A Swedish study published in BJOG: An International Journal of Obstetrics and Gynaecology has found that infants of women who received substandard care1 during labour had a three-fold increased risk of asphyxia at birth.
Asphyxia results from an inadequate supply of oxygen to the fetus during labour and delivery. Although rare, it can lead to perinatal brain injury and perinatal death. A low Apgar score2 at five minutes after birth correlates well with asphyxia and was used to identify cases of newborn asphyxia.
In this study, researchers sought to investigate the impact of substandard care during labour and delivery on infant outcome. The study is based on all births in Stockholm County, Sweden, between 2004 and 2006. The study population represents 24% (74 539) of all births in Sweden during this time. Risk factors and handling of 313 infants with signs of asphyxia at birth (infants with an Apgar score <7 at 5 minutes of age) were compared to 313 healthy control infants (infants with an Apgar score of 10 at 5 minutes).
The researchers found that if there was substandard care during labour, the risk was three-fold that the infant would have low Apgar score at 5 minutes of age. The main reasons for substandard care were related to misinterpretation of CTG,3 not acting on an abnormal CTG in a timely fashion, and misuse of oxytocin.4 In cases of traumatic instrumental deliveries, the risk that the infant would have low Apgar score was almost 18-fold.
While the data relates to deliveries in Sweden, the results emphasize the importance of reacting promptly to signs of asphyxia. The authors call for educational efforts among physicians and midwives to improve CTG interpretation and fetal surveillance.
Lead author, Dr Sophie Berglund, from the Karolinska Institute in Stockholm, Sweden, said “There was substandard care during labour in two thirds of infants born with signs of asphyxia, and in one third of healthy infants. Assuming that substandard care is a risk factor for a low Apgar score, the number of infants with an Apgar score of <7 at 5 minutes of age could be substantially reduced by preventing substandard care.
“The main reasons for substandard care are factors that, in theory, are possible to prevent, and in practice, should be possible to reduce through educational efforts and increased awareness of risk factors associated with risk for low Apgar score.”
Prof. Philip Steer, BJOG editor-in-chief, said “The findings of this study make sense and underline the importance of safe, quality care. Studies in the UK have similarly shown that mandatory skills training in obstetric emergencies improves infant outcome.
"Although a rare occurrence, severe asphyxia and neonatal death can cause immense suffering to parents, families and those affected. Every effort should be made to prevent substandard care through skills training, cooperative teamwork, and ensuring adequate resources for maternity services."
Ends
Notes
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1 Care during labour was considered substandard when supervision of fetal wellbeing was neglected. This included when there was no CTG recording for more than 2.5 hours after admission or in between CTG recordings, when CTG recordings were not interpretable because they were of poor quality, or when there was inadequate follow-up and/or untimely action on abnormal CTG. Care during delivery was considered substandard in cases of threatening asphyxia if the time from the decision to deliver to birth exceeded 30 minutes, if there was a spontaneous vaginal delivery despite longstanding (at least 45 minutes) abnormal or uninterpretable CTG recordings, or if there was a complex instrumental delivery.
2 Apgar score is an evaluation of a newborn’s physical condition, based on assigning a value (0,1 or 2) to each of five criteria: heart rate, respiratory effort, muscle tone, response to stimuli, and skin color. The higher the score, the better the infant will fare during the neonatal period.
3 Cardiotocography (CTG) is a technical means of recording the fetal heartbeat and the uterine contractions during childbirth.
4 Oxytocin is administered in cases of induction of labour or after diagnosed uterine inertia, defined as no progress of labour during 2 hours after initially normal progress.
Reference
Berglund S, Pettersson H, Cnattingius S, Grunewald C. How often is a low Apgar score the result of substandard care during labour? BJOG 2010; DOI: 10.1111/j.1471-0528.2010.0265.x.
To view an abstract of the paper, click here.
