suggest that a pediatrician not be required to be in attendance at repeat cesarean deliveries of full-term infants. For those done because of fetal distress and fetopelvie disproportion, attendance by a pediatrician or Other competent professional is necessary. We thank Dr. William Cleveland, Dr. William Rapoport, and Mrs. Eileen Gately for their help. REFERENCES
1. Cesarean childbirth: Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development. Bethesda, Md., 1981, National Institutes of Health, Publication 82-2067, pp 49482, 2. Phillips RN, Thornton J, Gleicher N: Physician bias in cesarean sections. JAMA 248:1082, 1982. 3. Arnirikia H, Zarewych B, Evans TN: Cesarean section: A 15-year review of changing incidence, indications, and risks. Am J Obstet Gynecol 140:81, 1981. 4. Guidelines for perinatal care. Evanston, !11., 1983, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, pp 67-73.
Clinical and laboratory observations
tcPcoe mm Hg
Respiratory rate Change
63.2 + 17.7 41.7 _+ 3,5 53.5 _+ 13.7
477
Heart rate
Per minute
Change
Per minute
Change
-4,8 • 6.2
56.8 +_ 15.6
-11.5 _+ 9.9~"
144.0 • 31.0
-0.7 + 7.1
0 • 1,0
44.0 +_ 11.4
--4,8 +_ 2,3w
111.6 _+ 17.2
-2.8 _+ 5.0
-1 _+ 1.4
69.0 +_ 19.5
-5.5 _+ 7.6
129.0 +_ 23.5
-0.2 _+ 3.9
Cesarean delivery of full-term infants." Identification of those at high risk for requiring resuscitation Shirley Press, M.D., Carlos Teilechea, M.D., and Samson Pregen, M.D. M i a m i , Florida
ALMOST 90% OF INFANTS born by cesarean delivery weight >2500 gin. The most frequent reasons for these deliveries are previous cesarean delivery, fetal distress, fetopelvic disproportion, breech presentation, and failure of labor to progress.t-~ Currently, there are no standard conventions concerning attendance of a physician to care for the infant at cesarean deliveries. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have published guidelines stating that each institution should develop a list of maternal and fetal complications that require the presence in the delivery room of an individual qualified in newborn infant resuscitation. 4 Cesarean delivery is included in their sample list. Their guidelines also state that the person who resuscitates the infant should be specifically trained and immediately available in the hospital at all times. This individual may be a physician, nurse anesthetist, nurse, nurse-midwife, or respiratory therapist? From the Department of Pediatrics. University of Miami School of Medicine. Submitted for publication June 4, 1984; accepted A~ug. 17, 1984. Reprint requests: Shirley Press, M.D., Department of Pediatrics, University of Miami School of Medicine (R-131), P.O. Box 016960, Miami, FL 33101.
To identify prior to cesarean delivery those newborn infants at high risk for requiring resuscitation, a prospective study was undertaken. The need for medical intervention or treatment was analyzed with respect to the reasons for cesarean birth.
METHODS Between December 1, 1981, and September 1, 1983, data were collected regarding 377 full-term neonates born by cesarean delivery. All deliveries were attended by one of us. The infants were born to private patients at North Miami General Hospital. Fourteen different obstetricians delivered the babies. The population was heterogeneous with respect to age and race. The information obtained included identification of the attending pediatrician and obstetrician, reason for the cesarean delivery, treatment of the infant, Apgar scores and outcome. When there was more than one reason for the cesarean delivery, the one judged to be most important was recorded. Fetal distress overrode all other reasons. An exception was made in the categories of maternal disease and failure of lab0i" to progress because they were thought to be of equal significance. Infants of <37 weeks gestational age were not considered. Dystoeia. Dystocia is characterized by abnormal progress in labor. ~ Because of this broad definition, dysto-
4 78
Clinical and laboratory observations
The Journal of Pediatrics March 1985
Table I. Reason for cesarean delivery
Repeat cesarean delivery Fetopelvic disproportion Fetal distress Breech presentation Failure of labor to progress Maternal disease Maternal disease and failure of labor to progress Other abnormal presentations Fetal conditions Total
n
%
111 76 66 41 28 28 9
29.4 20.2 17.5 10.9 7.4 7.4 2.4
9 _~9 377
2.4 2.4 100.0
cia was not used in this study as a reason for cesarean delivery. Instead, failure of labor to progress, fetopelvic disproportion, and malpresentations other than breech were selected as more specific. Failure of labor to progress. The fourteen obstetricians involved in this study had different criteria for failure of labor to progress. Generally, this was labor lasting longer than 8 to 12 hours without progression in Friedman's category of the latent phase of labor. Friedman's category of secondary arrest of dilation was also included in the definitions. Fetopelvic disproportion. Fetopelvic disproportion included abnormalities of the birth canal, in the soft tissues and in the bony pelvis. The size of the pelvis and its relationship to the size of the fetal head was judged clinically. X-ray pelvimetry was used when the maternal pelvis was clinically too small, malpresentation was suspected, or in cases of arrested labor. If fetopelvic disproportion was not seen on the radiographs in the cases of arrested labor, the diagnosis of failure of labor to progress was recorded. Fetal distress. Fetal monitoring was done only in selected patients. The definition of fetal distress used in this study included late or severe variable decelerations of fetal heart rate to <100/min. The presence of meconiumstained amniotic fluid was considered to be suggestive, although not indicative, of fetal distress when seen before delivery. If meconium staining was discovered at delivery, the original reason for the cesarean delivery, rather than fetal distress, if present, was re.corded. Meconium-stained amniotic fluid dictated mandatory direct laryngoscopy, tracheal intubation, and deep tracheal suctioning. Tracheal intubation, In general, neonates, other than those with meconium staining, required tracheal intubation when the 1-minute Apgar score was --<4. Infants with hypoventilation who did not respond to suctioning, oxygen,
and manual bag-and-mask ventilation also required tracheal intubati0n, as did those whose clinical condition rapidly deteriorated to respiratory failure. Routine care. Routine care consisted of stimulation and or nasopharyngeal suctioning with or without administration of oxygen. Manual ventilation was done with a standard resuscitation bag (Puritan manual resuscitator, Puritan-Bennett Corp., Kansas City, Mo.) and mask. RESULTS Cesarean delivery constituted 23.5% of all deliveries at North Miami General Hospital during the 21-month study period. One of us was in attendance at 85.1% of the cesarean deliveries performed. The remainder were attended by other pediatricians, based on parental selection. There were nine different categories for the election of cesarean deliveries. Maternal disease included abruptio placenta, herpes simplex, placenta previa, prolonged rupture of membranes (>48 hours), prolapsed cord, preeclampsia, and vaginal bleeding (Table I). Included in the category of maternal disease and failure of labor to progress were prolonged rupture of membranes and preeclampsia. Abnormal presentations other than breech comprised face, hyperextended head, and transverse lie. The fetal conditions were postmaturity, Rh incompatibility, and twins. The most common reason for cesarean delivery was repeat operation. Previous cesarean section, fetopelvic disproportion, fetal distress, breech presentation, and failure of labor to progress made up the reasons for 85.4% of these deliveries. In the groups with breech presentation and failure of labor to progress, none of the infants required tracheal intubation (Table II). Only one (0.9%) of those in the repeat cesarean group needed resuscitation. Infants delivered because of fetal distress and fetopelvic disproportion had the highest rates of tracheal intubation, 36.4% and 13.2%, respectively. Of these, 25.0% and 20.0%, respectively, required prolonged (>5 minutes) tracheal intubation. No infants required external cardiac massage or resuscitative drug therapy. The overall rate of tracheal intubation for all the full-term cesarean-delivered neonates was 10.9%. In the one infant born because of repeat cesarean delivery who required tracheal intubation, meconiumstained amniotic fluid was seen only after surgery had begun; there was no evidence of fetal distress prior to operation. No infant died in the delivery room; there were two subsequent deaths, both from persistent fetal circulation
Volume 106 Number 3
479
Clinical a n d laboratory observations
T a b l e II. Intervention in the delivery room
Reason for cesarean delivery
Repeat cesarean delivery Fetopelvic disproportion Fetal distress Breech presentation Failure of labor to progress Maternal disease Maternal disease and failure o f labor to progress Other abnormal presentations Fetal conditions
Routine care + manual ventilation
Routine care + naloxone
Tracheal suction +_ manual ventilation +_ naloxone
Tracheal intubation +_ manual ventilation +_ naloxone
Tracheal intubation + manual ventilation + resuscitative drug therapy
n
Routine care
111 76 66 41 28 28 9
108 60 29 38 25 25 7
1
0
1
1
0
2 4 0 0
l 2 1 0
3 7 2 3
10 24 0 0
0 0 0 0
1 1
0 1
0 0
2 0
0 0
9 9
5 7
2 0
0 0
0 0
2 2
0 0
secondary to meconium aspiration. Both infants had fetal distress and required tracheal intubation in the delivery room. The neonatal mortality was 0.6% among all the full-term cesarean-delivered infants in this study: DISCUSSION At Present there is no standard practice o r policy as to whether an individual competent in neonatal resuscitation should be present at all cesarean deliveries. North Miami General Hospital, and many others, requires a qualified pediatrician to be present at all cesarean deliveries. We believed it important to be a b l e to identify prior to cesarean delivery those full2term infants at h i g h r i s k for resuscitation. An occasiona ! neonate at low risk will require resuscitation, as may some infants delivered vaginally. The rate of tracheal intubation i n the repeat cesarean group was lower than for infants born vaginally in our hospital, but there are no reported data to confirm this as standard. This report is intended to help pediatricians and hospitals decide which cesarean deliveries in full-term pregnancies must be attended because of the high risk for requiring resuseita-
tion, when it is impractical to have physicians in attendance for all cesarean births. Based on our data, we suggest that a pediatrician not be required to be in attendance at repeat cesarean deliveries of full-term infants. For those done because of fetal distress and fetopelvie disproportion, attendance by a pediatrician or Other competent professional is necessary. We thank Dr. William Cleveland, Dr. William Rapoport, and Mrs. Eileen Gately for their help. REFERENCES
1. Cesarean childbirth: Report of a consensus development conference sponsored by the National Institute of Child Health and Human Development. Bethesda, Md., 1981, National Institutes of Health, Publication 82-2067, pp 49482, 2. Phillips RN, Thornton J, Gleicher N: Physician bias in cesarean sections. JAMA 248:1082, 1982. 3. Arnirikia H, Zarewych B, Evans TN: Cesarean section: A 15-year review of changing incidence, indications, and risks. Am J Obstet Gynecol 140:81, 1981. 4. Guidelines for perinatal care. Evanston, !11., 1983, American Academy of Pediatrics and the American College of Obstetricians and Gynecologists, pp 67-73.