INTRA PARTUM FOETAL DISTRESS

Navorsing is gedoen om vas te stel of intra-partum fetale nood, die apgartelling en biochemise analise van die suur-basis balans van die bloed van die chorioniese ar­ teries enige langtermyn neurologiese defekte kan voorspel. Die steekproef het bestaan uit eksperimentele en nie-eksperimentele groepe, met nege-en-twintig moeders in elke groep. Slegs twee babas het na 24-uur neurolo­ giese abnormaliteite getoon en geen voorspellings kon dus in die verband gemaak word nie. Daar is egter bevind dat lae abgartellings voorspel kan word met die kliniese diagnose van intrapartum fetale nood. • Apgar scoring Accurate assessment of apgar score at 1 m inute, 5 minutes and 15 minutes was done.


INTRODUCTION
T he occurrence of neonatal as phyxia at B aragw anath H ospital is a daily problem . The question was raised as to w hether intra partum foetal distress, apgar scoring at birth and the biochem ical analysis of blood acid base status from the chorionic arteries can predict any short-term neurological defects.

AIMS O F TH E STU D Y
• To detect factors directly related to the incidence of asphyxia n eo natorum . • To detect factors coincidentally related to the incidence of as phyxia neonatorum . • To establish param eters to detect com plications with their seque lae. • To reduce the occurrence of as phyxia neonatorum thus im prove the quality of life.

TH E HYPO TH ESIS
T here is no correlation betw een apgar scoring, biochem ical analysis of chorionic arterial blood and s h o rt-te r m n e u ro lo g ic a l d e fe c ts within the first tw enty four hours of neonatal life.
This research project won the 1984 Juta Nursing Research Prize for stu dents on courses leading to a post registration diploma or certificate in Nursing. The researchers were study ing for the Diploma in Advanced Midwifery and Neonatal Nursing Sci ence at Baragwaneth Hospital.

T Y P E O F STU D Y
A prospective clinical study consist ing of asphyxiated and non-asphyxiated groups was undertaken. Twenty-nine m others with clinical signs of foetal distress (these re presented the asphyxiated group) were m onitored during labour. The non-asphyxiated group consisted of twenty-nine m others who w ere also m onitored during labour; of these twenty-six presented later with only one of the clinical signs of foetal dis tress when the second stage of labour was im m inent. The subjects chosen were full term and the babies' birth weights had to exceed 2 , 2 kilograms.
The investigators assessed both m aternal and foetal condition and obtained the following data from the m other's clinical records.

• Clinical signs of foetal distress:
These are listed in table 1.

• Technological signs of foetal dis tress
The asphyxiated group only was m onitored with internal cardiotocography. The foetal heart rate and the uterine contractions w ere plotted on the Philpott charts as indi cated in table 1 .
Two heparinised syringes were used to w ithdraw blood from both umbilical arteries within fif teen m inutes of expulsion of the placenta. These sam ples were im m ediately taken for analysis to the acid base m achine (R adio m eter A B I 3). In a pilot study concern was raised because of difference in acid base status betw een blood from the two chorionic arteries of the sam e placenta. B ecause of this phenomenon, sp e c im e n s were taken in each case from both chorionic arteries and the results com pared.
• The assessment of short-term neurological defects 12-24 hours A clinical assessm ent was con ducted as indicated in

Liquor
Colour, thickness and duration of rupture of m em branes.

Labour
D uration of the first and second stages and the m ethod of delivery. Special note was m ade of the occur rence of the cord around the neck -w hether tight or loose, how many tim es, the presence of true knots in the cord.

Resuscitation
W hether the new born was suc tioned and characteristics of the secretations obtained. W hether intu bated and the m ethod of ventilation employed. A ccurate timing of the occurrence of the first spontaneous breath.

Immediate examination of the neonate
Special note was taken of infarcts which becam e significant if they covered a large enough area to in terfere with the uterine placental foetal exchange ( l.p 591).
A retro-placental clot, which sig nifies prem ature separation of the placenta thus interfering with the uterine placental foetal exchange, was also noted.

Results and analysis
A total of fifty-eight patients in labour enrolled in the study. C om parisons were m ade between: -the intrapartum non-asphyxiated group (N = 28) and the in trapartum asphyxiated group (N = 28) -the subjects who had babies with apgar score 3s 7 (N = 36) and apgar score < 7 (N = 22). -the blood values of the two chorionic arteries of all placen tae -intrapartum asphyxia, neonatal asphyxia and short-term n eu ro logical defects.
The t-test was used to test corre lated samples and the chi-square for discrete data.

Intrapartum non-asphyxiated group versus intrapartum as phyxiated group
There was a significant difference between the two samples regarding: -hypertension during pregnancy.
M ore hypertension occurred in the experim ental group (p=0,05) -normal deliveries/caesarian sec tion and intubation. N ot suprisingly m ore caesarian sections (p = 0 ,0 0 2 ) and intubations (p=0,005) were perform ed on cases from the experim ental group -cord around the neck. This was m ore common in the experi m ental group (p= 0,05) -apgar scores. A pgar scores at one m inute (p < 0,001), at 5 min utes (p <0,001) and at 15 m in utes (p < 0 ,0 1 ) were lower in the intrapartum asphyxiated group with the great correlation at 15 minutes -birth weight. The birth weight in the experim ental group was sig nificantly lower (p < 0,05).
T here was no significant difference between the groups regarding: -m aternal age, parity, booking status, post dates (^7 days past E D D ), W R (W asserm an posi tive) -hypertension during labour (dia stolic & 90), delay in cervical di latation, in stru m en tal deliveries (forceps and vacuum ) -chorionic arterial P H , C 0 2 H C 0 3 betw een th e tw o chori onic arteries.

Apgar & 7 group versus 7< group
T here was a significant difference betw een th e tw o groups regarding: -parity. M others o f low p arity oc curred m o re in th e n eo n atal as phyxiated group (p < 0 ,0 5 ) prim igravidas as such w ere no t com p ared , but this could have been a co n trib u to ry factor.
-Chorionic blood pH. A low pH was found to be significantly dif ferent in th e low apgar group (p < 0 ,0 5

Blood values of the two chori onic arteries of all placentae
No significiant difference was found w hen com paring th e p H , P C 0 2 and H C O 3 b etw een isoplacental chori onic arteries.

Asphyxia and short-term neuro logical defects
Only tw o neo n ates w ere judged to be neurologically abnorm al at 24 hours of age. T hese small num bers prohibit statistical analysis.

LIMITATIONS
-O bservations were m ade late in labour, a com m on problem in the hospital is th at patients p re sent late in labour. -T he unavailablity of cardiotocographs for the non-asphyxiated group and even for six subjects in the foetal distress group. -Loss of d ata fo r tw o asphyxiated subjects an d tw o non-asphyxiated subjects because the acid base m achine w as ou t of order for tw enty-four hours.

R EC O M M EN D A TIO N S
-To do a sim ilar study in a larger group in o rd e r to test short-term neurological outcom es. -A n im provem ent in facilities and services to avoid a delay in im plem enting im m ediate action to facilitate delivery. -A vailability o f p ro p e r function ing cardiotocographs and intro ducers to have m ade it possible for the investigators to use equal instrum ents for subjects in both groups.
-That m others receive good an te natal care and vigilant m onitor ing during labour, followed by an accurate assessm ent of the newborn infant, especially with regard to apgar scoring. -It would appear th at it is un necessary to provide acid base facilities to prevent or assess neonatal asphyxia.

SU M M AR Y
Low apgar scores can be predicted from the clinical diagnosis of in tra partum foetal distress but neither low apgar score nor intrapartum foetal distress correlated with arte rial acid base changes. Too few babies had neurological deficit to w arrant analysis.