Retinal haemorrhages in the newborn. Comparison of delivery by forceps and by vacuum extractor

Instruments for assisted vaginal birth

BACKGROUND

Assisted vaginal births are carried out to expedite birth for the benefit of mothers and babies but are sometimes associated with significant morbidity for both. Various instruments are available, broadly divided into forceps and vacuum cups, and choice may be influenced by clinical circumstances, operator preference, experience and availability.  OBJECTIVES: To evaluate the different instruments in terms of success in achieving a vaginal birth, and the risk of morbidity for mother and baby.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (14 May 2021), and reference lists of retrieved studies.

SELECTION CRITERIA

We selected randomised controlled trials of assisted vaginal birth using different instruments. The review did not include quasi-randomised trials, cluster-randomised trials or cross-over designs. The review included trials for which abstracts alone were available as long as there was sufficient information to assess eligibility.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the GRADE approach to assess the certainty of evidence.  The main outcomes assessed included failed delivery with allocated instrument, any maternal trauma, third- and fourth-degree tears, postpartum haemorrhage, any neonatal trauma, low Apgar and low umbilical artery pH.  MAIN RESULTS: We included 31 studies involving a total of 5754 women.  Risk of bias criteria were largely assessed as 'unclear', due to a lack of detail in trial reports. Blinding would have been challenging for all trials due to their inability to conceal the type of instrument used from either the woman or the operator, which is reflected in the risk of bias assessment. Any type of forceps versus any type of vacuum cup (12 studies, 3129 women) Forceps may be less likely to fail in achieving vaginal birth: risk ratio (RR) 0.58, 95% confidence interval (CI) 0.39 to 0.88; 11 studies, 3080 women; low certainty. 'Any maternal trauma' may be slightly more likely with forceps: odds ratio (OR) 1.53, 95% CI 0.98 to 2.40; 5 studies, 1356 women; low certainty; and third- or fourth-degree tears may also be more likely with forceps: RR 1.83, 95% CI 1.32 to 2.55; 9 studies, 2493 women; low certainty. There is no evidence of a difference in the incidence of postpartum haemorrhage (PPH) between the two groups: RR 1.71, 95% CI 0.59 to 4.95; 2 studies, 523 women; low certainty, because the evidence is very imprecise due to a very wide CI.  More women in the forceps group reported requiring pain relief. There is probably no evidence of difference in rates of low Apgar: RR 0.83, 95% CI 0.46 to 1.51; 7 studies, 1644 women; moderate certainty; or low umbilical artery pH in the forceps group compared to any vacuum: RR 1.33, 95% CI 0.91 to 1.93; 2 studies, 789 women; low certainty; both of these outcomes are imprecise and have wide CIs that include both benefit and harm. There were also lower rates of fetal trauma with 'any forceps' (cephalhematoma, retinal haemorrhage and jaundice). The composite outcome of 'any neonatal trauma' was not reported. Low-cavity forceps versus any vacuum cup (2 studies, 218 women) We included two small studies with 218 participants in this comparison, but we judged most of the evidence as very low certainty, hence it was not feasible to make judgements on the difference in the rates of failed delivery, any maternal trauma or third- and fourth- degree tears. PPH and low umbilical artery pH were not reported. Soft vacuum cup versus any rigid cup (9 studies, 1148 women) Failed delivery may be more likely in the soft vacuum cup group: RR 1.62, 95% CI 1.21 to 2.17; 9 studies, 1148 women; low certainty. There may be no difference in the rates of 'any maternal trauma': OR 0.63, 95% CI 0.24 to 1.67; 2 studies, 348 women; low certainty, but the confidence interval is wide, indicating possible benefit or harm. There may be no difference in the rates of third- or fourth-degree tears: RR 0.93, 95% CI 0.35 to 2.44; 4 studies, 619 women; low certainty. There is probably no difference in the rates of PPH: RR 0.89, 95% CI 0.49 to 1.61; 5 studies, 737 women; moderate certainty between the soft and rigid cup groups.   There may be little or no difference in the incidence of low Apgar scores: RR 0.82, 95% CI 0.49 to 1.37; 9 studies, 1148; low certainty; or low umbilical artery pH: RR 0.80, 95% CI 0.47 to 1.36; 1 study, 100 women; low certainty. Handheld vacuum versus any vacuum cup (4 studies, 968 women) There may be no difference in the rates of failures with allocated instrument: RR 1.35, 95% CI 0.81 to 2.25; 4 studies, 962 women; low certainty, any maternal trauma: OR 1.16, 95% CI 0.71 to 1.88; 2 studies; 394 women; low certainty, PPH: RR 0.31, 95% CI 0.03 to 2.92; 1 study, 164 women; low certainty, low umbilical artery pH: RR 1.06, 95% CI 0.71 to 1.59; 1 study, 164 women; low certainty, or low Apgar scores: RR 1.25, 95% CI 0.34 to 4.61; 3 studies, 784 women; low certainty) between the two groups. There is probably no difference in the rates of third- or fourth-degree tears between the 'handheld vacuum' and 'any vacuum cup' groups: RR 1.15, 95% CI 0.62 to 2.12; 4 studies, 962 women; moderate certainty.

AUTHORS' CONCLUSIONS

This review provides low-certainty evidence that forceps may be more likely to achieve vaginal birth and have lower rates of fetal trauma, but at a greater risk of perineal trauma and higher pain relief requirements compared with vacuum cups. There was low-certainty evidence that rigid vacuum cups may be more likely to achieve a vaginal birth than soft cups but with more fetal trauma, whilst handheld vacuum cups had similar success rates compared to other cups. There was no evidence of a difference in the rates of third- or fourth-degree tears or postpartum haemorrhages between types of cups, but wide confidence intervals around the estimates indicate further research is needed in this area.

Higher prevalence of fundus haemorrhages in early-screened (NEST Study) as compared to late-screened (SUNDROP Study) newborn populations

BACKGROUND/AIMS

To determine whether timing of ophthalmic screening influences prevalence of neonatal fundus haemorrhages. We compared the prevalence of fundus haemorrhages in two populations: term newborns screened early (less than 72 hours) and preterm newborns screened late (4-11 weeks). Additionally, we reviewed the literature on timing and prevalence of newborn haemorrhages.

METHODS

Retrospective observational cohort study. Infants who underwent wide-angle ophthalmic digital imaging over one overlapping year in the Newborn Eye Screen Testing (NEST) or Stanford University Network for Diagnosis of Retinopathy of Prematurity (SUNDROP) programme were included. The PubMed database was filtered to include English-language articles dating back to 1950. Nine articles were selected for review based on inclusion of the prevalence of newborn fundus haemorrhages at multiple time points.

RESULTS

A total of 202 patients received early imaging in the NEST cohort and 73 patients received late imaging in the SUNDROP cohort. In the NEST cohort, 20.2% of newborns had haemorrhages. In contrast, we found haemorrhages in only one case or 1.4% of the SUNDROP cohort. Using prevalence data from nine additional studies, we developed a predicted probabilities model of newborn haemorrhages. Per this model, the probability of seeing a haemorrhage if you screen an infant at 1 hour is 18.8%, at 2 weeks is 2.9% and at 1 month is 0.28%.

CONCLUSION

We found a significant difference in the prevalence of fundus haemorrhages between the early-screened NEST cohort and the late-screened, preterm SUNDROP cohort. Likely, this difference is due to the transient nature of most newborn haemorrhages.

Newborn retinal hemorrhages: a systematic review

PURPOSE

To systematically review the characteristics, prevalence, evolution, and obstetric associations of retinal hemorrhages (RH) in newborns.

METHODS

A systematic review, searching 10 databases (1970-2011), identified 45 studies, which underwent two independent reviews via the use of standardized critical appraisal. Studies meeting the following criteria were included: examination by an ophthalmologist, use indirect ophthalmoscopy, and first examination conducted within 96 hours of birth and before hospital discharge.

RESULTS

Thirteen studies were included, representing 1,777 infants. The studies revealed that 25.6% of newborns born via spontaneous vaginal deliveries had RH. In contrast, infants delivered by vacuum extraction had a 42.6% rate of RH (OR, 2.75; 95% CI, 1.32-5.70), and infants delivered by double-instrument deliveries (forceps and vacuum) had a 52% rate of RH (OR, 3.27; 95% CI, 1.68-6.36). The hemorrhages are commonly bilateral (59%), of varying severity, from "mild" (22%-56%) to "severe" (18%-37%), and predominantly intraretinal and in the posterior pole. The majority of RH (83%) resolved within 10 days; isolated cases persisted to 58 days.

CONCLUSIONS

Birth-related RH in infants occurs in one-quarter of normal deliveries and are far more common after instrumental deliveries. Commonly bilateral, they were predominantly intraretinal, posterior, resolved rapidly, and very rarely persisted beyond 6 weeks.

WITHDRAWN: Vacuum extraction versus forceps for assisted vaginal delivery

BACKGROUND

Proponents of vacuum delivery argue that it should be chosen first for assisted vaginal delivery, because it is less likely to injure the mother.

OBJECTIVES

The objective of this review was to assess the effects of vacuum extraction compared to forceps, on failure to achieve delivery and maternal and neonatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: February 1999.

SELECTION CRITERIA

Acceptably controlled comparisons of vacuum extraction and forceps delivery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Ten trials were included. The trials were of reasonable quality. Use of the vacuum extractor for assisted vaginal delivery when compared to forceps delivery was associated with significantly less maternal trauma (odds ratio 0.41, 95% confidence interval 0.33 to 0.50) and with less general and regional anaesthesia. There were more deliveries with vacuum extraction (odds ratio 1.69, 95% confidence interval 1.31 to 2.19). Fewer caesarean sections were carried out in the vacuum extractor group. However the vacuum extractor was associated with an increase in neonatal cephalhaematomata and retinal haemorrhages. Serious neonatal injury was uncommon with either instrument.

AUTHORS' CONCLUSIONS

Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity. The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit.

Choice of instruments for assisted vaginal delivery

BACKGROUND

Instrumental or assisted vaginal birth is commonly used to expedite birth for the benefit of either mother or baby or both. It is sometimes associated with significant complications for both mother and baby. The choice of instrument may be influenced by clinical circumstances, operator choice and availability of specific instruments.

OBJECTIVES

To evaluate different instruments in terms of achieving a vaginal birth and avoiding significant morbidity for mother and baby.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2010).

SELECTION CRITERIA

Randomised controlled trials of assisted vaginal delivery using different instruments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality, extracted the data, and checked them for accuracy.

MAIN RESULTS

We included 32 studies (6597 women) in this review. Forceps were less likely than the ventouse to fail to achieve a vaginal birth with the allocated instrument (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.45 to 0.94). However, with forceps there was a trend to more caesarean sections, and significantly more third- or fourth-degree tears (with or without episiotomy), vaginal trauma, use of general anaesthesia, and flatus incontinence or altered continence. Facial injury was more likely with forceps (RR 5.10, 95% CI 1.12 to 23.25). Using a random-effects model because of heterogeneity between studies, there was a trend towards fewer cases of cephalhaematoma with forceps (average RR 0.64, 95% CI 0.37 to 1.11).Among different types of ventouse, the metal cup was more likely to result in a successful vaginal birth than the soft cup, with more cases of scalp injury and cephalhaematoma. The hand-held ventouse was associated with more failures than the metal ventouse, and a trend to fewer than the soft ventouse.Overall forceps or the metal cup appear to be most effective at achieving a vaginal birth, but with increased risk of maternal trauma with forceps and neonatal trauma with the metal cup.

AUTHORS' CONCLUSIONS

There is a recognised place for forceps and all types of ventouse in clinical practice. The role of operator training with any choice of instrument must be emphasised. The increasing risks of failed delivery with the chosen instrument from forceps to metal cup to hand-held to soft cup vacuum, and trade-offs between risks of maternal and neonatal trauma identified in this review need to be considered when choosing an instrument.

Retinal haemorrhages in premature infants: a pathogenetic alternative diagnosis to child abuse

PURPOSE

To present the occasional observation of retinal haemorrhages in premature babies, as a diagnostic alternative to those observed as part of shaken baby syndrome.

METHODS

We carried out an observational study on 11 infants in whom retinal and/or vitreous haemorrhages had been observed within their first months of life. Ten infants were under surveillance for retinopathy of prematurity (ROP), with gestational ages and birth weights in the ranges of 27--34 weeks and 790--1665 g, respectively. One infant was diagnosed with Zellweger's syndrome and one received substitution therapy for coagulation factor II deficiency. The last child had been delivered at 38 weeks, weighing 2070 g; he died on day 5 from severe brain oedema with incarceration and extensive bilateral fundus bleeding.

RESULTS

Four of the 11 infants had some evidence of ROP, and two later received retinal ablation therapy. Contrary to the quick absorption (<1-2 weeks only) usually seen in most newborn term infants, the ocular bleeding in preterms was generally longstanding. A quick increase in intracranial pressure probably played a role in the lethal case with delivery near term, and one infant received lung physiotherapy for pneumonia at the age of 6 months. Some bleeding appeared to be truly postnatal (i.e. it was observed as a new occurrence during the course of surveillance).

CONCLUSIONS

In the series under study there was no suspicion of child abuse. In term infants, retinal haemorrhages are extremely rare except when due to shaking, but other diseases should be ruled out, coagulopathies in particular. We suggest that prematurity as such is added to the list of possibly underlying causes when retinal bleedings are evaluated in very small infants and shaken baby mechanisms are suspected.

[Complications of vacuum extractor deliveries]

OBJECTIVES

To describe maternal and neonatal complications following deliveries assisted by vacuum extraction and to compare outcomes with those obtained after spontaneous vaginal delivery. We wanted to know if vacuum extractor was a risk factor by itself.

MATERIALS AND METHODS

We conducted a retrospective study of two years activity involving 4524 deliveries of which 845 (18.7%) were vacuum extractor assisted. We precisely defined maternal and neonatal complications to compare their rates in spontaneous vaginal delivery and vacuum extractor groups.

RESULTS

There were 1333 maternal complications and 114 neonatal complications. The adjusted risks of maternal complications were significantly higher in the vacuum extractor group for simple vaginal tears (OR=3.0; p<0.001), the simple perineal tears (OR=1.8; p<0.001) and third degree perineal tears (OR=2.7; p<0.01). For neonatal complications, the difference was significant for cephalhematomas (OR=10; p<0.001) and scalp abrasions (OR=53; p<0.001). No cases of skull fracture or subgaleal subaponeurotic hemorrhage were recorded.

CONCLUSION

Our rates of maternal and neonatal complications after vacuum extractor were similar to those described in the literature. We have been able to show that vacuum extraction is itself a risk factor for third degree perineal tears and cephalhematoma. However, these complications are so infrequent that the advantages of this method of extraction argue in favor of wide use in obstetrics.

Operative vaginal delivery and neonatal and infant adverse outcomes: population based retrospective analysis

OBJECTIVE

To compare the risk of neonatal and infant adverse outcomes between vacuum and forceps assisted deliveries.

DESIGN

Population based study.

SETTING

US linked natality and mortality birth cohort file and the New Jersey linked natality, mortality, and hospital discharge summary birth cohort file.

PARTICIPANTS

Singleton live births in the United States (n = 11 639 388) and New Jersey (n = 375 351).

MAIN OUTCOME MEASURES

Neonatal morbidity and mortality.

RESULTS

Neonatal mortality was comparable between vacuum and forceps deliveries in US births (odds ratio 0.94, 95% confidence interval 0.79 to 1.12). Vacuum delivery was associated with a lower risk of birth injuries (0.69, 0.66 to 0.72), neonatal seizures (0.78, 0.68 to 0.90), and need for assisted ventilation (< 30 minutes 0.94, 0.92 to 0.97; > or = 30 minutes 0.92, 0.88 to 0.98). Among births in New Jersey, vacuum extraction was more likely than forceps to be complicated by postpartum haemorrhage (1.22, 1.07 to 1.39) and shoulder dystocia (2.00, 1.62 to 2.48). The risks of intracranial haemorrhage, difficulty with feeding, and retinal haemorrhage were comparable between both modes of delivery. The sequential use of vacuum and forceps was associated with an increased risk of need for mechanical ventilation in the infant and third and fourth degree perineal tears.

CONCLUSION

Although vacuum extraction does have risks, it remains a safe alternative to forceps delivery.

Obstetric vacuum extraction: state of the art in the new millennium

This article summarizes the current state of knowledge of obstetric vacuum extraction. The discussed topics include the history of vacuum extraction, indications and contraindications, technique of the procedure, currently marketed instruments, special uses of the vacuum extractor, comparison of vacuum extraction with forceps delivery, and maternal and fetal outcomes. Areas of controversy are identified and discussed. Vacuum extraction is replacing forceps as the preferred method of instrumental delivery.

Survey of retinal haemorrhages in neonatal thoroughbred foals

Twenty-seven of 167 neonatal thoroughbred foals (16 per cent) were found to have retinal haemorrhages after a careful examination of the entire fundus. Experience in differentiating haemorrhages from other lesions, and the selection of foals from normal populations, were considered to have an important effect on their apparent incidence. Bilateral haemorrhages were more common and there was a significantly higher incidence in female foals. The numbers of haemorrhages ranged between one and 20; 36 per cent of eyes with retinal haemorrhages had the small punctate type and 56 per cent had the splash-like form. There was no change from one type of haemorrhage to another, and the patterns of resolution were similar. The haemorrhages were in the tapetal fundus, except two that were recorded in the optic disc, and they resolved within 10 days. No short- or long-term ocular or neurological effects of the retinal haemorrhages were detected, and they were not related to the incidence of abnormal foal behaviour.

Vacuum extraction versus forceps for assisted vaginal delivery

BACKGROUND

Proponents of vacuum delivery argue that it should be chosen first for assisted vaginal delivery, because it is less likely to injure the mother.

OBJECTIVES

The objective of this review was to assess the effects of vacuum extraction compared to forceps, on failure to achieve delivery and maternal and neonatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register. Date of last search: February 1999.

SELECTION CRITERIA

Acceptably controlled comparisons of vacuum extraction and forceps delivery.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Ten trials were included. The trials were of reasonable quality. Use of the vacuum extractor for assisted vaginal delivery when compared to forceps delivery was associated with significantly less maternal trauma (odds ratio 0.41, 95% confidence interval 0.33 to 0.50) and with less general and regional anaesthesia. There were more deliveries with vacuum extraction (odds ratio 1.69, 95% confidence interval 1.31 to 2.19). Fewer caesarean sections were carried out in the vacuum extractor group. However the vacuum extractor was associated with an increase in neonatal cephalhaematomata and retinal haemorrhages. Serious neonatal injury was uncommon with either instrument.

REVIEWER'S CONCLUSIONS

Use of the vacuum extractor rather than forceps for assisted delivery appears to reduce maternal morbidity. The reduction in cephalhaematoma and retinal haemorrhages seen with forceps may be a compensatory benefit.

A randomised prospective study comparing the new vacuum extractor policy with forceps delivery

OBJECTIVE

To compare assisted vaginal delivery by forceps with delivery by vacuum extractor, where a new vacuum extractor policy was employed which dictated the cup to be used in specific situations.

DESIGN

Multicentre randomised controlled trial.

SETTING

Four district general hospitals in the West Midlands.

SUBJECTS

Six hundred-seven women requiring assisted vaginal delivery, of whom 296 were allocated to vacuum extractor delivery and 311 to forceps.

MAIN OUTCOME MEASURES

Delivery success rate, maternal perineal and vaginal injuries, maternal anaesthetic requirements, neonatal scalp and facial injuries.

RESULTS

Of the vacuum extractor group, 85% were delivered by the allocated instrument compared to 90% in the forceps group (odds ratio (OR) 0.64; 95% confidence intervals (CI) 0.4-1.04). However, more women in the vacuum extractor group were delivered vaginally (98%) than in the forceps group (96%). There were significantly fewer women with anal sphincter damage or upper vaginal extensions in the vacuum extractor group (11% vs 17%, OR 0.6; 95% CI, 0.38-0.97). There were significantly fewer women in the vacuum extractor group requiring epidural or spinal anaesthetics (25.4% vs 32.7%, OR 0.69; 95% CI 0.49-0.99) or general anaesthetics (1% vs 4%, OR 0.17; 95% CI 0.04-0.76). Although there were significantly more babies in the vacuum extractor group with cephalhaematomata (9% vs 3%, OR 3.3; 95% CI 1.4-7.4) there were fewer babies in the vacuum extractor group with other facial injuries. There were three babies in the forceps group with unexplained neonatal convulsions.

CONCLUSIONS

Assisted vaginal delivery using the new vacuum extractor policy is associated with significantly less maternal trauma than with forceps. Further studies are required to assess neonatal morbidity adequately.

Long-term effects of vacuum and forceps deliveries

The long-term effects of vacuum and forceps deliveries are largely unknown. We determined the long-term outcome of instrumental deliveries in 52,282 infants born in Jerusalem between 1964 and 1972. For each individual, events at birth were related to results of an intelligence test and medical examination done at 17 years of age by the Israeli Defence Forces draft board. 1747 individuals were delivered by vacuum, 937 by forceps, 47,500 by spontaneous delivery, and 2098 by caesarean section. Crude data showed that mean intelligence scores at 17 were significantly higher (p less than 0.0001) in the vacuum and forceps deliveries groups than in the spontaneous-delivery group; however, after adjustment for confounding factors by stepwise multiple regression, these differences were no longer seen. Although the forceps-delivery group had functional impairment of feet, vision, and retina compared with the spontaneous-delivery group, and the vacuum-extraction group had impairment of the legs, differences were small. Our findings suggest that infants delivered by vacuum or forceps are not at risk of physical and cognitive impairment at 17 years of age.

Ocular features other than retinopathy of prematurity in the pre-term infant

218 premature infants born 1985-87 in Frederiksborg County were followed in the eye clinic, mainly due to the risk of developing retinopathy of prematurity (ROP). The median gestational age was 33 weeks, the median birth weight 1.750 g. ROP being analysed elsewhere, emphasis is on a) retinal haemorrhages (long-standing in 11) and vitreous bleeding (3 cases); b) the oval shape of the pre-term optic disc, considered a true finding and not merely an optical artifact; c) the pre-term presence of the optic disc cup, otherwise considered of about-term development; and d) refractive state, with myopia as a prevailing finding at post-conceptional ages shorter than 40 weeks. A shift towards hypermetropia became obvious after 2-3 months. Only 4 cases deserved the label myopia of prematurity, the criteria being early recording of ROP and persistent myopia (for more than 18-24 months).

Retinal hemorrhages and traction forces in vacuum extraction

The relationship between the traction forces used in 53 clinically indicated vacuum extractions and the incidence and degree of retinal hemorrhages observed in the neonates within 24 hours after birth was examined. A Vacuum Extractor Recorder (Type SF 30, Knick), was used to measure the traction force necessary for delivery of the fetal head. No relationship could be demonstrated between the force time integral and the appearance and grading of retinal bleedings.

Perinatal retinal haemorrhages and development. Follow-up in seven year olds

Depending on methods of delivery, 7-50% of all children are born with retinal haemorrhages (RH). To assess the prognostic value of extensive RH for the future development of the child, the ophthalmological, neurological and psychological status of 52 children, 26 born with RH and 26 controls, were examined at the age of seven years. There were significant differences between the two groups using only psychological measures. Children with RH performed poorer than the control group, but the results did not point to any particular cerebral areas being affected. However, children with both RH and low socio-economic status were significantly less emotionally stable than the controls. Socio-economic factors also seem to be more highly correlated with later performance than do RH.

Neurology and behaviour of newborn infants delivered by vacuum extraction on maternal indication

23 full-term neonates delivered by vacuum extraction (VE) on maternal indication (primary or secondary uterine inertia) but with no sign of fetal asphyxia and a control group of 16 infants were studied. The infants were examined on the 1st and 5th days after birth with the Brazelton Neonatal Behavioural Assessment Scale and by a standardized neurological examination. On day 1 the VE-infants showed lower visual and auditory responsiveness in the behavioural assessment, and fewer optimal responses in the neurological examination than did the controls. Obstetrical factors such as abnormal presentation, long duration of the second stage of labour, and long duration of VE (greater than or equal to 15 minutes) may explain the differences. The differences between the groups had largely disappeared by day 5.

Epidural analgesia and perinatal retinal haemorrhages

The incidence and magnitude of retinal haemorrhages in a group of neonates delivered spontaneously (n = 50), whose mothers received epidural analgesia during labour, has been compared to those of a spontaneously delivered control group (n = 50) who received conventional analgesia. The second stage of labour was significantly longer in the epidural group (P less than 0.001), which contained a higher number of primiparas than did their controls. Still, a lower incidence of retinal haemorrhages was noted in the epidural group (P less than 0.01). The study indicates that epidural analgesia offers a certain degree of protection against perinatal retinal haemorrhages in the spontaneously delivered neonate.

Visual functions after perinatal macular haemorrhage

Perinatal macular haemorrhage has been suggested as being a cause of amblyopia and strabismus. 39 of 48 children with macular haemorrhage after birth were examined at the age of 5 years. The study comprised visual acuity with E-test types and cycloplegic refraction. Binocular function was evaluated by cover test, and 4d-prism test. Fixation was studied by an ophthalmoscope with a central dark star. Sensory function was estimated by Schober test and Worth 4-dot-test. The observations gave no support to the existence of organic amblyopia or strabismus following perinatal macular haemmorrhage.