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We report the findings of a longitudinal study of children who were treated in the neonatal intensive care units in 1975-78. Relationships are described between measures of conditions and treatments of both mothers and newborns during the perinatal period and measures representing motor, neurological, developmental, and ability functions of the children at 15 months, 4 years and 7 years. The results of multivariate and path analyses are presented in which a latent variable approach is used to characterize the covariation between signs, symptoms, and treatment in the perinatal period and the major dimensions of functioning at the follow-up occasions. Included among several noteworthy pathways between the latents of the various periods were ones from fetal distress, asphyxia, early crisis, intraventricular hemorrhage, anemia of prematurity, and number of days in the unit.

An analysis of 105 cases of prematures with respiratory distress syndrome, the idiopathic type were 9.5% (10/105). Fetal anoxia and ischemia, induced by pregnancy and during labour amounting to 87.6% (92/105), and of which 2.9% (3/105) was due to diabetes. It indicated that most cases of RDS are predominantly related with fetal anoxia and ischemia which results in pulmonary surfactant abnormality or impaired activity. It is important that in clinical diagnosis one should monitor cautiously the presence of premature birth with anoxia and ischemia, Thus, a preventive treatment must be given at least 24 hours prior to birth, and the earlier the least morbidity of RDS occurred.

All babies born in a University maternity unit over a period of four months had bacteriological swabs taken in the labour ward. This was to see whether a list of criteria in the history for bacterial infection of the newborn could be relied on. The criteria were: premature rupture of the membranes (before labour had started at all), rupture of the membranes for more than 12 hours, stained liquor, prematurity, fetal tachycardia of more than 160 per minute or abnormal rhythm of the heartbeat, an Apgar score of less than 7 after 1 minute, maternal genital or urinary tract infection (not cured) in month before delivery, maternal temperature above 38 degrees C in labour. During the study there were: 570 live births of which 222 (39%) were at risk of infection according to the above list of criteria, 35 had bacterial colonies present and 4 were definitely infected. More cultures from the placenta, the gastric fluid and the skin came back positive when there was a recognised risk of infection. Both the clinical and bacteriological results show that the risk was 5.24 of colonisation when the risk of infection had been recognised. These prospective results when checked against the retrospective results already obtained in the same department, suggest that this kind of screening for infection is worthwhile without being too expensive, and one can rely on the history to screen for neonatal bacterial infection.

Knowledge of how cesarean birth rates vary by hospital characteristics may aid in understanding and perhaps modifying some of the structural and process components of newborn delivery services to decrease the necessity of birth by cesarean procedure. To examine the influence of select hospital characteristics, data on hospital newborn deliveries in Illinois for 1986 among women 10-50 years of age inclusive (N = 130,249) were obtained from computerized hospital discharge abstract files. Characteristics of the hospitals were obtained from the annual American Hospital Association survey. Adjusting for mother's age at delivery; presence of pregnancy, labor, and delivery complications; expected primary payer; and size of hospital, women delivering in hospitals with teaching status were less likely (odds ratio = 0.76, p less than .001, 95 percent CL: 0.73, 0.79) to have a primary cesarean birth than women delivering in hospitals without this designation. A significantly lower cesarean birth rate in teaching hospitals was also observed in women of all age groups, in Medicaid and non-Medicaid women, and for most categories of delivery complications. These data suggest the need to identify the programmatic, technologic, and manpower functions associated with hospital teaching status that could decrease the likelihood of a primary cesarean delivery. The study also suggests that changes aimed at the manner of diagnosis, monitoring, and/or management of pregnancy/delivery complications may reduce the cesarean birth rate because of large differences in the primary cesarean birth rate found between teaching and other hospitals for most categories of newborn delivery complications.

Retinal hemorrhages occur with increased frequency in neonates following prolonged or difficult labor, especially if associated with primipara, surgical or mechanical intervention, low Apgar scores, perinatal hypoxia, low birth weight or coagulopathy. When involvement occurs peripheral to the arcades resolution occurs generally without sequelae. Hemorrhages involving the macula are much more serious since resolution in these cases may result in degenerative changes or an exudative or glial scar, resulting in amblyopia and possible strabismus. Early examination is warranted in high-risk infants in order to facilitate intervention and the prevention of more serious visual sequelae.

The study involves aetiological evaluation of various adverse perinatal causes leading to bilateral sensorineural hearing impairment in children born during the 5-year period of 1981-1985 (inclusive) in the Greater Manchester area of England, United Kingdom. This group comprised over 12% of the total number of hearing-impaired children in the area. Individual possible adverse factors are discussed in the light of present understanding of the pathogenesis and previous reports.

The examination of 1712 neonates by using an ultrasound method provided the findings of the incidence and echographic pattern of subependymal hemorrhages (SEH). A long-term follow-up of 32 newborns with SEH detected at birth by dynamic brain echography indicated that the mental and motor development in 30 of them was normal, whereas 2 babies had mild specific growth retardation unrelated to SEH. EEG abnormalities were found in 9 of 20 examined children. It was suggested that SEH failed to affect the mental and nervous development in infants, regardless of the extent and site of an injury.

Six full-term newborn infants are described who suffered from severe adult respiratory distress syndrome (ARDS). The triggering event was intrauterine/perinatal asphyxia in five, and group B streptococcal (GBS) septicemia in three. All had severe respiratory distress/failure and were ventilated mechanically with high concentrations of inspired oxygen and positive end-expiratory pressure. Radiography of the chest showed dense bilateral consolidation with air bronchograms and reduced lung volume. Persistent pulmonary hypertension (PPH) was documented in all cases. The coincidence of ARDS and PPH rendered respiratory management extremely difficult. For this reason high-frequency ventilation was instituted in all patients in order to improve CO2 elimination and induce respiratory alkalosis. Acute complications of respiratory therapy were encountered in five patients (pneumothorax, pulmonary interstitial emphysema, pneumopericardium). Three infants died (irreversible septic shock, progressive severe hypoxemia, and sudden cardiac arrest) after 17, 80, and 175 h of life. Histologic examination of the lungs was possible in all fatal cases and revealed typical changes of acute to subacute stages of ARDS. Three infants survived, the mean time of mechanical respiratory support being 703 h. Two patients were still dependent on oxygen after 1 month of life, and all survivors had increased interstitial markings and increased lung volumes on their chest roentgenograms at this time.

Cesarean section use in the United States has increased to 24.7% of deliveries in 1988 and is the most common hospital surgical procedure. California cesarean section rates were examined to measure recent trends in obstetric practices and to project future patterns of cesarean section use. Using discharge abstracts from 1983 to 1987 California hospital deliveries, total cesarean section rates were found to increase from nearly 22% in 1983 to 25% in 1987, an increase of 15%. Using a series of least-squares regression models, time trends in the distribution of indications associated with cesarean section among all deliveries and indication-specific cesarean section rates were evaluated. Increases in the number of women with previous cesarean section and fetal distress contributed to rising cesarean section rates. In addition, indication-specific cesarean section rates increased for breech presentation and dystocia. These trends were counterbalanced, in part, by declining rates of repeat cesarean sections. Trends noted for July 1985 through 1987 did not differ substantially from those observed for January 1983 to June 1985, suggesting that recent policy attempts to alter cesarean section use have not had a measurable effect on existing trends. Projections suggest that California cesarean section rates will rise to a level of 34% by the year 2000.

There have been many reports of lidocaine toxicity especially after maternal paracervical block anesthesia. We recently treated a term infant with evidence of fetal distress who presented with symptoms of lidocaine toxicity after maternal pudendal anesthesia. The infant developed apnea and bradycardia soon after birth which responded to mechanical ventilation and epinephrine. A prolonged Q-T interval was noted on day 1 which normalized by day 3. Cord blood was assayed and revealed an elevated lidocaine level. Lidocaine toxicity has been associated with fetal distress secondary to fetal ion trapping in the presence of acidosis. Although good response to supportive therapy occurred in our patient, other methods of therapy such as exchange transfusion and treatment of seizures may be required in some cases. Awareness of this now uncommon syndrome will lead to prompt diagnosis, appropriate work-up, and management.

Report is given on the first example in which the clinical and electrographic criteria of brain death were obtained at birth. Global destruction of the central nervous system of a type seen only with anoxia and circulatory failure had occurred in utero without appreciable disturbance of maternal health. Neuropathologic reaction in fetal tissues was identical with that which has been observed in the child or adult in the brain death syndrome. Functional disturbance of cerebral spinal circulation of sufficient degree to destroy neuronal tissue had happened without change in maternal circulation and without demonstrable lesions in the placenta or the cardiovascular apparatus of the fetus.

A randomly selected sample of 252 infants aged 5--18 months was evaluated through medical and developmental examinations. Developmental achievement scores and factors such as management of delivery and fetal distress were studied in relation to Apgar scores. Low-Apgar-score infants aged 5--8 months achieved consistently lower scores on all developmental fields. High-Apgar-score infants at younger and older ages did not differ on their achievement scores. Low Apgar score was much more frequent in infants delivered by vacuum extraction than in those delivered spontaneously, with forceps or by cesarian section. The frequency of low Apgar score was higher when fetal distress occurred.

In a prospective study of 133 spontaneous premature deliveries the relation between premature rupture of the membranes (PRM) and development of respiratory distress syndrome (RDS) in newborn infants is examined. PRM is associated with a significantly decreased incidence of RDS in newborn infants (P less than 0.002). This relation is valid at a gestational age of 28 weeks or more and a birthweight greater than 1000 g. Total respiratory morbidity in newborn infants (transient tachypnea + RDS) is also significantly decreased when labor is associated with PRM (P less than 0.005). Assessment of the influences of sex of the infant, fetal asphyxia, and delivery by cesarian section shows that PRM bears a stronger relation than each of these individual factors to a decreased incidence of RDS. Duration of the latent period has no influence on protection from RDS, and it is suggested that fetal lung maturity occurs before the membranes rupture.

A prospective study of neonatal status with a follow-up of 4 to 7 years, was performed in 74 full-term newborns with acute fetal distress (AFD). They were born between 0.1.12.1971 ad 31.12.1975. Mental retardation (M.R.) occurred in 4,8% of the control children (born in 1972 without problem) and in 20,2% (15 children) of the children who suffered from AFD; in 12 of these 15 cases, IQ is between 65 and 90, in 3 between 50 and 65. The prognosis is worse only after unexpected neonatal distress, not after AFD with a known etiology, or after use of a forceps. The prognosis is better when FD secondary to a cord anomaly lead to an obstetrical operation. It is also better after cesarean section (1 MR among 17) or when the mother chose a private obstetrician (0 MR among 25. Apgar score has no prognostic value. Some neonatal clinical and EEG symptoms have a poor significance : persistence of anomalies at one week, seizures lasting more than 2 days. Severe retardation is always associated with cerebral palsy (C.P.). Among 12 children with moderate retardation, only one has a C.P., the 11 others have a poor--intellectual, social and/or affective--environment.

Six newborn infants with myocardial infarction are presented. All of them had a history of perinatal hypoxemia and their natal weights were below 2,500 g. All infants developed cardiogenic "shock" during and required assisted ventilation. Autopsy confirmed the diagnosis in five of the six infants. Other autopsy findings were intracranial bleeding (three cases) and pulmonary atelectasis (two cases). Authors review pathophysiology of this clinical picture and point out its possible influence in the origin of neonatal shock.

Values of pH, base deficit and Pco2 in 885 unselected samples of umbilical blood collected at birth were related to pregnancy and delivery details. An increase in acidosis in both umbilical vein and artery was associated with placental abruption, maternal pethidine, pre-eclampsia, primigravidity, vaginal operative delivery for fetal distress and a long second stage of labour. Increased acidosis in arterial, but not venous, blood occurred with cord entanglement, vaginal breech delivery, postmaturity, high birthweight and a long first stage of labour. The relationship between obstetric factors and the acid-base state of the neonate suggests a possible role for cord blood gas measurements in assessing the results of obstetric practice.

Routine measurement of blood pressure in high risk neonates admitted to the intensive care nursery during a 2 year period resulted in detection of 18 infants with persistent hypotension requiring definitive treatment. The perinatal events in these babies were compared to those in a control group of infants. No single well defined factor responsible for neonatal hypotension could be found in the antenatal period or during labour. However 14 of the 18 babies were asphyxiated at the time of admission compared to 6 of 18 controls (p less than 0.02). Seventeen of 18 babies were preterm. Treatment consisted of maintenance of ventilation, oxygenation and acid-base status, volume expansion when indicated and inotropic agents. Nine of the 18 hypotensive babies died compared to 1 of 18 controls. Failure to respond within a few hours of commencement of treatment indicated poor prognosis.

A rare case of severe fetal heart bradycardia at 29 weeks gestation by dates followed by prolonged extreme tachycardia is reported and the literature on antepartum fetal bradycardia and fetal tachycardia is reviewed. Fetal bradycardia at the beginning of the third trimester with good fetal movements is not necessarily due to fetal distress. A prolonged fetal tachycardia does not have to be due to hypoxia but is probably due to unknown changes in the exitability of the myocardium. A prolonged fetal tachycardia antepartum and during delivery is in itself no indication for a Caesarean Section.

Etiologic and pathogenetic factors responsible for respiratory disturbances in full-term infants are still unclear. The authors' intention was to analyze to what extent fetal stress, expressed in terms of abnormal fetal heart rate pattern, was reflected in neonatal respiratory disturbance. The study was performed prospectively over one year and included 157 term infants. Contrary to general belief, there was a significantly lower incidence of respiratory disturbances after ominous fetal heart rate pattern, ie, basal bradycardia, late or severe variable decelerations, and reduced variability than after a normal fetal heart rate pattern. It is suggested that these results may be due to a favorable effect on the fetal lung of systemic or local factors, produced in response to intrauterine stress.

A group of term infants malnourished in utero and classified as a subacute fetal distress at birth were followed up with a group of normally grown term infants matched for age, sex, birth rank and social class. Both groups were free from other perinatal morbidity and chronic diseases. At three years of age behaviour was studied using the behaviour screening questionnaire of Richman and Graham and a behaviour observation report, whereas neurological dysfunction was assessed according to the pro forma of Touwen. Both problematic behaviour and neurological dysfunction occurred more frequently in the subacute fetal distress group. Behaviour problems are comparable to neurological signs as indicators for brain dysfunction.

Ten patients clinically diagnosed as having perinatal aspiration syndromes were found to have pulmonary hypertension. These infants were either term or postmature babies and had the following characteristics: (1) systemic or suprasystemic levels of pulmonary artery pressure (range, 50 to 117 mm Hg); (2) a degree of pulmonary hypertension not related to the degree of aspiration evident on chest roentgenograms; (3) evidence of right-to-left shunting at the ductal or foramen ovale level; and (4) sustained severe hypoxemia despite 100% inspired oxygen concentration. The overall mortality for the group was 50%. Since these patients had marked clinical and physiologic similarities to patients previously reported as having the persistent fetal circulation syndrome (PFC), they were classified as having "PFC with aspiration." The existence of pulmonary hypertension should be suspected despite roentgenographic evidence of aspiration in any patient who also manifests the clinical characteristics of PFC because its treatment may alter the prognosis of such patients.

Determination of CSF lactate levels were performed in 150 nonasphyxiated and 46 asphyxiated high risk neonates. Statistical analysis of log lactate levels of nonasphyxiated infants showed significant relationship to gestational and postnatal ages (P < .0001 and < .0002, respectively). CSF lactate elevation was seen in 16/29 infants studied within eight hours of asphyxia in contrast to 0/17 infants studied after eight hours (P < .001). Higher incidence of CSF lactate elevation was seen in term infants (7/8), infants with fetal distress (13/17), and very low Apgar scores (11/18). Seven of eight infants with markedly elevated lactate levels had both fetal distress and very low Apgar scores. CSF lactate determination in the immediate postasphyxial period appears to be an objective way of assessing the severity of cerebral hypoxia.

Beau's lines are a depression of the nail surface associated with a severe disturbance which temporarily interferes with the rate of nail growth. They appear several weeks or more after incurrence of the damage and continue to extend during nail growth. These lines were observed soon after birth in all twenty fingernails of an infant girl. The depression extended through the whole thickness of the nails. This would appear to be the first reported case in which Beau's lines have developed so early in life, probably as a result of intrauterine distress.

Obstruction of the tracheobronchial tree in the fetus-newborn is well recognized with meconium-stained amniotic fluid, but this problem is not usually considered in the absence of meconium. In the case reported here, airway obstruction by a large mucous-like plug apparently developed in the context of severe oligohydramnios and fetal distress. The infant required resuscitation but it was initially impossible to expand the chest despite endotracheal intubation and positive pressure ventilation. The lung compliance changed abruptly at 6 minutes of age and breath sounds were audible unilaterally on the left. A chest radiograph confirmed an atelectatic right lung. After aspiration of a large plug, both lungs became normally aerated. Airway obstruction must be included in the differential diagnosis of respiratory distress occurring in the context of severe oligohydramnios.

Perinatal asphyxia at term is a major cause of mortality and morbidity. In many instances obstetric or maternal complications during pregnancy, labor, or delivery account for the asphyxia, but there is a group of infants in whom asphyxia occurs without any recognizable risk factors. The histories of 1602 infants were evaluated with these problems in mind. There were 547 infants without any complicating factors, 329 with obstetric complications, and 356 with miscellaneous maternal, fetal, and neonatal problems. The mean gestational age of these infants was 277.4 days. Fetal distress was noted in 183 cases without subsequent neonatal disease; the mean gestation of these infants was 282.7 days. Unexpected intrapartum asphyxia was observed in 187 instances with a mean gestation of 288.8 days. Those who died or had neurologic symptoms had the longest mean gestation, 291 days. Only 5% of the infants dying of unexpected perinatal asphyxia and less than 16% of those with neurologic symptoms were born before their due dates; approximately 64% of the infants with obstetric complications, miscellaneous problems, or no complications or morbidity were born before 280 days. The implications for management of pregnancy at or beyond 280 days are discussed.

A reactive nonstress test (NST) has been demonstrated to be an excellent predictor of fetal well-being. Unfortunately, some fetuses continue to be lost, perhaps secondary to umbilical cord accidents. While examining this problem, we noted a unique "double variable," or "W pattern," on the NSTs of fetuses found at delivery to have a nuchal cord. In a prospective study to examine the accuracy of predicting the presence of a nuchal cord, 200 consecutive patients undergoing antepartum fetal heart rate testing were monitored for the occurrence of a W pattern on their NSTs. One hundred percent of the women with a W pattern delivered infants with at least one nuchal cord. In addition, the W pattern was associated with a higher incidence of five-minute Apgar scores of less than 7. The ability to identify infants with nuchal cords prior to delivery may be beneficial in identifying infants at increased risk of unexpected fetal distress or death.

Twenty-one neonates of over 36 weeks' gestation suffered perinatal asphyxia but not chronic hypoxia. Three clinical stages of postanoxic encephalopathy were distinguished. Stage 1 lasted less than 24 hours and was characterized by hyperalertness, uninhibited Moro and stretch reflexes, sympathetic effects, and a normal electroencephalogram. Stage 2 was marked by obtundation, hypotonia, strong distal flexion, and multifocal seizures. The EEG showed a periodic pattern sometimes preceded by continuous delta activity. Infants in stage 3 were stuporous, flaccid, and brain stem and autonomic functions were suppressed. The EEG was isopotential or had infrequent periodic discharges. Infants who did not enter stage 3 and who had signs of stage 2 for less than five days appeared normal in later infancy. Persistence of stage 2 for more than seven days or failure of the EEG to revert to normal was associated with later neurologic impairment or death.

A review of the literature shows that intensive neonatal care has reduced the incidence of neurological handicaps in children. Babies born before term and small for date are, however, more exposed to these handicaps. The pregnancy and socio-economical factors which are now known to play a role in the occurrence of prematurity and small-for-date babies bring about acute fetal distress which results in a demand for more intensive care. However, long-term neurological defects also result from these factors. Prospective studies can be used to assign a predictive score for these predisposing factors. The Maternity Hospital in Liège University has been using a score of these factors for more than 10 years to set up "a risk of premature birth coefficient." This could help towards a more scientific prognosis of the neurological state of the infant.

One hundred nineteen very low-birth weight infants were studied to see whether intrapartum fetal distress with or without acidosis correlated with the development of intraventricular and subependymal hemorrhage. Of 112 infants studied prospectively, 24% (27/112) had intraventricular/subependymal hemorrhage documented by real-time ultrasound studies shortly after birth; only 4.4 (5/112) had severe hemorrhage (grade 3/4). Ominous fetal heart rate patterns occurred in 50% of monitored infants with severe intraventricular/subependymal hemorrhage compared to 8% of matched controls (p less than 0.01). Reassuring fetal heart rate patterns were more predominant in infants without intraventricular/subependymal hemorrhage (p less than 0.05). Neonatal depression and the need for assisted ventilation beyond the immediate delivery period were more frequent in infants who developed intraventricular/subependymal hemorrhage. Antepartum and intrapartum complications, fetal presentation, cesarean section, duration of labor, hyaline membrane disease, and volume expansion appeared to play no role in the incidence of intraventricular/subependymal hemorrhage. Preliminary data presented here suggest that intrapartum fetal distress and acidosis may be significant factors in predicting which very low-birth weight infant will develop intraventricular/subependymal hemorrhage. The condition of the infant at birth may be more significant with respect to the extent of intraventricular/subependymal hemorrhage than a variety of obstetric variables. Aggressive management of appropriately selected patients and judicious resuscitation of the very low-birth weight infant may keep the incidence of severe intraventricular/subependymal hemorrhage at a minimum, thereby optimizing neurological outcome for this high-risk group.

Modern obstetrics can no longer be content to statistically analyse deaths only but must also concern itself with injuries. Cerebral damage in the new-born at term may result in grave sequelae. A study was made in the maternity department of the Port-Royal hospital of 65 infants, born at 38 weeks or later, with neurological signs, over the period 1968/69. The study was aimed at clarifying neonatal neurological signs, analysing the obstetric circumstances in which the complications occurred and observing future development of the children involved. In most instances a combination of neurological signs was present, falling into three broad clinical categories on the basis of severity. These neurological signs may appear during the hours after birth even when the Apgar score was satisfactory. Analysis of the cases showed that obstetric factors were responsible for the neurological disorder in 45 cases. The obstetric circumstances were almost always identical: abnormalities of presentation, dynamic problems during labour, and trials of labour. Modern methods for in-utero foetal surveillance are excellent but can nerve replace a perfect and hard won understanding of basic obstetric principles. Follow-up showed that sequelae remained in 7 children. It would appear, then, that in addition to "high risk" pregnancies, there exist "high risk" deliveries in part unpredictable before the onset of labour. There exists also a group of children in whom risk is increased and in whom surveillance over many years is indicated.