Long-term outcome in term breech infants with low Apgar score--a population-based follow-up

Moderation of parental socioeconomic status on the relationship between birth health and developmental coordination disorder at early years

Objective

This study investigated whether parental SES moderates the effect of birth health on Developmental Coordination Disorder (DCD) in preschool children.

Methods

One hundred and twenty-two children aged 4 to 6 years were enrolled in the study. The Movement Assessment Battery for Children --2nd Edition (MABC-2) test was used to assess the motor coordination of children. They were preliminarily categorized into either the DCD (<=16th percentile, n = 23) or typically developing (TD) group (>16th percentile, n = 99) based on the testing results. All children in the DCD group were further confirmed to meet other diagnostic criteria of the DSM-V using the intellectual test and parental questionnaires. Moderation analysis was conducted using the PROCESS macro for SPSS, and 95% confidence intervals with a bootstrap procedure were calculated to identify the significant moderating effect.

Results

Maternal education (unstandardized coefficient = 0.6805, SE = 0.3371, p < 0.05) and maternal employment status (unstandardized coefficient = 0.6100, SE = 0.3059, p < 0.05) were found to moderate the relationship between birth length and the probability of having DCD. Moreover, the relationship between birth weight and the probability of having DCD was moderated by the annual household income (unstandardized coefficient = -0.0043, SE = 0.0022, p < 0.05).

Conclusion

The lower maternal education level and maternal unemployment strengthened the negative relationship between birth length and the probability of having DCD. Additionally, the negative relationship between birth weight and the probability of having DCD was statistically significant in high annual household salaries.

Association of Apgar score at 5 minutes with academic performance and intelligence in youth: A cohort study

INTRODUCTION

The Apgar score is routinely given at childbirth worldwide. A low Apgar score at 5 minutes is a strong predictor for neonatal death. Scores below 7 have been associated with higher risks of later neurologic disability. Few studies have assessed the association between Apgar score and school performance and intelligence. The existing literature points towards a possible association between Apgar score and later cognitive function, but the contradictions call for further investigation to fully understand the potential association. This study aimed to examine the possible association between Apgar score at 5 minutes and academic performance and intelligence in youth.

MATERIAL AND METHODS

The study is a cohort study. The cohort consists of all Danish liveborn children in 1978-2000 (n = 1 450 681). Data regarding pregnancies, births, parents, school grades, and intelligence of the children were retrieved from different Danish registers. Multiple imputations were performed to avoid discarding data. After exclusion, the final cohort consisted of 1 005 241 children. Associations between Apgar score at 5 minutes and school graduation, grades and attendance, and intelligence scores from conscription were analyzed using univariate and multivariate logistic and linear regressions.

RESULTS

No association was found between Apgar score and graduating primary school. Adjusted odds ratio (aOR) of graduating upper secondary education and attending conscription were significantly lower for children with scores below 7 compared with 7-10: graduating upper secondary education: Apgar 0-3: aOR 0.79 (95% CI 0.67-0.93), Apgar 4-6: aOR 0.86 (95% CI 0.81-0.93), attending conscription: Apgar 0-3: aOR 0.73 (95% CI 0.59-0.91), Apgar 4-6: aOR 0.73 (95% CI 0.66-0.80). The Apgar 4-6 group had significantly lower total mean primary school grade average: -0.13 (95% CI -0.21 to -0.054) and lower mean intelligence scores at conscription: -0.57 (95% CI -1.09 to -0.058). All other differences remained insignificant.

CONCLUSIONS

Performances when graduating school and attending conscription were overall equal regardless of Apgar score at 5 minutes. Chances of graduating primary school were the same irrespective of the score, but chances of graduating upper secondary education and attending conscription were significantly lower with scores below 7. The results suggest that children with scores below 7 may fail to appear at upper secondary education and conscription, but if they do, they perform equally to anyone else.

Intrapartum Cesarean Delivery Due to Nonreassuring Fetal Heart Rate and the Risk of Pediatric Infectious Morbidity-related Hospitalizations of the Offspring

OBJECTIVES

One of the most common indications for intrapartum cesarean delivery (CD) is nonreassuring fetal heart rate (NRFHR) patterns. We aimed to study the long-term effect of CD due to NRFHR on the risk for subsequent childhood infectious morbidity-related hospitalizations of the offspring.

STUDY DESIGN

A population-based cohort study was performed, comparing total and different subtypes of infectious morbidity-related pediatric hospitalizations among offspring born by CD due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Infectious-related morbidities included hospitalizations involving a predefined set of International Classification of Diseases, 9th revision codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative morbidity, and a Cox proportional hazards model was constructed to adjust for confounders.

RESULTS

The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) were born via CD following labor dystocia with normal fetal heart rate (comparison group). Offspring born following NRFHR had higher rates of infectious morbidity-related hospitalizations (11.4% vs. 9.1%; odds ratio, 1.3; 95% confidence interval, 1.1-1.5; P < 0.01; Kaplan-Meier survival curve P < 0.01). The association remained significant and independent while adjusting for gestational age, maternal age and comorbidities, using a Cox proportional hazards model (adjusted hazard ratio, 1.3; 95% confidence interval, 1.2-1.4; P < 0.01).

CONCLUSIONS

In our population, CD due to NRFHR is a risk factor for pediatric infectious morbidity-related hospitalizations of the offspring.

Non-reassuring fetal heart rate patterns: Is it a risk factor for long- term pediatric cardiovascular diseases of the offspring?

OBJECTIVE

We aimed to study the long-term effect of non-reassuring fetal heart rate (NRFHR) patterns on the risk for subsequent pediatric cardiovascular morbidity of the offspring.

STUDY DESIGN

A population based cohort study, comparing total and different subtypes of cardiovascular morbidity related pediatric hospitalizations among offspring born by caesarean delivery (CD) due to NRFHR versus labor dystocia (failure of labor to progress during the 1st or 2nd stage). The analysis included all singletons born between the years 1999-2014 at a single tertiary regional medical center. Cardiovascular related morbidities included hospitalizations involving a pre-defined set of ICD-9 codes, as recorded in hospital computerized files. Infants with congenital malformations, multiple gestations, vaginal deliveries and vacuum failure were excluded from the analysis. Perinatal mortality cases were excluded from the long-term analysis. A Kaplan-Meier survival curve was used to compare the cumulative cardiovascular morbidity incidence, and a Cox proportional hazards model was used to adjust for confounders.

RESULTS

The study population included 9956 newborns who met inclusion criteria; among them, 5810 (58%) were born by CD due to NRFHR, and 4146 (42%) due to labor dystocia with normal FHR (comparison group). Rate of long- term cardiovascular related hospitalizations was comparable between both groups (0.8% vs. 0.7%, OR 0.9, 95% CI 0.6-1.4, p = 0.664; Kaplan-Meier survival curve p = 0.320(. Using a Cox proportional hazards model, controlling for gestational age, no association was found between NRFHR patterns and the risk for subsequent pediatric cardiovascular morbidity of the offspring (Adjusted HR = 0.8, 95% CI 0.5-1.3, p = 0.376).

CONCLUSION

In our population, NRFHR patterns do not affect the risk of long- term pediatric cardiovascular morbidity of the offspring.

Utility of the 5-Minute Apgar Score as a Research Endpoint

Although Apgar scores are commonly used as proxy outcomes, little evidence exists in support of the most common cutpoints (<7, <4). We used 2 data sets to explore this issue: one contained planned community births from across the United States (n = 52,877; 2012-2016), and the other contained hospital births from California (n = 428,877; 2010). We treated 5-minute Apgars as clinical "tests," compared against 18 known outcomes; we calculated sensitivity, specificity, positive and negative predictive values, and the area under the receiver operating characteristic curve for each. We used 3 different criteria to determine optimal cutpoints. Results were very consistent across data sets, outcomes, and all subgroups: The cutpoint that maximizes the trade-off between sensitivity and specificity is universally <9. However, extremely low positive predictive values for all outcomes at <9 indicate more misclassification than is acceptable for research. The areas under the receiver operating characteristic curves (which treat Apgars as quasicontinuous) were generally indicative of adequate discrimination between infants destined to experience poor outcomes and those not; comparing median Apgars between groups might be an analytical alternative to dichotomizing. Nonetheless, because Apgar scores are not clearly on any causal pathway of interest, we discourage researchers from using them unless the motivation for doing so is clear.

Pre- and Perinatal Characteristics Associated with Apgar Scores in a Review and in a New Study of Dutch Twins

A literature review was carried out to identify pre and perinatal characteristics associated with variation in Apgar scores in population-based studies. The parameters identified in the literature search were included in the classical twin design study to estimate effects of pre and perinatal factors shared and nonshared by twins and to test for a contribution of genetic factors in 1- and 5-min Apgar scores in a large sample of Dutch monozygotic (MZ) and dizygotic (DZ) twins. The sample included MZ and DZ twins (N = 5181 pairs) recruited by the Netherlands Twin Register shortly after birth, with data on prenatal characteristics and Apgar scores at first and/or fifth minutes. The ordinal regression and structural equation modeling were used to analyze the effects of characteristics identified in the literature review and to estimate genetic and nongenetic variance components. The literature review identified 63 papers. Consistent with the review, we observed statistically significant effects of birth order, zygosity and gestational age (GA) for 1- and 5-min Apgar scores of both twins. Apgar scores are higher in first-born versus second-born twins and DZ first-born versus MZ first-born twins. Birth weight had an effect on the 5-min Apgar of the first born. Fetal presentation and mode of delivery had different effects on Apgar scores of first- and second-born twins. Parental characteristics and chorionicity did not have significant main effects on Apgar scores. The MZ twins' Apgar correlations equaled the DZ Apgar correlations. Our analyses suggest that individual differences in 1- and 5-min Apgar scores are attributable to shared and nonshared pre and perinatal factors, but not to genotypic factors of the newborns. The main predictors of Apgar scores are birth order, zygosity, GA, birth weight, mode of delivery and fetal presentation.

One-minute and five-minute Apgar scores and child developmental health at 5 years of age: a population-based cohort study in British Columbia, Canada

OBJECTIVES

We investigated the associations between Apgar scores at 1 and 5 min, across the entire range of score values, and child developmental health at 5 years of age.

SETTING

British Columbia, Canada PARTICIPANTS: All singleton term infants without major congenital anomalies born between 1993 and 2009, who had a developmental assessment in kindergarten between 1999 and 2014.

MAIN OUTCOMES AND MEASURES

Developmental vulnerability on one or more domains of the Early Development Instrument and special needs requirements. Adjusted rate ratios (aRRs) and 95% CIs were estimated using log-linear regression.

RESULTS

Of the 150 081 children in the study, 45 334 (30.2%) were developmentally vulnerable and 3644 (2.5%) had special needs. There was an increasing trend in developmental vulnerability and special needs with decreasing 1 min and 5 min Apgar scores. Compared with children with an Apgar score of 10 at 5 min, the aRR for developmental vulnerability increased steadily with decreasing Apgar score from 1.02 (95% CI 1.00 to 1.04) for an Apgar score of 9 to 1.57 (95% CI 1.03 to 2.39) for an Apgar score of 2. Among children with 1 min Apgar scores in the 7-10 range, changes in Apgar scores between 1 and 5 min were associated with significant differences in developmental vulnerability. Compared with children who had an Apgar score of 9 at 1 min and 10 at 5 min, children with an Apgar score of 9 at both 1 and 5 min had higher rates of developmental vulnerability (aRR 1.03, 95% CI 1.01 to 1.05). Compared with infants with an Apgar of 10 at both 1 and 5 min, infants with a 1 min score of 10 and a 5 min score of <10 had higher rates of developmental vulnerability (aRR 1.53, 95% CI 1.08 to 2.17).

CONCLUSION

Risks of adverse developmental health and having special needs at 5 years of age are inversely associated with 1 min and 5 min Apgar scores across their entire range.

Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden

OBJECTIVE

To investigate associations between Apgar scores of 7, 8, and 9 (versus 10) at 1, 5, and 10 minutes, and neonatal mortality and morbidity.

DESIGN

Population based cohort study.

SETTING

Sweden.

PARTICIPANTS

1 551 436 non-malformed live singleton infants, born at term (≥37 weeks' gestation) between 1999 and 2016, with Apgar scores of ≥7 at 1, 5, and 10 minutes.

EXPOSURES

Infants with Apgar scores of 7, 8, and 9 at 1, 5, and 10 minutes were compared with those with an Apgar score of 10 at 1, 5, and 10 minutes, respectively.

MAIN OUTCOME MEASURES

Neonatal mortality and morbidity, including neonatal infections, asphyxia related complications, respiratory distress, and neonatal hypoglycaemia. Adjusted odds ratios (aOR), adjusted rate differences (aRD), and 95% confidence intervals were estimated.

RESULTS

Compared with infants with an Apgar score of 10, aORs for neonatal mortality, neonatal infections, asphyxia related complications, respiratory distress, and neonatal hypoglycaemia were higher among infants with lower Apgar scores, especially at 5 and 10 minutes. For example, the aORs for respiratory distress for an Apgar score of 9 versus 10 were 2.0 (95% confidence interval 1.9 to 2.1) at 1 minute, 5.2 (5.1 to 5.4) at 5 minutes, and 12.4 (12.0 to 12.9) at 10 minutes. Compared with an Apgar score of 10 at 10 minutes, the aRD for respiratory distress was 9.5% (95% confidence interval 9.2% to 9.9%) for an Apgar score of 9 at 10 minutes, and 41.9% (37.7% to 46.4%) for an Apgar score of 7 at 10 minutes. A reduction in Apgar score from 10 at 5 minutes to 9 at 10 minutes was also associated with higher odds of neonatal morbidity, compared with a stable Apgar score of 10 at 5 and 10 minutes.

CONCLUSIONS

In term non-malformed infants with Apgar scores within the normal range (7 to 10), risks of neonatal mortality and morbidity are higher among infants with lower Apgar score values, and also among those experiencing a reduction in score from 5 minutes to 10 minutes (compared with infants with stable Apgar scores of 10).

Adverse perinatal outcomes associated with trial of labor after cesarean section at term in pregnancies complicated by maternal obesity

INTRODUCTION

Obesity is associated with higher risks for intrapartum complications. Therefore, we sought to determine if trial of labor after cesarean section (TOLAC) will lead to higher maternal and neonatal complications compared to repeat cesarean section (RCD).

METHODS

This was a retrospective cohort analysis of singleton nonanomalous births between 37 and 42 weeks GA complicated by maternal obesity (body mass index (BMI) ≥ 30 kg/m²) and history of one or two previous cesarean deliveries. Outcomes were compared between TOLAC and RCD. The maternal outcomes of interest included blood transfusion, uterine rupture, hysterectomy, and intensive care unit admission. Neonatal outcomes of interest included 5-minute Apgar score <7, prolonged assisted ventilation, neonatal intensive care unit admission, neonatal seizures, and neonatal death.

RESULTS

There were 538,264 pregnancies included. Compared with RCD, TOLAC was associated with an absolute increase in the following neonatal outcomes: low 5-min Apgar score (0.6%, p < .001), neonatal intensive care unit (NICU) admission (0.8%, p < .001), neonatal seizure (0.1 per 1000 births, p = .037), and neonatal death (0.2 per 1000 births, p = .028). Additionally, TOLAC was associated with an absolute increase in following maternal outcomes: blood transfusion (0.1%, p < .001), uterine rupture (0.18%, p < .001) and ICU admission (0.1%, p = .011).

CONCLUSIONS

TOLAC among obesity pregnancies at term increases the risk of maternal and neonatal complications compared with RCD.

Apgar Scores Are Associated with Attention-Deficit/Hyperactivity Disorder Symptom Severity

OBJECTIVE

Adverse events during pregnancy and delivery have been linked to attention-deficit/hyperactivity disorder (ADHD). Previous studies have investigated Apgar scores, which assess the physical condition of newborns, in relation to the risk of developing ADHD. We propose to go one step further and examine if Apgar scores are associated with ADHD symptom severity in children already diagnosed with ADHD.

METHOD

ADHD symptoms severity, while off medication, was compared in 2 groups of children with ADHD: those with low (≤6, n = 52) and those with higher (≥7, n = 400) Apgar scores sequentially recruited from the ADHD clinic.

RESULTS

Children with low Apgar at 1 minute after birth had more severe symptoms as assessed by the externalizing scale of the Child Behaviour Checklist, the Conners' Global Index for Parents, and the DSM-IV hyperactivity symptoms count (P = 0.02, <0.01, <0.01, respectively).

CONCLUSION

Low 1-minute Apgar scores are associated with a significant increase in ADHD symptom severity. These findings underline the importance of appropriate pregnancy and perinatal care.

Five-minute Apgar score as a marker for developmental vulnerability at 5 years of age

OBJECTIVE

To assess the relationship between the 5 min Apgar score and developmental vulnerability at 5 years of age.

DESIGN

Population-based retrospective cohort study.

SETTING

Manitoba, Canada.

PARTICIPANTS

All children born between 1999 and 2006 at term gestation, with a documented 5 min Apgar score.

EXPOSURE

5 min Apgar score.

MAIN OUTCOME MEASURES

Childhood development at 5 years of age, expressed as vulnerability (absent vs present) on five domains of the Early Development Instrument: physical health, social competence, emotional maturity, language and cognitive development, and communication skills.

RESULTS

Of the 33,883 children in the study, most (82%) had an Apgar score of 9; 1% of children had a score <7 and 5.6% had a score of 10. Children with Apgar scores <10 had higher odds of vulnerability on the physical domain at age 5 years compared with children with a score of 10 (eg, adjusted OR (aOR) for Apgar 9=1.23, 95% CI 1.05 to 1.44). Similarly, children with Apgar scores of <10 were more vulnerable on the emotional domain (eg, aOR for Apgar 9=1.20, 95% CI 1.03 to 1.41). Nevertheless, the Apgar-based prognostic model had a poor sensitivity for physical vulnerability (19%, 95% CI 18% to 20%). Although the Apgar score-based prognostic model had reasonable calibration ability and risk-stratification accuracy for identifying developmentally vulnerable children, classification accuracy was poor.

CONCLUSIONS

The risk of developmental vulnerability at 5 years of age is inversely associated with the 5 min Apgar score across its entire range, and the score can serve as a population-level indicator of developmental risk.

Twin Birth Study: 2-year neurodevelopmental follow-up of the randomized trial of planned cesarean or planned vaginal delivery for twin pregnancy

BACKGROUND

The Twin Birth Study randomized women with uncomplicated pregnancies, between 32(0/7)-38(6/7) weeks' gestation where the first twin was in cephalic presentation, to a policy of either a planned cesarean or planned vaginal delivery. The primary analysis showed that planned cesarean delivery did not increase or decrease the risk of fetal/neonatal death or serious neonatal morbidity as compared with planned vaginal delivery.

OBJECTIVE

This study presents the secondary outcome of death or neurodevelopmental delay at 2 years of age.

STUDY DESIGN

A total of 4603 children from the initial cohort of 5565 fetuses/infants (83%) contributed to the outcome of death or neurodevelopmental delay. Surviving children were screened using the Ages and Stages Questionnaire with abnormal scores validated by a clinical neurodevelopmental assessment. The effect of planned cesarean vs planned vaginal delivery on death or neurodevelopmental delay was quantified using a logistic model to control for stratification variables and using generalized estimating equations to account for the nonindependence of twin births.

RESULTS

Baseline maternal, pregnancy, and infant characteristics were similar. Mean age at assessment was 26 months. There was no significant difference in the outcome of death or neurodevelopmental delay: 5.99% in the planned cesarean vs 5.83% in the planned vaginal delivery group (odds ratio, 1.04; 95% confidence interval, 0.77-1.41; P = .79).

CONCLUSION

A policy of planned cesarean delivery provides no benefit to children at 2 years of age compared with a policy of planned vaginal delivery in uncomplicated twin pregnancies between 32(0/7)-38(6/7)weeks' gestation where the first twin is in cephalic presentation.

Five-minute Apgar score and educational outcomes: retrospective cohort study of 751,369 children

BACKGROUND

The Apgar score is used worldwide for assessing the clinical condition and short-term prognosis of newborn infants. Evidence for a relationship with long-term educational outcomes is conflicting. We investigated whether Apgar score at 5 min after birth was associated with additional support needs (ASN) and educational attainment.

METHODS

Data on pregnancy, delivery and later educational outcomes for children attending Scottish schools between 2006 and 2011 were collated by linking individual-level data from national educational and maternity databases. The relationship between Apgar score and overall ASN, type-specific ASN and educational attainment was assessed using binary, multinomial and generalised ordinal logistic regression models, respectively. Missing covariate data were imputed.

RESULTS

Of the 751,369 children eligible, 9741 (1.3%) had a low or intermediate Apgar score and 49,962 (6.6%) had ASN. Low Apgar score was independently associated with overall ASN status (adjusted OR for Apgar ≤3, OR 1.52 95% CI 1.35 to 1.70), as well as ASN due to cognitive (OR 1.26, 95% CI 1.09 to 1.47), sensory (OR 2.49 95% CI 1.66 to 3.73) and motor (OR 3.57, 95% CI 2.86 to 4.47) impairments. There was a dose-response relationship between Apgar score and overall ASN status: of those scoring 0-3, 10.1% had ASN, compared with 9.1% of those scoring 4-7 and 6.6% of those scoring 7-10. A low Apgar score was associated with lower educational attainment, but this was not robust to adjustment for confounders.

CONCLUSIONS

Apgar scores are associated with long-term as well as short-term prognoses, and with educational as well as clinical outcomes at the population level.

Association between maternal obesity and offspring Apgar score or cord pH: a systematic review and meta-analysis

Previous results are inconsistent regarding the association between maternal obesity and Apgar score or cord pH in humans. The aim of this study was to investigate the association between maternal pre-pregnancy and pregnancy body mass index (BMI) and infant Apgar score or cord pH. We conducted a systematic review of studies published in English before 20 August 2015 using PubMed, EMBASE, and Cochrane Library. Eleven cohort studies with a total of 2,586,265 participants finally met our inclusion criteria. Pooled results revealed the following factors associated with Apgar score <7 at 5 minutes: overweight (odds ratio [OR] 1.13; 95% confidence interval [CI], 1.08-1.20), obese (OR 1.40; 95% CI, 1.27-1.54), and very obese (OR 1.71; 95% CI, 1.55-1.89). The pooled analysis also revealed that maternal overweight or obesity increased the risk for Apgar score <7 at 1 minute. There was no association between maternal BMI and neonatal cord pH. Thus, this study suggests that maternal overweight and obesity affect baby's condition immediately after birth in general. More studies are needed to confirm these results and detect the influence of variables across studies.

Can Caesarean section improve child and maternal health? The case of breech babies

This paper examines the health effects of Caesarean section (CS) for children and their mothers. We use exogenous variation in the probability of CS in a fuzzy regression discontinuity design. Using administrative Danish data, we exploit an information shock for obstetricians that sharply altered CS rates for breech babies. We find that CS decreases the child's probability of having a low APGAR score and the number of family doctor visits in the first year of life. We find no significant effects for severe neonatal morbidity or hospitalizations. While mothers are hospitalized longer after birth, we find no effects of CS for maternal post-birth complications or infections. Although the change in mode of delivery for the marginal breech babies increases direct costs, the health benefits show that CS is the safest option for these children.

Disruptive behaviour disorders: a systematic review of environmental antenatal and early years risk factors

Disruptive behaviour disorders (DBDs), including attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD) and conduct disorder (CD) are chronic disorders with significant overlap in aetiology and presentation. An integrative examination of environmental risk factors is lacking. Six literature searches of web-based bibliographic databases were completed to identify literature on DBDs in general and five disorders in particular: CD, ODD, ADHD, deficits of attention, motor control and perception, and reactive attachment disorder. Searches were filtered to focus on studies including diagnostic assessment, focussing on environmental risk and protective factors in the first 4 years of life. The database searches generated 9806 papers of which 47 were reviewed after filters had been applied. The evidence suggests links between a number of early life risk factors and DBDs, including prenatal cigarette smoking and alcohol use, prenatal viral illness, maternal stress and anxiety, low birthweight, peri-partum and early neonatal complications, parental stress and parenting styles in infancy, early deprivation, adoption and separation. Despite the understanding that there is sharing of risk factors between the DBDs, there has been a disproportionate focus on the role of certain risk factors at the expense of others and the field is weakened by difficulties in controlling for all potential confounding variables.

Planned vaginal delivery of term breech remains an option – result of eight years experience at a single centre

In order to compare the short term outcome of vaginal and abdominal delivery of babies with breech presentation at term at a single centre, a retrospective study of 299 women presenting with singleton normal breech fetuses at term between 1st January 1996 and 31st December 2003, at a tertiary referral centre, was conducted. The rates of perinatal mortality, neonatal mortality, serious neonatal morbidity and low Apgar scores of neonates delivered after either planned vaginal or planned abdominal delivery were compared. Among 299 women with singleton normal breech at term, 32.1% delivered vaginally and 67.9% had C/S. Successful planned vaginal delivery rate was 97.9%. There was no perinatal or neonatal death in either group and no significant difference in the rates of serious perinatal morbidity between the two groups. We concluded that planned vaginal delivery is associated with no significant adverse perinatal outcome and remains an option for selected term breech presentation.

Association of Apgar score at five minutes with long-term neurologic disability and cognitive function in a prevalence study of Danish conscripts

BACKGROUND

Apgar score is used for rapid assessment of newborns. Low five-minute Apgar score has been associated with increased risk of severe neurologic outcome, but data on milder outcomes, particularly in the long term, are limited. We aimed to examine the association of five-minute Apgar score with prevalence of neurologic disability and with cognitive function in early adulthood.

METHODS

We conducted a prevalence study among draft-liable men born in Denmark in 1978-1983 and presenting for the mandatory army evaluation in a northern Danish conscription district. We linked records of this evaluation, which includes medical exam and intelligence testing, with the conscripts' records in the Medical Birth Registry, containing perinatal data. We examined prevalence of neurologic disability and of low cognitive function according to five-minute Apgar score.

RESULTS

Less than 1% (136/19,559) of the conscripts had 5-minute Apgar scores <7. Prevalence of neurologic disability was 2.2% (435/19,559) overall; among conscripts with Apgar scores <7, 7-9, and 10 (reference), it was 8.8%, 2.5%, and 2.2% respectively. The corresponding prevalences of low cognitive function (intelligence test score in the bottom quartile) were 34.9%, 27.2%, and 25.0%. The outcomes were more prevalent if Apgar score <7 was accompanied by certain fetal or obstetric adversities. After accounting for perinatal characteristics, 5-minute Apgar score <7 was associated with prevalence ratios of 4.02 (95% confidence interval: 2.24; 7.24) for neurologic disability and 1.33 (0.94; 1.88) for low cognitive function.

CONCLUSION

A five-minute Apgar score <7 has a consistent association with prevalence of neurologic disability and with low cognitive function in early adulthood.

Neonate - newborn condition and prematurity with breech delivery

Introduction. Before birth, most of foetuses located in mother's uterus have head presentation down towards the breech exit. Preterm delivery presents the delivery before the end of the 37th gestational week. Etiology of preterm breech deliveries is the same as of the ones at term, such as uterine malformations and myomas, polyhydramnion, foetal abnormalities, high parity, short umbical cord, placenta previa. The complications include passing of the body through insufficiently dilated cervical channel and 'capturing' of the head, umbilical cord prolapse, intrapartal hipoxy, discoordinated delivery, aspiration pneumonia, traumatic injuries. The basic aim of the research was to determine prematurity, mortality, colority of the amniotic fluid, and newborn condition with breech deliveries comparing to the head presentation deliveries. Material and methods. The study group consisted of 282 newborns that came from breech deliveries and the same number of the controls born with head presentation. In cases of breech deliveries there was greatly higher quantity of green and meconium amniotic fluid, significantly higher prematurity, significantly lower average Apgar score as well as seven times higher mortality of newborns comparing with the values in head presentation deliveries. Discussion. Meconium amniotic fluid can result in greater risk than aspiration pneumonia which is the characteristics of breech deliveries. There are more causes endangering fetal vitality after breech delivery and those are along with prematurity, gretaer number of congenital malformations, often traumas which depend on delivery course as well as hipoxy caused during delivery. Prematurity of fetus is one of risk factors resulting in breech delivery but it is also its main characteristics. Conclusion. Breech delivery brings greater risk measured by Apgar score values, appearance of meconium amniotic fluid, prematurity with its consequences and perinatal mortality.

The relation of breech presentation at term to epilepsy in childhood

OBJECTIVE

To investigate the relation between breech at term and epilepsy in childhood, and identify risk factors for epilepsy in term breech infants.

STUDY DESIGN

Register-based study of all (n = 7514) singleton term infants without malformations, born between 1980 and 1994 and hospitalised with epilepsy until year 1996. For each case delivered in breech presentation (n = 290), the two subsequent deliveries of non-malformed, singleton infants delivered in breech presentation at term at the same hospital were selected as controls (n = 580).

RESULTS

Breech presentation was a risk factor for epilepsy (OR: 1.2 [95% CI: 1.1, 1.3]). Breech infants with epilepsy were more often small for gestational age (9.7%) than breech infants without epilepsy (4.7%). Vaginal delivery was associated with low Apgar score, but mode of delivery and low Apgar score were not related to epilepsy.

CONCLUSION

The increased risk of epilepsy in term breech infants is not related to intrapartum events, but to growth restriction in pregnancy.

Outcomes of children at 2 years after planned cesarean birth versus planned vaginal birth for breech presentation at term: the International Randomized Term Breech Trial

OBJECTIVE

The purpose of this study was to determine whether planned cesarean delivery for the singleton fetus in breech presentation at term reduces the risk of death or neurodevelopmental delay at 2 years of age.

STUDY DESIGN

In selected centers in the Term Breech Trial, children were screened for abnormalities at > or =2 years of age with the Ages and Stages Questionnaire, followed by a neurodevelopmental assessment if the Ages and Stages Questionnaire score was abnormal.

RESULTS

A total of 923 of 1159 children (79.6%) from 85 centers were followed to 2 years of age. The risk of death or neurodevelopmental delay was no different for the planned cesarean than for the planned vaginal birth groups (14 children [3.1%] vs 13 children [2.8%]; relative risk, 1.09; 95% CI, 0.52- 2.30; P = .85; risk difference, +0.3%; 95% CI, -1.9%, +2.4%).

CONCLUSION

Planned cesarean delivery is not associated with a reduction in risk of death or neurodevelopmental delay in children at 2 years of age.