Application of criteria developed by the Task Force on Neonatal Encephalopathy and Cerebral Palsy to acutely asphyxiated neonates.

OBJECTIVE: To estimate whether term neonates with acute intrapartum hypoxic ischemic encephalopathy and permanent brain injury satisfied the criteria for causation of cerebral palsy developed by the Task Force on Neonatal Encephalopathy and Cerebral Palsy. METHODS: In this descriptive study, patients in the case group were obtained from a registry of singleton, liveborn, term, neurologically impaired neonates. Entry criteria included a reactive intrapartum fetal heart rate pattern followed by a sudden, rapid, and sustained deterioration of the fetal heart rate that lasted until delivery and an umbilical artery cord pH. All patients in the case group were then assessed to determine if they met the criteria developed by the Task Force on Neonatal Encephalopathy and Cerebral Palsy. RESULTS: Thirty-nine neonates met the entry criteria, and the proportion meeting each essential criterion was as follows: 38 of 39 (97.4%) had umbilical artery pH of less than 7.00 and 30 of 30 (100%) had a base deficit of 12 mmol/L or higher; 33 of 34 (97%) had either moderate or severe encephalopathy; 34 of 36 (94%) had spastic quadriplegia or dyskinetic cerebral palsy or death attributable to brain injury; and 39 of 39 (100%) had no identifiable reason for exclusion. CONCLUSION: Fetuses that underwent a sudden and sustained deterioration of the fetal heart rate and that subsequently were found to have cerebral palsy demonstrated characteristics consistent with criteria developed by the Task Force on Neonatal Encephalopathy and Cerebral Palsy for intrapartum asphyxial injury. LEVEL OF EVIDENCE: III.

Establishing a culture of perinatal safety in a community hospital.

While unsafe behavior of frontline hospital staff, primarily physicians and nurses, is sometimes the proximal cause of adverse events, the critical importance of system-wide, hospital organizational factors is now being acknowledged(1,2). These organizational factors create the "safety culture" that influences the occurrence of these proximal failures.(3) The concept of safety culture originated in high-reliability organization theory, which was largely developed by a group of social scientists at the University of California at Berkeley who studied high-risk organizations that have achieved very low accident and error rates, for example, aircraft carrier flight decks, nuclear power plants and air-traffic control systems.(4-6) Safety culture refers to the enduring and shared beliefs and practices of organization members regarding the organization's willingness to detect and learn from errors.(7).

Nonclinical factors affecting women's access to trial of labor after cesarean delivery.

The use of trial of labor after cesarean (TOLAC) has declined in the last decade, and the clinical risks of TOLAC remain low. Nonclinical factors continue to affect women's access to TOLAC. This article considers 5 categories of factors that seem to be influencing rates of TOLAC and vaginal birth after cesarean: opinion leaders and professional guidelines, hospital facilities and cesarean availability, reimbursement for providing TOLAC, medical liability, and patient-level factors. An evidence base and strategies to provide guidance to create a safe environment for vaginal birth after cesarean are needed. Obstetric information systems are critical to this effort.

Causation--fetal brain injury and uterine rupture.

The purpose of this article is to familiarize the reader with the concept of causation and the role of the concept of foreseeability of harm in obstetric malpractice lawsuits. These concepts are incorporated into several hypothetical fetal brain injury and uterine rupture cases. The discussion involves an overview of available scientific evidence used to substantiate or refute whether a child's brain damage or a maternal uterine rupture was in fact related to the obstetric care in question. In the event of the delivery of a depressed newborn, a checklist of scientific evidence to be gathered at the time of delivery is also provided.

Nucleated red blood cell and platelet counts in asphyxiated neonates sufficient to result in permanent neurologic impairment.

OBJECTIVE: Recent research has suggested that a nucleated red blood cell (NRBC) count >or=26 per 100 white blood cells (%) or the development of a platelet count or=26% was: group 1, 10/21 (47.6%); group 2, 0/14 (0%); group 3, 0/12 (0%). Those with a platelet count or=26% than group 3 (p = 0.0135). A platelet count or=26% and/or a platelet count

Perinatal risk management: obstetric methods to prevent birth asphyxia.

Because obstetric care frequently is associated with the potential for liability, the purpose of this article is to familiarize the reader with perinatal risk management using the concept of foreseeability of harm and its potential application to obstetric care. At the same time, this article introduces the concept of notice, and explains the critical conduct intervals that are used to gauge how well the health care teams handle obstetric emergencies. The focus then shifts to incorporate these concepts into several maternal-child health quality management programs. It is hoped that this article will result in an improvement of perinatal outcome for pregnant women and their unborn children.

Birth asphyxia and cerebral palsy.

There has been a societal presumption that most, if not all, cases of hypoxic ischemic encephalopathy-induced cerebral palsy occur during the 3 hours that are related to the events of labor and delivery; society has tended to overlook the remaining 7000 hours of the pregnancy. As a result of this societal perspective, often times the obstetrician has been targeted unfairly as the person who is responsible for a given child's neurologic injuries. Rather, the entire pregnancy, labor, delivery, and well beyond birth require examination to understand fully the pathophysiologic mechanisms that are responsible for an infant's brain injuries, and their long-term impact on the child.

A comparison of shoulder dystocia-associated transient and permanent brachial plexus palsies.

OBJECTIVE: To estimate differences between shoulder dystocia-associated transient and permanent brachial plexus palsies. METHODS: We performed a retrospective case-control analysis from national birth injury and shoulder dystocia databases. Study patients had permanent brachial plexus palsy and had been entered into a national birth injury registry. Cases of Erb or Klumpke palsy with documented neonatal neuromuscular deficits persisting beyond at least 1 year of life were classified as permanent. Cases of transient brachial plexus palsy were obtained from a shoulder dystocia database. Non-shoulder dystocia-related cases of brachial plexus palsy were excluded from analysis. Cases of permanent brachial plexus palsy (n=49) were matched 1:1 with cases of transient brachial plexus palsy. RESULTS: Transient brachial plexus palsy cases had a higher incidence of diabetes mellitus than those with permanent brachial plexus palsy (34.7% versus 10.2%, odds ratio [OR] 4.68, 95% confidence interval [CI] 1.42, 16.32). Patients with permanent brachial plexus palsies had a higher mean birth weight (4519+/-94.3 g versus 4143.6+/-56.5 g, P<.001) and a greater frequency of birth weight greater than 4500 grams (38.8% versus 16.3%, OR, 0.31, 95% CI 0.11, 0.87). There were, however, no statistically significant differences between the two groups with respect to multiple antepartum, intrapartum, and delivery outcome measures. CONCLUSION: Transient and permanent brachial plexus palsies are not associated with significant differences for most antepartum and intrapartum characteristics.